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One of the aims of our paper "The Paradox of Suicide Prevention" is to promote greater discourse on suicide prevention, with a particular focus on the mental health models used for the identification of, and interventions with, individuals who come into contact with tertiary mental health services [...].

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The recognition that we cannot use risk stratification (high, medium, low) to predict suicide or to allocate resources has led to a paradigm shift in suicide prevention efforts. There are challenges in adapting to these new paradigms, including reluctance of clinicians and services to move away from traditional risk categorisations; and conversely, the risk of a pendulum swing in which the focus of care swings from one approach to determining service priority and focus (e.g., diagnosis, formulation, risk and clinical care) to a new focus (e.g., suicide specific and non-clinical care), potentially supplanting the previous approach. This paper argues that the Prevention Paradox provides a useful mental model to support a shift in paradigm, whilst maintaining a balanced approach that incorporates new paradigms within the effective aspects of existing ones. The Prevention Paradox highlights the seemingly paradoxical situation where the greatest burden of disease or death is caused by those at low to moderate risk due their larger numbers. Current planning frameworks and resources do not support successful or sustainable adoption of these new approaches, leading to missed opportunities to prevent suicidal behaviours in healthcare. Adopting systems approaches to suicide prevention, such as the Zero Suicide Framework, implemented in a large mental health service in Australia and presented in this paper as a case study, can support a balanced approach of population- and individual-based suicide prevention efforts. Results demonstrate significant reductions in re-presentations with suicide attempts for consumers receiving this model of care; however, the increasing numbers of placements compromise the capacity of clinical teams to complete all components of standardised pathway of care. This highlights the need for review of resource planning frameworks and ongoing evaluations of the critical aspects of the interventions.

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OBJECTIVE: Long-acting injectable buprenorphine (LAI-BPN) was introduced in recent years as a novel treatment for opioid use disorder. Despite growing evidence-base of its effectiveness, there is limited research on the relationship between this treatment and patient characteristics. METHODS: This descriptive, retrospective cohort study compared sociodemographic and clinical variables between patients treated with SL-BPN and those treated with LAI-BPN at a large metropolitan health service in Queensland, Australia. RESULTS: Patients that transitioned to LAI-BPN were more likely to be single, have a comorbid mental illness, untreated hepatitis C infection and longer duration of unsanctioned opioid use. Patients continuing treatment with SL-BPN were more likely to fail to attend appointments and have urine drug screen results positive for gabapentinoids. CONCLUSIONS: The results of this study contribute to currently limited literature on this novel treatment option in an Australian context, highlighting factors which may influence patient and prescriber treatment choices. Clinicians may be more inclined to prescribe LAI-BPN to patients with higher psychosocial comorbidity to facilitate engagement in treatment.

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This paper describes the development and implementation of a peer-support program Always There in a large public mental health service in Queensland, Australia. The program is modelled on Scott's three tier model of peer support, with trained responders providing emotional support to staff following a traumatic adverse event, or when experiencing acute or cumulative stress. Support is provided in complete confidentiality. Main lessons learned in the 2 years since the launch of the program are shared in this paper, outlining successes such as improvements in staff's perception of organisational culture, and challenges related to embedding the program to "business as usual".

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This study explored the experiences of healthcare consumers who had recently attempted suicide, and their carers, following placement on a Suicide Prevention Pathway based on the Zero Suicide framework. Qualitative interviews were conducted with 10 consumers and 5 carers using a semi-structured interview schedule. Interviews were transcribed and thematic analysis was applied to identify prominent themes and sub-themes. Three interrelated themes were identified. The first theme was 'Feeling safe and valued' with the associated sub-theme pertaining to perceived stigmatizing treatment and self-stigma. The second was 'Intersection of consumer and staff/organizational needs' with a related sub-theme of time pressure and reduced self-disclosure. The final theme was 'Importance of the 'whole picture', highlighting the relevance of assessing and addressing psychosocial factors when planning for consumer recovery. Overall, consumers and their carers reported a favorable experience of the Suicide Prevention Pathway; however, there were several areas identified for improvement. These included reconciling the time-pressures of a busy health service system, ensuring consumers and carers feel their psychosocial concerns are addressed, and ensuring that adequate rapport is developed. Key to this is ensuring consumers feel cared for and reducing perceptions of stigma.

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OBJECTIVE: Reductions in suicidal and self-harm presentations to emergency departments (EDs) since COVID-19 indicate changes in help-seeking behaviours, but it is unknown if hospital avoidance equally affects all population groups. METHOD: Socio-demographic and clinical information relating to suicidal and self-harm presentations to EDs in Queensland, Australia, were compared for the period before (March-August 2019) and since the COVID-19 outbreak (March-August 2020). RESULTS: Since COVID, Indigenous Australians and persons with less severe suicidal and self-harm presentations had significantly reduced presentations, while persons younger than 18 years had more presentations. Less suicidal presentations resulted in an admission to inpatient care. CONCLUSIONS: Patterns of reduced attendance to ED in some groups suggest the need for innovative and community-based models of care to help prevent suicides during the pandemic.

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BACKGROUND: The Zero Suicide framework is a system-wide approach to prevent suicides in health services. It has been implemented worldwide but has a poor evidence-base of effectiveness. AIMS: To evaluate the effectiveness of the Zero Suicide framework, implemented in a clinical suicide prevention pathway (SPP) by a large public mental health service in Australia, in reducing repeated suicide attempts after an index attempt. METHOD: A total of 604 persons with 737 suicide attempt presentations were identified between 1 July and 31 December 2017. Relative risk for a subsequent suicide attempt within various time periods was calculated using cross-sectional analysis. Subsequently, a 10-year suicide attempt history (2009-2018) for the cohort was used in time-to-recurrent-event analyses. RESULTS: Placement on the SPP reduced risk for a repeated suicide attempt within 7 days (RR = 0.29; 95% CI 0.11-0.75), 14 days (RR = 0.38; 95% CI 0.18-0.78), 30 days (RR = 0.55; 95% CI 0.33-0.94) and 90 days (RR = 0.62; 95% CI 0.41-0.95). Time-to-recurrent event analysis showed that SPP placement extended time to re-presentation (HR = 0.65; 95% CI 0.57-0.67). A diagnosis of personality disorder (HR = 2.70; 95% CI 2.03-3.58), previous suicide attempt (HR = 1.78; 95% CI 1.46-2.17) and Indigenous status (HR = 1.46; 95% CI 0.98-2.25) increased the hazard for re-presentation, whereas older age decreased it (HR = 0.92; 95% CI 0.86-0.98). The effect of the SPP was similar across all groups, reducing the risk of re-presentation to about 65% of that seen in those not placed on the SPP. CONCLUSIONS: This paper demonstrates a reduction in repeated suicide attempts after an index attempt and a longer time to a subsequent attempt for those receiving multilevel care based on the Zero Suicide framework.

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OBJECTIVE: The Zero Suicide Framework, a systems approach to suicide prevention within a health service, is being implemented across a number of states in Australia, and internationally, although there is limited published evidence for its effectiveness. This paper aims to provide a description of the implementation process within a large health service in Australia and describes some of the outcomes to date and learnings from this process. METHOD: Gold Coast Mental Health and Specialist Services has undertaken an implementation of the Zero Suicide Framework commencing in late 2015, aiming for high fidelity to the seven key elements. This paper describes the practical steps undertaken by the service, the new practices embedded, emphasis on supporting staff following the principles of restorative just culture and the development of an evaluation framework to support a continuous quality improvement approach. RESULTS: Improvements have been demonstrated in terms of processes implementation, enhanced staff skills and confidence, positive cultural change and innovations in areas such as the use of machine learning for identification of suicide presentations. A change to 'business as usual' has benefited thousands of consumers since the implementation of a Suicide Prevention Pathway in late 2016 and achieved reductions in rates of repeated suicide attempts and deaths by suicide in Gold Coast Mental Health and Specialist Services consumers. CONCLUSION: An all-of-service, systems approach to suicide prevention with a strong focus on cultural shifts and aspirational goals can be successfully implemented within a mental health service with only modest additional resources when supported by engaged leadership across the organisation. A continuous quality improvement approach is vital in the relentless pursuit of zero suicides in healthcare.

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This paper presents trends and characteristics for 32,094 suicidal presentations to two Emergency Departments (EDs) in a large health service in Australia across a 10-year period (2009-2018). Prevalence of annual suicidal presentations and for selected groups of consumers (by sex, age groups, and ethnicity) was determined from a machine learning diagnostic algorithm developed for this purpose and a Bayesian estimation approach. A linear increase in the number of suicidal presentations over 10 years was observed, which was 2.8-times higher than the increase noted in all ED presentations and 6.1-times higher than the increase in the population size. Females had higher presentation rates than males, particularly among younger age groups. The highest rates of presentations were by persons aged 15-24. Overseas-born persons had around half the rates of suicidal presentations than Australian-born persons, and Indigenous persons had 2.9-times higher rates than non-Indigenous persons. Of all presenters, 70.6% presented once, but 5.7% had five or more presentations. Seasonal distribution of presentations showed a peak at the end of spring and a decline in winter months. These findings can inform the allocation of health resources and guide the development of suicide prevention strategies for people presenting to hospitals in suicidal crisis.

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OBJECTIVE: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. METHOD: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. RESULTS: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. CONCLUSIONS: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

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INTRODUCTION: Past evaluations of psychiatric short stay units have shown positive outcomes for patients, yet very little is known about the factors related to readmissions. METHODS: A Short Stay Pathway (SSP) has been introduced on the Gold Coast, Australia, for patients in acute mental health crisis with admissions of up to 3 days. Rates of readmissions within 28 days were compared for SSP patients (N = 678), and a diagnosis-matched control group of patients from acute mental health beds (N = 1356). Demographic and clinical factors were considered as predictors of subsequent readmissions. RESULTS: Average length of stay for SSP patients was 3.4 days, compared to 7.6 days in the control group. 10.6% of SSP patients and 18.4% of the control group were readmitted within 28 days (P < .001). For both groups, a 7-day follow up significantly reduced readmissions (P < .05). Indigenous patients on SSP had higher odds of readmissions than non-Indigenous patients (P < .05), and a diagnosis of a personality disorder increased readmission in the control group but not the SSP group (P < .001). DISCUSSION: SSP reduced repeated hospitalizations for patients in acute crisis by 42%. An identification of factors related to future admissions can inform future tailoring of this model of care to subgroups of patients.

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BACKGROUND: The accuracy of data on suicide-related presentations to Emergency Departments (EDs) has implications for the provision of care and policy development, yet research on its validity is scarce. OBJECTIVE: To test the reliability of allocation of ICD-10 codes assigned to suicide and self-related presentations to EDs in Queensland, Australia. METHOD: All presentations due to suicide attempts, non-suicidal self-injury (NSSI) and suicidal ideation between 1 July 2017 and 31 December 2017 were reviewed. The number of presentations identified through relevant ICD-10-AM codes and presenting complaints in the Emergency Department Information System were compared to those identified through an application of an evolutionary algorithm and medical record review (gold standard). RESULTS: A total of 2540 relevant presentations were identified through the gold standard methodology. Great heterogeneity of ICD-10-AM codes and presenting complaints was observed for suicide attempts (40 diagnostic codes and 27 presenting complaints), NSSI (27 and 16, respectively) and suicidal ideation (38 and 34, respectively). Relevant ICD codes applied as primary or secondary diagnosis had very low sensitivity in detecting cases of suicide attempts (18.7%), NSSI (38.5%) and suicidal ideation (42.3%). A combination of ICD-10-AM code and a relevant presenting complaint increased specificity, however substantially reduced specificity and positive predictive values for all types of presentations. ED data showed bias in detecting higher percentages of suicide attempts by Indigenous persons (10.1% vs. 6.9%) or by cutting (28.1% vs. 10.3%), and NSSI by female presenters (76.4% vs. 67.4%). CONCLUSION: Suicidal and self-harm presentations are grossly under-enumerated in ED datasets and should be used with caution until a more standardised approach to their formulation and recording is implemented.

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Background and Objective: Wesley Mission LifeForce training is an Australian suicide prevention gatekeeper program which has not been formally evaluated. The aims of this evaluation were to (1) determine the short- and medium- term impacts of the training on worker capabilities (perceived and declarative knowledge), attitudes, and reluctance to intervene measures; and (2) compare the impact of the half and full day workshops on these measures. Method: 1,079 Australian community workers of diverse professional backgrounds completed a pre-workshop questionnaire as part of registration for the Wesley LifeForce suicide prevention training between 2017 and 2019. Of these, 299 participants also completed the post workshop questionnaires (matched sample). They attended either half day (n = 97) or full day workshops (n = 202) and completed also a 3- and 6- month follow-up questionnaire. We used linear mixed-effect modeling for repeated measures to analyze data. Results: LifeForce training participants experienced an increase in perceived capability, declarative knowledge, more positive attitudes and reduced reluctance to intervene, at least in the short term. The program is particularly well targeted for community gatekeepers with no prior training, albeit those with prior training in this study also experienced positive and significant gains on most measured constructs. Conclusions: We found evidence of effectiveness of the Wesley LifeForce training over time, without difference between the short (half day) and longer (full day) formats of delivery. Nevertheless, the latter format offers skills-based and skills rehearsal opportunities, the impacts of which we were unable to measure in this evaluation and should be estimated in the future.

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BACKGROUND: Restricting access to lethal means is a well-established strategy for suicide prevention. However, the hypothesis of subsequent method substitution remains difficult to verify. In the case of jumping from high places ('hotspots'), most studies have been unable to control for a potential shift in suicide locations. This investigation aims to evaluate the short- and long-term effect of safety barriers on Brisbane's Gateway Bridge and to examine whether there was substitution of suicide location. METHODS: Data on suicide by jumping - between 1990 and 2012, in Brisbane, Australia - were obtained from the Queensland Suicide Register. The effects of barrier installation at the Gateway Bridge were assessed through a natural experiment setting. Descriptive and Poisson regression analyses were used. RESULTS: Of the 277 suicides by jumping in Brisbane that were identified, almost half (n=126) occurred from the Gateway or Story Bridges. After the installation of barriers on the Gateway Bridge, in 1993, the number of suicides from this site dropped 53.0% in the period 1994-1997 (p=0.041) and a further reduction was found in subsequent years. Analyses confirmed that there was no evidence of displacement to a neighbouring suicide hotspot (Story Bridge) or other locations. CONCLUSIONS: The safety barriers were effective in preventing suicide from the Gateway Bridge, and no evidence of substitution of location was found.

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BACKGROUND: While numerous past reviews of psychological autopsy (PA) studies have examined the relationship between mental disorder and suicide, there has been little systematic investigation of suicide occurring in the absence of any identifiable psychiatric condition. AIM: This article reviews available literature on the topic by considering Axis I, sub-threshold, mild disorders and personality disorders. METHOD: We conducted a systematic review of PA studies from 2000 onwards. Studies included in the review had to clearly describe the proportion of suicide cases without a classifiable mental disorder or sub-threshold condition. RESULTS: Up to 66.7% of suicide cases remained without diagnosis in those studies that only examined Axis I disorders (n = 14). Approximately 37.1% of suicide cases had no psychiatric condition in research papers that assessed personality and Axis I disorders (n = 9), and 37% of suicides had no Axis I, sub-threshold/mild conditions (n = 6). In general, areas in China and India had a higher proportion of suicides without a diagnosis than studies based in Europe, North America or Canada. CONCLUSION: Variation in the proportion of suicide cases without a psychiatric condition may reflect cultural specificities in the conceptualization and diagnosis of mental disorder, as well as methodological and design-related differences between studies.

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OBJECTIVE: A first study to compare suicides by missing persons with other suicide cases. DESIGN: Retrospective cohort study for the period 1994-2007. GEOGRAPHICAL LOCATION: Queensland, Australia. POPULATION: 194 suicides by missing persons and 7545 other suicides were identified through the Queensland Suicide Register and the National Coroners Information System. MAIN OUTCOME MEASURE: χ(2) statistics and binary logistic regression were used to identify distinct characteristics of suicides by missing persons. RESULTS: Compared with other suicide cases, missing persons significantly more often died by motor vehicle exhaust gas toxicity (23.7% vs 16.4%; χ(2)=7.32, p<0.01), jumping from height (6.7% vs 3.2%; χ(2)=7.08, p<0.01) or drowning (8.2% vs 1.8%; χ(2)=39.53, p<0.01), but less frequently by hanging (29.4% vs 39.9%; χ(2)=8.82, p<0.01). They were most frequently located in natural outdoors locations (58.2% vs 11.1%; χ(2)=388.25, p<0.01). Persons gone missing were less likely to have lived alone at time of death (OR 0.45, 95% CI 0.26 to 0.76), yet more likely to be institutionalised (OR 3.12, 95% CI 1.28 to 7.64). They were less likely to have been physically ill (OR 0.64, 95% CI 0.43 to 0.95) or have a history of problematic consumptions of alcohol (OR 0.52, 95% CI 0.31 to 0.87). In comparison to other suicide cases, missing persons more often communicated their suicidal intent prior to death (OR 1.58, 95% CI 1.13 to 2.22). CONCLUSIONS: Suicides by missing persons show several distinct characteristics in comparisons to other suicides. The findings have implications for development of suicide prevention strategies focusing on early identification and interventions targeting this group. In particular, it may offer assistance to police in designing risk assessment procedures and subsequent investigations of missing persons.

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In comparing Indigenous to non-Indigenous suicide in Australia, this study focussed on the frequency of the association between some psychiatric conditions, such as depression and alcohol abuse, and some aspect of suicidality, in particular communication of suicide intent. Logistic regression was implemented to analyze cases of Indigenous (n = 471) versus non-Indigenous suicides (n = 6,655), using the Queensland Suicide Register as a data source. Compared to non-Indigenous suicides, Indigenous cases had lower odds of being diagnosed with unipolar depression, seeking treatment for psychiatric conditions or leaving a suicide note. Indigenous suicides had greater odds of verbally communicating suicide intent and having a history of alcohol and substance use. The magnitude of these differences is remarkable, underscoring the need for culturally sensitive suicide prevention efforts.

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