Research Prioritization Task Force Research Articles

A Suicide-Specific Diagnosis – The Case Against

A Suicide-Specific Diagnosis – The Case Against

Screening youth for suicide risk in medical settings: time to ask questions.

This paper focuses on the National Action Alliance for Suicide Prevention's Research Prioritization Task Force's Aspirational Goal 2 (screening for suicide risk) as it pertains specifically to children, adolescents, and young adults. Two assumptions are forwarded: (1) strategies for screening youth for suicide risk need to be tailored developmentally; and (2) we must use instruments that were created and tested specifically for suicide risk detection and developed specifically for youth. Recommendations for shifting the current paradigm include universal suicide screening for youth in medical settings with validated instruments.

A review of evidence-based follow-up care for suicide prevention: where do we go from here?

Follow-up services are an important component of a comprehensive, national strategy for suicide prevention. Increasing our knowledge of effective follow-up care has been identified as an Aspirational Goal by The National Action Alliance for Suicide Prevention's Research Prioritization Task Force. Several recent comprehensive reviews informed the selection of studies included in this brief review. Studies of follow-up services that reported significant effects for the outcomes of death by suicide, suicide attempts, or suicidal ideation were included. Although there is a paucity of research in this area, promising paradigms that have demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideation will be discussed. The major limitations of the literature in this area include numerous methodological flaws in the design and analyses of such studies and the lack of replication of studies with positive findings. This paper identifies several breakthroughs that would be helpful for advancing this area of research and describes a comprehensive research pathway for achieving both short- and long-term research objectives.

Increasing help-seeking and referrals for individuals at risk for suicide by decreasing stigma: the role of mass media.

Increasing help-seeking and referrals for at-risk individuals by decreasing stigma has been defined as Aspirational Goal 10 in the National Action Alliance for Suicide Prevention's Research Prioritization Task Force's 2014 prioritized research agenda. This article reviews the research evidence on the impact of mass media awareness campaigns on reducing stigma and increasing help-seeking. The review will focus on both beneficial and iatrogenic effects of suicide preventive interventions using media campaigns to target the broad public. A further focus is on collaboration between public health professionals and news media in order to reduce the risk of copycat behavior and enhance help-seeking behavior. Examples of multilevel approaches that include both mass media interventions and individual-level approaches to reduce stigma and increase referrals are provided as well. Multilevel suicide prevention programs that combine various approaches seem to provide the most promising results, but much more needs to be learned about the best possible composition of these programs. Major research and practice challenges include the identification of optimal ways to reach vulnerable populations who likely do not benefit from current awareness strategies. Caution is needed in all efforts that aim to reduce the stigma of suicidal ideation, mental illness, and mental health treatment in order to avoid iatrogenic effects. The article concludes with specific suggestions for research questions to help move this line of suicide research and practice forward.

National pathways for suicide prevention and health services research.

In 2012, the National Action Alliance for Suicide Prevention's Research Prioritization Task Force (RPTF) released a series of Aspirational Goals (AGs) to decrease suicide deaths and attempts. The RPTF asked experts to summarize what was known about particular AGs and to propose research pathways that would help reach them. This manuscript describes what is known about the benefits of access to health care (AG8) and continuity of care (AG9) for individuals at risk for suicide. Research pathways are proposed to address limitations in current knowledge, particularly in U.S. healthcare-based research. Using a three-step process, the expert panel reviewed available literature from electronic databases. For two AGs, the experts summarized the current state of knowledge, determined breakthroughs needed to advance the field, and developed a series of research pathways to achieve prevention goals. Several components of healthcare provision have been found to be associated with reduced suicide ideation, and in some cases they mitigated suicide deaths. Randomized trials are needed to provide more definitive evidence. Breakthroughs that support more comprehensive patient data collection (e.g., real-time surveillance, death record linkage, and patient registries) would facilitate the steps needed to establish research infrastructure so that various interventions could be tested efficiently within various systems of care. Short-term research should examine strategies within the current healthcare systems, and long-term research should investigate models that redesign the health system to prioritize suicide prevention. Evidence exists to support optimism regarding future suicide prevention, but knowledge is limited. Future research is needed on U.S. healthcare services and system enhancements to determine which of these approaches can provide empirical evidence for reducing suicide.

Improving the short-term prediction of suicidal behavior.

Aspirational Goal 3 of the National Action Alliance for Suicide Prevention's Research Prioritization Task Force is to predict who is at risk for attempting suicide in the near future. Despite decades of research devoted to the study of risk and protective factors for suicide and suicidal behavior, surprisingly little is known about the short-term prediction of these behaviors. In this paper, we propose several questions that, if answered, could improve the identification of short-term, or imminent, risk for suicidal behavior. First, what factors predict the transition from suicidal thoughts to attempts? Second, what factors are particularly strong predictors of making this transition over the next hours, days, or weeks? Third, what are the most important objective markers of short-term risk for suicidal behavior? And fourth, what method of combining information about risk and protective factors yields the best prediction? We propose that the next generation of research on the assessment and prediction of suicidal behavior should shift, from cross-sectional studies of bivariate risk and protective factors, to prospective studies aimed at identifying multivariate, short-term prediction indices, examining methods of synthesizing this information, and testing the ability to predict and prevent suicidal events.

Experiences and wisdom behind the numbers: qualitative analysis of the National Action Alliance for Suicide Prevention's Research Prioritization Task Force stakeholder survey.

The Research Prioritization Task Force of the National Action Alliance for Suicide Prevention conducted a stakeholder survey including 716 respondents from 49 U.S. states and 18 foreign countries. To conduct a qualitative analysis on responses from individuals representing four main stakeholder groups: attempt and loss survivors, researchers, providers, and policy/administrators. This article focuses on a qualitative analysis of the early-round, open-ended responses collected in a modified online Delphi process, and, as an illustration of the research method, focuses on analysis of respondents' views of the role of life and emotional skills in suicide prevention. Content analysis was performed using both inductive and deductive code and category development and systematic qualitative methods. After the inductive coding was completed, the same data set was re-coded using the 12 Aspirational Goals (AGs) identified by the Delphi process. Codes and thematic categories produced from the inductive coding process were, in some cases, very similar or identical to the 12 AGs (i.e., those dealing with risk and protective factors, provider training, preventing reattempts, and stigma). Other codes highlighted areas that were not identified as important in the Delphi process (e.g., cultural/social factors of suicide, substance use). Qualitative and mixed-methods research are essential to the future of suicide prevention work. By design, qualitative research is explorative and appropriate for complex, culturally embedded social issues such as suicide. Such research can be used to generate hypotheses for testing and, as in this analysis, illuminate areas that would be missed in an approach that imposed predetermined categories on data.

Population health outcome models in suicide prevention policy.

Suicide is a leading cause of death in the U.S. and results in immense suffering and significant cost. Effective suicide prevention interventions could reduce this burden, but policy makers need estimates of health outcomes achieved by alternative interventions to focus implementation efforts. To illustrate the utility of health outcome models to help in achieving goals defined by the National Action Alliance for Suicide Prevention's Research Prioritization Task Force. The approach is illustrated specifically with psychotherapeutic interventions to prevent suicide reattempt in emergency department settings. A health outcome model using decision analysis with secondary data was applied to estimate suicide attempts and deaths averted from evidence-based interventions. Under optimal conditions, the model estimated that over 1 year, implementing evidence-based psychotherapeutic interventions in emergency departments could decrease the number of suicide attempts by 18,737, and if offered over 5 years, it could avert 109,306 attempts. Over 1 year, the model estimated 2,498 fewer deaths from suicide, and over 5 years, about 13,928 fewer suicide deaths. Health outcome models could aid in suicide prevention policy by helping focus implementation efforts. Further research developing more sophisticated models of the impact of suicide prevention interventions that include a more complex understanding of suicidal behavior, longer time frames, and inclusion of additional outcomes that capture the full benefits and costs of interventions would be helpful next steps.

Prognostic models to detect and monitor the near-term risk of suicide: state of the science.

Aspirational Goal 3 of the National Action Alliance for Suicide Prevention's Research Prioritization Task Force research agenda is to "find ways to assess who is at risk for attempting suicide in the immediate future." Suicide risk assessment is the practice of detecting patient-level conditions that may rapidly progress toward suicidal acts. With hundreds of thousands of risk assessments occurring every year, this single activity arguably represents the most broadly implemented, sustained suicide prevention activity practiced in the U.S. Given this scope of practice, accurate and reliable risk assessment capabilities hold a central and irreplaceable position among interventions mounted as part of any public health approach to suicide prevention. Development of more reliable methods to detect and measure the likelihood of impending suicidal behaviors, therefore, represents one of the more substantial advancements possible in suicide prevention science today. Although past "second-generation" risk models using largely static risk factors failed to show predictive capabilities, the current "third-generation" dynamic risk prognostic models have shown initial promise. Methodologic improvements to these models include the advent of real-time, in vivo data collection processes, common data elements across studies and data sharing to build knowledge around key factors, and analytic methods designed to address rare event outcomes. Given the critical need for improved risk detection, these promising recent developments may well foreshadow advancement toward eventual achievement of this Aspirational Goal.

The Baby or the Bath Water?

The Research Prioritization Task Force of the National Action Alliance for Suicide Prevention conducted a comprehensive literature review of suicide prevention/intervention trials to assess the quality of the scientific evidence. A literature "review of reviews" was conducted by searching the most widely used databases for mental health and public health research. The quality of the reviews was evaluated using the Revised Assessment of Multiple Systematic Reviews system; the quality of the scientific evidence for the suicide preventions/interventions was assessed using U.S. Preventive Services Task Force criteria. The reviews were limited to peer-reviewed publications with human subjects published in English. Ninety-eight systematic reviews and 45 primary sources on suicide prevention/interventions published between January 2000 and September 2012 were evaluated. The results suggest that the quality of both the systematic reviews and the scientific evidence for suicide preventions/interventions were mixed. The majority of the systematic reviews and prevention/interventions were evaluated as fair to poor in quality. There are many promising suicide prevention/intervention trials, but research findings are often inconclusive because of methodologic problems. Methodologic problems across systematic reviews include not conducting hand searches, not surveying gray literature, and being unable to aggregate data across studies. Methodologic problems with the scientific quality of the prevention/intervention trials include paucity of information on sample demographic characteristics, poorly defined outcomes, and excluding actively suicidal participants. Suggestions for ways to improve the quality of the systematic reviews and suicide preventions/interventions are provided.

Suicide risk screening and assessment: designing instruments with dissemination in mind.

This paper summarizes recommendations made regarding the National Action Alliance for Suicide Prevention Research Prioritization Task Force's Aspirational Goal 2, to "determine the degree of suicide risk (e.g., imminent, near-term, long-term) among individuals in diverse populations and in diverse settings through feasible and effective screening and assessment approaches." We recommend that researchers shift to using "design for dissemination" principles to maximize both the goodness of fit and validity of screening and assessment measures for a given setting. Three specific recommendations to guide research efforts are made to achieve this shift: (1) the parameters related to each setting, including the logistics, scope of practice, infrastructure, and decision making required, should be identified and used to choose or design screening and assessment instruments that have a good fit; (2) to the greatest feasible extent, technology should be used to support screening and assessment; and (3) researchers should study the best methods for translating validated instruments into routine clinical practice. We discuss the potential barriers to implementing these recommendations and illustrate the paradigm shift within the emergency department setting.

Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force.

The National Action Alliance for Suicide Prevention Research Prioritization Task Force (RPTF) has created a prioritized national research agenda with the potential to rapidly and substantially reduce the suicide burden in the U.S. if fully funded and implemented. Viable, sustainable scientific research agendas addressing challenging public health issues such as suicide often need to incorporate perspectives from multiple stakeholder groups (e.g., researchers, policymakers, and other end-users of new knowledge) during an agenda-setting process. The Stakeholder Survey was a web-based survey conducted and analyzed in 2011-2012 to inform the goal-setting step in the RPTF agenda development process. The survey process, and the final list of "aspirational" research goals it produced, are presented here. Using a modified Delphi process, diverse constituent groups generated and evaluated candidate research goals addressing pressing suicide prevention research needs. A total of 716 respondents representing 49 U.S. states and 18 foreign countries provided input that ultimately produced 12 overarching, research-informed aspirational goals aimed at reducing the U.S. suicide burden. Highest-rated goals addressed prevention of subsequent suicidal behavior after an initial attempt, strategies to retain patients in care, improved healthcare provider training, and generating care models that would ensure accessible treatment. The Stakeholder Survey yielded widely valued research targets. Findings were diverse in focus, type, and current phase of research development but tended to prioritize practical solutions over theoretical advancement. Other complex public health problems requiring input from a broad-based constituency might benefit from web-based tools that facilitate such community input.

Suicide Experts Identify Six Questions to Guide Research in Next Decade

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessSuicide Experts Identify Six Questions to Guide Research in Next DecadeAaron LevinAaron LevinSearch for more papers by this authorPublished Online:19 Mar 2014https://doi.org/10.1176/appi.pn.2014.3a19AbstractMore clearly defining the goals and mechanisms of research into suicide may move the field forward and lead to a substantial reduction in suicides.Despite efforts at prevention, suicide rates in the United States have remained the same for the last half century. Clarifying approaches to research into suicide and its antecedents might ultimately lead to reductions in those rates, according to a new report.The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force issued a prioritized research agenda on February 5 by the public-private consortium led by Phillip Satow, chair of the board at the Jed Foundation, and Thomas Insel, M.D., director of the National Institute of Mental Health (NIMH). About 38,000 Americans die by suicide every year, and 650,000 hospital visits are attributed to suicide attempts, noted the report.“To reduce suicide, we need to know how to target our efforts: to be able to reliably identify who is at risk, how to reach them, and how to deter them from acting on suicidal thoughts,” said Insel in a statement.The NIMH funds $44 million in suicide research annually, said the research agenda authors.The document took about three years to produce, said Jane Pearson, Ph.D., chair of the Suicide Risk Consortium at NIMH and lead staffer for the research agenda. Task force members volunteered their time, and private groups and federal agencies provided administrative and meeting support.A number of organizations and advocacy groups observed that prioritizing research into other diseases helped to advance the science in those areas, she said. At present, many gaps in the science of suicide exist: surveillance, causes, detection, treatment, and trajectories through age groups.To begin the process of filling those gaps, the task force sought the views of 700 individuals, including scientists, funding bodies, clinicians, public health leaders, as well as survivors of suicide attempts and families of those who died by suicide.The research agenda distilled their inquiry down to six key questions that its authors hope will guide research over the coming decade, with an initial goal of reducing suicides by 20 percent over the next five years:Why do people become suicidalHow can we better or more optimally detect/predict risk?What interventions prevent individuals from engaging in suicidal behavior?What services are most effective for treating the suicidal person and preventing suicidal behavior?What other types of interventions (outside health care settings) reduce suicide risk?What new and existing research infrastructure is needed to reduce suicidal behavior?“This document will draw attention and researchers to the topic and facilitate funding,” said Robert Ursano, M.D., a professor and chair of the Department of Psychiatry at the Uniformed Services University of the Health Sciences School of Medicine in Bethesda, Md. Ursano is co-principal investigator of the ongoing Army STARRS research on military suicides (Psychiatric News, March 7) but did not take part in the task force’s work.The task force hopes to draw attention to measures already known to be effective, to test whether commonly used antisuicide programs are indeed effective, and to identify new research needed in less-studied areas.Research methodology needs attention, as well. For example, alternative trial designs may be needed to overcome difficulties in randomization. Models based on accident research or behavioral economics may be useful. Standardizations of nomenclature, national patient registries, and expansion of the National Violent Death Reporting System (which now collects data in only 18 states) would improve surveillance, to cite just some of the issues raised in the research agenda.“At NIMH, we have been trying to steer the field in this general direction to move interventions tested in clinical trials into clinical practice,” said Pearson. “We really have to compress the 17-year gap between research and clinical practice.”“[S]uicide has proven stubbornly difficult to understand, to predict, and to prevent,” said Insel. “We believe the research agenda gives us a roadmap to save lives.” ■“A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives” can be accessed here. ISSUES NewArchived

Primary Prevention Research in Suicide

At the American Association of Suicidology’s (AAS) 46th Annual Conference in Austin, Texas (http://www.suicidology.org/web/guest/education-and-training/annualconference), participants were challenged to address why there has not been more progress in reducing the rates of completed suicides (Berman, 2013). A draft of recommendations from the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force was presented at the meeting and subsequently published in this journal (National Action Alliance for Suicide Prevention [NAASP], 2013a, 2013b). The purpose of this commentary is to address this challenge by emphasizing the importance of employing a disease etiology strategy that integrates molecular data with clinical data, environmental data, and health outcomes in a dynamic, iterative fashion. The recommendations of the Research Prioritization Task Force tackle important public health program issues and are embedded within seven key questions, summarized as: 1. Why do people become suicidal? 2. How do we better detect/predict risk? 3. What interventions prevent suicidal behavior? 4. What are the effective services for treating suicidal persons and preventing suicidal behavior? 5. How do we reduce stigma? 6. What are the suicide prevention interventions outside of health-care settings? 7. Which existing and new infrastructure needs are required to further reduce suicidal behavior? (NAASP, 2013b; Silverman et al., 2013)

The Agenda Development Process of the United States’ National Action Alliance for Suicide Prevention Research Prioritization Task Force

The Agenda Development Process of the United States’ National Action Alliance for Suicide Prevention Research Prioritization Task Force