The Scottish Government

« Previous | Contents | Next »

Listen

SUICIDE AND SUICIDAL BEHAVIOUR: ESTABLISHING THE TERRITORY FOR A SERIES OF RESEARCH REVIEWS

CHAPTER FIVE: SUGGESTED TERRITORIES FOR A SERIES OF RESEARCH REVIEWS

INTRODUCTION

5.1 The feedback from the research specialists and the expert group gathered through the survey and consultation process respectively has been used to refine the review options. This section provides additional guidance to the National Implementation Support Team as to how they might prioritise and allocate resources to potential review options related to suicide and suicidal behaviour while ensuring that all issues and gaps in the evidence will be addressed.

5.2 We suggest that five reviews are commissioned. Three relate to the 'determinants' element of the framework, while two relate to the 'interventions' element.

Epidemiology

5.3 Following advice from the expert group, it is recommended that work on the epidemiology of suicide and deliberate self-harm should not be commissioned as a review, but as a separate project based on secondary data analysis. Suggested changes to the proposed specification of this project, following the consultation process, have been described in paragraphs 4.18 to 4.21 (above).

Determinants and interventions

5.4 Under the 'determinants' element, three reviews are identified:

D1. Towards a comprehensive biopsychosocial model of suicidal behaviour
D2. Current knowledge of risk conditions and risk factors for suicidal behaviour
D3. What protects against suicidal behaviour?

Under the 'interventions' element, two linked reviews are identified:

E1. Preventing suicidal behaviour for key risk groups: what works and what doesn't work?
E2. Preventing suicidal behaviour in the general population: what works and what doesn't work?

Issues for consideration relating to the review specifications

5.5 The reviews will seek to employ a range of appropriate methods. Systematic review may not be appropriate for dealing with all of the review tasks; methods such as synthetic overview and conceptual synthesis will also have relevance, particularly in respect of review D1.

5.6 When drawing up specifications for the reviews, commissioners will need to bear the following points in mind:

• Recent reviews have identified a diversity of definitions and understandings of suicidal behaviour and suicidal ideation. This is particularly important in relation to deliberate self-harm because of the inherent difficulties in distinguishing between DSH that is intentional but not suicidal (i.e. intended to result in death) and DSH that is a suicide attempt ( see glossary). The Scottish Executive commissioning team will have to decide what aspects of suicidal behaviour they want to include in the reviews.

• Successful bids for commissioned reviews should demonstrate an understanding of the need to contribute to policy development and support effective practice. Final reports should include recommendations ('so what?') for the development of national and local policy and practice (for instance, consideration of the cost benefits of interventions or investment in training)

• Successful bids for commissioning reviews would be expected to recognise the importance of assessing the transferability of findings to the Scottish context, including consideration of socio-cultural and economic contexts, and service structures.

• Final Reports should discuss the implications of findings for future monitoring, evaluation and research, with particular reference to the Scottish context.

• The commissioning tenders should recommend that the review research team includes a practitioner and/or a service user (or else can demonstrate that practitioner/user views have been canvassed in the course of producing the review)

• The commissioning tenders should recommend that the review research team is a partnership combining diverse disciplinary perspectives/understandings and user and carer representation where appropriate.

DETERMINANTS OF SUICIDAL BEHAVIOUR

D1. Towards a comprehensive biopsychosocial model of suicidal behaviour

5.7 Although the expert group expressed some reservations, there was broad support to retain this topic in the review portfolio (see box 4.2, paragraphs 4.23 to 4.27). In order to ensure that the review meets the needs of the Choose Life implementation programme, the commissioned team will need to demonstrate the practical relevance and usefulness of the review work, at both national and local levels. The implications of the model(s), developed in the course of the review, for stimulating and innovative cross-cutting interventions should be highlighted.

5.8 Pre-definition of the composition of the review team is not recommended, although acknowledgement of the importance of adequate disciplinary representation would be expected in the proposal. We recommend that the review team be directed towards the production of separate models of deliberate self-harm and suicide, although explicit comparisons of the elements and pathways of each model would be expected.

D2. Current knowledge of risk conditions and risk factors for suicidal behaviour

5.9 Among members of the expert group, there was broad support for the topic and its retention in the review portfolio ( box 4.3 and paragraphs 4.29 to 4.32). Few changes to the outline specification ( box 4.3) were suggested.

5.10 It is recommended that the specification for the review add to the list of high risk groups those mentioned by the experts ( see paragraph 4.30), although it should be pointed out that some of these were mentioned in the original consultation document. In particular, the reference to inequalities (the growing divide related to age, income and locality) highlights an important issue which was not sufficiently emphasised in the original consultation document.

5.11 The comment by one expert on the need to focus on attributable risk (the proportion of DSH or suicide in the whole population that can be ascribed to a particular risk factor, e.g. unemployment or psychiatric illness) rather than relative risk (the rate of DSH or suicide among those exposed to a particular risk factor, e.g. unemployed, psychiatrically ill, compared to those not exposed e.g. employed, not psychiatrically ill) underlines the importance of ensuring that the review is based on a comprehensive and sophisticated approach to conceptualising risk.

D3. What protects against suicidal behaviour?

5.12 Among members of the expert group, there was broad support for the topic and its retention in the review portfolio (see box 4.4, paragraphs 4.34 to 4.39). On the basis of comments made by the expert group, and the desirability of differentiating clearly between reviews on determinants and reviews on interventions, we recommend that this review should exclude a synthesis of knowledge about the effectiveness of interventions to promote resilience.

EFFECTIVE INTERVENTIONS TO REDUCE SUICIDAL BEHAVIOUR

E1. Preventing suicidal behaviour in key risk groups: what works and what doesn't work?

and

E2. Preventing suicidal behaviour in the general population: what works and what doesn't work?

5.13 The two review topics (E1) and (E2) above were presented in the original consultation documentation as a single review topic ( see box 4.5). This was given the highest priority by those in the expert group who attempted to prioritise the topics. Specialists who participated in the survey also highlighted the importance of interventions as a top priority.

5.14 On the basis of views expressed by the expert group, we recommend the commissioning of two separate reviews, one covering the effectiveness of interventions to reduce suicidal behaviour in high risk groups (E1), the other on the effectiveness of general population, public health interventions (E2). However, in order to avoid duplication and maximise opportunities for comparison of findings between the reviews, two approaches to commissioning should be considered: either combining the reviews into a single tender; or (if the reviews are commissioned from different teams) insisting that adequate liaison and communication between the two research teams are in place for the duration of the project.

5.15 Suggested changes to the outline specification (box 4.5, paragraphs 4.41 to 4.47) included: importance of highlighting evidence concerning ineffectiveness (what doesn't work) as well as effectiveness; ensuring that findings are written to be accessible and relevant at local and national levels; differentiating between interventions to reduce (repeat) deliberate self-harm and interventions to reduce suicide; and identifying variations in strategic approach to the reduction of suicidal behaviour in different high risk groups.

5.16 We also recommend that the research tender should draw attention to a more recent review of suicide prevention strategies (Guo, Scott and Bowker 2003) which builds on earlier reviews. One question, which we are unable to resolve on the basis of responses to the expert consultation, is whether one or both of the proposed effectiveness reviews could be based on a synthesis of evidence from existing reviews (a 'review of reviews'), rather than requiring analysis of the primary literature. The commissioners might like to consider the possibility of leaving this issue unresolved in the tender, and inviting researchers to decide upon, and defend, their particular approach.

5.17 The above suggested territories for a series of research reviews are based on a strong foundation of consultation with international and Scottish experts in the field of suicide and suicidal behaviour. This gives grounds for confidence that, if the Scottish Executive commissioners follow these suggestions, the research reviews they commission will meet the particular needs of Scotland in relation to the implementation of Choose Life whilst covering all aspects of suicide and suicidal behaviour and avoiding duplication.

REFERENCES

General Registrar Office Annual Report of the Registrar General for Scotland (2000) www.gro-scotland.gov.uk

Data Protection Act 1998 Elizabeth II. Chapter 29, The Stationery Office: London; The Privacy and Electronic Communications (EC Directive) Regulations 2003, The Stationery Office: London

Guo B, Scott A, Bowker S. Suicide prevention strategies: Evidence from systematic reviews. Edmonton, AB: Alberta Heritage Foundation for Medical Research, Health Technology Assessment; 2003. Report No. HTA 28. http://www.ahfmr.ab.ca/publications.html

Scottish Executive (2002) Choose Life: A National Strategy and Action Plan to Prevent Suicide in Scotlandhttp://80.75.66.189/well/files/CHOOSE%20LIFE.pdf

Scottish Executive (2003) Improving Health in Scotland: The Challenge. The Stationery Office: Edinburgh.

GLOSSARY

Key words and phrases used in this report are defined below.

« Previous | Contents | Next »