National Pathways for Suicide Prevention and Health Services Research


      In 2012, the National Action Alliance for Suicide Prevention’s Research Prioritization Task Force (RPTF) released a series of Aspirational Goals (AGs) to decrease suicide deaths and attempts. The RPTF asked experts to summarize what was known about particular AGs and to propose research pathways that would help reach them. This manuscript describes what is known about the benefits of access to health care (AG8) and continuity of care (AG9) for individuals at risk for suicide. Research pathways are proposed to address limitations in current knowledge, particularly in U.S. healthcare-based research.

      Evidence acquisition

      Using a three-step process, the expert panel reviewed available literature from electronic databases. For two AGs, the experts summarized the current state of knowledge, determined breakthroughs needed to advance the field, and developed a series of research pathways to achieve prevention goals.

      Evidence synthesis

      Several components of healthcare provision have been found to be associated with reduced suicide ideation, and in some cases they mitigated suicide deaths. Randomized trials are needed to provide more definitive evidence. Breakthroughs that support more comprehensive patient data collection (e.g., real-time surveillance, death record linkage, and patient registries) would facilitate the steps needed to establish research infrastructure so that various interventions could be tested efficiently within various systems of care. Short-term research should examine strategies within the current healthcare systems, and long-term research should investigate models that redesign the health system to prioritize suicide prevention.


      Evidence exists to support optimism regarding future suicide prevention, but knowledge is limited. Future research is needed on U.S. healthcare services and system enhancements to determine which of these approaches can provide empirical evidence for reducing suicide.
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        • Heron M.
        Deaths: leading causes for 2009.
        Natl Vital Stat Rep. 2012; 61: 1-94
        • Rockett I.R.
        • Regier M.D.
        • Kapusta N.D.
        • et al.
        Leading causes of unintentional and intentional injury mortality: U.S., 2000–2009.
        Am J Public Health. 2012; 102: e84-e92
        • Crosby A.E.
        • Ortega L.
        • Stevens M.R.
        Suicides—U.S., 1999–2007.
        MMWR Surveill Summ. 2011; 60: S56-S59
        • Holinger P.C.
        • Klemen E.H.
        Violent deaths in the U.S., 1900–1975. Relationships between suicide, homicide and accidental deaths.
        Soc Sci Med. 1982; 16: 1929-1938
        • CDC.
        Suicide among adults aged 35–64 years—U.S., 1999–2010.
        MMWR Morb Mortal Wkly Rep. 2013; 62: 321-325
        • USDHHS Office of the Surgeon General and National Action Alliance for Suicide Prevention
        2012 National Strategy for Suicide Prevention: Goals and Objectives for Action.
        HHS, Washington, DCSeptember 2012 (
        • Mrazek P.J.
        • Haggerty R.J.
        Reducing risks for mental disorders: frontiers for preventive intervention research.
        National Academies Press, Washington DC1994
        • McDowell A.K.
        • Lineberry T.W.
        • Bostwick J.M.
        Practical suicide-risk management for the busy primary care physician.
        Mayo Clin Proc. 2011; 86: 792-800
        • Unutzer J.
        • Schoenbaum M.
        • Druss B.G.
        • Katon W.J.
        Transforming mental health care at the interface with general medicine: report for the presidents commission.
        Psychiatr Serv. 2006; 57: 37-47
        • Ahmedani B.K.
        • Coffey M.J.
        • Coffey C.E.
        Collecting mortality data to drive real-time improvement in suicide prevention.
        Am J Manag Care. 2013; 19: e386-e390
        • Simon G.E.
        • VonKorff M.
        Suicide mortality among patients treated for depression in an insured population.
        Am J Epidemiol. 1998; 147: 155-160
        • McMillan D.
        • Gilbody S.
        • Beresford E.
        • Neilly L.
        Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis.
        Psychol Med. 2007; 37: 769-778
        • O’Connor E.
        • Gaynes B.N.
        • Burda B.U.
        • Soh C.
        • Whitlock E.P.
        Screening for and treatment of suicide risk relevant to primary care: a systematic review for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2013; 158: 741-754
        • Hoge C.W.
        • Castro C.A.
        • Messer S.C.
        • McGurk D.
        • Cotting D.I.
        • Koffman R.L.
        Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care.
        N Engl J Med. 2004; 351: 13-22
        • Ahmedani B.K.
        Mental health stigma: society, individuals, and the profession.
        J Soc Work Values Ethics. 2011; 8: 4-1-4-16
        • Ahmedani B.K.
        • Kubiak S.P.
        • Kessler R.C.
        • et al.
        Embarrassment when illness strikes a close relative: a World Mental Health Survey Consortium Multi-Site Study.
        Psychol Med. 2013; 43: 2191-2202
        • Vannoy S.D.
        • Tai-Seale M.
        • Duberstein P.
        • Eaton L.J.
        • Cook M.A.
        Now what should I do? Primary care physicians’ responses to older adults expressing thoughts of suicide.
        J Gen Intern Med. 2011; 26: 1005-1011
        • Vannoy S.D.
        • Fancher T.
        • Meltvedt C.
        • Unutzer J.
        • Duberstein P.
        • Kravitz R.L.
        Suicide inquiry in primary care: creating context, inquiring, and following up.
        Ann Fam Med. 2010; 8: 33-39
        • Luoma J.B.
        • Martin C.E.
        • Pearson J.L.
        Contact with mental health and primary care providers before suicide: a review of the evidence.
        Am J Psychiatry. 2002; 159: 909-916
        • Ahmedani B.K.
        • Simon G.E.
        • Stewart C.
        • et al.
        Health care contacts in the year before suicide death.
        J Gen Intern Med. 2014; 29: 870-877
        • Cavanagh J.T.
        • Carson A.J.
        • Sharpe M.
        • Lawrie S.M.
        Psychological autopsy studies of suicide: a systematic review.
        Psychol Med. 2003; 33: 395-405
        • Hooper L.M.
        • Epstein S.A.
        • Weinfurt K.P.
        • DeCoster J.
        • Qu L.
        • Hannah N.J.
        Predictors of primary care physicians’ self-reported intention to conduct suicide risk assessments.
        J Behav Health Serv Res. 2012; 39: 103-115
        • Graham R.D.
        • Rudd M.D.
        • Bryan C.J.
        Primary care providers’ views regarding assessing and treating suicidal patients.
        Suicide Life Threat Behav. 2011; 41: 614-623
        • Garfield R.L.
        • Druss B.G.
        Health reform, health insurance, and mental health care.
        Am J Psychiatry. 2012; 169: 675-677
        • Lang M.
        The impact of mental health insurance laws on state suicide rates.
        Health Econ. 2013; 22: 73-88
        • Bruce M.L.
        • Ten Have T.R.
        • Reynolds III, C.F.
        • et al.
        Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial.
        JAMA. 2004; 291: 1081-1091
        • Unutzer J.
        • Katon W.
        • Callahan C.M.
        • et al.
        Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial.
        JAMA. 2002; 288: 2836-2845
        • Gunnell D.
        • Metcalfe C.
        • While D.
        • et al.
        Impact of national policy initiatives on fatal and non-fatal self-harm after psychiatric hospital discharge: time series analysis.
        Br J Psychiatry. 2012; 201: 233-238
        • While D.
        • Bickley H.
        • Roscoe A.
        • et al.
        Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study.
        Lancet. 2012; 379: 1005-1012
        • Mohr D.C.
        • Ho J.
        • Duffecy J.
        • et al.
        Effect of telephone-administered vs face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients: a randomized trial.
        JAMA. 2012; 307: 2278-2285
        • Andrews G.
        • Cuijpers P.
        • Craske M.G.
        • McEvoy P.
        • Titov N.
        Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis.
        PLoS One. 2010; 5: e13196
        • Linehan M.M.
        Suicide intervention research: a field in desperate need of development.
        Suicide Life Threat Behav. 2008; 38: 483-485
        • Morthorst B.
        • Krogh J.
        • Erlangsen A.
        • Alberdi F.
        • Nordentoft M.
        Effect of assertive outreach after suicide attempt in the AID (assertive intervention for deliberate self harm) trial: randomised controlled trial.
        BMJ. 2012; 345: e4972
        • Johannessen H.A.
        • Dieserud G.
        • De L.D.
        • Claussen B.
        • Zahl P.H.
        Chain of care for patients who have attempted suicide: a follow-up study from Baerum, Norway.
        BMC Public Health. 2011; 11: 81
        • Simon G.E.
        • Ludman E.J.
        • Rutter C.M.
        Incremental benefit and cost of telephone care management and telephone psychotherapy for depression in primary care.
        Arch Gen Psychiatry. 2009; 66: 1081-1089
        • Britton P.C.
        • Bossarte R.M.
        • Thompson C.
        • Kemp J.
        • Conner K.R.
        Influences on call outcomes among veteran callers to the National Veterans Crisis Line.
        Suicide Life Threat Behav. 2013; 43: 494-502
        • Gould M.S.
        • Munfakh J.L.
        • Kleinman M.
        • Lake A.M.
        National suicide prevention lifeline: enhancing mental health care for suicidal individuals and other people in crisis.
        Suicide Life Threat Behav. 2012; 42: 22-35
        • DeMartino R.E.
        • Crosby A.E.
        • EchoHawk M.
        • et al.
        A call to collaboration: the federal commitment to suicide prevention.
        Suicide Life Threat Behav. 2003; 33: 101-110
        • Miller M.
        • Hemenway D.
        Guns and suicide in the U.S..
        N Engl J Med. 2008; 359: 989-991
        • Miller M.
        • Warren M.
        • Hemenway D.
        • Azrael D.
        Firearms and suicide in U.S. cities.
        Inj Prev. 2013;
        • Reisch T.
        • Steffen T.
        • Habenstein A.
        • Tschacher W.
        Change in suicide rates in Switzerland before and after firearm restriction resulting from the 2003 “Army XXI” reform.
        Am J Psychiatry. 2013; 170: 977-984
        • Hemenway D.
        Preventing gun violence by changing social norms.
        JAMA Intern Med. 2013; 173: 1167-1168
        • Knox K.L.
        • Litts D.A.
        • Talcott G.W.
        • Feig J.C.
        • Caine E.D.
        Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force: cohort study.
        BMJ. 2003; 327: 1376
        • Hampton T.
        Depression care effort brings dramatic drop in large HMO population’s suicide rate.
        JAMA. 2010; 303: 1903-1905
        • Coffey C.E.
        • Coffey M.J.
        • Ahmedani B.K.
        An update on perfect depression care.
        Psychiatr Serv. 2013; 64: 396
        • Gahm G.A.
        • Reger M.A.
        • Kinn J.T.
        • Luxton D.D.
        • Skopp N.A.
        • Bush N.E.
        Addressing the surveillance goal in the National Strategy for Suicide Prevention: the Department of Defense Suicide Event Report.
        Am J Public Health. 2012; 102: S24-S28
        • Britton P.C.
        • Conner K.R.
        • Maisto S.A.
        An open trial of motivational interviewing to address suicidal ideation with hospitalized veterans.
        J Clin Psychol. 2012; 68: 961-971
        • Pecoraro A.
        • Royer-Malvestuto C.
        • Rosenwasser B.
        • et al.
        Factors contributing to dropping out from and returning to HIV treatment in an inner city primary care HIV clinic in the U.S.
        AIDS Care. 2013; 25: 1399-1406
        • Simon G.E.
        • Rutter C.M.
        • Peterson D.
        • et al.
        Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death?.
        Psychiatr Serv. 2013; 64: 1195-1202
        • Reiss-Brennan B.
        • Briot P.
        • Daumit G.
        • Ford D.
        Evaluation of “depression in primary care” innovations.
        Adm Policy Ment Health. 2006; 33: 86-91
        • Solberg L.I.
        • Glasgow R.E.
        • Unutzer J.
        • et al.
        Partnership research: a practical trial design for evaluation of a natural experiment to improve depression care.
        Med Care. 2010; 48: 576-582
        • Pearson J.L.
        • Stanley B.
        • King C.A.
        • Fisher C.B.
        Intervention research with persons at high risk for suicidality: safety and ethical considerations.
        J Clin Psychiatry. 2001; 62: S17-S26
        • King C.A.
        • Kramer A.C.
        Intervention research with youths at elevated risk for suicide: meeting the ethical and regulatory challenges of informed consent and assent.
        Suicide Life Threat Behav. 2008; 38: 486-497