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National Strategy for Suicide Prevention [Internet]. Washington (DC): US Department of Health and Human Services; 2024.
Strategic Direction 3 focuses on enhancing data on suicide thoughts, attempts, deaths, and risk and protective factors, as well as promoting rigorous research.
Surveillance of health outcomes and associated factors allows us to do the following:
Quality improvement in surveillance data is needed to better capture the diversity and needs of the population; enhance the completeness and consistency of data collection; and further accessibility, useability, and timeliness. Good quality data enable suicide prevention evaluation and are important for applying research advances to improve prevention practices, and ultimately, to reduce the impact of suicide. Implementing a prioritized and robust research agenda allows for building of the evidence base on what contributes to suicide risk and what can be done to prevent suicide.
The goals of Strategic Direction 3 provide guidance on continued enhancements and necessary innovations in these areas. Goal 10 emphasizes the importance of improving data relevant to suicide prevention for public health surveillance, research, evaluation, and quality improvement. The focus is on improving the quality, timeliness, scope, usefulness, and accessibility of data on suicide thoughts, attempts, and deaths. It also addresses the need for better data to understand the contributors to suicide and the context in which these suicide outcomes may occur. This includes using diverse data sources (containing health outcomes, known risk and protective factors, or other data) and applying emerging technologies and methods to extract information from these data. This goal promotes a comprehensive understanding of suicide thoughts and attempts and potential trajectories of risk, and it provides the metrics to assess the effectiveness of prevention strategies.
Goal 10 emphasizes the benefits of collaboration among public and private partners (e.g., health systems and academic centers). Collaborations are also an important component in establishing agreements for accessibility and stewardship of tribal-owned data. Tribal nations’ inherent sovereign authority to administer the collection, ownership, and application of their own data is rooted in a tribal nation’s right to govern their people. Effective collaborations with tribal nations around data sharing will be founded on the tribe’s rights and through partnerships with tribal leadership. The core purpose of all data collected in tribes is to benefit their citizens.
Goal 11 focuses on promoting and supporting suicide prevention research. These research priorities will build upon what we know about the complexities of suicide and effective prevention strategies. A significant aspect of this goal is the inclusion of diverse settings such as tribal communities and populations (e.g., middle-aged males), in research. Inclusion of individuals receiving or delivering interventions (e.g., providers, individuals with lived experience, family members) in addressing factors that impede or enhance delivery of evidence-based suicide prevention programs and practices is important for implementation. This goal also explores the technology’s role in mental health and suicide risk, particularly among youth.
Quality, timely, and actionable data about suicide thoughts, attempts, and deaths, and related risk and protective factors are essential to successful prevention efforts. Public health leaders rely on data collected and reported through multiple systems to help prioritize investment, track progress, build the evidence base, and guide quality improvement efforts. While there have been notable advances in the field related to the accessibility and timeliness of suicide-related data, more work is needed to improve timeliness without sacrificing data quality. Ongoing efforts to modernize data system infrastructure and better connect data systems and sources can do the following:
Improvements in analytic tools and methodology can help maximize the benefits of data extracted from various sources. Incorporating new methods and diverse data sources enhances capabilities for translating data for decision-making.
The National Action Alliance for Suicide Prevention established the Data and Surveillance Task Force to help improve and expand the information available about suicidal thoughts, attempts, and deaths. The task force issued recommendations for improving national data systems for suicide surveillance, for enhancing or expanding existing systems, and for improving the quality, timeliness, usefulness, and accessibility of data on suicidal thoughts, attempts, and deaths. The 2014 publication reviewed 28 national data systems for feasibility of use in the surveillance of suicidal thoughts, attempts, and deaths. The review included data systems capturing the full continuum of suicide risk (e.g., thoughts, attempts, deaths); how the data are collected (e.g., census, sample, survey, administrative data files, self-report, reporting by care providers); and the strengths and limitations of the survey or data system. The task force also made the following recommendations to improve data and surveillance efforts in the United States:
Progress has been made on several of these recommendations:
Data on Suicide Deaths. Suicide mortality data in the United States are derived from death certificates and captured in CDC’s National Vital Statistics System (NVSS). Suicides may be tracked over time to observe trends and changes in overall suicide rates or by sex, race, ethnicity, geography, age, and means of suicide, among other factors. In the past, suicide mortality data lagged by several years which created a barrier for suicide prevention planning. The lag time is now significantly reduced, and provisional mortality data are available within about six months. Final and provisional data are available at https://wonder.cdc.gov/, and https://www.cdc.gov/injury/wisqars/index.html . The CDC’s National Center for Health Statistics provides access to provisional mortality tables, chart, and reports as part of its Vital Statistics Rapid Release program.
In addition to NVSS, CDC’s National Violent Death Reporting System (NVDRS), a state-based surveillance system, captures information on suicide—including the who, when, where, and how—from death certificates, the coroner, the medical examiner, and law enforcement reports. Data from states are compiled into an anonymized database for analysis. Since the 2012 National Strategy for Suicide Prevention, the NVDRS expanded from 16 states to all 50 states, the District of Columbia, and Puerto Rico. For more information, visit https://www.cdc.gov/violenceprevention/datasources/nvdrs/ .
Despite positive changes, data challenges remain. Delays in reporting suicide mortality to the public continue. In part, this is due to the need to conduct death investigations to determine if a death was self-inflicted, and if it was, whether it was intentional (i.e., suicide) or unintentional. Suicide rates have long been underestimated (Snowdon & Choi, 2020) given the following reasons:
These and other factors may lead to misclassification of suicide outcomes, and the impact has been found to vary across race, ethnicity, sex, and method of death (e.g., Ali et al., 2021; Huguet et al., 2012). Efforts are underway to improve practices and policies related to death scene investigations and manner of death determinations. See https://www.cdc.gov/nchs/comec/index.htm .
Additional improvements are needed in suicide data collection to reduce racial and ethnic misclassification (Arias et al., 2016; Jim et al., 2014) and to capture information on sexual orientation, gender identity, and Veteran status to better quantify the impact in these groups. Fortunately, federal activities are currently underway to modernize standards for data collection on race and ethnicity. For more information, see Initial Proposals for Revising the Federal Race and Ethnicity Standards and recommendations for advancing the collection of sexual orientation and gender identity at time of death (see Haas et al., 2019).
Incomplete External Cause of Injury Coding in Health Care Systems. Knowing if and when individuals attempt suicide is fundamental for suicide prevention efforts in health care settings. About half of U.S. states require documentation of “external cause” for emergency care and hospitalizations involving injury. External cause signifies whether the injury was intentional self-harm, unintentional, due to assault, legal intervention/war, or undetermined. Recent analyses using data from the Agency for Healthcare Research and Quality’s (AHRQ’s) Healthcare Cost and Utilization Project documented considerable variation in the rate of missing external cause codes among ED visits and hospitalizations involving injury. This is associated with documentation mandates (AHRQ, 2021a and 2021b). Documentation of external cause for all health care events involving injury is essential for appropriate patient care, clinical quality improvement, and public health surveillance.
What’s Being Done? The 2021 Surgeon General’s Call to Action to Implement the National Strategy for Suicide Prevention highlighted the need for complete external cause of injury. It is also mentioned in Priority 4 of the Action Alliance’s An Action Plan to Strengthen Mental Health and the Prevention of Suicide in the Aftermath of COVID-19. The National Institute of Mental Health (NIMH) is committed to working with federal partners to explore and pursue any potentially viable path to complete documentation of external cause of injury in health care data.
Data on Suicide Thoughts, Behaviors, and Risk and Protective Factors. The landscape of data sources for suicidal thoughts, attempts, and associated risk and protective factors is wider ranging than for suicide deaths. These data come from population-based surveys, administrative databases, other contextual sources, and near real-time emergency department (ED) data.
Two major population surveys that provide annual or biennial information on suicide risk include SAMHSA’s National Survey on Drug Use and Health (NSDUH) and CDC’s Youth Risk Behavior Surveillance System (YRBSS).
Both NSDUH and YRBSS collect data at the national level. This provides a snapshot of what is happening across the country and a comparison for state or local data when available. State-level estimates are available for NSDUH, and YBRSS data are available for most states, some territories, some local school districts, and some tribal governments.
Another population-based survey is CDC’s Behavioral Risk Factor Surveillance System (BRFSS). It collects data on adult U.S. residents in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and Palau. The BRFSS questionnaire includes a core component asked by all states, optional modules that states may choose to use, and state-added questions. Data are available at the national and state levels, while some data are available for geographic subdivisions within states (https://www.cdc.gov/brfss/). The BRFSS does not include a direct question about suicide risk, but it does include several items related to mental health, health care access, substance use, and adverse childhood experiences (ACEs), as well as other related topics, as part of the core component or a module. The ACEs module includes a question that asks whether the respondent ever lived with someone “who was depressed, mentally ill, or suicidal.”
Additional databases are available through AHRQ’s Healthcare Cost and Utilization Project (HCUP). Currently, the availability of nationwide databases may lag up to two years, while the majority of state databases are typically available within one year. AHRQ provides information from health care systems related to nonfatal suicidal behavior and treatment and in-hospital deaths.
One important advance since 2012, is the use of syndromic surveillance to track and monitor ED visits for instances of suicide thoughts and attempts in near real time (i.e., within 24 hours of patient visits). These data cover 78% of EDs across all 50 states, Washington, D.C., and Guam, and can detect, understand, and monitor unusual levels of suicide thoughts and attempts to determine if a response is needed. These data can also inform timely suicide prevention planning.
Data limitations include a lack of complete data on race and ethnicity and no information on sexual orientation, gender identity, or Veteran status. As of September 2023, 20 recipients of CDC’s Comprehensive Suicide Prevention program were funded to analyze syndromic surveillance data for suicide prevention planning and evaluation. For more information on CDC’s National Syndromic Surveillance Program, see https://www.cdc.gov/nssp/overview.html.
Information on risk and protective factors can also be gleaned from certain records that provide information on living contexts. These include sources of data on economic indicators such as livable wages, foreclosures, bankruptcy filings, and unemployment rates; data on gun ownership and attitudes and beliefs around storage during periods of crisis; and data on health service accessibility barriers (e.g., health professional shortage areas from the Health Resources and Services Administration [HRSA; https://data.hrsa.gov/tools/shortage-area]). Data on state and federal funding allocations supporting prevention, intervention, treatment, and postvention infrastructure, as well as data on training availability and utilization among professionals serving the community, can also be used by public health leaders and communities to consider available resources to reduce risk.
Local Data. Local communities and organizations can gather, maintain, and share data to inform suicide prevention efforts. Core community institutions can maintain data records pertaining to suicide, mental health, and known risk and protective factors for suicide, such as rates of substance use, ACEs, and social determinants of health. These institutions may include local departments of public health, K–12 schools, universities, social services agencies, juvenile justice institutions, and health and mental health providers. Exploring ways for partners to share data, as appropriate, and honoring tribal sovereignty and tribal data sovereignty can improve local suicide prevention efforts.
Community groups can also benefit from conducting their own needs assessment and listening sessions, hosting other community discussions, and collaborating with local or state public health officials to understand the following:
Some community coalitions have formed data subcommittees. These subcommittees bring together partners with access to different types of data as well as those with suicide-centered lived experience to facilitate stronger data sharing and more equitable data analysis.
Some tools and other resources available to assist communities in their data collection efforts include:
Ultimately, understanding local context is important in guiding communities’ suicide prevention decision-making (also see Goals 1 and 2).
Advances in Data Science Methods and Use of Novel Data Sources. Since the 2012 National Strategy, major advances have occurred in analytic methods and novel data sources for tracking and monitoring suicide thoughts, attempts, deaths, and related risk and protective factors. The number of publications applying data science methods (e.g., data linkage, machine learning) to identify, predict, classify, or describe suicidal thoughts, nonfatal attempts, or deaths doubled between 2017 and 2020 (Wulz, et al., 2022). Data science methods are also being applied to reduce data processing time. Advances in the use of novel data sources, such as social media, Internet browser data, and other social networking and digital platforms are also now available. Using these data sources and data science methods, scientists estimated weekly suicide fatalities in the United States that closely correlated with actual mortality data (Choi et al., 2020). This important study establishes a novel real-time approach of tracking suicides and provides the potential for an effective public health response (Choi et al., 2020). Further work is needed to identify, validate, and apply novel data and methods for suicide surveillance, research, evaluation, and quality improvement to keep pace with current and emerging methods and technology.
Data Integration. Data integration involves combining data from multiple data sources to facilitate a more comprehensive understanding of health outcomes and associated risk and protective factors and to verify data quality. Achieving this goal requires collaboration and data sharing among groups that collect suicide-related data and those seeking to use data for program improvement. For example, a recent quality improvement study in California reviewed deaths in electronic health records (EHRs) from an academic health setting and compared them against the state’s public health death file. The study found 19% of deceased patients were marked alive in the EHR (Wenger et al., 2023). Key groups seeking to improve the quality of data include state vital statistics offices, local coroners and medical examiners, death scene investigators, EDs, health care systems, and insurance companies.
For more information about prioritized data and surveillance for suicide prevention, see Prioritizing Improved Data and Surveillance for Suicide in the United States in Response to COVID-19.
Knowing whether suicide prevention efforts reduce the risk of suicide death is fundamental. The 2021 Surgeon General’s Call to Action to Implement the National Strategy for Suicide Prevention, and the 2017 Interdepartmental Serious Mental Illness Coordinating Committee’s (ISMICC) Report to Congress call for tracking and reporting survival/mortality as outcomes (ISMICC, 2017). Yet accessing death data in the U.S. is challenging, as these data are owned by 57 jurisdictions (50 states, the District of Columbia, New York City, and five territories). Each has their own policies on accessing and using the data for research, surveillance, and quality improvement. The 57 jurisdictions’ policies collectively determine policies for using the two national systems for linkable death data: CDC’s National Death Index and the Social Security Administration’s full Death Master File. National access generally based on the most restrictive policy among the 57 jurisdictions.
What’s Being Done? The Office of the Assistant Secretary for Planning and Evaluation’s Office of Behavioral Health, Disability, and Aging and the National Institute of Mental Health are conducting a systematic inventory (https://aspe.hhs.gov/compendium-policies-use-linkable-mortality-data) of the formal policies on the use of linkable death data for patient-centered outcomes. Identifying which entities can use data, the scope of permitted uses, and requirements for use may also help identify approaches to increase the access and useability of death data systems. This in turn would increase opportunities to assess effectiveness and quality of suicide prevention efforts.
Workforce. Increased capacity is needed in states, tribes, localities, and territories to improve the accessibility and usefulness of data. These jurisdictions will need clear policies, protocols, and staff training related in data sharing, data quality standards, and data literacy at all levels. This ranges from basic data skills to advanced data science methods (see Goal 6). Improvements in these areas will impact and support best practices in areas such as collecting suicide-related morbidity and mortality data that includes information about race, ethnicity, sexual orientation, gender identity, Veteran status, and occupation. Expanding workforce training is a key component of ongoing efforts to modernize data and ensure our workforce is equipped to use these data. As the Council of State and Territorial Epidemiologists (CSTE) noted in their 2019 report Driving Public Health in the Fast Lane: The Urgent Need for a 21st Century Data Superhighway, “a capable workforce that uses data well ensures critical public health action to save lives.” For more information, visit https://cdn.ymaws.com/www.cste.org/resource/resmgr/pdfs/pdfs2/Driving_PH_Display.pdf .
The CSTE Injury Surveillance Workgroup with support from CDC published a core set of data science competencies and developed an on-the-job training program to promote data science training at the state, territory, local, and tribal levels. For more information, visit https://www.cste.org/page/dstt-webpage.
Perspectives from Lived Experience. Agencies and organizations engaged in data collection, analysis, and reporting can benefit from insights of persons with lived experience. They can help identify what information maybe be most useful for program and policy efforts in the community. Engaging individuals with lived experience and leaders from the community ensure that data are actionable and interpreted and communicated in a way that avoids unintentionally marginalizing communities disproportionately affected by suicide thoughts, attempts, or deaths (also see Goal 7).
Evaluating the National Strategy and the Federal Action Plan. An effective National Strategy guides and generates activities across the public and private sectors that can ultimately play a role in reducing suicidal thoughts, attempts, and deaths. The 2024 National Strategy for Suicide Prevention is the first to include an action plan. The Federal Action Plan (Action Plan) is strategically aligned to advance National Strategy goals and objectives. Many of these actions directly impact states and communities. For example, expanding funding to states for comprehensive suicide prevention, training educators in suicide prevention, and expanding mobile crisis services. Additionally, states, tribes, local communities, and territories can use the National Strategy and Action Plan to create their own actions.
A forthcoming federal monitoring and evaluation plan will:
Effective monitoring and evaluation will help update and improve the National Strategy, inform policy and programmatic decision-making, and enhance future suicide prevention efforts.
Success for Goal 10 means agencies and organizations that collect and store data related to suicide will have up-to-date, high-quality, actionable data and information that can be appropriately shared with community partners. Communities can use these data and information to strengthen suicide prevention efforts through program implementation, policymaking, and research. Clear evidence of positive impact can create momentum and lead to increased resources and support. This will benefit ongoing quality improvement in community-based suicide prevention and accelerate positive health outcomes. Additionally, a robust national effort to track implementation of the 2024 National Strategy will help identify areas of progress for the field as well as areas that need further investment and focus.
Below are the objectives for Goal 10 that will help advance the National Strategy to improve suicide outcomes in the country.
Efficient and effective suicide prevention is guided by understanding the contributors to and the progression of suicidal thinking and attempts, along with related risk and protective factors. Pursuing a prioritized research agenda helps to focus efforts on the information that will have the most significant impact on addressing suicide risk.
An Action Alliance Task Force developed the Prioritized Research Agenda for Suicide Prevention in 2014. This agenda focused support on the research most likely to reduce suicide rates (National Action Alliance for Suicide Prevention, 2014). This allowed public and private funders to consider a common strategy to reduce suicide thoughts and attempts more efficiently. Some examples of scientific advancements over the past decade include the following:
Many programs and practices now recommended in other Strategic Directions benefited from the evidence of effectiveness driven by this prioritized research. Continuing to focus on research that can have the greatest potential impact, can further contribute to the success of National Strategy efforts.
The 2014 Prioritized Research Agenda for Suicide Prevention considered high-risk populations, suicide methods used, and settings where at-risk individuals may be found (e.g., EDs, criminal justice system) to focus on opportunities to save lives most quickly. These opportunities were built on available surveillance data, highlighting the importance of accessible quality surveillance investments. Although a number of intervention approaches have been found to be effective, their implementation and sustainability are important for achieving reductions in suicide prevention.
Substance use is a risk factor for suicide. New research addresses interventions for both substance use and suicide risk (see Ries et al., 2022, and Voss et al., 2013). This research resulted from improved specialty care options addressing mental disorders and addictions (e.g., Certified Community Behavioral Health Centers) and interest among primary care providers to address both issues. Moreover, growing evidence indicates that youth exposed to upstream substance use prevention programs have reduced risk for suicide thoughts and attempts in their later teens and early adulthood. This may be due to building protective factors and reducing risk factors that are common to both substance use and suicide (e.g., Posamentier et al., 2023). Leveraging public-private partnerships recommended under Strategic Direction 1 can spur other collaborative research, for example studies engaging workers from industries with increased risk of substance use and suicide (e.g., construction industry workers).
Technology-based communications present new opportunities for outreach, support, and treatment for underserved groups. Social media and digital technology are rapidly evolving and often exert dynamic influence over the thoughts and behaviors of users, particularly young people. Digital monitoring and assessment are important tools for evaluating fluctuating suicide risk. An ongoing need exists to produce high-quality and up-to-date research that can provide guidance on how best to use digital technology to support protective factors and safety during use to reduce potential harms.
Research to Practice. Implementing evidence-based and promising practices is critical for advancing suicide prevention. However, translating research findings into actionable practice, remains a challenge. Research is needed that supports expansion and reach of effective programs and initiatives in communities. Resources are needed for program evaluation (e.g., pre-, and post-surveys, training in data literacy) to establish baseline risk and potential program benefits. Adoption, implementation, and sustainment of proven interventions will also be needed. For example, a study of implementation of the effective ED-SAFE suicide prevention program in emergency care found that the reduced patient suicide risk outcomes were more pronounced over the stages of implementation. This reflects the iterative improvements that need to take place as part of continuous quality improvement (Boudreaux et al., 2023). The researchers noted that implementation of interventions in health care settings face challenges over time. These challenges include staff turnover, fatigue, and reduced adherence to the delivery of suicide preventive practices that can contribute to waning effectiveness.
Perspectives from Lived Experience. Individuals with lived experience can offer valuable perspectives from the identification of research priorities through the interpretation and communication of research results. Multiple benefits result from experiences in what’s called Community-Based Participatory Research (CBPR). Some of the benefits include increased relevance and usefulness of research results, improved community trust, enhanced cultural responsiveness, and increased participation rates in research. For more information on CBPR, see https://pubmed.ncbi.nlm.nih.gov/29355352/.
Experiential knowledge of community members provides essential context for research design and results. Lived experience offers insights into real-world factors that impact the effectiveness of interventions. Individual and group experiences grounded in the local community context can help ensure equity and cultural relevance in research approaches. Clinical research that systematically develops, adapts, and validates interventions with different populations will prove the most effective for broad implementation and benefits.
Individuals with lived experience note that there is a need for more research on peer support programs identified as promising practices (Schlichthorst et al., 2020). A wide range of potential interventions are catalogued under “peer support services,” however more research is needed to enhance the many ways in which peers can safely and effectively provide support.
Achieving Goal 11 would result in focused and prioritized research studies that are valued and informed by the field and end users. These include people with lived experience, concerned family members, peers, and suicide loss survivors, among others. People who provide intervention and support to individuals struggling with suicidal thoughts or who are impacted by suicide, can use research findings to inform their organizational, community, and policy efforts and decisions. Communication about research progress tailored to people invested in suicide prevention can instill hope. Input from the users of research remains critical to further improve and expand available evidence-based prevention efforts. Public opinion surveys increasingly indicate that people view suicide as preventable (National Action Alliance for Suicide Prevention, 2022). Knowing how to advance and sustain effective prevention strategies can ensure time and money are well-invested.
Below are the objectives for Goal 11 that will help advance the National Strategy to improve suicide outcomes in the country.
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