Dr Katie McGill

For more than a decade, suicide rates in Australia have shown no improvement despite significant investment in reforms to support regionally driven initiatives. Further recommended reforms by the Productivity Commission call for Federal and State and Territory Government funding for mental health to be pooled and new Regional Commissioning Authorities established to take responsibility for efficient and effective allocation of ¿taxpayer money.¿ This study explores the sufficiency of this recommendation in preventing ongoing policy resistance. A system dynamics model of pathways between psychological distress, the mental health care system, suicidal behaviour and their drivers was developed, tested, and validated for a large, geographically diverse region of New South Wales; the Hunter New England and Central Coast Primary Health Network (PHN). Multi-objective optimisation was used to explore potential discordance in the best-performing programs and initiatives (simulated from 2021 to 2031) across mental health outcomes between the two state-governed Local Health Districts (LHDs) and the federally governed PHN. Impacts on suicide deaths, mental health-related emergency department presentations, and service disengagement were explored. A combination of family psychoeducation, post-attempt aftercare, and safety planning, and social connectedness programs minimises the number of suicides across the PHN and in the Hunter New England LHD (13.5% reduction; 95% interval, 12.3¿14.9%), and performs well in the Central Coast LHD (14.8% reduction, 13.5¿16.3%), suggesting that aligned strategic decision making between the PHN and LHDs would deliver substantial impacts on suicide. Results also highlighted a marked trade-off between minimising suicide deaths versus minimising service disengagement. This is explained in part by the additional demand placed on services of intensive suicide prevention programs leading to increases in service disengagement as wait times for specialist community based mental health services and dissatisfaction with quality of care increases. Competing priorities between the PHN and LHDs (each seeking to optimise the different outcomes they are responsible for) can undermine the optimal impact of investments for suicide prevention. Systems modelling provides essential regional decision analysis infrastructure to facilitate coordinated federal and state investments for optimal impacts.

Background: The Australian Institute of Health and Welfare has reported an increased rate of hospital-treated intentional self-harm in young females (2000¿2012) in Australia. These reported increases arise from institutional data that are acknowledged to underestimate the true rate, although the degree of underestimation is not known. Objective: To consider whether the reported increase in young females¿ hospital-treated intentional self-harm is real or artefactual and specify the degree of institutional underestimation. Methods: Averages for age- and gender-standardised event rates for hospital-treated intentional self-harm (national: Australian Institute of Health and Welfare; state: New South Wales Ministry of Health) were compared with sentinel hospital event rates for intentional self-poisoning (Hunter Area Toxicology Service, Calvary Mater Newcastle) in young people (15¿24 years) for the period 2000¿2012. A time series analysis of the event rates for the sentinel hospital was conducted. Results: The sentinel hospital event rates for young females of 444 per 100,000 were higher than the state (378 per 100,000) and national (331 per 100,000) rates. There was little difference in young male event rates ¿ sentinel unit: 166; state: 166 and national: 153 per 100,000. The sentinel hospital rates showed no change over time for either gender. Conclusion: There was no indication from the sentinel unit data of any increase in rates of intentional self-poisoning for young females. The sentinel and state rates were higher than the national rates, demonstrating the possible magnitude of underestimation of the national data. The reported increases in national rates of hospital-treated self-harm among young females might be due to artefactual factors, such as changes in clinical practice (greater proportion admitted), improved administrative coding of suicidal behaviours or possibly increased hospital presentations of community self-injury cases, but not intentional self-poisoning. A national system of sentinel units is needed for the accurate and timely monitoring of all hospital-treated self-harm.

Assessment of a patient after hospital-treated self-harm or psychiatric hospitalization often includes a risk assessment, resulting in a classification of high risk versus low risk for a future episode of self-harm. Through systematic review and a series of meta-analyses looking at unassisted clinician risk classification (eight studies; N¿=¿22,499), we found pooled estimates for sensitivity 0.31 (95% CI: 0.18¿0.50), specificity 0.85 (0.75¿0.92), positive predictive value 0.22 (0.21¿0.23), and negative predictive value 0.89 (0.86¿0.92). Clinician classification was too inaccurate to be clinically useful. After-care should therefore be allocated on the basis of a needs rather than risk assessment.

Objective: This study aimed to identify the information that people who have attempted suicide and those who support them believed to be helpful to receive after an attempt. Methods: Thirty-seven people with lived experience of suicide attempt(s) (suicide attempt survivors and family members/friends of survivors) were recruited through two national lived experience community groups in Australia. Participants completed a semi-structured telephone interview that included questions about the types of information they believed important to receive after an attempt. Results: Using thematic analysis, the key information participants identified was helpful to receive following a suicide attempt was that which could challenge stigma and address negative community attitudes towards suicide. Participants spoke of a need for practical information and information that provided hope. Personal stories of recovery were identified as an important way of communicating this sort of health information. Conclusions: People who have attempted suicide and their family members and friends want information that challenges stigma and supports recovery expectations. Practice implications: Providing people with accurate information about recovery and using personal stories to communicate health information is one way people affected by suicide attempt identify can challenge stigma, and address information needs after a suicide attempt.

The first aim of this systematic review was to evaluate the evidence for family psychoeducation (FPE) interventions for major depressive disorder (MDD). A second aim was to compare the efficacy of different modes of delivering face-to-face FPE interventions. Ten studies (based on nine distinct samples) were identified comprising four single-family studies, four multifamily studies, one single versus multifamily comparative study, and one peer-led, mixed-diagnosis study. Seven studies measured patient functioning and six reported positive outcomes. Six studies measured carer's well-being and four reported positive outcomes. Results provide preliminary evidence that FPE leads to improved outcomes for patient functioning and family¿carer's well-being for persons with depression. The implications for future development and delivery of FPE interventions for MDD are discussed.

Background Prediction of suicidal behaviour is an aspirational goal for clinicians and policy makers; with patients classified as 'high risk' to be preferentially allocated treatment. Clinical usefulness requires an adequate positive predictive value (PPV). Aims To identify studies of predictive instruments and to calculate PPV estimates for suicidal behaviours. Method A systematic review identified studies of predictive instruments. A series of meta-analyses produced pooled estimates of PPV for suicidal behaviours. Results For all scales combined, the pooled PPVs were: suicide 5.5% (95% CI 3.9-7.9%), self-harm 26.3% (95% CI 21.8-31.3%) and self-harm plus suicide 35.9% (95% CI 25.8-47.4%). Subanalyses on self-harm found pooled PPVs of 16.1% (95% CI 11.3-22.3%) for high-quality studies, 32.5% (95% CI 26.1-39.6%) for hospital-treated self-harm and 26.8% (95% CI 19.5-35.6%) for psychiatric in-patients. Conclusions No 'high-risk' classification was clinically useful. Prevalence imposes a ceiling on PPV. Treatment should reduce exposure to modifiable risk factors and offer effective interventions for selected subpopulations and unselected clinical populations.