Suicide prevention – the role of psychiatry

Purpose

The aim of this position statement is to outline the complex factors that contribute to suicide, the role of psychiatrists in preventing suicide, and the best ways to support individuals, families/whānau and communities to cope with suicidal behaviours and prevent suicides.

Key messages

• Suicide prevention requires a comprehensive approach that spans systems, organisations, communities, cultures and environments, combining treatment, support and intervention, and bridges gaps between fragmented services.
• Universal access to timely, coordinated, high quality mental health care is a critical component of suicide prevention, particularly for people with serious mental illness and substance use disorders. Access to 24-hour crisis care is one of the most important aspects of mental health service provision in the prevention of suicide.
• Psychiatrists are committed to working in partnership with individuals, and other health professionals, to alleviate the distress involved in suicidal thoughts and behaviours, and importantly, preventing suicides.
• Clinical assessment and care will be more effective when an individual’s needs are identified and prioritised, and a strong therapeutic partnership is developed. 
• Families/whānau, friends, peer support and those with lived experience, provide crucial support and insights in suicide prevention efforts.
• Trauma is a key risk factor for suicide and a trauma-informed approach can enhance recovery. 
• Population-based measures can reduce risk factors for suicide, such as reducing inequities and limiting access to lethal means of suicide, and promote protective factors against suicide, such as fostering social connectedness and inclusivity.

Introduction

Suicide is complex and has devastating and long-term impacts on families/whānau and communities. Psychiatrists acknowledge the pain and suffering of those experiencing suicidal thoughts and behaviours, suicide attempt survivors, those caring for someone who is experiencing suicidal behaviours, and bereaved family/whānau. 

While suicide prevention is primarily focussed on reducing deaths, suicide can be viewed as a collection of behaviours that range in severity, frequency and fluidity, including ideation, attempts, deliberate self-harm and death by suicide. These experiences are crisis points that are usually driven by a desire to escape from deep emotional pain and difficult life circumstances. 

Psychiatrists are committed to working in partnership with individuals, their family/whānau, and other health professionals, to alleviate the distress involved in suicidal thoughts and behaviours, and importantly, preventing suicides. This network of supporters encompasses, but is not limited to, the community sector, primary health services including general practitioners, allied health professionals, psychologists, social workers, mental health nurses, peer workers and non-government organisations. 

People with lived experience of suicide are important partners in designing and delivering appropriate suicide prevention supports. They can act as mentors for others, foster greater empathy within the service system and enhance the capacity of services to be person-centred, family inclusive, and culturally safe.
As a result of their training and experience, psychiatrists have comprehensive clinical knowledge that can inform current approaches to suicide prevention. The RANZCP welcomes opportunities to contribute to the design and implementation of policy, programs and services targeting suicide. 

The RANZCP believes that the best outcomes can be achieved through a collaborative, multidisciplinary, all-of-community approach to suicide prevention. 

Background

Suicidal behaviour is a global public health concern of major policy significance. While suicide deaths are rare events, suicidal ideation is experienced by many people at one or many points in their lives. An Australian study showed that at some point in their lifetime, 1 in 8 (or 13.3%) people aged 16-85 years have had serious thoughts about taking their life; 1 in 25 have made a suicide plan; and 1 in 33 attempted suicide.[1] A small but significant number of those attempts are fatal. 

Australia and New Zealand have comparable rates of suicide mortality at around 13 per 100,000 population (2019/2020); both countries have reported modest declines of a similar magnitude over a thirty year period.[2] The suicide rates of migrants tend to reflect those of their country of birth.[3] More data on suicide deaths in Australia is available from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare, and in New Zealand from the Ministry of Health and Coronial Services of New Zealand. 

A true understanding of suicide requires an understanding of all suicidal behaviours. Identifying intent is not always straightforward. Deliberate self-harm can occur without the intent to die. Conversely, not everyone who dies by suicide has a history of previous suicide attempts. The majority of people who die by suicide have not accessed mental health services in the 12 months before their death.[4]

An individual’s vulnerability to suicide arises from a confluence of individual and environmental factors, including genetic,[5] psychological,[6] social and cultural, and adverse life events such as loss, trauma and interpersonal conflict.[7, 8] Suicidal ideation can arise when vulnerable individuals are under stress, often from cumulative sources, and magnified by mood and certain personality traits such as impulsivity, aggression, perfectionism and rigidity.[9] It has been linked to intense feelings of desperation, abandonment, humiliation, shame, perceived burdensomeness, thwarted belongingness,[10] hopelessness and entrapment. It almost always occurs in the context of extreme distress.[8] Mental illness and substance use and substance use disorders are significant and independent risk factors for suicide.[11-13]

Suicide prevention requires a whole-of-life approach that considers the social determinants of health and includes health promotion, prevention, early intervention, and life-skills training and management, as well as crisis support and access to comprehensive mental health care.

Support provided by friends, nominated family members/whānau and carers or other support people is a crucial protective factor, which has been shown to be associated with decreased likelihood of a lifetime suicide attempt.[14] This may be particularly important within some cultural and social groups.[15] 

Psychiatrists’ role in supporting people in suicidal distress

Psychiatrists are mental health specialists who understand suicide and its potential causes and triggers. Psychiatrists are committed to providing and promoting high quality mental health care in the community, and can support people who are experiencing psychological distress, with or without mental illness.
Psychiatrists’ training, of which supervised clinical practice is a core part, enables them to provide clinically effective, safe and person-centred assessment and treatment. The RANZCP is committed to embedding suicide prevention approaches in the psychiatry training curriculum to ensure that psychiatrists provide the most appropriate and effective, evidence-based treatment and practice to support people in distress. Psychiatrists have a critical role in identifying and treating any underlying mental illness.

The challenges associated with predicting suicide in clinical practice are widely recognised.[16-18] Suicide risk fluctuates with the number and intensity of key risks and protective factors experienced and is strongly influenced by an individual’s own perceptions of their circumstances.[19] Some individuals may experience persistent suicidality. Risk is better managed when the individual’s needs and traumas (past and current) are understood, allowing interventions to be targeted to an individual. 

Psychiatrists endeavour to take a structured approach to risk reduction, which includes assessing the strength of the intention to act, developing safety plans and identifying access to available supports for points of crisis. 
Individualised approaches that are warm, empathetic, respectful, culturally-responsive and non-judgemental provide the best opportunity to create a strong therapeutic relationship.[8] Identifying and undertaking appropriate supports and treatments should always be done using an enabled supported decision-making framework in partnership with the individual and their families/whānau or carers. Clinical care should also routinely encompass peer and multidisciplinary support.

Given the well-established link between childhood adversity and suicide across the lifespan, suicide treatment and interventions need to understand and address these experiences.[20] Psychiatrists have an important role in the early identification of mental illness in children, and actively guiding appropriate treatment and interventions. Improving the mental wellbeing of children and young people could have lifelong benefits.
Trauma-informed practice is particularly important in the context of suicidal behaviour and self-harm and should be routinely incorporated into mental health care. A trauma-informed approach maximises the potential for recovery and minimises the risk of re-traumatisation. It should be guided by respectful approaches to suicidality and disclosures of trauma, and instilling hope, optimism and the knowledge that recovery and post-traumatic growth is possible.

Coordinated, assertive, aftercare plays an important role in preventing suicide following an attempt. Ongoing psychotherapy and psychosocial support is required beyond acute phases of illness or distress towards recovery.[21] Family therapy [22] and online (CBT-based) interventions have been shown to be effective in the treatment of depression and anxiety, particularly with young people.[23] Other psychological treatments and medications are also effective in reducing suicide attempts for people with symptoms of mental illness.[22]
Postvention support for families, friends and communities impacted by suicide is also an important aspect of suicide prevention, not only to alleviate the effects of stress and loss experienced by the survivors of suicide, but to reduce the potential for further suicides, as survivors are at greater risk.[8] Open dialogues (adhering to principles of confidentiality) between health professionals and bereaved family can promote healing and understanding. 

Populations at higher risk of suicide

Several populations are at greater risk of suicide. These include (but are not limited to) males, Māori, Pasifika, and Aboriginal and Torres Strait Islander peoples, lesbian, gay, bisexual, transgender, gender diverse and intersex people,[24] people living in rural and remote locations and those who are socioeconomically disadvantaged. While males have higher suicide mortality, females are more likely to experience suicidal thoughts and attempt suicide.[1] Suicide remains the leading cause of maternal mortality in New Zealand, with Māori women at higher risk,[25] and a significant cause of maternal mortality in Australia.[26]

Suicide is the leading cause of death for people aged between 15-49 years and accounts for the highest number of years of potential life lost compared to other causes of death. Older men (aged 85 years and over) have the highest age-specific rates.[11, 27] Prison inmates, including those on remand, have a higher rate of suicide than their counterparts in the general community. Offenders enter the prison system with more risk factors for suicide and remain at elevated risk of suicide following their release.[28] Discharged Australian veterans are also at higher risk or suicide.[29]

Mental illness, particularly mood disorders, borderline personality disorder, schizophrenia and substance use disorder, is associated with a higher risk of suicide.[8] People with comorbid depressive and anxiety disorder and high severity of depression are at an even higher risk of suicide.[30] Addictive behaviours, including substance use disorders and gambling, have been shown to be a significant risk factor for suicide,[31] and is amplified by the presence of depression.[32]

Suicide is not always associated with a diagnosable mental illness or substance use disorder. It is more common in areas of socioeconomic deprivation, social fragmentation, and unemployment.[33] Other risk factors include inequity, experiences of marginalisation and trauma, deficits across the social determinants of health, exposure to family violence, and personal experiences of discrimination. The most commonly reported psychosocial risk factors associated with suicide include a history of self-harm, disruption of family by separation or divorce, relationship problems with a spouse or partner, disappearance or death of a family member, legal problems, economic problems, and limitations due to disability or chronic health condition.[11]

Chronic physical pain, especially in the elderly, is associated with increased suicide risk. Helplessness and hopelessness about physical pain, and the desire to escape from pain contribute to suicidality in people with chronic pain.[34] Similarly, insomnia elevates risk of suicide.[35] The management of pain and insomnia should be prioritised in people experiencing negative moods and/or suicidal thoughts or behaviours. People experiencing chronic pain and/or insomnia should be routinely assessed for suicidal ideation.

There are higher rates of suicide among certain occupational groups, such as those with access to lethal means.[36] 

Emerging research shows that suicidal thoughts are more likely to progress to a suicide attempt when there has been childhood trauma, a culturally and linguistically diverse (CALD) background, lower educational achievement, earlier onset of mood disorders, comorbid lifetime alcohol use disorder, less sense of control in their lives, and poor social support.[30]

Public health measures 

The public health component of suicide prevention should focus on systematically reducing societal inequities by targeting modifiable risk factors such as unemployment, educational disadvantage, socio-economic disadvantage, homelessness, loneliness and poor social-connectedness. 

Suicide prevention requires a comprehensive approach spanning systems, organisations, communities, cultures and environments (social, economic and health), integrating social supports, treatment and intervention. Research suggests that systems approaches could lead to significant reductions in suicide attempts and suicide deaths.[21] Integrated systems (both within and beyond health) that facilitate information sharing, communication and collaboration, could improve the identification of individuals at risk, and the subsequent provision of support.

Public health measures can contribute to suicide prevention through the promotion of protective factors and environments, (and conversely, the reduction of modifiable risk factors). Protective factors include social engagement, problem-solving confidence and a sense of control.[37] For young people, a caring home and fair, safe school environments,[38] and effective help-seeking,[39] are protective. Social services and supports can reduce isolation, promote life skills, and provide practical support to vulnerable individuals and families/whanau to improve quality of life. Peer support can also play a crucial role in improving social connectedness and guiding help-seeking.[40]

Accessing individual support

Public health messaging on mental health and suicide prevention in Australia and New Zealand has successfully raised awareness but has not always been matched with people accessing appropriate mental health care and support services, nor is there evidence of a reduction in suicide rates.[41, 42] Barriers to people seeking support include: beliefs that treatment is not warranted and/or is likely to be ineffective, stigma, shame, negative prior experiences with mental health services, financial difficulties, and a lack of knowledge about where to go for help.[39, 43] 

Even when people actively seek support, many find it difficult to navigate the system to find the help and support they need. There can also be a reluctance to disclose suicidal thoughts to health professionals due to concerns around inadequate support and low continuity of care, privacy and stigma.[44] Anecdotal reports suggest that people who have experienced trauma have adverse experiences of mental health care services. Ideally, people should be provided with continuity of care with appropriate follow-up services from the first point of contact or help-seeking.

However, workforce shortages and under-resourced services means many mental health services are stretched beyond capacity, particularly in rural or remote communities. Many people in psychological distress report that their only option to receive care in a time of crisis is through hospital emergency departments. Access to 24-hour crisis care is one of the most important aspects of mental health service provision in the prevention of suicide.[21] Crisis services can allow time for the crisis to dissipate, but should include pathways to clinical assessment and ongoing support. Early clinical assessments are essential to identify any serious mental illness. Emergency departments have an important role in suicide prevention and should be appropriately resourced to provide comprehensive mental health assessments and treatment. 

Crisis services need to be complemented by adequate community mental health services to better meet the demand for ongoing mental health care. Emerging models of care that blend clinical and trained non-clinical supports in community settings, with proactive outreach, may be beneficial to people with acute episodic distress. Recovery requires longer term clinical interventions and support from continued therapeutic relationships with mental health professionals.[21]

People from vulnerable communities can face additional barriers accessing support, including language and cultural differences, experiences of discrimination, religious beliefs or concerns about confidentiality.[3] Suicide prevention strategies must respond to diversity and sensitivities within communities, including the impacts of intergenerational trauma. Ideally this would occur through co-production with high-risk groups, with information provided in languages and forms best understood by recipients. People in detention should be able to access comprehensive mental health assessment and treatment services.[28]

Training for recognising and preventing suicide

As timely access to mental health professionals can be difficult, upskilling the frontline health and community workforce in mental health and suicide prevention skills could provide more immediate support to people experiencing suicidal distress, particularly general practitioners.[22] Gatekeeper training of community members who have regular contact with others such as police officers, teachers, coaches, and co-workers to recognise and support people at potential risk of suicide, and to support those who are bereaved by suicide or have lived experience, has been shown to be beneficial.[21] Psychiatrists have the skills and expertise to be involved in the development and delivery of such training.

Addictive behaviours 

A greater focus on integrating suicide prevention strategies and drug and alcohol services is needed. The complex relationship between suicide and alcohol and other substance use has been robustly demonstrated, with problems related to substance use being present in many suicide deaths.[11] However gaps in data collection for substance use disorder and suicide may have led to underestimations of the problem and a subsequent lack of measures targeting substance use and gambling within broader strategies.[45] Similarly, drug and alcohol services should screen for suicide risk factors and provide integrated support. 
Alcohol policy is known to impact suicide, with lower rates linked with lower availability and higher price of alcohol, and older legal drinking age.[46] A holistic approach to suicide prevention must include public health measures to reduce alcohol consumption.

Access to means

The impulsivity of suicide provides opportunities to reduce the risk by restricting access to lethal means and enabling time for suicidal thoughts to subside.[21, 47] Effective strategies include limiting access to analgesics and changes to their packaging, installing barriers at sites used for jumping,[22] and restricting access to firearms.[48] Interventions that encourage help-seeking at suicide hotspots (such as crisis telephones and contact points), and interventions that increase the likelihood of intervention by a third party (CCTV or increased police presence) can reduce the number of suicides.[47] 

Childhood

Primary prevention efforts need to begin early to reduce exposure to adverse childhood experiences, identify early mental illness, and provide direct interventions and support to vulnerable children and families.[20] School-based awareness programs on mental health literacy, suicide risk awareness, and skills training have been shown to reduce suicide attempts and ideation.[22] Economic hardship or parental unemployment may have a serious long-term impact on mental health in children and young people.[33] Broader social and economic supports, combined with targeted support to families/whānau under stress, could reduce lifelong negative impacts on children. 

Data

The complexities of data collection relating to suicide can lead to under-reporting and delays in reporting.[49] The release of data on suicide varies across jurisdictions and countries and can typically take between 12 and 24 months to be finalised. Delays can result from coronial requirements, difficulties determining intent, and inconsistencies across jurisdictions. Access to more real-time data on suicides could improve our understanding of, and response to, changes in the number of suicides in the community and enhance evaluations of influential factors. 

The RANZCP supports efforts in New Zealand and Australia to develop new systems to collect more timely data on suicides. However, suicide mortality data has a high degree of variability, so all reports of changes in rates need to be interpreted with care, especially when analysed over short periods of time and/or for sub groups based on age, gender, or other characteristics. 

Suicide attempts that require hospitalisation are considered important targets for suicide prevention programs. The current official data sources have several deficiencies that create the potential for error and misunderstanding of reported changes.[50] Improvements in data systems and the development of sentinel unit networks for hospital-treated suicidal behaviours are being undertaken in Australia and New Zealand. 
The collection and analysis of wider demographics, including CALD background,[3] and key risk factors including mental illness, substance use and gambling, would increase our understanding of the drivers of suicide to better guide future policy and research. 

Recommendations 

The RANZCP welcomes opportunities to be involved in national and jurisdictional suicide prevention strategic and service planning, and recommends that:

• Evidence-based interventions and practices be identified and implemented to reduce the incidence of suicides across all geographic areas in Australia and New Zealand. 
• High-quality psychiatric consultation and collaborative mental health care should be available to all people presenting at emergency departments and primary health settings for suicidal ideation or behaviour.
• Individualised and comprehensive post-attempt care should be provided by clinical mental health services and aftercare programs in collaboration with trained peer support workers.
• Psychiatrists and other mental health professionals should recognise trauma and its impacts on individuals, adopting the principles of Trauma Informed Practice to enhance recovery.
• Training of frontline health and community workers should include suicide prevention strategies and competencies relating to mental health and suicide. This includes embedding suicide prevention approaches in the psychiatry training curriculum to ensure that psychiatrists provide the most appropriate and effective, evidence-based treatment and practice to support people in distress
• The public health component of suicide prevention should focus on systematically reducing societal inequities by targeting modifiable risk factors such as unemployment, educational disadvantage, socio-economic disadvantage, homelessness, loneliness and poor social-connectedness. These measures should be complemented by access to clinical and direct care in all instances. 
• Crisis mental health care should be easily accessible 24 hours per day, 7 days a week in settings beyond hospital emergency departments.
• Targeted, culturally responsive suicide prevention initiatives should be implemented and evaluated for populations at higher risk. 
• Lived experience of suicidal behaviours should be harnessed in the content and delivery of undergraduate and specialist medical training. 
• Australian and New Zealand governments specifically commit to:
  • integrating psychiatric expertise, alongside peer support and multidisciplinary partners, in suicide prevention policy and practice, including in the evaluation of new treatments and interventions, and developing and delivering training modules.
  • improving the efficiency and accuracy of collecting and reporting real-time data on suicide, and expanding the collection of wider demographic information, environmental factors, and key risk factors for suicide including mental illness and addiction comorbidities. Continuance and full collection of data is vital for understanding trends.  
  • integrating suicide prevention strategies and drug and alcohol services, including implementing public health measures to reduce alcohol consumption.
  • allocating ongoing funding toward research on the causes and treatments of suicidal ideation and behaviour, and reducing barriers to care.
  • facilitating and monitoring the translation of knowledge from funded research to improve practice.

RANZCP Resources

Clinical Practice Guideline for the Management of Deliberate Self-harm
Position Statement 70: Suicide Reporting in the Media
Position Paper: Enabling supported decision-making
Position Statement 67: Voluntary Assisted Dying
Position Statement 80: The Role of the Psychiatrist in Australia and New Zealand
Position Statement 100: Trauma-informed practice
Position statement 87: Recognising and reducing alcohol-related harm

Other Resources

Australian Open Disclosure Framework

Getting Help

If you are worried about someone you know feeling suicidal, more information about how to help is available on the Your Health in Mind website.

If you or someone you know needs immediate support, the following services offer crisis telephone support:

Responsible committee: President’s Advisory Group on Suicide 

References

1.    Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J, et al. The mental health of Australians 2. Report on the. 2007;20(07).
2. Ritchie H, Roser M, Ortiz-Ospina E. Suicide. Our World In Data. 2015 [Available from: https://ourworldindata.org/suicide.
3.    Bowden M, McCoy A, Reavley N. Suicidality and suicide prevention in culturally and linguistically diverse (CALD) communities: A systematic review. International Journal of Mental Health. 2019:1-28.
4.    Pirkis J, Burgess P. Suicide and recency of health care contacts. A systematic review. British Journal of Psychiatry. 1998;173(12):462-74.
5.    van Heeringen K, Mann JJ. The neurobiology of suicide. The Lancet Psychiatry. 2014;1(1):63-72.
6.    O'Connor RC, Nock MK. The psychology of suicidal behaviour. The Lancet Psychiatry. 2014;1(1):73-85.
7.    Hawton K, van Heeringen K. Suicide. Lancet. 2009;373(9672):1372-81.
8.    Kapur N, Goldney RD. Suicide Prevention: Oxford University Press; 2019.
9.    Fazel S M, and Runeson, B MD, Ph. D. Suicide. N Engl J Med. 2020;382:266-74.
10.    Silva C, Ribeiro JD, Joiner TE. Mental disorders and thwarted belongingness, perceived burdensomeness, and acquired capability for suicide. Psychiatry Research. 2015;226(1):316-27.
11. Australian Bureau of Statistics. Causes of Death, Australia 2019, Intentional self-harm (suicides), key characterstics. Australia.2020 [Available from: https://www.abs.gov.au/statistics/health/causes-death/causes-death-australia/2019#intentional-self-harm-suicides-key-characteristics.
12.    Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychological medicine. 2003;33(3):395-405.
13.    Chesney E, Goodwin GM, Fazel S. Risks of all‐cause and suicide mortality in mental disorders: a meta‐review. World psychiatry. 2014;13(2):153-60.
14.    Kleiman EM, Riskind JH, Schaefer KE. Social support and positive events as suicide resiliency factors: Examination of synergistic buffering effects. Archives of Suicide Research. 2014;18(2):144-55.
15.    Clark TC, Robinson E, Crengle S, Fleming T, Ameratunga S, Denny SJ, et al. Risk and protective factors for suicide attempt among indigenous Maori youth in New Zealand: The role of family connection. International Journal of Indigenous Health. 2011;7(1):16.
16.    Carter G, Milner A, McGill K, Pirkis J, Kapur N, Spittal MJ. Predicting suicidal behaviours using clinical instruments: Systematic review and meta-analysis of positive predictive values for risk scales. British Journal of Psychiatry. 2017;210(6):387-95.
17.    Large MM. The role of prediction in suicide prevention. Dialogues in clinical neuroscience. 2018;20(3):197.
18.    Woodford R, Spittal MJ, Milner A, McGill K, Kapur N, Pirkis J, et al. Accuracy of clinician predictions of future self‐harm: a systematic review and meta‐analysis of predictive studies. Suicide and Life‐Threatening Behavior. 2019;49(1):23-40.
19.    Kleiman EM, Turner BJ, Fedor S, Beale EE, Huffman JC, Nock MK. Examination of real-time fluctuations in suicidal ideation and its risk factors: Results from two ecological momentary assessment studies. Journal of abnormal psychology. 2017;126(6):726.
20.    Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. Jama. 2001;286(24):3089-96.
21.    Krysinska K, Batterham PJ, Tye M, Shand F, Calear AL, Cockayne N, et al. Best strategies for reducing the suicide rate in Australia. Australian & New Zealand Journal of Psychiatry. 2015;50(2):115-8.
22.    Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry. 2016;3(7):646-59.
23.    Robinson J, Bailey E, Witt K, Stefanac N, Milner A, Currier D, et al. What works in youth suicide prevention? A systematic review and meta-analysis. EClinicalMedicine. 2018;4:52-91.
24.    Morris S. Snapshot of Mental Health and Suicide Prevention Statistics for LGBTI People and Communities, National LGBTI Health Alliance, Newtown NSW. Sydney National LGBTI Health Alliance. 2016.
25.    Perinatal, Committee MMR. Twelfth annual report of the perinatal and maternal mortality review committee: reporting mortality 2016. Wellington: Health Quality & Safety Commission; 2018.
26. Australian Institute of Health and Welfare. Maternal deaths in Australia 2019. [Available from: https://www.aihw.gov.au/reports/mothers-babies/maternal-deaths-in-australia/contents/maternal-deaths-in-australia.
27.    Barak Y, Cheung G, Fortune S, Glue P. No country for older men: ageing male suicide in New Zealand. Australasian Psychiatry. 2020;28(4):383-5.
28.    Willis M, Baker A, Cussen T, Patterson E. Self-inflicted deaths in Australian prisons. Trends and Issues in Crime and Criminal Justice. 2016(513):1.
29.    Australian Institute of Health and Welfare, Harrison JE, Henley G. Suicide and hospitalised self-harm in Australia: trends and analysis Canberra.2014 [Available from: https://www.aihw.gov.au/reports/injury/suicide-hospitalised-self-harm-in-australia/contents/summary.
30.    Wiebenga JXM, Eikelenboom M, Heering HD, van Oppen P, Penninx BWJH. Suicide ideation versus suicide attempt: Examining overlapping and differential determinants in a large cohort of patients with depression and/or anxiety. Australian & New Zealand Journal of Psychiatry. 2020:0004867420951256.
31.    Karlsson A, Håkansson A. Gambling disorder, increased mortality, suicidality, and associated comorbidity: A longitudinal nationwide register study. Journal of behavioral addictions. 2018;7(4):1091-9.
32.    Sullivan LE, Fiellin DA, O’Connor PG. The prevalence and impact of alcohol problems in major depression: a systematic review. The American journal of medicine. 2005;118(4):330-41.
33.    Frasquilho D, Matos MG, Salonna F, Guerreiro D, Storti CC, Gaspar T, et al. Mental health outcomes in times of economic recession: a systematic literature review. BMC Public Health. 2016;16:115-.
34.    Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological medicine. 2006;36(5):575.
35.    Woznica AA, Carney CE, Kuo JR, Moss TG. The insomnia and suicide link: toward an enhanced understanding of this relationship. Sleep medicine reviews. 2015;22:37-46.
36.    Milner A, Spittal MJ, Pirkis J, LaMontagne AD. Suicide by occupation: systematic review and meta-analysis. The British Journal of Psychiatry. 2013;203(6):409-16.
37.    Donald M, Dower J, Correa-Velez I, Jones M. Risk and protective factors for medically serious suicide attempts: a comparison of hospital-based with population-based samples of young adults. Australian & New Zealand Journal of Psychiatry. 2006;40(1):87-96.
38.    Fleming TM, Merry SN, Robinson EM, Denny SJ, Watson PD. Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand. Australian & New Zealand Journal of Psychiatry. 2007;41(3):213-21.
39.    Rowe SL, French RS, Henderson C, Ougrin D, Slade M, Moran P. Help-seeking behaviour and adolescent self-harm: A systematic review. Australian & New Zealand Journal of Psychiatry. 2014;48(12):1083-95.
40. Maple M, Wayland S, Pearce T, Hua P. Services and programs for suicide prevention: an evidence check rapid review brokered by the Sax Institute for Beyond Blue 2018. [Available from: https://www.beyondblue.org.au/docs/default-source/policy-submissions/suicide-prevention-programs_final-1.pdf?sfvrsn=b082bcea_6.
41.    Jorm AF. Lack of impact of past efforts to prevent suicide in Australia: Please explain. Australian & New Zealand Journal of Psychiatry. 2019;53(5):379-80.
42. Black Dog Institute. What can be done to decrease suicidal behaviour in Australia? A call to action. 2020. [Available from: What-Can-Be-Done-To-Decrease-Suicide-a-call-to-action_Black-Dog-Institute.pdf (blackdoginstitute.org.au) ]