National Institutes of Health Pathways to Prevention Workshop: Advancing Research to Prevent Youth Suicide
Venue: Annals of Internal Medicine

Suicide is the second leading cause of death in youth (aged 10 to 24 years) and young adults (aged 25 to 34 years) and has claimed the lives of 12073 persons in these age brackets in 2014 (1) Many risk factors (for example, depression, mental disorders, substance abuse, prior suicide attempts, family history of suicide, family violence, exposure to suicidal behavior, or incarceration) precipitating events (such as shame, loss, or relationship disruption) and environmental circumstances (for example, access to lethal means) contribute to suicidal behavior. Although prevention is daunting, the obstacles created by the complex factors involved in suicide are surmountable. New coordinated research strategies that embrace this complexity are necessary. To address these issues, the National Institutes of Health (NIH) convened the Pathways to Prevention Workshop Advancing Research to Prevent Youth Suicide in March 2016. The overarching goal of the workshop was to summarize youth suicide prevention efforts. The workshop was cosponsored by the NIH Office of Disease Prevention, National Institute of Mental Health, National Institute on Drug Abuse, and National Center for Complementary and Integrative Health. A multidisciplinary working group developed the agenda, and an Evidence based Practice Center prepared an evidence report that addressed data systems relevant to suicide prevention efforts through a contract with the Agency for Healthcare Research and Quality. During the workshop, experts discussed the evidence and participants commented during open forums. After considering the evidence report, expert presentations, and public comments, an independent panel prepared a draft report that was posted on the NIH Office of Disease Prevention Web site for 5 weeks for public comment. This abridged version of the final report (https:/prevention.nih.gov/programs events/pathways to prevention/workshops/binders/2016/suicide prevention/workshop resources) highlights strategies for guiding future research on youth suicide. These strategies include recommendations for improving data systems, enhancing data collection and analysis methods, and strengthening the research and practice community. Improving Data Systems Table 1 shows recommendations for improving data systems that focus on better identifying persons at risk for suicide and advancing knowledge of risk factors. The availability of effective data systems for examining risk and outcomes is limited. For example, the accompanying systematic evidence review (2) identified only 6 of the 153 suicide prevention studies that linked suicide data from multiple sources, which limited researchers' capacity to study determinants, mediators, and moderators of suicidal behaviors and suicides. Poor documentation of interventions (for example, scarcity of usable data dictionaries and comprehensive clinical records) compounds the problem of inadequate data systems. The lack of comprehensive linked data resources makes it difficult to identify at risk persons. Table 1. Recommendations for Enhancing Data Systems to Improve the Ability to Identify Persons at Risk for Suicide Because not all states mandate use of cause of injury codes, the ability to understand the magnitude of suicide, suicide attempts, and risk factors of suicide is hampered when they are not used by medical departments or on insurance claims. Obtaining a complete picture of suicide and related factors would require federal mandates for health care providers to use cause of injury codes. Improved standardization and consistent use of such codes would enable researchers to conduct more accurate studies of suicide risk and prevention. Without additional mandatory coding, it is not possible to determine whether the death was a homicide, suicide, or accident. Implementing mandatory external cause of injury coding would enable public health officials and prevention science researchers to capitalize on these data to identify means of suicide. This recommendation is paramount because nearly half of reported suicides involve firearms as the means. Additional surveillance on suicides is paramount to obtain a complete picture. The National Violent Death Reporting System provides an example of a surveillance system that could yield insights into the causes of and context for suicides by linking data from death certificates, law enforcement reports, crime laboratories, and medical examiner reports. These data are not available in all states, and the reporting only addresses deaths from suicide. However, surveillance systems should be expanded to capture suicide attempts and related behaviors. Linking surveillance and administrative data should be encouraged because it would better inform suicide risk and behaviors that could lead to suicide. Researchers need training to identify and obtain permission to use data sources found in school, municipal, state, and federal records (for example, to make sure consent forms explicitly ask permission to link with other data sources) Policies at the state and community levels share a role in improving our ability to understand suicide and suicide attempts. State all payer claims databases could provide communities with local data about suicide and suicide attempts. Under the Patient Protection and Affordable Care Act, accountable care organizations or health information exchanges could provide local communities with population data. Claims databases can be cumbersome, require extensive cleaning and specialized expertise to analyze, and are not always timely. Some of these limitations can be addressed through coordinated efforts at the state level. By improving these systems, states have the opportunity to be innovative with syndromic surveillance data, which could be used to identify patients who need better care management or to help target community level interventions. Some policy and practice issues are difficult to rectify because of social stigma, governance, conflicting legal goals, a fragmented death scene investigation system, silos of isolated research teams, and unique data systems. Until suicide and mental health issues are destigmatized, reporting will be inaccurate. Reporting and tracking suicidal behavior and its precursors are hampered by disincentives embedded in policies and practices from the federal to the local level. Families and medical providers are often reluctant to label events as suicides or suicide attempts for many reasons, including legal concerns, cultural issues, community referral patterns, and the lack of standard procedures for investigating suicide death scenes. Improving Research Design and Analysis Table 2 depicts the panel's recommendations for improving research design and analysis of complex systems. Descriptions of several innovative and promising techniques follow. Table 2. Recommendations for Improving Design and Analysis Conduct measurement at multiple levels. Measurement is an especially ripe area for improving data systems in suicide prevention research. Measuring risk and protective processes at several levelsincluding the individual, family, peer group, school, and communityfacilitates the process of investigating and understanding the complex factors central to suicide risk across diverse populations. At the lowest level, information on biomarkers and biological processes is important for advancing the continuum of suicide research, from surveillance to basic research and then prevention studies. Novel ways of integrating neurobiological measures into the science of suicide prevention research are needed. Schools could collect electronic data on student head injuries, for example, and link these to school and health records to help identify youth at increased risk for suicide. Biological measures may improve the effectiveness of evaluation research. Evidence for the protective effects of mindfulness and meditation practices would be strengthened by including biological measures, such as cortisol. Incorporating these measures into studies of suicide risk and prevention will help identify potential treatment approaches for ameliorating the adverse effects that trauma and stress have on youth suicide risk. Psychological and developmental processes also play key roles in suicide risk and prevention. Workshop participants noted the need for psychometric work addressing the measurement of personal characteristics, such as sexual orientation and identity, and for processes displaying universal prominence and culture and context specific importance across diverse populations. Rather than adapting existing measures to new cultural contexts, direct development of theoretically informed measures for a given cultural context is warranted. For persons identifying as sexual and gender minorities, measures of peer and self behaviors and attitudes salient to gender identity and sexual orientation can help to better identify the correlates of suicide risk. Research indicates higher rates of suicide among transgender youth than gay or lesbian youth. General methodological improvements in measurement, such as visual analogue scales, computerized adaptive testing, and multiform questionnaire protocols to collect data, would increase the generalizability of findings. Perhaps the least extensively investigated domain concerns measuring the settings and contexts beyond the individual and family levels. Ecometrics, the measurement of environmental contexts, is essential to accommodate the multilevel analytic approaches needed for this field of research. Innovation in this area includes direct assessment of constructs, such as climate and aggregate indicators that can come from linkable administrative data (for example, police records) Assess developmental and longitudinal change. Despite the importance of dynamic change processes in youth suicidal behavior, few studies have addressed how changes and reciprocal influences among risk and protective factors influenc