SUICIDE AND SUICIDAL BEHAVIOUR: ESTABLISHING THE TERRITORY FOR A SERIES OF RESEARCH REVIEWS
CHAPTER FOUR: IDENTIFYING THE FOCUS AND STRUCTURE OF THE REVIEWS: CONSULTATION WITH EXPERT GROUP
APPROACH
4.1 The key task of the project was to define the scope of the proposed research reviews and to ascertain how best the reviews might be focused and structured. The analysis of survey data assisted with a preliminary identification of priorities. The purpose of stage 3 of the project 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.
4.2 The research team arrived at an adaptation of the Delphi technique for the purposes of their consultation with the expert group ( see paragraphs 2.31 to 2.35). Two consecutive consultation rounds were undertaken with the expert group. The first consultation was to gain affirmation that the analysis of the survey data was sound. The second consultation was to verify that the suggested review topics reflected a focus and structure compatible with their opinion of how the reviews could usefully contribute to the development and implementation of suicide prevention policy in Scotland.
CONSULTATION WITH EXPERT GROUP: PHASE 1
4.3 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 the following questions:
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
Response from expert group to consultation with expert group: phase 1
4.4 A third of the members of the expert group responded to phase 1 of the consultation process, including 2 consultants in public health medicine, 2 Choose Life co-ordinators and one civil servant. All the members of the expert group, including non-responders to phase 1 of the process, were willing to take part in phase 2.
Key issues from expert group's responses to consultation with expert group: phase 1
4.5 All the experts who responded confirmed the validity of the proposed framework, although one expert pointed out a potential tension between risk groups interventions and quality of services, which could overlap. All suggested small refinements and changes which were incorporated into the review topics, for example the addition of a consideration of cost benefits to help prioritise investment.
4.6 The expert group identified areas of analysis that they felt should be covered by the reviews:
Socio-economic factors that increase risk, including poverty and worklessness
The impact of place e.g. neighbourhood factors, quality of housing, rurality
Differences that emerge for or between specific groups e.g. ethnic minorities; people who have disabilities; people who are lesbian, gay, bisexual, transgender; refugees and asylum seekers; men/women
4.7 Experts emphasised the importance of understanding determinants and interventions for suicide and suicidal behaviour at societal, service, community and individual levels.
4.8 It was pointed out that the most obvious omission so far was the detail and importance of a Scottish context and that this was vital if the reviews were to have practical utility.
4.9 There was interest in whether there could be comparison between Scotland and other countries regarding different service systems, population characteristics in terms of suicidal behaviour, and whether national culture was a determinant of suicide and suicidal behaviour.
4.10 Experts felt that it was difficult to justify a split in terms of reviews along risk and protective factors, as many links were made in the survey between risk and protective factors and interventions at the different levels. If there was a split, it was suggested that there should be less emphasis placed upon protective factors.
4.11 The research team used the feedback from the expert group from phase 1 of the consultation process and the analysis of the survey data to arrive at a set of suggested topics and commentary that would be tested in Phase 2.
CONSULTATION WITH EXPERT GROUP: PHASE 2
Changes to the expert group
4.12 At phase 2, some changes were made to the expert group. In discussion with the Scottish Executive commissioners it was agreed to widen the membership of the expert group to include representation from service users, the Chief Scientist Office, mental health primary care research, and a specialist in young people who deliberately self-harm.
Suggested topics for reviews
4.13 After processing comments from the expert group on the survey data, the research team produced a document which synthesised findings from the survey using the agreed framework. The document included 5 suggested review topics (see boxes 1.4 to 1.5 below) which covered 3 broad areas: epidemiology of DSH and suicide in contemporary Scotland; understanding the determinants of suicidal behaviour; and effective interventions to reduce suicidal behaviour.
Questions for consultation with expert group: phase 2
4.14 The expert group were asked to comment on the suggested review topics to help shape the final territories for the research reviews. It was emphasised to the expert group that the research team was particularly interested in their thoughts on how well the suggested topics for the reviews would inform the policy development and implementation phases of Choose Life. Participants were asked to structure their comments by reading the suggested review topics and answering the following key questions:
For each review topic
Are the most important issues relevant to each topic area given the prominence / priority they deserve?
Do the reviews sufficiently address the 'so what?' question to produce maximum understanding and utility in the Scottish context?
Are the methods suggested appropriate to the task?
For all of the review topics taken together:
Do the review topics together sufficiently address the relevant issues and gaps in knowledge concerning suicide, suicidal behaviour and deliberate self-harm?
Can the review topics be arranged in order of priority?
Other questions that were specific to individual review topics were also included (see italicised text in boxes 4.1 to 4.5).
Response
4.15 Twelve members of the expert group responded to the phase 2 consultation, representing the following perspectives:
Service delivery manager and practitioner
Choose Life local co-ordinator
Scottish executive civil servant public health and social policy maker
Mental health service user
Those working in suicide prevention service
Psychiatrist
Scottish prison service
Local health and social services commissioners
Academic experts from Scotland and other parts of the UK and Ireland
Research commissioner
4.16 Ten experts provided detailed responses to the extent that they gave comments on each of the 5 suggested topics, while the other 2 experts voiced a general approval of the topics suggested. The following section summarises the comments related to each topic area.
Key issues arising from expert group's response to phase 2 questions
Epidemiology of suicide and DSH (and suicidal ideation) in Scotland.
4.17 Box 4.1 gives the text from the suggested topics for reviews document that the expert group was asked to comment on regarding epidemiology of suicide and DSH (and suicidal ideation) in Scotland.
Box 4.1 Suggested review topic: epidemiology of suicide and DSH
Epidemiology of suicide and DSH
1. Epidemiology of suicide and DSH (and suicidal ideation) in Scotland
It is vital that implementation and evaluation of the Choose Life strategy is informed by accurate information on the epidemiology of suicide and DSH. A dataset containing detailed information about suicide and DSH in Scotland over the period 1993-2002 should be prepared, through collaboration with GRO(S) [General Register Office] and ISD [Information and Statistics Division] (respectively). The deaths dataset should include 'undetermined' deaths as well as those officially labelled suicide. Each record should contain all available socio-demographic information. For DSH events, hospital discharge data will have to serve in the absence of a more appropriate data source, although it will be important to explore the gathering of information on those who DSH and are not admitted to hospital. Again, all available information about the characteristics of each DSH event should be included in the dataset, including whether the DSH was identified as a suicide attempt. For each dataset a marker for address (e.g. postcode sector) should be included, thus permitting allocation of each suicide /DSH event to a specific local authority and /or health board area.
On the basis of the constructed datasets, a report will be prepared, describing the epidemiology of DSH and suicide in Scotland during 1993-2002, at both local and national levels, with indication of trends over time and assessment of variations relating to key socio-demographic characteristics (e.g. sex, age, marital status, occupation, socio-economic deprivation, ethnicity). The possibility of establishing individual-level linkage between the two datasets should also be explored (although ethical and data protection issues will need careful consideration).
In addition to the above two datasets, an exploration of the epidemiology of suicidal ideation could be undertaken.
Consideration should be given to what learning can be gleaned from a comparison of the epidemiology of suicide, deliberate self-harm and suicidal ideation in Scotland with international datasets. |
4.18 Although survey participants had highlighted the importance of addressing the gaps in understanding the epidemiology of suicide and suicidal behaviour in Scotland, the expert group were clear that this should not be considered a research review topic. Rather, it would require secondary analysis of existing Scottish datasets on suicide and deliberate self-harm or even the collection of new primary data. Such an analysis would allow testing of current assumptions about risk groups against reliable data and offer a better opportunity for comparison of Scottish epidemiological information with international datasets. One member of the expert group suggested that the Scottish Executive link with National Suicide Research Foundation in Cork which is coordinating a National Suicide Registry as part of World Health Organization European Parasuicide Study.
4.19 With respect to the epidemiology of deliberate self-harm, however, it is important to acknowledge the current limitations of available hospital data to inform this area, particularly where the definition and recording of deliberate self-harm as suicidal behaviour is concerned. It is unlikely that detailed information such as deprivation categories and educational attainment as suggested for inclusion in an epidemiological study by members of the expert group would be available or useful. Linking of available datasets would be desirable to explore the relationship between suicide and deliberate self-harm.
4.20 The relatively small numbers of suicide events would suggest that a study of at least ten years would be required to produce a useful suicide dataset. It would be important to track evidence at a local area and to have clear criteria for its robustness. There would inevitably be implications for consideration and discussion of variation in definitions and the extent of recording at local level. The study would have a key role in determining future standardised data collection. Dissemination of the results at local level of such a study would also be of key importance.
4.21 There was interest from both survey participants and the expert group in an exploration of suicidal ideation and its relationship to suicide and suicide attempts and to risk and protective factors.
Determinants of suicidal behaviour: towards a comprehensive biopsychosocial model of suicidal behaviour
4.22 Box 4.2 gives the text from the suggested topics for reviews document that the expert group was asked to comment on regarding a comprehensive biopsychosocial model of suicidal behaviour.
Box 4.2 Suggested review topic: towards a comprehensive biopsychosocial model of suicidal behaviour
Determinants of suicidal behaviour 2. Towards a comprehensive biopsychosocial model of suicidal behaviour
There have been many attempts to describe the aetiology of suicidal behaviour from distinct disciplinary perspectives. Thus, there are sociological, psychiatric, psychological, anthropological, epidemiologic, biological / genetic, economic and many other understandings of suicide, deliberate self-harm and related suicidal phenomena. Each offers useful, but partial, insight into the nature of the behaviour. What is lacking is a concerted effort to bring together (some of) these perspectives in order to produce an integrated, comprehensive understanding. This is true for all suicidal phenomena, taken individually or in combination. Whether or not it is advisable or possible to produce a single model is open to question. It may be necessary to differentiate between completed suicide, deliberate self-harm (perhaps distinguishing between those with high and low suicidal intent) and suicidal thoughts / ideation. To address this gap, a synthetic overview by an experienced research team, which brings together suicide experts from a range of disciplines and seeks to embody a genuine inter-disciplinary approach, is required. The synthetic overview would draw on distinct and diverse expert opinion in a discourse based on evidence from the empirical and theoretical literature. The review will seek to answer the question: What does the evidence tell us about the causes of suicidal behaviour? The synthetic overview will: Produce one (or multiple) inter-disciplinary model(s) of the determinants of suicidal behaviour Examine the implications of this (these) model(s) for providing cross-cutting (inter-sect oral) interventions that will have maximum impact.
In terms of the Scottish context, such a model(s) will have utility for improving understanding of suicide determinants and for promoting joint action towards effective intervention targeting among local and national stakeholders. A key question is whether the number and type of disciplines to be represented in the review research team should be predefined. |
4.23 This review topic was generated for 2 main reasons: developing a biopsychosocial model was one of the key suggestions from survey participants on how to divide up the reviews, and the survey participants demonstrated a great variety of distinct approaches to understanding suicide and suicidal behaviour through their specialist interest areas and the issues they felt the reviews should focus on. However, there was some scepticism amongst the expert group as to the applicability and relevance of a new biopsychosocial model and fears that such a model could be too generalised to have any practical utility.
"Could be over ambitious, range of disciplines could make it a talking shop reflecting opinion more than evidence."
"… the output of this bit of work could end up being too rich with detail and move us away from the specifics of where we can best target resources. This is not to detract from the basic need to acquire a finer-grained image of suicidal behaviour, only to put down a marker about its applicability."
4.24 Some of the experts picked up on the utility of such a model in terms of the implications it would have for future interventions; this could have relevance at societal, community, individual and service levels and for future primary research.
"Multi-factorial model would emphasise the possibility of different means and models of intervention for suicide prevention."
4.25 In terms of prioritising this topic, the expert group had mixed views, although there was broad support to retain the topic in the review series.
4.26 There were also mixed views about predefining the number and type of disciplines to be represented in a research team for this topic, although there was a sense that the team should include a good cross section of experts.
"Team should have a good cross section of strong, competent people with a range of skills, with competencies at sufficient level, to properly undertake this project."
4.27 It was also suggested that there could be benefit to the Scottish Executive in linking with the Glasgow Centre for Population Health, which has recently proposed a combined, psychosocial and biochemical model of risk for heart disease.
Determinants of suicidal behaviour: current knowledge of risk conditions and risk factors for suicidal behaviour
4.28 Box 4.3 gives the text from the suggested topics for reviews document that the expert group was asked to comment on regarding current knowledge of risk conditions and risk factors for suicidal behaviour.
Box 4.3 Suggested review topic: current knowledge of risk conditions and risk factors for suicidal behaviour
Determinants of suicidal behaviour 3. Current knowledge of risk conditions and risk factors for suicidal behaviour
The implementation of Choose Life would benefit from an updated review of the state of current knowledge with regard to the broad (societal, cultural) factors associated with increased incidence of suicide (risk conditions) and population subgroups which are at increased risk of suicidal behaviour. Risk conditions identified in previous reviews include: mass media influences, macro-economic conditions (especially the level of unemployment), availability of / access to suicidal methods and suicidal ideation. High risk groups that have been identified in previous reviews include: current/former psychiatric patients (inpatients and outpatients); patients in current / recent contact with psychiatric services; patients recently discharged from psychiatric inpatient treatment; individuals with a history of previous suicidal behaviour (DSH); individuals who abuse substances (alcohol and illegal drugs); individuals with a family history of suicidal behaviour; individuals with serious illness/disability; individuals with a diagnosis of HIV / AIDS; prisoners (especially remand and long-term); unemployed people; homeless people, people at certain life stages (especially young men) and people in certain occupations (especially related to human and veterinary medicine). The review would seek to update this picture, relying on primary studies and reviews published during the last 10 years. It will be important to differentiate between different outcomes (suicide, DSH, suicidal ideation) and to focus on marginalised groups within current Scottish society, such as ethnic minorities, disabled people, refugees, asylum seekers, gender, lesbian, gay, bisexual and transgender. In addition to identifying the high risk groups, it would also be helpful to have: Some estimates of the proportion of suicides in Scotland that (are likely to) fall into each group The proportion of each group that are likely to engage in suicidal behaviour in the short / medium / long term The estimated increase in risk experienced by these groups (in comparison with the general population) Information about other (socio-demographic, psychiatric, etc.) characteristics of these groups. Wherever possible, special attention should be paid to evidence relating to Scotland and the rest of the UK, although it will be important to cover all international literature available. The issue of the universality of risk groups identified in the international literature should be addressed, taking into account variations in the characteristics of excluded groups within different societies. This will permit an assessment of the transferability of findings from studies conducted outside the UK to the Scottish context.
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4.29 The expert group were broadly supportive of this topic.
"This updated work would be very welcome - it might also be useful to develop guidance on ensuring that initiatives can take some of these key factors properly into account."
4.30 Four experts identified issues that they felt needed to be given prominence, including:
The growing health divides between young men and other population groups and between rich and poor and rural and urban dwellers
Long term survival with HIV / AIDS
Prisoners
Those known to suffer from psychiatric illness
Those with chronic physical illness
The bereaved, especially those who lose a young child
All these issues have been incorporated into the revised review topics in section 5.
4.31 One expert suggested that this topic should include protective factors in the title. However, protective factors defined as the opposite of risk factors could be overwhelmed by the wealth of material on risk factors, and therefore would be better considered in a separate review.
4.32 Another expert suggested that this review should focus on attributable risks over relative risks due to the possibility that high relative risks may be unimportant if the risk factor is scarce and / or non-modifiable.
Determinants of suicidal behaviour: what protects against suicidal behaviour?
4.33 Box 4.4 gives the text from the suggested topics for reviews document that the expert group was asked to comment on regarding what protects against suicidal behaviour.
Box 4.4 Suggested review topic: what protects against suicidal behaviour?
Determinants of suicidal behaviour
4. What protects against suicidal behaviour?
The prediction of rare events such as suicide, and the delineation of the complex pathways leading to completed suicide, is extremely difficult and most attempts to do so have met with, at best, only moderate success. Even less is understood about the factors and processes that protect against suicide, especially in circumstances which typically elevate suicide risk. In accordance with the National Programme's concern to maximise well being and positive mental health (as well as reducing mental ill-health), a stock take of knowledge concerning resilience and healthy survival would be of considerable value. Resilience refers to:
"the capability of individuals and systems (families, groups, and communities) to cope successfully in the face of significant adversity or risk. This capability develops and changes over time, is enhanced by protective factors within the individual / system and the [psychosocial] environment, and contributes to the maintenance or enhancement of health" (Health Canada 1995).
Several important components of this definition should be emphasised: First, while most research has focused on individuals, resilience may be a characteristic of the social environments (communities, workplaces, schools, service support systems etc) and / or the social, cultural and economic structures in which individuals live. Second, appropriate outcomes for measuring resilience are oriented towards positive adaptation, maintenance or enhancement of health and well being, successful coping, and recovery; the traditional focus on negative outcomes (pathology, morbidity, mortality) is of limited relevance. Third, adversity or risk entails the experience of stressful or traumatic life events, typically entailing loss and / or harm. Protective factors are influences which serve to buffer or decrease the negative consequences of being at risk and to facilitate recovery. They may be stabilising or enhancing despite increasing risk, or reactive where risk is low. Fourth, resilience is not a static characteristic or attribute but may develop and change over time, depending on changes in risk and protective factors. Different challenges to individual capacity for positive adaptation are encountered at different stages of the life course.
This review will adopt an inter-disciplinary approach to identifying the factors and processes which promote resilience in different populations at different stages of the life course. The review will be expected to differentiate and identify relationships between individual protective factors (e.g. self-efficacy, high self-esteem, previous experience of problem-solving and crisis resolution) and environmental protective factors (available social support, models of healthy coping).
It could also incorporate a synthesis of knowledge about the effectiveness of interventions to promote resilience.
References
Canada's Drug Strategy. Resiliency: Relevance to Health Promotion
http://www.hc-sc.gc.ca/hecs-sesc/cds/publications/resiliency/issues.htm |
4.34 The expert group gave broad support for this review topic. It was suggested that there should be emphasis on high risk groups, such as those with a psychiatric diagnosis, and exploring the impact of positive parenting initiatives, such as 'Starting Well'.
4.35 The expert group suggested that the subject of resilience might be currently under review under the health inequalities agenda and that this review regarding suicidal and suicidal behaviour should build on evidence already available.
"It's too early to look at the relationship between resilience and effective interventions although it may be possible to re-interpret other studies with other badges on them."
"(I have a) reservation that protection and resilience part of project could wade in very deep to a much bigger issue. It is under substantial study in 'inequalities health' circles as well as the mental health cluster of issues."
4.36 There was some scepticism from a couple of experts concerning the relevance of the resilience concept in terms of using this knowledge to inform interventions to address risk and prevent suicide and suicidal behaviour.
"Even in relatively high risk groups, the likelihood of suicide is very low, so resilience is unlikely to discriminate helpfully between people who do or don't commit suicide. It may be a little more helpful in relation to DSH, but I'm sceptical whether the concept of resilience is precise enough to be useful"
4.37 There was, however, a view that not enough was known about the evidence around resilience and suicide and suicidal behaviour to discount the need for the proposed review.
"Concept of resilience to stress in the population is in research infancy and cost effective interventions are likely to be a long way off, but may need review to determine this!"
4.38 Although there were doubts about the amount of evidence that would be available on this topic, the expert group were supportive of a review that would draw links between resilience and effective interventions to assist the targeting of resources.
"We need to look at those interventions which can build and maintain resilience, and ensure that suicide prevention is a factor in the diverse and complex inputs to such an area."
4.39 However, if the prevention of suicide and suicidal behaviour work in Scotland is firmly embedded in a positive approach to mental health and well-being, the place of suicide must be considered within the wider debates regarding resilience and inequalities.
Effective interventions to reduce suicidal behaviour: Preventing suicidal behaviour: what works?
4.40 Box 4.5 gives the text from the suggested topics for reviews document that the expert group was asked to comment on regarding preventing suicidal behaviour: what works?
Box 4.5 Suggested review topic: preventing suicidal behaviour: what works?
Effective interventions to reduce suicidal behaviour 5. Preventing suicidal behaviour: what works?
In 1994 Gunnell and Frankel published a review of the evidence relating to effective interventions (both public health measures (general population approach) and interventions targeted at high risk groups) for suicide prevention. This review needs to be updated. It should be undertaken systematically, according to established procedures. It will be important to differentiate between different outcomes (suicide, DSH, suicidal ideation) and different life stages (e.g. youth, young adults, older adults). Rather than starting from scratch (i.e. revisiting the primary studies covered in the Gunnell and Frankel review), the study could concentrate instead on examining the literature on suicide prevention and control published over the last 10 years. If a review of a specific (sub-) field has been published, it would appear to make sense to include that review (with updating, if necessary), rather than go back to the original studies. (Examples here would be the review of the effectiveness of interventions to prevent repetition of DSH [secondary prevention of DSH]; and the review of the effectiveness of screening for suicide risk in primary care settings.) Gunnell and Frankel's earlier conclusions should be revisited in the light of the findings from the more recent time period. This strategy is dependent on the perceived adequacy of the Gunning and Frankel review (and of other reviews included in the paper). One key issue to be debated is the desirability and feasibility of commissioning a single review. Consideration should be given to the possibility of commissioning two reviews, one dealing with the effectiveness of the general population approach, the other dealing with the effectiveness of the high risk group approach. The review(s) should make special efforts to consider the transferability of the research to the Scottish context and examine the implications for implementation and replication. References Gunnell D and Frankel S (1994) Prevention of suicide: aspirations and evidence. BMJ 308: 1227-33
Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R et al (1998) Deliberate self-harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ 317: 441-7.
Bradley NG, West SL, Ford CA, Frame P, Klein J, Lohr KN (2004) Screening for suicide risk in adults: a summary of the evidence for the U.S. preventative services task force. Annals of Internal Medicine 140: 822-35 |
4.41 As well as being the clear priority area for survey participants, this suggested review topic was the most popular among expert group members and considered to have key importance for local Choose Life groups.
"This is obviously the area where most local Choose Life groups would wish to have some support for their thinking."
4.42 A key suggestion from the expert group was to include a review of interventions that do not work or do harm as well as those that are effective.
4.43 On the question of whether 2 reviews should be commissioned, one concentrating on interventions targeted at key risk groups and another covering universal interventions, the expert group were supportive of 2 separate reviews.
"I would opt for 2 reviews as I think this has more potential to encourage the view that different approaches are needed for the different populations."
4.44 However, the importance of ensuring that the output of the review topic was useful for local Choose Life implementation groups was also stressed.
"Commissioning of either a single or 2 reviews is less an issue for me, than how the outputs of that review / those reviews are presented for local CL groups to consider (which might require a synthesis in any case)."
4.45 One expert suggested that the review findings might be given more utility in the Scottish context if there was a section on how findings might apply to Scotland.
"…seems inevitable that some questions thrown up by review will have a Scottish relevance and hopefully these research areas could be pursued in due course."
4.46 It was suggested that there would be practical utility in dividing a study of what works by high risk group.
"May be important to also differentiate, not just on life stages, but also whether there are strategies that specifically relate to prevention of suicide for other marginalised or high risk groups such as refugee populations (where the causes and solutions required may differ)."
4.47 A further suggestion was that a 'what works?' review should include a careful exploration of deliberate self-harm in terms of whether and how interventions focus on the self-harming behaviour and / or the underlying issues.
"Interestingly, various self-harm users groups deal specifically, exclusively with self-harming activity, often in great detail; they don't give much value to "underlying" issues. So, perhaps this topic should be around method, and explore the detail of parasuicidal behaviour."
Do the review topics together sufficiently address the relevant issues and gaps in knowledge?
4.48 The expert group identified some key topics they felt the reviews should address. Alcohol misuse and other addictions and misuses were highlighted, in view of the wealth of evidence associating alcohol with self-harm, suicide and low mood. Family relationships and key breakdown events, abuse and available supports to work through the mental consequences of such relationships were also highlighted as crucial issues, although there was uncertainty as to the nature of the research evidence.
4.49 One expert was interested in whether interventions have been found to increase the likelihood that depressed people might seek assistance, in the light of evidence that depression is a key factor in suicide.
4.50 A couple of the experts specifically highlighted the importance of the reviews tackling the underlying themes of the sometimes 'taboo' background circumstances, such as poverty and abuse, of people more liable to commit suicide.
"Notions of exclusion, the experience of poverty and poor life circumstances, shame and concealment of abusive relationships which fuel poor mental health are deeply engrained features ….. This really underlines the importance of wider social and health policy towards narrowing inequalities and tackling taboos."
4.51 There was also concern that the reviews, in taking a broad public health approach to understanding suicide and suicidal behaviour, should not lose track of the current evidence that psychiatric illness and its treatment are very important factors in suicide and its prevention.
Structure, content and dissemination of the output from reviews
4.52 The expert group gave further comments on the structure, content and dissemination of the output from the reviews. They laid emphasis on the importance of sharing the review findings with a broad audience using a variety of dissemination techniques. It was suggested that, in addition to full reports, there should be short, readable and accessible summaries which would be highly relevant and accessible to those working at the local level.
"I know that many of the local Choose Life groups with which I have had contact would appreciate that - as well as some kind of dissemination event to discuss findings in due course."
4.53 Researchers should also be made aware that the reviews are part of a policy formulation process: the approach to their studies and the way they articulate them should be framed accordingly. In order to have relevance and utility in the Scottish context, it was suggested that each study must have a section that identifies how the review findings might apply to Scotland.
Can the review topics be arranged in order of priority?
4.54 On the question of whether the review topics could be arranged in order of priority, views were mixed and no concrete order of priority emerged. However there was a general acknowledgement amongst the group that a review of what works was of key importance. One expert felt that it was more important to make strong links between the topics to maximise the knowledge gathered, than to attempt to prioritise the topics.