Moving from Foundational Research to Practice: Suicide Prevention - A Case Example

The purpose of injury research, ultimately, is to reduce disabling and deadly injuries by contributing knowledge that leads to safer policies and practices. Injury Research Centers play a critical role in this by working at several levels, from building foundational knowledge and improving surveillance information, to training students and professionals, to evaluating policies and programs and helping to ensure that successful interventions are broadly disseminated.

As a case example, we present here the role that the Harvard Injury Control Research Center has played in working at each of these levels to bring a public health approach to suicide prevention, particularly reducing a suicidal person's access to lethal means of suicide.

Foundational Research and Literature Reviews

HICRC scientists Matthew Miller, Deborah Azrael, and David Hemenway published a series of seminal papers on the association between firearm ownership and suicide risk at the ecologic level, as well as syntheses of the case control and ecologic literature in this area (Miller & Hemenway 1999 and Hemenway 2006).

Surveillance Infrastructure    

a. Suicide Surveillance - HICRC spearheaded a multi-million dollar project to design and test the pilot for what is now the National Violent Death Reporting System. With foundation support, HICRC funded ten pilot sites around the country to collaborate in developing the system (NVISS). HICRC also led the science arm of a three-way partnership (with a communications firm and public health advocacy group) to build support for federal funding for the system.

b. Suicide Attempt Surveillance - Starting in 2008, the nation will have state- and national-level annual data on suicide attempts among teenagers and adults because HICRC convinced SAMHSA to add a series of free-standing questions on suicide attempts to the National Survey on Drug Use and Health. (Previously the survey asked about suicide attempts only among those respondents screening positive for symptoms of depression.)

Graduate Training
HICRC's Miller and Azrael began offering "Principles of Suicide Prevention" at the Harvard School of Public Health in 2007. A survey by the Association of Schools of Public Health and the Centers for Disease Control and Prevention in 2002-2003 found that no other school of public health offered a graduate level course on suicide.

Practitioner Research and Training Partnership
In 2000, the injury control professionals in each of the eight state health departments in our region (the Northeast Injury Prevention Network) launched efforts to develop statewide suicide prevention plans.  HICRC agreed to provide training in suicide prevention and analyze their morbidity and mortality data. 

We organized two regional trainings for members of the state suicide prevention teams in 2002 and 2003.  The in-person trainings were well received, but they also wanted us to reach more professionals.  We worked with the Educational Development Center and received funding from HRSA's Maternal and Child Health Bureau to establish the National Center for Suicide Prevention Training which has provided online training to more than 3,000 professionals from across the U.S. and 19 other countries. We published two articles about the trainings, and a book chapter is currently in press.

A research question posed by the Northeast Injury Prevention Network was why some New England states had much higher suicide rates than others.  Our analyses showed that it was not because of more suicide attempts.  Instead, the principal explanatory variable was household gun ownership levels.  Non-gun suicide rates were similar across all the states, while gun suicide rates were highly correlated with levels of household gun ownership (Miller, Azrael & Hemenway. Firearms and suicide in the Northeast. Journal of Trauma, 2004).  In New England, the case-fatality rate from suicide attempts with firearms was over 90%; for suicide attempts with the most common methods-poisoning and cutting-the case fatality rate was less than 3% (Miller, Azrael & Hemenway. The epidemiology of case fatality rates for suicide in the Northeast. Annals of Emergency Medicine, 2004). A HICRC survey of Massachusetts psychiatrists (Gallagher and Patel, unpublished) found that many were not counseling at-risk patients about firearm access. These results were then written up in a reader-friendly summary for the states (Barber 2006) and presented in trainings.

Intervention Development and Evaluation
In response to this and other information, the New Hampshire suicide prevention coalition and the University of Dartmouth developed the CALM training (Counseling on Access to Lethal Means) to train mental health providers on counseling suicidal patients and their families to reduce access to guns at home. HICRC evaluated the CALM intervention and found that it was well-received by providers and increased (by self-report) the proportion who counseled family members about gun access.

Policy Development
We surveyed the 50 agencies or coalitions responsible for statewide suicide prevention planning in the U.S. and found that while the majority call for reducing access to lethal means of suicide, few were taking any active steps in this area. We also provided technical assistance in 2007 to the International Association of Chiefs of Police in developing their policies to reduce police suicide (Preventing Law Enforcement Officer Suicide: A Compilation of Resources and Best Practices; Bureau of Justice Assistance and IACP, 2008).

Dissemination and Translation Research
To increase the proportion of state suicide prevention planning groups that actively take steps to reduce a suicidal person's access to lethal means, HICRC launched the Means Matter Campaign. The campaign includes a website, booklet, factsheets, slide CDs, online training, and dozens of presentations around the country. It introduces a "lethal means counseling" approach, which involves training providers and others who work with suicidal people on how to talk with family members about reducing the suicidal person's access to firearms and lethal medications at home.  HICRC has applied for funding to evaluate the impact of the campaign on state groups' practices.