Profiles of clinical service use for suicide ideation and suicide attempts across Australian cultural and linguistic groups: A latent class analysis using data from the National Study of Mental Health and Wellbeing (2020-2022)

doi:10.21203/rs.3.rs-5301410/v1

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Research Article

Profiles of clinical service use for suicide ideation and suicide attempts across Australian cultural and linguistic groups: A latent class analysis using data from the National Study of Mental Health and Wellbeing (2020-2022)

https://doi.org/10.21203/rs.3.rs-5301410/v1

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Background

Suicide ideation and suicide attempts represent a public health problem in Australia, for which most people do not seek formal clinical care. However, little research currently exists on the prevalence of STB within the culturally and linguistically diverse (CALD) community, and whether the help-seeking behaviours of CALD persons differs from non-CALD persons.

Methods

This is a secondary analysis of data from the National Study of Mental Health and Wellbeing, which surveyed a representative sample of Australian residents aged 16–85 years (N = 15,882) between December 2020 and October 2022. The prevalence of lifetime suicide ideation and suicide attempts by region of birth were calculated, and latent class analysis was used to examine patterns in both formal and informal help-seeking for both suicide ideation and suicide attempts separately. Logistic regression models were used to identify and quantify associations between region of birth and likelihood of class membership.

Results

Of the sample, 2602 (16.4%) reported suicide ideation and 753 (4.8%) people reported a suicide attempt. The prevalence of both was generally higher in the Australian-born population (18.3%), and lowest in people born in South Asia (5.9%). Most people reported no, or limited, use of clinical services for suicide ideation (76%) or suicide attempt (60%). People born in East Asia and the Pacific or Sub-Saharan Africa were 55% less likely and 70% less likely, respectively, to seek help from clinical services for suicide ideation compared to Australian-born people. People with moderate English proficiency were 92% less likely than people with native English proficiency to seek help from clinical services following a suicide attempt.

Conclusions

Most people in this sample were did not use clinical services for suicide ideation or suicide attempts. This is particularly so for persons born in East Asia and the Pacific or Sub-Saharan Africa. There is a need to understand and address social and cultural factors which may prevent people from these regions from engaging with clinical services. The CALD population in general may benefit from enhanced cultural responsiveness from clinical services, including the use of bicultural support workers and interpreters to improve help-seeking from clinical services.

Suicide

Self-harm

Help-seeking

Services

Culturally and linguistically diverse (CALD)

Suicidal thoughts and behaviours (STB), including suicide, suicide attempts, self-harm, and suicide ideation, significantly impact Australians. In 2022, suicide was the leading cause of death among Australians aged 15 to 44, with 3,249 deaths (12.3 per 100,000) recorded (1). The is only one part of a broader public health issue. In 2021-22, hospitalisations for self-harm were nearly nine times higher, with 26.900 episodes (116.4 per 100,000). However, those seeking clinical help after STB represent just the ‘tip of the iceberg’ (2), as many incidents go unreported. In 2023, 393,700 people (1485.7 per 100,000) reported self-harming without seeking clinical care (3). Nationally, 3.3% of the population reported suicide ideation (4), which is a strong predictor of future suicide attempts (5), though not all with suicide ideation will attempt suicide (6). Suicide ideation, even without attempts, is a distressing experience requiring clinical intervention. Formal help-seeking and clinical intervention following STB provide access to evidence-based treatments, enable risk assessment and management, facilitate early intervention, address underlying mental health issues, and offer additional resources and support systems (7–9). Clinical services play an important role in reducing the risk of STB (10, 11).

People from culturally and linguistically diverse (CALD) backgrounds have been identified as a priority group for suicide prevention research in Australia (12). Australia has a significant CALD population, which includes over seven million people born overseas who alone account for over a quarter of the population, while over one in five report using a language other than English at home (13).

Analyses of existing data indicate that around one in five suicides are by CALD people (14–16). Pham and colleagues (17) have previously reported that CALD individuals have a 30% lower risk of suicide following a self-harm hospital admission compared to non-CALD individuals, with variations among subgroups. Generally, the CALD population has lower rates of self-harm hospital admissions compared to the non-CALD population (43.8 vs 141.2 admissions/100,000 population, respectively) (18). Community occurrences of STB are inadequately captured in the CALD population. However, reliable statistics on STBs in CALD communities are less clear given lack of data, stigma influencing reporting, and potential misclassification of suicides as unintentional or accidental deaths (19). Some CALD indicators, such as race and ethnic origin, are subject to additional privacy regulations in healthcare settings (20), potentially affecting data recording. Truong and colleagues (16) have previously examined the availability and quality of data relating to suicides by CALD people in the Australian state of Victoria recorded in the Victorian Suicide Register (VSR) in 2016. They also found inconsistencies in CALD identity coding, with only moderate to substantial inter-rater reliability, potentially accounting for the underreporting of CALD cases due to a lack of clear guidance for coders in capturing CALD identity evidence. Additionally, there was limited information on language, an important indicator of CALD status as identified by Pham and colleagues (21).

International evidence indicates differential engagement with clinical services among CALD communities, such as lower levels of contact with primary care services prior to suicide (22). Among Asian Americans experiencing suicide ideation, less than a quarter consulted medical doctors, only five per cent engaged with mental health professionals, and one quarter preferred to seek help from informal sources in the first instance by, for example, confiding in friends (23). However, Australia-specific data are scarce, and this lack of data extends to informal support networks which appear to vary in importance across populations. For example, Han and colleagues (24) found that nearly half of Chinese university students in China preferred informal support sources for suicide ideation, compared to only one-tenth of Australian or European-origin students in Australia. Understanding help-seeking experiences of CALD Australians, and how these may differ from the non-CALD population, given informal support from family and friends can facilitate formal help-seeking (25).

International evidence shows that CALD communities engage differently with clinical services, with lower contact levels before suicide (22). For instance, among Asian Americans experiencing suicide ideation, fewer than a quarter consulted medical doctors, only 5% engaged with mental health professionals, and one-quarter sought help from informal sources, such as confiding in friends (23). Australia-specific data on these patterns are limited, particularly regarding informal support. Han and colleagues (24) found that nearly half of Chinese university students preferred informal support for suicide ideation, while only one-tenth of Australian or European-origin students preferred informal support. Understanding both formal and informal help-seeking behaviours among CALD Australians is important considering informal support can facilitate formal help-seeking. Some CALD individuals may not use formal health services unless recommended by their social networks (Eylem 2016). However, those who disclose STB to informal supports are less likely than non-CALD people to be advised to seek formal help, contributing to lower odds of formal help-seeking (Wong 2014).

However, there are several barriers to understanding help-seeking within the CALD community for suicide ideation and suicide attempts specifically. These include variations in the outcome of interest reported (which can include composite ‘suicidality’ measures encompassing suicide ideation and self-harm (26). and variations in how CALD status is defined as reported by Pham and colleagues (21). Australian literature on help-seeking from clinical services for STB within the CALD population is limited (27) and primarily focussed on hospital settings. While hospitals are an important and frequent point of contact (28), they are not the sole source of clinical support available (29) and give an incomplete picture of help-seeking behaviours within this population.

Given the lack of help-seeking in general for STB in Australia (30), it is also important to understand help-seeking within the CALD community, and to identify CALD subpopulations that may need focussed efforts to increase help-seeking from clinical services. The aims of this study are to, firstly, understand the prevalence of suicide ideation and suicide attempts in the community across non-CALD and CALD groups, and secondly, to understand help-seeking behaviours from both informal and formal sources of help. In particular, we are interested in how these help-seeking behaviours may differ for the CALD population as compared with the non-CALD population. Our specific research questions are:

What is the lifetime prevalence of suicide ideation and suicide attempts in Australia, and how (if at all) does this vary by region of birth?

What are the patterns of help-seeking behaviours in people with suicide ideation and/or suicide attempts?

Do differences exist in help-seeking patterns in people of different cultural backgrounds (e.g., region of birth, English language proficiency, number of years in Australia, refugee status)?

Study design and participants

This study involved a secondary analysis of data from the National Study of Mental Health and Wellbeing (NSMHW) (2020–2022), a cross-sectional survey conducted by the Australian Bureau of Statistics. The target population included Australian residents aged 16–85 years, with an oversampling of younger people aged 16–24 years to improve estimates for this age group. While this oversampling occurred during data collection, weighting procedures were used to adjust for this overrepresentation. Specifically, data were calibrated to align with independent population estimates, ensuring the final weighted results align with the age distribution in the general population. As a result, the study sample is generally representative of the Australian population in terms of age and gender (31). Detailed methodology for the survey has been described elsewhere (32), but in brief, a total of 15,893 participants completed the survey across two periods of data collection. The first cohort (Cohort 1; n = 5,554) was surveyed between December 2020 and July 2021. The second cohort (Cohort 2; n = 10,339) was surveyed between December 2021 and October 2022. Both cohorts were analysed together as one sample to improve estimates (Grand N = 15,893).

Data source and measures

All measures were self-reported. Lifetime measures were extracted for suicide ideation and suicide attempts, as well as service use for these. For the purposes of this study, we requested variables that focussed on lifetime suicide attempts, suicide ideation (a composite of serious suicide thoughts and plans), and both formal (specifically, crisis and emergency services, general practitioner (GP), mental health professional, other health professional) and informal support (specifically, confiding in another person) sources. Crisis and emergency services included crisis support and counselling services, emergency response services (e.g. police, ambulance officer or paramedic) and hospital emergency department. Mental health professionals included psychologists and psychiatrists. Other health professional included hospital inpatient services and other unspecified health professionals.

Demographic information (e.g., age, gender, socio-economic status [SES]) and clinical information (e.g., lifetime ICD-10 mental disorder diagnosis) were also requested from the NSMHW. Age was grouped as young people (16–24 years), middle age (25–64 years), and older adults (65–85 years). Gender was grouped as cisgender male, cisgender female, and trans and non-binary people. However, due to small cell counts in the trans and non-binary people category, this category was removed from subsequent analysis. People were thus classified as male or female. The index of relative advantage and disadvantage (IRSAD) was used to approximate SES status. Other variables included weekly income, highest educational attainment, level of social support from family and friends available, and sense of community belonging.

Cultural diversity was operationalised as region of birth, English language proficiency, number of years in Australia, and refugee status (33). Region of birth was derived using the country of birth variable, grouped according to the World Bank regional units (34), resulting in the following regions of birth: Australia, East Asia and the Pacific excluding Australia, Europe and Central Asia, Middle East and North Africa, Sub-Saharan Africa, South Asia, and the Americas. Number of years in Australia were grouped in five-year intervals to aid interpretation. Responses to questions were recoded to exclude non-informative responses such as “not known” or “refused”, and totals for each question varied based on these exclusions. Statistical code for data preparation and analyses, including all variables used, are provided in Supplementary file X.

Statistical analysis

To determine prevalence, frequencies and percentages were calculated based on lifetime measures of suicide ideation and suicide attempt for each region of birth. Latent Class Analysis (LCA) was then used to identify distinct classes among those who reported suicide ideation or suicide attempts based on patterns of help-seeking from formal and informal sources of support. Separate models were used for suicide ideation and suicide attempts. For each LCA model, indicator variables for formal support included use of crisis and emergency services (i.e. crisis support and counselling services, emergency services, emergency department), general practitioner, and mental health professional (i.e. psychologist, psychiatrist). Seeking help from an informal support source was also included as an indicator variable. We aimed estimated LCA models with an increasing number of classes to identify the most appropriate model based on both statistical criteria (e.g. Akaike Information Criterion [AIC] and Bayesian Information Criterion [BIC]) and the interpretability of the resulting classes (35–37) (Table S1).

Univariate logistic regression models were first used to identify associations between cultural diversity (i.e. region of birth, language proficiency, number of years in Australia in 5-year increments, and refugee status) and class membership for both LCA models. Multinomial regression models were then used to identify associations between each CALD variable and class membership, adjusting for gender, age group, IRSAD, weekly income, educational attainment, lifetime mental health diagnosis, social support, and community belonging (reported as odds ratios and 95% confidence intervals). Analyses were conducted using Stata/MP 18.0 for Windows (38).

The final sample consisted of 15,893 people. Almost two-thirds of the sample (n = 9954, 63%) were aged between 25 and 64 years, slightly over half the sample were female (n = 8360, 53%), and just over two-thirds were born in Australia (n = 10,643, 67%) (Table 1).

Table 1

Sociodemographic characteristics, lifetime suicide ideation and suicide attempt, and formal and informal help-seeking, by region of birth
	Australia	East Asia and the Pacific^a	Europe and Central Asia	Middle East and North Africa	Sub-Saharan Africa	South Asia	Americas	Total
Responses, n(%)	10643 (67.0)	1726 (10.9)	1794 (11.3)	221 (1.4)	313 (2.0)	888 (5.6)	297 (1.9)	15882
Demographic characteristics
Age group, n(%)
Young people (16–24 years)	1281 (12.0)	131 (7.6)	55 (3.1)	18 (8.1)	33 (10.5)	82 (9.2)	19 (6.4)	1619 (10.2)
Middle age (25–64 years)	6397 (60.1)	1325 (76.8)	890 (49.6)	143 (64.7)	219 (70.0)	744 (83.8)	236 (79.5)	9954 (62.7)
Older adults (65–85 years)	2965 (27.9)	270 (15.6)	849 (47.3)	60 (27.2)	61 (19.5)	62 (7.0)	42 (14.1)	4309 (27.1)
Gender, n(%)
Male	4827 (46.0)	734 (43.4)	859 (48.5)	116 (53.2)	155 (50.2)	467 (53.3)	142 (48.3)	7300 (46.6)
Female	5671 (54.0)	958 (56.6)	913 (51.5)	102 (46.8)	154 (49.9)	410 (46.8)	152 (51.7)	8360 (53.4)
Index of relative socioeconomic advantage and disadvantage, n(%)
1st quintile (most disadvantaged)	1754 (16.4)	215 (12.5)	232 (12.9)	40 (18.1)	32 (10.2)	109 (12.3)	31 (10.4)	2404 (15.1)
2nd quintile	1969 (18.5)	255 (14.8)	334 (18.6)	38 (17.2)	43 (13.7)	151 (17.0)	36 (12.1)	2826 (17.8)
3rd quintile	2261 (21.2)	321 (18.6)	363 (28.2)	52 (23.5)	62 (19.8)	193 (21.7)	44 (14.8)	3296 (20.8)
4th quintile	2257 (21.2)	415 (24.0)	389 (21.7)	32 (14.5)	79 (25.2)	232 (26.1)	76 (25.6)	3480 (21.9)
5th quintile (most advantaged)	2411 (22.7)	520 (30.1)	476 (26.5)	59 (26.7)	97 (31.0)	203 (22.9)	110 (37.0)	3875 (24.4)
Weekly income, n(%)
1st quintile	1985 (20.1)	337 (20.9)	434 (26.1)	66 (32.7)	35 (12.4)	106 (13.0)	46 (16.6)	3009 (20.4)
2nd quintile	1941 (19.6)	240 (14.9)	373 (22.4)	46 (22.8)	54 (19.2)	136 (16.7)	42 (15.2)	2832 (19.2)
3rd quintile	1943 (19.6)	346 (21.5)	267 (16.0)	31 (13.4)	64 (22.7)	196 (24.1)	53 (19.1)	2900 (19.7)
4th quintile	2073 (20.9)	369 (22.9)	282 (16.9)	29 (14.4)	57 (20.2)	192 (23.6)	64 (23.1)	3066 (20.8)
5th quintile	1956 (19.8)	320 (19.9)	310 (18.6)	30 (14.9)	72 (25.5)	185 (22.7)	72 (26.0)	2945 (20.0)
Educational attainment
Year 11 or below	2294 (21.9)	139 (8.2)	368 (20.8)	36 (16.7)	21 (6.8)	33 (3.8)	11 (3.9)	2902 (18.6)
Year 12 or below	1384 (13.2)	253 (14.9)	203 (11.5)	35 (16.3)	48 (15.5)	99 (11.4)	37 (12.9)	2059 (13.2)
Certificate	2352 (22.4)	208 (12.3)	368 (20.8)	21 (9.8)	40 (12.9)	52 (6.0)	22 (7.7)	3063 (19.6)
Advanced	1718 (16.4)	256 (15.1)	311 (17.6)	31 (14.4)	71 (23.0)	131 (15.1)	33 (11.5)	2551 (16.3)
Bachelor	2092 (20.0)	563 (33.2)	353 (20.0)	57 (26.5)	78 (25.2)	303 (34.9)	122 (42.7)	3568 (22.8)
Postgraduate	647 (6.2)	276 (16.3)	166 (9.4)	35 (16.3)	51 (16.5)	250 (28.8)	61 (21.3)	1486 (9.5)
English proficiency
Main language/native proficiency	10504 (98.7)	1006 (58.3)	1593 (88.8)	119 (53.9)	244 (78.0)	257 (28.9)	207 (69.7)	13930 (87.7)
Moderate proficiency	*	246 (14.3)	82 (4.6)	48 (21.7)	49 (15.7)	360 (40.5)	37 (12.5)	*
Limited proficiency	*	474 (27.5)	119 (6.6)	54 (24.4)	20 (6.4)	271 (30.5)	53 (17.9)	*
Number of years in Australia, median (interquartile range)	50 (33–66)	18 (10–33)	43 (18–55)	22 (10–50)	17 (10–30)	10 (5–16)	15 (6–33)	41 (23–61)
Past and/or present refugee status, n(%)
Yes	*	80 (4.6)	56 (3.1)	33 (15.0)	26 (8.3)	28 (3.2)	*	223 (4.5)
No	*	1646 (95.4)	1738 (96.9)	187 (85.0)	287 (91.7)	860 (96.7)	*	4718 (95.5)
Lifetime ICD-10 mental health diagnosis, n (%)
Yes	5019 (47.2)	533 (30.9)	672 (37.5)	61 (27.6)	109 (34.8)	173 (19.5)	124 (41.8)	6691 (42.1)
No	5624 (52.8)	1193 (69.1)	122 (62.5)	160 (72.4)	204 (65.2)	715 (80.5)	173 (58.3)	9191 (57.9)
Level of social support, n(%)
Low	660 (6.2)	90 (5.2)	130 (7.3)	17 (7.7)	14 (4.5)	51 (5.7)	17 (5.7)	979 (6.2)
Moderate	1287 (12.1)	251 (14.6)	223 (12.5)	37 (16.7)	43 (13.7)	102 (11.5)	45 (15.2)	1988 (12.5)
High	8684 (81.7)	1381 (80.2)	1437 (80.3)	167 (75.6)	256 (81.8)	735 (82.8)	235 (79.1)	12895 (81.3)
Level of belonging, n(%)
Low	1447 (13.6)	211 (12.3)	256 (14.3)	25 (11.4)	24 (7.7)	61 (6.9)	28 (9.5)	2052 (13.0)
Moderate	2457 (23.1)	479 (27.9)	437 (24.5)	53 (24.2)	76 (24.3)	214 (24.2)	84 (28.4)	3800 (24.0)
High	6720 (63.3)	1030 (59.9)	1093 (61.2)	141 (64.4)	213 (68.1)	611 (69.0)	184 (62.2)	9992 (63.1)
Lifetime suicide ideation, n(%)
Yes	1946 (18.3)	229 (13.3)	263 (14.7)	25 (11.3)	40 (12.8)	52 (5.9)	47 (16.0)	2602 (16.4)
No	8683 (81.7)	1494 (86.7)	1528 (85.3)	196 (88.7)	272 (87.2)	835 (94.1)	247 (84.0)	13255 (83.6)
Lifetime suicide attempt, n(%)
Yes	562 (5.3)	65 (3.8)	78 (4.4)	11 (5.0)	11 (3.5)	14 (1.6)	12 (4.0)	753 (4.8)
No	10072 (94.7)	1661 (96.2)	1715 (95.7)	209 (95.0)	302 (96.5)	874 (98.4)	285 (96.0)	15118 (95.3)

[Table ABOUT HERE]

Lifetime prevalence of suicide ideation and suicide attempts

Overall, almost one-in-five of the sample (n = 2602, 16.4%) reported lifetime suicide ideation (Table 1). This was highest in people born in Australia (n = 1946, 18.3%) and the Americas (n = 47, 16.0%) and lowest in people from South Asia (n = 52, 5.9%). Amongst those who reported lifetime suicide attempts (n = 753, 4.8%), people born in Australia (n = 562, 5.3%) or the Middle East and North Africa (n = 11, 4.0%) had the highest prevalence, while people born in South Asia (n = 14, 1.6%) had the lowest prevalence.

[Table ABOUT HERE]

Table 2

Associations between variables and class membership for suicide ideation (Model 1) and suicide attempt (Model 2)
Characteristic	Model 1		Model 2
	OR	aOR	OR	aOR
Region of birth, n(%)
Australia			-	-
East Asia & Pacific	0.48 (0.33–0.70), p < 0.001	0.45 (0.28–0.71), p = 0.001	0.84 (0.49–1.42), p = 0.511	0.69 (0.35–1.37), p = 0.285
Europe & Central Asia	0.60 (0.43–0.83), p = 0.002	0.61 (0.41–0.90), p = 0.12	0.83 (0.51–1.35), p = 0.451	0.75 (0.42–1.36), p = 0.347
Middle East & North Africa	0.53 (0.18 − 0.16), p = 0.249	0.58 (0.19–1.82), p = 0.353	0.71 (0.21–2.40), p = 0.587	0.80 (0.21–3.15), p = 0.754
Sub-Saharan Africa	0.48 (0.20–1.14), p = 0.097	0.30 (0.10–0.88), p = 0.028	0.82 (0.24–2.82), p = 0.749	0.84 (0.21–3.34), p = 0.808
South Asia	0.50 (0.23–1.06), p = 0.070	0.59 (0.25–1.37), p = 0.221	0.39 (0.11–1.41), p = 0.152	0.39 (0.09–1.61), p = 0.193
Americas	0.88 (0.46–1.70), p = 0.706	0.63 (0.29–1.37), p = 0.248	0.71 (0.21–2.40), p = 0.587	0.47 (0.12–1.83), p = 0.279
English proficiency
Main language/native	-	-	-	-
Moderate proficiency	0.38 (0.17–0.83), p = 0.015	0.51 (0.22–1.19), p = 0.119	0.23 (0.05-1.00), p = 0.051	0.08 (0.01–0.71), p = 0.023
Limited proficiency	0.38 (0.18–0.80), p = 0.011	0.62 (0.27–1.40), p = 0.251	0.37 (0.10–1.31), p = 0.122	0.32 (0.08–1.35), p = 0.121
Years lived in Australia, M (SD)	0.98 (0.95-1.00), p = 0.035	0.98 (0.94–1.03), p = 0.401	0.97 (0.93-1.00), p = 0.076	0.94 (0.87–1.01), p = 0.083
Refugee status
Yes	0.88 (0.33–2.39), p = 0.807	1.30 (0.40–4.21), p = 0.664	1.53 (0.31–7.61), p = 0.606	4.06 (0.64–25.92), p = 0.138
No	-	-	-	-
Age group
Young people	1.13 (0.86–1.47), p = 0.384	1.05 (0.73–1.51), p = 0.792	1.10 (0.71–1.71), p = 0.658	0.83 (0.45–1.51), p = 0.537
Middle aged	-	-	-	-
Older adults	0.59 (0.46–0.75), p < 0.001	0.83 (0.58–1.20), p = 0.319	0.66 (0.45–0.96), p = 0.030	0.91 (0.51–1.65), p = 0.766
Gender
Male	-	-	-	-
Female	1.25 (1.04–1.51), p = 0.017	1.27 (1.04–1.56), p = 0.019	1.43 (1.05–1.95), p = 0.022	1.35 (0.96–1.89), p = 0.077
Lifetime ICD-10 mental disorder diagnosis
Yes	2.05 (1.61–2.62), p < 0.001	1.76 (1.35–2.33), p < 0.001	1.86 (1.16–2.98), p = 0.009	1.48 (0.87–2.51), p = 0.147
No	-	-	-	-
Educational attainment
Year 11 or below	-	-	-	-
Year 12 or equivalent	1.66 (1.20–2.94), p = 0.002	1.48 (1.04–2.12), p = 0.031	1.27 (0.76–2.10), p = 0.363	1.01 (0.56–1.83), p = 0.965
Certificates	1.27 (0.94–1.71), p = 0.126	1.15 (0.83–1.59), p = 0.399	1.43 (0.95-4-2.18), p = 0.099	1.52 (0.95–2.44), p = 0.083
Advanced diploma	1.97 (1.44–2.71), p < 0.001	1.88 (1.33–2.65), p < 0.001	1.49 (0.90–2.45), p = 0.119	1.49 (0.86–2.59), p = 0.159
Bachelor’s degree	2.23 (1.65–3.01), p < 0.001	1.92 (1.37–2.72), p < 0.001	1.71 (1.05–2.79), p = 0.032	2.01 (1.14–3.54), p = 0.016
Postgraduate degree	1.62 (1.08–2.43), p = 0.019	1.52 (0.96–2.43), p = 0.076	1.30 (0.64–2.64), p = 0.462	1.90 (0.83–4.36), p = 0.127
Social support
Low	-	-	-	-
Moderate	1.14 (0.84–1.56), p = 0.417	1.07 (0.76–1.51), p = 0.693	1.10 (0.69–1.75), p = 0.686	1.01 (0.60–1.71), p = 0.967
High	1.08 (0.83–1.40), p = 0.571	1.09 (0.80–1.48), p = 0.594	0.95 (0.65–1.39), p = 0.810	0.86 (0.53–1.38), p = 0.533
Belonging
Low	-	-	-	-
Moderate	1.16 (0.92–1.47), p = 0.220	1.15 (0.88–1.50), p = 0.307	1.07 (0.74–1.55), p = 0.727	1.11 (0.72–1.72), p = 0.639
High	0.98 (0.79–1.22), p = 0.847	0.93 (0.71–1.22), p = 0.609	1.26 (0.89–1.78), p = 0.188	1.52 (1.00-2.36), p = 0.066
Index of relative socioeconomic advantage and disadvantage
1st quintile	-	-	-	-
2nd quintile	1.49 (1.09–2.03), p = 0.012	1.53 (1.10–2.13), p = 0.012	1.00 (0.64–1.54), p = 0.993	0.82 (0.50–1.32), p = 0.407
3rd quintile	1.88 (1.40–2.34), p < 0.001	1.85 (1.22–2.56), p < 0.001	0.70 (0.45–1.09), p = 0.114	0.68 (0.41–1.13), p = 0.140
4th quintile	1.72 (1.28–2.31), p < 0.001	1.58 (1.14–2.20), p = 0.006	0.73 (0.46–1.15), p = 0.173	0.68 (0.40–1.16), p = 0.159
5th quintile	1.96 (1.46–2.65), p < 0.001	1.69 (1.20–2.37), p = 0.003	1.27 (0.81-2.00), p = 0.297	1.18 (0.69–2.02), p = 0.552
Weekly income
1st quintile	-		-	-
2nd quintile	0.85 (0.63–1.15), p = 0.295	0.78 (0.56–1.06), p = 0.116	0.90 (0.59–1.38), p = 0.634	0.86 (0.54–1.38), p = 0.537
3rd quintile	1.38 (1.04–1.83), p = 0.024	1.06 (0.78–1.44), p = 0.722	1.17 (0.76–1.82), p = 0.473	0.84 (0.51–1.39), p = 0.499
4th quintile	1.55 (1.17–2.06), p = 0.002	1.01 (0.74–1.40), p = 0.927	1.11 (0.70–1.75), p = 0.656	0.83 (0.48–1.43), p = 0.508
5th quintile	1.48 (1.09–2.01), p = 0.012	0.92 (0.65–1.32), p = 0.665	1.03 (0.62–1.70), p = 0.917	0.65 (0.35–1.18), p = 0.158

Help-seeking behaviours for lifetime suicide ideation

Attempts to model more than two latent classes failed to converge (Table S1), suggesting that a two-class model provided optimal fit. Among those who reported lifetime suicide ideation (n = 2602), two help-seeking classes were identified: a low help-seeking (Class 1: n = 1999, 76.1%) and a high help-seeking (Class 2: n = 628, 23.9%) (Fig. 1). The low help-seeking class was characterised by almost no use of formal health services and 38% of this class sought help from an informal support source, such as family, friends, and colleagues. The high help-seeking class was characterised by use of all formal health services, particularly mental health professionals and general practitioners, and 69% sought help from an informal support source (Table S1). Compared to people born in Australia, those born in East Asia and the Pacific were 55% less likely to be in the high help-seeking class (i.e., Class 2), whilst those born in Sub-Saharan Africa were 70% less to be in this class (Table 2).

[Figure 1: Probability of use of help sources following most recent suicide ideation, by help-seeking class]

Help-seeking behaviours for lifetime suicide attempt

Among those who had reported a lifetime suicide attempt (n = 753), two help-seeking classes were also identified: a low help-seeking (Class 1: n = 461, 60.3%) and a high help-seeking (Class 2: n = 303, 39.7%) (Fig. 2). The low help-seeking class was characterised by low use of crisis and emergency services and with mental health professionals, and almost no use of other formal health services. The high help-seeking class was characterised by use of all formal health services, particularly crisis and emergency services and mental health professionals. Both the low and high help-seeking classes sought informal help equally (51% and 53%, respectively) (Table S1). Compared to people with native language proficiency, people with moderate English proficiency were 92% less likely to be in the high help-seeking class (i.e., Class 2) than the low help-seeking class (i.e., Class 1).

[Figure 2: Probability of use of help sources following most recent suicide attempt, by help-seeking class]

Key findings

Out of the 2602 people who had reported lifetime suicide ideation, almost one-in-five people born in Australia or the Americas reported this outcome, while people born in other regions had lower prevalence. Similarly, among the 753 people who had attempted suicide, the highest prevalence rates were in people born in Australia (5.3%), followed by people born in the Middle East and North Africa (5.0%). This study identified two distinct classes of help-seeking behaviours following suicidal ideation or a suicide attempt. Most people reported low or no use of clinical service for suicide ideation (76%) and suicide attempts (60%).

Among the 16.4% of the total sample that reported suicide ideation, around three-quarters (76%) did not seek help from clinical services. For those who did report seeking help from clinical services (24%), the marked preference for mental health professionals, compared with general practitioners or crisis and/or emergency services, aligns with earlier research indicating that such professionals are often preferred for STB disclosure, especially by young people (29, 39, 40). However, it is possible that those who did use clinical services following suicide ideation were already connected with clinical services in the management of other mental health-related problems, given those with a lifetime ICD-10 mental health diagnosis were 76% more likely to be in the high help-seeking class. No such association was observed among those who had attempted suicide. Among those who did not seek clinical help, the lack of help-seeking from GPs and crisis/emergency services may explain the lack of use of mental health professionals. GPs and hospitals frequently act as a gateway to specialist mental healthcare for individuals with STB (41). The limited use of these entry points by people who do not seek help from clinical services to the same extent could account for their reduced engagement with mental health professionals.

Of those who attempted suicide and but reported very minimal use of clinical services, there was a marked preference for crisis and emergency services. We have previously found that Australian emergency department staff express challenges in providing adequate care for self-harm presentations, particularly for youth, including a lack of awareness of age-appropriate services and insufficient time to prepare discharge summaries and referral letters (42). As a result, individuals who rely on crisis and emergency services are at risk of experiencing a lack of continuity of care, especially during the heightened risk period following an index presentation (43). This lack of continuity between services may explain the lack of use of other services observed in this study. Although there is limited research on the differential stigma associated with various health services, some evidence suggests that seeking mental health care in primary settings is perceived as less stigmatising compared to dedicated mental health services (44). Similar perceptions when comparing emergency services to mental health services may account for the differences in clinical service use we observed in this study.

People born in East Asia and the Pacific were less likely to seek help from clinical services for suicide ideation compared to their Australian-born counterparts, suggesting that people from these cultural backgrounds may rely exclusively on informal supports, if they seek help at all. This aligns with existing research on help-seeking patterns within Asian migrant populations (25). Lower rates of help-seeking among Asian Australians may be attributed to a broader unfamiliarity with the healthcare system and services available (45–47). Additionally, Asian cultural norms, which value familial harmony and discourage expressions of personal distress (48, 49), might deter Asian Australians from seeking support, particularly where this could upset family unity (48). Even if informal supports are available, reduced use of formal health services suggests that Asian help-seekers might not feel encouraged or supported by their personal networks to seek professional help, despite evidence that disclosure to informal supports can lead to increased use of formal health services (25). Cultural stigma, minority and/or acculturative stress may further contribute to the apparent reluctance of Asian Australians to seek formal support following an episode of suicidal ideation (47, 48). Similarly, people born in Sub-Saharan Africa were also less likely to use clinical services compared to their Australian-born counterparts. This may be due to difficulties in navigating the Australian healthcare system and a lack of understanding of the criteria for accessing services (46, 50, 51). Further barriers may include fear of engaging with emergency services and cultural conceptions of mental health and stigma (50, 52).

For attempted suicide, people with moderate English proficiency were far less likely than those with native English proficiency to seek help from clinical services. Unexpectedly, such an association was not found for those with limited English proficiency. Whilst there is evidence that, in the Australian population, speaking a non-English language at home is associated with a reduced likelihood of mental health service use for suicide ideation (53), there is a lack of research on people with moderate level of English proficiency and their level of service use, particularly following a suicide attempt. Language proficiency is a noted barrier to engagement with health services among African refugees (46), and English language proficiency is positively associated with help-seeking behaviours in African migrants in the United States (50). Understanding the relationship between service use and varying levels of English proficiency in the Australian population would therefore be a useful area for future research. Interpreters are used in less than one in 100 Medicare-funded health consultations, despite one in 35 Australians having limited English proficiency (54). Infrequent use of interpreter services may be further driving help-seeking disparities between CALD and non-CALD Australians. Further research is needed to improve integration of interpreter services into clinical care.

Whilst economic factors have previously been identified as influential in driving disparities in help-seeking behaviours between CALD and non-CALD Australians (25, 46, 53), the economic variables used in this study (i.e. IRSAD, income) did not fully explain the help-seeking disparities identified in this study. Thus, barriers to help-seeking among these groups may be socially and culturally specific to East Asian, Pacific, and Sub-Saharan African populations, distinct from other Asian and African communities, where similar barriers likely exist (50, 55).

Most people, following suicide ideation or suicide attempt, sought informal support more often than formal support. The discrepancies between informal and formal help-seeking suggest that informal disclosures do not always facilitate pathways to clinical care. Wong and colleagues (56) found that, among Chinese Americans who attempted suicide, interactions with family members often negatively influenced attitudes towards service use, preventing formal help-seeking. While some research suggests that family support and involvement can benefit individuals receiving treatment, other studies indicate that family members may react negatively, resenting the hospitalisation or scolding the person in distress (57), further contributing towards stigma associated with help-seeking (58). Informal disclosures may also involve individuals who are themselves engaging in STB, potentially normalising these experiences (59). Our findings suggest that future research into the facilitators of clinical care following informal disclosure in CALD people is warranted.

Implications

Suicide prevention initiatives in Australia should include strategies to increase help-seeking behaviours among those not engaging with clinical services for both suicide ideation and/or suicide attempts. Enhancing continuity of care, particularly for those who may rely on crisis and emergency services, could be significantly supported by the integration of interpreters, bicultural support workers, and culturally competent clinical staff (60). For people from CALD backgrounds, especially those with moderate English proficiency, access to information and resources is crucial for engaging with health services (46). A more culturally diverse mental health workforce could also elevate quality of care from specialist mental health services (61). Among African migrants, cultural sensitivity of health services is associated with better wellbeing (50). Future research should explore inclusive methods to evaluate and enhance the cultural sensitivity of mental health services and GPs. Given the use of informal support observed for both suicide ideation and suicide attempts, community-level interventions to increase mental health literacy, decrease contextualised public stigma (e.g. within a community or faith group), and gatekeeper training to help informal supports encourage professional help-seeking (53), may increase formal help-seeking for STB (62).

Strengths and limitations:

This is the first study to report the prevalence of suicide ideation, suicide attempts, and help-seeking behaviours among CALD Australians using a nationally-representative sample. In contrast to most studies which report on mental health among African migrants as one homogenous group (50), this study distinguished between regions (i.e. Sub-Saharan Africa and Middle East and North Africa) and between non-voluntary and voluntary migration (i.e. refugee status), finding that help-seeking behaviours differed by region but not refugee status. Second, this study used data from a representative sample of Australians. Third, the use of latent class analysis has identified subgroups within the Australian population that would benefit from additional support and prevention initiatives. Lastly, several measures such as region of birth, language proficiency, and refugee status were used in place of a binary CALD status that is often used in research. Additionally, operationalising language proficiency to include those with limited, moderate, and native English proficiency allowed the identification of moderate English proficiency rather than limited English proficiency as a significant factor, which is a novel finding. Together with measures of cultural diversity, measures of acculturation such as number of years in Australia and subjective level of community belonging allowed for a more nuanced and comprehensive analysis on the influence of cultural diversity on help-seeking behaviours.

However, several limitations also need to be considered. First, CALD people in general are less likely to respond to questions about serious suicidal behaviours than non-CALD people (48), which may have resulted in an underestimation of the prevalence of suicide ideation and suicide attempt and subsequent undercount of use with formal and informal supports. Second, although informal disclosure of suicide ideation and suicide attempts was captured in this study, the motive or function of the disclosure was not. This study has interpreted confiding in another person as informal help-seeking, whereas it is possible people may have confided in another person to share distress without necessarily seeking help. Similarly, we have measured use of clinical services but not engagement or any broader measures of service provision or satisfaction with services rendered. Third, the use of lifetime measures may not reflect current behaviours. Last, this study was unable to discern generation status (i.e. first, second, third-plus generation immigrants) which Han and colleagues (63) have found to be associated with rates of suicide attempt and suicide ideation among people of East Asian backgrounds in the United States.

The prevalence of suicide ideation and suicide attempts were highest in those born in Australia and lowest in those born in South Asia. This study has identified disparities in formal and informal help-seeking behaviours for suicide ideation and attempts and has revealed a reluctance by people of CALD backgrounds to seek help from formal health services, and to a lesser extent, to informally seek help. This study has also identified that people from East Asia and the Pacific and Sub-Saharan Africa may benefit from suicide prevention initiatives that seek to increase formal help-seeking for suicide ideation. These findings suggest a need for more culturally responsive and culturally sensitive health services, particularly an increase in the use of interpreters for those with moderate English proficiency. Enhanced referral systems, and strengthening community supports for people who have experienced suicide ideation or attempted suicide may also improve formal help-seeking across all demographics.

ABS

Australian Bureau of Statistics

AIC

Akaike Information Criterion

BIC

Bayesian Information Criterion

CALD

Culturally and/or linguistically diverse

General practitioner

IRSAD

Index of relative socioeconomic advantage and disadvantage

LCA

Latent class analysis

NSMHW

National Study of Mental Health and Wellbeing

SES

Socioeconomic status

STB

Suicidal thoughts and behaviours

VSR

Victorian Suicide Register

Ethics approval and consent to participate

Institutional ethics approval was not required to access these de-identified data from the Australian Bureau of Statistics (ABS) for secondary analyses. However, all co-authors completed mandatory Safe Researcher training provided by the ABS as a prerequisite for obtaining access to this data. This training covered principles of maintaining data confidentiality, statistical disclosure control, and adhering to the ABS Five Safes Risk Framework to ensure safe and ethical handling of data throughout the analysis process. GR maintained communication with the ABS to ensure all outputs leaving the secure virtual DataLab environment were vetted for confidentiality risks before public release.

Consent for publication

Not applicable

Availability of data and materials

The data that support the findings of this study are available from the National Study of Mental Health and Wellbeing (2022-2022), but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. The data are available from the ABS.

Competing interests

The authors declare that they have no competing interests.

Funding

GR receives a scholarship from Suicide Prevention Australia. JR is supported by a National Health and Medical Research Council Investigator Grant (NHMRC: ID2008460) and a Dame Kate Campbell Fellowship from The University of Melbourne. KW is supported by an NHMRC Investigator Grant (ID1177787) and a Dame Kate Campbell Fellowship from The University of Melbourne.

Authors’ contributions

GR conceptualised the study and conducted all analyses. GR and KW contributed to the methodology. GR, KW and JR contributed to the interpretation of the findings, drafting and final edit of the manuscript.

Acknowledgements

The authors wish to thank Lei Yu, Josh Briers, Talei Parker, Caroline Blink, Saksham Aggarwal, Miriam Jerobon, Alessandro Cavoli and the ABS DataLab team for their support in accessing data and providing output clearance.

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No competing interests reported.

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Profiles of clinical service use for suicide ideation and suicide attempts across Australian cultural and linguistic groups: A latent class analysis using data from the National Study of Mental Health and Wellbeing (2020-2022)

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Abstract

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Background

Methods

Study design and participants

Data source and measures

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Results

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Lifetime prevalence of suicide ideation and suicide attempts

[Table ABOUT HERE]

Help-seeking behaviours for lifetime suicide ideation

Help-seeking behaviours for lifetime suicide attempt

Discussion

Key findings

Implications

Strengths and limitations:

Conclusions

Abbreviations

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References

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