Jane Pirkis

Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing

Objectives: To provide an overview of 12 month rates of service use for mental health problems and mental disorders by the general Australian adult population. Method: Data came from the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB), a nationally representative household survey of 8841 individuals aged between 16 and 85 years. Results: Overall, 11.9% of the general Australian adult population made use of any services for mental health problems in a 12 month period. Approximately one-third of people (34.9%) meeting criteria for a mental disorder did so. Female subjects with mental disorders were more likely to use services than male subjects (40.7% vs 27.5%). People in the youngest age group made relatively less use of services than older adults. Those with affective disorders were most likely to make use of services (58.6%), followed by those with anxiety (37.8%) and substance use disorders (24.0%), respectively. Mental health hospitalizations were less common than consultations with community-based providers (2.6%), whereas 34.6% consulted a community-based provider – particularly general practitioners (24.7%) and psychologists (13.2%). There was a clear dose-response effect between severity of disorders and rates of community-based service use: 63.5% of those with severe mental disorders used community-based services, compared with 40.2% and 17.7% of those with moderate and mild mental disorders, respectively. There was also a relationship between comorbidity of mental disorders and service use. Conclusions: Rates of service use for mental health problems among those with mental disorders in Australia are less than optimal. Little international guidance is available regarding appropriate levels of treatment coverage and other comparable countries face similar difficulties. Further work is required to determine what an appropriate rate of service use is, and to set targets to reach that rate. Australia has demonstrated that concerted policy efforts can improve rates of service use. These efforts should be expanded.

Suicidal ideation and suicide attempts among Australian adults.

Too little is known about suicidal thoughts and behaviors at a population level to recommend appropriate preventive strategies. Using data from the Australian National Survey of Mental Health and Wellbeing (NSMHWB), this study examined rates of, and risk factors for, suicidal ideation and suicide attempts. For 10,641 respondents, the 12-month and lifetime cumulative incidence rates of suicidal ideation were 3.4% and 16.0%, respectively; the 12-month and lifetime cumulative incidence rates of suicide attempts were 0.4% and 3.6%, respectively. 12-month ideation was associated with anxiety disorders (relative risk ratio [RRR] = 3.51; population attributable risk percent [PAR%] = 19.6%), affective disorders (RRR = 11.94; PAR% = 38.8%) and substance abuse disorders (RRR = 1.85; PAR% = 6.1%). Attempts in the past 12 months were also associated with anxiety disorders (RRR = 7.06; PAR% = 37.0%), affective disorders (RRR = 12.24; PAR% = 39.5%), and substance abuse disorders (RRR = 2.09; PAR% = 7.7%). Age, marital status, and disability were associated with ideation; marital status and employment status with attempts. Approximately 12% of ideators in the sample progressed to making an attempt; employment status was the only significant predictor. Reducing suicidal ideation and attempts requires a multi-faceted approach that targets those with mental illness but also adopts population-based strategies that address other factors, such as unemployment.

Suicide in developing countries (2): risk factors.

The majority of studies on risk factors for suicide have been conducted in developed countries, and less work has been done to systematically profile risk factors in developing countries. The current paper presents a selective review of sociodemographic, clinical, and environmental/situational risk factors in developing countries. Taken together, the evidence suggests that the profiles of risk factors in developing countries demonstrate some differences from those in developed countries. In some developing countries, at least, being female, living in a rural area, and holding religious beliefs that sanction suicide may be of more relevance to suicide risk than these factors are in developed countries. Conversely, being single or having a history of mental illness may be of less relevance. Risk factors that appear to be universal include youth or old age, low socioeconomic standing, substance use, and previous suicide attempts. Recent stressful life events play a role in both developing and developed countries, although their nature may differ (e.g., social change may have more of an influence in the former). Likewise, access to means heightens risk in both, but the specific means may vary (e.g., access to pesticides is of more relevance in developing countries). These findings have clear implications for suicide prevention, suggesting that preventive efforts that have shown promise in developed countries may need to be tailored differently to address the risk factor profile of developing countries.

Suicide in Developing Countries (1)

OBJECTIVE Suicide is a global public health problem, but relatively little epidemiological investigation of the phenomenon has occurred in developing countries. This paper aims to (1) examine the availability of rate data in developing countries, (2) provide a description of the frequency and distribution of suicide in those countries for which data are available, and (3) explore the relationship between country-level socioeconomic factors and suicide rates. It is accompanied by two companion papers that consider risk factors and preventive efforts associated with suicide in developing countries, respectively. METHOD Using World Health Organization data, we calculated the average annual male, female, and total suicide rates during the 1990s for individual countries and regions (classified according to the Human Development Index [HDI]), and examined the association between a range of socioeconomic indicators and suicide rates. RESULTS For reasons of data availability, we concentrated on medium HDI countries. Suicide rates in these countries were variable. They were generally comparable with those in high HDI countries from the same region, with some exceptions. High education levels, high telephone density, and high per capita levels of cigarette consumption were associated with high suicide rates; high levels of inequality were associated with low suicide rates. CONCLUSION Epidemiological investigations of this kind have the potential to inform suicide prevention efforts in developing countries, and should be encouraged.

Suicide and the media. Part I: Reportage in nonfictional media.

Numerous studies have considered the association between media reporting and portrayal of suicide and actual suicidal behavior or ideation. This review considered 42 studies that have examined the nonfiction media (newspapers, television, and books). Consideration was given to the extent to which inferences could be made about the relationship between portrayal of suicide in the given media and actual suicidal behavior in terms of: the strength of its association; and the extent to which it could be considered causal. The review demonstrated that there is an association between nonfictional media portrayal of suicide and actual suicide. The association satisfies sufficient of the criteria of consistency, strength, temporality, specificity and coherence for it to be deemed causal.

The Burden Attributable to Mental and Substance Use Disorders as Risk Factors for Suicide: Findings from the Global Burden of Disease Study 2010

Background The Global Burden of Disease Study 2010 (GBD 2010) identified mental and substance use disorders as the 5th leading contributor of burden in 2010, measured by disability adjusted life years (DALYs). This estimate was incomplete as it excluded burden resulting from the increased risk of suicide captured elsewhere in GBD 2010s mutually exclusive list of diseases and injuries. Here, we estimate suicide DALYs attributable to mental and substance use disorders. Methods Relative-risk estimates of suicide due to mental and substance use disorders and the global prevalence of each disorder were used to estimate population attributable fractions. These were adjusted for global differences in the proportion of suicide due to mental and substance use disorders compared to other causes then multiplied by suicide DALYs reported in GBD 2010 to estimate attributable DALYs (with 95% uncertainty). Results Mental and substance use disorders were responsible for 22.5 million (14.8–29.8 million) of the 36.2 million (26.5–44.3 million) DALYs allocated to suicide in 2010. Depression was responsible for the largest proportion of suicide DALYs (46.1% (28.0%–60.8%)) and anorexia nervosa the lowest (0.2% (0.02%–0.5%)). DALYs occurred throughout the lifespan, with the largest proportion found in Eastern Europe and Asia, and males aged 20–30 years. The inclusion of attributable suicide DALYs would have increased the overall burden of mental and substance use disorders (assigned to them in GBD 2010 as a direct cause) from 7.4% (6.2%–8.6%) to 8.3% (7.1%–9.6%) of global DALYs, and would have changed the global ranking from 5th to 3rd leading cause of burden. Conclusions Capturing the suicide burden attributable to mental and substance use disorders allows for more accurate estimates of burden. More consideration needs to be given to interventions targeted to populations with, or at risk for, mental and substance use disorders as an effective strategy for suicide prevention.

Factors associated with suicidal thoughts in a large community study of older adults.

BACKGROUND Thoughts about death and self-harm in old age have been commonly associated with the presence of depression, but other risk factors may also be important. AIMS To determine the independent association between suicidal ideation in later life and demographic, lifestyle, socioeconomic, psychiatric and medical factors. METHOD A cross-sectional study was conducted of a community-derived sample of 21 290 adults aged 60-101 years enrolled from Australian primary care practices. We considered that participants endorsing any of the four items of the Depressive Symptom Inventory -Suicidality Subscale were experiencing suicidal thoughts. We used standard procedures to collect demographic, lifestyle, psychosocial and clinical data. Anxiety and depressive symptoms were assessed with the Hospital Anxiety and Depression Scale. RESULTS The 2-week prevalence of suicidal ideation was 4.8%. Male gender, higher education, current smoking, living alone, poor social support, no religious practice, financial strain, childhood physical abuse, history of suicide in the family, past depression, current anxiety, depression or comorbid anxiety and depression, past suicide attempt, pain, poor self-perceived health and current use of antidepressants were independently associated with suicidal ideation. Poor social support was associated with a population attributable fraction of 38.0%, followed by history of depression (23.6%), concurrent anxiety and depression (19.7%), prevalent anxiety (15.1%), pain (13.7%) and no religious practice (11.4%). CONCLUSIONS Prevalent and past mood disorders seem to be valid targets for indicated interventions designed to reduce suicidal thoughts and behaviour. However, our data indicate that social disconnectedness and stress account for a larger proportion of cases than mood disorders. Should these associations prove to be causal, then interventions that succeeded in addressing these issues would contribute the most to reducing suicidal ideation and, possibly, suicidal behaviour in later life.

Assessing the value of existing recovery measures for routine use in Australian mental health services

Object: The concept of recovery has been recognized as important in the treatment of mental illness. A number of specific instruments exist which are designed to: (i) measure recovery at an individual level; and (ii) assess the recovery orientation of services. The current review aimed to identify these and evaluate their potential for routine use in Australian public sector mental health services. Method: We identified potential instruments by drawing on existing reviews, searching MEDLINE and PsycINFO, and consulting with experts. We used a hierarchical criterion-based approach to assess whether given instruments might be candidates for measuring recovery in the Australian context. Results: We identified 33 instruments: 22 designed to measure individuals’ recovery and 11 designed to assess the recovery orientation of services (or providers). Four of the former (Recovery Assessment Scale; Illness Management and Recovery Scales; Stages of Recovery Instrument; Recovery Process Inventory) and four of the latter (Recovery Oriented Systems Indicators Measure; Recovery Self Assessment; Recovery Oriented Practices Index; Recovery Promotion Fidelity Scale) were identified as promising candidates for routine use in Australian public sector mental health services. Conclusions: Further work is required, however, to determine which, if any, might best be used for this purpose; the possibility that modifications to existing instruments or the development of new instruments might be required should not be ruled out. It might be desirable to invest in two instruments: one designed to measure individuals’ recovery and one designed to measure the recovery orientation of services. If Australia were to go down this path, it would make sense to align indicators in each as far as possible, and to ensure that they were consistent with existing endeavours aimed at monitoring and improving recovery-focused aspects of service quality.

Suicidal thoughts and behaviours among Australian adults: findings from the 2007 National Survey of Mental Health and Wellbeing

Objectives: To provide an overview of the lifetime and 12 month prevalence of suicidal ideation, suicide plans and suicide attempts for Australian adults as a whole and for particular sociodemographic and clinical population subgroups, and to explore the health service use of people with suicidality. Method: Data came from the 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB), a nationally, representative household survey of 8841 individuals aged 16–85 years. Results: A total of 13.3% of respondents had suicidal ideation during their lifetime, 4.0% had made a suicide plan and 3.2% had made a suicide attempt. The equivalent 12 month prevalence rates were 2.3%, 0.6% and 0.4%, for ideation, plans and attempts, respectively. In general, suicidality in the previous 12 months tended to be relatively more common in women, younger people, those outside the labour force, and those with mental disorders; and less common in those who were married or in de facto relationships, and those with moderate levels of education. A number of the differences in prevalence rates between sociodemographic and clinical subgroups did not reach statistical significance due to data availability constraints and the conservative tests of significance that were used by necessity. These patterns warrant further exploration. Service use for mental health problems was higher among people with suicidality than it was among the general population, but significant numbers of those experiencing suicidality did not receive treatment. Conclusions: Suicidal thoughts and behaviours are not uncommon among the Australian adult population. These thoughts and behaviours are not only predictive of subsequent fatal suicidal acts, but are significant public health problems in their own right. They are associated with high levels of burden at an individual and societal level. Further analysis is required to assess the effectiveness of the national policy frameworks in reducing the spectrum of suicidal thoughts and behaviours.

Changes in suicide rates following media reports on celebrity suicide: a meta-analysis

Background A growing number of studies indicate that sensationalist reporting of suicide is associated with increases in suicide rates, but in the light of some negative findings, the issue has remained controversial. The aim of this study was to evaluate the best current evidence on the association between celebrity suicide stories and subsequent suicides. Methods Literature searches of six data sources (Medline, Psychlit, Communication Abstracts, Education Resources Information Center, Dissertation Abstracts and Australian Public Affairs Database (APAIS)) were conducted. Studies were included if they (1) adopted an ecological design, (2) focused on celebrity suicide, (3) had completed suicide as outcome variable, (4) analysed suicide rates across all suicide methods, (5) used data from after World War II and (6) satisfied basic quality criteria. Results 10 studies with totally 98 suicides by celebrities met the criteria. The pooled estimate indicated a change in suicide rates (suicides per 100 000 population) of 0.26 (95% CI 0.09 to 0.43) in the month after a celebrity suicide. There was substantial heterogeneity between studies, which was explained by the type of celebrity (entertainment elite vs others) and the region of study, as indicated by mixed-effects meta-regression. The region-of-study–specific effect of reporting a suicide by an entertainment celebrity was 0.64 (95% CI 0.55 to 0.73) in North America, 0.58 (95% CI 0.47 to 0.68) in Asia, 0.36 (95% CI −0.10 to 0.61) in Australia and 0.68 (95% CI 0.51 to 0.85) in Europe. There was no indication of publication bias. Conclusions Reports on celebrity suicide are associated with increases in suicides. Study region and celebrity type appear to have an impact on the effect size.