the new zealand suicide prevention strategy looking back to move forward dr sarb johal and maria...
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The New Zealand Suicide Prevention Strategy
Looking back to move forward
Dr Sarb Johal and Maria CotterMinistry of Health
Suicide Facts
• 2004 - 486 people died by suicide compared to 517 in 2003
• Males have higher rate of death by suicide than females - 3.1:1 in 2002-2004, unchanged from 2001-2003
• 2005 - 4,433 hospitalisations for intentional self-harm, virtually same as 2004
• Women have higher rate than men, 2:1• Maori hospitalisation rate is almost 1.5 x non-Maori
rates
Te Rau Hinengaro - The NZ Mental Health Survey
• About 1 in 5 experienced a mental disorder in last 12 months• About half of population will meet criteria for a mental disorder
by age 75 years
• 15.7% reported having thought seriously about suicide at some time
• 4.5% report having made a suicide attempt
• Suicide Trends reports trends / patterns in suicidal morbidity and mortality from 1921 to 2003 but does not provide explanations for these behaviours
New Zealand Suicide Trends
• Mortality 1921-2003• Hospitalisations for Intentional Self-Harm
1978-2004• Data broken down into specific population
groups, i.e. age, ethnicity, sex
• To inform prevention efforts and to show whether progress is being made in reducing suicidal behaviour
Three-year moving averages
• These are the average age-standardised rates for three year periods
• i.e. 1983-1985, 1984-1986 1985-1987 and so on…
• These allow for underlying trends over time to be more clearly illustrated
• They also provide for a more reasonable level of certainty as to the level of change than would a rate for only one year
Summary
• Overall pattern
• Then, suicide and hospitalisation trends by:
• Sex• Ethnic Group• Age• Socioeconomic Status• Method• DHB area
Leading causes of death for the total population, 2003
0 5 10 15 20 25 30 35 40 45 50
Genitourinary
Suicide
Digestive system
Mental disorders
Nervous system
Endocrine
Unintentional injury
Respiratory
Cancers
Heart disease
Percentage
Major cause
Age-standardised suicide rates, 3-year moving averages, 1921-2003
0
2
4
6
8
10
12
14
16
18
20
19
23
19
25
19
27
19
29
19
31
19
33
19
35
19
37
19
39
19
41
19
43
19
45
19
47
19
49
19
51
19
53
19
55
19
57
19
59
19
61
19
63
19
65
19
67
19
69
19
71
19
73
19
75
19
77
19
79
19
81
19
83
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
Midpoint year of moving average
Age-standardised rate per 100,000
Overall trends• From 1921 – 2003, two peaks in
overall suicide rate
• 1927-1929 – 18.5/100,000
• Steep period of decline to 1942
• Relatively stable to mid-1980s
• 1996-1998 second peak at 16.7/100,000
• Rate declined to 14.2/100,000 in 2001-2003
• Hospitalisation for intentional self-harm, similar trend to increases in suicide rate since the mid 1970s.
• 1978-1980 period – 76.6/100,000
• 1994-1996 – increased to 104/100,000
• Change of data coding in 1999 & 2000 – further increases
• 2002-2004 – 150.5/100,000
Beneath the overall trends
• Overall trends conceal trends within sex, age and ethnic groups
• Many of the trends in the document are primarily driven by changes of pattern in suicide in younger age groups and by differences between males and females
Suicide rate, by sex, 3-year moving average, 1921-2003
0
5
10
15
20
25
30
35
19
23
19
25
19
27
19
29
19
31
19
33
19
35
19
37
19
39
19
41
19
43
19
45
19
47
19
49
19
51
19
53
19
55
19
57
19
59
19
61
19
63
19
65
19
67
19
69
19
71
19
73
19
75
19
77
19
79
19
81
19
83
19
85
19
87
19
89
19
91
19
93
19
95
19
97
19
99
20
01
Midpoint year of moving average
Males
Females
Age-standardised rate per 100,000
Age-standardised intentional self-harm hospitalisation rates, by sex, 3-year moving averages, 1978-2004
0
50
100
150
200
250
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Midpoint year of moving average
Females
Males
Age-standardised rate per 100,000
Trends by Sex
• Overall trends in suicide mortality driven by male rates of suicide
• Trends in hospitalisation are driven by female rates
Age-standardised suicide rates, by ethnicity, 3-year moving averages 2000-2003
17.7
13.5
9.6
8.2
17.8
13.7
11.1
9.4
0
2
4
6
8
10
12
14
16
18
20
Māori European/Other Pacific Asian
Ethnic group
2000–02
2001–03
Age-standardised rate per 100,000
Age-standardised intentional self-harm hospitalisation rates, by ethnicity, 3-year moving averages, 1978-2004
0
50
100
150
200
250
1979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003
Midpoint year of moving average
Māori
Pacific
Asian
European/Other
Age-standardised rate per 100,000
Age-standardised intentional self-harm hospitalisation rates, by ethnicity and sex, 3-year moving averages, 1978-2004
0
50
100
150
200
250
300
1979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003
Midpoint year of moving average
Māori males
Non-Māori males
Māori females
Non-Māori females
Age-standardised rate per 100,000
Trends by Ethnic Group
• Highest suicide rate is for Maori, then European / Other, Pacific, then Asian ethnic groups
• Disparity between Maori and all other ethnic groups is particularly high for Maori males < 35years
• Disparity disappears for Maori males > 45• Maori females had higher rate of hospitalisation than
all other combinations of sex & ethnic group• Maori males had higher rates of hospitalisation than
non-Maori males
Age-specific suicide rate, by age group, 3-year moving average, 1921-2003
0
5
10
15
20
25
30
35
40
45
1923
1925
1927
1929
1931
1933
1935
1937
1939
1941
1943
1945
1947
1949
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
Midpoint year of moving average
5–14 years
15–24 years
25–34 years
35–44 years
45–64 years
65+ years
Age-specific rate /100,000
Age-specific intentional self-harm hospitalisation rates, by age group, 3-year moving averages, 1978-2004
0
50
100
150
200
250
300
350
1979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003
Midpoint year of moving average
5–14 years
15–24 years
25–34 years
35–44 years
45–64 years
65+ years
Age-specific rate per 100,000
Age-specific intentional self-harm hospitalisation rates by sex, 15-24 years, 3-year moving averages, 1978-2004
0
50
100
150
200
250
300
350
400
450
500
1979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003
Midpoint year of moving average
Males
Females
Age-specific rate per 100,000
Trends by Age Group
• Major changes in pattern over time• 1921-1987 suicide deaths most common in
those aged > 45 years• 1987 onwards, suicide deaths more common
in those 15-24 years, then 25-34 years
• Changes seem to have begun in the mid-1970s, though disparity between age groups have reduced over time
Age-standardised suicide rates, by quintile of deprivation (NZDep01), 3-year moving averages, 1983-2004
0
5
10
15
20
25
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Midpoint year of moving average
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Age-standardised rate per 100,000
a
Age-standardised intentional self-harm hospitalisation rate, by quintile of depression, 3-year moving averages, 1983-2003
0
50
100
150
200
250
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Midpoint year of moving average
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Age-standardised rate per 100,000
Trends by socioeconomic status
• Over last 20 years, clear, unambiguous trend of higher rates of suicide in more deprived areas of NZ
• Suicide rates in the least deprived areas are higher than any other time in last 20 years
• Rates of hospitalisation have increased since 1983-1985 at all levels of deprivation - least deprived = biggest increases
Suicide rate, by method, 3-year moving average, 1921-2003
0
1
2
3
4
5
6
7
8
192
3
192
5
192
7
192
9
193
1
193
3
193
5
193
7
193
9
194
1
194
3
194
5
194
7
194
9
195
1
195
3
195
5
195
7
195
9
196
1
196
3
196
5
196
7
196
9
197
1
197
3
197
5
197
7
197
9
198
1
198
3
198
5
198
7
198
9
199
1
199
3
199
5
199
7
199
9
200
1
Midpoint year of moving average
Poisoning by solid or liquid substances
Poisoning by gases and vapours
Hanging, strangulation and suffocation
Drowning
Firearms and explosives
Cutting and piercing
Jumping from a high place
Age-standardised rate per 100,000
Maps of age-standardised suicide rates, by District Health Board (DHB), three-year moving
averages,1983–1985, 1992–1994 and 2001–2003
Maps of age-standardised intentional self-harm hospitalisation rates, by District Health Board (DHB), three-year moving
averages, 1983–1985, 1992–1994, 2001–2003
Trends by DHBs
• No consistent trends in suicide and intentional self-harm hospitalisation rates across DHBs
• However, some indication that DHBs with high suicide rates have low rates of hospitalisation
• Those with low rates of suicide have high rates of hospitalisation
• HOWEVER, low numbers of suicide at DHB level of analysis so comparisons need to be interpreted cautiously
Why do we need a Strategy?
• Suicide is complex • Contributing factors are many and varied• Requires a multi-sectoral approach• Linking of individual and population
approaches• Need for a mechanism to organise and
mobilise these efforts nationally, to address gaps and monitor progress.
Purpose
• To reduce the rate of suicide and suicidal behaviour
• To reduce the harmful effect and impact associated with suicide and suicidal behaviour on families/whanau, friends and the wider community
• To reduce inequalities in suicide and suicidal behaviour
Principles• Be evidence based• Be safe and effective• Be responsive to Maori• Recognise and respect diversity• Reflect a coordinated multisectoral approach• Demonstrate sustainability and long term
commitment• Acknowledge that everyone has a role in suicide
prevention• Have a commitment to reduce inequalities
Pathways to suicidal behaviour
• Wide range of factors – individual to macro-social
• These can contribute directly, but also indirectly by influencing susceptibility to mental health problems
Pathways to suicidal behaviour (ctd)
• Contextual factors also influence the extent to how these factors contribute to suicidal behaviours, eg:Cultural factors may modify risk and protective
factors Institutional settings (school, workplaces, hospitals
and prisons) may influence risk Media climates may influence extent and
expression of suicidal tendenciesPhysical environments may influence availability of
methods
Risk factors• A mix of conditions that contribute to the end
point of suicide: Mental disorders, including depression, bipolar
disorders, schizophrenia, anxiety disorders, substance use disorders, antisocial and offending behaviours
Exposure to recent stress or life difficultyExposure to childhood adversity and traumaTendencies to react impulsively or aggressively
under stressSocioeconomic and educational disadvantages
Protective factors• Good coping and problem solving skills • Positive beliefs and values• Feelings of self-esteem and belonging• Social connections• Secure cultural identity• Supportive and nurturing family• Responsibility for children• Social support and access to services• Holding attitudes against suicide
Goal 1.
• Promote mental health and wellbeing, and prevent mental health problems.
Goal 2.
• Improve the care of people who are experiencing mental disorders associated with suicidal behaviour.
Goal 3.
• Improve the care of people who make non-fatal suicide attempts.
Goal 4.
• Reduce access to the means of suicide.
Goal 5.
• Promote the safe reporting and portrayal of suicidal behaviour by the media.
Goal 6.
• Support families/whanau, friends and others affected by a suicide or suicide attempt.
Goal 7.
• Expand the evidence about the rates, causes and effective interventions.
Next steps
• Identify what works
• Take stock of what we have, what we don’t have, and what we need more of
• Agree to a plan of action for the next 5 years
• Establish a system to monitor our efforts nationally
