By Michael Carr-Gregg MAPS.

Suicide is the second most common cause of death among young men in the Western world. The emotional impact of suicide, especially of young people, has a devastating effect on any school community and often results in a frenzied call for action. Such a response has often produced what psychiatrist Stephen Rosenman calls a "do something, do anything" flurry of activity.

While this is understandable, Rosenman and others argue that much of this activity often represents an inappropriate knee jerk reaction, is ineffective and sometimes makes things even worse.

A recent discussion paper by the Australian Psychological Society acknowledged that despite the fact that statistically suicide (and particularly youth suicide) was a rare event, psychologically it is far from rare. The paper states: "It is a salient preoccupation and issue for many cultures, for contemporary western societies and media and for many individuals and families whose lives have been touched by the suicide death of others".

Many adolescent psychologists are concerned that with this increasing openness, suicide is becoming more and more a pre-eminent (and unhealthy) preoccupation for many young people. These professionals question the wisdom of talking publicly about the topic, let alone including the topic in the school syllabus.

While this has been an ongoing debate within the profession, a consensus has emerged that while one should not censor the subject, it is preferable to reframe such discussions in the context of good and bad mental health, with a particular focus on depression.

The youth suicide industry

In recent years, some schools have elected to directly address the suicide issue by inviting outside community-based groups to run programs with students. Many of these groups lack an evidence base for such programs.

Suicidologists such as Annette Beautrais, an expert who has dedicated her life to understanding suicide and suicide prevention, suggest that there may be dangers in using such groups. While acknowledging that many students will be at best unaffected, she maintains that in every school there may be some vulnerable students who may be adversely affected by such sessions. She singles out those students who (unbeknownst to the school) have made a previous attempt, suggesting that they may react more negatively to such sessions in schools. These students would be less likely to reveal suicidal intention or to believe that they could be helped by a mental health professional as a result of attending such sessions.

This means that some such programs, no matter how well intentioned, may increase the level of risk for a minority of students. In Australia, a range of interested parties have expressed serious concerns about the lack of demonstrated safety and effectiveness of youth suicide-prevention programs being delivered by some community-based organisations that focus on education alone. Indeed, Dr Jane Burns from beyondblue - the national depression initiative - argues that the few studies that have measured the impact of traditional suicide education indicate that their impact is less than positive, for young men in particular, increasing symptoms of depression and anxiety rather than reducing them.

The New Zealand Government, late in 2002, issued a warning to schools urging them to be cautious when engaging such organisations. The report, by the NZ Ministry of Youth Affairs, accuses such organisations of fostering a view that youth suicide is far more common than it actually is, generating unnecessary fear and anxiety.

What prompted the NZ Government to issue such a warning was the realisation that some of the programs were actively spreading inaccurate information. There was an urgent need for all programs that sought to improve adolescent mental health to demonstrate that they were safe, effective and evidence-based. The frustration for government officials, on both sides of the Tasman, is that many of these organisations receive no government funding, and therefore levers for modifying their approach in line with evidence and best practice are limited if not non-existent.

This is problematic for many academics and government departments because elements of this 'youth suicide industry' in both countries have raised large amounts of money and secured significant sponsorships which might otherwise have gone to much needed academic research programs.

But this issue goes far beyond academic sour grapes. It is the manner by which these group garner such funds and publicity that has attracted the ire of many academics. Some academics accuse the groups of actively fostering a number of public perceptions that are often inaccurate or, at best, distortions of the facts.

These include promoting the following so-called 'facts' (often on television through well-meaning, high profile individuals, who are unaware that the information they are given to regurgitate is both misleading and inaccurate):

  • that the rate of youth suicide is unacceptably high and increasing (the rate has actually decreased in Australia each year for the past three years);
  • that governments are not doing enough to reduce youth suicide (the Federal government's total commitment, for example, is $66.4 million, which includes the $22 million National Suicide Prevention Strategy);
  • there's a high rate of suicide amongst high school students (suicide rate is highest in the 25-44 age group [Australian Bureau of Statistics, 2000]);
  • some of these programmes are run by people who have lost a child to suicide themselves, so they must know what it's about. The government should leave them alone. (there's no empirical evidence for this view);
  • community programs that focus on education are doing a great job - at least they're doing something (some may do harm).

Evidence-based responses

Prevention of youth suicide is something all schools can contribute to by promoting good mental health via evidence-based programs (see box story this page for examples), supporting young people by responding to suicidal young people in a helpful way, and by being better informed about youth suicide.

It is important to recognise that there are times when specific discussion about suicide is essential - for example, when a young person appears to be at risk, suicide should be discussed in a therapeutic context, or it should be discussed as part of post-vention support with a community or school that has lost a student.

Beyond this context, however, the evidence base around youth suicide prevention is continually growing and we need to ensure that current research findings are distributed to key sectors (such as schools) to ensure programmes are safe, effective and evidence-based. There are three key issues that emerge in the research literature:

  • The NZ Government report suggests that the strongest evidence indicates that raising awareness about suicide can increase suicidal behaviour amongst those who are already vulnerable. Raising awareness can normalise and glorify suicide, and make it seem like a preferred option for young people who are distressed and "not thinking straight".This means that we should not encourage young people to focus on suicide.
  • There is also research that says that within the context of peer support programs, expecting young people to take on high levels of responsibility for the complex and difficult problems of their peers can also make the situation worse. Often peers don't respond in a helpful way.
  • The challenge for Australian educational leaders is simple. It involves the incorporation of life skills into the curriculum and the creation of supportive environments at home and at school. It is also important to identify young people who may be at risk, using an appropriate screening tool, and to ensure these young people get appropriate support. This is also fraught with problems, as there is research that suggests many screening devices are ineffective - missing cases and identifying some young people who aren't actually cases.

Government responses

The New Zealand Government is leading the world in attacking this issue. It has commissioned a report (which will be available in late 2003) that will review the research and assess three community-based programs.

In Australia, however, there has been little overt direction from State Departments of Education or Health. Generally speaking, schools have been left alone to decide for themselves which programs are suitable for their students and their community.

More worryingly, groups that have never been properly evaluated often gain credibility by attending conferences and presenting papers of little or no substance. Some then use the fact of their participation in such conferences as evidence of their status in the mental health community.

The Federal government has no less than 16 different national mental health and suicide prevention projects as of February 2003 and has successfully partnered with the education sector through Mindmatters and the Australian Principals Associations Professional Development Council.

While the systems are more open to advice and are increasingly moving towards an evidence-based framework, the challenge lies in making sure that schools understand the importance of using evidence-based programs. This may be a role for the Department of Health and Ageing, in being more proactive by producing guidelines for schools which warn them against engaging community based youth suicide prevention organisations that have no scientific basis.

Dr Michael Carr-Gregg is the Honorary Psychologist to the Victorian Association of Secondary School Principals. This article is an edited version a paper he presented to the Association on 7 March 2003 at their State-wide general meeting.

Some evidence-based resources

Friends
An anxiety prevention and life-skills enhancement program promoting psychological resilience for children aged 7-11 and young people aged 12-16. More information about the Program and a number of publications are available to download from this site: www.friendsinfo.net

Gatehouse Project
The Gatehouse Project is a research project aimed at promoting emotional well-being of young people in schools. The project has been conducted by the Centre for Adolescent Health (Royal Children's Hospital, Women's and Children's Health, and the Murdoch Children's Research Institute) in Victorian secondary schools since 1996. Website provides access to further information about the Project and associated resources. www.rch.unimelb.edu.au/gatehouseproject

HeartMasters
Great programs for the promotion of resilience and emotional intelligence in schools. www.inyahead.com.au

MindMatters
MindMatters is a mental health promotion program for secondary schools. It offers resources for schools and a national professional development and training strategy. www.mindmatters.edu.au/default.asp

Adolescents Coping with Emotions
ACE aims to build resilience, enhance coping skills and teach positive thinking styles in young people.It's an indicated depression prevention program.It's designed for adolescents with low mood: the group who we've identified as gaining most from joining in the program.
www.nscchealth.nsw.gov.au/services/cahms/ACE_Program/body_ace_program.shtml