Volume 219 - Issue 2
Advancing our knowledge of people who die by suicide in order to improve suicide prevention
Authors: David M Lawrence and Barbara Sheil
Med J Aust 2023; 219 (2): 60-61. || doi: 10.5694/mja2.52011
Published online: 17 July 2023
Published online: 17 July 2023
Too many people with severe depression do not receive appropriate and timely support and care
With suicide rates high and burgeoning rates of self‐harm, suicide prevention is a key national priority. While there are many paths to wanting not to live, some common patterns have been identified. Most people who die by suicide have histories of mental health problems, most frequently depression, and many have repeatedly sought help prior to their deaths.1
This issue of the MJA includes the report by Chitty and colleagues2 on the ASHLi study, a review of Pharmaceutical Benefits Scheme (PBS) prescribing and post mortem toxicology for people who died by suicide. Their report provides insights into the prescribing and use of pharmaceuticals in the period immediately preceding suicide. The authors identified three main concerns: people with depression not being prescribed antidepressants; people with prescribed antidepressants not taking them; and people using stockpiled drugs for self‐harm. These findings provide concrete evidence for what has long been suspected: too many people with severe depression do not receive appropriate support and care.
The ASHLi study provides a unique opportunity to deepen our knowledge of suicide and to support prevention strategies with new information. Chitty and colleagues are to be commended for extending our knowledge of suicide in Australia by linking National Coronial Information System (NCIS) and PBS data.2 The NCIS provides detailed information about the nature and means of suicide deaths, but not on the reasons why a person no longer wanted to live, antecedent events, life challenges, and opportunities to provide support.3
The findings of Chitty and her colleagues confirm that many people have contact with support services prior to death by suicide, as most had current prescriptions at the time of death, often for antidepressants. One concern about which the analysed data provide no information is the proportion of people with severe depression who are prescribed antidepressants but do not also receive psychological therapies. People with mental illness and suicidal ideation, like others with mental illness, have problems gaining access to and receiving the support they need from a mental health system constantly under stress and inadequately resourced to meet the level of demand.4 The risks of suicidal ideation and behaviour in people who stop using prescribed antidepressants, particularly if they do so abruptly, are well known.5,6 But do we do enough to support people at risk by applying this knowledge? Antidepressants can play a role in treatment, but should be routinely combined with psychological therapies and psychosocial support.7
The broader ASHLi study will comprehensively track the health service and medicine use of people who die by suicide,8 including Medicare and community mental health services use. Analyses of the rich information acquired could serve as the basis for monitoring progress in ensuring that people at risk benefit from a consistent, timely, minimum standard of care.
Through our own experience in working with the Western Australian Coronial Suicide Information System, we are familiar with the many challenges associated with access to suicide‐related data for research, including legal and systemic barriers.9 All Australian states now have suicide registers, and routine linkage with health and other support services records could be used to map the interactions of people with service providers prior to death. Public support for suicide prevention is strong,10 but it has not been matched by institutional support for evidence‐based research in this area. Rapid advances in both electronic record systems and safe mechanisms for linking data while preserving individual privacy offer genuine opportunities to expand our knowledge of the pathways to suicide.
National commitment to suicide prevention should include facilitating data analysis to better understand the life circumstances and services used by people who attempt or die by suicide.11 The National Suicide and Self‐harm Monitoring System (NSSMS) is now tracking trends in self‐harm or suicide, advancing our understanding of phenomena that exact a high toll on too many families and communities.12 Not everyone contemplating suicide seeks help, but those who do should receive timely support. The NSSMS could further advance suicide prevention by monitoring progress in indicators such as quality of care provided to people in acute distress, including those with severe mental illness. National health care agreements could help this approach13 by establishing a systematic and coordinated data capture strategy that encompasses Medicare, the NCIS, and ASHLi. The NSSMS would be an ideal platform to monitor suicide and self‐harm and quality of care at the national level, and could be expanded to include other organisations that support people in times of crisis, such as the police.14
While the life circumstances that precede suicide are diverse, inadequacies in the mental health care system have been a contributing factor to suicide deaths for many years.15 Improving mental health care is an important suicide prevention strategy.16,17 The ASHLi authors have identified some clear areas of risk that should be monitored for progress in reducing the incidence of suicide.
Competing interests
No relevant disclosures.
References
- Stene‐Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: a systematic review of the literature from 2000 to 2017. Scand J Public Health 2019; 47: 9‐17.
- Chitty KM, Buckley NA, Lim J, et al. Psychotropic and other medicine use at time of death by suicide: a population‐level analysis of linked dispensing and forensic toxicology data. Med J Aust 2023; 219: 63‐69.
- Dunstan L. The National Coronial Information System: saving lives through the power of data. Australian Economic Review 2019; 52: 247‐254.
- Productivity Commission (Australian Government). Mental health: inquiry report. 16 Nov 2020. https://www.pc.gov.au/inquiries/completed/mental‐health/report (viewed May 2023).
- Palmer EG, Sornalingam S, Page L, Cooper M. Withdrawing from SSRI antidepressants: advice for primary care. Br J Gen Pract 2023; 73: 138‐140.
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- Chitty KM, Schumann JL, Schaffer A, et al. Australian Suicide Prevention using Health‐Linked Data (ASHLi): protocol for a population‐based case series study. BMJ Open 2020; 10: e038181.
- Government of Western Australia Education and Health Standing Committee. Learnings from the message stick: the report of the Inquiry into Aboriginal youth suicide in remote areas. Nov 2016. https://www.parliament.wa.gov.au/parliament/commit.nsf/(WebInquiries)/B7C324463C7E020A4825806E00050947?opendocument (viewed May 2023).
- Research!America. Public supports research to prevent suicide prevention [blog]. 10 Sept 2019. https://www.researchamerica.org/blog/public‐supports‐research‐to‐prevent‐suicide (viewed May 2023).
- Council of Australian Governments Health Council. The fifth national mental health and suicide prevention plan. Aug 2017. https://www.mentalhealthcommission.gov.au/Monitoring‐and‐Reporting/Fifth‐Plan (viewed May 2023).
- Australian Institute of Health and Welfare. Suicide and self‐harm monitoring. Updated 20 Mar 2023. https://www.aihw.gov.au/suicide‐self‐harm‐monitoring/data/suicide‐self‐harm‐monitoring‐data (viewed May 2023).
- Council of Australian Governments. National mental health and suicide prevention agreement. Feb 2022. https://federalfinancialrelations.gov.au/sites/federalfinancialrelations.gov.au/files/2022‐05/nmh_suicide_prevention_agreement.pdf (viewed May 2023).
- McPhee R, Carlin E, Seear K, et al. Unacceptably high: an audit of Kimberley self‐harm data 2014–2018. Australas Psychiatry 2022; 30: 70‐73.
- Stokes B. Review of the admission or referral to and the discharge and transfer practices of public mental health facilities/services in Western Australia. 14 Nov 2012. https://www.health.wa.gov.au/Reports‐and‐publications/Review‐of‐the‐admission‐referral‐and‐discharge‐transfer‐practices‐of‐public‐mental‐health‐facilities (viewed May 2023).
- van der Feltz‐Cornelis CM, Sarchiapone M, Postuvan V, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis 2011; 32: 319‐333.
- Krysinska K, Batterham PJ, Tye M, et al. Best strategies for reducing the suicide rate in Australia. Aust N Z J Psychiatry 2016; 50: 115‐118.
Provenance: Commissioned; not externally peer reviewed.