Implementation and evaluation of the Victorian Suicide Register

Suicide within five years of hospital-treated self-harm: A data linkage cohort study

BACKGROUND

Hospital-treated self-harm is a strong predictor of suicide and hospital contacts may include missed opportunities for suicide prevention. We conducted a data linkage study to identify factors associated with suicide in people treated in hospital for self-harm in Victoria, Australia.

METHOD

We undertook a cohort study following 14,307 people treated in hospital for an episode of self-harm (i.e., either admitted or non-admitted ED presentations) over the period 2011 and 2012 and used data from the Victorian Suicide Register to identify suicides within 5 years. We estimated unadjusted hazard ratios (HRs) for suicide using survival analysis for each exposure variable and then computed adjusted HRs using a multivariate model that included all exposure variables.

RESULTS

Among females, the risk of suicide was higher in those aged 50-74 years (HR 1.78; Cl: 1.02, 3.10), residing in areas of least disadvantage (HR 2.58; Cl: 1.21, 5.50), who used hanging as a method of self-harm (HR 5.17; Cl: 1.86, 14.35) and with organic disorders (HR 6.71; Cl: 2.61, 17.23) or disorders of adult personality and behaviour (HR 2.10; Cl: 1.03, 4.27). In males, the risk of suicide was higher in those who used motor vehicle exhaust gas (MVEG) as a method of self-harm (HR 3.48; Cl: 1.73, 7.01), and with disorders due to psychoactive substance abuse (HR 1.75; Cl: 1.14, 2.67).

CONCLUSION

Although all patients should be routinely assessed for risk and needs following hospital-treated self-harm including appropriate follow-up care, people who use MVEG or hanging as methods of self-harm are obvious candidates for close follow-up.

Guiding principles for the implementation of a standardized psychological autopsy to understand and prevent suicide: a stakeholder analysis

Background

Around 700,000 people die by suicide each year. While the global number of suicides declined over the last decade, the rates remained unchanged in the Netherlands. With this study, we aimed to provide guiding principles for the implementation of a national standardized psychological autopsy to better understand and prevent suicide, by exploring stakeholder perceptions and needs, and barriers to implementation.

Methods

We interviewed 47 representative stakeholders from various fields (e.g., mental healthcare professionals, policy advisors, researchers). A semi structured interview design was used, based on the RE-AIM and Consolidated Framework for Implementation Research (CFIR) theoretical frameworks.

Results

Themes relating to stakeholder perceptions and needs for a standardized psychological autopsy included valorization, accountability, integrability and the needs of the bereaved. Stakeholders believed that participation in a psychological autopsy can help bereaved in their process of grief but noted that evidence to frame the psychological autopsy as postvention is insufficient. The primary focal point should accordingly be to better understand and prevent suicide. Several key limitations of the proposed psychological autopsy approach were detailed, both methodological and implementational.

Conclusion

The stakeholder analysis delineates guiding principles for implementation. Stakeholders believe that a standardized psychological autopsy has merit, provided that key considerations, including valorization and accountability, are integrated in its design. Routine evaluation should be ensured. The findings may guide policy makers and researchers in their endeavors to support a learning, community-based approach for suicide prevention based on a standardized psychological autopsy.

Real-Time Suicide Surveillance: Comparison of International Surveillance Systems and Recommended Best Practice

OBJECTIVE

Some countries have implemented systems to monitor suicides in real-time. These systems differ because of the various ways in which suicides are identified and recorded. The main objective of this study was to conduct an international comparison of major real-time suicide mortality surveillance systems to identify joint strengths, challenges, and differences, and thereby inform best-practice criteria at local, national, and international levels.

METHODS

Five major real-time suicide mortality surveillance systems of various coverage levels were identified and selected for review via an internet-based scoping exercise and prior knowledge of existing systems. Key information including the system components and practices was collated from those organizations that developed and operate each system using a structured template. The information was narratively and critically synthesized to determine similarities and differences between the systems.

RESULTS

The comparative review of the five established real-time suicide surveillance systems revealed more commonalities than differences overall. Commonalities included rapid, routine surveillance based on minimal, provisional data to facilitate timely intervention and postvention efforts. Identified differences include the timeliness of case submission and system infrastructure.

CONCLUSION

The recommended criteria could promote replicable components and practices in real-time suicide surveillance while offering flexibility in adapting to regional/local circumstances and resource availability.HIGHLIGHTSEvidence-informed recommendations for current best practice in real-time suicide surveillance.Proposed comprehensive framework can be adapted based on available resources and capacity.Real-time suicide mortality data facilitates rapid data-driven decision-making in suicide prevention.

Availability and quality of data related to cultural and linguistic diversity in the Victorian Suicide Register: A pilot study

OBJECTIVE

While people from culturally and linguistically diverse (CALD) backgrounds have been identified as a priority for suicide prevention in Australia, little is known about suicide in CALD communities. We aim to describe the availability and quality of CALD data in the Victorian Suicide Register (VSR).

METHODS

A retrospective consecutive case series review of suicides reported to the Coroners Court of Victoria during 2016 was conducted. Using the VSR, we identify suicides showing evidence of CALD identity and relevant variables were extracted and coded according to an adapted Australian Institute of Health and Welfare framework.

RESULTS

During 2016, 126 of 652 suicides (19.3%, 95% confidence intervals 16.4-22.6) were flagged as showing evidence of CALD. The two most frequent CALD indicators for which information was recorded were country of birth and year of arrival. There was less information pertaining to citizenship, residency/visa status, preferred language, English language proficiency and religious affiliation.

CONCLUSIONS

This study demonstrates that the VSR, like other databases, has substantial gaps in availability and quality of CALD data.

IMPLICATIONS

A framework to capture richer data on cultural, religious and linguistic diversity when coding suicides is needed to inform policy on suicide prevention initiatives designed for CALD communities.

Structural intervention at one bridge decreases the overall jumping suicide rate in Victoria, Australia

AIMS

There is clear evidence that installing safety barriers is effective in preventing jumping suicides from high-risk bridges with only moderate displacement to other nearby bridges. However, the impact of barriers on jumping suicides across broader geographical areas is not well understood. We examined patterns in jumping suicides across the state of Victoria, Australia, after a safety barrier was installed at the West Gate Bridge which, before the installation of the barrier, was the site of approximately 40% of Victoria's jumping suicides.

METHODS

We used negative binomial regression analyses on Victorian data from 2000 to 2019 to compare rates of jumping suicides at the West Gate Bridge, other bridges and non-bridge jumping locations before, during and after the West Gate Bridge barrier installation. We conducted linear regression analyses to examine whether the distance travelled from the deceased's usual residence to the location of their jumping suicide changed between the before, during and after barrier installation periods.

RESULTS

After installation of the barrier, there were no jumping suicides at the West Gate Bridge (rate ratio [RR] = 0.00, 95% credible intervals [95% Cr] = 0.00-0.0001) and there was strong evidence that the rate of jumping suicides at all locations declined by 65% (RR = 0.35, 95% Cr = 0.22-0.54). At other bridges, there was also evidence of a reduction (RR = 0.31, 95% Cr = 0.11-0.70), but there was no evidence of a change at non-bridge locations (RR = 0.74, 95% Cr = 0.39-1.30).

CONCLUSION

After installation of the safety barrier at the West Gate Bridge, jumping suicide in Victoria decreased overall and at other bridges, and did not appear to change at non-bridge locations. Our findings show that when barriers are installed at a site responsible for a disproportionately high number of jumping suicides, they are not only highly effective at the site where the barriers are installed but can also have a prevention impact beyond the immediate locale at similar sites.

Family violence homicide rates: a state-wide comparison of three data sources in Victoria, Australia

BACKGROUND

Family violence homicide (FVH) is a major public health and social problem in Australia. FVH trend rates are key outcomes that determine the effectiveness of current management practices and policy directions. Data source-related methodological problems affect FVH research and policy and the reliable measurement of homicide trends.

OBJECTIVE

This study aimed to determine data reliability and temporal trends of Victorian FVH rates and sex and relationship patterns.

METHOD

FVH rates per 100,000 persons in Victoria were compared between the National Coronial Information System (NCIS), Coroners Court of Victoria (CCoV) Homicide Register, and the National Homicide Monitoring Program (NHMP). Trends for 2001-2017 were analysed using Joinpoint regression. Crude rates were determined by sex and relationship categories using annual frequencies and Australian Bureau of Statistics population estimates.

RESULTS

NCIS closed FVH cases totalled 360, and an apparent downward trend in the FVH rate was identified. However, CCoV and NHMP rates trended upwards. While NCIS and CCoV were case-based, NHMP was incident-based, contributing to rate variations. The NCIS-derived trend was particularly impacted by unavailable case data, potential coding errors and entry backlog. Neither CCoV nor NHMP provided victim-age in their public domain data to enable age-adjusted rate comparison.

CONCLUSION

Current datasets have limitations for FVH trend determination; most notably lag times for NCIS data.

IMPLICATIONS

This study identified an indicative upward trend in FVH rates in Victoria, suggesting insufficiency of current management and policy settings for its prevention and control.

It Is Official, They Are Different - Discrepancies Between National Statistical Agency and Register-Based State Suicide Mortality Statistics in Australia

Background: In Australia, most state-based suicide registers now publicly release suicide mortality data alongside those the Australian Bureau of Statistics (ABS) releases annually. Aims: This study compared ABS's recorded suicides with three state-based suicide registers (Queensland, Victoria, and Tasmania). We compared their case definitions and coding approaches to assist users in choosing the most suitable data source and interpret differences between sources. Method: We collated the number of suicides by year of registration and occurrence (2006-2020). We compared the scope and coding of suicides between ABS and the registers using publicly available suicide reports and data releases. Results: The ABS's annual suicide numbers are similar to (and in Tasmania exceed) the numbers reported by state-based registers. The ABS year of occurrence data diverges substantially from the Victoria and Queensland register data in 2020, perhaps attributable to ongoing ABS revision processes. Minimal overlap exists between the case definitions and coding practices of the ABS and registers. Limitations: This is not an individual-level concordance study. Conclusion: Despite different case definitions and coding practices, the two sources produced largely consistent data. They have complementary strengths: timeliness (suicide register data) and enabling cross-jurisdictional comparisons (ABS data).

Identification of young females at high risk of suicide following hospital-treated self-harm in Victoria, Australia

OBJECTIVE

We conducted a data linkage study in Victoria, Australia, to determine the proportion of young females who are treated in hospital for self-harm who go on to die by suicide within 5 years and to identify factors associated with increased suicide risk in this same cohort.

METHOD

We undertook a cohort study following 3689 female patients aged 10-24 years, who were initially treated in hospital for self-harm during the 2-year period January 2011 to December 2012. We followed each patient for 5 years unless they died first, in which case, they were followed until their date of death. We used inpatient admissions from the Victorian Admitted Episodes Dataset and emergency department presentations from the Victorian Emergency Minimum Dataset linked to death data from two sources, the Victorian Suicide Register and the National Death Index.

RESULTS

Twenty-eight individuals (0.76% of the total cohort) died by suicide within 5 years of their index admission. In multivariate survival analysis, only suicide ideation at the time of self-harm (hazard ratio = 4.59; 95% confidence interval: 1.70, 12.38) and a decreasing time between successive self-harm episodes (hazard ratio = 4.38; 95% confidence interval: 1.28, 15.00) were associated with increased suicide risk.

CONCLUSION

Although the vast majority of young females who present to hospital for self-harm do not die by suicide within 5 years, our results suggest young females expressing suicide ideation and those presenting frequently with decreasing time between successive episodes should be prioritised for suicide-prevention efforts.

Police-led real-time surveillance system for suspected suicides in Great Britain

It has become increasingly apparent that rapidly available information about the occurrence of suicides is needed, particularly to support suicide prevention efforts. Concerns about the potential impact of the COVID-19 pandemic on vulnerability to suicide highlighted the need for such early data internationally. Here, we set out the nature, current status and content of a real-time suicide monitoring system in Great Britain (England, Scotland and Wales), and explore its potential to contribute to timely and targeted suicide prevention initiatives. We also discuss the challenges to successful implementation.

Stakeholder insights into implementing a systems-based suicide prevention program in regional and rural tasmanian communities

PURPOSE

With emerging evidence indicating that systems-based approaches help optimise suicide prevention efforts, the National Suicide Prevention Trial sought to gather evidence on the appropriateness of these approaches to prevent suicide among at-risk populations, in regional and rural communities throughout Australia. The Tasmanian component of the Trial implemented the LifeSpan systems framework across three distinct rural areas with priority populations of men aged 40-64 and people 65 and over. The University of Tasmania's Centre for Rural Health undertook a local-level evaluation of the Trial.

AIMS

To explore key stakeholder perceptions of implementing a systems-based suicide prevention program in regional and rural communities in Tasmania, Australia.

METHOD

This study utilised qualitative methods to explore in depth, stakeholder perspectives. Focus groups and interviews were conducted with 46 participants, comprising Trial Site Working Group members (n = 25), Tasmania's Primary Health Network employees (n = 7), and other key stakeholders (n = 14). Approximately half of participants had a lived experience of suicide. Data were thematically analysed using NVivo.

RESULTS

Key themes centred on factors impacting implementation of the Trial. These included how the Trial was established in Tasmania; Working Group governance structures and processes; communication and engagement processes; reaching priority population groups; the LifeSpan model and activity development; and the effectiveness, reach and sustainability of activities.

DISCUSSION

Communities were acutely aware of the need to address suicide in their communities, with the Trial providing resources and coordination needed for community engagement and action. Strict adherence to the Lifespan model was challenging at the community level, with planning and time needed to focus on strategies influencing whole or multiple systems, for example health system changes, means restriction. Perceived limitations around implementation concerned varied community buy-in and stakeholder engagement and involvement, with lack of role clarity cited as a barrier to implementation within Working Groups. Barriers delivering activities to priority population groups centred around socio-cultural and technological factors, literacy, and levels of public awareness. Working Groups preferred activities which build on available capital and resources and which meet the perceived needs within the whole community. Approaches sought to increase awareness of suicide and its prevention, relationships and partnerships, and the lived experience capacity in Working Groups and communities.

CONCLUSION

Stakeholder insights of implementing the National Suicide Prevention Trial in regional and rural Tasmanian from this study can help guide future community-based suicide prevention efforts, in similar geographic areas and with high-risk groups.

Identifying Points of Prevention in Firearm-Related Suicides: A Mixed-Methods Study Based on Coronial Records

PURPOSE

Firearm-related suicide is a noteworthy and preventable public health issue that has drawn limited attention in Australian research. Firearms are highly lethal and remain in the top three methods of suicide among Australian males. This study examines suicides occurring in Tasmania, the jurisdiction with the highest rate of firearm-related suicide, with the aim of aiding suicide prevention strategies.

METHODS

A mixed-methods approach was used to analyze data from the Tasmanian Suicide Register. The quantitative analysis examined socio-demographic factors, substance use, physical and mental health, and access to services for suicides occurring between January 1, 2012 and December 31, 2016. The qualitative analysis comprised firearm-related suicides occurring between January 1, 2012 and December 31, 2017.

RESULTS

Firearms users were more likely than those employing other means of suicide to be male, retired, and residing in remote areas but were less likely to have had a previous mental illness diagnosis or evidence of suicidal ideation or self-harming behaviors. There was some evidence of increased impulsiveness among firearm users. We found 54% of decedents were licensed to own a firearm at the time of death. Firearms most often belonged to the decedent (52%) and 26% sourced a firearm from family or friends. Only 58% of cases involved a firearm with a dedicated storage facility.

CONCLUSIONS

Prevention efforts need to take into account the unique profiles of those at risk of firearm-related suicide. Impulsiveness and the varying levels of adherence to firearms safety practices point to the need for strategies that limit physical access to firearms.HIGHLIGHTSFirearms-related suicides have a unique risk profile compared with other means of suicide.Mental illness diagnosis, suicidal thoughts, and self-harming behaviors were less commonly identified among firearms-related suicides than other means of suicide.Impulsiveness and the varying levels of adherence to firearms safety practices point to the need for strategies that limit physical access to firearms.

Evaluation of a System for Real-Time Surveillance of Suicide in England

Background: Access to timely data on suicide is crucial to support suicide prevention. A real-time suicide surveillance (RTSS) system enables public health teams and allied agencies to review information following suicides promptly and take action quickly. Aims: The aim of this paper was to report on an evaluation of an RTSS system in South Yorkshire, England. Method: The system was reviewed, and outcome data were analyzed for 2019 and 2020 based on recorded suspected suicides, a stakeholder focus group, evaluation of postvention bereavement service outcomes, and lessons learned. Results: The benefits of RTSS included rapid response to emerging trends, identifying clusters, effective bereavement support, information to inform measures to mitigate risk, and supporting evaluation of interventions. The challenges faced included limited resources, data quality, consistency across places, and linkages with coronial processes. Limitations: This was an evaluation of one RTSS system based on routinely collected data covering one area, South Yorkshire, and hence some data limitations, and direct comparison with other services or against a control group was not possible. Conclusion: The RTSS system has led to better support for suicidal people and a responsive, timely, and effective service for those bereaved by suicide, all of which are likely to lead to enhanced well-being and community resilience.

Suicide following hospital admission for mental health conditions, physical illness, injury and intentional self-harm in Victoria, Australia

Objective

The majority of suicide decedents have had contact with health services close to their death. Some of these contacts include admissions to hospitals for physical and mental health conditions, injury and intentional self-harm. This study aims to establish and quantify the risks of suicide following hospital admission for a range of mental and physical illnesses.

Methods

A retrospective analysis was carried out on existing morbidity and mortality data in Victoria. Data was extracted from the Victorian Admitted Episodes Dataset and the Victorian Suicide Register. Unplanned hospital admissions among adult patients (> = 15 years of age), discharged between 01 January 2011 and 31 December 2016 (2,430,154 admissions), were selected. Standardised Mortality Ratios were calculated for conditions with at least five linked suicides within one year of discharge from hospital.

Results

Forty-three conditions defined at the three-digit level of the International Statistical Classification of Diseases and Related Health Problems 10th Revision, were associated with at least five subsequent suicides (within one year of hospital discharge); 14 physical illnesses, 5 symptoms, signs and abnormal clinical and laboratory findings, 12 mental health conditions, and 12 types of injury and poisonings. The highest Standardised Mortality Ratios were for poisonings (range; 27.8 to 140.0) and intentional self-harm (78.8), followed by mental health conditions (range; 15.5 to 72.9), symptoms, signs and abnormal clinical and laboratory findings (range; 1.4 to 43.2) and physical illnesses (range; 0.7 to 4.9).

Conclusions

Hospital admissions related to mental health conditions and injury and poisonings including self-harm were associated with a greater risk of suicide than physical conditions. Mental health conditions such as depressive episodes, personality disorders and psychotic episodes, injuries caused by intentional-self-harm and poisonings by certain types of drugs, carbon monoxide and hormones such as insulin can be prioritised for targeting suicide prevention initiatives for persons discharged from hospitals.

Preventing railway suicides through level crossing removal: a multiple-arm pre-post study design in Victoria, Australia

PURPOSE

Rail level crossing removals to improve transport performance across metropolitan Melbourne (state of Victoria) resulted in new rail fencing and grade-separation of tracks from the surrounding environment at several sites. These design changes restricted pedestrian access to the rail tracks, which is a countermeasure known to prevent railway suicide in other settings. We examined whether any such suicide prevention effect followed the removals.

METHODS

We used a multiple-arm pre-post design to test whether a decrease in monthly frequency of railway suicides occurred at level crossing removal sites (intervention sites), compared to randomly matched sites where level crossings had not yet been removed (control sites). We used data available in the Victorian Suicide Register covering the period 1st January 2008 to 30th June 2021.

RESULTS

The mean monthly number of railway suicides decreased by 68% within a 500 m radius of intervention sites (RR: 0.32; CI 95% 0.11-0.74) and by 61% within a 1000 m radius of intervention sites (RR: 0.39; CI 95% 0.21-0.68). There was no evidence that the mean monthly number of railway suicides changed at the control sites, either within a 500 m radius (RR: 0.88; CI 95% 0.47-1.56) or a 1000 m radius (RR: 0.82; CI 95% 0.52-1.26).

CONCLUSION

The reduction in railway suicides at locations where level crossings were removed, demonstrates the suicide prevention benefits that can be derived from a major infrastructure project even if not initially intended. Planning for major infrastructure projects should include consideration of these benefits, with designs incorporating features to maximise suicide prevention impact.

Suicide among those who use mental health services: Suicide risk factors as evidenced from contact-based characteristics in Victoria

OBJECTIVE

The majority of suicide decedents have had contact with health services in the months before their death. Contacts for mental health services present potential suicide prevention opportunities. This study aims to compare contact-based characteristics among suicide decedents and living controls in the year subsequent to clinical mental health contact with the public health system in Victoria, Australia.

METHODS

A population-based nested case-control study of those who had mental health-related hospital and community contacts with the public health system was conducted. Cases (suicide decedents) were age and gender-matched to living controls (suicide non-decedents). These records were linked to records of suicides that occurred in the 12 months following the health service contact, between January 1, 2011, and December 31, 2016. Victorian residents aged 10 years and above were selected at the time of contact (483,933 clients). In the study population, conditional logistic regression models were used to assess the relationship between contact-based characteristics and suicide. Socio-demographics and mental health-related hospital and community contact data was retrieved from the Victorian Admitted Episodes Dataset, the Victorian Emergency Minimum Dataset and the Public Clinical Mental Health database and suicide data from the Victorian Suicide Register.

RESULTS

During a six-year period, 1,091 suicide decedents had at least one mental health contact with the public health system in the 12 months preceding the suicide. Overall, controls used more mental health services than cases; however, cases used more mental health services near the event. The relationship between the type of service and suicide differed by service type: hospital admissions and emergency department presentations had a significant positive association with suicide with an OR of 2.09 (95% CI 1.82-2.40) and OR of 1.13 (95% CI 1.05-1.22), and the effect size increased as the event approached, whereas community contacts had a significant negative association with an OR of 0.93 (95% CI 0.92-0.94), this negative association diminished in magnitude as the event approached (OR∼1).

CONCLUSION

Suicide decedents had less contact with mental health services than non-decedents; however, evidence suggests suicide decedents reach out to mental health services proximal to suicide. An increase in mental health service contact by an individual could be an indication of suicide risk and therefore an opportunity for intervention. Further, community level contact should be further explored as a possible prevention mechanism considering the majority of suicide decedents do not access the public clinical mental health services.

Rural suicide risk and physical ill health: A qualitative study of the Victorian Suicide Register, 2009-2015

OBJECTIVE

To gain new insight into contextual factors shaping how physical ill health acts as a stressor in rural suicides-informing the development of appropriate targeted interventions.

DESIGN

Retrospective cohort study.

SETTING

Non-metropolitan Victoria, Australia.

SAMPLE

802 rural (non-metropolitan) suicide deaths between the years 2009 and 2015.

MAIN OUTCOME MEASURE

Qualitative data from the Victorian Suicide Register relating to physical ill health of suicide decedents.

RESULTS

Thematic analysis identified 4 themes: (a) 'living with physical ill health in a rural area' highlights both practical and cultural challenges associated with managing physical ill health within the context of life in a rural setting; (b) 'causes and experience of chronic pain' highlights rural risk factors for chronic pain, how pain was experienced and treatment managed; (c) 'when living an independent, contributing life is no longer possible' describes the debilitating physical and mental outcomes of chronic ill health and pain; and (d) 'the cumulative impact of physical ill health and other factors on suicide risk' highlights the complexity of risk factors-in combination with (or as a result of) physical ill health-that contribute to a suicide death.

CONCLUSION

Identified themes suggest pathways to improve understanding and support for those experiencing physical ill health and associated suicide risk. These supports include contextually and culturally appropriate rural services to provide effective and necessary treatment, pain relief and mental health support; acknowledgement and response to a culture of alcohol misuse as an (ultimately ineffective) coping strategy; proactive psychosocial support mechanisms; and alternative approaches to support including consideration of innovative peer support models.

COVID-19 as a context in suicide: early insights from Victoria, Australia

OBJECTIVE

To examine how the coronavirus (COVID-19) pandemic and its consequences may have influenced suicide in Victoria, Australia.

METHODS

A mixed methods study of consecutive Victorian suicide cases spanning 1 January 2015 to 31 January 2021. Interrupted time series analysis examined whether suicide frequency changed following the pandemic onset. Thematic analysis was undertaken of police reports in suicides linked with COVID-19 to try to understand how COVID-19 acted as a stressor.

RESULTS

The frequency of Victorian suicides did not change following the onset of COVID-19. Sixty COVID-linked suicides were identified, featuring three recurring themes: COVID-19 as a disturbance in the self, in relationships with others and institutions.

CONCLUSIONS

While COVID-19 has not led to an increase in Victorian suicide frequency to date, it is an important background stressor that can erode one's wellbeing, sense of agency and connectedness to others. Implications for public health: Clinical interventions that serve to reconnect people with a sense of agency and seek to re-establish contact with significant others are indicated. Clinicians should ensure they are familiar with pathways for their patients to access government social and economic supports. A better understanding of how government interventions may be lessening psychological distress is needed.

Sociodemographic characteristics associated with hospital contact in the year prior to suicide: A data linkage cohort study in Victoria, Australia

Aims

The aims of this study were to examine the prevalence of hospital contact in the year prior to suicide in Victoria, Australia, and to compare characteristics among those who did and did not have contact in the year prior to suicide.

Methods

The study was a data linkage cohort study of 4348 Victorians who died by suicide over the period 2011–2017. Data from the Victorian Suicide Register (VSR) was linked with hospital separations and Emergency Department (ED) presentations datasets by the Centre for Victorian Data Linkages (CVDL). The main outcomes were: (1) hospital contact for any reason, (2) hospital contact for mental-health-related reasons, and (3) hospital contact for intentional self-harm. Unadjusted and adjusted odds ratios were calculated as the measures of association.

Results

In the year prior to suicide, half of the decedents (50.0%) had hospital contact for any reason (n = 2172), 28.6% had mental-health-related hospital contact (n = 1244) and 9.9% had hospital contact for intentional self-harm (n = 432).

In the year prior to suicide, when compared with males aged 25–49 years (the reference group):

males aged 75+ years and females of all ages were significantly more likely to have hospital contact for any reason

females aged 10–24 years and 25–49 years were significantly more likely to have mental-health-related hospital contact

females aged 10–24 years and 25–49 years had 3.5 times and 2.4 times the odds of having hospital contact for intentional self-harm.

Conclusions

The comparatively high proportion of female decedents with mental-health related hospital contact in the year prior to suicide suggests improving the quality of care for those seeking help is an essential prevention initiative; this could be explored through programs such as the assertive outreach trials currently being implemented in Victoria and elsewhere in Australia. However, the sizeable proportion of males who do not have contact in the year prior to suicide was a consistent finding and represents a challenge for suicide prevention. Programs to identify males at risk in the community and engage them in the health care system are essential. In addition, promising universal and selective interventions to reduce suicide in the cohort who do not have hospital contact, include restricting access to lethal means and other public health interventions are also needed.

Patterns of Suicide in the Context of COVID-19: Evidence From Three Australian States

Aims: We aimed to determine whether there has been a change in the number of suicides occurring in three Australian states overall, and in age and sex subgroups, since the COVID-19 pandemic began, and to see if certain risk factors for suicide have become more prominent as likely underlying contributing factors for suicide. Method: Using real-time data from three state-based suicide registers, we ran multiple unadjusted and adjusted interrupted time series analyses to see if trends in monthly suicide counts changed after the pandemic began and whether there had been an increase in suicides where relationship breakdown, financial stressors, unemployment and homelessness were recorded. Results: Compared with the period before COVID-19, during the COVID-19 period there was no change in the number of suicides overall, or in any stratum-specific estimates except one. The exception was an increase in the number of young males who died by suicide in the COVID-19 period (adjusted RR 1.89 [95% CI 1.11-3.23]). The unadjusted analysis showed significant differences in suicide in the context of unemployment and relationship breakdown during the COVID-19 compared to the pre-COVID-19 period. Analysis showed an increase in the number of suicides occurring in the context of unemployment in the COVID-19 period (unadjusted RR 1.53 [95% CI 1.18-1.96]). In contrast, there was a decrease in the number of suicides occurring in the context of relationship breakdown in the COVID-19 period (unadjusted RR 0.82 [95% CI 0.67-0.99]). However, no significant changes were identified when the models were adjusted for possible over-dispersion, seasonality and non-linear trend. Conclusion: Although our analysis found no evidence of an overall increase in suicides after the pandemic began, the picture is complex. The identified increase in suicide in young men indicates that the impact of the pandemic is likely unevenly distributed across populations. The increase in suicides in the context of unemployment reinforces the vital need for mitigation measures during COVID-19, and for ongoing monitoring of suicide as the pandemic continues.

Understanding the Context of Suicides by Older Men Compared With Younger Old Men and Women

Background: The rate of suicide among men aged 85 years or older is the highest of any age or gender group in many countries, but little is known about their pathways to suicide. Aims: This study aimed to determine the context of suicide by men aged 85 years or older. Method: Data were extracted from the Victorian Suicide Register regarding suicide deaths between 2009 and 2015. Chi-squared test or Fisher's exact test was used to compare old men (65-84 years old) and older men (85 years or more), and old women and old men (both 65 years or more). Results: The context of suicide by older men differed significantly from that of old men, as did that of old men compared with old women, on variables related to suicidal behavior and intention, mental illness, mental health treatment, and life stressors. Limitations: The study is limited by the small numbers of deaths by suicide in this age group in Victoria. Conclusion: The context of suicide by older and old men is different from that of old men and old women, respectively. More research is needed to understand the pathways to suicide by older men.

Coroners' investigations of suicide in Australia: The hidden toll of borderline personality disorder

Borderline Personality Disorder (BPD) is associated with a high risk of death by suicide. Our study describes a population-based analysis of Coroners' investigations of suicides where there was evidence of a BPD diagnosis. We utilised the Victorian Suicide Register to identify suicides occurring between 2009 and 2013 where evidence of a BPD diagnosis was recorded. Of the 2870 suicides during this period, 181 (6.3%) had a BPD diagnosis recorded. Evidence of other diagnosed personality disorders was recorded in an additional 14 (0.5%) suicides and BPD was suspected in another 72 (2.5%) suicides. Information coded in the 181 diagnosed BPD suicides was compared with the 2689 suicides without a BPD diagnosis. Compared to the 'no BPD suicide group', the 'BPD suicide group' was younger, comprised a smaller proportion of women, had greater diagnostic complexity, a higher proportion of death by drug overdose, and a higher proportion of social and contextual stressors. 99% of people with a BPD diagnosis who died from suicide had contact with emergency and mental health services within 12 months of death; 88% sought help from these services within 6 weeks of death. These findings demonstrate the magnitude of this most severe outcome of mental illness, confirming that BPD belongs in the same category as schizophrenia, bipolar disorder and depressive disorder with respect to suicide representation. The help-seeking behaviours evident in almost all cases highlight a critical window of opportunity for providing timely support and treatment to help avert future deaths.

Identifying Typologies of Persons Who Died by Suicide: Characterizing Suicide in Victoria, Australia

The objective of the study was to determine whether people who died by suicide form groups based on demographic, psychosocial, mental and physical health factors and exposure to stressors. A retrospective case series review of 2,839 individuals who died by suicide in Victoria, Australia over the period 2009-2013 was conducted. A two-stage cluster analysis was performed. Diagnosis of mental illness was present in 52% of cases and initial cluster analysis determined two groups with the main predictor of group membership being the presence of diagnosed mental illness. Further analysis identified four subgroups within the mental illness group and two within the non-mental illness group. The study demonstrates that suicide does not always occur in the context of mental illness; people who die by suicide cannot be considered a homogenous group.

Characteristics of patients with cancer who die by suicide: Coronial case series in an Australian state

OBJECTIVE

Suicide rates are elevated in epidemiological studies, but extrapolating population level data to the individual patient cancer is difficult, and there is a dearth of studies examining how suicidality might be linked to the cancer experience. We examine the cancer-suicide correlates to explore clinical implications and future research directions.

METHOD

We used a novel database to examine all suicide deaths reported to the Coroners Court of Victoria between 2009 and 2013 in individuals with active, diagnosed cancer. Cases were classified in relation to whether cancer had been a probable, possible, or unlikely influence on suicidal ideation. Sociodemographic, clinical, health service contacts, and suicide method data were analysed to describe the characteristics of individuals with cancer at the time of their suicide.

RESULTS

There were 2870 suicide deaths, and 118 cases met inclusion criteria. Clinically distinct patient subgroups emerged through a contrast between those cases where the data suggested a correlate between cancer and suicide, and those where the data did not. The former group had many more cancer-related health problems than the latter group, who had a higher burden of psychiatric illness that predated their cancer diagnosis. The intent to suicide was known to most clinicians.

CONCLUSIONS

All clinicians working with cancer patients should be prepared to explore suicidal ideation. Understanding how the patient conceptualises suicidality with respect to cancer experience and mental health may be of central importance in determining whether mental health care is best provided as part of cancer care, or through a separate mental health service.

Pathways to Suicide Among People With a Diagnosed Mental Illness in Victoria, Australia

Background: People who have mental illness are at increased risk of suicide. Therefore, identifying "typical" trajectories to suicide in this population has the potential to improve the effectiveness of suicide prevention strategies. Aim: The aim of this study was to explore the pathways to suicide among a sample of Victorians with a diagnosed mental illness. Method: Victorian Suicide Register (VSR) data were used to generate life charts and identify typical life trajectories to suicide among 50 Victorians. Results: Two distinct pathways to suicide were identified: (1) where diagnosis of mental illness appeared to follow life events/stressors; and (2) where diagnosis appeared to precede exposure to life events/stressors. Some events acted as distal factors related to suicide, other events were more common as proximal factors, and still others appeared to act as both distal and proximal factors. Limitations: The data source might be biased because of the potential for incomplete information, or alternatively, the importance of some factors in a person's life may have been overstated. Conclusion: Strategies to reduce suicide need to consider the chronology of exposure to stressors in people's lives and clearly need to be different depending on whether proximal or distal risk factors are the target of a given strategy or intervention.

Relative risk of suicide following exposure to recent stressors, Victoria, Australia

OBJECTIVE

This study aimed to identify stressors over-represented in the 12 months prior to death among 553 Victorian adults who died by suicide.

METHODS

Age- and sex-specific suicide rates and relative risks of suicide were calculated using numerator data on suicides occurring in 2013 by people with a given exposure sourced from the Victorian Suicide Register and denominator data on the total Victorian population with that exposure sourced from the 2014 Australian Bureau of Statistics General Social Survey.

RESULTS

Mental illness was associated with increased suicide risk among people of all age groups and both sexes. Alcohol and/or other drug problems were associated with increased risk for males and females of all ages, with the exceptions of the oldest males and females, and the youngest females. Trouble with the police was associated with increased risk among all but the oldest males, whereas among females it was associated with elevated risk in those aged 25-44 years and 65+ years. Conclusions and Implications for public health: Males experiencing mental illness and alcohol and other drug problems should be a particular priority for suicide prevention initiatives but people exposed to other stressors such as contact with the police and divorce/relationship separation also warrant attention.

Differences by age and sex in adolescent suicide

OBJECTIVES

To compare demographic and psychosocial characteristics of completed suicide between younger and older adolescents, and by sex.

METHODS

Data was collected from the Victorian Suicide Register, which contains information on suicides reported to the Coroners Court of Victoria.

RESULTS

Between 2006 and 2015, there were 273 completed suicides aged 10-19 years, with none aged 10-12 years. There were 171 (63%) suicides in the older adolescent group (17-19 years), and 102 (37%) in the younger group (13-16 years). Males comprised 184 cases (67%) and females 89 (33%). A higher proportion of both younger and female adolescents had experienced abuse, peer conflict and bullying. There was also a higher incidence of previous self-harm in younger and female adolescents. Older adolescents were more likely to not be in formal education, employment or training.

CONCLUSION

Suicide in younger adolescents and females appear to share characteristics, and differ from older and male adolescents. Negative interpersonal relationships and previous self-harm with possible co-existenting mental illness appear to be key differentiating features. Implications for public health: Understanding completed suicide is an important step towards prevention, and our results suggest a need for developmentally and sex-specific suicide prevention strategies.

Differences in Characteristics and Exposure to Stressors Between Persons With and Without Diagnosed Mental Illness Who Died by Suicide in Victoria, Australia

Background: Mental illness is an established risk factor for suicide. To develop effective prevention interventions and strategies, the demographic characteristics and stressors (other than, or in addition to, mental illness) that can influence a person's decision to die by suicide need to be identified. Aim: To examine cases of suicide by the presence or absence of a diagnosed mental illness (mental illness status) to identify differences in factors associated with suicide in the groups. Method: Logistic regression analyses were used to investigate mental illness status and exposure to stressors among 2,839 persons who died by suicide in Victoria, Australia (2009-2013), using the Victorian Suicide Register. Results: Females, metropolitan residents, persons treated for physical illness/injury, those exposed to stressors related to isolation, family, work, education, and substance use and those who had made a previous suicide attempt had increased odds of having a diagnosed mental illness. Employed persons had decreased odds of having a diagnosed mental illness. Limitations: The retrospectivity of data collection as well as the validity and reliability of some of the data may be questionable owing to the potential for recall bias. Conclusion: The point of intervention for suicide prevention cannot always be a mental health professional; some people who die by suicide either do not have a mental illness or have not sought help.