Te aukatinga o te whakamomoritanga o te taiohi Māori
Suicide prevention in Māori youth

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Key concepts:
  • The rate of suicide in young Māori males is higher than in any other population group in New Zealand
  • Mental illness is strongly associated with suicide but is not the only risk factor
  • Suicide risk is influenced by both static background factors and changeable factors
  • In primary care, assessing wellness at every opportunity, providing culturally appropriate care and identifying risk early are important factors for suicide prevention in Māori

Kia korowaitia āku mokopuna ki te korowaitanga hauora
Let our future generations be embraced with good health

Young Māori are most at risk of suicide

Youth suicide rates in New Zealand have been decreasing since a peak in the mid 1990’s, however suicide remains a significant cause of death for young people.1

Māori are a youthful population. Almost half (45%) of the Māori population in New Zealand are aged between 0–19 years.2 Suicide rates for Māori youth (28 per 100,000) are higher than those for non-Māori youth (12 per 100,000).3 Of the 96 young people who died by suicide in 2007 in New Zealand, 35% were of Māori ethnicity.3

Young Māori males are most at risk
Suicide rates for young Māori males (15–24 years) in particular have been very high for the last decade. Although this rate now appears to be reducing, it still remains high – 40 per 100,000 in 2007 for young Māori males compared to 19 per 100,000 for young non-Māori males.3

Age distribution of deaths by suicide changes with ethnicity
Younger Māori are more likely to die from suicide than older Māori.3 This is in contrast to the age distribution of suicide deaths in non-Māori. In 2007, 65% of all deaths attributed to suicide in Māori were in those aged less than 35 years. This compares to approximately 32% in non-Māori, in the same age group.3

Risk factors for suicide

Both background risk factors, which are mainly static, and changeable risk factors can increase the overall risk of suicide.

Mood disorders and substance misuse (including alcohol) are strongly linked with suicide among young people. Young people who die by suicide often had a history of being irritable, impulsive, volatile and prone to angry outbursts.4
*Conduct disorder is defined as a repetitive and persistent pattern of behaviours in which the basic rights of others, or major age-appropriate norms or rules of society, are violated.19
Conduct disorder* was also common in young males who died by suicide.4

Other background risk factors may include:5,6

  • Past history of suicidal behaviour
  • Past trauma including physical or sexual abuse
  • Social and educational disadvantage
  • A history of exposure to a dysfunctional living situation
  • Identity issues e.g. ethnicity, sexual orientation

The risk of suicide is sensitive to changeable factors, which can increase vulnerability. For example, a male with a history of sexual abuse has background risk factors for suicide which may be increased by the onset of alcohol or drug binges, a relationship breakdown or other life crisis.

Accumulative risk of suicidal behaviour
Suicidal behaviour in young people is unlikely to be solely due to a stressful life event or psychiatric disorder, but rather, a response to an unhappy or adverse life course, which has been characterised by the accumulation of risk factors during childhood and adolescence.5 Profound hopelessness is a strong risk factor for depression and suicide.

Māori ethnicity and the risk of suicide

Risk factors for suicide in Māori are likely to be no different to those for non-Māori youth.5 However, there may be differences in the magnitude and prevalence of these risk factors specifically those relating to social, educational and economic disadvantage.

As with other cultures, Māori are diverse and not all young Māori will have strong ties to their culture. Māori ethnicity should therefore be thought of as a risk marker rather than a risk factor.5 It may alert GPs to the possibility of increased risk, but does not always guarantee it.

Protective factors against suicide
For Māori, a strong cultural identity and support within a caring community is thought to strengthen resilience to mental disorder, even in the presence of adverse socioeconomic conditions.7,8 This may also provide a protective effect against suicide.5,7,9

Key protective factors against suicide include:10

  • A strong sense of self-esteem and self-worth
  • Well developed coping skills
  • Whānau support and harmony
  • Positive school experiences
  • Cultural and religious beliefs that discourage suicide

The influence of culture on suicide

Beliefs and attitudes towards mental health disorders and suicide may vary depending on the cultural background of the individual and the community in which they live. Differing attitudes, religious and spiritual beliefs may influence the way in which distress is manifested and also the way friends and family respond to this distress.10

For Māori, whakamomori is the term often interpreted as suicide. However, whakamomori has a broader meaning which includes feelings, thoughts, emotions and actions that may escalate and result in an attempt at suicide.11 It has been defined in several ways including “committing suicide or any other act of desperation”, “a deep seated underlying sadness”, “in built tribal suffering” and a “psychological, spiritual and cultural or collective state of being that may, or may not result in death”.11

Factors that may protect against suicide, arising from a cultural perspective, include:11

  • An understanding of Māori concepts and experiences
  • A strengthening of cultural identity
  • Access to cultural resources e.g. kaumātua and marae
  • Reconnecting and maintaining cultural connections

Prevention of suicide in young people

What can be done at a primary care level to prevent suicide?

  • Recognition is the key - assess wellness at every opportunity
  • Ensure effective, youth friendly communication
  • Ensure confidentiality - if whānau are to be part of the solution, the patient must consent to the sharing of information
  • Identify and treat any mental health problems and provide active follow-up and referral if required

Recognising the risk of suicide in young people

Primary care is the first point of contact for most young people with any health problem, therefore primary care clinicians are ideally placed to identify and help young people in distress.12 Every interaction can be regarded as an opportunity to assess psychosocial, as well as physical, wellbeing.

It is important to ask the right questions, consider the presence of any suicidal behaviour and continually assess suicide risk. Although a recognisable mental health problem (e.g. depression or substance misuse) has been reported in 80–90% of young people who die by suicide, or who have made a serious suicide attempt,5 many other reasons may contribute to suicidal behaviour. Ask about relationships with whānau and friends, how school or work is and if the young person is experiencing any stressful life events. Be aware of all of the risk factors for suicide in young people including the potential for increased risk due to issues surrounding ethnicity.

Early detection of distress should allow effective interventions within a primary care setting, with the aim of preventing a suicide attempt.13

Applying a Māori health framework
For Māori, a framework such as Te Whare Tapa Whā (see Table 1) incorporates the four cornerstones of Māori health; spiritual, psychological, physical and whānau and provides a holistic view of health. This framework can be used to identify issues that need to be addressed to restore wellbeing.14

Table 1: Applying Te Whare Tapa Whā framework to suicide prevention14
Wairua (Spiritual) Hinengaro (Psychological) Tinana (Physical) Whānau (Family)
Assist in the development of a strong and positive cultural identity Help the young person recognise their strengths and encourage effective coping strategies and problem solving techniques Encourage good nutrition, rest, recreation and exercise
Encourage reconnection with whānau to ensure a sense of belonging

Communicating with young people
Consultations with young people can be difficult. History taking may be challenging especially when the young person has feelings such as embarrassment, fear, shame and shyness.

The aim is to establish effective, non-judgemental communication, to be empathic and to gain trust. Ask open questions to encourage conversation. Consider cultural context as this may help in the correct interpretation of a person’s behaviours, fears and thoughts.5,15 A behaviour that is regarded as “normal” in one cultural setting may not be normal in another.5,10

Be aware that some young Māori may be unwilling or unable to speak up and potentially challenge their elders.15

Issues of confidentiality
Reassure the patient that the consultation will remain confidential. However be aware that confidentiality has limits. If a high risk of suicide is suspected then there is an obligation for the GP to inform others, such as parents or a mental health team, even if the young person has not given their consent.

With consent from the patient, establish an effective relationship with their whānau. Involvement of whānau is important, not only to provide support, but also to allow the GP to gain an accurate appreciation of the problems faced by the young person.

Identifying mental health problems in young people

Young people are faced with challenges on many levels – physical, emotional, behavioural, educational and social. Determining what is normal and what may constitute a mental health problem can be difficult.16 Young people may be reluctant to seek help or may not know who to approach, therefore take every opportunity to ask about mental health issues.

The following criteria may be useful to help distinguish normal behaviours from behaviours that may be indicative of a mental health disorder:16

  • Duration – e.g. problems that persist for more than a few weeks
  • Severity – changes in mood and behaviour that are beyond the normal fluctuations for that age group
  • Impact – how the symptoms are affecting schoolwork, relationships with family and friends, involvement in activities

Young people, particularly young Māori, with mental health problems may be more likely to describe physical symptoms such as nausea, stomach ache, headache, weight change and alterations in sleep patterns, than to express feelings of sadness, hopelessness or unhappiness.9 Be aware that any patient who presents with a minor physical complaint may have a “hidden” primary reason for attending. Other presentations of adolescent depression may include behavioural disturbances, problems at school and social withdrawal.17

Best practice tip: If suicidal ideation has been identified in a young patient, design and write an action plan with them. This could be in two parts:

  1. Specific actions appropriate for that young person that may help distract them if they feel at risk of self harm e.g. talking to someone they trust, taking the dog for a walk or playing music
  2. Contact details (covering 24 hours) of who they can turn to urgently if they are suicidal. Give several options such as contacting a parent or other trusted adult, phoning their general practice during work hours (especially if whānau support is limited or absent), or contacting an emergency after hours service e.g. after hours general practice service, hospital emergency department

Group therapy may be preferable for Māori

Consider referral to Child and Adolescent Mental Health Services (CAMHS). Feedback from Māori who have accessed these services show that many prefer to work within a group situation and to have their whānau and iwi connections acknowledged.15 Services in both primary and secondary care are also likely to be more effective if they are youth friendly.

Youth friendly secondary care services are likely to provide:15

  • Comfortable, informal surroundings
  • Group therapy sessions
  • Creative methods of participation
  • Activities that include food, humour and movement

Check with your DHB for services available in your area.

Indications for referral to secondary mental health services

Immediate (same day) referral to secondary mental health services should be made for any young person who has:18

  • Serious suicidal intent
  • Psychotic symptoms
  • Severe self-neglect

Urgent (within 24 hours) referral should be made if the young person has:18

  • Severe depression or anxiety
  • Persistent symptoms
  • Profound hopelessness
  • Other serious mental health disorder (including substance misuse)
  • Significant functional impairment
  • Suspected bipolar disorder

Referral to secondary services may be required if a mental health problem is suspected but an accurate diagnosis has not been made. Referral should also be considered for young people who fail to respond to treatment in a primary care setting, or who may require medication.

Management of mental health problems in young people in primary care

Early intervention has been identified as a key priority to help improve health outcomes. For youth with mental health problems early intervention may potentially prevent these problems from continuing into adulthood.19 Psychological problems, such as behaviour and conduct issues, significant truancy and excessive anxiety, may be the precursors to adult mental health disorders.

In any young person presenting with mental health problems, an assessment of suicide risk should always form part of the initial consultation and risk should be continually monitored.

Structured clinical assessment tools

A structured clinical assessment tool can be used to help gain a more complete understanding of the patient’s wellbeing. These tools are intended as a guide for questioning. Other factors, such as the specific presenting problem and clinical judgement, may alter the flow of questions within a consultation.

The following tools could be used:

HEARTS5

  • Home: general behaviour, conduct, manageability
  • Education: behaviour, progress
  • Activities: attention span, anxiety, ability to finish tasks, friendship
  • Relationships: with peers, parents, whānau, recent changes, bullying
  • Temper: mood
  • Size: weight change, appetite

HEEADSSS5

  • Home: existing and new relationships, communication
  • Education/Employment: school grades, work hours, responsibilities
  • Eating: body image, weight changes, dieting, exercise
  • Activities: with peers, whānau
  • Drugs: tobacco, alcohol, other drugs, use by self, whānau, friends
  • Sexuality: sexual identity, relationships, coercion, contraception, pregnancy, sexually transmitted infections
  • Suicide and depression: sadness, boredom, sleep patterns, loss of enjoyment
  • Safety: injury, violence, rape, bullying, weapons

A strengths-based approach to management
Most young people with mild to moderate mental health problems can be managed in primary care with advice, active support and monitoring. Referral to other services may be required for severe problems and for some conditions, e.g. a suspected psychotic disorder. Referral may also be required to access specialised therapies, e.g. cognitive behavioural therapy or psychotherapy.

The overall aim of management is to promote a positive attitude and encourage development of the skills required to help overcome issues affecting the person. Using a strengths-based approach helps to identify and develop these strengths and positive attributes.

A strengths-based approach for mental health problems

A strengths-based approach helps to build confidence, motivation and self esteem. Key components include:

  • Identification and development of skills and strengths – these may not always be obvious or recognised by the young person or the people around them
  • Building of motivation to deal with problems
  • Increasing social interaction and enhancing relationships. Encourage social interactions especially with whānau, friends and school or work contacts.

Encourage the young person to adopt coping strategies and to take an active role in their management, as this may be empowering and a significant influence in promoting recovery.15

Listening to and appreciating the unique perspective of a young person may help them feel valued and appreciated.15 Help the young person to think of a trusted adult that they can talk to. This may not necessarily be a parent, particularly if the parental relationship is the cause of any distress. Support may come from someone else in the whānau such as a grandparent, uncle or aunt. In some cases the trusted adult may be an outreach worker, practice nurse or GP. Ensure the patient knows how to access urgent help if required.

Offer self management advice including guidance on exercise, sleep hygiene, stress management and misuse of alcohol and other substances. Provide educational information for the young person and their whānau, including web-based resources. Ensure there is a plan for follow-up and ongoing monitoring of suicidality. Consider referral to support services such as counselling, group therapy and other outreach services. Check if follow-up is in place for young people, who have been discharged from secondary care following admission for self-harm or mental health problems.

Medication in young people with mental health problems
Some young people with moderate to severe mental health problems, particularly depression, may require medication. However, it is recommended that GPs only prescribe antidepressants for young people in consultation with a psychiatrist or paediatrician. Fluoxetine may be used for major depression in young people, but requires careful monitoring to detect any worsening of symptoms, suicidality or changes in behaviour.20

For further information see BPJ Special Edition (Feb, 2010), “Depression in Young People” and the bestpractice Decision Support Depression module.

Resources:

 

The Lowdown is a free website aimed at young people, with downloadable self-management resources and youth counsellors available to provide online and text-based support services. Web: www.thelowdown.co.nz
 
 

The Ministry of Health, as part of the New Zealand National Depression Initiative, has launched a website including information, case studies, video stories and an online self-management programme, fronted by John Kirwan. Web: www.depression.org.nz

Out of the Blue from the Mental Health Foundation of New Zealand provides information and personal stories. Web: www.outoftheblue.org.nz

ACKNOWLEDGEMENT: Thank you to Dr Nicole Coupe, Kai Tahu, Te Atiawa, Manager Te Ira Tangata: Cutural Assessment for Suicide Prevention, Auckland for expert guidance in developing this article.

Reach Out Central is an Australian based website which provides information, support, and an interactive game for youth aged 16–25 years. Web: www.reachoutcentral.com.au

References:

  1. Ministry of Social Development. 2009 The social report. Available from: www.socialreport.msd.govt.nz/health/suicide.html (Accessed May 2010).
  2. The Werry Centre. 2008 Stocktake of child and adolescent mental health services in New Zealand. 2009. Available from: www.werrycentre.org.nz (Accessed May 2010).
  3. Ministry of Health. Suicide facts: Deaths and intentional self-harm hospitalisations 2007. Wellington: Ministry of Health; 2009.
  4. American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry 2001;40:7 (Suppl): 23S-51S.
  5. Ministry of Youth Development. Detection and management of young people at risk of suicide: guidelines for primary care providers. Wellington: RNZCGP, Ministry of Youth Development; 2004.
  6. Ministry of Health. The New Zealand suicide prevention strategy 2006-2016. Wellington: Ministry of Health; 2006.
  7. Oakley Browne M, Wells J, Scott K. Te Rau Hinengaro: The New Zealand mental health survey. Wellington: Ministry of Health; 2006.
  8. Marie D, Fergusson DM, Boden JM. Ethnic identification, social disadvantage and mental health in adolescence/young adulthood: results of a 25 year longitudinal study. Aust NZ J Psych 2008;42:293-300.
  9. Coupe N. Whakamomori: Maori suicide prevention. Thesis presented in partial fulfilment of the requirements for the degree of Doctor of Philosophy. Maori Studies, Massey University: Palmerston North; 2005.
  10. Washington State Department of Health. Washington State’s plan for youth suicide prevention 2009. Available from: www.doh.wa.gov/preventsuicide (Accessed May, 2010).
  11. Tapsell R, Mellsop G. The contributions of culture and ethnicity to New Zealand Mental Health research findings. Int J Soc Psychiatry 2007;53(4):317-24.
  12. Ministry of Health. Te Puawaiwhero: The second Maori mental health and addiction national strategic framework 2008-2015. Wellington: Ministry of Health; 2008.
  13. Wintersteen MB. Standardised screening for suicidal adolescents in primary care. Pediatrics 2010;125(5):938-44.
  14. Ihimaera L, MacDonald P. Te Whakauruora. Restoration of health: Maori suicide prevention resource. Wellington: Ministry of Health; 2009.
  15. The Werry Centre. Not just another participation model: guidelines for enabling effective youth consumer participation in CAMH and AOD services in New Zealand. 2nd Edition. Auckland: The Werry Centre; 2009.
  16. Michaud P, Fombonne E. ABC of adolescence: Common mental health problems. BMJ 2005;330:835-8.
  17. Hawton K, James A. Suicide and deliberate self-harm in young people. BMJ 2005;330:891-4.
  18. New Zealand Guidelines Group (NZGG). Identification of common mental disorders and management of depression in primary care. An evidence-based best practice guideline. Wellington; NZGG; 2008.
  19. Ministry of Health. Te Raukura: Mental health and alcohol and other drugs: Improving outcomes for children and youth. Wellington: Ministry of Health; 2007.
  20. Medsafe. Selective serotonin re-uptake inhibitors in children and adolescents. Prescriber Update 2009;30(1):1. Available from: www.medsafe.govt.nz/profs/puarticles/ssri-feb09.htm (Accessed May, 2010).

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