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ANP0010.1177/0004867415620024ANZJP ViewpointKrysinska et al.

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Australian & New Zealand Journal of Psychiatry

Best strategies for reducing the suicide 2016, Vol. 50(2) 115­–118
DOI: 10.1177/0004867415620024

rate in Australia © The Royal Australian and

New Zealand College of Psychiatrists 2015
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Karolina Krysinska1, Philip J Batterham2, Michelle Tye1,

Fiona Shand1, Alison L Calear2, Nicole Cockayne1
and Helen Christensen1
Editor’s Choice

Abstract
Objectives: There is accumulating evidence about effectiveness of a number of suicide prevention interventions, and a
multilevel systems approach seems promising in reducing suicide risk. This approach requires that components ranging
from individual-level to public health interventions are implemented simultaneously in a localised region. This paper pres-
ents estimated reductive effects on suicide attempts and deaths that might be expected in Australia if active components
of the systems approach were to be implemented.
Method: The study estimated population preventable fractions which indicate the extent to which suicide attempts and
deaths might be decreased if the each of the proposed interventions was fully implemented. The population preventable
fractions were based on the best available evidence available in the literature for the risk ratio for each intervention.
Prevalence estimates were assessed for each component of the proposed systems approach: reducing access to suicide
means, media guidelines, public health campaigns, gatekeeper programmes, school programmes, general practitioner
training, psychotherapy and co-ordinated/assertive aftercare.
Results: There was insufficient evidence available for the impact of a number of strategies, including frontline staff
gatekeeper training, on either suicide attempts or deaths. Taking prevalence of exposure to the intervention into con-
sideration, the strategies likely to bring about the strongest reduction in suicide attempts were psychosocial treatments
and co-ordinated/assertive aftercare. The greatest impact on reductions in suicide deaths was found for psychosocial
treatment, general practitioner training, gatekeeper training and reducing access to means of suicide.
Conclusion: The evidence regarding the overall efficacy of the systems approach is important in identifying what strate-
gies should be prioritised to achieve the biggest impact. The findings of the population preventable fraction calculations
indicate that the systems approach could lead to significant reduction in suicide attempts and suicide deaths in Australia.
Potential synergistic effects between strategies included in the approach could further increase the impact of imple-
mented strategies.

Keywords
Population preventable fraction, risk ratio, suicide, suicide prevention

In 2013, 2522 people died by suicide in
Australia, and an estimated 65,000
made an attempt (Australian Bureau of
Statistics [ABS], 2015b; Johnston et al.,
2009). Australia’s suicide rate (approx-
imately 11 per 100,000) has remained
stubbornly consistent over the last
decade or more (ABS, 2015b).
Moreover, it exceeds that of some
European countries, including the
United Kingdom, the Netherlands,
Spain and Switzerland (World Health
Organization [WHO], 2014).
Recently, there have been signifi-
cant changes, globally, to suicide pre-
vention by researchers and policy
makers. First, evidence is accumulat-
ing about the effectiveness of a num-
ber of suicide prevention interventions
(Mann et al., 2005). Second, a new idea
has emerged that a multilevel, multi-
factorial systemic approach is needed
1The University of New South Wales and
Black Dog Institute, Randwick, NSW,
Australia
2Centre for Mental Health Research, The
Australian National University, Canberra,
ACT, Australia
Corresponding author:
Helen Christensen, The University of New
South Wales and Black Dog Institute, Hospital
Road, Randwick, NSW 2031, Australia.
Email: h.christensen@blackdog.org.au

Australian & New Zealand Journal of Psychiatry, 50(2)

116 ANZJP Perspectives
to comprehensively reduce suicide
risk (Hegerl et al., 2013; While et al.,
2012). This approach requires that
components ranging from public
health interventions to individual-
level interventions are implemented
simultaneously in a localised region.
While many of these suicide preven-
tion strategies have been individually
implemented in Australia, no attempt
has been made to simultaneously com-
bine these strategies using a systems
approach framework.
As a systems approach to suicide
prevention has not yet been imple-
mented in Australia, the present paper
attempts to estimate the reductive
effects on suicide deaths and attempts
that might be expected if active com-
ponents of a systems approach were
to be implemented. The method
involves three steps. First, nine evi-
dence-based suicide prevention strat-
egies were identified: reducing access
to lethal means, responsible media
reporting, community awareness pro-
grammes, gatekeeper training, school-
based suicide prevention programmes,
training of general practitioners and
frontline staff, psychotherapy and fol-
low-up for individuals with a recent
suicide attempts (Calear et al., 2015;
Mann et  al., 2005; Van der Feltz-
Cornelis et al., 2011). Second, the size
of the effect of each of these strate-
gies were estimated using existing
risk ratio (RR) estimates for suicide
deaths and suicide attempts. Third,
the extent to which each of these
strategies will reach the communities
so that they can have impact (the
prevalence) was estimated. These two
estimates were used to calculate the
population preventable fractions
(PPFs, analogous to Population
Attributable Risk, PAR), which indi-
cate the extent to which suicide
attempts/deaths might be decreased
if the each of the proposed systems-
based interventions was fully imple-
mented. The ultimate goal of the
paper is to provide policy makers and
community organisations with evi-
dence-based information that will
help set priorities.
Australian & New Zealand Journal of Psychiatry, 50(2)
Method
Existing literature was used to esti-
mate PPF for each intervention. Using
the best available estimates of risk
ratio relating to either suicide deaths
or suicide attempts and proportion
exposed, the PPF was calculated
(Rockhill et al., 1998). The PPFs were
based on the best available evidence
for the risk ratio (RR) for each inter-
vention provided in the literature.
The best available evidence for the
RR estimate for each component was
chosen from a meta-analysis when
available. When no meta-analysis was
available, a multicentre randomized
controlled trial (RCT) or systematic
review was chosen as the data source.
If none of these was available, a single
study with a large sample size and
clear reporting of RR was selected.
Prevalence estimates were assessed
uniquely for each component as fol-
lows (Table 1): Reducing access to
means: the proportion of suicide
attempts/deaths attributed to self-poi-
soning, Media Guidelines the propor-
tion of the population exposed to
media, Public Health Campaigns: the
proportion of residents reached by a
flyer campaign; Gatekeeper programmes:
assumption that gatekeeper pro-
grammes could be established in 20%
of workplaces, with 52.5% of the tar-
get population in employment; School
Programmes: the proportion of resi-
dents that are school-aged combined
with an assumption that 50% of
schools would agree to participate in
such a programme; General practitioner
(GP) training: the proportion of suicidal
people who receive primary care
treatment; Psychotherapy: based on an
increase in the proportion of suicidal
people who receive mental health care
from 31.6% to 50%; and Co-ordinated
and assertive aftercare: the proportion
of people who attempt suicide that
reach an emergency department.
There was insufficient evidence for
frontline training as current studies
only examined the effect of training on
knowledge and attitudes, not on sui-
cidal deaths or attempts. This paper
rests on the requirement that data are
available on the expected size of the
effect to allow modelling, an assump-
tion that was not met for a number of
the strategies.
Results
Estimates of PPF are provided in
Table 1, with references to the source
of the RR data. Insufficient evidence
was available for the impact of a num-
ber of strategies on either suicide
attempts or deaths (Table 1). In respect
to suicide attempts, most interven-
tions have RRs that are not dissimilar
(ranging from .397 to .680). These RRs
indicate that all strategies have demon-
strated effectiveness in reducing sui-
cide attempts. Taking prevalence of
exposure to the intervention into con-
sideration, psychosocial treatments
and coordinated/assertive/brief after-
care are the strategies likely to bring
about the strongest reduction in sui-
cide attempts. Similarly, for suicide
deaths all interventions are associated
with relatively high risk ratios (ranging
from .580 to .971). Taking into account
population exposure, however, psy-
chosocial treatment, GP training, gate-
keeper training and reducing access to
means appear to have the greatest
impact on reductions in suicide deaths.
Discussion
The findings of the PPF calculations
indicate that a systems approach could
lead to significant reduction in suicide
attempts and suicide deaths in
Australia. Two interventions with the
greatest impact on suicide attempts,
psychosocial treatments and coordi-
nated/assertive/brief aftercare, could
decrease the prevalence of attempts
by 8.0% and 19.8%, respectively. In
regards to suicide deaths, the biggest
reductions can be achieved through
GP training, psychosocial treatments,
gatekeeper training and reducing
access to means (6.3%, 5.8%, 4.9% and
4.1%, respectively). Given that, in 2013,
there were 27,112 suicide attempts
(Harrison and Henley, 2014) and 2522
Krysinska et al. 117

Table 1.  Estimated population preventable fraction for each of the strategies in the systems approach.

Strategy Suicide attempts Suicide RR sources* Prevalence

  estimates*
RR Exposure PPF RR Exposure PPF

Reducing access to 0.500 0.005 0.5% 0.720 0.110 4.1% Pirkis et al. (2013), ABS (2015b),
suicide means Skegg and Herbison Harrison and
(2009) Henley (2014)

Media guidelines – – – 0.950 0.240 1.2% Niederkrotenthaler Niederkrotenthaler

and Sonneck (2007) and Sonneck (2007)

Suicide public – – – 0.971 0.109 0.3% Matsubayashi et al. Matsubayashi et al.

awareness (2014) (2014)
campaign

School-based 0.546 0.037 2.9% – – – Wasserman et al. ABS (2015a)

programmes (2015)

Gatekeeper – – – 0.670 0.105 4.9% Knox et al. (2003) ABS (2015c)

training

Frontline staff – – – – – –  
gatekeeper training

GP training – – – 0.920 0.769 6.3% Henriksson and Pirkis and Burgess

Isacsson (2006) (1998)

Psychosocial 0.680 0.184 8.0% 0.750 0.185 5.8% O’Connor et al. Bruffaerts et al.
treatment (2013), Erlangsen (2011)
et al. (2015)

Coordinated/ 0.397 0.163 19.8% 0.580 0.016 1.1% Hvid et al. (2011), Carroll et al.
assertive/brief Milner et al. (2015) (2014)
aftercare

PPF: population preventable fraction; GP: general practitioner.

*Please, see supplementary file for full references.

suicide deaths (ABS, 2015b), these
results suggest that up to 160 lives
could be saved annually, and up to
5370 hospitalisations due to inten-
tional self-harm could be prevented. It
is possible, however, that a systems
approach may have an even greater
combined impact, due to potential
synergistic effects between strategies
(Van der Feltz-Cornelis et al., 2011).
These PPF estimates are designed
to generate further planning and dis-
cussion around the best avenues for
suicide prevention. The PPF calcula-
tions need to be considered in respect
to a number of caveats. We have used
the best available evidence for the RR
estimate for each component, such as
a meta-analysis, a multicentre RCT, a
systematic review or a single study
with a large sample size and clear
reporting of RR. Using different
sources might have resulted in differ-
ent findings. We did not include error
margins with the estimates, as many
further assumptions would be required
for these calculations. The PPFs may
vary in response to a number of fac-
tors including regional effects, imple-
mentation challenges, the context in
which the intervention is delivered and
baseline variations in terms of pre-
existing programmes that may already
be impacting on suicide attempts or
deaths. The impact of interventions
may overlap, for example, the combi-
nation of brief contact and aftercare
interventions would impact the same
population. Combined effects from
multiple interventions may be less than
the sum of their individual effects, or
synergise to create a stronger effect.
However, partial implementation of an
intervention would reduce the impact
of that intervention. In addition, the
studies from which the risk estimates
were drawn come from various
regions, where the context of the
intervention may or may not reflect
the Australian context, and do not
include the impact of social determi-
nants of health. Second, we were una-
ble to source accurate estimates for a
number of the effects of interest, as
there is insufficient research on the
effects of several of the strategies on
suicide attempts or deaths.
Conclusion
Currently, there is an absence of data
available to be able to calculate the
potential reductive effects of a number
of suicide prevention interventions on
suicide deaths and attempts. The
absence of appropriate data highlights

Australian & New Zealand Journal of Psychiatry, 50(2)

118 ANZJP Perspectives
the need for improved evaluation of
suicide prevention interventions, espe-
cially in the Australian context. The
available evidence regarding the overall
efficacy of the systems approach, how-
ever, is critically important in identify-
ing what strategies should be
prioritised, and where, in order to
achieve the biggest impacts.
Declaration of Conflicting
Interests
The author(s) declared no potential con-
flicts of interest with respect to the
research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial sup-
port for the research, authorship, and/or
publication of this article.
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