PICO QUESTIONS DRAFT Background This work is primarily intended to inform the VA/DoD working group creating the clinical practice guideline for suicide prevention. The reports will also be disseminated to VA and DoD suicide prevention researchers and healthcare providers. Suicide is a national health concern, and members of the United States armed forces may be at higher risk for suicide than civilians due an increased prevalence of multiple risk factors (e.g., depression, substance abuse, post-traumatic stress disorder, etc.). Suicide prevention among Veterans and members of the United States military is a priority of the Department of Defense and the Veterans Health Administration. A 2009 evidence synthesis report conducted by the VA's Evidence-based Synthesis Program documented suicide prevention strategies and updated a similar report by Mann et al., conducted in 2005. These reports highlighted both existing evidence for suicide prevention strategies as well as areas of suicide prevention in need of further study. Both reports identified several promising avenues for future interventions designed to prevent suicide. Research Objectives The objectives of these reviews are to assess the state of suicide prevention research with a particular focus on risk assessment and intervention strategies applicable to military and veteran populations. Specifically, these reports focus on examining (a) effectiveness and applicability of clinical interventions used to reduce suicidal self-directed violence; (b) identification of risk factors for suicidal ideation and/or suicidal self-directed violence as defined by CDC guidelines ( Brenner, 2010); (c) assessment of risk for engaging in suicidal self-directed violence; and (d) the effectiveness and applicability of referral and follow-up services designed to improve referral follow-through and attendance. Page 1 of 5
REVIEW #1: INTERVENTIONS, REFERRALS, AND FOLLOW-UP SERVICES Key Questions: To accomplish these objectives, we will address the following key questions: 1) What is the effectiveness of specific interventions for reducing rates of suicidal selfdirected violence in military and/or veteran populations? 2) What lessons can be learned from suicidal self-directed violence prevention intervention research conducted outside of veteran or military settings that can be applied to veteran and/or military populations? 3) What is the effectiveness of referral and follow-up services (e.g., strategies designed to provide referrals, improve referral follow-through and attendance, etc.) for reducing rates of suicidal self-directed violence in military and/or veteran populations? 4) What lessons can be learned from research on suicidal self-directed violence referral and follow-up services conducted outside of veteran or military settings that can be applied to veteran and/or military populations? Methods: Key question 1 Primary literature review of studies with the following characteristics: Canada, New Zealand, and Australia. This key question will focus on patients who have been classified as being at risk for engaging in suicidal self-directed violence (e.g., patients who have had a positive screening score indicative of increased risk of engaging in suicidal self-directed violence, patients who have made a suicide attempt, etc.) as defined by the CDC classification system (Brenner, 2010). This report will focus on individuals who have been identified as being at risk for engaging in suicidal selfdirected violence regardless of patient diagnosis; the report will not examine interventions designed to treat individuals with specific mental health diagnoses (e.g., bipolar disorder or schizophrenia) even if those disorders are associated with a higher risk of suicidal self-directed violence. Intervention: Any intervention primarily designed to reduce or prevent suicidal selfdirected violence including interventions related to environmental modification, psychotherapy, medication, somatic treatment, and monitoring. This report will include any intervention applicable to clinical encounter settings (i.e., services that can be provided to specific patients), and will exclude more broadly focused public health types of interventions (i.e., large-scale suicide prevention measures implemented among populations rather than specific patients). Interventions designed specifically to treat mental health diagnoses, even those associated with suicidal self-directed violence, will not be included in this report; however, interventions designed to treat suicidal selfdirected violence regardless of patient diagnosis will be included. This distinction will be determined by only examining studies that use suicidal self-directed violence as an outcome (see below). Outcomes: Suicidal self-directed violence including suicide attempt and completed suicide, not including suicidal self-directed violence ideation and non-suicidal selfdirected violence (i.e., behavior resulting in injury for which there is no implicit or explicit evidence of intent to die). Serious harms related to medication interventions will also be evaluated. Page 2 of 5
Setting: Veteran or military inpatient or outpatient settings. Key question 2 Review of suicidal self-directed violence prevention intervention research conducted in non-veteran and/or non-military settings with the same parameters as Key Question 1 other than population. If adequate data can be obtained from a review of existing good-quality systematic reviews, then a primary literature review of studies will not be conducted. Key question 3 Primary literature review of studies with the following characteristics: Canada, New Zealand, and Australia. This key question will focus on patients who have been classified as being at risk for engaging in suicidal self-directed violence (e.g., patients who have had a positive screening score indicative of increased risk of engaging in suicidal self-directed violence, patients who have made a suicide attempt, etc.) and who are being offered referral or follow-up services to assure access to or participation in intervention services. Intervention: Any referral or follow-up service primarily designed to reduce or prevent suicidal self-directed violence by assuring access to or participation in intervention services (e.g., case management services to assure that patients are offered interventions within a certain timeframe or attend scheduled intervention appointments, etc.). Followup services and referrals will be included in this key question if they focus on providing referrals for interventions or increasing attendance at such services but not if they are primarily individual-level interventions (these will be covered in another key question). Referral or follow-up services designed specifically to assure access to or participation in interventions designed specifically to treat mental health diagnoses, even those associated with suicidal self-directed violence, will not be included in this report. Only referral or follow-up services designed specifically to reduce or prevent suicidal self-directed violence regardless of patient diagnosis will be included. This distinction will be determined by only examining studies that use suicidal self-directed violence as an outcome (see below). Outcomes: Suicidal self-directed violence including suicide attempt and completed suicide, not including suicidal self-directed violence ideation and non-suicidal selfdirected violence (i.e., behavior resulting in injury for which there is no implicit or explicit evidence of intent to die). Setting: Veteran or military inpatient or outpatient settings. Key question 4 Review of suicidal self-directed violence referral and follow-up services research conducted in non-veteran and/or non-military settings with the same parameters as Key Question 3 other than population. If adequate data can be obtained from a review of existing good-quality systematic reviews, then a primary literature review of studies will not be conducted. Page 3 of 5
REVIEW #2: RISK ASSESSMENT TOOLS AND OTHER RISK FACTOR RESEARCH Key Questions: To accomplish these objectives, we will address the following key questions: 1) What assessment tools are effective for assessing risk of engaging in suicidal selfdirected violence in veteran and military populations? 2) What lessons can be learned from suicidal self-directed violence risk assessment research conducted outside of veteran or military settings that can be applied to veteran and/or military populations? 3) In addition to the risk factors included in current assessment tools, what other risk factors predict suicidal self-directed violence in veteran and military populations? 4) What lessons can be learned from suicidal self-directed violence risk factor research conducted outside of veteran or military settings that can be applied to veteran and/or military populations? Methods: Key question 1 Primary literature review of studies with the following characteristics: Canada, New Zealand, and Australia. The report will not examine risk factors for specific mental health diagnoses (e.g., bipolar disorder or schizophrenia) even if those disorders are associated with a higher risk of suicidal self-directed violence; rather, this report will focus on risk factors related to suicidal self-directed violence regardless of patient diagnosis. Intervention: Not applicable to this key question. Outcomes and measures: (1) Proportion of individuals in each risk group who exhibit suicidal self-directed violence including suicide attempt and completed suicide, not including suicidal self-directed violence ideation and non-suicidal self-directed violence (i.e., behavior resulting in injury for which there is no implicit or explicit evidence of intent to die). (2) Standard measures of discrimination and reclassification for risk assessment tools. Setting: Veteran or military inpatient or outpatient setting. Key question 2 Review of suicidal self-directed violence assessment research conducted in non-veteran and/or non-military settings with the same parameters as Key Question 1 other than population. If adequate data can be obtained from a review of existing good-quality systematic reviews, then a primary literature review of studies will not be conducted. Key question 3 Primary literature review of studies with the following characteristics: Canada, New Zealand, and Australia. The report will not examine assessment of specific mental health diagnoses (e.g., bipolar disorder or schizophrenia) even if those disorders are associated with a higher risk of suicidal self-directed violence; rather, this report will focus on assessment of risk for engaging in suicidal self-directed violence regardless of patient diagnosis. Intervention: Not applicable to this key question. Page 4 of 5
Outcomes and measures: Proportions or relative risk ratios for suicidal self-directed violence including suicide attempt and completed suicide, not including suicidal selfdirected violence ideation and non-suicidal self-directed violence (i.e., behavior resulting in injury for which there is no implicit or explicit evidence of intent to die). Setting: Veteran or military inpatient or outpatient setting. Key question 4 Review of suicidal self-directed violence risk factor research conducted in non-veteran and/or non-military settings with the same parameters as Key Question 3 other than population. If adequate data can be obtained from a review of existing good-quality systematic reviews, then a primary literature review of studies will not be conducted. Page 5 of 5