Advancing Intervention and Prevention Research for Behavioral Health Problems Through Data Synthesis.

This commentary on the special issue, "Innovations and Applications of Integrative Data Analysis (IDA) and Related Data Harmonization Procedures in Prevention Science" summarizes the utility of data synthesis techniques to elucidate prevention effects in important ways, including effects on low base-rate conditions and effects across multiple small-scale studies of preventive interventions, long-term and crossover effects of preventive interventions, and addressing for whom preventive interventions work, and for how long. In addition, articles tackle methodological challenges by integrating and harmonizing data. Much progress has occurred in the past 5 years. We consider in this commentary the full collection of papers in the special issue, and their ongoing contributions of data synthesis methods for advancing research on the prevention of mental, emotional, and behavioral health problems. We organize our observations by several themes noted across the papers. We also highlight the National Institute of Mental Health's investments that align with many of the efforts summarized here to advance our understanding of prevention research.

Preventing Youth Suicide: Potential "Crossover Effects" of Existing School-Based Programs.

Notable increases in youth mental health problems combined with strains on the already stretched mental health workforce raise concerns that there will be an ensuing increase in youth suicide thoughts, behaviors, and even deaths. Schools are recognized as crucial settings for youth mental health support and suicide prevention activities, yet schools also face staff shortages and ever-increasing responsibilities for student well-being. Evidence is emerging that prevention programs originally designed to improve problem-solving skills and social-emotional functioning in youth have demonstrated downstream, "crossover effects," that is, unanticipated benefits, on youth suicidal behavior. Relatively little research on crossover effects has been conducted within school settings, despite the strong potential for commonly administered programs to have an impact on later suicide risk. We review key suicide risk factors and their proposed mechanisms of action; we also discuss factors that may protect against suicide risk. We then identify upstream prevention programs targeting the same factors and mechanisms; these programs may hold promise for downstream, crossover effects on youth suicide risk. This paper is intended to provide a framework to help researchers, practitioners, and policymakers as they consider how to prevent youth suicide using existing school-based resources. Rigorous investigation of upstream prevention programs is urgently needed to determine ideal approaches schools and communities can deploy to prevent youth suicide.

Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach.

BACKGROUND: Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide. PURPOSE: The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide. HIGHLIGHTS: Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors. OUTCOMES: The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised. PRACTICAL APPLICATIONS: Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

Using science to improve communications about suicide among military and veteran populations: looking for a few good messages.

Concern about suicide in US military and veteran populations has prompted efforts to identify more effective prevention measures. Recent expert panel reports have recommended public communications as one component of a comprehensive effort. Messaging about military and veteran suicide originates from many sources and often does not support suicide prevention goals or adhere to principles for developing effective communications. There is an urgent need for strategic, science-based, consistent messaging guidance in this area. Although literature on the effectiveness of suicide prevention communications for these populations is lacking, this article summarizes key findings from several bodies of research that offer lessons for creating safe and effective messages that support and enhance military and veteran suicide prevention efforts.

Consensus Statement on Ethical & Safety Practices for Conducting Digital Monitoring Studies with People at Risk of Suicide and Related Behaviors.

OBJECTIVE: Digital monitoring technologies (e.g., smart-phones and wearable devices) provide unprecedented opportunities to study potentially harmful behaviors such as suicide, violence, and alcohol/substance use in real-time. The use of these new technologies has the potential to significantly advance the understanding, prediction, and prevention of these behaviors. However, such technologies also introduce myriad ethical and safety concerns, such as deciding when and how to intervene if a participant's responses indicate elevated risk during the study? METHODS: We used a modified Delphi process to develop a consensus among a diverse panel of experts on the ethical and safety practices for conducting digital monitoring studies with those at risk for suicide and related behaviors. Twenty-four experts including scientists, clinicians, ethicists, legal experts, and those with lived experience provided input into an iterative, multi-stage survey, and discussion process. RESULTS: Consensus was reached on multiple aspects of such studies, including: inclusion criteria, informed consent elements, technical and safety procedures, data review practices during the study, responding to various levels of participant risk in real-time, and data and safety monitoring. CONCLUSIONS: This consensus statement provides guidance for researchers, funding agencies, and institutional review boards regarding expert views on current best practices for conducting digital monitoring studies with those at risk for suicide-with relevance to the study of a range of other potentially harmful behaviors (e.g., alcohol/substance use and violence). This statement also highlights areas in which more data are needed before consensus can be reached regarding best ethical and safety practices for digital monitoring studies.

Advancing Research in Child Suicide: A Call to Action.

OBJECTIVE: To highlight the problem of child suicide, summarize what is known and not known about the problem in the empirical literature, and provide recommendations with ethical considerations for future research and practice. METHOD: The development of this paper was informed by a meeting of national experts on the topic hosted by the National Institute of Mental Health, as well as by a review of the empirical literature. RESULTS: We know something about demographic characteristics that are related to higher child suicide rates, but beyond that we know relatively little about risk factors, prevention, and intervention for suicide risk in children <12 years. It is important for child suicide researchers and practitioners to pay particular attention to ethical issues that may be likely to arise in doing this type of work. CONCLUSION: Much more research is needed on child suicide in the areas of measurement, prevention, and intervention in order to advance the field and provide practitioners with the tools that they critically need.

Increases in Demand for Crisis and Other Suicide Prevention Services After a Celebrity Suicide.

OBJECTIVE: This study examined data on acute (i.e., within 30 days) increases in suicides, help and information seeking, and service capacity after a celebrity suicide. METHODS: Daily suicide data, call volume to the National Suicide Prevention Lifeline (NSPL), and visits to two suicide prevention Web sites before and after entertainer Robin Williams' death on August 11, 2014, were examined. RESULTS: Before August 11 in 2012, 2013, and 2014, daily suicide deaths averaged between 113 and 117; in 2014, the count increased to 142, an increase not observed in 2012 and 2013. The number of calls to the NSPL rose by up to 300%, but answered calls decreased from an average of 71% to 57%. Visits to both Web sites also increased dramatically. CONCLUSIONS: Dramatic increases in all three measured outcomes in the days after a celebrity suicide were noted, suggesting the need for contingency plans to meet immediate increased demand.

Modeling the Cost-Effectiveness of Interventions to Reduce Suicide Risk Among Hospital Emergency Department Patients.

OBJECTIVE: This study estimated the expected cost-effectiveness and population impact of outpatient interventions to reduce suicide risk among patients presenting to general hospital emergency departments (EDs), compared with usual care. Several such interventions have been found efficacious, but none is yet widespread, and the cost-effectiveness of population-based implementation is unknown. METHODS: Modeled cost-effectiveness analysis compared three ED-initiated suicide prevention interventions previously found to be efficacious-follow-up via postcards or caring letters, follow-up via telephone outreach, and suicide-focused cognitive-behavioral therapy (CBT)-with usual care. Primary outcomes were treatment costs, suicides, and life-years saved, evaluated over the year after the index ED visit. RESULTS: Compared with usual care, adding postcards improved outcomes and reduced costs. Adding telephone outreach and suicide-focused CBT, respectively, improved outcomes at a mean incremental cost of $4,300 and $18,800 per life-year saved, respectively. Monte Carlo simulation (1,000 repetitions) revealed the chance of incremental cost-effectiveness to be a certainty for all three interventions, assuming societal willingness to pay ≥$50,000 per life-year. These main findings were robust to various sensitivity analyses, including conservative assumptions about effect size and incremental costs. Population impact was limited by low sensitivity of detecting ED patients' suicide risk, and health care delivery inefficiencies. CONCLUSIONS: The highly favorable cost-effectiveness found for each outpatient intervention provides a strong basis for widespread implementation of any or all of the interventions. The estimated population benefits of doing so would be enhanced by increasing the sensitivity of suicide risk detection among individuals presenting to general hospital EDs.

Substance use, firearm availability, depressive symptoms, and mental health service utilization among white and African American suicide decedents aged 15 to 64 years.

PURPOSE: We investigated whether the substance use problems of excessive alcohol consumption and marijuana use, firearm availability, depressive symptoms, and mental health service utilization, differed among white and African American suicide decedents compared with natural cause-of-death decedents. METHODS: The subjects were a representative sample of 22,957 deceased individuals aged 15 years or older from the 1993 US National Mortality Followback Survey (NMFS). A matched case-control study was constructed for suicide decedents aged 15 to 64 years, with natural death controls frequency matched to cases by age and gender. Conditional logistic regression analysis was used to examine the associations of risk factors with suicide by race. RESULTS: When compared with natural causes of death, suicide deaths among white decedents were associated with use of mental health services, heavy drinking, marijuana use, depression symptoms, and firearm availability. Suicides by African American decedents were associated only with use of mental health services, marijuana, and firearm availability. The interaction of mental health service use and marijuana use was significant only for white suicide decedents. CONCLUSION: This study contributes to the limited understanding of how risk factors unique to suicide differ, and possibly interact, among African American and white decedents. Similarities and differences in risk factors should be considered in suicide prevention planning efforts.

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life.

OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.

The science of public messages for suicide prevention: a workshop summary.

There is minimal guidance for efforts to create effective public messages that increase awareness that suicide is preventable. To address this need, several agencies in the U.S. Department of Health and Human Services and the Annenberg Foundation convened a workshop consisting of suicide prevention advocates and persons with expertise in public health evaluation, suicide contagion, decision-making, and marketing. "Logic models" were used to define intended messages and audiences, assumed mechanisms of change, and outcomes. This summary describes some of the challenges and opportunities identified by workshop participants in evaluating public awareness campaigns in suicide prevention, technical assistance needs, and a proposed research agenda.

Contact with mental health and primary care providers before suicide: a review of the evidence.

OBJECTIVE: This study examined rates of contact with primary care and mental health care professionals by individuals before they died by suicide. METHOD: The authors reviewed 40 studies for which there was information available on rates of health care contact and examined age and gender differences among the subjects. RESULTS: Contact with primary care providers in the time leading up to suicide is common. While three of four suicide victims had contact with primary care providers within the year of suicide, approximately one-third of the suicide victims had contact with mental health services. About one in five suicide victims had contact with mental health services within a month before their suicide. On average, 45% of suicide victims had contact with primary care providers within 1 month of suicide. Older adults had higher rates of contact with primary care providers within 1 month of suicide than younger adults. CONCLUSIONS: While it is not known to what degree contact with mental health care and primary care providers can prevent suicide, the majority of individuals who die by suicide do make contact with primary care providers, particularly older adults. Given that this pattern is consistent with overall health-service-seeking, alternate approaches to suicide-prevention efforts may be needed for those less likely to be seen in primary care or mental health specialty care, specifically young men.

Indirect Self-Destructive Behavior Among Elderly Patients in Nursing Homes: A Research Agenda.

Although suicide is rare in nursing homes, indirect self-destructive behaviors (ISDBs), such as the refusal to eat or take life-sustaining medications, are commonplace. For some, ISDB represents a cry for help, whereas in others it is a reasoned behavioral expression of legitimate preference for an earlier death. This article reports on the proceedings of a workshop held in May 1994 to discuss ISDB in long-term care settings. After a historical review, issues discussed by workshop participants are presented and a research agenda proposed. Future studies are advocated with regard to correlates for ISDB that are relevant to the patient and characteristic of the nursing home environment.

Outcome Measures in Late-Life Depression.

The constructs and suggested measures listed here are recommended for inclusion in clinical treatment trials of late-life depression to optimize the return on the significant effort involved in these studies. The suggested measures have shown utility in studies documenting outcomes in depression studies; however the measures listed are by no means to be interpreted as exhaustive. The authors propose that consistent use of a broad set of outcome measures will assist clinicians and policymakers in the identification of appropriate treatments for older, depressed patients.

Challenges in preventing relapse in major depression. Report of a National Institute of Mental Health Workshop on state of the science of relapse prevention in major depression.

On 21 and 22 May 2001, the National Institute of Mental Health convened a workshop to explore imminent scientific opportunities and encourage new research on preventing relapse in major depression, as a part of a larger effort to find treatments capable of producing durable long-term recovery from major depression. Participants considered definitional and developmental perspectives on depression relapse, the prophylactic potential of current treatments and their cost effectiveness and the neurobiological and psychological risk factors for episode return. It was recommended that the definition of the relapse construct be expanded to capture salient features of incomplete recovery or partial response to treatment that are associated with significant functional impairment. This information is often overlooked by the categorical criteria currently in use. With respect to interventions, there was support for sequencing pharmacological remission with psychological prophylaxis. Provision of focal, short-term treatments that embed relapse prevention skills augment the routes to effective prevention available to patients, beyond that afforded by continuation pharmacotherapy. The challenge will be to identify those subgroups of patients for whom each treatment algorithm is indicated. Finally, the link between basic science findings of biological and psychological markers of relapse vulnerability and treatment design needs to be strengthened. This could be accomplished by assessing patients in clinical prevention trials for the presence of, and changes in, relapse vulnerability markers, thereby providing direct, outcome-based data to gauge the protective value of different treatments that modify these markers.

Major depressive disorder in a population of urban, African-American young adults: prevalence, correlates, comorbidity and unmet mental health service need.

BACKGROUND: The U.S. Surgeon General recently highlighted the relative dearth of research on the mental health of minority populations in the U.S. The present report describes the prevalence of major depressive disorder (MDD) in an epidemiologically-defined population of 1197, predominately poor, African-American 19-22-year-olds, living in the greater Baltimore, MD metropolitan area. METHODS: The prevalence and correlates of MDD, its comorbidity with other mental and substance disorders, and unmet mental health service need were assessed via a structured clinical interview administered by lay interviewers. RESULTS: Using DSM-IV criteria, the overall prevalence of lifetime MDD for the study population was 9.4%, whereas the last year and last month prevalences were 6.2 and 2.7%, respectively. Females were approximately 1.6 times more likely to report a lifetime episode of MDD than males. MDD was highly comorbid with substance disorders. Just under 10% of those who had experienced an episode of MDD within the last year reported receiving mental health specialty services within the last year. LIMITATIONS: A major limitation was the reliance on a single interview conducted by a lay interviewer as opposed to a comprehensive psychiatric assessment carried out by a highly trained clinician, integrating information on symptoms and functioning from multiple sources. CONCLUSIONS: The lifetime prevalence of MDD found in the present study suggests that it is a significant mental health problem in the African-American young adults studied, particularly amongst women. Moreover, most episodes of MDD went untreated.