As a suicide prevention researcher, several times each year I am asked to consult with research groups on the possibility of supplementing their primary study aims with a secondary focus on suicide risk and suicide-related outcomes. These investigators are studying phenomena that overlap with suicide in terms of risk and resiliency. Their areas of research have spanned childhood trauma, aggression and violence, depression and anxiety, alcohol/substance abuse, sleep disturbance, chronic medical illness and, most recently, bariatric surgery.
What has been the outcome of these consultations? Some investigators have supplemented their studies to address suicide-related concerns; others have not. There are real barriers to doing so — investigator fears, misinformation, risk management issues and resource requirements. However, if the research team has a strong infrastructure and the capacity to consult with someone familiar with suicide risk management, it is possible to do so.
This article asks two questions: Why is it important for more researchers to work together to address the problem of suicide? And how can researchers overcome perceived and real barriers? Suicide is a tragedy that cuts across all demographic lines in the United States. In 2013, suicide was the 10th leading cause of death overall and the second leading cause of death among young people ages 15 to 34 years, according to the Centers for Disease Control and Prevention. Perhaps surprising to many, the suicide rate is consistently higher than the homicide rate in the United States and continues to trend upward. Moreover, for every adult death by suicide, there are approximately three hospitalizations and 10 emergency department visits for suicide attempts, according to the Suicide Prevention Resource Center Among our nation's high school students, 17 percent report having seriously considering suicide and 2.7 percent report having made a suicide attempt necessitating medical treatment during a one-year period (Kann et al., 2014).
How could a larger community of researchers contribute to our understanding of suicide and its prevention? Of equal importance, how could researchers in areas pertinent to suicide risk bring their differing expertise to bear on this problem? Suicide risk factors overlap with risk factors for myriad health and social problems including homicide, motor vehicle accidents, drug overdoses, trauma, chronic illness, unemployment and more. Researchers in these areas may be able to leverage existing resources to contribute to our understanding of suicide prevention.
Understandably, researchers are often reluctant to "go there." Many fear dealing with suicide risk, in addition to various regulatory and risk management requirements. Putting this into context, 15 to 20 years ago, even treatment studies targeting psychiatric disorders (primary suicide risk factors) commonly excluded people with a history of a suicide attempt or current suicidal thoughts (Pearson, Stanley, King, & Fisher, 2001). Such exclusions are now uncommon as the study of representative samples of participants has been increasingly emphasized and funded. This leaves us to take the next step — encouraging researchers in other areas to also "go there."
Three primary barriers and possible resolutions are:
Concern that asking about suicide may exacerbate risk. Participant safety is a primary concern of researchers. Some researchers fear that asking study participants questions about suicidal thoughts or attempts will "put the idea" in their heads or exacerbate their suicide risk. Fortunately, several studies have been conducted on this issue. One study examined the impact of responding to research questions about suicidal thoughts on students and found no negative effects (Gould et al., 2005). Another study examined the impact of such questions on individuals recently discharged from a psychiatric inpatient service and found they were rarely associated with increased self-harm (Eynan et al., 2014). In this study, the few participants who required intervention following the assessment were highly suicidal at baseline. If the assessment is conducted in a sensitive manner and a risk management protocol is in place (discussed below), it is possible to conduct such research without a negative impact.
The burden of risk management. Concerns about risk management may be voiced as "how do I recognize risk?" and "how do I manage risk?" Researchers may also wonder how often they should monitor participants' survey responses for possible suicide risk and whether there is an obligation for direct action if the participant's responses indicate possible suicide risk. Researchers may also be concerned about the time and resources required for risk management, in addition to a fear of making an error in risk management with tragic consequences.
There are no easy answers to these questions as the risk management protocol will vary with the participant sample, the study assessment plan and the primary study aims.
If the primary study aims pertain to suicide risk, if study participants are known to be at elevated risk for suicide or if the study assesses indicators of highly elevated risk, a comprehensive risk management protocol with involvement of a mental health professional is highly recommended and probably necessary for IRB approval. Such a protocol specifies:
- The indicators of a possible risk concern (e.g., study participant responds "yes" to question regarding suicide preparations or suicidal intent).
- The action steps to be taken by research staff when the indicator is present (including identifying a mental health professional who can be contacted regarding next steps).
- A list of referral resources and emergency contact numbers. In these protocols, the timeliness of reviewing participants' responses (before they leave the study setting) is usually emphasized. Such a systematic approach, involving a series of steps with follow-through and record keeping, facilitates both quality assurance and peace of mind for the researcher. Examples of such risk management approaches have been published and may be helpful to readers (e.g., Linehan, Comtois, & Ward-Ciesielski, 2012; Brown, Bruce, & Pearson, 2001).
It is important to note, however, that some "added value" studies may provide important data on suicide, yet infrequently or rarely encounter participants with acute suicide risk. Their primary study aims do not pertain to suicide risk, and they do not involve a high-risk sample of participants. The risk management approach ("action steps") may differ in these studies, and may or may not require the availability of an on call mental health professional. If a subject's response to a study question triggers a suicide risk concern, such studies might put a system in place to provide the subject with mental health referral and resource information. If the risk seems to be more acute, referral could be to a local emergency department or may involve calling the National Suicide Prevention Lifeline (1-800-273-TALK), which has trained crisis counselors. It is recommended that the specifics of the risk management protocol for added value studies be considered carefully with consultation from a suicide prevention expert or mental health professional. The reader is also referred to the article by Pearson, Stanley, King and Fisher (2001), which outlines various safety and ethical issues.
A need for incremental resources. There is no question that some incremental resources in staff time or consultation fees are generally necessary for these added value studies. Resources may be needed for the involvement of a consultant who is familiar with suicide risk assessment tools and risk management, the training of study personnel in risk management, the cost of having an on call mental health professional if warranted, and assistance with the interpretation of findings.
Increasing the pool of researchers who study suicide through added value research could advance our understanding of how to prevent this tragedy. Although the concerns and barriers to doing so are real, they can be addressed with consultation, a systematic risk management strategy and modest incremental resources.
Cheryl King, PhD, is a professor in the departments of psychiatry and psychology, director of the Youth Depression and Suicide Prevention Research Program, and director of the Mary A. Rackham Institute at the University of Michigan.
