Promising Strategies for Advancement in Knowledge of Suicide Risk Factors and Prevention

https://doi.org/10.1016/j.amepre.2014.05.041Get rights and content

Suicide is an important public health problem. Although there have been advances in our knowledge of suicide, gaps remain in knowledge about suicide risk factors and prevention. Here, we discuss research pathways that have the potential to rapidly advance knowledge in suicide risk assessment and reduction of suicide deaths over the next decade. We provide a concise overview of the methodologic approaches that have the capacity to rapidly increase knowledge and change practice, which have been successful in past work in psychiatry and other areas of medicine. We suggest three specific pathways to advance knowledge of suicide risk factors and prevention. First, analysis of large-scale epidemiologic surveys and administrative data sets can advance the understanding of suicide. Second, given the low base rate of suicide, there is a need for networks/consortia of investigators in the field of suicide prevention. Such consortia have the capacity to analyze existing epidemiologic data sets, create multi-site cohort studies of high-risk groups to increase knowledge of biological and other risk factors, and create a platform for multi-site clinical trials. Third, partnerships with policymakers and researchers would facilitate careful scientific evaluation of policies and programs aimed at reducing suicide. Suicide intervention policies are often multifaceted, expensive, and rarely evaluated. Using quasi-experimental methods or sophisticated analytic strategies such as propensity score-matching techniques, the impact of large-scale interventions on suicide can be evaluated. Furthermore, such partnerships between policymakers and researchers can lead to the design and support of prospective RCTs (e.g., cluster randomized trials, stepped wedge designs, waiting list designs) in high-risk groups (e.g., people with a history of suicide attempts, multi-axial comorbidity, and offspring of people who have died by suicide). These research pathways could lead to rapid knowledge uptake between communities and have the strong potential to reduce suicide.

Introduction

Suicide is an important cause of death throughout the world.1 Suicide rates in the U.S. have increased rather than decreased in the last decade.2 There is an urgent need for research that rapidly advances knowledge and has rapid uptake by policymakers and clinicians to reduce suicide deaths.

One of the major challenges in advancing knowledge around suicide prevention is that deaths by suicide are relatively infrequent events. Although the gold standard test of an intervention is an RCT, conducting RCTs that are powered for detecting impact on suicides are expensive, difficult to coordinate, and require long periods of follow-up.3 Here, we discuss three key research pathways (analysis of existing data sets that include suicide variables, networks and consortia focused on suicide prevention, and researchers working with policymakers to address important questions related to suicide) that we believe can advance the field of suicide prevention in a manner that will reduce suicides over the next 10 years. To guide the current discussion, we list the well-established suicide risk factors4 and prevention strategies at the individual, family, and community levels (Table 1) and describe the limitations of the current knowledge in these areas.

Suicide is, fortunately, a relatively rare event. Unfortunately, this makes it hard to study for a variety of reasons.4 First, empirical data on optimal screening and prediction tools for suicide are lacking.5 Many suicide risk assessment tools (e.g., SAD PERSONS scale) have good sensitivity but poor positive predictive value in their ability to forecast future suicide attempts.5, 6

Second, there is a lack of understanding of suicide risk in vulnerable groups (e.g., military personnel, ethnic minorities, socially deprived individuals). For example, depending on the group studied, social markers such as income and marital status have been shown to be both suicide risk and protective factors.7, 8

Third, with the recent increase in use of social media, information is lacking on the impact of exposure to suicide in social media on suicide contagion. Fourth, although there has been an increase in prevalence of non-suicidal self-injury,9 the longitudinal course and risk for death by suicide among people with non-suicidal self-injury remains unknown. Fifth, most epidemiologic studies of suicidal ideation and attempts have been cross-sectional, may be affected by recall bias, and are not generalizable to death by suicide.

Although a wide range of suicide prevention strategies are suggested in guidelines worldwide (Table 1), it is important to underscore that most of the suicide prevention strategies, with the exception of means restriction policies,10 training of physicians in treating depression,11 and postcards after hospitalization for suicide attempts,12 lack strong empirical evidence for reducing suicidal behavior. There is, therefore, an urgent need to rigorously test promising suicide prevention strategies.

Owing to the low base rate phenomenon of suicide, extremely large sample sizes (thousands of people) often followed over relatively long periods of time are required to test whether interventions are effective. The most-cited studies in the field of suicide prevention to date are quasi-experimental designs in high-risk adult groups (e.g., Air Force personnel,13 regions of Hungary14) where improving/increasing gatekeeper training for suicide and treatment of depression by primary care physicians reduced suicide rates.

Furthermore, large-scale clinical trials for mental disorders often exclude people with a high risk of suicidal behavior. Thus, there is little information available from RCTs regarding effective interventions in high-risk adults. Even less data are available for optimal methods of intervention in culturally diverse groups.15 Finally, given the complex multifactorial and heterogeneous etiology of suicide, large-scale public health interventions may be expensive and typically have small effect sizes.16 In the context of limited funding for research, investigators often face significant obstacles in designing fundable studies.

Section snippets

Suggested Research Pathways

In order to advance knowledge of suicide risk factors and evaluate suicide prevention strategies, the following three main research pathways are suggested (Table 2).

Acknowledgments

Publication of this article was supported by the Centers for Disease Control and Prevention, the National Institutes of Health Office of Behavioral and Social Sciences, and the National Institutes of Health Office of Disease Prevention. This support was provided as part of the National Institute of Mental Health-staffed Research Prioritization Task Force of the National Action Alliance for Suicide Prevention.

Preparation of this article was supported by a Canadian Institutes of Health Research

References (34)

  • E. Agerbo

    High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients

    Arch Gen Psychiatry

    (2007)
  • K. Hawton et al.

    Suicide and deliberate self-harm in Oxford University students over a 30-year period

    Soc Psychiatry Psychiatr Epidemiol

    (2012)
  • W. Rutz et al.

    Frequency of suicide on Gotland after systematic postgraduate education of general practitioners

    Acta Psychiatr Scand

    (1989)
  • G.L. Carter et al.

    Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning

    BMJ

    (2005)
  • K.L. Knox et al.

    Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force: cohort study

    BMJ

    (2003)
  • K. Szanto et al.

    A suicide prevention program in a region with a very high suicide rate

    Arch Gen Psychiatry

    (2007)
  • L.Y. Katz et al.

    Aboriginal suicidal behaviour research: from risk factors to culturally-sensitive interventions

    J Can Acad Child Adolesc Psychiatry

    (2006)
  • Cited by (36)

    • Does social support prevent suicidal ideation in women and men? Gender-sensitive analyses of an important protective factor within prospective community cohorts

      2022, Journal of Affective Disorders
      Citation Excerpt :

      While a strength of our study refers to the large overall sample size and the combined investigation of cohorts from two different German regions that also differ with respect to social, cultural and economic factors, we need to point out that the number of people reporting suicidal ideation in the SHIP study was small, especially for men. A widespread difficulty in suicide research is that suicidal ideation and behavior are comparatively rare events in the population (with suicidal ideation still much more common than suicide attempts or deaths (Turecki and Brent, 2016)), while some risk factors concern many citizens (e.g., male gender) (Sareen et al., 2014). In the current study, we also observed low numbers of individuals reporting suicidal ideation.

    • Suicide in psychiatric disorders: rates, risk factors, and therapeutics

      2020, Ketamine for Treatment-Resistant Depression: Neurobiology and Applications
    • Comparison of familial and non-familial suicidal behaviors among people with major depressive disorder: Testing the discriminative predicting role of high-yield clinical variables

      2018, Journal of Psychiatric Research
      Citation Excerpt :

      Assessment of suicide risk in patients with major depressive disorder (MDD) is one of the most challenging and important tasks for the clinician. Despite intensive research ranging from clinical epidemiological, psychosocial (Gonda et al., 2007; Mann et al., 2005; Miret et al., 2013; Owens et al., 2014; Rihmer et al., 2004; Sareen et al., 2014) and neurobiological (Guilloux et al., 2015; Mann and Currier, 2012; Mann et al., 2006; Mullins et al., 2014) studies, suicidal behavior is difficult to predict in an individual patient, even among high-risk out- or inpatients with a previous history of attempt (Goldstein et al., 1991; Malone et al., 1995; Oquendo et al., 2004; Pokorny, 1983). Familial risk for suicidal behavior, especially first degree relatives with (FDR+) a history of suicide or attempt, represents a putative clinical predictor of suicidal behavior in both general population (Rihmer et al., 2013; Torzsa et al., 2009) and clinical (Lizardi, D. et al., 2009; Serretti et al., 2013) settings.

    • Latent classes of childhood poly-victimization and associations with suicidal behavior among adult trauma victims: Moderating role of anger

      2016, Child Abuse and Neglect
      Citation Excerpt :

      However, some victims of childhood maltreatment may be more at risk of suicidal behavior than others. A large range of familial and community level factors (e.g., substance use by parents, access to guns) and individual factors (e.g., shame proneness, personality traits) play important roles in identifying individuals who go on have suicidal behavior (cf. Sareen et al., 2014). The identification of such impelling factors in addition to experiences of childhood victimization facilitates understanding of the role of risk factors leading up to suicidal behavior, and in turn would aid the formulation of clinical interventions.

    View all citing articles on Scopus
    View full text