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Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington (DC): US Department of Health & Human Services (US); 2012 Sep.

Cover of 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action

2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention.

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Strategic Direction 4: Surveillance, Research, and Evaluation

The National Strategy’s fourth strategic direction addresses suicide prevention surveillance, research, and evaluation activities, which are closely linked to the goals and objectives in the other three areas. Public health surveillance refers to the ongoing, systematic collection, analysis, interpretation, and timely use of data for public health action to reduce morbidity and mortality. In contrast, research and evaluation are activities that assess the effectiveness of particular interventions, thereby adding to the knowledge base in the area of suicide prevention.

The past decade has seen substantial improvements in suicide-related surveillance, research, and evaluation. However, additional efforts are needed to inform and guide suicide prevention efforts nationwide. The collection and integration of surveillance data should be expanded and improved. In addition, although some evidence is available regarding the effectiveness of particular interventions and approaches, there is a need to assess the effectiveness of new and promising practices.

Goal 11. Increase the timeliness and usefulness of national surveillance systems relevant to suicide prevention and improve the ability to collect, analyze, and use this information for action

The regular collection and rapid dissemination of suicide-related data are needed to guide appropriate public health action. The time between when an event takes place and when the data are ready for dissemination must be shortened. This is no simple task, as it involves collecting information on several behaviors (e.g., suicidal thoughts, attempts, deaths) that may be available at many levels (e.g., local, state, national). The information may come from several different sources, including vital statistics, EDs, inpatient hospital records, and urgent care centers, and may not be linked. In addition, there are continuing concerns and constraints regarding the accumulation of potentially identifiable data.

Examples of existing nationally representative data sources containing information regarding suicidal behaviors include:

It is important to strengthen systems and to improve the quality of the data collected for surveillance purposes. It is equally necessary to enhance the ability of jurisdictions to use available information for strategic planning aimed at preventing suicidal behaviors.

Objective 11.1. Improve the timeliness of reporting vital records data

Timeliness of reporting of national statistics on suicide mortality is a core issue. Although several states are able to rapidly provide information about suicide-related deaths, many others experience delays certifying and reporting these deaths. As a result, there is a two-year gap between the close of the calendar year and when the national data for that year become available. For example, data for 2009—the most recent final data available—were released in December of 2011. This makes it difficult to know when national suicide rates climb as a result of contextual factors, such as an economic crisis, as well as to plan interventions or to know if suicide prevention efforts are having an effect in reducing deaths by suicide. Efforts should be made to gradually reduce this gap with an ultimate target of 12 months.

Objective 11.2. Improve the usefulness and quality of suicide-related data

Consistent suicide-related data can help public health practitioners better understand the scope of the problem, identify high-risk groups, and monitor the effects of suicide prevention programs. However, existing data regarding suicide and suicidal behavior continue to have many limitations. Deaths from suicide may be misclassified as homicides, accidents, or even as death from natural causes. Information available from death certificates is limited and provides an incomplete picture of the risk factors for suicide. For example, death data regarding sexual orientation and gender identity are generally not collected, so it is not possible to calculate a reliable suicide rate for LGBT people.

Death scene investigations can reveal important information about the circumstances of a suicide and its method. This information can be used to improve understanding of suicide and enhance prevention efforts. Emergency medical technicians, police, medical examiners, and coroners may all contribute to the collection of these data. There is a need to improve the quality and accuracy of death scene investigations by providing training to these responders.

Data on fatal and nonfatal self-directed violence often are not standardized. To address this issue, in 2011, CDC published the report Self-Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements.108 The definitions and data elements were developed in collaboration with the VA and have been adopted by the Department of Defense.

Lack of external cause-of-injury coding in administrative datasets (e.g., ED, hospital discharge) greatly reduces the utility of these datasets. The CDC has developed an action agenda for improving external cause coding that could be a useful framework for addressing this issue within these administrative datasets.109

Efforts to link and analyze information coming from separate data systems, such as law enforcement, emergency medical services, and hospitals, are also needed. Such linked data can provide much more comprehensive information about an event, its circumstances, the occurrence and severity of injury, the type and cost of treatment received, and the outcome in terms of both morbidity and mortality.

Objective 11.3. Improve and expand state/territorial, tribal, and local public health capacity to routinely collect, analyze, report, and use suicide-related data to implement prevention efforts and inform policy decisions

The surveillance of suicidal behaviors and related issues (e.g., mental and substance use disorders) has improved over the years, but additional advances are needed. In particular, there is a need to increase the number of states and territories that are funded to integrate data sets as a part of NVDRS and to improve relevant data sets and facilitate access to them. In addition, staff members in states/territories, tribes, and local governments require training on how to analyze and interpret data for policy and prevention purposes.

Although national data provide an overall view of the problem, local data are key to effective prevention efforts. State/territorial, tribal, and local suicide rates vary considerably from national rates. There is a need to promote the development of local reports on suicide and suicide attempts, and to integrate data from multiple data management systems. These reports should describe the magnitude of the suicide problem and how suicide differentially affects particular groups. In addition, the reports should also address the use of mental health and substance use services. These publications would be useful in tracking trends in suicide rates over time, identifying changes in groups at risk and methods used, and evaluating suicide prevention efforts. At the local level, they could serve as a resource for developing timely and targeted interventions to prevent suicidal behaviors. State epidemiologists and suicide prevention coordinators could play an important role in supporting and providing assistance for these local efforts.

Objective 11.4. Increase the number of nationally representative surveys and other data collection instruments that include questions on suicidal behaviors, related risk factors, and exposure to suicide

Existing sources of data on suicidal behaviors underestimate the burden that suicide-related problems place on our society. There is a need to increase the number of nationally representative surveys and other data collection instruments that include questions on suicidal behaviors and related risk and protective factors. Questions about suicide attempts should identify the person’s age at the time of the attempt and whether medical attention was required. Data collection tools also should include questions that better identify vulnerable populations, such as items addressing sexual orientation and gender identity.

Exposure to suicide, particularly of someone emotionally close to the bereaved, can increase the risk for depression, complicated grief and trauma reactions, and suicide. Yet little is known about the number of people who have been exposed to suicide and about those who have been adversely affected by that exposure. Nationally representative surveys and other data collection instruments and systems should include questions on exposure to suicide and its links with suicidal thoughts and behaviors, mental and substance use disorders, and violence. Obtaining this data would help greatly in planning support services for those who have been bereaved by suicide.

There also is a need to collect suicide data on deaths among those who are currently receiving active inpatient or outpatient care (e.g., outpatient mental health care, inpatient cancer treatment). Although these events may be particularly amenable to prevention, there is currently no national system that can provide this information.

Goal 12. Promote and support research on suicide prevention

Research on suicide prevention, and on the treatment of mental and substance use disorders, has increased considerably during the past 20 years. Findings have contributed to the development of assessment tools, resiliency-building interventions, and treatment and symptom-monitoring techniques. Continued advancements will lead to the development of better assessment tools, treatments, and preventive interventions. It also will lead to more effective and efficient therapeutic interventions for individuals who engage in suicidal behaviors.

Objective 12.1. Develop a national suicide prevention research agenda with comprehensive input from multiple stakeholders

Everyone has a stake in the development and implementation of a national suicide research agenda that can ultimately be measured in terms of knowledge gained and measurable declines in suicide attempts and deaths. This agenda should build on existing knowledge of suicide prevention and surveillance findings to identify priority research areas. Topics could include: groups with increased suicide risk, gender and ethnic differences, social and economic factors, genetic contributions, protective factors, promising interventions for suicide prevention and treatment, and interventions for individuals who have been affected by suicide.

The Research Prioritization Task Force, launched under the Action Alliance, has developed a prioritization process that includes a stakeholder survey, portfolio analyses, and input by experts. The research summaries published in the 2002 IOM report Reducing Suicide: A National Imperative9 can serve as a starting point for updating the state of the science and research infrastructure needs.

Objective 12.2. Disseminate the national suicide prevention research agenda

After the research agenda is developed, it should be disseminated to researchers and program planners at the local, regional, and national levels, so that it can inform the development of new suicide prevention interventions and programs. The research agenda will also be useful to the various groups that fund suicide prevention research in identifying knowledge gaps and areas of need.

As part of the prioritization process discussed in Objective 12.1, an inventory of currently funded suicide research will be created. Funders, both public and private, will be asked to provide annual updates of currently funded research to a web-based system that can be inventoried and queried. This effort will help facilitate funding coordination and serve as a way to disseminate to funders and program planners information on research that is currently in progress.

Moving forward, the research agenda should be updated on a regular basis, with input from its various users, to ensure that it remains relevant. Expanded surveillance efforts, discussed under Goal 11, will help enhance the ability of researchers and program planners to develop and evaluate interventions targeting specific groups. Updating the agenda to address new questions posed by program planners, agencies, and organizations will help ensure that it remains a living document that helps save lives.

Objective 12.3. Promote the timely dissemination of suicide prevention research findings

Emerging suicide prevention research findings must be translated into recommendations and suggestions for practical application in multiple settings. Researchers should be encouraged to publish their findings so that practitioners can incorporate them into the development of new interventions targeting particular groups. There is also a need to disseminate these findings more widely via communication efforts targeting specific groups, such as health care providers, public health officials, providers of aging services, school officials, and others.

Objective 12.4. Develop and support a repository of research resources to help increase the amount and quality of research on suicide prevention and care in the aftermath of suicidal behaviors

Conducting research on suicide prevention involves many challenges. Although the absolute number of suicides in a population may be cumulatively quite large, the risk of suicide to any given individual, even those with multiple risk factors, is relatively small. Suicide is a relatively rare outcome, which makes it difficult to conduct randomized controlled trials (RCTs) that evaluate the impact of an intervention in preventing suicide.

Researchers would benefit from information on the most appropriate research designs for rare events, and on appropriate outcomes that are suitable to answer well-defined research questions. Although RCTs are expensive, they could be done more economically by including only patients with high suicide risk, such as individuals who have recently attempted suicide. Suicide attempts, particularly medically serious suicide attempts, may serve as a sufficiently powerful proxy (i.e., substitute) measure to address some specific research questions.

A national repository of research methods would be a useful resource for suicide prevention researchers. The repository could include a link to national databases (e.g., CDC, national, state/territorial, tribal, and local) that can be used as research tools. Other contents could include information on appropriate and rigorous study designs, common measures that should be used in research studies, successful implementation efforts and adaptations, and safety and ethical considerations.

Goal 13. Evaluate the impact and effectiveness of suicide prevention interventions and systems and synthesize and disseminate findings

Program evaluation is a driving force for planning effective suicide prevention strategies, improving existing programs, informing and supporting policy, and demonstrating the results of resource investments. Suicide prevention interventions should be guided by specific testable hypotheses and implemented among groups of sufficient size to yield reliable results. Given the state of the field, program evaluations should emphasize measurable behavioral outcomes, in addition to other outcomes (e.g., changes in knowledge or attitudes) and process measures (e.g., number of people attending program sessions).

Programs that share risk factors with suicide should be encouraged to incorporate suicide prevention components and related measures in their program design and evaluation plans. For example, suicide shares risk and protective factors with other forms of violence, including interpersonal violence among youth. These factors include problem-solving and coping skills and characteristics of school and community environments, such as bullying, intolerance, and prejudice.128 Violence prevention approaches that address these types of shared factors, such as by promoting coping skills and family functioning, are likely to also contribute to suicide prevention. The evaluation of these interventions should incorporate suicide-related outcome measures as a way of assessing the potential effect of such programs on preventing suicidal behaviors.

Objective 13.1. Evaluate the effectiveness of suicide prevention interventions

A broad range of interventions can be used for suicide prevention. Examples include: education and awareness programs, life skills development, the use of media reporting guidelines for suicide, school-based and other community programs, clinical provider training, screening for individuals at high risk, the use of crisis lines, medications, psychotherapy, and followup care for suicide attempts.72, 73, 110 Program evaluations and other studies must evaluate the effectiveness of these interventions and their impact on the prevention of suicide attempts and deaths. In particular, there is a need to implement and evaluate the effectiveness of interventions for individuals who have been bereaved by suicide, as few studies have focused specifically on this population.

Objective 13.2. Assess, synthesize, and disseminate the evidence in support of suicide prevention interventions

Although the number of evaluated suicide prevention programs has increased over the years, findings from individual studies must be assessed and synthesized in order to understand the strength of the evidence in support of particular interventions. Systematic reviews serve an important role in the assessment and synthesis of research findings. These reviews can help identify effective interventions and provide recommendations for future programs and research.

Findings from a review of studies conducted in the United States and abroad suggest that interventions can be effective for preventing suicide including for example, physician education and the training of gatekeepers in institutional settings (e.g., the U.S. Air Force).72 Another umbrella review examined findings from six systematic reviews of multilevel suicide prevention interventions.73 These interventions were defined as having multiple components and targeting different populations or several levels within a health care system and/or having more than one area of focus, such as combining medications with psychotherapy. The review found support for physician education and means restriction and improving access to care for individuals with suicide risk.

Although the umbrella review focused on interventions delivered in health care systems, multilevel suicide prevention interventions can also be conducted in other settings. As an example, a multilevel intervention could combine the following components: building life skills among high school students, training school staff as gatekeepers, ensuring the school has appropriate crisis protocols and has strong links to community referral resources, and other activities conducted in the community. These activities could include promoting the Lifeline (800–273–TALK/8255) to the general public and distributing gunlocks.

More research is needed to better understand the strength of the evidence in support of suicide prevention interventions. After findings are synthesized, they should be disseminated to promote the broader implementation of the specific types of interventions that have been found to be effective in preventing suicide.

Objective 13.3. Examine how suicide prevention efforts are implemented in different states, territories, tribes, and communities to identify the types of delivery structures that may be most efficient and effective

Suicide prevention efforts are implemented differently across states/territories, tribes, and local communities. There is a need to evaluate the delivery structure of suicide prevention systems to identify these differences, and to assess the effectiveness of different system designs for the delivery of suicide prevention services. Findings from these assessments could be used to generate recommendations regarding the types of delivery structures that appear to be most efficient and effective.

Objective 13.4. Evaluate the impact and effectiveness of the National Strategy for Suicide Prevention in reducing suicide morbidity and mortality

The National Strategy represents a comprehensive, long-term approach to suicide prevention. As discussed in the Introduction section (under “Looking Ahead”), the goals and objectives are broad in scope and encompass a wide range of activities.

The National Strategy represents a roadmap that, when followed, will lead to the vision of a nation free from the tragic experience of suicide. Different groups (e.g., associations, government agencies, educational institutions, health systems) may find it useful to review the goals and objectives in the National Strategy and identify their own priority areas for action.

As an example, the Action Alliance has identified four priority areas for 2012–14 and will monitor progress toward their achievement. Several considerations helped guide the development of this action agenda, including the potential impact on suicide-related morbidity and mortality and the availability of organizations, agencies, or other groups that may be willing to take on different roles in implementing activities and evaluating progress.

What You Can Do to Advance the Goals and Objectives in Strategic Direction 4 of the National Strategy for Suicide Prevention

The Federal Government Can

State, Territorial, Tribal, and Local Governments Can

  • Analyze and identify strategies to increase the efficiency of state-based processes for certifying, amending, and reporting vital records related to suicide deaths. (Objective 11.1)
  • Implement CDC’s action plan for improving external cause of injury coding. (Objectives 11.2 and 11.3)
  • Adopt recommended self-directed violence uniform definitions and data elements developed by CDC and VA. (Objective 11.2)
  • Improve data linkage across agencies and organizations, including hospitals, psychiatric and other medical institutions, and police departments, to better capture information on suicide attempts. (Objective 11.2)

Businesses and Employers Can

Health Care Systems, Insurers, and Clinicians Can

  • Implement the recommendations for health care providers in CDC’s action plan for improving external cause of injury coding within administrative data, such as emergency department and hospital discharge systems. (Objective 11.2)
  • Routinely document suicide-related information (e.g., alcohol use, drug use, description of intent) in emergency department charts. (Objective 11.2)
  • Initiate continuous quality improvement studies to determine the effectiveness of policies and procedures intended to rapidly connect individuals at risk for suicide with services. (Objective 13.1)

Schools, Colleges, and Universities Can

  • Conduct research to identify new, effective policy and program interventions to reduce suicide and suicidal behavior. (Objective 12.1)
  • Share suicide-related research findings with state and local suicide prevention coalitions, health care providers, and other relevant practitioners. (Objective 12.3)

Nonprofit, Community-, and Faith-Based Organizations Can

Individuals and Families Can

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