LifeSpan: A whole-population stepped-wedge cluster-randomized trial of a multilevel systems approach to reduce suicide attempts and deaths in four NSW regions.

LifeSpan is a large-scale, community-wide trial for suicide prevention that will be implemented in four sites within New South Wales. LifeSpan will involve implementing nine strategies ranging from universal interventions to indicated interventions. The interventions will be implemented in each of the four trial sites for a period of two years, with evaluation occurring at 12-months and 24-months after baseline. Each site has a minimum population of 140,000 and its own local implementation team so that interventions, whilst maintaining core features for effectiveness, may be implemented differently to suit the local environment. The four sites are supported by a central implementation team and a research team based at the Black Dog Institute. The universal strategies include: 1. Means restriction: A suicide audit will be conducted, which will include the analysis of coronial and police data to assess trends, access to means and other contextual factors contributing to suicides and suicide attempts, at each of the four sites. The suicide audit will inform recommendations for tailored means restrictions strategies to reduce further suicide attempts and deaths in each of the four sites. The suicide audit will be supplemented by a focus group with professionals (e.g. hospital emergency department staff, community mental health staff) who have local knowledge of any suicide clusters in their community and what measures have been taken to deal with the risk. The site lead agencies and suicide prevention collaboratives will be provided with a guide to evidence-based strategies to reduce access to or lethality of means. The Black Dog Institute and the sites will work collaboratively to develop means restrictions strategies, based on the evidence-based guide. Strategies will also be guided by the dominant means identified, local needs, and local stakeholders relevant to facilitating specific means restriction. All means restriction actions will be documented for trial evaluation purposes. 2. School programs: Year nine high school students in all public, independent, and Catholic high schools within the four sites will be offered an evidence-based, universal school program designed to reduce stigma, increase help seeking behaviours and resilience, and reduce suicidal ideation and behaviours. YAM will be delivered over the two-year duration of the LifeSpan trial, meaning two consecutive cohorts of year 9 students will receive the YAM program. The intervention being used is Youth Aware Mental Health (YAM), which is a school-based suicide prevention program delivered by trained facilitators from outside of the school. YAM was developed by researchers and clinicians from the Karolinska Institute in Sweden and Cornell University in the US. Its primary aim is to raise awareness about suicide risk and the factors that may protect against suicidality. YAM will be delivered as per the SEYLE study protocol: Master trainers will travel from US and Europe to conduct a 4.5 day course to certify YAM instructors. YAM instructors will identify helpers and conduct half- day helper training. The helper can either be another accredited instructor, relevant youth worker or person with lived experience. YAM consists of five sessions delivered over a three-week period. These sessions include a mix of direct instruction, reading material, visual information and interactive workshops where young people are encouraged to role play skills within a supervised environment. The program is delivered by the accredited YAM instructors with the aid of one helper to class groups of up to approximately 30 students. The five sessions cover the following six central themes: what is mental health?; self-help advice; stress and crisis; depression and suicidal thoughts; helping a friend in need; and who can I ask for advice? 3. Community campaigns: Centrally developed resources and materials, created with the assistance of a media and advertising agency and containing key consistent messages, will be disseminated within each of the four sites. Locally delivered communications campaigns will be disseminated to the general public to reduce stigma, and to increase identification and referral of individuals with suicidal ideation or self-harming behaviours. In addition, sites will be provided with a budget and support to engage with existing suicide prevention campaign providers, such as beyondblue and R U OK, to deliver their campaigns within their region. Number of type of activities will be recorded for evaluation purposes. 4. Media guidelines: Journalists, media representatives and local health services will receive group-based face-to-face media training, delivered by MindFrame Australia, aimed at reducing dangerous reporting of suicide, and increasing responsible coverage of mental health and suicide. Local media organisations will be targeted to ensure sufficient training in, and compliance with, these guidelines, including: report suicide deaths in a sensitive and non-sensationalist manner; avoid giving suicide deaths undue prominence (e.g. front page of newspaper, or lead items in radio bulletins); prevent ‘copycat’ incidents, avoid providing specific details about the suicide, such as method or location; take the opportunity to educate the public and challenge myths about suicide; provide help and support resources to vulnerable viewers, such as listing crisis and helpline numbers; consider the needs of at-risk individuals in the aftermath of a suicide (e.g. taking care when interviewing the bereaved); provide opportunities for debriefing of those exposed to suicide stories, such as journalists themselves. The target audience is local media representatives, suicide prevention multiagency group members, organisational leaders and local leaders who might be asked to comment on suicide by media and who are involved in community support after suicide. A 2-day, face-to-face group program will be delivered early in year 1 of implementation at each site, with a half day refresher program delivered in year 2. The individual-based strategies are: 5. Gatekeepers (e.g. sports coaches, pharmacists, welfare workers) will receive training to identify and refer individuals with suicidal ideation or self-harming behaviour. Training will be provided to gatekeepers in each of the four sites in both face-to-face and online format. Gatekeeper training teaches lay and professional gatekeepers to recognise and respond positively to someone exhibiting suicide warning signs and behaviours, including providing appropriate referral information. The program includes orientation to suicide prevention and the role of gatekeepers, a review of the common myths about suicide, review and recognition of suicide warning signs, instruction on how to set up an intervention and how to ask the suicide question, how to persuade a suicidal person to accept help, how to refer a suicidal person to local/national resources, and how to improve self-efficacy and enhance hope by offering a personal belief in a positive outcome. One hundred gatekeepers will be trained per region. 6. Frontline staff training: First responders (police, paramedics, and emergency department staff) will receive face to face and online training to support individuals with suicidal ideation or self-harming behaviours. Training will be provided to first responders in each of the four sites. Where training already exists, such as the NSW Police Mental Health IT program, support will be offered to ensure the program is meeting local needs. Other frontline staff, such as emergency department staff, will be offered tailored training which includes gatekeeper skills but also addresses their particular needs. The local implementation teams have identified key decision makers within each sector to work with them in implementing training. The total number of staff trained will vary by sector and site. 7. Psychosocial treatments: A guide to evidence-based psychological and pharmacological treatments for the care of individuals with suicidal ideation and/or behaviours will be provided to privately and publicly employed psychologists, psychiatrists, and other mental health professionals at each site. The Advanced Suicide Prevention Training program, designed and facilitated by the Black Dog Institute, will be provided for these professionals, to inform appropriate assessment of suicidal ideation and/or behaviours. This 6 hour face-to-face group program trains participants to undertake a suicide risk assessment effectively; develop a collaborative safety plan; implement a team approach to treatment planning; provide effective management following a suicide attempt; and respond to the needs of people bereaved by suicide. This training will be supplemented by information on local referral pathways, delivered by a local subject matter expert and program champion. We aim to train 200 mental health professionals at each of the four sites. 8. GP capacity building and support: General practitioners will receive training and practice support to identify and refer individuals with suicidal ideation or self-harming behaviours. The Advanced Suicide Prevention Training program, designed and facilitated by the Black Dog Institute, will be provided to general practitioners. This 6 hour face-to-face group-based program trains participants to undertake a suicide risk assessment effectively; develop a collaborative safety plan; implement a team approach to treatment planning; provide effective management following a suicide attempt; and respond to the needs of people bereaved by suicide. Practice support is in the form of an electronically delivered stepped care program. General practices will be provided with training by the Black Dog Institute developers of the program (StepCare). Participating ractices will be provided with tablets to be placed in the waiting room. Practice staff will invite patients over the age of 18 years to complete a 2-minute screener in the waiting room on a mobile tablet. The patient is provided with information about StepCare and is asked to provide consent prior to progressing. If consent is provided, the patient will be asked to complete demographic information and questionnaires assessing anxiety, depression, alcohol use, suicidal ideation and risk. The patient will receive minimal immediate feedback and will be encouraged to discuss the results with their GP in detail. The GP will also be provided with more detailed immediate feedback, verbal scripts and recommendations for the patient within the practice management software. The recommended treatment steps up for more severe symptoms. The program automatically populates a Medicare Mental Health Treatment Plan if required. Patients who report symptoms are asked to complete screening every two weeks for 12 weeks, and these results are transmitted back to their GP so that the treatment plan can be modified if necessary. Training for the general practice staff in StepCare will come from a trainer located within the Primary Health Network, who will have received ‘train-the-trainer’ from the Black Dog Institute StepCare coordinator. We aim to train and/or provide StepCare access to 50-60 general practitioners per site. 9. Aftercare and crisis care following a suicide attempt: The reform of care in the emergency department and aftercare will be ongoing through the two-year implementation phase of the project. Guidelines will be developed regarding most appropriate aftercare and crisis care. These guidelines will be implemented in collaboration with hospitals, community mental health centres, and others involved in aftercare in each of the four sites. The guidelines will include recommendations for completing a psychosocial assessment for all patients who present at hospital following a suicide attempt (not just those considered high-risk), explicit communication to the patient about the role of the psychosocial assessment, and an emphasis on the relational aspects of the assessment. With the patient’s consent, families and carers will be included in the aftercare process. Each site has or will commission an aftercare support service which is based on the Outreach, Problem Solving, Adherence, and Continuity (OPAC) model, which includes assertive outreach, solution focused counselling, support to adhere to treatment, and where possible, continuity of contact with the same staff member.