Developing a Research Strategy for Suicide Prevention in the Department of Defense

Status of Current Research, Prioritizing Areas of Need, and Recommendations for Moving Forward

by Rajeev Ramchand, Nicole K. Eberhart, Christopher Guo, Eric R. Pedersen, Terrance Dean Savitsky, Terri Tanielian, Phoenix Voorhies

This Article

RAND Health Quarterly, 2014; 4(3):16

Abstract

In response to the elevated rate of suicide among U.S. service members, a congressionally mandated task force recommended that the U.S. Department of Defense (DoD) create a unified, comprehensive strategic plan for suicide prevention research to ensure that DoD–funded studies align with DoD's goals. To help meet this objective, a RAND study cataloged the research funded by DoD and other entities that is directly relevant to military personnel, examined the extent to which current research maps to DoD's strategic research needs, and provided recommendations to ensure that proposed research strategies align with the national research strategy and integrate with DoD's data collection and program evaluation strategies. The study found that although DoD is one of the largest U.S. funders of research related to suicide prevention, its current funding priorities do not consistently reflect its research needs. The study indexed each of 12 research goals according to rankings of importance, effectiveness, cultural acceptability, cost, and learning potential provided by experts who participated in a multistep elicitation exercise. The results revealed that research funding is overwhelmingly allocated to prevention goals already considered by experts to be effective. Other goals considered by experts to be important and appropriate for the military context receive relatively little funding and have been the subject of relatively few studies, meaning that there is still much to learn about these strategies. Furthermore, DoD, like other organizations, suffers from a research–to–practice gap. The most promising results from studies funded by DoD and other entities do not always find their way to those responsible for implementing suicide prevention programs that serve military personnel. The RAND study recommended approaches to thoughtfully integrate the latest research findings into DoD's operating procedures to ensure that evidence–based approaches can benefit suicide prevention programs and prevent the further loss of lives to suicide.

For more information, see RAND RR-559-OSD at https://www.rand.org/pubs/research_reports/RR559.html

Full Text

The U.S. Department of Defense (DoD) has been increasingly concerned about the elevated rate of suicide among U.S. service members. At the end of the last decade, a report by the RAND Corporation (Ramchand et al., 2011) and another by the congressionally mandated Task Force on the Prevention of Suicide by Members of the Armed Forces offered a series of recommendations to help strengthen DoD's suicide prevention programs. The task force's final recommendation was for DoD to “create a unified, strategic, and comprehensive DoD plan for research in military suicide prevention ensuring that the DoD's military suicide prevention research portfolio is thoughtfully planned to cover topics in prevention, intervention, and postvention” (U.S. Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces, 2010, p. ES-18).

Shortly after the task force report's release, the National Action Alliance for Suicide Prevention (NAASP), a public-private partnership charged with advancing the National Strategy for Suicide Prevention, established the Research Prioritization Task Force to develop “an agenda for research with the stated goal to reduce morbidity (attempts) and mortality (deaths), each by at least 20% in five years and 40% or greater in 10 years, if implemented fully and successfully” (NAASP, 2014, p. 7; emphasis in original). This study, produced by the RAND National Defense Research Institute, represents an effort to assist DoD in creating a strategic research plan that aligns with the national research agenda.

This study's objective was to provide guidance that DoD could use to develop the recommended unified, strategic, and comprehensive plan. The study was organized around three overarching research aims: (1) catalog research being conducted on suicide prevention that is directly relevant to military personnel, (2) examine whether current research maps onto DoD's strategic research needs related to suicide prevention, and (3) ensure that any proposed DoD research strategy aligns with the national research strategy and is integrated with DoD's data, surveillance, and program evaluation strategies. We took a multidisciplinary approach to achieving these three aims, drawing from the disciplines of psychology, epidemiology, statistics, and economics.

What Suicide Prevention Research Being Done in the United States Is Directly Relevant to Military Personnel?

We conducted a comprehensive scan to identify who in the United States is funding research on suicide prevention that is relevant to military personnel and to catalog exactly what they were funding. We found that DoD is the largest single funder of suicide prevention research, having recently funded 61 studies at a cost of more than $100 million. This figure does not include the Army Study to Assess Risk and Resilience in Servicemembers (known as Army STARRS), a $65 million study funded jointly by the U.S. Army and the National Institute of Mental Health. While DoD is the largest funder of suicide prevention research with relevance to military personnel in the United States, this total represents a little less than one-third of all relevant studies, with the U.S. Department of Health and Human Services (primarily through the National Institutes of Health), the U.S. Department of Veterans Affairs (VA), and the American Foundation for Suicide Prevention funding the remaining two-thirds.

The results focused primarily on DoD and overall trends relative to 12 NAASP categories representing “aspirational goals” for suicide prevention and seven Military Operational Medicine Research Program (MOMRP) categories that make up MOMRP's continuum of care framework. With respect to the NAASP categories, current suicide prevention research funded by DoD and other funders tends to focus on studies that attempt to identify who dies by suicide (i.e., risk and protective factor interactions), psychotherapeutic interventions to treat individuals at risk for suicide (i.e., psychosocial interventions), and ensuring that those at risk can access affordable, accessible, and effective care. We based this assessment on the number of studies funded and the total amount of funding devoted to these areas of research.

In contrast, relatively few studies funded by DoD and other entities focus on preventing reattempts among those who have previously attempted suicide or the reduction in access to lethal means. These were also areas for which there were relatively low amounts of funding. Interestingly, although prevention was an area of low overall spending, DoD's highest level of mean funding per study was for studies on the prevention of reattempts. Studies on access to lethal means are particularly underfunded across funders compared with the rest of the research portfolio, perhaps because of legislation that greatly restricted this type of research or because of the perceived lack of cultural acceptability of means reduction as an effective component of military suicide prevention. It is also notable that DoD funded fewer studies of biological interventions, compared with other funders, but it still accounted for 65 percent of all funding in this category.

Accounting for studies according to the MOMRP categories shows that most, by far, both overall and by DoD specifically, are being conducted on who is at risk of dying by suicide (i.e., epidemiology or basic science/neurological mechanisms). There are also a large number of studies focusing on treatment and prevention training/education. Similarly, the most funding by far is being spent on epidemiology/basic science/neurological mechanisms and treatment, with a moderate amount of spending on prevention education and training and on assessment. Among DoD studies, mean funding per study was highest for studies of treatment, epidemiology and basic science, and—surprisingly—postvention, despite the low level of overall funding going to studies on that topic. Indeed, relatively few studies are examining either postvention or recovery and return to duty, and there is very little spending by non-DoD funders in these areas as well, suggesting that if DoD does value research in these areas, it will likely have to fund the requisite studies. Indeed, recovery and return to duty may be particularly central to DoD's mission (despite DoD's relatively low funding levels for research in this area), but it may not be not viewed as a key area of research by other funders.

These results concerning research priorities should be interpreted with the caveat that they do not include the major Army STARRS study, for which the Army has allocated $50 million (of $65 million in total funding for the study) to examine 11 of 12 NAASP categories and all seven MOMRP categories of suicide prevention research. When we report that funding is low in a given area, that assessment does not take into account Army STARRS research.

Which Suicide Prevention Research Needs Are DoD Priorities?

Having established what research DoD is conducting on suicide, we conducted an assessment of DoD's suicide prevention research needs to identify the department's priorities. We modified 12 aspirational goals identified by the NAASP Research Prioritization Task Force so that we could isolate the input and priorities of DoD stakeholders from those of other, non-DoD stakeholders. Table 1 shows the modified set of aspirational goals and the shorthand used in the analysis.

Table 1. Modified DoD Aspirational Goals

NAASP Aspirational Goal DoD Aspirational Goal RAND Shorthand
Population-based risk-reduction/resilience-building Implement population-based programs that reduce suicide risk factors and build resilience. Risk reduction
Provider and gatekeeper training Ensure non–health professionals
(i.e., noncommissioned officers, chaplains) who come in contact with suicidal individuals are trained to identify, care for, and refer persons at risk.
Gatekeeper training
Provider and gatekeeper training Train health care professionals to identify those at risk for suicide and to manage their treatment. Provider training
Stigma reduction Encourage service members and their families to be knowledgeable about and proactively seek treatment. Help-seeking
Affordable, accessible, and effective care Deliver high-quality treatments for mental illnesses (e.g., depression, post-traumatic stress disorder) that are associated with suicide. Quality care
Population-based screening Conduct population-based screening to identify those at risk for suicide. Screening
Reduction in access to lethal means Reduce service members' access to the means that they might use to take their own lives. Reduced access
Psychosocial interventions for those at risk Improve psychosocial interventions used by clinicians (e.g., psychiatrists, psychologists, social workers) to identify and treat those at risk for suicide. Psychosocial interventions
Improved biological interventions Identify biological interventions that clinicians could use to treat suicidal behavior. Biological interventions
Prediction of imminent risk Develop strategies to predict which individuals are at imminent risk of suicide. Prediction
Enhanced continuity of care Achieve continuity of care between providers, across installations, and with the civilian and VA systems. Continuity of care
Prevention of reattempts Implement strategies to prevent suicide reattempts. Prevent reattempts
Risk and protective factor interactions N/A  

NOTE: Goals are worded verbatim from the RAND ExpertLens elicitation exercise conducted for this study. The goal “risk and protective factor interactions” was excluded because we could not equate it with a specific aspirational goal.

We used the same procedures as the NAASP Research Prioritization Task Force, including identical online elicitation software and processes. We asked DoD stakeholders to consider the goals' merits on five grounds: (1) overall importance, (2) effectiveness, (3) cultural acceptability, (4) cost, and (5) learning potential (i.e., the amount that could be learned by pursuing strategies tied to the goals). Participants ranked the goals relative to the criteria using the online RAND ExpertLens elicitation process. Because of lower-than-anticipated participation among DoD stakeholders, we sought to confirm responses in two domains—effectiveness and learning potential—by implementing a modified expert elicitation among seven RAND researchers, all of whom have conducted recent research on or related to military suicide prevention.

According to these criteria, gatekeeper training stands out. Although DoD experts did not believe that this goal was currently very effective, they ranked it as important, culturally acceptable, and the least costly. The RAND panel ranked research relating to gatekeeper training as having the second highest learning potential. Furthermore, prior research suggests that these types of trainings are widely used in DoD. Provider training and strategies for enhancing continuity of care appear similarly promising in terms of their importance and effectiveness; however, the RAND panel ranked them as likely to yield low returns in future research, largely because they believed that there was not much more to learn about these approaches.

How Do DoD's Prioritized Needs Map Against the Ongoing Suicide Prevention Research?

We conducted a preliminary gap analysis by combining the data on research being conducted and the elicited DoD prioritized needs to examine whether current research on suicide prevention that is relevant to military personnel—in terms of both the number of ongoing studies and the amount of funds allocated—aligned with those DoD needs. We examined “needs” across the five domains: importance, effectiveness, cultural acceptability, cost, and potential learning. The aim was to help DoD begin thinking about a strategic research agenda for suicide prevention research.

The results suggest there is a gap between priorities and research. Specifically, current studies and funding align best with the domains of effectiveness and cost. In other words, more studies and more funding are going toward suicide prevention goals that are already ranked as most highly effective, as well as those considered the most costly to implement. However, there is no direct link between what is being funded and what DoD representatives perceive as important. Furthermore, while there are few studies and little funding is being allocated to goals ranked as least culturally acceptable, there are also few studies and little funding allocated to goals ranked as most culturally acceptable. Finally, there is an inverse relationship between the number of studies and the amount of funding allocated to goals with the most learning potential, with more studies and funding going toward goals ranked as having the lowest learning potential.

We improved on the preliminary gap analysis by creating an econometric model that uses the input from the needs assessment and incorporates additional parameters to rank or prioritize research in a way that yields maximum impact in terms of reduced mortality—a benefit-cost index that accounts for both the explicit benefit (i.e., suicides prevented) and the explicit cost of implementing an intervention. For each aspirational goal, we first calculated the benefit-cost index and used this information to rank the aspirational research goals in a way that accounted for effectiveness and cost. We then compared the result to the rankings of “importance” derived from the RAND ExpertLens panel. Using the index, we provide a preliminary snapshot of research priorities, with the provider training and help-seeking goals having the highest benefit-cost index values (93.3 and 49.6, respectively); the values for the other goals drop quickly, starting with 1.80 for reduced access and going down to 0.56 for prediction. Further analysis suggests that the ordinal ranking of goals that ranked in the middle of the group in the ExpertLens exercise are sensitive to the assumptions used to parameterize the model while the goals ranking very high and very low are least sensitive.

We also took the index value rankings and plotted them against the cultural acceptability rankings to highlight the strategies that look very promising based on the explicit benefit-cost index but carry high implicit implementation costs (i.e., those that ranked low with respect to cultural acceptability) and that, as a consequence, would need to be discounted. The scatterplot in Figure 1 shows how the goals align, revealing that psychosocial interventions, help-seeking, and reduced access may need to be discounted.

Figure 1. Cultural Acceptability Ratings

Figure 1. Cultural Acceptability Ratings

Drawing on recent insights from the economics literature on research and development portfolio choice and learning value, we used both the benefit-cost index and future learning potential to provide even more insight into optimizing a suicide prevention research portfolio. Figure 2 shows how the 12 strategies rank in terms of perceived learning values, with the longer error bars reflecting more potential learning value. Although provider training ranked first in terms of our benefit-cost index, research in this field is perceived to be mature and thus has a low learning potential. Help-seeking ranked slightly lower but has greater learning potential. Because it has a higher learning value (i.e., greater uncertainty), it is possible that the maximum potential return for help-seeking is greater than the maximum potential return for provider training. The figure reflects this difference in that the top of the error bar for help-seeking is higher than the top of the error bar for provider training. Gatekeeper training, which also has a high learning potential, similarly offers a high maximum potential return. Population-based risk reduction is another strategy with a high learning potential, and its error bar overlaps those of several adjacent strategies with lower learning values.

Figure 2. Learning Potential Ratings

Figure 2. Learning Potential Ratings

Determining the proper investment model is especially complicated because of the inherent lack of traditional data sets to support the empirical analysis of research outcomes. We recognize that there are many “unknowns,” and our methodology, combined with expert elicitation, is designed to organize the unknowns into a more manageable problem. Our primary goal was to provide and populate a metric in a field in which such a metric is lacking and to do so transparently. We believe that this process, and the ExpertLens elicitation exercise, provides a solid ground from which to make strategic recommendations that can inform the development of a comprehensive research program for suicide prevention in DoD.

How Can This Research Be Translated into Practice?

Although the ultimate objective of any suicide prevention research study is to provide empirically supported insight that can be used to improve or inform suicide prevention strategies, there is a “research-practice gap” when it comes to disseminating research conducted in academic settings to individuals who may actually benefit from the findings. Based on a literature review, we outlined ten components for successfully adopting research programs in practice. We augmented this information by holding discussions with experts at RAND in the areas of education, substance abuse, occupational safety, criminal justice, behavioral health, and health care to identify “case studies” of research programs that have been successfully implemented into practice.

The first three components focus on demonstrating that the program is needed, that it has the potential to be successful at a particular site, and that it is rooted in scientific evidence. Successful diffusion begins with (1) establishing evidence of an identified need—that is, collecting data to demonstrate to organizational leaders and adopters on the ground that the innovation has relative advantages over an existing program. The next two components relate to examining the supporting evidence for a new program. Ensuring that the program has (2) evidence of research quality and (3) evidence of real-world effectiveness can help inform leadership decisions about which programs to adopt.

Following these first essential components are those related to having internal leadership and financial support for a program. These components are (4) leadership buy-in and support from key stakeholders, which can ensure that programs are championed and commissioned by individuals in a position to execute change within an organization (which is essential to the other nine components). Most programs also cannot exist without some form of (5) funding or other institutional support to finance the program's start-up, staff pay, and the infrastructure necessary to keep a program running on a day-to-day basis.

The remaining components deal primarily with the process of garnering support and disseminating the new program at the ground level (i.e., working with those involved in the actual implementation of the program). This can begin with (6) collaboration with credible sponsors, designing research programs with target audiences involved at the development stage. This also includes collaboration across and within organizations—across departments and disciplines—to promote innovation. When implementing a new program in a system with individuals who may be used to or invested in the current approach or who are now expected to perform additional or different duties, the (7) provision of incentives or development of policies can be helpful in promoting widespread diffusion of the program. In addition, the role of (8) peer networks supportive of adoption cannot be underestimated, because individuals learn about new practices from their peers. Providing adopters on the ground with (9) dissemination materials can facilitate the process of diffusion through marketing and the promotion of ideas. Step-by-step toolkits or guidelines can assist in this effort. Finally, when a new program is adopted, there should be an (10) expectation of a cultural shift that takes time and will require the continued support of new program adopters. Awareness of, and preparation for, resistance and delays in adoption can help leaders remain flexible in meeting the needs of their organization while supporting those charged with implementing the new program.

Recommendations

In light of the study results, we offer a series of ten recommendations (see Table 2). The first is an overarching recommendation, and the remaining nine fall into three general categories: (1) areas in which DoD should prioritize research funding, (2) processes that DoD should adopt or enhance to more efficiently allocate research funding, and (3) processes that DoD should adopt or enhance to ensure that evidence-supported suicide prevention strategies are integrated into current operations.

Table 2. Study Recommendations

Category Recommendations
Overarching Recommendation 1. Leadership is needed to provide strategic guidance for implementing a unified research strategy.
Areas in which DoD should prioritize research funding 2. Eliciting the opinions of relevant stakeholders can inform the development of DoD's research priorities.
3. Research investment is needed to prioritize strategies with low benefit-cost values; policy changes are needed to make already high benefit-cost strategies more culturally acceptable.
4. Funding agencies in DoD should make a proactive effort to fund effectiveness research, in which interventions that prior research (funded by DoD or another entity) has deemed efficacious are evaluated for their effectiveness in the military context.
Processes that DoD should adopt or enhance to more efficiently allocate research funding 5. DoD should have a central repository to identify and track the research it is funding on suicide prevention.
6. The designated leadership agency in DoD (per recommendation 1) should continually reevaluate its research priorities in light of new research findings, new policies, and the adoption of new suicide prevention strategies.
Processes that DoD should adopt or enhance to ensure that evidence-supported suicide prevention strategies are integrated into current operations 7. DoD should encourage both formal and informal collaboration across the DoD entities responsible for funding and implementing suicide prevention programs and strategies.
8. Agencies that fund suicide prevention research and those responsible for implementing suicide prevention programs should keep abreast of new research, bearing of mind the quality of different studies. Efficiencies may be gained by creating a centralized clearinghouse for this purpose, perhaps capitalizing on existing sources.
9. Agencies and organizations within DoD should be encouraged to adopt evidence-based technologies. Such encouragement may include funding, materials, and technical assistance.
10. Both leadership buy-in and peer engagement are key in promoting new technologies.

References

NAASP—See National Action Alliance for Suicide Prevention.

National Action Alliance for Suicide Prevention, A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives, Rockville, Md., 2014. As of February 4, 2014:
http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf

Ramchand, Rajeev, Joie Acosta, Rachel M. Burns, Lisa H. Jaycox, and Christopher G. Pernin, The War Within: Preventing Suicide in the U.S. Military, Santa Monica, Calif.: RAND Corporation, MG-953-OSD, 2011. As of February 4, 2014:
http://www.rand.org/pubs/monographs/MG953.html

U.S. Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces,
The Challenge and the Promise: Strengthening the Force, Preventing Suicide and Saving Lives, Washington, D.C., August 2010. As of August 14, 2014:
http://www.sprc.org/library_resources/items/challenge-and-promise-strengthening-force-preventing-suicide-and-saving-live

This research was sponsored by the National Action Alliance for Suicide Prevention and produced by the RAND National Defense Research Institute.

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