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.

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.

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.

Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force.

BACKGROUND: The National Action Alliance for Suicide Prevention Research Prioritization Task Force (RPTF) has created a prioritized national research agenda with the potential to rapidly and substantially reduce the suicide burden in the U.S. if fully funded and implemented. PURPOSE: Viable, sustainable scientific research agendas addressing challenging public health issues such as suicide often need to incorporate perspectives from multiple stakeholder groups (e.g., researchers, policymakers, and other end-users of new knowledge) during an agenda-setting process. The Stakeholder Survey was a web-based survey conducted and analyzed in 2011-2012 to inform the goal-setting step in the RPTF agenda development process. The survey process, and the final list of "aspirational" research goals it produced, are presented here. METHODS: Using a modified Delphi process, diverse constituent groups generated and evaluated candidate research goals addressing pressing suicide prevention research needs. RESULTS: A total of 716 respondents representing 49 U.S. states and 18 foreign countries provided input that ultimately produced 12 overarching, research-informed aspirational goals aimed at reducing the U.S. suicide burden. Highest-rated goals addressed prevention of subsequent suicidal behavior after an initial attempt, strategies to retain patients in care, improved healthcare provider training, and generating care models that would ensure accessible treatment. CONCLUSIONS: The Stakeholder Survey yielded widely valued research targets. Findings were diverse in focus, type, and current phase of research development but tended to prioritize practical solutions over theoretical advancement. Other complex public health problems requiring input from a broad-based constituency might benefit from web-based tools that facilitate such community input.

A strategic approach for prioritizing research and action to prevent suicide.

It is time to strategically apply science and accountability to the public health problem of preventable suicide. U.S. suicide rates have remained stable for decades. More than 36,000 individuals now die by suicide each year. A public health-based approach to quickly and substantially reduce suicides requires strategic deployment of existing evidence-based interventions, rapid development of new interventions, and measures to increase accountability for results. The purpose of this Open Forum is to galvanize researchers to further develop and consolidate knowledge needed to guide these actions. As researchers overcome data limitations and methodological challenges, they enable better prioritization of high-risk subgroups for targeted suicide prevention efforts, identification of effective interventions ready for deployment, estimation of the implementation impact of effective interventions in real-world settings, and assessment of time horizons for taking implementation to scale. This new knowledge will permit decision makers to take strategic action to reduce suicide and stakeholders to hold them accountable for results.

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.

Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis.

CONTEXT: To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. EVIDENCE ACQUISITION: A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. EVIDENCE SYNTHESIS: An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). CONCLUSIONS: Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level.

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.

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.

African American children's reports of depressed mood, hopelessness, and suicidal ideation and later suicide attempts.

This study attempted to assess whether family demographic characteristics and child aggressive behavior are equal to or better than child self-reported depressive symptoms in predicting suicidal behavior. Participants were a community population of African Americans first recruited at age 6 and followed periodically through age 19-20. Measures included child self-reports of depressed mood, hopelessness, and suicidal ideation, teacher reported child aggression in grades 4-6, 6 th grade caregiver report of family demographic characteristics, and the participants' report at age 19-20 of suicide attempts. Depressed mood proved the most consistent predictor of adolescent/young adult attempts in our logistic regression analyses of the data from the population as a whole and among females. The relationship between depressed mood and suicide attempts in males was in the expected direction, but was not statistically significant. Teacher-reported youth aggressive behavior did prove to be a significant predictor of attempts in 4 th and 5 th grade for the population as a whole, but not in our analyses by gender. The relationships between family demographic characteristics and attempts failed to reach statistical significance, but were, generally, in the expected direction. The study revealed that African American children's self-reports of depressed mood as early as grade 4 may prove useful in predicting adolescent/young adult suicide attempts, particularly among females. Neither family demographics nor teacher-reported child aggressive behavior proved equal to child self-reported depressive symptoms in predicting later suicide attempts.

Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.

CONTEXT: Suicide rates are highest in late life; the majority of older adults who die by suicide have seen a primary care physician in preceding months. Depression is the strongest risk factor for late-life suicide and for suicide's precursor, suicidal ideation. OBJECTIVE: To determine the effect of a primary care intervention on suicidal ideation and depression in older patients. DESIGN AND SETTING: Randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) with patient recruitment from 20 primary care practices in New York City, Philadelphia, and Pittsburgh regions, May 1999 through August 2001. PARTICIPANTS: Two-stage, age-stratified (60-74, > or =75 years) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened negative patients. This analysis included patients with a depression diagnosis (N = 598). INTERVENTION: Treatment guidelines tailored for the elderly with care management compared with usual care. MAIN OUTCOME MEASURES: Assessment of suicidal ideation and depression severity at baseline, 4 months, 8 months, and 12 months. RESULTS: Rates of suicidal ideation declined faster (P =.01) in intervention patients compared with usual care patients; at 4 months, in the intervention group, raw rates of suicidal ideation declined 12.9% points (29.4% to 16.5%) compared with 3.0% points (20.1% to 17.1% in usual care [P =.01]). Among patients reporting suicidal ideation, resolution of ideation was faster among intervention patients (P =.03); differences peaked at 8 months (70.7% vs 43.9% resolution; P =.005). Intervention patients had a more favorable course of depression in both degree and speed of symptom reduction; group difference peaked at 4 months. The effects on depression were not significant among patients with minor depression unless suicidal ideation was present. CONCLUSIONS: Evidence of the intervention's effectiveness in community-based primary care with a heterogeneous sample of depressed patients introduces new challenges related to its sustainability and dissemination. The intervention's effectiveness in reducing suicidal ideation, regardless of depression severity, reinforces its role as a prevention strategy to reduce risk factors for suicide in late life.

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.