The relationship between mental health reforms and general population suicide rates in Australia over the past three and a half decades: 1987 – 2021

Nearly 3,000 Australians tragically end their lives by suicide each year, underscoring a major national public health challenge with substantial socio-economic ramifications. Australia ’ s National Mental Health Plans (NMHPs) aim to improve mental health and reduce suicide rates. This study investigates their effectiveness by analyzing how age-standardized suicide rates across Australian jurisdictions have fluctuated alongside the implementation of five NMHPs from 1987 to 2021. Findings reveal mixed impacts, with some plans linked to decreases and others associated with increases in suicide rates across different periods and regions. Notably, the recent decline in 2020 requires careful consideration amidst COVID-19 pandemic influences. These insights not only provide valuable evidence for shaping future mental health policies and initiatives but also for future health services research.


Introduction
In Australia, suicide remains a devastating public health crisis, claiming nearly 9 lives every day on average, annually and impacting countless families and communities.Beyond the immeasurable personal loss, suicides contribute to lost workdays, increased healthcare utilization for survivors, and strain on social services.While mental health service utilization has increased among Australians aged 16-85 (Burgess et al., 2009), a concerning gap persists in the quality and accessibility of care for those struggling with mental health challenges.
This highlights the critical need for effective interventions to address this complex issue.National Mental Health Plans (NMHPs) represent a significant effort to improve mental health outcomes in Australia.However, the extent to which these plans have specifically impacted suicide rates remains unclear.This research aims to fill this gap by examining the association between NMHPs and age-standardized suicide rates across Australian jurisdictions over 35 years .By analyzing how suicide rates fluctuated alongside the implementation of different NMHPs, we seek to understand their effectiveness in reducing suicidality and inform future mental health policy development.

National mental health strategy
In response to the evident shortfalls in mental health care, Australia commenced its mental health reform with the National Mental Health Strategy in April 1992(Australian Government National Mental Health Commission [NMHC], 2017).This strategy, comprising the National Mental Health Policy, the Mental Health Statement of Rights and Responsibilities, and subsequent National Mental Health Plans (NMHPs), sculpted mental health service delivery for the subsequent twenty-five years.The strategy was intended to enhance the mental health and well-being of Australians, prevent mental illnesses, mitigate their impact, and protect the rights of those diagnosed.From the first NMHP in 1993 to the Fifth Plan in 2017, Australia implemented various strategies to address service delivery, public perception, economic impacts, and rights-based approaches.Despite these efforts, challenges persisted, including funding shortfalls and inconsistent service provision.The plans across different periods are described as follows.(1993)(1994)(1995)(1996)(1997)(1998) This policy recognised the high prevalence of mental health problems and disorders across Australia, as well as its extensive impact on the well-being of individuals, families and society (Whiteford, 1993).It was pivotal in instilling a long-term vision and direction to alter the mental health landscape completely, namely, facilitating the promotion of mental health and the delivery of its services.The need to develop systems to influence mental health policies had active consumer involvement at the heart of it.It simultaneously aimed to reshape how mental health services fit into mainstream healthcare services, better integrating them while retaining their specialised identity (Rosen, 2006;Whiteford, 1993).This paradigm shift made it possible to link mental health services to a variety of crucial support networks, such as housing, social assistance, employment, and training.To further refine the plan, several initiatives were taken, including launching community awareness campaigns (Rosen et al., 2000), encouraging consumer and carer participation in policymaking, conducting extensive research on the cost of mental health care, and establishing national mental health standards that would later serve as the basis for accreditation exams within the mental health industry (Rosen, 2006).This all-encompassing strategy established the framework for a mental health system that is more inclusive, integrated and consumer-focused, reflecting Australia's dedication to a holistic approach to addressing mental health.(1998)(1999)(2000)(2001)(2002)(2003) The second NMHP was founded on the basis of promotion, prevention, collaboration, and Quality.It marked the beginning of a new era in Australian mental health treatment.By acknowledging the value of early intervention and shared mental healthcare, this strategy sought to integrate mental health promotion and prevention into the fabric of mental health services.Furthermore, it highlighted the need for carer education, training, and support programmes.This plan also aimed to improve the expertise and understanding of medical personnel through continual training (Rosen, 2006).It sought to create laws that abide by both the Mental Health Statement of Rights and Responsibilities as well as the United Nations Resolutions, to comply with international norms.With the vision of a more educated and caring community, it also created anti-stigma programmes, such as media kits and mental health education for students.This was also complemented by extensive surveys of mental health and well-being and early psychosis intervention (Whiteford and Buckingham, 2005).The introduction of the use of outcome measures in mental health care also encouraged accountability and quality improvement in both public and mental health institutions (Rosen, 2006).This second NMHP was a significant step to enable Australia to have a more inclusive, proactive, and responsive mental healthcare system.(2004)(2005)(2006)(2007)(2008) Spanning from 2004 to 2008, the Third NMHP laid forth a thorough strategy comprised of four main goals.The promotion of mental health and prevention of mental health issues and disorders, enhancement of quality and service responsiveness, and encouragement of research, innovation, and sustainability were the four main objectives of this strategy.It symbolised a determined effort to fully address mental health and improve the calibre and efficacy of mental health services throughout Australia (Rosen, 2006).However, despite a progressive approach to mental health reform over the past decade, the Third NMHP has received flak for the lack of concrete goals for more financing and better services (Hickie et al., 2005).Rather, it placed emphasis on the chance to expand on the current policy framework.Nevertheless, there was a general agreement, particularly from the Australian Health Ministers (Australian Health Ministers, 2003) that this strategy was weak: it lacked incentives for governments and there were no effective accountability measures in place (Hickie et al., 2005).As a result, the National Strategy's initial successes started to fade, leading to service gaps, especially when community-based services were reduced in favour of hospital-based treatment.Additionally, there was a sudden increase in acute instances of co-occurring mental illness and substance abuse, which caused access issues in emergency and inpatient units.As a consequence of the increased public awareness of these problems, the Australian Senate (Australian Senate, 2006), the Mental Health Council of Australia (Groom et al., 2003), the Human Rights and Equal Opportunity Commission (Summers and McKenzie, 2006) launched enquiries before major government funding was injected, particularly for private services addressing common mental health conditions.This action pushed states to make modest improvements to essential public services for serious but, less common, illnesses (Rosen, 2006).1.5. Fourth national mental health plan (20091.5. Fourth national mental health plan ( -2014) ) Ratified by Australia's Health Ministers in September 2009, the Fourth NMHP partnered with a variety of stakeholders, including consumers, government agencies and healthcare professionals (Roberts, 2011).It recognised the complex nature of mental health, considering not just the biological and psychological aspects but also societal and economic influences, such as housing, employment and community involvement (National Mental Health Performance Subcommittee [NMHPS], 2011).

Third national mental health plan
Additionally, it recognised that in order to prevent mental health problems from deteriorating, early detection and treatment are essential.The Fourth Plan adopted a whole-of-government approach that extended beyond the healthcare sector in response to gaps found in its predecessor, highlighting the importance of cross-sector cooperation, and raising public awareness of mental health issues at all levels of government and within the community (Parliament of Australia (PoA), 2009;NMHPS, 2011).The five main areas that are at the heart of this $2.2 billion strategy are social inclusion and recovery, prevention and early intervention, service access, coordination and continuity of care, quality improvement and innovation, and accountability via measuring and reporting success.A key step towards better mental health services and outcomes for all Australians, each of these categories has defined goals and metrics to measure success.Learning from the shortfalls of its predecessor, the Fourth Plan established a strong accountability system with yearly reporting to promote openness and spur significant transformation in the mental health sector (PoA, 2009).This all-encompassing strategy highlights Australia's dedication to building a mental health system that promotes recovery, early intervention, and equal access to care and support, allowing people with mental illness to fully engage in society.
However, despite the diversity of stakeholder input, the priority actions and experiences that were written on paper were greatly overlooked during decision-making regarding funding (Roberts, 2011).The significant underfunding of the vast majority of the 34 agreed-upon priority measures underscores a shortfall in strategic implementation (PoA, 2009), potentially leading to the disengagement of consulted stakeholders (Roberts, 2011).Overall, this plan demonstrated a substantial lack of funding for leadership to achieve better communication between governments and stakeholders, as well as optimal utilisation of existing skills and resources, to achieve successful mental health reform.
1.6.Fifth national mental health and suicide prevention plan (2017)(2018)(2019)(2020)(2021)(2022) Echoing the visions of its predecessors, the Fifth National Mental Health and Suicide Prevention Plan also acknowledged the demand for a gradual and holistic approach to reform.Integrated planning, effective suicide prevention and service delivery, multidisciplinary treatment for complex cases, improved Indigenous mental health and wellbeing, improved physical health for those with mental illnesses, safety and quality in service delivery, stigma reduction, and productive system performance are the eight priority actions.This plan included preparatory measures that make provisions for comprehensive system reform alongside continual cooperation between governments and S.S. Wang et al. stakeholders.In particular, a national suicide prevention strategy was brought to the foreground, acknowledging that different governmental levels share accountability for this issue.The goals of this initiative included establishing interdisciplinary mental health centres, creating a digital platform called Head to Health, expanding mental health treatment beyond conventional venues, improving primary care, and ensuring follow-up care following hospital release for suicidal attempts (Conn, 2021).This $2.3 billion strategy, largely motivated by consumer experience emphasised prevention, compassion and care, and marked a major investment in mental health services.Despite these improvements, it is crucial to also account for the significance of the COVID-19 pandemic midway through the tenure of this plan (Page and Spittal, 2022).

Death-by-suicide by states and territories
The Australian Institute of Health and Welfare (AIHW) 35-year dataset reveals regional differences (Kinchin and Doran, 2018).While total suicides increased, the consistent metric of age-standardised rates of suicide per 100,000 population is crucial to compare patterns fairly across Australia.Though New South Wales (NSW) and Victoria, with large populations, had below-average suicide rates as reflected in Fig. 1, high-rate Northern Territory (NT) had low death counts, highlighting rate importance.Notably, Queensland and Western Australia (WA), with significant population growth, suggest potentially different rate patterns and future challenges.Analyzing both rates and population dynamics offers a nuanced understanding of Australia's suicide patterns.
The intricate landscape of suicide trends underscores the importance of examining these patterns within the context of NMHPs.Understanding the association between jurisdiction-specific suicide rates and the NMHPs is vital for future policy development and interventions.Furthermore, to ensure that the research is a thorough ecological analysis, this study will dissect the Fifth Plan's evaluation into pre-pandemic (2017-2019) and pandemic periods (2020-2022) to add value to existing literature surrounding the potential acute and long-term impacts of the pandemic on the nation's suicide rates in the context of longterm trends.In light of the limited research investigating this intricate relationship, this study aims to test the null hypothesis that there is no uniform statistically significant association between the implementation of the plans and age-standardised suicide rates across all Australian jurisdictions and the First to Fifth NMHPs .

Methods
The study relied predominantly on nationally representative datasets: primarily the AIHW National Mortality Database Suicide (ICD-10 × 60-X84, Y87.0) and the Australian Bureau of Statistics (ABS) (AIHW, 2023(AIHW, , 2024)).The AIHW procures the Cause of Death Unit Record file from both the Registries of Births, Deaths and Marriages, and the National Coronial Information System.The Victorian Department of Justice manages the latter.Within these datasets, information regarding the cause of death is systematically coded by the ABS.From these, the dataset "NMD S5: Suicide (ICD 10 × 60-X84, Y87.0), by year of occurrence of death, states and territories, 1979 to 2021″, which was computed by governmental officials, was pivotal.It compiled the age-standardised rates of suicide per 100,000 population and detailed the number of jurisdictional suicides from 1987 to 2021.
The independent variable underpinning this research was the successive changes in the National Mental Health Plans (NMHPs).These changes were quantitatively represented using specific indicators associated with each NMHP phase, including policy introductions, amendments, and other significant shifts.The primary outcome variable was suicide rates, expressed as per 100,000 per population years.Directly standardisation was used in this calculation, where age-specific rates, segmented into 5-year intervals such as 15-19 and 80-84, were multiplied against the Australian standard population as of 30 June 2001 (AIHW, 2023).This represents the non-recast Australian estimated resident population (ERP) during that period.Utilizing age-standardised rates ensures that variations in age distribution across jurisdictions and over time are accounted for (AIHW, 2024), providing a more accurate representation of underlying suicide trends.

Statistical approach
Central to the study's analytical approach was Kendall's Tau correlation test.This non-parametric method was preferred given its proficiency in assessing non-linear, monotonic correlations, aligning well with the nuanced shifts in sociocultural factors and their potential effects on jurisdictional suicide rates (Van den Heuvel and Zhan, 2022).While the year-wise data itself is quantitative, capturing specific values for each year, Kendall's Tau's robustness to non-normality and its capacity to detect non-linear trends make it a suitable choice for our analysis (Prematunga, 2012).Additionally, its ability to handle potential outliers in the data further strengthens its applicability in this context (Schaeffer and Levitt, 1956).
Prior to the main analysis, age-standardised suicide rate values missing from specific jurisdictions and years between 1979 and were expunged using the Statistical Package for the Social Sciences (SPSS).The resultant data was visually represented through a line graph, with each jurisdiction highlighted in unique colours for clarity.This was followed by Kendall's Tau analysis, in which the NMHP time periods were revised to ensure accuracy and relevance.Rather than recalculating the theoretical period of each plan and designating that as the start date, an adjustment was made to commence each plan at the beginning of the subsequent calendar year.For example, while the endorsement of the First National Mental Health Plan occurred in July 1993, the start of the plan was rounded up to 1994 for analysis purposes.This was repeated for the other four plans.This adjustment was made to accommodate anticipated changes in the Mental Health Act across jurisdictions and to align with the expected onset of plan effects.Table B (Appendix B) reports the correlation coefficients for the unadjusted, theoretical period.The results are methodically tabulated in Table 1.Statistical significance was demarcated at p < .05,setting the stage for hypothesis testing.

Ethical considerations
This research, rooted in aggregate data collated by the AIHW, abstained from using individually identifiable data.As such, this study does not fall under the purview of human-subject research requiring extensive human research ethics approval.

Results
Figs. 2, A3 to A10 (Appendix A) present annual suicide rates per 100,000 population, with demarcations for the National Mental Health Plan (NMHP) periods and the Fifth Plan's pre-pandemic and pandemic segments.Table 1 contains Kendall's Tau correlation coefficients (τ b ) for corresponding periods.
Age-standardised suicide rates in Australia exhibited a modest decline from 14.3 deaths per 100,000 population in 1987 to 12.1 deaths per 100,000 population in 2021.However, the overall trend reveals a pattern of relative stability punctuated by fluctuations around the mean across the 34-year period.Notably, the data display a trimodal distribution with peaks in 1987 (14.3 deaths per 100,000 population), (14.8 deaths per 100,000 population), and 2017 (12.1 deaths per 100,000 population).

Discussion
Spanning 1987-2021, this study investigates the evolving National Mental Health Plans (NMHPs) in Australia and their potential relationship with suicide rates, offering insight into the complex interplay between mental health interventions and suicide prevention efforts (Shand et al., 2020).As depicted in Fig. 2, with moderate decline in suicide rates across Australia, it can be deduced that the NMHPs have not had much of an effect on suicide rates.Notably, a significant decrease in suicides between 1998 and 2005 could be influenced by a myriad of factors.One of the factors that might contribute to the reduction of suicide rates during this period is the gun law reforms in 1996.Previous evidence suggests firearm-related suicides rapidly decreased after the 1996-1997 Australia's 1996 Firearms Buyback program (Chapman et al., 2006).Apart from the reduction in the availability of lethal methods, such as firearms, Large and Neilssen (2010) also highlight a decline in suicides by methods like shooting, gassing, and poisoning.This analysis of suicide rates and NMHPs in Australia (1987-2022) reveals mixed results.While the Second and Fifth NMHPs coincided with national declines in suicide rates, suggesting a potential benefit, the relationship is complex.Some regions like Queensland and the ACT even saw declines before any NMHPs existed.Conversely, the First, Third, and Fourth Plans coincided with contrasting trends, including significant increases in jurisdictions such as WA during the Third Plan.Comparing Table 1 to Table B, which analysed the correlation coefficients for suicide rates nationally across the practical and theoretical Plan periods, respectively, it can be noted that both analyses shared similar significance findings.Overall, these regional variations highlight the complexity of suicide, influenced by a multitude of factors beyond national policy.While a slight national downward trend emerged during the Fifth Plan, with significant declines in Victoria and Queensland, a cautious approach is necessary.Further research is needed to isolate the specific impact of individual plan elements and account for the multifaceted nature of suicide risk.

Highlighting challenges
Australia's mental health policy landscape, while rich in history (Whiteford, 1992), faces significant challenges in translating policy into effective implementation.The evolution of NMHPs reflects a growing understanding of mental healthcare needs.They have transitioned from a clinical focus towards a more holistic, community-driven approach (Whiteford et al., 2002).This is exemplified by the Fourth Plan's emphasis on collaboration across sectors.The Fifth Plan's recognition of cultural responsiveness highlights the importance of tailored interventions in Australia's diverse population.
However, the effectiveness of these plans can be hindered by the flawed nature of Australia's healthcare structure, which include variations in policy interventions among states, workforce concentration in urban areas, and historical deficiencies in plan evaluation and implementation (Rosenberg et al., 2023;Whiteford, 1992).In particular, the level of funding is not proportionate to the burden of disease that mental health has in Australia.
Examining the recent decline in Australia's suicide rates during the 2020 pandemic, it is important to note that this drop was unexpected, yet not unique to Australia.Other high-income countries also experienced similar declines (Page and Spittal, 2022;Pirkis et al., 2021).Historical patterns show peaks and troughs in suicide rates during times of socio-economic disruption (Chang et al., 2013), but this single-year drop should not be over-interpreted.The influence of government financial support mechanisms, such as JobKeeper and JobSeeker, during this period likely provided protective layers against suicide, particularly among susceptible populations like working-aged men (Page and Spittal., 2022;Phillips et al., 2020).Additionally, this period fostered a sense of community and increased trust in the government (Biddle et al., 2020), potentially contributing to the decline.The pandemic has also reshaped the mental health landscape, impacting distress levels across employed and unemployed populations.Employment status is no longer a definitive indicator of mental wellbeing (Pierce et al., 2020).This reinforces the significance of socio-economic determinants in understanding and preventing suicide.Consequently, ongoing and adaptive suicide prevention strategies remain crucial.
Australia's NMHPs highlight critical gaps, including inconsistencies in policy implementation over the past two decades (Grace et al., 2015).Comprehensive evaluations are crucial to address persistent stigma and serve specific community needs.

Limitations and future research directions
It is essential to acknowledge the limitations of the study's design and methods.The study's reliance on preliminary data for 2019-2021 introduces the possibility of revisions.Using suppressed and nonpublished suicide numbers from specific jurisdictions introduces biases and limits the comprehensiveness and reliability of the findings.
Coroner data on suicide rates can be influenced by legal regulations, economic conditions, and healthcare quality, which vary significantly between Australian states.These variations can affect how deaths are classified and access to resources.De Leo et al. ( 2010) have identified a substantial proportion of cases where coroners make no explicit reference to intent are deemed intentional self-harm upon further examination.Furthermore, inconsistencies in coroner practices and potential under-reporting of suicides prior to 2006 complicate data interpretation nad hinder the development of effective prevention efforts.Additionally, underidentification of certain demographic characteristics, such as Indigenous status and sexual orientation, can lead to inaccurate measurement and analysis of suicide trends within these populations.Future research should consider local Mental Health Acts (MHAs) and their interplay within the national framework, to better understand their impact on suicide prevention across the nation (Shand et al., 2020;Hassan, 1996).They have different financial and data collecting systems, which might impact services, accessibility and equity and consequently, suicide rates (Rosenberg et al., 2023).As well as reviewing local MHAs, it would be beneficial to investigate the underlying cause of suicide (mental illness, serious physical illness, or palliative illness), potentially obscuring associations with specific health conditions and hindering targeted prevention efforts.Future research incorporating detailed disease data could enhance our understanding of suicide risk factors and refine intervention strategies.Furthermore, long-term trends by age and gender, with a focus on age-standardized suicide rates, should also be analyzed in 10-year intervals.Thus, refining future mental health interventions and ensuring their effectiveness across demographics.

Implications for future mental health policies
Australia's NMHPs highlight critical gaps, including inconsistencies in policy implementation over the past two decades (Grace et al., 2015).Comprehensive evaluations are crucial to address persistent stigma and serve specific community needs.
The recent suicide trends in Australia during the pandemic emphasize the need for a multifaceted Sixth National Mental Health Plan (NMHP).This should prioritise robust data systems and integrated healthcare frameworks for timely, universal care access (Whiteford et al., 2002).Rationing of mental health services, worsened by workforce shortages (Ramsay, 1996;Hickie et al., 2011), necessitates staff retention initiatives.
A key focus of the Sixth Plan should be enhancing the quality and accessibility of mental health services, integrating them seamlessly within the broader healthcare system (Ramsay, 1996;Hickie et al., 2011).Improving workforce conditions through competitive remuneration, professional development opportunities (Henderson et al., 2008), and ongoing government support is critical (Phillips et al., 2020).
The Sixth Plan should be developed with input from stakeholders, fostering open communication channels and community engagement to ensure an adaptable mental health infrastructure (Hassan, 1996).These recommendations, informed by resources like the Productivity Commission Inquiry Report and the National Suicide Prevention Adviser's insights, can provide valuable guidance for strengthening Australia's mental health system.While Australia's NMHPs offer a framework for other nations to consider in reducing suicide rates, significant challenges exist in translating this approach to other contexts.The focus on quality, accessibility, and integration of mental health into general healthcare provides a valuable model, but successful implementation requires tailoring these strategies to address the specific needs and resources of each country.

Conclusion
This study investigated the complex relationship between National Mental Health Plans and suicide rates across Australian jurisdictions over three and a half decades.While some NMHPs coincided with national declines in suicide rates, definitively attributing these reductions solely to the plans is not possible.The limitations of the data and the multitude of factors influencing suicide risk necessitate a cautious approach to interpreting the findings.The ongoing challenge lies in translating mental health policy into effective implementation at the state level.Disparities in access to services, workforce shortages, and a lack of comprehensive evaluations all contribute to these challenges.Future research should delve deeper into long-term trends and explore the impact of demographic factors.The development of the Sixth National Mental Health Plan presents an opportunity to address these challenges and build a more robust and adaptable mental health system for Australians.By incorporating a focus on data collection, workforce development, service integration, and ongoing evaluation following each plan reform, Australia can continue its journey towards a more effective mental healthcare system and a reduction in suicide rates.

Fig. 1 .
Fig. 1. A. Comparison of the four Australian jurisdictions with the highest age-standardised suicide rates with the Australian average, per 100,000 population.This figure depicts the four jurisdictions with the highest age-standardised suicide rates per 100,000 population: Queensland (purple line), Western Australia (orange line), Tasmania (light green line), Northern Territory (pink line), and the national average (khaki line) across the years 1987 to 2021.B. Comparison of the four Australian jurisdictions with the lowest age-standardised suicide rates with the Australian average, per 100,000 population.This figure depicts the four jurisdictions with the lowest age-standardised suicide rates per 100,000 population: New South Wales (blue line), Victoria (dark green line), South Australia (dark brown line), Australian Capital Territory (red line), and the national average (khaki line) across the years 1987 to 2021.The X-axis represents the year, and the Y-axis represents the age-standardised suicide rate.

Fig. 2 .
Fig. 2. Age-standardised suicide rates in Australia between 1987 and 2021.Yearly trends across Australia.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A single red asterisk denotes significance of the association between the NMHP and Australia's suicide rates at the 0.05 level; a double red asterisk denotes significance at the 0.01 level.

Fig. A3 .
Fig. A3.Age-standardised suicide rates in New South Wales between 1987 and 2021.Yearly trends across New South Wales.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A single red asterisk denotes significance of the association between the NMHP and New South Wales' suicide rates at the 0.05 level.

Fig. A4 .
Fig. A4.Age-standardised suicide rates in Victoria between 1987 and 2021.Yearly trends across Victoria.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A single red asterisk denotes significance of the association between the NMHP and Victoria's suicide rates at the 0.05 level.

Fig. A5 .
Fig. A5.Age-standardised suicide rates in Queensland between 1987 and 2021.Yearly trends across Queensland.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A double red asterisk denotes significance of the association between the NMHP and Queensland's suicide rates at the 0.01 level.

Fig. A6 .
Fig. A6.Age-standardised suicide rates in Western Australia between 1987 and 2021.Yearly trends across Western Australia.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A single red asterisk denotes significance of the association between the NMHP and Western Australia's suicide rates at the 0.05 level.

Fig. A7 .
Fig. A7.Age-standardised suicide rates in South Australia between 1987 and 2021.Yearly trends across South Australia.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.

Fig. A8 .
Fig. A8.Age-standardised suicide rates in Tasmania between 1987 and 2021.Yearly trends across Tasmania.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.

Fig. A9 .
Fig. A9.Age-standardised suicide rates in the Australian Capital Territory between 1987 and 2021.Yearly trends across the Australian Capital Territory.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A double red asterisk denotes significance of the association between the NMHP and Australian Capital Territory's suicide rates at the 0.01 level.

Fig. A10 .
Fig. A10.Age-standardised suicide rates in the Northern Territory between 1987 and 2021.Yearly trends across the Northern Territory.The X-axis represents the years from 1987 to 2021, and the Y-axis denotes the age-standardised suicide rates (per 100,000 population).Shaded areas indicate the active periods of the five NMHPs.Dashed vertical lines demarcate the subdivision of the Fifth Plan into pre-pandemic and pandemic periods.A single red asterisk denotes significance of the association between the NMHP and Northern Territory's suicide rates at the 0.05 level.
Abbreviations: NSW, New South Wales; VIC, Victoria; QLD, Queensland; WA, Western Australia; SA, South Australia; TAS, Tasmania; ACT, Australian Capital Territory; NT, Northern Territory; N, Number of years the respective National Mental Health Plan (NMHP) was in effect.aAdjusted period of the plan to accommodate the onset of National Mental Health Plan amendments.For example, the endorsement of the First National Mental Health Plan occurred in July 1993, but for calculation, the plan's commencement was 1995 (1994 data was expunged).Likewise, the Second Plan was adjusted from July 1998-June 2003 to 1999-2003, the Third was adjusted from July 2003-June 2008 to 2004-2009, the Fourth from September 2009-2014 to 2010-2017, and the Fifth from August 2017-December 2021 to 2018-2021.* indicates p < .05(2-tailed).** indicates p < .01(2-tailed).

Table B
Kendall's Tau-b Correlation Coefficients (τ b ) for Australian Jurisdictions between 1987 and 2021.New South Wales; VIC, Victoria; QLD, Queensland; WA, Western Australia; SA, South Australia; TAS, Tasmania; ACT, Australian Capital Territory; NT, Northern Territory; N, Number of years the respective National Mental Health Plan (NMHP) was in effect.