Lessons from the development and delivery of a rural suicide prevention program

AIMS: Suicide prevention remains a priority in rural and remote Australia, where suicide rates continue to be higher than those in urban communities. This commentary describes the Good SPACE suicide prevention program, and the lessons learned from delivering this program over a 14‐year period. CONTEXT: The Good SPACE program has been operating in rural New South Wales since 2007. The program focuses on educating rural community members to recognise the signs of suicide vulnerability, and how to take appropriate action if they encounter someone considering suicide. APPROACH: Communities are selected to receive Good SPACE training in consultation with key stakeholder organisations, or by request from communities. Across the life of the program, key challenges in its administration have included short‐term funding arrangements and staff turnover. Strengths have included the ability to adapt content to meet the needs of rural communities (eg from an initial focus on helping farmers during periods of drought, to a broader focus on all rural residents and a wider range of adversities). As the program moves forward, emphasis will be placed on harder‐to‐reach populations, including males and those with lower mental health literacy. CONCLUSION: The Good SPACE program has ongoing funding to adapt its content and continue administration through the Rural Adversity Mental Health Program (https://www.ramhp.com.au/). The lessons learned throughout the life of the program might be of use to other organisations aiming to provide community‐based education programs in rural and remote communities

Psychological distress in rural Australia: regional variation and the role of family functioning and social support

AIM Regional variation in the prevalence of mental disorders and particularly variation in the role of risk and protective factors has received limited research attention. This study investigates variation in the prevalence of significant psychological distress across regions, and quantifies the relative impact of family functioning and social support. SUBJECT AND METHOD Multilevel analysis of data from the longitudinal Australian Rural Mental Health Study, comprising a stratified random sample from non-metropolitan New South Wales. Distress was assessed using the Kessler-10. The analysis considered clustering within households and across geographic regions based on Local Government Areas and collapsed to represent residence in inner regional, outer regional, remote and very remote locations. RESULTS There was limited clustering of psychological distress within areas (0.4 %). However, the household accounted for almost 45 % of the variance in psychological distress, and the salience of the household was greater in more remote regions (33.1 % in inner regional to 60.5 % in very remote areas). Family functioning and perceived social support were associated with increased risk of psychological distress, but explained only a modest amount of variance in mental health at household level. After controlling for individual and family/social covariates, 34.5 % of the remaining variance in psychological distress was observed at the household level. CONCLUSION The findings suggest that individuals in remote locations are more reliant on their family/confidants for their mental health than those in more populated areas. Future research will consider whether this simply reflects differences in the accessibility of formal health services or broader social and cultural differences.The study was funded by the National Health and Medical Research Council (Project Grants No. 401241; No. 631061), the Australian Research Council grant arcID:ft130101444 and also supported by a Research Capacity Building Grant to the Australian Rural Health Research Collaboration

Urban-rural influences on suicidality: gaps in the existing literature and recommendations for future research

Suicide is a major public health issue of particular concern among rural populations, which experience a consistently higher suicide rate than urban areas. Although extensive research efforts have been directed towards understanding suicidality and related factors, there is a continued lack of clinically useful factors to target preventive measures, particularly among some regional and demographic groups. This suggests limitations in the conceptualisation of this important construct. A review of the literature was undertaken, using a snowballing and saturation approach. Literature was considered relevant if it addressed the research question ‘what are the current limitations in research on urban/rural influences on suicidality?’ Findings were used to develop a set of guidelines to inform future research. A number of gaps in existing research relevant to limitations in rural suicide research were identified: inconsistencies in terminology; a focus on high-end suicidal behaviours; a disproportionate focus on urban populations; a dominance of cross-sectional research; and a high use of clinical samples. These limitations are discussed in terms of their implications for rural suicidality, and are used to support the development of recommendations for future research, with a focus on encouraging consistency and standardisation. A number of limitations can be identified in existing research on suicide. Targeting these specific areas can be an important step in addressing the current gaps in knowledge relating to rural suicide prevention

Feasibility of internet-delivered mental health treatments for rural populations

Purpose: Rural populations face numerous barriers to mental health care. Although internet-delivered mental health treatments may offer an accessible and cost-effective answer to these barriers, there has been little evaluation of the feasibility of this approach among rural communities. Methods: Data were obtained from a random rural community sample through the third wave of the Australian Rural Mental Health Study. Attitudes towards internet-delivered mental health treatments and availability of internet access were explored. Data were analysed to identify sub-groups in whom internet-delivered treatments may be usefully targeted. Results: Twelve hundred and forty-six participants completed the survey (mean age 59 years, 61 % females, 22 % from remote areas). Overall, 75 % had internet access and 20 % would consider using internet-based interventions, with 18 % meeting both of these feasibility criteria. Logistic regression revealed feasibility for internet-delivered mental health treatment was associated with younger age, male gender, being a carer, and a 12-month mental health problem. Participants who had used internet-delivered services in the past were significantly more likely to endorse these treatments as acceptable. Conclusions: There is considerable potential for internet-delivered treatments to increase service accessibility to some sub-groups, particularly among people with mental health problems who are not currently seeking help. Resistance to internet treatments appears to be largely attitudinal, suggesting that enhancing community education and familiarity with such programs may be effective in improving perceptions and ultimately access

Is the reported increase in young female hospital-treated intentional self-harm real or artefactual?

BACKGROUND: The Australian Institute of Health and Welfare has reported an increased rate of hospital-treated intentional self-harm in young females (2000–2012) in Australia. These reported increases arise from institutional data that are acknowledged to underestimate the true rate, although the degree of underestimation is not known. OBJECTIVE: To consider whether the reported increase in young females’ hospital-treated intentional self-harm is real or artefactual and specify the degree of institutional underestimation. METHODS: Averages for age- and gender-standardised event rates for hospital-treated intentional self-harm (national: Australian Institute of Health and Welfare; state: New South Wales Ministry of Health) were compared with sentinel hospital event rates for intentional self-poisoning (Hunter Area Toxicology Service, Calvary Mater Newcastle) in young people (15–24 years) for the period 2000–2012. A time series analysis of the event rates for the sentinel hospital was conducted. RESULTS: The sentinel hospital event rates for young females of 444 per 100,000 were higher than the state (378 per 100,000) and national (331 per 100,000) rates. There was little difference in young male event rates – sentinel unit: 166; state: 166 and national: 153 per 100,000. The sentinel hospital rates showed no change over time for either gender. CONCLUSION: There was no indication from the sentinel unit data of any increase in rates of intentional self-poisoning for young females. The sentinel and state rates were higher than the national rates, demonstrating the possible magnitude of underestimation of the national data. The reported increases in national rates of hospital-treated self-harm among young females might be due to artefactual factors, such as changes in clinical practice (greater proportion admitted), improved administrative coding of suicidal behaviours or possibly increased hospital presentations of community self-injury cases, but not intentional self-poisoning. A national system of sentinel units is needed for the accurate and timely monitoring of all hospital-treated self-harm

Determinants of suicidal ideation and suicide attempts: parallel cross-sectional analyses examining geographical location

Background: Suicide death rates in Australia are higher in rural than urban communities however the contributors to this difference remain unclear. Geographical differences in suicidal ideation and attempts were explored using two datasets encompassing urban and rural community residents to examine associations between socioeconomic, demographic and mental health factors. Differing patterns of association between psychiatric disorder and suicidal ideation and attempts as geographical remoteness increased were investigated. Methods: Parallel cross-sectional analyses were undertaken using data from the 2007 National Survey of Mental Health and Wellbeing (2007-NSMHWB, n = 8,463), under-representative of remote and very remote residents, and selected participants from the Australian Rural Mental Health Study (ARMHS, n = 634), over-representative of remote and very remote residents. Uniform measures of suicidal ideation and attempts and mental disorder using the World Mental Health Composite International Diagnostic Interview (WMH-CIDI-3.0) were used in both datasets. Geographic region was classified into major cities, inner regional and other. A series of logistic regressions were undertaken for the outcomes of 12-month and lifetime suicidal ideation and lifetime suicide attempts, adjusting for age, gender and psychological distress. A sub-analysis of the ARMHS sample was undertaken with additional variables not available in the 2007-NSMHWB dataset. Results: Rates and determinants of suicidal ideation and suicide attempts across geographical region were similar. Psychiatric disorder was the main determinant of 12-month and lifetime suicidal ideation and lifetime suicide attempts across all geographical regions. For lifetime suicidal ideation and attempts, marital status, employment status, perceived financial adversity and mental health service use were also important determinants. In the ARMHS sub-analysis, higher optimism and better perceived infrastructure and service accessibility tended to be associated with a lower likelihood of lifetime suicidal ideation, when age, gender, psychological distress, marital status and mental health service use were taken into account. Conclusions: Rates and determinants of suicidal ideation and attempts did not differ according to geographical location. Psychiatric disorder, current distress, employment and financial adversity remain important factors associated with suicidal ideation and attempts across all regions in Australia. Regional characteristics that influence availability of services and lower personal optimism may also be associated with suicidal ideation in rural communities

You’ve got to have friends: the predictive value of social integration and support in suicidal ideation among rural communities

Purpose: To explore the role of social integration and support in the longitudinal course of suicidal ideation (SI) in a rural population. Methods: Baseline and 12-month data were obtained from participants within the Australian Rural Mental Health Study, a longitudinal study of community residents within rural and remote New South Wales, Australia. SI was assessed using the Patient Health Questionnaire. Individual psychological factors, family and community characteristics were examined alongside personal social networks (Berkman Syme Social Network Index), availability of social support (Interview Schedule for Social Interaction) and perception of local community (Sense of Community Index). Results: Thirteen hundred and fifty-six participants were included in the analysis (39% male, mean age 56.5 years). Sixty-one participants reported recent SI at baseline, while 57 reported SI at follow-up. Baseline SI was a strong predictor of SI at 12 months [odds ratio (OR) 19.0, 95% confidence interval (CI) 8.6–42.3); significant effects were also observed for baseline values of psychological distress (OR 1.4, 95% CI 1.0–1.9) and availability of social support (OR 0.76, 95% 0.58–1.0) on 12-month SI. The emergence of SI at 12-month follow-up was predicted by higher psychological distress (OR 1.8, 95% CI 1.3–2.4); there was a marginal effect of lower availability of support (OR 0.74, 95% CI 0.55–1.0); neither of these variables predicted SI resolution. Conclusions: This study investigated factors associated with SI over a 12-month period in a rural cohort. After controlling for known risk factors for SI, low availability of social support at baseline was associated with greater likelihood of SI at 12-month follow-up

Longitudinal course and predictors of suicidal ideation in a rural community sample

Objective: Suicide rates in rural Australia are higher than in urban areas. No existing research has explored the long-term patterns and predictors of change in suicidal ideation within rural areas. This report uses longitudinal data and multiple time points to determine predictors of the trajectory of suicidal ideation in rural Australia. Method: Participants in the Australian Rural Mental Health Study (ARMHS) completed self-report surveys at baseline, 12 and 36 months, reporting their psychological and social well-being, and suicidal ideation. Generalised linear mixed models explored these factors as correlates and predictors of suicidal ideation across 3 years using multiple data points. Results: A total of 2135 participants completed at least one wave of ARMHS, and hence were included in the current analysis. Overall, 8.1% reported suicidal ideation during at least one study wave, 76% of whom reported suicidal ideation intermittently rather than consistently across waves. Across the three time points, suicidal ideation was significantly associated with higher psychological distress (OR 1.30, 95% CI 1.23 to 1.37), neuroticism (OR 1.15, 95% CI 1.04 to 1.27), and availability of support (OR 0.80, 95% CI 0.69 to 0.92), with a non-significant association with unemployment (OR 1.73, 95% CI 0.93 to 3.24) even after controlling for the effects of perceived financial hardship. Future suicidal ideation was significantly predicted by distress (OR 1.16, 95% CI 1.09 to 1.23) and neuroticism (OR 1.17, 95% CI 1.03 to 1.32), with a non-significant association with unemployment (OR 2.11, 95% CI 0.41 to 2.27). Predictive effects for marital status, social networks, sense of community and availability of support did not remain significant in the full multivariate analysis. Conclusions: Fluctuations in suicidal ideation are common, and may be associated with changes in psychological and social well-being. Public health strategies, focusing on encouraging help-seeking among those with higher psychological distress, lower social support, and unstable or absent employment opportunities, may be a useful long-term initiative to reduce the prevalence of suicidal ideation in the general rural community