New paper identifies obstacles to suicide prevention research
August 2022
Suicide prevention is a pressing concern for physicians and healthcare researchers, but obstacles have impaired researchers’ ability to conduct effective clinical trials and collect evidence. A new paper calls for innovation and reform to the research process to overcome these obstacles.
The Centers for Disease Control and Prevention (CDC) says over 45,000 deaths from suicide occur in the United States each year. A disproportionate 80% of those deaths are men, particularly middle-aged men (aged 35-64 years). Men often will not disclose suicidal thoughts making it difficult to get them needed treatment, even though half of adults who die by suicide visit a primary care physician in the month before their death.
This uniquely positions primary care physicians to prevent unnecessary deaths. Yet primary care settings have not been a focus of clinical suicide prevention efforts, leaving specialty mental health care providers like psychiatric facilities and metal health clinics—or emergency departments after an attempted suicide—as the primary setting for treatment.
“Additional focus on suicide prevention efforts in primary care settings may provide critical opportunities to prevent deaths by suicide,” said the paper’s lead author Anthony Jerant. Jerant is the interim director of the Center for Healthcare Policy and Research (CHPR) and chair of the Department of Family and Community Medicine at UC Davis Health.
“Specialty mental health care providers are an important part of suicide prevention. But only 20% of men who die by suicide visit a specialty mental health care provider in the month leading up to their death, so we think primary care physicians could be uniquely situated to save lives.”
Previous suicide prevention papers coauthored by Jerant have focused on the Men and Providers Preventing Suicide (MAPS) program. MAPS is a tailored interactive computer program that encourages middle-aged men with suicidal thoughts to discuss the topic with their primary care physician. In a randomized controlled trial, MAPS was shown to prompt these men to discuss the topic with their physicians, opening the door to intervention and treatment. Yet, logistical difficulties with conducting the trial, especially the portion following the use of MAPS, limited the researchers’ ability to detect the program's long-term benefits. Such as a reduction in “making preparations” for suicide by planning and obtaining the means.
Specifically, Jerant said suicide prevention trials in primary care settings could provide useful insights, but the effectiveness of trials like his is limited by recruitment and methodological challenges stemming from well-intentioned but questionable Institutional Review Board (IRB) requirements.
For example, in randomized controlled trials, IRBs often require researchers to provide control arm participants with essentially the same care as those in the experimental arm. This can limit the potential to demonstrate longer term benefits of promising interventions like MAPS and waste valuable research funding and time.
Recruiting trial participants is another challenge. The MAPS study contacted over 4,000 men but only recruited 48 due to difficulties identifying and enrolling suicidal men in trials. Such recruitment challenges can lead to small sample sizes and further weaken the ability to demonstrate the benefits of the intervention, due to low statistical power.
“We need to focus on methodological innovations to enroll more trial participants and begin a conversation with IRB members, researchers and patients to reconsider and potentially reform IRB ethical guidance, allowing us to safeguard study participants but without undermining the scientific integrity of clinical trials of novel suicide prevention interventions,” Jerant said.
The paper’s coauthors are Richard Kravitz, Camille Cipri, David Liu, Lorin Scher and Peter Franks from UC Davis and colleagues from Rutgers University, University of Rochester, M. Freitas Therapy and MJH Therapy and Associates. It was published in the Journal of Psychiatric Research.
The MAPS studies were supported by CHPR and funded by the CDC.