What can and should we predict in mental health?

David Foster Wallace, in his novel Infinite jest (1996), described the impulse for a person at the point of suicide as like that of jumping from a burning high-rise building. “Their terror of falling from a great height is still just as great as it would be for you or me … [but] when the flames get close enough, falling to death becomes the slightly less terrible of two terrors.”

This is one way to conceptualise the situation for at least 2273 people in Australia who committed suicide in 2011. To understand how to prevent such deaths, we need to know — following Wallace’s metaphor — the point at which an individual will choose to jump rather than face the flames. Can we predict this? And to what extent can we predict any outcomes in psychiatry?

Much effort has gone into trying to identify patients who are at particular risk of completed suicide within a year after presenting in psychological crisis or after attempting suicide. Ryan and Large (doi: 10.5694/mja13.10437) argue that predicting the short-term risk of suicide for such patients is not possible given the lack of identified risk factors that sufficiently discriminate between those who successfully suicide and those who do not. In addition, many people without the factors suggested as being associated with increased risk go on to attempt suicide. In this light, the authors recommend renewed, close clinical engagement with each patient’s situation and appropriate tailored intervention.

While prediction of suicide risk in individuals may be problematic, at a population level, suicide prevention has for some time been integral to mental health policies. Christensen and Petrie (doi: 10.5694/mja12.11793) outline six recommendations that should be part of any suicide prevention strategy. These revolve around targeting interventions, addressing risk factors, providing online resources and addressing gaps in community knowledge and discussion.

There have been recent moves to encourage more public discussion about suicide. But, as Fitzpatrick and Kerridge argue (doi: 10.5694/mja12.11540), community discussion should not simply be equated to media reporting of suicides. While there is some evidence of an association between increased media reporting and the incidence of attempted or completed suicide, they argue that this should not cloud strategies to encourage general community discussion about how suicide affects us all. There is reason to hope that talk beyond that filtered through the media prism will more effectively address the social and cultural factors that relate to suicide.

The possibility of identifying children at high risk of emotional and behavioural problems has been the basis of the expansion of the voluntary Healthy Kids Check for 3-year-olds to include social and emotional wellbeing. Will such assessment predict later problems? Daubney and colleagues (doi: 10.5694/mja12.11455) argue that although early intervention in this age group does have benefits, many children with problems go undetected, and none of the currently available assessment instruments are suited to screening. In addition, no symptom clusters are predictive of later psychopathology, and there are potential problems with overdiagnosis and overmedicalisation.

From the outsider’s perspective, there often seems to be more bad than good news in mental health, with controversy, lack of progress and confusing evidence. However, there are bright spots, even in those conditions previously thought to be intractable. Grenyer (doi: 10.5694/mja13.10470) shows that the prognosis for borderline personality disorder has significantly improved, with effective psychotherapies and support to patients and their family members offering real hope for more stable and productive lives. This should also lower sufferers’ risk of suicide, which, either attempted or completed, is a well known feature of the disorder.

Twelve years after the publication of Infinite jest, David Foster Wallace committed suicide on a background of worsening, difficult-to-treat depression. His strangely prescient metaphor of flames rising up a burning building reaches beyond literary dilettantism. Perhaps, in the context of suicide, we need to ask ourselves whether we know what causes the fire, and how much we understand the person poised in terror at the top.

Suicide risk assessment: where are we now?

A definitive way to identify patients who will suicide remains elusive

Patients who present in psychological crisis or after a suicide attempt are more than 50 times more likely than the general population to die by suicide in the following year.1,2 They require careful assessment and management. Numerous publications suggest, and some health department policies insist, that such patients should undergo a “comprehensive suicide risk assessment” in addition to a standard clinical assessment.3,4 Although most guidelines warn that suicide risk assessment does not substitute for clinical judgement, almost all also include long lists of patient characteristics that are claimed to enable identification of those patients at high risk of suicide. These lists are often fashioned into ad-hoc scales that purportedly stratify patients into categories of low, medium and high risk. However, it is simply not possible to predict suicide in an individual patient, and any attempt to subdivide patients into high-risk and low-risk categories is at best unhelpful and at worst will prevent provision of useful and needed psychiatric care. Here, we explain why this is so and outline what we believe clinicians should do instead.

Although patients presenting after suicide attempts or in crisis have a greatly increased probability of eventual suicide compared with the general community, fewer than one in 200 will actually die by suicide in the next 6 months.1 Suicide risk assessment is usually suggested as a way of determining who among these presenting patients should be offered different or more intensive treatment. However, the low base rate of completed suicide, combined with the lack of defining characteristics of people who proceed to suicide, makes this task impossible. Any useful further risk assessment would need to rely on a risk factor or a combination of risk factors that are consistently present, can be reliably assessed, and are very strongly overrepresented in the few people who do eventually suicide and yet rare or absent in those who do not. There is no evidence that such a risk factor or combination of risk factors exists. In 1983, the author of a large, well conducted prospective study of suicide lamented that “we do not possess any item of information or any combination of items that permit us to identify to a useful degree the particular persons who will commit suicide”.5 Thirty years later, nothing has changed: a similarly large and methodologically sound prospective study of psychiatric inpatients found that only 12% of suicides occurred among high-risk patients, and that fewer than one in 400 high-risk patients suicided.6,7

The list of generally accepted suicide risk factors is long and includes male sex, old age, divorce, medical illness, substance use, past suicide attempts and guilt. The most often cited risk factor for future suicide is expressed suicidal ideation.3,4 However, among psychiatric patients, expressed suicidal ideation does not discriminate between suicide completers and non-completers.8 Presumably this is because thoughts of self-destruction are very common in this group and because many people intent on suicide will not disclose that intent. Other intuitively appealing candidate characteristics include depressed mood and hopelessness. These, too, are almost universally found in the risk factors nominated in suicide risk assessment guidelines.3,4 However, not only are they very common in patients presenting with psychological problems, but most people with depressed mood will also feel hopeless, and vice versa; therefore, the combination of these risk factors offers little additional discriminative ability.

In recent decades, an enormous amount of research has gone into finding the magic combination of risk factors that acts as a sensitive and specific discriminator.5,6,9,10 Almost every study of completed suicide is retrospective, examining dozens, sometimes hundreds, of characteristics recorded in the medical records of both patients who suicided and controls, searching for factors or combinations of factors that were present more often in the patients who died.11,12 Such studies are likely to yield chance findings that appear to be significant, and they could identify some potentially reproducible associations with suicide. However, meta-analysis finds contradictory results between studies, leaving very few candidate risk factors among all the studies examined.11–13 Moreover, even a combination of reproducible risk factors still fails to provide a useful way of identifying high-risk patients. We examined studies investigating risk factors for completed suicide within a year of inpatient psychiatric treatment. Even making assumptions that optimise the power of suicide risk assessment, we estimated that while some patients could be categorised as “ultra-high-risk”, as few as 3% of these would go on to suicide in the year after discharge. Meanwhile, about 60% of people who did eventually suicide during the same period would have been categorised as being at lower risk.11

In original research and in meta-analyses, no generally accepted risk factors individually or in combination provide any useful way of further categorising patients who present in crisis. We understandably want to identify those who will later kill themselves — but this is simply not possible.

Here and now, clinicians should not be conducting “comprehensive suicide risk assessments”. They should be conducting comprehensive clinical assessments of each patient’s situation and needs. Suicidal ideation, for example, is not useful as an indicator of the likelihood of future suicide, but it is an invaluable sign of a person’s inner despair. So-called risk factors like depression, hopelessness and substance misuse are far too common and non-specific to be useful indicators of suicide risk, but they can be seen as symptoms of mental illness and important pieces of a revealed inner life that, taken together, give us a better understanding of the individual person and guide us towards what needs attention and discussion.

This is not to say that we should abandon patient safety. Bolstering family or social support, restricting access to lethal methods of suicide or making a crisis plan are steps that should be taken for all patients in psychological crisis — not just those whom we imagine might be more likely to suicide than others.

We cannot prevent tragedy by trying to identify those few souls who will be consumed by it. We must instead gather a comprehensive picture of each individual patient, and use this to tailor optimal management for the patients and families needing our care.

Clinical staging for mental disorders: a new development in diagnostic practice in mental health

Matching the timing and intensity of interventions to the specific needs of patients

The release of the fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5)1 classification system, scheduled for May 2013, will create controversy due to the expanded range of problems now classed as mental disorders. However, in our view, it is unlikely to improve clinical care. The ultimate test for any system of diagnosis is its clinical utility. That is, does it assist clinicians to improve their selection or sequencing of treatments and enable them to make more accurate prognostic statements in keeping with newer concepts and knowledge? We propose that a refinement to traditional diagnostic practice — clinical staging — is more likely to improve clinical care and inform future research into the causes of mental disorders.2–5 Further, clinical staging draws the practice of clinical psychiatry closer to general medicine, especially with regard to chronic disease management.

In the past century, a major challenge for psychiatry was a lack of international consensus on diagnostic categories. For many decades, DSM and other international systems strived to enhance the reliability of psychiatric diagnoses. Recent field trials for DSM-5 indicate that acceptable reliability remains elusive.6 However, even diagnostic categories with modest reliability have limited validity. A major weakness is that the diagnoses refer to “categorical phenotypes” that fail to address critical differences in clinical presentations associated with age of onset or stage or course of illness.2–5 Most criteria reinforce categories derived from observations of middle-aged people with long-established stable illnesses, who have often been treated extensively by specialised mental health services. Inevitably, these map poorly onto earlier, less specific clinical presentations seen in general outpatient, primary care or community settings. They also presuppose that independent causal pathways exist for each clinical phenotype — an assumption that is not supported by contemporary family, genetic, neurobiological or risk factor research.2,3

What are the alternatives? Twenty-first century health care places an increasing premium on personalised or stratified medicine, with the goal of delivering more tailored treatments. Consequently, there is increasing international support for applying the concepts of clinical staging, particularly for adolescents and young adults with significant mood or psychotic disorders.4,7 Given that 50% of major mental disorders begin between 15 and 25 years of age, a focus on enhanced care and novel clinical research during this critical developmental phase is a timely test of this framework.5,8,9

At its core, the clinical staging model recognises the full spectrum of illness experience. For example, for ischaemic heart disease, the staging model identifies individuals at risk (because of genetics, lifestyle or other risk factors), those with symptoms or related syndromes that suggest illness progression (eg, hypertension, metabolic syndrome) and those with overt evidence of cardiac disease (eg, angina). Further, treatments differ at each point on the illness continuum, with interventions with lower risk–benefit ratios being provided at earlier stages (ie, dietary change or increased exercise for the at-risk stage, and more complex medical treatments for later stages). In psychiatry, this approach also differentiates at-risk individuals (stage 0; eg, family history of severe mental disorders) from those with early subthreshold or attenuated syndromes (stage 1; eg, brief episodes of psychotic or hypomanic symptoms) from those meeting threshold diagnostic criteria (stage 2) or with established or persisting illness (stage 3). Importantly, staging suggests that disorders emerge via a limited set of overlapping and fluctuating symptom clusters (microphenotypes), some of which resolve, while others progress and stabilise into clinical presentations (macrophenotypes) that ultimately resemble more traditional diagnoses.2–5 The clinical staging model is compatible with clinical reality and can be tested for reliability, predictive validity and patterns of association with developmental epidemiology and neurobiological markers.7,10

For mental health, the critical challenge is to help all patients entering care by reducing symptoms, promoting recovery and quality of life, and preventing progression to premature death or further disability.8 The means for achieving these outcomes may be better assisted by clinical staging rather than by prematurely assigning categorical diagnoses to an evolving clinical profile. Also, rather than encouraging early use of medical interventions, the specific intent of staging models is to mimic the disease-management principles now widely applied in general medicine, which enable clinicians to target stage-appropriate interventions from early in the course of illness. Thus, for most young people entering care before the development of full-blown mood or psychotic disorders, the emphasis is on providing relevant information and psychological strategies (including e-mental health), reducing known risk factors (notably alcohol and/or substance misuse), minimising self-harm, promoting resilience, encouraging self-monitoring and reviewing longitudinal course.8 In future, low-risk, evidence-based neuroprotective strategies (which are behaviourally, psychologically or medically based) may also become available.

Clinical staging revolutionised general medical practice, focusing attention on the benefits of intervening earlier in the course of life-threatening illnesses. For clinical psychiatry, it could enable appropriate matching of the timing and intensity of interventions to the specific needs of help-seeking individuals. Also, staging sheds light on the evolution of symptom networks and syndromes,5 and enhances our chances of validating specific pathophysiological pathways and of introducing more objective measures of illness risk, onset and progression.2 In medicine, the successor of clinical staging was clinicopathological staging. In the future, we hope that clinical psychiatry will also be based on the combination of objective markers of illness course and enhanced clinical care.

Improved prognosis for borderline personality disorder

New treatment guidelines outline specific communication strategies that work

Until recently, borderline personality disorder (BPD) was considered to be a chronic ongoing condition with a poor prognosis and no effective treatment. However, the tide of research and clinical opinion has turned, and the prognosis for this disorder is now considered improved for most patients if one of a number of effective evidence-based treatments is implemented.1 On 15 March 2013, the National Health and Medical Research Council (NHMRC) issued the Clinical practice guideline for the management of borderline personality disorder, which outlines best practice.2

BPD was first described in 1938 when referring to a recognised group of people who were thought to be on the “borderline” between neurosis (depression and anxiety) and psychosis (schizophrenia).3 The term “borderline personality disorder” became accepted medical terminology in 1980 with its inclusion in the third edition of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders.2 The prevalence of BPD in the community is between 1% and 4%, but at least one-quarter of all mental health presentations to emergency departments or inpatient mental health units are people with a personality disorder.4

People with BPD may try to avoid abandonment by others, and they may have intense and unstable relationships, and feelings of insecurity and emptiness. They have difficulty with emotional regulation, manifesting as low mood, sudden anger, irritability, detachment and impulsivity in activities such as using drugs or engaging in risky sexual activity. The illness may include both anxious and labile mood, along with occasional more severe components such as transient stress-related psychotic-like symptoms, including paranoid delusions or hallucinations.

BPD is currently understood to be caused by a combination of biological factors (eg, genetic interpersonal hypersensitivity) and early environmental influences (eg, adverse childhood experiences).5 It cannot be said that BPD only derives from post-traumatic stress.6 Therefore, in view of current understanding, it is not “the person’s fault” or a result of “personal weakness” or “being manipulative” — labels that are sometimes prompted by the negative reactions of health care workers to people with the condition.

Clinicians are familiar with the problem of young people who self-harm, or who present as needy and impulsive, and who have a history of presenting to emergency departments in crisis. Managing these people can be a challenge, in part because they often have difficulty describing themselves.7,8 Such people can present sometimes as aggressive, entitled and disinhibited, but at other times as needy, timid and compliant. It is important to recognise that self-harm does not indicate BPD if it is the only presenting problem.

Psychological therapies are the treatment of choice. Over 25 randomised controlled trials have now demonstrated the benefits of specific types of psychotherapy that are known to be effective, such as dialectical behavioural therapy, mentalisation-based therapy, and transference-focused therapy.3 An important factor that is common to all effective therapies is the use of a specific form of communication focused on discussing current relationship difficulties and methods of problem solving with patients, so that they are able to choose healthier relationships and maintain study and work.9 Clinicians should avoid discussing past traumas in the early stages of treatment, as this has rarely been found to be helpful and usually worsens patients’ mental health and increases their risk of suicidality. Unlike depression, anxiety or schizophrenia, there are currently no approved medications that are “on label” indicated for the disorder, with Recommendation 11 of the NHMRC guidelines stating that “medicines should not be used as primary therapy for BPD, because they have only modest and inconsistent effects, and do not change the nature and course of the disorder”.2

Effective treatments aim to strengthen self-esteem, and use the therapist–patient or doctor–patient relationship to provide a “safe place” for the patient to discuss alternatives to destructive behaviour and relationship insecurities, with an unhurried, step-by-step “here and now” approach to improve daily functioning. One of the principles of the NHMRC guidelines is that to be effective, doctors should try to “act consistently and thoughtfully . . . to make sure the person stays involved in finding solutions to their problems, even during a crisis”.2,10 The availability of resources to help doctors, patients and their families and carers to understand and better respond to the condition is important; the NSW Health Project Air Strategy for Personality Disorders10 (www.projectairstrategy.org) referred to in the NHMRC guidelines is an example of such resources being made available in one place. People who suffer from the disorder almost always experience receiving a diagnosis as helpful, because it allows them and their families to understand that this is a recognised disorder and that there are good psychotherapies that provide hope.

A major focus of effective treatment is to support families, partners and carers of people with BPD.2 Because of the interpersonal nature of the disorder, families often feel burdened by their relative’s condition, and also need to learn effective ways to communicate and cope with living with a person with the illness. The doctor or therapist can encourage families to stay connected to the person with BPD, even though this may be stressful.10 Doctors and therapists have an important role in supporting both patients and families to get the help they need, and in providing education about the latest developments in our understanding of the disorder. Most of all, doctors and therapists are in a powerful position to give hope to those with the diagnosis, and to work to overcome the stigma and prejudice surrounding BPD. This is particularly important, as people with the condition are now known to respond well to new treatments.

Challenges to a more open discussion of suicide

The value and meaning of public discussion of suicide requires broader consideration

Recently, some commentators have called for a more open public discussion of suicide to promote community awareness of this important issue.1 The rationale for this is based on international research that advocates a multilevel approach to suicide prevention, combining mental health care with public awareness campaigns and gatekeeper training for those in close contact with at-risk groups.2 While this is intuitively appealing, the problem is that, as well as being a public health problem, suicide is inscribed with deeply felt moral, religious and cultural meaning that will influence any discussion, and that the potential outcomes of public discussion are poorly understood.

Unfortunately, the debate about the public discussion of suicide has often failed to go beyond consideration of the risks of such a “dangerous” discourse and often conflates public discussion of suicide with media reporting of suicidal events. Indeed, there is very little research that investigates public discussion outside this context.3 Most existing research relates more specifically to the domain of news and information media,3 and the debate in Australia has often centred on media guidelines for the responsible reporting of suicide.1,4 Many of those who have contributed to debates about public discussion of suicide have noted that increased media reporting may have a detrimental effect and lead to increased suicidal behaviour in vulnerable, at-risk populations.4 In support of such concerns, they cite a strong body of research that demonstrates a correlation between media reporting of suicide and actual suicide. But while such research indicates the dangers of irresponsible or insensitive reporting of suicidal events, there is also a small body of literature that shows how media reporting of suicide may operate positively and reduce the risk of suicide.5,6

However, media representations of suicide and community discussions of suicide are two distinct issues. Many different kinds of conversations are possible (in terms of their focus, format, setting and target group).3 For example, it is possible to discuss prevention, intervention and postvention (for the bereaved); it is possible to have discussions online, in the workplace, within families and in educational settings; and it is possible to have one-on-one discussions, group discussions and community discussions.3 It is important, therefore, to recognise these differences and the potentially different impacts and implications that these might have.3

Most of the research on discussion of suicide focuses on individual-level interactions. For example, literature reviews conducted in New Zealand7 and Canada8 focus on the question of whether asking about an individual’s suicidal ideation or intent increases the risk of that person either attempting or completing suicide — with neither study finding evidence to support or refute this claim. A review of the literature conducted on behalf of Choose Life, Scotland’s national action plan to reduce suicide, adopted a broader approach, investigating individual-level discussions as well as general public education and awareness campaigns.9 Like the New Zealand and Canadian studies, the researchers found no evidence that encouraging people to talk about suicide had any positive or negative impacts on primary outcomes of decreasing suicidal acts or higher levels of treatment seeking. The same was true of public education and awareness campaigns, although there was some evidence to suggest that public awareness campaigns may increase awareness of suicide and available resources.9

The failure of research to demonstrate many measurable changes in complex social behaviour after health promotion campaigns is, in many ways, not surprising. There are intellectual and emotional barriers to discussing things that are painful, threatening and complex,10 and it is unrealistic to expect significant social change within a short period of time.

Limiting the outcomes of research to suicide rates and the number of people seeking treatment, as generally happens, is also problematic: these are not the only measures of success. Other meaningful outcomes of facilitated public discourse may include, for example, increased public tolerance of mental illness, reduction in discrimination and stigmatisation of both people who have attempted suicide and those with mental illness, increased awareness of the risk factors for suicide and increased community cohesion more generally. For suicide is not simply a medical “problem”, or even a public health “problem” — it is a complex cultural and moral concern that is deeply embedded in social and historical narratives and is unlikely to be greatly altered by any form of health intervention.

While recent efforts by the New South Wales Ministry of Health to develop evidence-based guidelines for community discussion about suicide are welcome,3 we suggest that such approaches continue to confuse clinical with public discourse, persistently focus on the risk of public representation of suicide, and misapprehend the scope and benefit of public discussion.

The cultural conversation required to address deep-seated issues of stigma, blame and social responsibility, as well as morally unsettling questions about the particular nature of the hopelessness and helplessness that compels individuals to contemplate suicide, is not easy to articulate and less easy to measure. And, like discussions of gender roles or racism with which we believe public discussion of suicide may be more suitably compared, any social or cultural transformation may take many years to achieve. Nor can such discussions ever be completely free of risk. Talking about grief, fear, loss, isolation and destruction will always be challenging and, irrespective of how sensitively it is done, some will inevitably find that such discussions do not reduce these feelings but amplify them. We can try, as best we can, to respond to these feelings, thoughts and anxieties when they arise, but we cannot imagine their possibility out of existence.

While medicalisation of suicide has provided secular ways to understand suicide and has enabled the development of therapies and programs to prevent its occurrence and to assist at-risk individuals and those bereaved by suicide, it has also led to a narrowing of public discussion. A genuinely open discussion of suicide must be a wide discussion — not just a medical or public health discussion, but a social, cultural, moral, political and even religious discussion.

Public conversations about suicide are happening — and have always happened. Rather than seek to suppress or control such discussions, we need to understand that medicine does not have all the answers to such complex problems and to trust in people’s capacity to reflect on even the most difficult issues. It is time for us to have a much richer, more honest and more open public discussion about suicide.

Suicide prevention: signposts for a new approach

Suicide prevention can be improved by implementing effective interventions, optimising public health strategies and prioritising innovation

Suicide has overtaken motor vehicle accidents as the leading cause of death among young adults aged 15–44 years in Australia. In 2011, 410 Australians aged 25–34 years took their own lives, with a total of 2273 deaths from suicide reported across all age groups.1 In terms of funding allocations, the Australian Government’s investment in the National Suicide Prevention Program (NSPP) more than doubled from $8.6 million in the financial year 2005–06 to $23.8 million in the financial year 2010–11.2 However, it is uncertain whether specific activities funded under this and similar schemes have reduced suicide rates. One study reported that Australia’s efforts to improve youth suicide prevention through locally targeted suicide prevention activities under the National Youth Suicide Prevention Strategy were unsuccessful in the period 1995–2002.3 Recent studies highlighting the limitations of individual risk assessments have contributed to a sense of nihilism. In suicide prevention, there is an acute mismatch between evidence-based interventions and clinical and population-based practice. The evidence of effectiveness is very limited,4 while the need to act is compelling.

Given this picture, a new approach must be considered — one that optimises implementing the few public health interventions that are backed by strong research evidence, as well as testing innovative strategies. The following six recommendations may help focus a new suicide prevention policy.

Recommendation 1: implement known effective interventions

A first step in reducing suicide rates is to implement interventions that are known to work. The three public health interventions with the strongest evidence base in reducing suicide are gatekeeper training, reduction in access to means, and good-quality effective mental health care.4 Gatekeeper training involves teaching individuals such as health care professionals, army and air force officers, school staff and youth workers, who are primary points of contact for high-risk populations, to effectively identify, assess and manage risk of suicidality and provide referral to treatment if necessary. Reduction in access to means of suicide includes increased restriction of access to firearms, domestic gas and pesticides, reduced pack size of analgesics and physical barriers at suicide sites. Good-quality mental health care, such as training for general practitioners to identify depression, combined with collaborative care, quality assurance programs and nurse management, is effective in reducing depression. A descriptive, cross-sectional before-and-after analysis of national United Kingdom suicide data from 1997 to 2006 provided evidence supporting the utility of combining various prevention strategies within mental health services.5 In 2005, for example, services that implemented seven to nine out of a total of nine recommendations had suicide rates of 10.50 per 10 000 patients, while services that implemented zero to six recommendations had rates of 13.45 per 10 000 patients.

However, even as a first step in reducing suicide in Australia, the value of these strategies is limited. Most evaluations of community gatekeeper programs report improved knowledge about suicide and increased self-efficacy in gatekeepers (ie, gatekeeper trainees’ self-reported perceptions and appraisal of their own ability, competence and skills to successfully identify and assess suicidal risk and refer to appropriate services if necessary). However, gatekeeper training has established effectiveness for suicidal ideation or suicide attempts only in certain medical or institutional contexts, such primary care or the military.4 Community gatekeeper training, which is currently funded under the NSPP, has not been subject to rigorous empirical tests for core suicide outcomes. Means restriction is influential where access to suicide methods (such as pesticides) is prevalent. However, in Australia, efforts to restrict means are already in place. Improved mental health care will only be effective for those in contact with mental health services, estimated to be less than half of those who attempt suicide,6 and for only one-third (34.9%) of those with any mental disorder over a 12-month period.7 Health reform and investment to increase early access to headspace: the National Youth Mental Health Foundation and e-health services for young people may increase rates of help-seeking. However, effectiveness research is very limited — of the “effective” public health interventions for suicide described above, only gatekeeper training has been subjected to a single randomised controlled trial (RCT).4,8 In contrast, a 2012 paper reported more than 30 RCTs of non-pharmacological interventions to prevent depression,9 and a 2005 retrospective evaluation reviewed 477 RCTs of selective serotonin reuptake inhibitors to explore whether antidepressants increased risk of suicide.10

Recommendation 2: model for best
“bang for buck”

To gain maximum benefit from the available suicide prevention funds, we need to determine the impact, circumstances and audience of targeted or universal population-based approaches. Targeted approaches aim to lower risk in groups with higher risk of suicide, such as Indigenous youth, lesbian, gay, bisexual and transgender people, and older men,1 or those with higher risk of suicide attempts, such as young women. A broader population-based approach aims to lower the overall level of risk factors and behaviours in the population, thereby reducing the number in the “high risk” tail of the distribution.11 Modelling is required to determine the extent to which targeted or population approaches will deliver the best “bang for buck” in reducing suicide attempts, risk and burden on the health system, and in facilitating the uptake of specific prevention activities and health services. The economic costs of suicide need to be assessed more broadly.

Recommendation 3: evaluate if simpler interventions are as effective as more
complex ones

Internationally, the trend is to combine multiple elements into broader programs, such as the European Alliance Against Depression (EAAD), which involves 20 international partners representing 18 European countries, Optimizing Suicide Prevention Programs and their Implementation in Europe (OSPI Europe)12 and the “Don’t hide it. Talk about it” campaign, undertaken in conjunction with the Choose Life training program in Scotland. For most of these programs, we are unable to determine whether a single element, a combination of elements or the sheer intensity of the cumulative effect of the approach is the key to any potential impact. The downside of complex interventions is that costs rise and translation to practice requires intense effort, so there is urgency about evaluating each of the elements separately.

Recommendation 4: take advantage of opportunities early in the suicide prevention chain

Risk models indicate that suicide risk arises from depression, hopelessness and capability which, in combination with proximal and immediate triggers, lead to suicidal acts. Systematic intervention early in this “chain” is important. If depression is a necessary (albeit not sufficient) condition and prominent risk factor for suicide, intervening early for depression is critical. From a population perspective, schools are an ideal environment in which to deliver interventions that may lower the risk of suicide later. Australian researchers have shown that “upstream” modification of depression and alcohol misuse is achievable.13 However, these upstream interventions are not systematically implemented. Postvention programs have been newly introduced into high schools to deal with the fallout of an attempted suicide or a suicide, without support from RCTs. These may be useful, although this remains to be seen. The point is that our strategy needs to put more emphasis on prevention in those with risk, where evidence is relatively strong. Put simply, the hospital emergency department should not be the first point of intervention in the suicide prevention chain.

Recommendation 5: offer suicide programs directly through the internet to those at risk and not in contact with mental health services

There is promising evidence that online programs are effective and able to reach many who do not seek traditional health services.14

Recommendation 6: develop clear prevention messages and practices to improve suicide literacy

Media guidelines promote responsible professional coverage and caution against the possibility of social contagion. This social transmission of suicidal behaviour through social media needs immediate attention, particularly in young people, given the potential for harm. However, there is recognition that the issue of suicide must be discussed to improve understanding and, hopefully, to lower risk. The National Mental Health Commission recently commissioned research to explore Australians’ attitudes to suicide. The report concluded that since “simple advice can help stem the tide of some diseases”, a public campaign around suicide was warranted.15 Recent Australian research uncovered similar findings. Literacy levels around suicide are low, and people do not know what constitutes the triggers to suicide, or how to identify suicide risk in their friends and family.16

There may be overall harm in shutting down talk about suicide if this strategy inhibits a more integrated community and medical response to identifying those at risk. The information needs of the community need to be mapped out, and tailored messages should be trialled through community and expert consultation. We reiterate that before a campaign around suicide literacy and stigma is launched, the proposed campaign messages and dissemination practices should be tested using controlled experiments to determine if they raise appropriate awareness.

A new suicide prevention strategy

Suicide is a complex behaviour, and likely to have different causes and triggers depending on context and individual characteristics (eg, Indigenous and remote communities, culturally and linguistically diverse groups, people in prisons and those with a psychiatric disorder). However, suicide rates will not lower substantially if we continue a scattergun approach to funding diverse projects, failing to prioritise interventions with proven effectiveness, ignoring the opportunity to optimise a broader population health approach, or failing to fund innovation using new technologies. We must invest in new strategies with demonstrated impact to avoid further loss of life.

Reviewing the revisions: what are the Australian Bureau of Statistics suicide figures really telling us?

To the Editor: For several years, the Australian Bureau of Statistics (ABS) has cautioned data users of likely underreporting of suicide statistics due to delays in coronial processes and (since 2006) exclusive reliance on the National Coronial Information System, which often contains incomplete information on cause of death.1 In 2009, the ABS introduced data revision processes that allowed additional information received to be added in two rounds of revisions at 12 and 24 months after the initial processing of coroner-certified deaths. This assisted coders in assigning more specific causes of death, thereby replacing the previous default “accident” category for ambiguous cases.

These changes have increased reported suicide rates, predominantly due to parallel reductions in deaths assigned to “Other ill-defined and unspecified causes of mortality” (International Classification of Diseases, 10th revision [ICD-10] code R99), which have more than halved, and “Event of undetermined intent” (ICD-10 codes Y10–Y34, Y87.2), which have reduced by around two-thirds.2,3 As these categories often represent “holding bays” for cases with insufficient information at initial processing, such decreases would be expected after the revisions. However, the figures remained inflated: in the 2006–2009 data (which have undergone two rounds of revision), ill defined causes of death remained more than double the levels recorded during the 1990s, and deaths of undetermined intent more than three times higher.3

Currently, the only reliable alternative source of suicide mortality data in Australia, albeit at the state level, is the Queensland Suicide Register (QSR). The differences between the two datasets have been detailed elsewhere.4 From 2003, the discrepancy between QSR data and ABS preliminary data on suicide grew exponentially, reaching 47.1% in 2007.4 Final revisions of ABS data from 2006 have reduced the gap to levels comparable to those seen during the 1990s and early 2000s (Box). However, the two datasets remain significantly different for 2003–2005, for which ABS data were not revised. It is reasonable to conclude that considerable numbers of suicides in these years remain misclassified.

Data users should be aware of these caveats when interpreting ABS statistics, particularly the recently announced 17% drop in suicide rate over the past decade.2 Continuous efforts to improve the reliability
and validity of suicide data are of paramount importance for developing and evaluating suicide prevention programs.

Differences in Queensland suicide rates reported by the
QSR and the ABS, 2001–2009

	Rate per 100 000
Year	QSR	ABS	Difference

2001	14.05	13.75	2.2%
2002	15.64	14.46	8.2%
2003	14.33	12.23	17.2%
2004	15.25	11.61	31.3%
2005	14.17	11.49	23.3%
2006	12.91	12.08 (F)	6.9%
2007	12.89	12.39 (F)	4.0%
2008	13.86	12.83 (F)	8.0%
2009	13.39	11.86 (F)	13.0%
QSR = Queensland Suicide Register. ABS = Australian Bureau of Statistics. F = final data after ABS revisions.

The role of depression in the primary prevention of cardiovascular disease

To the Editor: We would like to add a cautionary note to O’Neil’s support for the inclusion of “depression and other psychosocial factors” in the updated National Vascular Disease Prevention
Alliance guidelines for assessing cardiovascular disease (CVD) risk. Her statement “it is now clear that depression is also an important risk factor for CVD” is premature.1 Different authors have challenged the suggested relationship and, given divergent findings and opinions, it is misleading to claim that the matter is now “clear”.2–5 We do not deny a possible link between depression and coronary heart disease (CHD) but suggest that the extent and nature of the relationship has yet to be clarified. Premature acceptance and promotion of the idea that depression is a risk factor for CHD might contribute to overdiagnosis and overtreatment of depression as well as undue worry about the risk of CHD by individuals diagnosed with depression.

The role of depression in the primary prevention of cardiovascular disease

In reply: I thank Stampfer, Hince and Dimmitt for their response.
While I acknowledge that there are aspects of the relationship between cardiovascular disease (CVD)
and depression that remain undetermined, recent evidence clearly supports the role of depression as an independent risk factor for CVD and is indeed convincing.1–3 This is especially true in studies that assess depression using diagnostic criteria.4 We know that the risk of developing coronary heart disease (CHD) for individuals with depression is twofold, and these individuals have a similar risk of CVD-related death.2 We also know that the independent contribution of depression to CVD is at least comparable to that of more traditional risk factors including diabetes, hypercholesterolaemia, smoking or obesity.5 A decade has now passed since the National Heart Foundation’s seminal position paper concluded that: “there is strong
and consistent evidence of an independent causal association between depression, social isolation and lack of quality social support and the causes and prognosis of CHD”.5 Despite this, depression remains underestimated as a meaningful contributor to CVD.

Long-term health and wellbeing of people affected by the 2002 Bali bombing

The 2002 Bali bombing resulted in the deaths of over 200 people, including 88 Australians and 35 Indonesians, making it the single worst act of terrorism to have affected either country.1 A further 209 people were injured, including 66 Australians who suffered severe burns and complex shrapnel wounds.2,3

Terrorism exposure may have significant long-term effects on the mental health and wellbeing of survivors. Post-traumatic stress disorder (PTSD) is the most common psychological condition observed in the aftermath of such events, but it often coexists with depression, functional impairment or substance misuse.4,5 Few studies have examined the long-term effects on terrorism survivors, although one large study found increases in PTSD between 3 and 5 years after the September 11 attacks.6,7 Risk factors included direct exposure (proximity, injury, witnessing horror), incident-related bereavement and low social support.

Bereavement that occurs in traumatic circumstances may have a considerable long-term impact on psychological distress and appears to slow the rate of recovery.8 Deaths involving deliberate violence are associated with higher prevalence of trauma conditions, depression and prolonged or “complicated” grief.8,9 Complicated grief is characterised by continuing separation distress and bereavement-related traumatic distress. While frequently comorbid with depression or PTSD, it is increasingly recognised as a distinct condition that is associated with persistent functional impairments and negative health outcomes, particularly among those bereaved through terrorism.9,10

The health and psychosocial effects of terrorism exposure have rarely been investigated beyond 3–4 years after such incidents.4,11 No studies have examined these effects among Australian survivors. Our aim was to examine the physical and mental health status of individuals directly affected by the 2002 Bali bombing, 8 years after the incident, and to determine demographic, exposure and loss-related correlates of these health outcomes.

Methods

Participants constituted a cross-sectional convenience sample of individuals who had experienced personal exposure and/or loss related to the 2002 Bali bombing and had current contact details listed with a New South Wales Ministry of Health therapeutic support program (Bali Recovery Program), where they had attended at least one consultation. Those who registered interest in response to a written invitation were contacted, given a description of the study, and asked for verbal consent. Professional interviewers from the NSW Health Survey Program completed computer-assisted telephone interviews between 9 July and 22 November 2010, excluding a period around the bombing anniversary (1–23 October). The validity of telephone-based interviews to assess stress and anxiety conditions has been demonstrated.12

Measures

We examined demographic and exposure factors to determine their relationship with physical and mental health outcomes. Exposure variables were: lifetime traumatic incident exposure,13 presence in Bali during/after the bombing, involvement in the search for missing friends/relatives (first 48 hours), and bereavement circumstance (eg, multiple loss, family). Perceived social support from family and friends was assessed with two items from the Perceived Social Support Scale,14 as well as single items regarding neighbourhood social connectedness15 and overall support since the bombing.

Current bereavement experience (“experiential” grief) was measured using six items from the Inventory of Complicated Grief-Revised (ICG-R): separation distress (longing/yearning) and cognitive, affective or behavioural items (anger, acceptance, detachment, emptiness/meaninglessness, difficulty moving on). High factor loadings related to the single underlying complicated grief factor and elapsed time since bereavement guided item selection.16

Self-rated physical health in the previous month was measured with a single validated item from the NSW Population Health Survey.15 We used the short form of the Connor-Davidson Resilience Scale (CD-RISC2) to measure current perceived personal adaptability and ability to continue to function effectively in stressful circumstances.17 A score of 7–8 indicates high personal resilience.

Anxiety, depression, agitation, psychological fatigue and associated functional impairment (ie, full days unable to manage day-to-day activities due to symptom effects) in the past month were measured using the Kessler Psychological Distress Scale (K10+). Individual scores range from 10 to 50, indicating low (10–15), moderate (16–21), high (22–29) and very high (30–50) psychological distress. The latter is indicative of a significant mental health condition.18

We used the Primary Care PTSD Screen (PC-PTSD) to measure past-month traumatic stress-related symptoms (TSRS) specific to Bali-related experiences. Single items relate to one underlying characteristic specific to PTSD: re-experiencing, numbing, avoidance and hyper-arousal. The endorsement of 3–4 symptoms indicates “probable” PTSD and the need for specialist assessment.19

Statistical analysis

The dataset was weighted by age and sex to reflect registered participants in the Bali Recovery Program (n = 115). Current physical and mental health were analysed as outcome measures, with demographic, traumatic incident exposure, perceived support and bereavement factors used as independent variables.

Responses to the support and bereavement questions were expressed as dichotomous variables, with a value of 1 assigned to responses “agree” or “strongly agree”, and 0 to “disagree”, “strongly disagree” and “don’t know”. The outcome variables of physical health, personal resilience and functional loss were dichotomised into high and low (or good and poor) outcomes. Three outcome categories based on established clinical cut-offs were adopted for psychological distress (low–moderate, high and very high) and TSRS (low, moderate and high).18,19

Analyses were performed using Stata statistical software, version 12.0 (StataCorp), with “Svy” commands to allow for adjustments for sampling weight. We used the Taylor series linearisation method to determine prevalence estimates, and χ2 tests to test for significant differences in the prevalence of physical and mental health outcomes. Due to the relatively small sample size, an α significance level (P < 0.15) was adopted, as it is a commonly used threshold for entry into multiple logistic regression analyses,20 and could provide indicative findings in the context of this exploratory study. Multiple testing using the Bonferroni correction was also carried out by dividing the target α level by the number of tests being performed. The significant adjusted P values are reported.

Ethics approval

All study protocols were approved by the ethics committees of the Northern Sydney Local Health District and the University of Western Sydney (H7143).

Results

Of 81 individuals contacted, 55 agreed to participate (68% of eligible respondents). The mean interval between the 2002 bombing and the interview was 7 years and 11 months (range, 7 y 9 m – 8 y 1 m). There were no significant differences between the respondents and the total Bali Recovery Program population in terms of mean age (P = 0.38) or male sex (P = 0.39).

Respondent characteristics

Demographic, exposure and bereavement characteristics of the respondents are shown in Box 1. Of the 55 respondents, 21 were present in Bali during or shortly after the bombing. Almost three-quarters (39/54) experienced at least one family bereavement due to the bombing. The loss of children (of adult age) was predominant (21/54). Fifteen respondents experienced multiple losses of exclusively non-family members (average of seven friends and acquaintances killed).

Physical health and personal resilience

Physical and mental health prevalence estimates for the weighted sample are presented in Box 2 and Box 3. Good physical health in the past month and high personal resilience were reported by 45 and 30 of the 55 respondents, respectively. Respondents had an aggregate resilience score on the CD-RISC2 of 6.45. Poor self-rated health showed a significant relationship with current yearning for the deceased (P = 0.04) and perceived current difficulties moving on with life after the loss (P = 0.02). Experiential bereavement factors were the only variables associated with low personal resilience: current yearning (P = 0.02); perceived detachment from others (P = 0.04); life feeling empty without the deceased (P = 0.02); and perceived difficulty moving on (P = 0.003).

Psychological distress and daily functioning

Current high and very high psychological distress was reported by seven and five respondents, respectively. High distress was significantly associated with difficulty accepting the loss (P = 0.03); feeling detached (P = 0.001); and anger (P = 0.04). Very high distress was associated with bombing-related injury (P = 0.005); current yearning (P = 0.004); difficulty moving on (P = 0.003); and life feeling empty (P < 0.001). Very high distress also showed significant inverse relationships with current marital or de facto relationship (P = 0.02); perceived family support (P = 0.03); and better neighbourhood connectedness (P = 0.02). Loss of at least one full day of functioning in the past month was reported by nine respondents (range, 0–16 days; mean, 0.74). Significantly greater functional loss was associated with bombing-related injury (P = 0.04) and not being in a current marital or de facto relationship (P = 0.04).

Traumatic stress-related symptoms

Moderate TSRS (two symptoms) and high TSRS (three or more symptoms) in the past month were reported by 11 and 15 respondents, respectively. High TSRS was positively associated with all assessed features of bereavement but no other outcome variables: current yearning (P = 0.007); difficulty accepting the loss (P = 0.005); feeling detached (P = 0.01); anger (P = 0.002); life feeling empty (P = 0.02); and difficulty moving on (P < 0.001).

Comparisons with the NSW
general population

Compared with NSW population estimates, the respondents reported greater rates of high (12.7% v 8.2%) and very high (9.1% v 2.9%) psychological distress (Box 4) and functional impairment (mean, 0.74 v 0.60 days lost in the past month).15 Respondents were significantly less likely to report low levels of psychological distress (P < 0.05). Good self-reported health was slightly higher among respondents than the population mean (81.8% v 80.4%).

Discussion

Eight years after the first Bali bombing, a substantial proportion of this directly affected group were experiencing high levels of psychological distress and TSRS. These individuals, who had sought help, were also experiencing near-normal physical health, and their aggregate resilience score fell within a “high resilience” range observed in United States population estimates.17 Although a specific comparison group is not available, access to modern treatment methods and support may have promoted these positive long-term outcomes. Notably, experiential features of grief (eg, emptiness, difficulty moving on) were the only factors associated with reduced resilience, suggesting that early intervention with a specific focus on these factors may be indicated for such groups.10

Direct exposure to disasters is considered to have a dose–response effect. Factors such as proximity, injury and perceived threat to life are consistently associated with adverse mental health effects, but they are rarely examined beyond 3–4 years after terrorism incidents because of difficulty accessing affected cohorts.11 Eight years after the Bali bombing, a significant association was observed between incident-related physical injury and both psychological distress and functional impairment. These findings extend the current literature, showing that some of the most direct forms of exposure (proximity and injury) remain substantial risk factors at this extended time point.

Social support has a positive role in mental health and may foster recovery from trauma over time.21 We found that being in a marital or de facto relationship was the only demographic factor associated with distress in the respondent group, showing an inverse relationship with high psychological distress. Inverse relationships were also observed with the broader social support factors of high perceived family support and neighbourhood social connectedness.

The strength of our findings in relation to complicated grief variables appears to highlight important aspects of grief, as it relates to terrorism violence and loss. The ability to “make sense” of a loved one’s death is considered a central process of grieving.8 However, the irrational or meaningless nature of violent death, particularly through terrorism, has been found to interfere with this cognitive process for many survivors.22 Moreover, it is associated with more severe complicated grief, higher psychological distress and poorer physical health.23 While such mediating variables cannot be inferred in relation to our data, it is notable that complicated grief symptoms in this study were also associated with distress and poor physical health, as well as TSRS. Similarly, grief symptoms were also the only factors associated with significantly lower personal resilience. This suggests that among bereaved survivors of terrorism, grief maladaptation may represent a more significant long-term risk factor for health outcomes than incident exposure or post-event variables.

Our findings have implications for the support of people directly affected by terrorism. Complicated grief factors emerged as the strongest correlates of adverse physical and mental health status. Longer-term monitoring of survivor groups is indicated, including screening programs that incorporate grief-specific items. Previous short-term screening has effectively linked survivors with evidence-based care.10,24 However, case-finding from primary care pathways was poor, suggesting that outreach is required for longer-term initiatives.24 Significantly, 7 years after the September 11 attacks, registered individuals who had escaped the World Trade Center reported difficulty accessing physical and mental health care and often failed to connect long-term symptoms with their September 11 exposures.25

Our study has some notable strengths and several limitations. The sample ostensibly constitutes a traumatically bereaved population, with varying levels of direct incident exposure and use of clinical services. Respondents may represent a more seriously affected, but possibly better supported cohort than those who did not seek services from the program. This may limit generalisability of these findings to other survivor groups. This cross-sectional study can only determine significant associations at a single time point. No conclusions can be drawn regarding longitudinal health effects or their causes.

The response rate had the potential to introduce responder bias, although no significant differences in sex or age were found between the respondent sample and the total program population. Items from the complicated grief measure (ICG-R) examined a subset of symptoms only and cannot be considered to indicate syndrome-level complicated grief.

Importantly, this analysis presents the largest study sample to date of Australians directly affected by a single terrorist incident. In completing a quantitative analysis of their health status 8 years after a major bombing, it also represents, to our knowledge, the longest follow-up period of a terrorism-affected population reported in the literature.

1 Demographic, exposure and bereavement-related variables of the respondents

Variable	Unweighted (n = 55)	Weighted (n = 115)

Mean age (range)	50 (20–73)	50 (42–53)
Male	23 (41.8%)	48 (41.8%)
Education
University degree	15 (27.2%)	31 (27.3%)
TAFE certificate or diploma	17 (30.9%)	36 (30.9%)
Higher school certificate	11 (20.0%)	23 (20.0%)
School certificate	9 (16.4%)	19 (16.4%)
Other	3 (5.5%)	6 (5.5%)
Marital status
Married or de facto	40 (72.7%)	84 (72.7%)
Widowed	3 (5.5%)	6 (5.5%)
Separated or divorced	4 (7.3%)	8 (7.3%)
Never married	8 (14.5%)	17 (14.5%)
Location during/after bombing
Bali, in club*	6 (10.9%)	13 (10.9%)
Bali, near club*	3 (5.5%)	6 (5.5%)
Bali, not nearby	3 (5.5%)	6 (5.5%)
Bali, arrived after bombing	9 (16.4%)	19 (16.4%)
Not in Bali	34 (61.8%)	71 (61.8%)
Injured during bombing
No	48 (87.3%)	100 (87.3%)
Yes	7 (12.7%)	15 (12.7%)
Involved in search (first 48 hours)
No	39 (70.9%)	84 (72.7%)
Yes	16 (29.1%)	31 (27.3%)
Primary bereavement type†
Child	21 (38.2%)	44 (38.9%)
Sibling	11 (20.0%)	23 (20.4%)
Spouse	3 (5.5%)	7 (5.6%)
Other family member	4 (7.3%)	9 (7.4%)
Non-family member(s)	15 (27.3%)	32 (27.8%)
Loss†
Single family member	29 (52.7%)	61 (53.7%)
Multiple family members	4 (7.3%)	9 (7.4%)
Multiple family and non-family	6 (10.9%)	13 (11.1%)
Multiple non-family	15 (27.3%)	32 (27.8%)

TAFE = technical and further education. * Bomb site. † Bereaved respondents (n = 54).

2 Prevalence estimates of individual health and wellbeing indicators in the weighted sample, by sociodemographic and perceived support factors

Covariate	Good self-rated health	High resilience*	Functional loss†	High distress‡	Very high distress‡	Moderate TSRS§	High TSRS§

Sex
Male	78.3%	60.9%	17.4%	8.7%	4.3%	13.0%	21.7%
Female	84.4%	53.1%	15.6%	15.6%	12.5%	25.0%	34.4%
Age
18–40 years	73.3%	57.9%	26.3%	10.5%	10.5%	26.3%	26.3%
> 40 years	86.1%	55.6%	11.1%	13.9%	8.3%	16.7%	30.6%
Education
University	86.7%	66.7%	20.0%	13.3%	6.7%	20.0%	26.7%
High school/other	80.0%	52.5%	15.0%	12.5%	10.0%	20.0%	30.0%
Employed
No	75.0%	41.7%	25.0%	16.7%	8.3%	8.3%	50.0%
Yes	83.7%	60.5%	14.0%	11.6%	9.3%	23.3%	23.3%
Household income
≤ $60 000	77.8%	44.4%	27.8%	22.2%	11.1%	16.7%	22.2%
> $60 000	82.9%	62.9%	11.4%¶	8.6%	5.7%	20.0%	31.4%
Marital status
Married or partnered	85.0%	52.5%	10.0%	12.5%	2.5%	17.5%	30.0%
Not married or partnered	73.3%	66.7%	33.0%**	13.3%	26.7%**	26.7%	26.7%
Have children
No	75.0%	58.3%	16.7%	8.3%	16.7%	33.3%	33.3%
Yes	83.7%	55.8%	16.3%	14.0%	7.0%	16.3%	27.9%
Perceived support, family
Low	80.0%	60.0%	20.0%	20.0%	40.0%	40.0%	20.0%
High	82.0%	56.0%	16.0%	12.0%	6.0%**	18.0%	30.4%
Perceived support, friends
Low	85.7%	42.9%	14.3%	14.3%	14.3%	0.0%	42.9%
High	81.3%	58.3%	16.7%	12.5%	8.3%	22.9%	27.1%
Social connections, neighbourhood
Low	88.9%	66.7%	33.3%	11.1%	33.3%	33.3%	22.2%
High	80.4%	54.3%	13.0%¶	13.0%	4.3%**	17.4%	30.0%
Long-term support, all sources
Low	75.0%	75.0%	0.0%	25.0%	12.5%	0.0%	37.5%
High	83.0%	53.2%	19.1%	10.6%	8.5%	23.4%	27.7%
Total respondent group (95% CI)	81.8% (68.9%– 90.1%)	56.4% (42.7%–69.1%)	16.4% (8.6%–29.0%)	12.7% (6.0%–24.8%)	9.1% (3.7%–20.5%)	20.0% (11.2%–33.1%)	29.1% (18.4%–42.8%)

TSRS = traumatic stress-related symptoms. * Score of 7–8 on the short form of the Connor-Davidson Resilience Scale. † Unable to complete usual activities on 1 or more days in previous month. ‡ Score of 22–29 on the Kessler Psychological Distress Scale indicates high psychological distress; 30–50 indicates very high distress. § Two symptoms on Primary Care PTSD Screen indicates moderate TSRS; 3–4 symptoms indicates high TSRS. ¶ P < 0.15. ** P < 0.05.

3 Prevalence estimates of individual health and wellbeing indicators in the weighted sample, by incident exposure and bereavement factors

Covariate	Good self-rated health	High resilience*	Functional loss†	High distress‡	Very high distress‡	Moderate TSRS§	High TSRS§

Lifetime exposure¶
Low	84.0%	60.0%	16.0%	16.0%	4.0%	32.0%	32.0%
High	80.0%	53.3%	16.7%	10.0%	13.3%	10.0%	26.7%‡‡
In Bali during or after bombing
No	88.2%	55.9%	11.8%	11.8%	2.9%	20.6%	20.6%
Yes	71.4%‡‡	57.1%	23.8%	14.3%	19.0%‡‡	19.0%	42.9%
Injured during bombing
No	83.3%	58.3%	12.5%	12.5%	4.2%	18.8%	27.1%
Yes	71.4%	42.9%	42.9%§§	14.3%	42.9%§§	28.6%	42.9%
Involved in search (first 48 hours)
No	87.5%	60.0%	12.5%	12.5%	5.0%	22.5%	22.5%
Yes	66.7%‡‡	46.7%	26.7%	13.3%	20.0%	13.3%	46.7%
Bereavement**
Non-family member(s)	80.0%	46.7%	20.0%	13.3%	13.3%	20.0%	40.0%
Family member(s)	84.6%	61.5%	12.8%	10.3%	7.7%	20.5%	23.1%
Bereavement involved child**††
No	81.8%	57.6%	15.2%	9.1%	9.1%	21.2%	30.3%
Yes	85.7%	57.1%	14.3%	14.3%	9.5%	19.0%	23.8%
Current yearning for loved one(s)**
No	93.1%	72.4%	10.3%	3.4%	0.0%	20.7%	10.3%
Yes	72.0%§§	40.0%§§	20.0%	20.0%	20.0%§§	20.0%	48.0%§§
Difficulty accepting loss**
No	90.6%	62.5%	15.6%	3.1%	6.3%	18.8%	12.5%
Yes	71.4%‡‡	47.6%	14.3%	23.8%§§	14.3%	19.0%	52.4%§§
Feel detached from others**
No	84.3%	60.8%	15.7%	7.8%	7.8%	21.6%	23.5%
Yes	66.7%	0.0%§§	0.0%	66.7%§§	33.3%	0.0%	100.0%§§
Feel angry about loss**
No	92.0%	60.0%	16.0%	0.0%	8.0%	24.0%	4.0%
Yes	75.9%‡‡	55.2%	13.8%	20.7%§§	10.3%	17.2%	48.3%§§
Life feels empty without loved one(s)**
No	86.4%	65.9%	11.4%	6.8%	2.3%	22.7%	20.5%
Yes	66.7%	22.2%§§	22.2%	33.3%	33.3%¶¶	11.1%	66.7%§§
Moving on remains difficult**
No	87.5%	64.6%	12.5%	8.3%	6.2%	22.9%	18.8%
Yes	50.0%§§	0.0%§§	21.4%	33.3%	33.3%§§	0.0%	100.0%¶¶
Total respondent group (95% CI)	81.8% (68.9%–90.1%)	56.4% (42.7%–69.1%)	16.4% (8.6%–29.0%)	12.7% (6.0%–24.8%)	9.1% (3.7%–20.5%)	20.0% (11.2%–33.1%)	29.1% (18.4%–42.8%)

TSRS = traumatic stress-related symptoms. * Score of 7–8 on the short form of the Connor-Davidson Resilience Scale. † Unable to complete usual activities on 1 or more days in previous month. ‡ Score of 22–29 on the Kessler Psychological Distress Scale indicates high psychological distress; 30–50 indicates very high distress. § Two symptoms on Primary Care PTSD Screen indicates moderate TSRS; 3–4 symptoms indicates high TSRS. ¶ Lifetime exposure to potentially traumatising events: low = 1–2 events; high ≥ 3 events (excluding Bali exposure). ** Bereaved respondents (n = 54). †† Non-dependent child. ‡‡ P < 0.15. §§ P < 0.05. ¶¶ P < 0.001 (Bonferroni adjusted).

4 Population comparison of prevalence estimates* of psychological distress† in the past month

* Bali Recovery Program 2010 weighted sample and New South Wales population weighted prevalence estimates (2010).15 † Measured using the Kessler Psychological Distress Scale. ‡ P < 0.05.