YOUTH SUICIDE AND SELF HARM

Norman Swan: For the last 15 years or so, there's been groundbreaking work
in Western Australia into suicide in young people. Youth suicide is a rare
event, but when it does occur the tragedy is enormous. The work in W.A. has
discovered a lot more about what increases the risk of suicide, what might
protect a young person from it and how, for example, hospital emergency
departments can recognise a person at risk and do the right thing.

Sven Silburn is Professor at the Centre for Developmental Health at Curtin
University and the Institute for Child Health Research, both in Perth.

Sven Silburn: Back in the late '80s, Western Australia experienced a number
of suicide clusters involving high school students, and this was enormously
distressing for the schools involved, and there was a huge amount of
community concern. That led to the Western Australian government setting up
a task force to look at what could be done and the commissioning of a
fairly comprehensive public health approach to tackling the problem.

Norman Swan: Was this an unusual set of clusters?

Sven Silburn: They were unusual in that they involved students at high
school, some of them were at private schools, and a number of these
students were known to each other. And the way in which schools were
prepared to handle those situations compounded the problem.

Norman Swan: Cutting a long story short, what did you end up with?

Sven Silburn: What we ended up with was a commitment to really looking at
the issue more systematically. That meant looking at what data was
available from within the hospital services, doing a pilot study of cases
coming through hospitals with deliberate self-harm.

Norman Swan: Let's just stop you there. Deliberate self-harm, what does
that mean?

Sven Silburn: Deliberate self-harm really covers a range of problems, but
it mostly covers deliberate overdoses and other actions to actually injure
oneself.

Norman Swan: Is this just another phrase for attempted suicide?

Sven Silburn: In a way, it is. But actually determining whether an overdose
or a deliberate overdose or a laceration of the wrist is a suicide attempt
is quite difficult. You really do need to find out the circumstances, what
the person intended.

Norman Swan: Does it cover the controversial issue of car crashes? Because
some people believe that there is a percentage of car crashes in young
people which are actually deliberate attempts at self-harm, or indeed suicide.

Sven Silburn: I think it probably does, but when one looks at those sorts
of accidents, I think what you're looking at is people who are really
pushing things to the limit. They're almost indifferent to whether they
live or die, and that when an accident happens, in retrospect one can look
at that and see that there may have been an element of suicidality in
what's happened, but it's very, very difficult to establish.

Norman Swan: OK, so you got data from hospitals about deliberate self-harm;
what else?

Sven Silburn: The other thing that we did is that we surveyed schools, to
see what was happening, just the extent of the problem, how schools were
actually managing, and we also went to get information from the Coroner's
office. What this has given us is very good information about emerging
trends, we've been able to identify what some of the key risk factors are,
and back in the early '90s, it was very clear from the data on completed
suicide that deliberate self-harm was a very important predictor of
subsequent suicide.

Norman Swan: To what extent?

Sven Silburn: We are looking at increased risk by a factor of 20 to 30.

Norman Swan: So if somebody came into a hospital casualty department or a
general practitioner, or some workplace in the system, having quite clearly
deliberately tried to harm themselves, they were 20 or 30 times more at
risk of committing suicide than somebody who hadn't done that?

Sven Silburn: Exactly right. But at the same time, one also has to take on
board the fact that the vast majority of people who make suicide attempts
will not go on to commit suicide. In fact probably around two-thirds of
them will get their life back in order, get things back on track and if you
see them a few years down the track, are doing just fine.

Norman Swan: So when we come now to the risk factors for completed suicide,
you've identified one, where you've got a history of deliberate self-harm;
what are the others?

Sven Silburn: Again this came from a study we did in hospitals where we
looked at every teenager admitted to Perth hospitals over a two-year
period. What we found there is that at the time these people came in, there
was information available to the doctor who examined them about the
person's history. If they took the time to collect it, about a previous
history of depression, that there was a history of substance misuse, or if
they'd made an earlier attempt. That information was sufficient for us to
predict accurately 8 out of 10 of the people in that study who subsequently
re-attempted and were admitted to hospital with a further suicide attempt.

Norman Swan: Let's go through that again: a history of depression, a
history of illicit substance abuse, what about binge drinking, because
there's work in America which suggests that binge drinking's associated,
because you get that rebound effect, and that's associated with suicide.

Sven Silburn: Binge drinking would really come into that as well, and I
think what we've seen from the data in the Coroner's office that acute
intoxication is one of the really critical factors that happens with
suicide. So many suicides are impulsive, and I think it's important for
young people to understand that acute intoxication, where there is that
sudden disinhibition, or where people can suddenly act out in a very
impulsive manner, and where their judgement can be quite impaired, that
whether they're intoxicated with alcohol, with cannabis, or with some other
substance, it doesn't really matter, but acute intoxication is a major
factor in many suicides.

Norman Swan: The implication then is that only three or four questions will
give you a very good idea of somebody's subsequent risk of suicide.

Sven Silburn: Yes, as long as you actually take the trouble to spend enough
time with the person to gain their confidence, take a good history and to
ensure that whatever treatment is provided is addressing some of their
immediate needs.

Norman Swan: So you found the major risk factors; what about the trends
over the last decade or so?

Sven Silburn: Another study we've done just in the last year, has looked
particularly at what's happening with illicit substance use, and we were
quite surprised to see the percentage of suicides involving an illicit
substance, as detected on post-mortem, has increased from around 10% twelve
years ago, to around close on 50% in the last two years.

Norman Swan: About fivefold.

Sven Silburn: Exactly.

Norman Swan: Do we know why?

Sven Silburn: The patterns of drugs reflect the pattern of drug
availability, and we notice that in one year where we had a particular peak
in suicides in Western Australia, corresponded to a year when there had
been a peak in police predictions involving cannabis. The story with
cannabis I think is an important development, because with all the moves
towards decriminalising cannabis, which I would support, at the same time
we need to be giving messages to the public that regular cannabis use is
clearly associated with increased risk for depression and increased risk
for suicide. There are a number of studies internationally that are showing
this, that any amount of regular cannabis use beyond once a week is likely
to quite significantly elevate the risk of depression.

Norman Swan: And you've done a report on that in Western Australia which
reflects the results that you just mentioned a moment ago?

Sven Silburn: I think part of the importance of that is that when we look
at the strategies of prevention, the sorts of strategies that we need to
prevent the early uptake of use of things like tobacco, alcohol and
cannabis, are probably going to be some of the things that make the most
difference to rates of suicide in the longer term. And we really do need to
be combining our efforts much more cleverly than we have been in the past.

Norman Swan: On early childhood.

Sven Silburn: Focusing on early childhood but also focusing on factors
during primary school. There are a number of factors there that can be
influenced through interventions in schools and that we're looking at some
interventions in Western Australian schools, targeting young people in
their late primary school that has shown some very promising results in
some randomised trials that we've done in preventing the early onset of
depression once these kids get to high school.

Norman Swan: What sort of things?

Sven Silburn: It basically involves some cognitive behavioural methods that
teach young kids ways of problem solving, dealing with their emotions,
recognising that there are constructive and destructive ways of dealing
with the motions, and being able to actually be emotionally literate in
giving voice to what some of these feeling states are, and thereby being
able to have much better control of them.

Norman Swan: OK, so you've got trends, you've got risk factors; are we
seeing increasing numbers?

Sven Silburn: In the last two to three years, the actual rates of suicide
in the youth age group have come down. In fact it's been quite a striking
observation around the whole country. In 1998 (these are the last figures
that are most recently available) they're around the lowest they've been in
the last 11 years.

Norman Swan: Do we know why?

Sven Silburn: Not certainly, but there are a number of possible
explanations. One is that economic conditions have improved slightly.
There's also been a huge concerted effort by governments around the whole
country to look at suicide prevention. A lot of that has been focused
around young people at schools and other youths. But the greatest reduction
has occurred in young people under the age of 20.

Norman Swan: Now you've used the information you've got to develop ways of
actually tackling the problem, what have you done?

Sven Silburn: The strategy we started with was to look at strategies which
would make a difference immediately, and to do that we looked at tackling
those at highest risk, and these were the young people coming through
accident and emergency departments following self-harm. We really looked at
what was happening, what needed to happen, and there were some gross
deficiencies in the kind of care that was being provided, that there really
were not adequate assessments being made, and the follow-up for these
people tended to be woeful. Given that the majority of subsequent suicides
were likely to occur within the first few months of discharge, we felt it
was particularly important to improve the likelihood of decent follow-up.
What we did there was to introduce some practice protocols that guaranteed
a much better level of assessment on admission and some requirements for
follow-up to happen within a few days of discharge. We also appointed some
social workers at those hospitals who would facilitate people who might be
without supports, might be homeless and things like that, to actually get
to appointments and to make sure that they were connected with someone who
would support them on discharge. Now that's been shown to be quite
effective. What we've seen since those protocols were introduced to West
Australian hospitals, is that the rates of self harm in this age group has
reduced quite substantially. But the big problem with hospitals is changing
hospital practices, a bit like turning around a super tanker, and that
bringing about change is a slow and laborious business. And the whole
culture needs to recognise that these are a group of patients who need to
be recognised as at much higher risk than was formerly accorded to them.

Norman Swan: Sven Silburn is Professor at Curtin University in the
Institute for Child Health Research in Perth.

Reference: Hillman SD et al. Suicide in Western Australia. Institute for
Child Health Research UWA May 2000

Guests: Professor Sven Silburn Centre for Developmental Health, Curtin
University and The Institute for Child Health Research, Perth, Western Australia