Chief investigator: Dr Tania King

Co-investigators: Dr George Disney, A/Prof Georgina Sutherland, Prof Matthew Spittal, Prof Anne Kavanagh, Dr Koen Simons, Ms Sanya Wadhwa, Dr Yamna Taouk

While workers’ compensation schemes aim to assist and support injured workers, there is some evidence that the process of pursuing a compensation claim may be extremely stressful for workers. While this stress is considered to be a contributing factor in some suicides, there is a lack of evidence regarding this putative association.

This research aimed to examine the evidence of an association between workers compensation and deliberate self-harm. To do this, we firstly carried out a systematic review, and then used hospital admissions data to empirically assess this relationship between workers’ compensation and self-harm. Here we describe these two separate but complementary programs of work.

1. Systematic review

This aim of this systematic review was to review and synthesise international evidence of the association between workers’ compensation and mental health and self-harm outcomes. We carried out a systematic review of the literature using a three-tiered search

strategy across five databases (PubMed, MEDLINE, PsycINFO, Web of Science and Scopus). To be included in the review, studies must have been based on a population of employed individual and must have used workers’ compensation claims as an exposure or risk factor. Eligible outcomes included mental health, self-harm, or suicide. and study participants being employed individuals. Of 4910 records arising in the search, 9 studies met the inclusion criteria. There was great heterogeneity across the nine included studies in terms of

study design, patient demographics and the measurement of outcome. Of included studies, two studies reported outcomes related to suicide and seven studies reported outcomes related to mental health. Overall, most studies indicated an adverse association between pursuing workers’ compensation and mental health and suicide outcomes, however the generalisability of some of these studies is limited. There was some evidence that specific aspects of the compensation system underpinned this association, including the perception of justice, the requirement of support to navigate the claims system, involvement in

litigation and whether the individual had additional sources of income.

2. Empirical research

The aim of this research was to compare hospital admissions for self-harm among workers’ compensation claimants and non-claimants. To do this, we carried out a retrospective case-series study using hospital admissions data from the Centre for Victorian Data Linkage. We used data for 44,324 patients from Victorian hospitals (2011-2018) to estimate rates of hospital admission for intentional self-harm and probable intentional self-harm (due to intentional self-harm, poisoning, or undetermined intent). We stratified rates by gender and calculated for each age-group. We found that for males, there was no observable difference between claimants and non-claimants for admission due to intentional self-harm. For female claimants, the incidence rate for hospital admission for intentional self-harm was higher than non-claimants (relative risk (RR) 2.4, risk difference (RD) 47.7 per 100,000). For the combined category of ‘self-harm and probable self-harm’, the incidence rate was elevated in both male (RR 5.8, RD 167.7 per 100,000) and female workers’ compensation claimants (RR 3.4, RD 114.8 per 100,000) relative to non-claimants. We concluded that female workers’ compensation claimants appear to be at elevated risk of admission for intentional self-harm and ‘self-harm and probable self-harm’ compared to non-claimants. Male claimants appear to be at increased risk of hospital admission for ‘self-harm and probable self-harm’. This suggests that the process of pursuing workers’ compensation may be associated with increased risk of hospital admission for self-harm, and highlights a need for further research.

Overall, the results of these two programs of work indicate that individuals who are workers’ compensation claimants may be at elevated risk of poor mental health and self-harm.

Outcomes of this research

Peer-reviewed publications

King, Disney, Sutherland, Kavanagh, Spittal, Simons. Associations between workers’ compensation and self-harm: a retrospective case-series study of hospital admissions data, submitted to Occupational and Environmental Medicine.

Wadhwa, Taouk, Spittal, King. Workplace injury compensation and mental health and self-harm outcomes: A Systematic Approach, submitted to Journal of Occupational and Environmental Medicine.

Title of Grant: Mapping the regional variability of non-suicidal self-harm, suicide attempts, and related risk and protective factors in Australian adolescents to inform suicide prevention strategies

Short project title: Australian Youth Self-Harm Atlas

Lead Investigator: Dr Emily Hielscher (QIMRB/UQ),

Co-Investigator: Prof James Scott (QIMRB), Prof David Lawrence (UWA), Prof Philip Batterham (ANU), Martina McGrath (Roses in the Ocean), Kathy Poulton (Roses in the Ocean), Dr Ivan Chang (QIMRB), Dr Karen Hay (QIMRB), Julie Blake (QIMRB), Erika Giebels (QIMRB)

Partner organisation: Roses in the Ocean (suicide prevention NGO)

Suicide prevention strategies in Australia have shifted in recent years, from a national approach to one that is regionally tailored and responsive to local community needs. Previous literature supports the need to understand suicidal behaviour within small-area geographies. However, this body of research has focused on suicide deaths which may not properly reflect prevention needs, and few studies have focused on young people. This is a priority population where urgent action needs to be taken to prevent suicides in Australia.

This was the first nationwide Australian study to examine regional variability of youth self-harm (non-suicidal self-harm and suicide attempts), and related risk and protective factors. This was achieved by analysing the Young Minds Matter survey, a nationally representative survey of Australian adolescents, and by conducting 14 focus groups with young people with lived experience of self-harm or suicidality and other key stakeholders (clinical/support staff) in geographically diverse areas. Collectively, this mixed methods project intended to identify characteristics of regions with lower and higher self-harm and suicide risk, and, in turn, help establish meaningful targets for youth suicide prevention informed by both national data and lived experience.

Overall, there was large regional variation in the prevalence and experience of self-harm (non-suicidal and suicidal) among young Australians, providing further support for the National Suicide Prevention Strategy of a systems-based regional approach. Nationwide spatial analyses of self-harm prevalence provided clear rationale for where future prevention efforts should be prioritised across Australia. This included self-harm clustering in metro and regional areas across Western Australia, Northern Territory, Queensland, Victoria, and New South Wales.

The mental health of young people was an important factor in spatial analyses and focus group discussions and should continue to be a key target in youth suicide prevention policy and planning. In addition, relations with parents and school staff, digital/online environment interactions, and a myriad of social determinants of health (parent employment and country of birth, housing quality, financial/transportation barriers) require equal consideration. Large and disruptive environmental stressors/events (climate change, COVID-19) also need to be factored into the sector’s policy planning and service delivery; highlighted in youth focus group discussions as the backdrop of today’s young people’s lives. This systems-based approach was further reiterated by staff focus group participants, viewed as key to effectively managing youth self-harm and suicidality out in the community.

Youth focus groups also provided new understandings of regional variability in (1) self-identified risk and protective factors, and (2) self-identified barriers to help seeking/receiving. In terms of the latter, metro and regional groups faced similar barriers, however, the nature of the problem differed with respect to service accessibility issues (wait times vs. travel distances) and types of stigma faced (staff vs. community stigma related to the small-town effect). Such findings should provide primary health networks (PHNs) and other service planners with a better understanding of the more pertinent service needs and barriers faced by young people in regional versus metro areas. Finally, there was overlap between youth and staff focus group suggestions for sector improvements, including increasing afterhours supports, more missing middle services, and including peer workers at all levels of the sector.

Collectively, our mixed methods results are reflective of the wider literature focused on the intersection of geography and psychology, where place is critical for one’s mental health and wellbeing. Recommended next steps focus on establishing/strengthening data partnerships in identified youth self-harm clustering regions; increased research efforts and program planning focused on youth mental health and employment/socioeconomic outcomes of single parents; hosting discussions on e-safety and service barriers (in regional vs. metro areas); and devising mental health and self-harm education programs for parents and school staff.