Auseinetter - Issue 3
Early Intervention in Youth Suicide in Australia
The Commonwealth Youth Suicide Prevention Advisory Group held its last
meeting in Canberra last month; up to that point it had advised
Mental Health Branch, and through them the Federal Minister for Health and
Family Services, on the National Youth Suicide Prevention Strategy (NYSPS). In
fact YSPAG had responsibility over two and a bit years for the $13m of the
Youth Suicide Prevention Initiative (most of which reaches completion by the
end of 1998), but had less to do with the more recent $18m or the targeting of
the programs which are just now beginning to get off the ground.
Responsibility for the total package will now reside with a new Ministerial
Advisory Committee which will have more formal representation from each state
and territory and, it is hoped, will be able to ensure better coordination of
funding and projects for Suicide Prevention between the Commonwealth and the
States. YSPAG, as a committed and representative group, was ever mindful in its
deliberations of the possible legacy from the Strategy and repeatedly focused
on the possible long term outcomes for young people from investing such a large
amount of money; how could we be sure that it was spent wisely?
The Evaluation Working Group (previously a subcommittee of YSPAG) will continue
to liaise with the 34 individual programs (for brief descriptions please see
http://Auseinet.flinders.edu.au/projects/index),
assisting the external evaluators for each program with their evaluations, and
will report to the MAC about both the outputs from the Strategy and the
outcomes gained. In addition, the Australian Institute for Family Studies is
evaluating the whole NYSPS - as a strategy and in terms of overall outcome (for
preliminary information please see http://aifs.org.au). These two processes
should, between them, provide most of the answers to two major questions: "Did
we in Australia get it right?" and "Where do we go from here?" In the early
days YSPAG was criticised for what appeared to be somewhat of a random process
of funding projects. Nothing could be further from the truth. Admittedly in
the first few months there was pressure to fund some major initiatives in
training for general practitioners, and, as a consequence, some felt that the
funding had occurred before an overall funding model was clear. However, the
rationale for each of the major areas of funding was clear (Mental Health
Branch, 1995a & 1995b), each of the processes followed due tender process,
and the many applications for each major area were carefully scrutinised in
depth by subcommittees of YSPAG which co-opted professionals with special
expertise where necessary. The overarching model adopted was that of Mrazek and
Haggerty (1994), and a basic tenet within this was to attempt at least some
innovative programs - not just replicate previous work from overseas. The focus
of course has been on prevention - more primary and secondary perhaps than
tertiary. Within this have been funded some Universal preventative programs
which include mental health promotion and education to both young people, their
carers, and the professionals who deal with them.
There are many programs targeted at Indicated prevention - that is at
populations thought to be at increased risk (indigenous young people, rural
youth, or gay and lesbian young people are good examples). Further programs
have addressed Selective (or Targeted) prevention with young people who may be
showing signs of early illness (homeless and marginalised youth, and/or those
with previous suicidal behaviours, provide a good example). A number of
programs have been funded for young people with early or first episode illness
(for instance those identified as cases of depression).
Finally a smaller number of programs have been funded to examine innovative
approaches in case management or rehabilitation in the community. If you read
Maris et al. (1992), it becomes clear that there is a process which leads up to
the final behaviour of suicide; it doesn't just come out of the blue. We could
call this a pathway or a 'trajectory'. It is complex and different for each
individual, but background, cultural, community, family or personal historical
factors prepare the ground, a series of negative events over the course of time
may escalate the person along the trajectory, gathering pace in the context of
an illness or (for example) a personal loss, reducing the options for healthy
change. At some point there is a spark which ignites the process to a speed
and final direction where no intervention is likely to change the trajectory.
Where we intervene as individual professionals in part depends on at what point
we come across the trajectory; we do the best we can at that time. For the
community, taking an overall view of the issue, it is different; there are some
points along the trajectory which are more likely (that is the evidence would
suggest this is the best place) to change its direction. To a certain extent
the earlier we can intervene, the more likely we may be to change the
trajectory. In contrast, if we intervene too early, we may not have clear
evidence for just who is most at risk; our targeting may be poor, and we may
'waste' effort and resources. As individuals we need to know what works best
at any given point along the trajectory so that we can do our best. As a
community we probably need to know more where to place the available resources;
if you like, we need to know the 'best buy'. The National Youth Suicide
Prevention Strategy can be expected to provide some of the Australian evidence
clarifying what may be done at which point along the trajectory. As a
community we can expect that it will also clarify a little about the best buy
or 'best combination of buys' to achieve reduction in the outrageous level of
young suicides in this country.
At Auseinet we believe that this model of trajectory may assist us to define
similar issues for early intervention in a range of mental health disorders and
problems. Two of our tasks are to collect the available evidence in each case
to clarify the 'trajectory', and then see whether we can move toward defining
'best buy'.
Professor Graham Martin, for the Auseinet Team
References
Maris, R.W., Berman, A.L. & Maltsberger, J.T. 1992. Summary and
Conclusions: What have we learned about Suicide Assessment and Prediction? In
R. Maris, A. Berman, J. Maltsberger & R.Yufit, Assessment and Prediction of
Suicide, The Guilford Press, New York.
Mrazek, P. and Haggerty, R.J. (Eds.), 1994. Reducing Risks for Mental
Disorder: Frontiers for Preventive Intervention Research. Committee on
Prevention of Mental Disorders, Institute of Medicine. Washington, DC,
National Academy Press.
Primary Health Care Group, Mental Health Branch, 1995a. Youth Suicide in
Australia: a background monograph. Commonwealth Department of Human Services
and Health, Australian Government Publishing Service. ISBN 0 644 45407 5
Primary Health Care Group, Mental Health Branch, 1995b.
Here for Life: A national plan for youth in distress. Commonwealth Department
of Human Services and Health, Australian Government Publishing Service.