SUICIDE AND SUICIDAL BEHAVIOUR: ESTABLISHING THE TERRITORY FOR A SERIES OF RESEARCH REVIEWS
EXECUTIVE SUMMARY
BACKGROUND
The last 30 years have seen a massive increase in suicide in Scotland, with rates more than doubling among young adult men. As a result suicide prevention has become an urgent public health issue. In 2002, following an extensive consultative process, the Scottish Executive's National Programme for Improving Mental Health and Well Being launched Choose Life, the National Strategy and Action Plan to Prevent Suicide in Scotland. Choose Life set a target of reducing the rate of people committing suicide in Scotland by 20% by 2013 (Scottish Executive, 2002). The Executive allocated 12 million over the period 2003-06 to support the implementation of the Choose Life strategy and action plans at national and local levels.
One of the main objectives of Choose Life is to improve the quality, collection, availability and dissemination of information relating to suicide and suicidal behaviour, and on relevant effective interventions. To meet this objective, the Scottish Executive has embarked on a three-stage process to ensure that practice is supported by a reliable, up-to-date evidence base. The work reported here is a scoping study to define the territory for a series of research reviews to co-ordinate the evidence base and inform the development and implementation of suicide prevention policy in Scotland. The reviews will determine what primary research is required to address gaps in the evidence base relating to suicide and suicidal behaviour.
RESEARCH AIMS
The overall aims of this research were to:
Co-ordinate information about the interests and areas of expertise of organisations and individuals specialising in suicide-related research
Establish the territory and focus of the series of reviews, with reference to: information on prevalence; risk and protective factors; and the effectiveness of specific preventive interventions.
APPROACH
The project was undertaken in three linked stages.
Stage 1: identified and established contact with researchers across the world who specialised in suicide and suicide related research.
Stage 2: involved a web-based survey of the research specialists to identify their key interest areas, their perception of how the reviews should be divided up, the issues on which the reviews should focus, and the main gaps in the existing evidence base related to suicide and suicidal behaviour. The survey data were coded and frequencies were calculated and sorted to identify priority themes. This information was used to develop the key elements of a framework for dividing up the reviews. The framework reflected and incorporated all priority issues, perceived gaps and most common suggestions for dividing up the reviews.
Stage 3: identified the focus and structure of the reviews to be commissioned. This involved analysis of the priority themes arising from the survey data and a two-part consultation with a group of (mainly Scottish based) suicide and suicidal behaviour experts (researchers, policy makers, practitioners responsible for policy implementation and other relevant stakeholders). The expert group was consulted in two phases. In the first phase members were presented with the survey data and asked to assess the framework for dividing up the reviews. In the second phase members were asked to comment on 5 research review topic options which were based on the survey findings and feedback from the first phase of expert group consultation.
KEY FINDINGS
Issues arising from the international survey
The survey was useful in terms of producing a set of priority issues to guide the focus and structure of the research reviews on suicide and suicidal behaviour
There was disparity between the research specialists' interest areas and the priority issues they suggested for focus of the research reviews
The survey served to raise awareness across the world about Scotland's suicide prevention strategy and build an international network that Scottish practitioners, policy makers and researchers can access
Survey participants were clear that the reviews should be split between suicide and deliberate self-harm, and across determinants, interventions and epidemiology
The survey participants were most commonly interested in interventions for the prevention of suicide
An extensive range of issues on which the reviews should focus and perceived gaps in the evidence on suicide and suicidal behaviour was suggested
Participants felt that the reviews should focus on what is known about the causes and prevention of suicide, with relevance to the effective targeting of local resources
The key priorities for focus were understanding more about preventative interventions for risk groups, particularly those with mental illness and those who misuse alcohol and drugs (at service level), and for the general population (at societal level). Another key suggestion for focus was epidemiological investigation.
Participants perceived gaps in the evidence to be concentrated around the effectiveness of preventative interventions, interventions for deliberate self-harm and good quality epidemiological data
The framework for dividing up the reviews was considered to be a useful tool for exploring the links between the issues and gaps identified in the survey
Consultation with the expert group: phase 1
The analysis of survey data assisted with a preliminary identification of priorities. The purpose of the consultation with the expert group was to assess and filter these priorities through consultation with a group of experts that balanced the research specialist perspectives gained in the survey with policy and implementation perspectives from a more 'home grown' expert group.
The first consultation was to gain affirmation that the analysis of the survey data was sound. Each member of the expert group was sent a summary of the survey findings, a copy of the framework for dividing up the reviews, and asked:
Does the framework for dividing up the reviews make sense of the data?
What is missing?
Are the issues and gaps matched well with the components of the framework?
Which matches are missing or need to be changed?
Comment on methodological considerations
Comment on questions that the reviews should answer
The feedback from the expert group on these questions included the following key points:
All the experts who responded confirmed the validity of the proposed framework for dividing up the reviews
It was suggested that the reviews should incorporate socio-economic factors that increase risk of suicide or deliberate self harm, the impact of the quality of environment and differences between high risk groups
Experts emphasised the importance of understanding determinants and interventions for suicide and suicidal behaviour at societal, service, community and individual levels
It was pointed out that a consideration of Scottish context was vital if the reviews were to have practical utility
Experts felt that it was difficult to justify a split in terms of reviews along risk and protective factors
Consultation with the expert group: phase 2
The second phase of consultation was to verify that the suggested review topics reflected a focus and structure compatible with opinion of how the reviews could usefully contribute to the development and implementation of suicide prevention policy in Scotland. After processing comments from the expert group on the survey data, the research team produced 5 review topic options based on a synthesis of the findings from the survey, the feedback from the expert group in phase 1 of consultation and the agreed framework for dividing up the reviews. The review topic options covered 3 broad areas: epidemiology of deliberate self-harm and suicide in contemporary Scotland; understanding the determinants of suicidal behaviour; and effective interventions to reduce suicidal behaviour.
Expert group members were clear that epidemiology of suicide and self harm should not be considered as a review topic. Rather, it should be commissioned as a separate project based on secondary data analysis.
The expert group was generally supportive of the other suggested review topics, although they suggested minor amendments.
SUGGESTED TERRITORIES FOR A SERIES OF RESEARCH REVIEWS
The feedback from the research specialists and the expert group, gathered through the survey and consultation process, was used to refine the review options.
In addition, some general issues relating to the review specifications were put forward for the Scottish Executive commissioners to consider:
The reviews should employ a range of methodologies
The Scottish Executive commissioning team will have to be clear about the aspects of suicidal behaviour they want to include in the reviews, in view of the diversity of definitions and understandings
Commissioned reviews should demonstrate an understanding of the need to contribute to policy development and support effective practice
Reviews should recognise the importance of assessing the transferability of findings to the Scottish context and discuss the implications of findings for future monitoring, evaluation and research
Review research teams should include a practitioner and/or a service user perspective and combine diverse disciplinary perspectives
Following advice from the expert group, it was recommended that work on the epidemiology of suicide and deliberate self-harm should not be commissioned as a review, but as a separate project based on secondary data analysis.
Five final review options emerged, three under the main topic of 'determinants' and two under the topic of 'interventions'.
Determinants: suggested review topics
Towards a comprehensive biopsychosocial model of suicidal behaviour
Conducted by an experienced research team, this overview would be expected to produce integrated models of suicide and deliberate self-harm which take account of and combine different disciplinary understandings and perspectives. The focus would be upon the causes of, and pathways to, suicidal behaviour. The research team should also consider the implications of such a model in terms of its practical relevance for national and local interventions that will have maximum impact on the prevention of suicide.
Current knowledge of risk conditions and risk factors for suicidal behaviour
This would involve the production of an updated review of the state of current knowledge of:
The review should be based on a comprehensive and sophisticated approach to understanding suicidal risk. It should make special reference to the impact of inequalities, e.g. relating to age, income and locality, on suicidal behaviour. It will also be important to incorporate an analysis of the relationship between groups at risk of suicide identified in the research review and what is known about the occurrence of suicide and suicidal behaviour in Scotland.
What protects against suicidal behaviour?
A stocktake of knowledge concerning resilience and healthy survival amongst people who are exposed to known suicidal risk conditions would form the basis of this review. It should take an inter-disciplinary approach to identifying what helps people to be resilient in different populations and at different stages of their life course. The review would be expected to differentiate and identify relationships between:
and
It is recommended that this review should exclude a review of knowledge about the effectiveness of interventions or actions that help to promote resilience.
Interventions: suggested review topics
Preventing suicidal behaviour in key risk groups: what works and what doesn't work?
and
Preventing suicidal behaviour in the general population: what works and what doesn't work?
On the basis of views expressed by the expert group, it was recommended that 2 separate systematic reviews of the effectiveness of intervention should be commissioned. One review would cover interventions or actions to reduce suicidal behaviour in high risk groups, while the other would address general population, public health interventions or actions. Within both reviews it would be important to:
Highlight evidence concerning what doesn't work as well as what does work
Ensure that findings are accessible and relevant to people locally and the Scottish Executive
Differentiate between interventions or actions to reduce (repeat) deliberate self-harm and interventions to reduce suicide
Identify variations in strategic approaches to the reduction of suicidal behaviour in different groups identified to be at high suicide risk