Opening up the gate on suicide prevention for young Victorians through gatekeeper training
Mr Nik Partsanis
Friday, September 23rd, 2016
VicHealth released its Bright Futures report in December 2015 identifying youth suicide as a problem facing young Victorians over the next 20 years. Youth suicide rates have fallen in Australia since the National Youth Suicide Prevention Strategy, however, data shows that there is still room for improvement. Prevention strategies to date have been understudied for a variety of reasons, including ethical limitations and being studied as part of a broader suicide policy. The author proposes that gatekeeper training should be piloted across Victoria to determine whether it will independently reduce youth suicide rates. It has potential benefits upon integration in schools, general practices, and rural Victorian settings given that it focuses on training people who are associated with those directly at risk of suicide.
For young Australians aged 15 to 24 years, suicide is the leading cause of death . Between 1997 and 2012, suicide rates among this age group have fallen by 47% . This reduction may be attributable to the introduction of the National Youth Suicide Prevention Strategy (NYSPS) in 1997, which reduced access to lethal methods of suicide, changed prescription patterns of antidepressants, and saw the introduction of catalytic converters in new cars . Worryingly, however, 76% of deaths are still “considered potentially avoidable” , illustrating the need for further intervention nearly 20 years on.
In 2000, the Australian government established the National Suicide Prevention Strategy (NSPS), which integrated and expanded on the NYSPS . Victoria has integrated this national strategy into the Victorian Mental Health Reform Strategy 2009-2019 . In December 2015, the Victorian Health Promotion Foundation published the ‘Bright Futures’ report and highlighted suicide as part of a “megatrend” that may threaten the stability of young Victorians over the next 20 years . It was hoped that the report would provide a foundation to guide future policies and improve community understanding of mental health, as well as explore the changing nature of service delivery models. Since this report, new data has been published by the Australian Bureau of Statistics (ABS) flagging the 2014 suicide rate as the highest in 10 years, at 12.0 deaths per 100,000 people in Australia . Unfortunately, intentional self-harm continues to remain the leading cause of death in those between the ages of 15 and 44 .
This new data is particularly alarming as the ABS was unable to attribute the 2014 rise to administrative system changes in the coding of these deaths , which highlights the need to act on reducing these potentially avoidable deaths. Hence, gatekeeper training should be evaluated in a pilot study aimed at young Victorians. Gatekeeper training aims to equip individuals with the skills to “identify at-risk individuals and direct them to appropriate assessment and treatment” . Gatekeepers are people who have primary contact with at risk groups and are able to identify them through recognition of suicide risk factors .
Summary of the Bright Futures report
VicHealth state that the future health and prosperity of Victoria is dependent upon the mental wellbeing of the youth, that is, those aged between 12 and 25 years . The report highlights that in contrast to the falling rates of suicide across other Organization for Economic Cooperation and Development (OECD) countries, there has been a rise in Australia from 6.2 deaths by suicide per 100,000 people in 2004 to 10.1 per 100,000 people in 2013 across all age groups. Vulnerable groups identified include Indigenous Australians, males, and people living in rural and remote areas, with suicide rates being 66% higher in country areas compared to metropolitan areas. Of particular concern is the alarming rate of suicide among young people aged 19-24, where suicide is the leading cause of death . Finally, the report states that to reduce these risks, efforts need to be made to develop preventative programs that target mental wellbeing .
Suicide in Australia and around the world
In 2012, the global age-standardised suicide rate was 11.4 per 100,000 people and accounted for 1.4% of deaths worldwide. More specifically, the World Health Organisation (WHO) estimated that in 2012 the suicide rate for high-income countries was closer to 12.7 per 100,000 people . For young people aged between 15 and 29 it is the second leading cause of death internationally, accounting for 8.5% of deaths in this age group .
According to the ABS, there were 2,864 deaths from intentional self-harm in 2014 . This made suicide the 13th leading cause of death in Australia . For males, it was the tenth-leading cause of death, as approximately three-quarters of those who died by suicide were male. The overall suicide rate was 12.0 per 100,000 people in 2014, up from 10.9 in 2013 [7,12].
Suicide only accounts for a small proportion (1.9%) of deaths in Australia overall, however, it is in the context of specific age groups that the results become alarming. For example, suicide was the cause of death for “over a third” of males between the ages of 15 and 19 in 2014 .
Finally, the median age of death from suicide was 44.2 years, compared to a median age of 81.8 for deaths via all other causes in 2014 . These figures illustrate that there are many years of life lost to suicide, particularly amongst the youth.
Suicide prevention strategies
Suicide prevention models differ around the world. The WHO divide suicide interventions into three categories that focus on: population level policies, selective preventative strategies to target vulnerable groups, and prevention strategies that target specific vulnerable individuals in a population . Gatekeeper training is an example of a selective preventative strategy that targets vulnerable groups, and is the focus of this article.
Pros and cons of gatekeeper training
Gatekeeper training has been shown to be a promising initiative for suicide prevention [9,10], particularly for vulnerable groups that may be at increased risk of suicide . In a 2016 article, Krysinska et al. state that gatekeeper training, as part of an overall preventative strategy, can lead to reductions in suicide . Mellanby et al. demonstrated that amongst veterinary undergraduates, who are at increased risk of suicide, a suicide workshop provided confidence in identifying the signs of suicide and asking about suicide .
The strengths of gatekeeper training include:
- The ability to equip gatekeepers with targeted skills to work with a specific vulnerable group , such as Indigenous youth [15,16]
- Increasing an individual’s knowledge about suicide 
- Training people who are already within a population and are familiar with the environment, as opposed to “outsiders” 
- Addressing and reducing stigma surrounding suicide through training 
There are some limitations surrounding gatekeeper training. A Cochrane Collaboration states that there is an inability to demonstrate longer-term effects, and questions whether suicide prevention programs are effective in post-secondary educational institutions . This is further supported by the WHO, who state that there is “no conclusive link … with reduced rates of suicide or suicide attempts”, but that gatekeeper training is “best practice” . However, a study published by Isaac et al. argues that the limited evidence is attributable to the fact that gatekeeper training exists within a broader suicide prevention strategy, which makes it difficult to isolate the effect of gatekeeper training alone [10,19]. Moreover, a randomised controlled trial published subsequent to the Cochrane Collaboration, demonstrated that Applied Suicide Intervention Skills Training (ASIST), a form of gatekeeper training, was able to improve feelings of hope and reduce pro-suicidal feelings in a Lifeline call centre . This is important, as feelings of hopelessness are closely related to suicidal ideation , and this may therefore provide some evidence to illustrate changes in suicide behaviour.
Why Victoria should trial a gatekeeper training model
Gatekeeper training, like many suicide preventative strategies, needs further evaluation [9,16]. Given Victoria’s commitment to the NSPS and their identification of suicide as part of a megatrend, there is a need to explore and develop evidence for prevention strategies.
Firstly, suicide rates are twice as high in rural areas as metropolitan areas, which is precisely why gatekeeper training in particular needs to be introduced . Gatekeeper training can be deployed at the ground level and provide individuals within a regional or remote town, who are already familiar with the local environment, the skills to identify those at risk of suicide.
Moreover, gatekeepers can be introduced within the institutions that young Victorians frequent (i.e. schools and universities). This could be achieved through equipping teachers with the skills to act as gatekeepers, which has been shown to lead to an “increase in recognition” of “suicidal students who manifest explicit warning signs” [22,23]. This is especially pertinent now, as VicHealth has flagged the future rise of artificial intelligence and emerging economies as potential challenges for young Victorians to remain competitive in the job market. Such competition is likely to require young people to seek further education and remain in education institutions for longer .
Gatekeeper training may also be applicable to primary healthcare, and act as another avenue to target young Victorians. There is evidence to suggest that training general practitioners can substantially reduce deaths by suicide [13,19]. This is supported by Mann et al., who state that “many suicide [victims] have had contact with primary care physicians within a month of death” . Unfortunately, there is some evidence to suggest that primary care physicians do not routinely screen for suicide risk amongst adolescents, and may lack sensitivity when discussing this issue due to a lack of training [10,24]. More recent qualitative evidence has shown further support for the provision of suicide risk assessment training to general practitioners . Therefore, providing general practitioners with gatekeeper training may enable them to better detect, and subsequently treat, youth who are contemplating suicide.
The flexibility of this approach, the vast Australian landscape, and access to a broad range of potential trainees through the established network of general practitioners across Australia suggests that the gatekeeper training model is a suitable strategy to target the high suicide rate among young Victorians.
Challenges that will be faced in implementing suicide prevention strategies
The research to date has focused on the efficacy of suicide prevention strategies as part of a broader overarching suicide policy , which is pre-existent in Victoria and Australia. This is based on the understanding that suicide is multifactorial and one preventative strategy will not provide a definitive solution, as each individual is a unique and complex case . To exacerbate this difficulty, suicide research in general is limited, and many preventative strategies implemented thus far have not been scientifically tested . Some of the reasons for this include [10,16,26,27]:
- The complexity of causes of suicide leads to difficulty in examining interventions
- Using control groups is difficult
- Suicide is a rare event in contrast to other deaths, which limits the research designs that may be utilised
- Outcomes measured are often qualitative rather than quantitative as they can measure decreased feelings of hopelessness rather than lower rates of suicide
Given these mixed results, Suicide Prevention Australia has provided a basis for future research of gatekeeper training, with a focus on key measurements and identifiable targets . Some identifiable targets include :
- Quantity of training required
- Referral patterns of gatekeepers
- Retraining requirements for gatekeepers
Consequently, I urge VicHealth to undertake a pilot study that quantitatively measures the implications of gatekeeper training alone across Victoria.
To address suicide prevention for young Victorians, a multifaceted approach needs to be taken that ensures that all vulnerable young populations are nurtured. However, further research should focus on quantitative measurements of gatekeeper training, to determine if such policy actually yields results. Ultimately, youth suicide rates are largely avoidable, and this needs to be urgently addressed to ensure that Victoria’s youth develop resilience in the coming 20 years.
Conflicts of interest
 Australian Institute of Health and Welfare. Deaths among young people aged 15-24 [Internet]: Australian Institute of Health and Welfare; 2016 [cited 2016 June 4]. Available from: http://www.aihw.gov.au/deaths/premature-mortality/ages-15-24/.
 Large MM, Nielssen OB. Suicide in Australia: meta-analysis of rates and methods of suicide between 1988 and 2007. Med J Aust. 2010;192(8):432-7.
 Life Is For Everyone. Research and evidence in suicide prevention. Canberra: Department of Health and Ageing, 2008.
 Mental Health and Drugs Division, Department of Human Services. Because mental health matters. Victorian Government, 2009.
 VicHealth, CSIRO. Bright futures: megatrends impacting the mental wellbeing of young Victorians over the coming 20 years. Melbourne (AU): Victorian Health Promotion Foundation; 2015 48 p.
 Australian Bureau of Statistics. Media release: changing patterns of mortality reflect ageing population [Internet] Canberra: Australian Bureau of Statistics; 7 March 2016 [updated 2016 March 8; cited 2016 April 17]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by Subject/3303.0~2014~Media Release~Changing patterns of mortality reflect ageing population (Media Release)~10048.
 Australian Bureau of Statistics. Causes of death, Australia, 2014 [Internet]: Canberra: Australian Bureau of Statistics; 8 March 2016 [updated 2016 March 10; cited 2016 April 17]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0.
 Australian Bureau of Statistics. Causes of death, Australia, 2014: explanatory notes [Internet]: Canberra: Australian Bureau of Statistics; 8 March 2016 [updated 2016 March 15; cited 2016 April 17]. Available from: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3303.0Explanatory Notes32014?OpenDocument.
 Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294:2064-74.
 Isaac M, Elias B, Katz LY, Belik S, Deane FP, Enns MW, et al. Gatekeeper training as a preventative intervention for suicide: a systematic review. Can J Psychiatry. 2009;54(4):260-8.
 World Health Organization. Preventing suicide: a global perspective. 2014.
 Australian Bureau of Statistics. Causes of death, Australia, 2013 [Internet] Canberra: Australian Bureau of Statistics; 31 March 2015 [updated 2016 Mar 7; cited 2016 February 7]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by Subject/3303.0~2013~Main Features~Suicide by Age~10010.
 Krysinska K, Batterham PJ, Tye M, Shand F, Calear AL, Cockayne N, et al. Best strategies for reducing the suicide rate in Australia. Aust N Z J Psychiatry. 2016;50(2):115-8.
 Mellanby RJ, Hudson NPH, Allister R, Bell CE, Else RW, Gunn-Moore DA, et al. Evaluation of suicide awareness programs delivered to veterinary undergraduates and academic staff. Veterinary Record. 2010;167:730-4.
 Clifford AC, Doran CM, Tsey K. A systematic review of suicide prevention interventions targetting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health. 2013;13:463-74.
 Suicide Prevention Australia. Transforming suicide prevention research: A national action plan. Volume 1. Sydney (AU): 2015.
 Bennett K, Rhodes AE, Duda S, Cheung AH, Manassis K, Links P, et al. A youth suicide prevention plan for Canada: a systematic review of reviews. Can J Psychiatry. 2015;60(6):245-57.
 Harrod CS, Goss CW, Stallones L, DiGuiseppi C. Interventions for primary prevention of suicide in university and other post-secondary educational settings. Cochrane Database Syst Rev. 2014;10:1-92.
 van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, Volker D, Roskar S, Grum AT, et al. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. Crisis. 2011;32(6):319-33.
 Gould MS, Cross W, Pisani AR, Munfakh JL, Kleinman M. Impact of Applied Suicide Intervention Skills training on the national suicide prevention Lifeline. Suicide Life Threat Behav. 2013;43(6):676-91.
 Beck A, Steer R, Beck J, Newman C. Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide Life Threat Behav. 1993;23(2):139.
 Wyman PA, Brown CH, Inman J, Guo J, Pena JB, Cross W, et al. Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. J Consult Clin Psychol. 2008;76(1):104-15.
 Robinson J, Cox G, Malone A, Williamson M, Baldwin G, Fletcher K, et al. A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behaviour in yound people. Crisis. 2013;34(3):164-82.
 Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry. 2006;47(3):372-94.
 Michail M, Tait L. Exploring general practitioners’ views and experiences on suicide risk assessment and management of young people in primary care: a qualitative study in the UK. BMJ Open. 2016;6:2016.
 Suicide Prevention Australia. Transforming suicide prevention research: A national action plan. Volume 2. Sydney (AU): Suicide Prevention Australia, 2015.
 Hawton K, van Heeringen K. Suicide. Lancet. 2009;373:1372-81.