Reflections on Expert Recommendations for U S Research Priorities in Suicide Prevention 2014...
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Reflections on Expert Recommendations for U.S. Research Priorities in Suicide Prevention Morton M. Silverman, MD, Jane E. Pirkis, PhD, Jane L. Pearson, PhD, Joel T. Sherrill, PhD Introduction T he articles in this special supplement represent the collective thinking of suicide prevention experts from across the U.S. and several other countries about where research efforts might best be invested to address the vexing public health problem of suicide. The authors of these articles—and other suicide prevention experts—came together under the aegis of the National Action Alliance for Suicide Prevention’s (Action Alliance) Research Prioritization Task Force (RPTF), an initiative that was resourced by the National Institute of Mental Health (NIMH) and the Substance Abuse and Mental Health Services Administration (SAMHSA). 1 As editors, we have had the pleasure of seeing this supplement come to fruition and the early manuscripts develop into articles that we are confident will have a major influence not only on the suicide prevention research agenda but also on reducing suicide. We brought different perspectives to our editorial roles. Two of us (Morton Silverman and Jane Pirkis) are career researchers with specialist expertise in various aspects of suicide prevention and were not directly involved in the RPTF process but were brought on board as independent editors. Two of us (Jane Pearson and Joel Sherrill) are members of the NIMH staff who oversee relevant portfolios of science and were involved in the RPTF initiative from the outset. The articles in this supplement represent a subset of the presentations made by suicide prevention experts to inform the RPTF agenda. As editors, we served as “curators” and collated a representative set of articles that address the RPTF’s Aspirational Goals (AGs) for suicide prevention. 2 The articles explicitly consider how these AGs might be achieved by reviewing existing research evidence, examining challenges to progress, and proposing future directions. Scope of the RPTF Process and the Articles in This Supplement Suicide prevention researchers are beset with methodo- logical and ethical problems when they design studies. For example, universal or community-wide interventions are not always easily amenable to evaluation by RCTs; it can be difficult to select appropriate control conditions for trials testing interventions for at-risk or actively suicidal individuals, and sample sizes required to power studies become prohibitively large given the low base rate of suicide events. Such challenges have historically limited our understanding of what works and what doesn’t work in suicide prevention. The articles in this supplement grapple with these issues and make intelligent suggestions about how to overcome them. It should be noted that the articles represent abridged summaries of the research overviews that topic experts prepared to inform the research prioritization process. By design, the articles provide a snapshot of where the field is with regard to each AG, and the directions necessary to progress knowledge in the area. In each article, the authors cite relevant references that provide additional detail and serve as supplementary resources for readers. The articles in this supplement summarize a unique undertaking in terms of the scope of the research prioritization activities and the RPTF process. The scope is remarkable, given the range of science that is considered (from basic science regarding the neurobio- logical underpinnings of suicide through science related to the dissemination/implementation of preven- tion strategies). The RPTF approach was to simultaneously consider priorities and strategies within each AG, both short-term and longer-term. In this manner, researchers or funders might use the information to help identify overall priorities as well as priorities and promising directions within a given area of science, depending on their particular interests. The process is also unprecedented in suicide research in terms of the multistage, multigroup approach to collecting input, and in terms of the up-front attention to systematically using available data (e.g., burden estimates and simulations regarding the potential From the Suicide Prevention Resource Center (Silverman), Waltham, Massachusetts; the National Institute of Mental Health (Pearson, Sherrill), Rockville, Maryland; and the University of Melbourne, Melbourne School of Population and Global Health (Pirkis), Melbourne, Australia Address correspondence to: Joel T. Sherrill, PhD, National Institute of Mental Health, 6001 Executive Blvd, Rockville MD 20892. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2014.05.025 & 2014 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine Am J Prev Med 2014;47(3S2):S97–S101 S97
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Reflections on Expert Recommendations for U.S.Research Priorities in Suicide Prevention
Morton M. Silverman, MD, Jane E. Pirkis, PhD, Jane L. Pearson, PhD, Joel T. Sherrill, PhD
Introduction
The articles in this special supplement representthe collective thinking of suicide preventionexperts from across the U.S. and several other
countries about where research efforts might best beinvested to address the vexing public health problem ofsuicide. The authors of these articles—and other suicideprevention experts—came together under the aegis of theNational Action Alliance for Suicide Prevention’s (ActionAlliance) Research Prioritization Task Force (RPTF), aninitiative that was resourced by the National Institute ofMental Health (NIMH) and the Substance Abuse andMental Health Services Administration (SAMHSA).1
As editors, we have had the pleasure of seeing thissupplement come to fruition and the early manuscriptsdevelop into articles that we are confident will have amajor influence not only on the suicide preventionresearch agenda but also on reducing suicide. We broughtdifferent perspectives to our editorial roles. Two of us(Morton Silverman and Jane Pirkis) are career researcherswith specialist expertise in various aspects of suicideprevention and were not directly involved in the RPTFprocess but were brought on board as independent editors.Two of us (Jane Pearson and Joel Sherrill) are members ofthe NIMH staff who oversee relevant portfolios of scienceand were involved in the RPTF initiative from the outset.The articles in this supplement represent a subset of
the presentations made by suicide prevention experts toinform the RPTF agenda. As editors, we served as“curators” and collated a representative set of articlesthat address the RPTF’s Aspirational Goals (AGs) forsuicide prevention.2 The articles explicitly consider howthese AGs might be achieved by reviewing existingresearch evidence, examining challenges to progress,and proposing future directions.
From the Suicide Prevention Resource Center (Silverman), Waltham,Massachusetts; the National Institute of Mental Health (Pearson, Sherrill),Rockville, Maryland; and the University of Melbourne, Melbourne Schoolof Population and Global Health (Pirkis), Melbourne, Australia
Address correspondence to: Joel T. Sherrill, PhD, National Institute ofMental Health, 6001 Executive Blvd, Rockville MD 20892. E-mail:[email protected].
0749-3797/$36.00http://dx.doi.org/10.1016/j.amepre.2014.05.025
& 2014 Published by Elsevier Inc. on behalf of American Journal of P
Scope of the RPTF Process and the Articlesin This SupplementSuicide prevention researchers are beset with methodo-logical and ethical problems when they design studies.For example, universal or community-wide interventionsare not always easily amenable to evaluation by RCTs; itcan be difficult to select appropriate control conditionsfor trials testing interventions for at-risk or activelysuicidal individuals, and sample sizes required to powerstudies become prohibitively large given the low base rateof suicide events. Such challenges have historicallylimited our understanding of what works and whatdoesn’t work in suicide prevention.The articles in this supplement grapple with these
issues and make intelligent suggestions about how toovercome them. It should be noted that the articlesrepresent abridged summaries of the research overviewsthat topic experts prepared to inform the researchprioritization process. By design, the articles provide asnapshot of where the field is with regard to each AG, andthe directions necessary to progress knowledge in thearea. In each article, the authors cite relevant referencesthat provide additional detail and serve as supplementaryresources for readers.The articles in this supplement summarize a unique
undertaking in terms of the scope of the researchprioritization activities and the RPTF process. The scopeis remarkable, given the range of science that isconsidered (from basic science regarding the neurobio-logical underpinnings of suicide through sciencerelated to the dissemination/implementation of preven-tion strategies).The RPTF approach was to simultaneously consider
priorities and strategies within each AG, both short-termand longer-term. In this manner, researchers or fundersmight use the information to help identify overallpriorities as well as priorities and promising directionswithin a given area of science, depending on theirparticular interests. The process is also unprecedentedin suicide research in terms of the multistage, multigroupapproach to collecting input, and in terms of the up-frontattention to systematically using available data (e.g.,burden estimates and simulations regarding the potential
reventive Medicine Am J Prev Med 2014;47(3S2):S97–S101 S97
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impact of intervening in particular contexts) to guide theprioritization of research.Other countries have engaged in research prioritiza-
tion exercises, but, to our knowledge, none of those haveoccurred on this scale. In Australia in the mid-2000s, forexample, Federal Government funding was provided fora project that examined existing priorities (throughreviews of published literature and funded grants) andconsidered future priorities (through a questionnaire ofstakeholders’ views and a series of focus groups).3,4
Existing priorities were re-examined last year.5 This workshowed that the bulk of the emphasis under Australia’sNational Suicide Prevention Strategy had been, andcontinues to be, given to epidemiologic studies at theexpense of intervention studies.This work in Australia was useful for identifying
priorities, but this effort did not have the same machinerybehind it as the RPTF. The Australian process relied on asmall project team conducting what was effectively aseries of small substudies, and sought the views of otherresearchers (and other relevant stakeholders) in a sys-tematic but somewhat limited way. The process ofdrawing together topic experts from across the spectrumof suicide prevention research, and asking them toconsider and write about the way in which researchcould be improved, clearly identifies the work of theRPTF as groundbreaking.
Prioritizing Across Interrelated but DiverseAreas of ScienceThe individual papers reflect concise reviews of thescience related to specific AGs; as such, the papers standalone. Table 1 lists the RPTF AGs and the correspondingpapers in this special supplement. Nevertheless, there issubstantial interdependence among the AGs and thecorresponding papers, and some goals are inexorablylinked.For example, the science of developing and testing
interventions to address individuals who have attemptedsuicide will share much in common in terms of contentand approach with that related to interventions targetingother at-risk groups (e.g., individuals at risk due todepression or other psychiatric/substance use disor-ders13). Likewise, although psychotherapeutic interven-tions12 and pharmacologic interventions14 are addressedin separate reviews, as Griffiths et al.14 note, it seemslikely that optimizing prevention and treatment willultimately require deploying evidence-based approachesin combination or sequentially.Many if not most of the goals are not only inter-
dependent, but also serially dependent in terms oftheir role in achieving prevention aims. For example,
the development of effective screening instrumentsand practices8,9 and actionable risk stratification algo-rithms11 depends on earlier stages of science that identifyreadily assessed risk factors that are highly correlatedwith the likelihood of attempting suicide.10 Similarly,the development and testing of effective interventionsdepends on the identification of modifiable riskand etiologic or maintaining factors that representpotential intervention targets, including neurobiologicaltargets.6,7
Furthermore, the ultimate utility of screening andintervention approaches will depend not only on thedevelopment of effective preventive and therapeuticstrategies but also on the development of effectivestrategies for training providers to ensure research-informed approaches are disseminated and implementedwith fidelity.16 Finally, the degree to which screening,identification, and intervention ultimately lead to areduction in the rate of suicide deaths and attempts willdepend on effective systems-level approaches to ensurethe availability of and access to affordable, effectiveservices.17,18
The interdependence of these AGs poses challenges forprioritizing across the full range of science. Is it necessaryto first achieve a firm understanding of the causes ofsuicidal behavior before undertaking research on poten-tial prevention strategies, or is it more important toprioritize science that has the potential for the mostimmediate impact on reducing suicide attempts anddeaths (e.g., development and testing of effective pre-ventive interventions and strategies)? Should effortsfocus on broad-based prevention21–23 and efforts toincrease help-seeking19 or on more intensive, targetedpreventive or therapeutic interventions with high-riskgroups (e.g., attempters,15 the elderly20)? If multilevel,layered interventions of varying intensities afford thebest protection, as suggested by Niederkrotenthalerand collegues,19 what is the optimal combination ofinterventions?The approach involved providing experts with several
information inputs as they considered optimal researchpathways.1 These inputs included examples of stake-holders’ ideas as to why a particular AG would helpreduce suicide attempts and deaths (including summariesof stakeholder feedback and verbatim suggestions); dataregarding what was known, or not known, about thescope (e.g., epidemiology or burden); and summaries ofthe current evidence and state of the science relevant totheir AG topic.This process often pushed experts to consider research
gaps (and AGs) outside their “comfort zones,” particu-larly in areas that would affect their estimates of thepublic health impact of their research focus. For example,
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Table 1. Aspirational goals and corresponding supplement manuscripts
Aspirationalgoal Aspirational goal topic Corresponding supplement manuscripts
1 Know what leads to, or protects against, suicidal behavior,and learn how to change those things to prevent suicide.
� Epigenetics and suicidal behavior researchpathways6
� Neurobiological risk factors for suicide: insightsfrom brain imaging7
2 Determine the degree of suicide risk (e.g., imminent, near-term, long-term) among individuals in diverse populationsand in diverse settings through feasible and effectivescreening and assessment approaches.
� Suicide risk screening and assessment: designinginstruments with dissemination in mind8
� Screening youth for suicide risk in medicalsettings: time to ask questions9
3 Find ways to assess who is at risk for attempting suicide inthe immediate future.
� Improving the short-term prediction of suicidalbehavior10
� Prognostic models to detect and monitor the near-term risk of suicide: state of the science11
4 Ensure that people who are thinking about suicide but havenot yet attempted receive interventions to prevent suicidalbehavior.
� Evidence-based psychotherapies for suicideprevention: future directions12
� Alcohol and suicidal behavior: what is known andwhat can be done?13
5 Find new biological treatments and better ways to useexisting treatments to prevent suicidal behavior.
� Existing and novel biologic therapeutics in suicideprevention14
6 Ensure that people who have attempted suicide can geteffective interventions to prevent further attempts.
� Evidence-based follow-up care for suicideprevention: where do we go from here?15
� Alcohol and suicidal behavior: What is known andwhat can be done?13
7 Ensure that healthcare providers and others in thecommunity are well trained in how to find and treat those atrisk.
� Advancing training to identify, intervene, and followup with individuals at risk for suicide throughresearch16
8 Ensure that people at risk for suicidal behavior can accessaffordable care that works, no matter where they are.
� National pathways for suicide prevention andhealth services research17
� Prioritizing research to reduce youth suicide andsuicidal behavior18
9 Ensure that people getting care for suicidal thoughts andbehaviors are followed throughout their treatment so they donot fall through the cracks.
� National pathways for suicide prevention andhealth services research17
� Prioritizing research to reduce youth suicide andsuicidal behavior18
10 Increase help-seeking and referrals for at-risk individuals bydecreasing stigma.
� Increasing help-seeking and referrals forindividuals at risk for suicide by decreasing stigma:the role of mass media19
11 Prevent the emergence of suicidal behavior by developingand delivering the most effective prevention programs tobuild resilience and reduce risk in broad-based populations.
� Suicide in later life: challenges and priorities forprevention20
� Developmental approach to prevent adolescentsuicides: Research pathways to efficaciousinterventions21
� Promising strategies for advancement inknowledge of suicide risk factors and suicideprevention22
12 Reduce access to lethal means that people use to attemptsuicide.
� Reducing a suicidal persons’ access to lethalmeans of suicide: a research agenda23
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experts who were asked about the benefits of providingeffective psychotherapy to prevent reattempts had to relyon estimates from longitudinal data of reattempt rates,which highlighted the need for better data regarding therate of reattempts in the U.S. Therefore, experts in
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psychotherapy might identify information on the trajec-tories of suicide attempters over time as a priority, inaddition to intervention research needs.A science has developed that helps identify such
research gaps: value of information (VOI) analysis is a
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strategy to inform priorities that can improve theeffectiveness of spending on health research.24 VOIprovides an analytic approach to establish the value ofacquiring additional information to inform a decisionabout how to approach a clinical problem. In the contextof the RPTF, an informal VOI-like approach helped theexperts identify gaps in knowledge and focus on essentialinformation needed in the U.S. to refine suicide researchprioritization that would contribute to the ultimategoal of reducing the number of suicide attempts anddeaths.
Future Directions to Advance SuicidePrevention ScienceSuicide has been a challenging and perplexing behaviorto study because suicidal behaviors are multideterminedand multifactorial, thus defying simple models of etiol-ogy and pathogenesis. As with the aforementionedAustralian review and research prioritization, the RPTFprocess and literature reviews highlight the fact thatmuch more is known about the general epidemiology ofsuicide and potential risk factors.Although the literature is replete with studies that
identify various correlates, much less is known aboutmutable risk factors that carry substantial variance andmight represent actionable intervention targets, and farless is known about effective strategies for preventingattempts and deaths. Despite the fact that, from a distance,the epidemiologic data suggest that we have made verylittle headway in significantly reducing the national suiciderate over the last 50 years, the research findings have beenaccumulating. The building blocks have been put in place:The critical factors have been identified and methodolo-gies to study the problems have been evolving.As part of the RPTF process, the NIH issued a “request
for information” (RFI) regarding key methodologicalroadblocks and potential new paradigms for suicideprevention science (Guide Notice: NOT-MH-12-017;see Action Alliance’s RPTF agenda, pp. 66–70, for adescription of the RFI process and responses). Across thepapers, many authors explicitly or implicitly suggestsimilar themes regarding challenges and barriers thatparallel the responses to the RFI.The authors also noted various strategies that might
help overcome barriers and facilitate progress, such asenhanced research infrastructure, including the develop-ment of a national cadre of well-trained researchers andclinicians with specialized expertise, to increase researchcapacity in the field; more timely, integrated regional andnational surveillance data systems, to allow for moreaccurate burden estimates and to track progress atreducing attempts and deaths; a uniform classification
system to describe suicidal phenomena paired withstandardized data collection,25 integration, and sharing(and application of emerging strategies for leveraging“big data”) to promote data sharing and meta-analyses;and utilization of new methodologies and analyticapproaches to facilitate study of low base rate events.Within and across the AGs, it is also evident that
translational science and interdisciplinary research col-laboration (“team science”) will be critical for advancingscience and ultimately identifying effective preventionstrategies. We believe that the time is now to stimulateand support creative, cross-cutting research on suicide. Acareful reading of these research summaries will confirmthat we are on the brink of breakthroughs in many areasand lines of research.One goal in publishing this supplement is to highlight
opportunities for researchers in the area of suicide andfor other talented scientists who have not yet appliedtheir skills and techniques to the study of suicidalbehaviors. As noted above, the papers in this serieshighlight the fact that progress will require interdisci-plinary, collaborative science; likewise, coordinated, col-laborative approaches to supporting research, involvingboth public and private partners, can effectively advancethe prevention of suicide through cross-cutting andinteractive research. The papers in this supplement, likethe RPTF agenda itself, are intended as inspirationalresources that highlight the challenges and rewards ofengaging in suicide prevention research, and suggestfuture research directions that have the potential toadvance the overall goal of reducing attempts and deaths.
Publication of this article was supported by the Centers forDisease Control and Prevention, the National Institutes ofHealth Office of Behavioral and Social Sciences, and theNational Institutes of Health Office of Disease Prevention.This support was provided as part of the National Institute ofMental Health-staffed Research Prioritization Task Force ofthe National Action Alliance for Suicide Prevention.The editor authors would like to acknowledge and thank
Maureen Iselin and Chelsea Booth, PhD for their thoughtfulassistance in editing, and efficient efforts at coordinating thereceipt and review of manuscripts for this supplement.No financial disclosures were reported by the authors of
this paper.
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