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

The Controversy Over
Australian Suicide Statistics
Dr Duncan Wallace
Consultant Psychiatrist
Australian Defence Force Centre for Mental Health
Joint Health Command

2
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?

3
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]

4
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]

5
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]

6
• 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]

7
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

8
• 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

9
• 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

10
• 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”

11
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

12
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

13
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

14
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

15
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

16
De Leo D et al, Achieving
standardised reporting of suicide
in Australia: rationale and
program for change MJA 2010;
192 (8): 452-456

17
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.

18
Large M, Nielssen O and Lackersteen S. The rise and fall of suicide in
NSW. MJA 2009; 190: 282.

19
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

20
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

21
Page A, Taylor R and Martin G. Recent declines in Australian male suicide
• 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)

22
Page A, Taylor R and Martin G. Recent declines in Australian male suicide are real,
not artefactual. ANZJP 2010,44,358-363.
• First scenario- male
suicide rates declined
38% to 24 per 100
000.
• Second scenario-
male suicide rates
declined 33% to 26
per 100 000

23
Page A, Taylor R and Martin G. Recent declines in Australian male suicide
• Australian all-cause
and selected cause-
specific mortality
rates in young men
(20-34years) (1979-
2005).

24
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]

25
Confounding variables in suicide statistics
• Insurance considerations
• State or religious sanctions
• Family and community sensitivity

26
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

27
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

28
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

29
• April 2009 establishment of National
Committee for Standardised Reporting of
Suicide
– To achieve cross-jurisdictional standardization
of all relevant procedures

30
• QUESTIONS?

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