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SUICIDE AND SUICIDAL BEHAVIOUR: ESTABLISHING THE TERRITORY FOR A SERIES OF RESEARCH REVIEWS
ANNEX THREE: SUMMARY OF DELPHI PROCESS GUIDE TO PHASE 1 FOR EXPERT GROUP
Suicide and Suicidal Behaviour: Establishing the Territory for a Series of Reviews
Delphi Process
Guide to Phase 1 for Expert Group
1. Introduction
The purpose of this document is to set out the first analysis of the survey data gathered in the Suicide and Suicidal Behaviour: Establishing the Territory for a Series of Reviews project to provide a basis for the expert group to participate in the Delphi process, the second stage of the research. The expert group was identified by the SDC and RUHBC research team, and the commissioners at the Scottish Executive's Mental Health Research Team on behalf of the
Choose Life National Implementation Support Team (see Appendix 1).
The document begins with a guide to the procedures for the Delphi process to expert group members. Members of the expert group should read the guide and refer to the data that follow in order to answer the questions the research team have set for phase one of the Delphi Process. The guide is followed by information on the final response to the international survey (see Appendix 2 for survey questionnaire), and a first analysis of the data gathered.
2. Guide to the Delphi Process
2.1 Purpose
The purpose of the Delphi process is to assess and refine the findings of the survey with a view to arriving at an agreed shortlist of research review topics that:
meet the specific needs of Scotland in relation to the implementation of Choose Life
the National Strategy and Action Plan to Prevent Suicide in Scotland
cover all aspects of suicide and suicidal behaviour whilst avoiding over duplication
2.2 Overview of the procedure
The research team has arrived at an adaptation of the classic Delphi process for the purposes of this study. The following sequence of procedures is proposed:
2.2.1. Preparation.Based on a 'first cut' of the survey responses, the research team has agreed a framework for dividing up the reviews (p.10) and how the main issues for the reviews and gaps in research suggested by respondents fit into it. This framework will serve as a reference point throughout the project. This part of the procedure is complete.
2.2.2. Delphi Phase 1 (two weeks)(This is the current phase of the process and further details of what is required from members of the expert group at this phase are given below [2.3]). The expert group is presented with the framework for dividing up reviews and tables 2,3,4 and 5, and asked a set of questions to establish a robust starting point for the generation of research review topic options. The research team will use this feedback from the expert group to:
Refine the framework, if necessary
Use the survey data to identify the highest priority issues for the focus of the reviews and the highest priority gaps and how they fit into the framework
Identify how issues and gaps cut across different components in the framework, and the common links
Assess how many issues and gaps are held within components in the framework at different levels - this will help to identify which components should be split e.g. prevention / intervention / postvention - do they merit being components on their own?
Decide how the framework should be split into review options and how these would be prioritised, making sure that every part of the framework is included within the series of reviews. These options will vary in depth of detail e.g. one review may be on postvention and all of the issues within it, whereas another review may be focussed on psychiatric inpatient issues only. The survey data will determine the order of priority.
2.2.3. Delphi Phase 2 (two weeks) The expert group is given the list of options without prioritisation and asked to rank them in to priority order, giving reasons. The research team will use this feedback to prioritise and, if necessary, refine the review options.
2.2.4 Delphi Phase 3 (two weeks) The expert group is given the prioritised and refined list of review options and asked to confirm or change the order of priority and give reasons why, and also suggest any refinements to the review options. The research team will use this feedback to re-prioritise and refine the review options, if necessary.
The research team will then produce a prioritised list of reviews and account of the Delphi process to the commissioners. This will give the
Choose Life National Implementation Support Team guidance on how they might prioritise and allocate resources to potential review options while providing reassurance that all issues will be covered to some extent.
2.3 What to do now: Phase 1 of the Delphi Process - what's required of the expert group
As a member of the expert group, please follow the guidance in this section to participate and respond to phase 1 of the Delphi process.
1. Read sections 3 (Response) and 4 (Specialist interest areas of respondents). These provide information about those who have participated in the preliminary survey.
2. Read section 5 (Framework for dividing up the reviews), and then refer to sections 6 and 7 below. This will help you to understand the process of analysis that has taken place so far. Phase one of the Delphi process requires your comments on this analysis.
3. Feedback to the research team by Tuesday 4
th May by answering the following questions and giving comments:
a. Does the framework for dividing up the reviews make sense of the data?
b. What's missing?
c. Are the issues and gaps in tables 2 and 4 matched well with the components of the framework?
d. Which matches are missing/need to be changed?
e. Comment on methodological considerations (see section 8)
f. Comment on questions that the reviews should answer (see section 8)
The research team has attempted to be as objective as possible when analysing the survey data. We felt that it was important that the expert group is able to have sight of the data at an early phase, enhancing the opportunity to become familiar with the original data and how it has been processed to date.
If you would like access to the raw database of responses to the survey please contact Joanne McLean. If you would like to discuss any part of this document or any aspect of the study, please contact Joanne or Steve Platt.
3. Response
In total 228 suicide and suicidal behaviour research experts were identified and contacted by email to be invited to participate in the research. Of these, 20 were failed contacts, that is, the individual had left their post or our contact details were incorrect for some other reason. Therefore the number of contacts and potential participants is 208.
We have received 60 completed questionnaires, of which 12 were submitted 'manually' and the rest using the electronic questionnaire system. Fifteen are professors, 36 are Dr's and the rest did not have an academic title. Those responding so far are based in 14 different countries.
4. Specialist interest areas of respondents (All respondents stated more than one specialist interest area.)
Table 1.
Specialist interest area | Number of respondents* |
Epidemiology / prevalence | 19 |
Young people | 18 |
Prevention / awareness raising / public health | 17 |
Mental illness | 14 |
Social causes (including relationships) | 14 |
Interventions / treatments | 12 |
Cultural influences / ethnic minorities | 10 |
Risk assessment / risk management | 9 |
Self harm (non-fatal suicidal behaviour) / repeated suicide attempts / general hospitals | 9 |
Psychological causes | 8 |
Contagion / media | 8 |
Risk and protective factors | 6 |
Suicide aftermath / bereavement / those affected | 5 |
Religiosity | 4 |
Prisons / offending | 3 |
Ethics and legal issues | 3 |
Suicide narrative / suicide notes | 3 |
Means of suicide | 3 |
Older people | 3 |
Neurobiological causes | 2 |
Males | 2 |
Occupational influences | 2 |
Domestic violence | 2 |
Psychiatric medication | 2 |
Urban / rural | 2 |
Multi-disciplinary approaches to suicide / joint working | 2 |
Primary care | 2 |
Intervention / program evaluation | 2 |
Suicide attempts / repeated attempts / general hospitals | 2 |
Physical illness | 1 |
Local suicide action plans | 1 |
Treatment emergent suicide | 1 |
Alcohol and drugs misuse | 1 |
Aggression / impulsivity | 1 |
5. Framework for dividing up the reviews
The framework for dividing up the research reviews (see figure 1 below) is based on the data received from survey question 4a. 'What would you consider to be the most constructive and useful approach to dividing up the reviews of previous research on suicide and suicidal behaviour to ensure comprehensive coverage of all issues whilst avoiding duplication?' The framework combines into one multi-factorial model all the criteria for dividing up the reviews emerging from responses to Q4a. The framework shows the following main levels of analysis:
incidence (split into suicide and deliberate self harm which might be considered as an indication of risk of suicide)
determinants (split into risk factors and protective factors)
interventions (split into primary, secondary and tertiary)
the societal, psychosocial environment, individual and quality of services dimensions
The components of the framework from A to 2n map out the above levels of analysis in detail. At present primary, secondary and tertiary interventions are not split into separate components, for the following reasons: there were fewer suggestions from the respondents that reviews should be split between these levels; and representing these components in the framework would make it unwieldy for the study's purposes at this stage. The purpose of the framework is to act as a reference tool to assist the systematic identification of priority areas for disaggregating and focusing the research reviews. This is where the data from Q's 4b ('What do you consider to be the main issues upon which the reviews should focus?') (tables 2 and 3) and Q5 ('What (do you) you perceive to be the main gaps in the evidence base relevant to the implementation of the Scottish Executive's suicide prevention strategy?) (tables 4 and 5) are relevant.
In order to start the process of prioritisation, the research team has matched each category of issues on which the reviews should focus (tables 2 and 3) and each category of perceived gaps in the research (tables 4 and 5) into the components of the framework. Tables 2 and 3 break down the respondents' suggestions for the issues upon which the reviews should focus and tables 4 and 5 break down the perceptions of the current gaps in the evidence base relevant to the implementation of the Scottish Executive's suicide prevention strategy. For tables 2, 3, 4 and 5 the frequency of an issue or gap category being suggested is given in column 2 and the position of the issue in relation to the framework for dividing up the reviews is given in column 3. For example, Mental illness (as risk factor / effectiveness of treatment / diagnoses)* has been identified by 13 respondents as an issue for focus and maps onto components 1h, 1l and 2n of the framework.
When this task is completed the research team will be able to use the framework and data in tables 2,3,4 and 5 to highlight the areas of priority for dividing up and focusing the reviews. From this, a set of research review options will be derived for phase 2 of the Delphi process.
Figure 1
G03
(Universal)
6. Main issues for reviews - list of priorities
Tables 2 and 3 below break down the respondents' suggestions for the issues upon which the reviews should focus. The frequency of an issue being suggested is given in column 2 and the position of the issue in relation to the framework for dividing up the reviews (1) is given in column 3. Table 2 is sorted by frequency and Table 3 is sorted by position in the framework for dividing up the reviews.
Table 2
*(comments in brackets denote sub-issues)
Issue | Frequency | Position in framework for dividing up the reviews |
Effectiveness of interventions of suicidal individuals | 18 | 2c 2n |
Mental illness (as risk factor / effectiveness of treatment / diagnoses)* | 13 | 1h 2n |
Effective prevention programs (public health) (within health services) | 13 | 2d |
Social causes of suicidal behaviour (international/culture/socio-economic /poverty/occupation/ethnicity/social capital) | 12 | 1f |
Epidemiology of attempted suicide (definitions) (outcomes) | 11 | 1c |
Risk factors | 10 | 1d |
Neurobiological / neuropsychological / genetic causes of suicidal behaviour | 7 | 1h |
Epidemiology of completed suicide | 6 | 1b |
Protective factors | 6 | 1e |
Epidemiology of suicidal ideation | 6 | 1c |
Media (stigma / contagion / attitudes) | 6 | 1f |
Availability of means for suicide | 5 | 1f |
Substance misuse | 5 | 1f 1h 2n |
Macro societal interventions | 5 | 2k |
Medication (psychiatric) | 4 | 2n |
Psychotherapy | 4 | 2n |
Risk assessment | 4 | 2g |
Link between attempted and completed suicide | 4 | 1b 2b |
Psychosocial causes of suicidal behaviour | 3 | 1g |
International / cross cultural differences | 3 | A |
Older people (ageism) | 3 | 2h 1l |
Community based interventions | 3 | 2l |
Identify high risk groups | 3 | 1h |
Current data collection methods | 2 | A |
Young people | 2 | 1h 1l |
Epidemiology over life course (international) | 2 | A 1h |
Primary care intervention | 2 | 2n |
Political decision makers intervention | 2 | 2k |
Promoting emotional literacy and resilience (early intervention) | 2 | 2d 2n |
Occupation and suicide | 2 | 1g 1k 2l |
School based interventions / intervention | 2 | 2n |
Prevalence by age and gender | 2 | A |
Impact of child abuse | 2 | 1h |
Attitudes to help seeking | 2 | 2n |
Engaging difficult to reach groups | 2 | 2m 2n |
Physical illness | 2 | 1h |
Suicidal ideation relationship to suicidal attempts | 2 | A 1b 2b 1d |
Alternatives to hospital treatment (people who refuse treatment) | 2 | 2n |
Evidence based risk assessment in clinical settings | 1 | 2n |
Mental Illness x risk factors | 1 | 1i |
Crisis intervention | 1 | 2e 2n |
Prison | 1 | 2k 2l 2n 1h |
Secondary prevention of deliberate self harm | 1 | 2d 2n |
Non-statutory agencies intervention | 1 | 2n |
Media interventions | 1 | 2k |
Risk factors across the life span | 1 | 1d 1h |
Religiosity and suicide | 1 | 1g 1k 2l |
Deliberate self harm services | 1 | 2n |
Rurality | 1 | 1g 1k |
Young women | 1 | 1h 1l |
Interventions at hospital discharge | 1 | 2n |
Mental health promotion | 1 | 2d 2n |
Middle aged | 1 | 2h 1l |
Interventions for high risk groups | 1 | 2m |
Prevention amongst those affected by suicidal behaviour | 1 | 2m 2n |
Changes in suicide mortality | 1 | A 1b |
Recovery | 1 | 1l |
Post natal depression | 1 | 1h |
Barriers to suicide prevention and treatment | 1 | 2c 2d 2e 2f |
Recognition of psychic pain | 1 | 1c |
Training programs for practitioners and planners | 1 | 2n |
Self help | 1 | 2m |
Domestic abuse | 1 | 1g 1h |
Young men | 1 | 1h |
Table 3
*(comments in brackets denote sub-issues)
Issue | Frequency | Position in framework for dividing up the reviews |
Epidemiology over life course (international) | 2 | A 1h |
Suicidal ideation relationship to suicidal attempts | 2 | A 1b 2b 1d |
Changes in suicide mortality | 1 | A 1b |
Current data collection methods | 2 | A |
International / cross cultural differences | 3 | A |
Prevalence by age and gender | 2 | A |
Psychotherapy | 4 | 2n |
Evidence based risk assessment in clinical settings | 1 | 2n |
Medication (psychiatric) | 4 | 2n |
Deliberate self harm services | 1 | 2n |
School based interventions / intervention | 2 | 2n |
Interventions at hospital discharge | 1 | 2n |
Attitudes to help seeking | 2 | 2n |
Primary care intervention | 2 | 2n |
Non-statutory agencies intervention | 1 | 2n |
Alternatives to hospital treatment (people who refuse treatment) | 2 | 2n |
Training programs for practitioners and planners | 1 | 2n |
Prevention amongst those affected by suicidal behaviour | 1 | 2m 2n |
Engaging difficult to reach groups | 2 | 2m 2n |
Interventions for high risk groups | 1 | 2m |
Self help | 1 | 2m |
Community based interventions | 3 | 2l |
Prison | 1 | 2k 2l 2n 1h |
Political decision makers intervention | 2 | 2k |
Media interventions | 1 | 2k |
Macro societal interventions | 5 | 2k |
Older people (ageism) | 3 | 2h 1l |
Middle aged | 1 | 2h 1l |
Risk assessment | 4 | 2g |
Crisis intervention | 1 | 2e 2n |
Promoting emotional literacy and resilience (early intervention) | 2 | 2d 2n |
Mental health promotion | 1 | 2d 2n |
Secondary prevention of deliberate self harm | 1 | 2d 2n |
Effective prevention programs (public health) (within health services) | 13 | 2d |
Effectiveness of interventions of suicidal individuals | 18 | 2c 2n |
Barriers to suicide prevention and treatment | 1 | 2c 2d 2e 2f |
Recovery | 1 | 1l |
Mental Illness x risk factors | 1 | 1i |
Mental illness (as risk factor / effectiveness of treatment / diagnoses) | 13 | 1h 1p 2n |
Young people | 2 | 1h 1l |
Young women | 1 | 1h 1l |
Neurobiological / neuropsychological / genetic causes of suicidal behaviour | 7 | 1h |
Identify high risk groups | 3 | 1h |
Impact of child abuse | 2 | 1h |
Physical illness | 2 | 1h |
Post natal depression | 1 | 1h |
Young men | 1 | 1h |
Occupation and suicide | 2 | 1g 1k 2l |
Religiosity and suicide | 1 | 1g 1k 2l |
Rurality | 1 | 1g 1k |
Domestic abuse | 1 | 1g 1h |
Psychosocial causes of suicidal behaviour | 3 | 1g |
Substance misuse | 5 | 1f 1h 2n |
Availability of means for suicide | 5 | 1f |
Social causes of suicidal behaviour (international/culture/socio-economic /poverty/occupation/ethnicity/social capital) | 12 | 1f |
Media (stigma / contagion / attitudes) | 6 | 1f |
Protective factors | 6 | 1e |
Risk factors across the life span | 1 | 1d 1h |
Risk factors | 10 | 1d |
Epidemiology of attempted suicide (definitions) (outcomes)* | 11 | 1c |
Epidemiology of suicidal ideation (definitions) | 6 | 1c |
Recognition of psychic pain | 1 | 1c |
Link between attempted and completed suicide | 4 | 1b 2b |
Epidemiology of completed suicide | 6 | 1b |
*(comments in brackets denote sub-issues)
NB: note that the issues that respondents suggest for the focus do not necessarily reflect the same priorities as their specialist interests.
7. Perceived gaps in evidence
Tables 4 and 5 below break down the respondents' perceptions of the current gaps in the evidence base relevant to the implementation of the Scottish Executive's suicide prevention strategy. The frequency of a gap being suggested is given in column 2 and the position of the gap in relation to the framework for dividing up the reviews (1) is given in column 3. Table 4 is sorted by frequency and Table 5 is sorted by position in the framework for dividing up the reviews.
Table 4
Issue | Frequency | Position in framework for dividing up the reviews |
Effectiveness of interventions of suicidal individuals (cost effectiveness / across different populations/crisis hotlines) | 18 | 2c 2n |
Effective prevention programs (mental health awareness / societal level / young people) | 11 | 2d |
Social causes of suicidal behaviour (international/culture/socio-economic /poverty/occupation/ethnicity/social capital) | 8 | 1f |
Deliberate self harm (ethnic minorities / pharmacological treatment/ means/general hospital/crisis/as a risk factor) | 8 | 2n |
International / cross cultural differences (tools to use in this research / within UK/ learn from each other) | 7 | A |
Identify (and targeting resources to) high risk groups | 7 | 1h 2m |
Protective factors (those with risk factors who don't commit suicide / social support) | 6 | 1e |
Medication (psychiatric) | 5 | 2n |
Current data collection methods (esp in US & UK) | 5 | A |
Promoting emotional literacy and resilience (early intervention / young people) | 5 | 2d 2n |
Media (stigma / contagion / attitudes) | 4 | 1f |
Mental illness (proximate cause or underlying long term factors) | 3 | 1h 1p 2n |
Epidemiology of attempted suicide (outcomes)* | 3 | 1c |
Substance misuse | 3 | 1f 1h 2n |
Psychotherapy | 3 | 2n |
Risk assessment | 3 | 2g |
Suicidal ideation relationship to suicidal attempts (motivation) | 3 | A 1b 2b 1d |
Interventions for deliberate self harm | 3 | 2n |
Epidemiology of suicidal ideation (definitions) | 2 | 1c |
Macro societal interventions | 2 | 2k |
Young people (long term studies) | 2 | 1h 1l |
School based interventions / intervention | 2 | 2n |
Interventions at hospital discharge | 2 | 2n |
Mental health promotion | 2 | 2d 2n |
Self help | 2 | 2m |
Neurobiological / neuropsychological / genetic causes of suicidal behaviour | 1 | 1h |
Availability of means for suicide | 1 | 1f |
Older people | 1 | 2h 1l |
Political intervention (wars / elections) | 1 | 2k |
Gender differences | 1 | A |
Attitudes to help seeking | 1 | 2n |
Evidence based risk assessment in clinical settings | 1 | 2n |
Prison interventions | 1 | 1h 2n |
Risk factors across the life span | 1 | 1d 1h |
Religiosity and suicide | 1 | 1g 1k 2l |
Rurality | 1 | 1g 1k |
How to provide support for those affected by suicidal behaviour (long & short term) | 1 | 2m 2n |
Post natal depression | 1 | 1h |
Barriers to suicide prevention and treatment (availability of services) | 1 | 2c 2d 2e 2f |
Effectiveness of user involvement in suicide prevention services | 1 | 2n |
Postvention (different support strategies for survivors) | 1 | 2f |
Table 5
Issue | Frequency | Position in framework for dividing up the reviews |
Suicidal ideation relationship to suicidal attempts (motivation) | 3 | A 1b 2b 1d |
International / cross cultural differences (tools to use in this research / within UK/ learn from each other) | 7 | A |
Current data collection methods (esp in US & UK) | 5 | A |
Gender differences | 1 | A |
Psychotherapy | 3 | 2n |
Medication (psychiatric) | 5 | 2n |
School based interventions / intervention | 2 | 2n |
Attitudes to help seeking | 1 | 2n |
Evidence based risk assessment in clinical settings | 1 | 2n |
Interventions for deliberate self harm | 3 | 2n |
Deliberate self harm (ethnic minorities / pharmacological treatment/ means/general hospital/crisis/as a risk factor) | 8 | 2n |
Interventions at hospital discharge | 2 | 2n |
Effectiveness of user involvement in suicide prevention services | 1 | 2n |
How to provide support for those affected by suicidal behaviour (long & short term) | 1 | 2m 2n |
Self help | 2 | 2m |
Macro societal interventions | 2 | 2k |
Political intervention (wars / elections) | 1 | 2k |
Older people | 1 | 2h 1l |
Risk assessment | 3 | 2g |
Postvention (different support strategies for survivors) | 1 | 2f |
Mental health promotion | 2 | 2d 2n |
Promoting emotional literacy and resilience (early intervention / young people) | 5 | 2d 2n |
Effective prevention programs (mental health awareness / societal level / young people) | 11 | 2d |
Effectiveness of interventions of suicidal individuals (cost effectiveness / across different populations/crisis hotlines) | 18 | 2c 2n |
Barriers to suicide prevention and treatment (availability of services) | 1 | 2c 2d 2e 2f |
Prison interventions | 1 | 1h 2n |
Identify (and targeting resources to) high risk groups | 7 | 1h 2m |
Mental illness (proximate cause or underlying long term factors) | 3 | 1h 1p 2n |
Young people (long term studies) | 2 | 1h 1l |
Neurobiological / neuropsychological / genetic causes of suicidal behaviour | 1 | 1h |
Post natal depression | 1 | 1h |
Religiosity and suicide | 1 | 1g 1k 2l |
Rurality | 1 | 1g 1k |
Substance misuse | 3 | 1f 1h 2n |
Social causes of suicidal behaviour (international/culture/socio-economic /poverty/occupation/ethnicity/social capital) | 8 | 1f |
Media (stigma / contagion / attitudes) | 4 | 1f |
Availability of means for suicide | 1 | 1f |
Protective factors (those with risk factors who don't commit suicide / social support) | 6 | 1e |
Risk factors across the life span | 1 | 1d 1h |
Epidemiology of attempted suicide (outcomes)* | 3 | 1c |
Epidemiology of suicidal ideation (definitions) | 2 | 1c |
8. Additional components of the reviews
Methodologies
Respondents suggested that the reviews consider the role of various research methodologies and approaches within research on suicide and suicidal behaviour, such as:
Retrospective studies (co relational), prospective studies (predictive), longitudinal evidence, ethnographic studies
Epidemiology
Effectiveness of interventions on all levels (e.g. from randomised controlled trials (RCTs) to qualitative studies with those affected by suicidal behaviour)
Does the research have a theoretical basis? Is it generalisable and suitable for replication?
Taking into account user perspectives
An appreciation of the value of qualitative and mixed methods research
Attention to reliability and validity
International comparisons (e.g. on impact of national suicide prevention strategies)
Transferability and translation of findings and knowledge
Multi-factorial models as basis for reviews
Questions that could be addressed by the reviews
Respondents suggested that the reviews ask the following questions:
What is known about the causes and determinants of suicide, what is unknown or inconclusive?
What is the robustness of findings by risk group and issue?
Where are there holes in the literature?
What works?
How can we identify effective preventative interventions ?
How can the impact or outcome of interventions be evaluated, monitored or measured at all levels?
How can best use be made of local resources on all levels?
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