Are suicide rates for young australian males really falling the recent controversy explained- wallace

The Controversy Over Australian Suicide Statistics

Dr Duncan WallaceConsultant Psychiatrist

Australian Defence Force Centre for Mental Health

Joint Health Command

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Australian Suicide Statistics Controversy

• Has there been a major reduction in suicides Australia since 1997?

• If so, what is the significance of this to the ADF?

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Relevance to the ADF?

• Suicide accounts for only 1.6% of all deaths in Australia

• But suicide comprises more than 20% of deaths for men aged between 20 and 39 years

• Men remain four times more likely than women to die by suicide [Goldney RD, Suicide in Australia: some good news. MJA 2006; 185: 304]

• Deaths from suicide exceed those from MVAs [De Leo 2010]

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Suicide Trends in Australia

1964-1993 • Suicide ‘epidemic’• Suicides trebled in Males aged 15-24 • 1964 Metro suicide rates higher • 1993 Rural suicide rates higher [Dudley M et al. Suicide

among young Australians, 1964-1993: an interstate comparison of metropolitan and rural trends MJA 1998; 169: 77-80]

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Suicide Trends in Australia

1964-1993• Towns with population <4000 suicide rates

increased by up to 12X• Methods- increased suicide by GSW in

rural areas despite overall reduction in suicides by GSW [Dudley et al, ibid]

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• Media coverage• Major Government and community response-

1995 National Youth Suicide Prevention Strategy

• Increased awareness by medical profession• Targeted rural programmes e.g., NSW Rural

Mental Health Skills Development Program [Owen C et al, A model for clinical and educational psychiatric service delivery in remote communities. ANZJP 1999, 33: 372- 378]

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Goldney RD, Suicide in Australia: some good news. MJA 2006; 185: 304

• 2004 ABS figures showed a sustained reduction in the number of suicides each year from peak in 1997

• Age-standardised suicide rate reduced to 10.4 per 100 000 population in 2004

• 29% lower than the rate of 14.7 per 100 000 in 1997

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• There was a reduction in all 5-year age groups for men and women between 1997 and 2004, except for women in the 45–49-years age group

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• Most striking for people aged 15–24 years, for whom there was a reduction in suicide rates of about 50% —– from 19.3 per 100 000 in 1997– to 9.6 per 100 000 in 2004

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• The highest suicide rates in 1997 were for men aged 15–24 years

• 2004 the peak was in that same group of men, now aged 25–44 years

• This is consistent with a “cohort effect”

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Why?• Better community awareness of the antecedents of

suicide• Suicide prevention programmes • Provision of more accessible services• Better recognition and treatment of depression• ? more prescription of antidepressants

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DeLeo D, Suicide mortality data need revision. MJA 2007; 186: 157-158

• In 2004, there were 580 cases of suicide in Queensland, and not 453, as reported by the Australian Bureau of Statistics (ABS) on 14 March 2006

• These data alone reverse the declining trend for suicide mortality nationally in the most recent years

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DeLeo D., Suicide mortality data need revision. MJA 2007; 186: 157-158

• Very large backlog of cases still under investigation by coroners, a phenomenon that is reported as increasing in recent years

• Claimed problems with ABS data from 2002 onwards

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Harrison J, Pointer S, Elnour AA. A review of suicide statistics in Australia.

Canberra: Australian Institute of Health and Welfare (AIHW), 2009.

• ABS reports contained a warning about possible under-reporting from 2005 onwards

• Criticism about ABS procedures led the AIHW to undertake a ‘recount’ of the official suicide data for 2004

• ABS had underestimated suicide for Australia by 16% in that year; Qld by 24.9%– Counting errors– Misclassification- open verdicts

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Williams R et al, Accuracy of official suicide mortality data in Queensland. ANZJP, 2010,44: 815–822

• Prior to 2006, ABS staff visited coroners’ offices to get data from files

• From 2006, reliance by ABS on electronic data only recorded on the National Coroners Information System (NCIS)

• NCIS becoming increasingly inaccurate • inaccuracy from the lack of staff resources in the

coroners’ offices in the states and territories • creating a backlog of closed cases to be entered

on the electronic system

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De Leo D et al, Achieving standardised reporting of suicide in Australia: rationale and program for change MJA 2010; 192 (8): 452-456

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Support for a decline in Suicide Rates in Australia

• McPhedran S and Baker J. Recent Australian suicide trends for males and females at the national level: Has the rate of decline differed? Health Policy 2008, 87; 350-358.

• Chapman S and Hayan A. Declines in Australian suicide: A reanalysis of McPhedran and Baker (2008) Health Policy 2008, 88;152-154.

• Morrell, S et al. The decline in Australian young male suicide. Social Science & Medicine. 64(3):747-54, 2007.

• Large M, Nielssen O and Lackersteen S. The rise and fall of suicide in NSW. MJA 2009; 190: 282.

• Large M, Nielssen O. Suicide in Australia: meta-analysis of rates and methods of suicide between 1988 and 2007. MJA 2010; 192: 432-437.

• Page A, Taylor R and Martin G. Recent declines in Australian male suicide are real, not artefactual. ANZJP 2010,44,358-363.

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Large M, Nielssen O and Lackersteen S. The rise and fall of suicide in NSW. MJA 2009; 190: 282.

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Large M, Nielssen O. Suicide in Australia: meta-analysis of rates and methods of suicide between 1988 and 2007. Med J Aust 2010; 192: 432-437

• Meta-analysis of pooled ABS data for decade long periods between 1988-2007– 8% decline in national pooled estimates of

male suicide– Significant local variation e.g. increase in rate

of male suicides in NT– Reductions in shooting, gassing and

poisoning

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Large M, Nielssen O. Suicide in Australia: meta-analysis of rates and methods of suicide between 1988 and 2007. Med J Aust 2010; 192: 432-437

Possible explanations?• Gun control laws• Catalytic converters in new cars• Reduced TCA prescription

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Page A, Taylor R and Martin G. Recent declines in Australian male suicide are real, not artefactual. ANZJP 2010,44,358-363.

• Two misclassification scenarios– 9% (2000-2005 Change to ICD-10

misclassification to unintentional causes e.g., accidental hanging, poisoning )

– 17% (due to misclassification of open cases and unintentional causes of death)

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• First scenario- male suicide rates declined 38% to 24 per 100 000.

• Second scenario- male suicide rates declined 33% to 26 per 100 000

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• Australian all-cause and selected cause- specific mortality rates in young men (20-34years) (1979- 2005).

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Goldney RD, A note on the reliability and validity of suicide statistics. Psychiatry, Psychology and Law 2010,71, 52-56

• Problems with reliability of suicide statistics dating back to 1790 [Moore C. A full inquiry into the subject of suicide etc 2 vols. London, 1790, JF and C Rivington]

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Confounding variables in suicide statistics

• Insurance considerations• State or religious sanctions• Family and community sensitivity

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Confounding variables in suicide statistics (ctd)

• Different professions recording suicide in different jurisdictions

• Differences between ‘legal’ and ‘clinical’ suicide– Legal- evidence of intent required to reach a

set standard– Clinical- balance of probabilities

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DeLeo D., Suicide mortality data need revision. MJA 2007; 186: 157-158

• Some underreporting in suicide statistics is ‘virtually ubiquitous’ and has to be tolerated eg, misclassification as – accident – disease-related esp. in the elderly– cover-up because of stigma– sociocultural norms– insurance reasons– remoteness of location

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Harrison J, et al. A review of suicide statistics in Australia. Injury research and statistics series No 49. Australian Institute of Health and Welfare, Canberra July 2009. Viewed at

http://www.aihw.gov.au/publications/index.cfm/title/10754 on 7 October 2010

ABS revision process for causes of death• Data on deaths registered before 2007 were

finalized by ABS before the annual release of the report of causes of death

• Some cases were still ‘open’ on NCIS• No revision of ABS data after coroner closed

case• New system- causes of death can be reviewed

for at least 2 years allowing longer for ABS to receive final info from coroners

http://www.aihw.gov.au/publications/index.cfm/title/10754

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• April 2009 establishment of National Committee for Standardised Reporting of Suicide– To achieve cross-jurisdictional standardization

of all relevant procedures

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• QUESTIONS?

Education

Are suicide rates for young australian males really falling the recent controversy explained- wallace