Resuscitation of out-of-hospital cardiac arrests in residential aged care facilities in Melbourne, Australia.

INTRODUCTION: CPR in patients in residential aged care facilities (RACF) deserves careful consideration. We examined the characteristics, management and outcomes of out-of-hospital cardiac arrest (OHCA) in RACF patients in Melbourne, Australia. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs occurring in RACFs in Melbourne. The characteristics and outcomes were compared to non-RACF patients in the VACAR. RESULTS: Between 2000 and 2009 there were 30,006 OHCAs, 2350 (7.8%) occurring in a RACF. A shockable rhythm was present in 179 (7.6%) patients on arrival of paramedics of whom bystander CPR had been performed in 118 (66%); 173 (97%) received an EMS attempted resuscitation. ROSC was achieved in 71 (41%) patients and 15 (8.7%) patients survived to leave hospital. Non shockable rhythm was present in 2171 patients (92%) of whom 804 (37%) had an attempted resuscitation by paramedics. ROSC was achieved in 176 patients (22%) and 10 patients (1.2%) were discharged alive. Survival from OHCA occurring in a RACF was less than survival in those aged >70 years of age who suffered OHCA in their own homes (1.8% vs. 4.7%, p=0.001). On multivariable analysis, witnessed OHCA (OR 3.0, 95% CI 2.4-3.7) and the presence of bystander CPR (OR 4.6, 95% CI 3.7-5.8) was associated with the paramedic decision to resuscitate. CONCLUSION: Resuscitation of patients in RACF is not futile. However, informed decisions concerning resuscitation status should be made by patients and their families on entry to a RACF. Where it is appropriate to perform resuscitation, outcomes may be improved by the provision of BLS training and possibly AED equipment to RACF staff.

Out-of-hospital cardiac arrests in young adults in Melbourne, Australia-adding coronial data to a cardiac arrest registry.

AIM: We aim to describe the coronial findings of young adults where the out-of-hospital cardiac arrest (OHCA) aetiology was 'presumed cardiac'. METHODS: Presumed cardiac aetiology OHCAs occurring in young adults aged 16-39 years were identified using the Victorian Ambulance Cardiac Arrest Registry (VACAR) and available coronial findings reviewed. RESULTS: We identified 841 young adult OHCAs where the Utstein aetiology was 'presumed cardiac'. Of these 740 died and 572 (77%) OHCAs were matched to coroner's findings. On review of the coroner's cause of death, 230 (40.2%) had a 'confirmed cardiac' aetiology, 221 (38.6%) were proven 'non-cardiac', 97 (17%) were inconclusive and 24 (4.2%) cases remained 'open'. 'Confirmed cardiac' causes of OHCA were ischemic heart disease (n=126, 55%), cardiomegaly (n=26, 11.3%), cardiomyopathy (n=25, 11%), congenital heart disease (n=15, 6.5%), cardiac tamponade due to dissecting thoracic aorta aneurysm (n=10, 4.3%), myocarditis (n=8, 3.5%), arrhythmia (n=7, 3%), others (n=13, 5.7%). 'Non-cardiac' causes of OHCA were epilepsy/sudden unexplained death in epilepsy (SUDEP) (n=56, 25%), pulmonary embolism (n=29, 13%), subarachnoid haemorrhage (n=17, 7.7%), other intracranial bleed (n=7, 3.2%), pneumonia (n=17, 7.7%), DKA (n=16, 7.2%), other complications of diabetes mellitus (n=8, 3.6%), complications of obesity (n=9, 4%), haemorrhage (n=12, 5.4%), sepsis (n=8, 3.6%), peritonitis (n=6, 2.7%), aspiration (n=6, 2.7%), renal failure (n=5, 2.3%), asthma (n=5, 2.3%), complications of anorexia (n=3) and alcohol abuse (n=2), thyrotoxicosis (n=2), meningitis (n=1) and others (n=12). Compared with coroner's diagnosed 'non-cardiac' OHCAs, 'confirmed cardiac' were more likely to be witnessed (41% vs 23%, p≤0.01), receive bystander CPR (35% vs 20%, p≤0.001), have a shockable rhythm (27% vs 6.3%, p<0.001) and have EMS attempted resuscitation (62% vs 44%, p<0.001). DISCUSSION: Linking OHCA registries with coronial databases for aetiology of the arrest will improve the quality of the data and should be considered by all OHCA registries, particularly for young adult OHCA.

Cardiac arrest outcomes before and after the 2005 resuscitation guidelines implementation: evidence of improvement?

BACKGROUND: Previous studies have reported improvements in out-of-hospital cardiac arrest (OHCA) outcomes with the introduction of the 2005 cardiopulmonary resuscitation guidelines however they have not adjusted for underlying trends in OHCA survival. We compare outcomes before and after the 2005 guideline changes adjusting for underlying trends in OHCA survival. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for adult (≥16 years) OHCA of presumed cardiac aetiology, unwitnessed by paramedics with attempted resuscitation. Outcomes for OHCA occurring between 2003 and 2005 were compared with 2007-2009. Segmented regression analysis of interrupted time series data was performed, adjusting for known predictors, to examine changes in survival to hospital and survival to hospital discharge. RESULTS: For the pre- and post- guideline periods there were 3115 and 3248 OHCAs, respectively. Asystole increased as presenting rhythm (33-43%, p<0.001) as did median EMS response times (7.1-7.8 min, p<0.001) over the two periods. VF/VT arrests decreased (40-35.5%, p=0.001) as did bystander witnessed arrests (63-59%, p=0.002). On univariate analysis survival to hospital discharge improved between the two periods (9.4-11.8%, p=0.002) due to improved outcomes in VF/VT (19-28%, p<0.001). Segmented regression analysis of interrupted time series data showed improvement in the rate of survival to get to hospital for shockable and non-shockable rhythms [OR (95% CI)=1.54 (1.10-2.15, p=0.01) and 1.45 (1.10-2.00, p=0.02), respectively] following implementation of the guidelines however survival to hospital discharge did not improve [OR=1.07 (0.70-1.62, p=0.70) and 1.40 (0.69-2.85, p=0.40), respectively]. CONCLUSIONS: OHCA outcomes have improved since introduction of the 2005 CPR guidelines, but multivariable segmented regression analysis adjusting for pre-existing trends in survival suggests that this improvement may not be due to implementation of the 2005 resuscitation guidelines.

Out-of-hospital cardiac arrests in young adults in Melbourne, Australia.

BACKGROUND: Characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in young adults are not well described in Australia. METHODS: A 10-year retrospective case review of all OHCA in young adults (aged 16-39) and not witnessed by EMS, was performed using data from the Victorian Ambulance Cardiac Arrest Registry (VACAR). RESULTS: Between 2000 and 2009 there were 30,006 adult cardiac arrests of which 3912 (13%) were in this age group. The median (IQR) age was 30 (25-35) years for both sexes with a 3:1 male to female ratio. Overdose was the most common precipitant (33.5%) followed by presumed cardiac (20%). Bystander CPR occurred in 21.2%, EMS median response time was 7 min and resuscitation was attempted in 36% of OHCAs. The presenting rhythm was asystole in 84.6%, PEA in 8.8% and VF/VT in 6.6%. Survival to hospital discharge, for all cause OHCA where resuscitation was attempted, was similar for young adult and older adults (8.8% vs 8.4%, p=0.2). However, for presumed cardiac aetiology OHCA, young adults had a greater proportion of survivors (14.8% vs 9.0%, p<0.001). Cardiac arrest with shockable rhythm (VF/pulseless VT) had a survival rate of 31.2% for young adults compared to 18.5% for older adults (p<0.001). CONCLUSION: Survival to hospital discharge rates from OHCA due to a 'presumed cardiac' precipitant in young adults is much better than older adults, however, all cause OHCA survival is similar. Multi agency novel upstream preventive strategies aimed at tackling drug overdose may reduce this aetiology of OHCA and save lives.

Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia.

BACKGROUND: Controversy exists around CPR in the elderly. The characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) in this age group were studied in Melbourne, Australia. METHODS: The Victorian Ambulance Cardiac Arrest Registry (VACAR) was searched for all OHCAs not witnessed by Emergency Medical Services (EMS) occurring in those aged 65 years and older. RESULTS: Between 2000 and 2009 there were 30,006 OHCAs of which 9703 (32%) were in people 65-79 years of age, 6430 (21%) in octogenarians, 1530 (5%) in nonagenarian and 40 (0.1%) in centenarians. Rates of attempted resuscitation decreased with advancing age: 48% for those aged 65-79 years, 39% for octogenarians, 31% for nonagenarians and 17% for centenarians. Similarly rates of survival to hospital discharge decreased with age: 8% for those aged 65-79 years, 4% for octogenarians, 2% for nonagenarians; for 65-79 year olds, octogenarians and nonagenarians survival if in VF/VT was - 17%, 10% and 4%; asystole - 1%, 1% and 0.5%; and PEA - 6%, 3% and 3%, respectively. Multivariable logistic regression shows that between 2000 and 2009 rates of transportation with return of spontaneous circulation have improved for both shockable and non-shockable rhythms [OR 95% CI 1.07(1.04-1.10) and 1.16(1.12-1.20), respectively] but survival to hospital discharge has improved in the shockable rhythm group only [OR 1.12(1.07-1.16)]. CONCLUSION: Outcomes for OHCA with shockable rhythm have improved over the last 10 years for people aged 65 years and over. Quality of life studies should be performed to help inform the community and EMS on appropriate resuscitative efforts.

Paediatric hanging associated out of hospital cardiac arrest in Melbourne, Australia: characteristics and outcomes.

INTRODUCTION: Hanging is a rare but devastating cause of out of hospital cardiac arrest (OHCA). The characteristics and outcomes of hanging associated OHCA in the paediatric age group are described. METHODS: The Victorian Ambulance Cardiac Arrest Registry was searched for patients aged less than 18 years where the precipitant cause of OHCA was hanging. Results were cross checked with the coronial database. RESULTS: During the years 2000-2009, there were 680 paediatric cardiac arrests of which 53 (7.8%) were precipitated by hanging with an incidence of 4.4 per million paediatric patients (<18 years) per year. Median age was 16 (IQR 14-17) years and 58.5% were males. Five were unintentional hangings; median age 3 (IQR 2-4) years. The youngest deliberate hanging associated OHCA was aged 10 years. Most hangings occurred in a house (85%) and bystander cardiopulmonary resuscitation (CPR) was performed in 30%. Asystole was the most common initial cardiac arrest rhythm seen in 50 cases (94%) while three patients had pulseless electrical activity. The emergency medical services (EMS) attempted resuscitation in 18 patients (34%), inserting an endotracheal tube in 13 patients. The majority (n=41) were not transported; seven patients were transported with return of spontaneous circulation (ROSC) and five patients were transported with ongoing CPR. Victims who had bystander CPR were more likely to have EMS attempted resuscitation (p<0.001). Only patients who had received bystander CPR achieved ROSC (p<0.001). Three patients survived to hospital discharge; two survivors suffered severe neurological injury (Cerebral Performance Category Scale 3-4). CONCLUSION: Non-intentional hanging is rare but deliberate hanging with suicidal intent represents a significant proportion of OHCAs in patients under 18 years of age. A focus on prevention is key, as outcomes are poor, with survivors likely to suffer a severe neurological insult.

Epidemiology of paediatric out-of-hospital cardiac arrest in Melbourne, Australia.

BACKGROUND: Previous studies of paediatric cardiac arrest have reported a low survival rate but there is limited data from Australia. We sought to determine the characteristics and outcomes of paediatric out-of-hospital cardiac arrest in Melbourne, Australia. METHODS: Between October 1999 and June 2007, all cases of out-of-hospital cardiac arrest attended by emergency medical services in Melbourne, Australia were entered into a database (the Victorian Ambulance Cardiac Arrest Registry). Data on patients aged less than 16 years in cardiac arrest on arrival of ambulance paramedics was analysed. RESULTS: There were 209 children in cardiac arrest on arrival of paramedics during the study period. Of these, resuscitation was not attempted in 16 children due to signs of definite death. Of the 193 children who had attempted resuscitation, 143 (74%) had an initial cardiac rhythm of asystole, 36 (18%) were in pulseless electrical activity and 14 (7%) were in ventricular fibrillation. There were 49 patients (25%) with return of spontaneous circulation at arrival to hospital of whom 14 (7%) survived to hospital discharge. Of 138 patients without return of a circulation, 120 were transported to hospital with continuing resuscitation and one survived (0.9%). Survival was higher in patients with an initial cardiac rhythm of ventricular fibrillation (5/14; 35%) compared with other rhythms (10/179; 4%), OR 9.38, 95% CI 2.64-33.2. CONCLUSIONS: Overall, 7.7% of paediatric patients with out-of-hospital cardiac arrest survive to leave hospital. Increased survival was seen if the initial cardiac rhythm was ventricular fibrillation. Survival was very rare (<1%) unless there was return of spontaneous circulation prior to hospital arrival.

The effect of rapid lipid lowering with atorvastatin on autonomic parameters in patients with coronary artery disease.

Many cardiovascular disease states are associated with autonomic dysfunction, specifically sympathetic activation and parasympathetic withdrawal. Both these autonomic derangements are independently associated with adverse prognostic outcomes. HMG CoA reductase inhibitors (statins) reduce cardiovascular mortality and morbidity when compared to placebo in subjects with proven coronary artery disease (CAD), including sudden presumed arrhythmic death. As autonomic dysfunction is associated with arrhythmogenesis, statins may be having a beneficial effect on autonomic function in these subjects. We conducted a randomised, double-blind, placebo-controlled, cross-over study examining the effect of rapid short-term lipid lowering with a statin on autonomic function in CAD patients. Ten subjects with proven CAD (8 male, 2 female; mean age 63.4 years) were randomised to receive either 80 mg atorvastatin or placebo over a 4 week period followed by a 4 week washout, then the alternative treatment for a further 4 weeks. Autonomic parameters assessed were plasma noradrenaline levels on recumbency and 80 degrees head-up tilt, cold pressor testing, and heart rate variability (HRV) analysis. Plasma noradrenaline levels were significantly reduced (p=0.050) after 20 min rest in the recumbent position, with atorvastatin compared to placebo. A nonsignificant reduction in plasma noradrenaline with atorvastatin compared to placebo was observed in the prolonged 80 degrees head-up position (p=0.207). In addition, sympathovagal balance was shifted to greater vagal predominance with atorvastatin (low-frequency/high-frequency ratio in the HRV frequency domain) when compared to placebo, p=0.06. We found that rapid lipid lowering with atorvastatin reduces sympathetic nervous system in this pilot study of CAD patients. Larger trials are required to definitively address the effects of statins on autonomic activity in these patients.

Deaths from all causes in a long-term follow-up study of 11,583 deliberate self-harm patients.

BACKGROUND: Deliberate self-harm (DSH) may be associated with increased risk of death from a variety of causes, not just suicide. METHOD: A follow-up study of 11,583 DSH patients who presented to a general hospital over a 20-year period was conducted to examine risk of death from a range of causes during a follow-up period of between 3 and 23 years. Deaths were identified through national death registries. Expected numbers of deaths were calculated from national death statistics. RESULTS: The number of deaths (1,185, 10.2%) was 2.2 times the expected number, the excess being significantly greater in males than females. Suicides were 17 times more frequent than expected and undetermined causes of death and accidental poisonings 15 times more frequent. Significantly more than expected numbers of deaths from most natural causes were found, including respiratory disease, circulatory, neurological, endocrine, digestive, skin and musculoskeletal and connective tissue disorders, and symptoms, signs and ill-defined conditions. Deaths due to accidents other than poisoning were more frequent than expected in both genders and homicides more frequent in males. CONCLUSIONS: In addition to increased risk of suicide, DSH patients are at increased risk of dying from a wide range of other causes. Possible explanations include lifestyle factors, physical disorders contributing to initial risk of DSH, and social disadvantage. The findings are relevant to clinical management and evaluation of outcome and health-care costs associated with DSH.

Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics.

BACKGROUND: Trends in deliberate self-harm (DSH) are important because they have implications for hospital services, may indicate levels of psychopathology in the community and future trends in suicide, and can assist in identification of means of suicide prevention. METHOD: We have investigated trends in DSH and characteristics of DSH patients between 1990 and 2000 based on data collected through the Oxford Monitoring System for Attempted Suicide. RESULTS: During the 11-year study period 8590 individuals presented following 13858 DSH episodes. The annual numbers of persons and episodes increased overall by 36.3% and 63.1% respectively. Rates (Oxford City) declined, however, in the final 3 years. There were gender- and age-specific changes, with a rise in DSH rates in males aged > or = 55 years and in females overall and those aged 15-24 years and 35-54 years. Repetition of DSH increased markedly during the study period. Antidepressant overdoses, especially of SSRIs, increased substantially. Paracetamol overdoses declined towards the end of the study period. Alcohol abuse, use of alcohol in association with DSH, and violence increased, especially in females, and the proportion of patients in current psychiatric care and misusing drugs also rose. CONCLUSIONS: While overall rates of DSH did not increase markedly between 1990 and 2000, substantial changes in the characteristics of the DSH population and a rise in repetition suggest that the challenges facing clinical services in the management of DSH patients have grown.

Substances used in deliberate self-poisoning 1985-1997: trends and associations with age, gender, repetition and suicide intent.

BACKGROUND: Rates of deliberate self-poisoning have increased in recent years. While over-the-counter availability and prescribing patterns may influence trends in substances used in overdose, these may also be related to clinical characteristics of patients. We investigate trends in substances used for self-poisoning and the influence of age, gender, suicidal intent and repetition status on the substances used. METHOD: Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends and patterns of self-poisoning between 1985 and 1997. RESULTS: There were substantial increases in self-poisoning with paracetamol and antidepressants. While the increase in antidepressant self-poisoning closely paralleled local prescribing figures during 1995-97, SSRI antidepressant overdoses occurred somewhat more often than expected compared with tricyclic overdoses. Paracetamol overdoses were more common in first-timers and young people, whereas overdoses of antidepressants and tranquillizers were more common in repeaters and older people. Self-poisoning with gas and non-ingestible poisons was associated with high suicidal intent. CONCLUSIONS: There have been marked changes in the substances used for self-poisoning, which seem primarily to reflect availability, as do the influences of age and repeater status on choice of substances used. Degree of suicidal intent may also influence choice of method of self-poisoning.

The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.

BACKGROUND: Geographic variations in the incidence of deliberate self-harm (DSH) and suicide have been shown to be associated with area-based measures of socio-economic deprivation and social fragmentation. Previous studies have been subject to methodological limitations. None has investigated whether ecological associations are reflected in characteristics of individuals involved in suicidal behaviour. METHODS: DSH patients presenting to a general hospital between 1985 and 1995 and suicides (including open verdicts) from the same catchment area were studied. Mean annual rates of DSH and suicide by gender were calculated for electoral wards. The wards were amalgamated into 20 groups according to their ranking for socio-economic deprivation (Townsend) and social fragmentation scores. Associations of these variables with DSH and suicide rates were investigated. Characteristics of DSH patients living in ward groups with the highest and lowest socio-economic deprivation and social fragmentation scores were compared. RESULTS: Socio-economic deprivation was associated with DSH rates among males (r = 0.89) and females (r = 0.87). After controlling for social fragmentation the associations remained relatively strong, particularly in young males. Associations with social fragmentation in both genders (males, r = 0.83; females, r = 0.86) were attenuated after controlling for socio-economic deprivation. For suicide, the only significant association was with socio-economic deprivation in males (r = 0.79), but this was attenuated after controlling for social fragmentation. The characteristics of individual DSH patients reflected those of the areas where they lived. CONCLUSIONS: Reducing socio-economic deprivation and its associated problems may be an important strategy in the prevention of suicidal behaviour, especially in young men.

Social class and suicidal behaviour: the associations between social class and the characteristics of deliberate self-harm patients and the treatment they are offered.

BACKGROUND: Rates of deliberate self-harm (DSH) in the United Kingdom are much higher in lower than upper social class groups. Previous investigations have shown differences in socio-demographic and clinical characteristics of male patients according to social class. In two studies of DSH patients in Edinburgh the extent of provision of psychiatric aftercare was inversely related to social class. These findings have not been investigated in other areas. METHOD: Data collected through the Oxford Monitoring System for Attempted Suicide were used to examine the association between social class and socio-demographic and clinical characteristics in male and female DSH patients who presented to the general hospital in Oxford between mid-1988 and 1996 and to determine whether the previously reported social class differences in provision of psychiatric aftercare were replicated. RESULTS: Data on social class were available for 2,828 DSH patients (1,290 males, 1,538 females). In both genders, lower social class group tended to be associated with younger age. In males, the main social class differences were found in under-35-year-olds, in whom lower social class was related to criminal record, violence to others and drug misuse. In females, psychiatric disorders were diagnosed more frequently in the higher social class groups, but only in the under-35 age group. In neither gender was there a significant association between social class and the frequency of offer of psychiatric aftercare following DSH. CONCLUSIONS: There are considerable variations in socio-demographic and clinical characteristics of both male and female DSH patients in different social classes, especially in younger patients. The reason for the absence of a marked social class gradient in psychiatric aftercare found in this study in contrast to the results from previous investigations may be related to differences in styles of service.

Effect of death of Diana, princess of Wales on suicide and deliberate self-harm.

BACKGROUND: The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour. AIMS: To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH). METHOD: Analysis, using Poisson regression, of the number of suicides and open verdicts ('suicides') in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital. RESULTS: Suicides increased during the month following the Princess's funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress. CONCLUSIONS: The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

The geographical distribution of suicides in farmers in England and Wales.

Farmers in England and Wales have an elevated risk of suicide. The aim of this study was to investigate the geographical distribution of suicides in farmers. Rates of suicide (including suicide and open verdicts) of farmers in England and Wales between 1981 and 1993 were calculated on a county basis. Trends in rates and differences in rates between counties, regions and England and Wales were then analysed. There were 719 suicides (634 suicide verdicts and 85 open verdicts). There was evidence of a decline in annual rates of suicide in farmers during the study period in England but not Wales. There was no evidence of geographical heterogeneity of farming suicides according to counties, but a relatively high rate for Devon (N = 62 suicides). County farming suicide rates did not appear to be related to local general population suicide rates, density of farmers or type of farm holding. While identification of counties with relatively large numbers of farming suicides should assist targeting of local preventive programmes, it is clear that any significant prevention strategies should be implemented on a national basis.

Methods used for suicide by farmers in England and Wales. The contribution of availability and its relevance to prevention.

BACKGROUND: Farmers in the UK have an elevated risk of suicide. It has been suggested that this may be related to their ease of access to dangerous means for suicidal behaviour. The extent to which farmers use these means and changes in their use may be relevant to suicide prevention. METHOD: Data on 719 deaths in farmers of both genders in England and Wales between 1981 and 1993 in which a verdict of suicide or undetermined cause (open verdict) was recorded were analysed. RESULTS: Of 702 deaths in male farmers, firearms were involved in 40.0%, hanging in 29.6%, carbon monoxide in 16.4%, poisoning in 8.0% (over half of which involved agricultural or horticultural poisons) and other methods in 6.1%. There was a considerable excess of deaths due to firearms compared with the distribution of methods of suicide and open verdict deaths in males in the general population. Hanging was also somewhat more frequent. During the study period there was a reduction in firearm death rates, particularly after 1989 when there was national legislation on firearm ownership, registration and storage. There were also fewer farming suicides after this date. By the end of the study period hanging was more frequent than deaths involving firearms. CONCLUSIONS: Farmers who commit suicide tend to use methods to which they have easy access. Restriction of the ready availability of such methods, particularly in farmers known to be depressed or otherwise at risk, might prevent some suicides.