By Don E. Workman, Ph.D. and Nigel E. Bush, Ph.D.
Aug. 3, 2020

PHCoE graphic

How do we know which military health research is most important in any given year? The Military Health System is confronted with many competing priorities for optimizing military health and readiness. With finite resources, it is vital that researchers and funding agencies know which research needs are greatest and which studies might give the best value in meeting those needs.

One way to answer this question is to conduct research gaps analyses: (a) Choose a health need of particularly high importance; (b) Find out what research is already being done to address that need, and; (c) Identify what research should be conducted but is not underway.

Suicides among service members and veterans have long been of significant concern. Military suicide rates have not decreased despite substantial ongoing efforts. Moreover, the ongoing Coronavirus pandemic has been described by some mental health professionals as creating the "perfect storm" to potentially increase what has already been dubbed a "public health crisis" of deaths by suicide.

The Psychological Health Center of Excellence recently completed a new analysis of gaps in military and veteran suicide research. We began this process with a careful review of research needs and gaps previously identified in the 2019 VA/DOD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (CPG). Using those guidelines as a base, we developed a comprehensive list of research needs, and conducted an updated systematic literature review. Next we identified gaps in the research and organized those gaps into categories and individual research topic statements. Finally, we presented that list to stakeholders outside of PHCoE who have expertise in military and veteran suicide prevention research and asked them to indicate which gaps should have highest priority for future research.

The six most highly ranked gaps in suicide research were as follows:

1. Lethal means safety interventions. The suicide prevention research gap rated highest by our experts was lethal means safety interventions. We know from the annual DOD Suicide Event Report that handguns are the most common means of suicides in the military. There are also numerous studies showing that restrictions of handgun access (or access to pesticides or other lethal "means") usually is accompanied by a drop in the suicide rate for that city, state or other jurisdiction. VA and DOD have encouraged clinicians to recommend that patients with suicidal ideation be asked about access to weapons in the home and about voluntarily allowing someone else to take temporary possession of them. Based on our gap analysis, lethal means restriction is a controversial but potentially promising intervention that our experts suggested has not been studied sufficiently in the clinical setting.
2. Crisis response plans/safety planning. The second most highly rated research gap was in crisis response and safety planning research. Crisis response planning or safety planning are used frequently in VA and DOD emergency departments and psychiatric units for patients with suicidal behaviors (ideation or acts of self-harm). There is some evidence for their effectiveness, and the 2019 VA/DOD Clinical Practice Guideline for the Management of Suicide Risk does recommend that crisis response plans be made for patients with suicidal ideation and a lifetime history of suicide attempt(s). The overall quality of evidence, however, remains low, and more research is needed. In particular, there is insufficient research on this topic that uses large sample sizes or controls adequately for confounds.
3. Implementation of cognitive-behavioral therapy for suicidal ideation. There is strong evidence for the effectiveness of cognitive-behavioral treatment for suicide prevention in patients with a recent history of suicidal behavior. This intervention has a sufficiently strong evidence base that the suicide guideline emphasized the need to develop implementation plans to ensure it is being used in military clinical settings, and is being delivered with fidelity to the protocols which have been shown to be effective in the context of clinical research.
4. Technology-based interventions and adjuncts for treatment. Numerous mobile applications and websites have been developed to address suicidal ideation and behaviors. There is little evidence, however, for their use as an adjunct to clinical practice or for self-help. Knowing more about the effectiveness of these tools is needed before they can be recommended or ruled out for use in the military.
5. Dialectical behavior therapy (DBT) for suicidal ideation. There is strong evidence for the use of DBT with individuals who have borderline personality disorder and suicidal behaviors. There remains insufficient evidence, however, for the applicability of treatment or components of the treatment in individuals who have suicidal behaviors and do not have a borderline personality disorder.
6. Caring contacts. The use of supportive follow-up communications to patients after leaving inpatient care for suicidality, is increasing. Evidence for the effectiveness of caring letters, texts, emails, and other types of caring contacts is mixed, however. Nonetheless, our expert stakeholders did find promise in this approach. In ranking caring contacts as their fifth most important research gap, our experts highlighted the importance in finding effective ways to intervene with individuals who are at high risk for suicide who are discharged from inpatient care or who present to the emergency department with suicidal behaviors.

Read or download the full Prioritized Research Gaps Report for Suicide Prevention Topics Calendar Year 2020, which is the fourth in a series of annual research gaps analyses. Previous reports have identified gaps in research on PTSD and depression, substance use disorder topics, and adjustment disorders.

Dr. Workman is a contracted clinical research psychologist supporting the Psychological Health Center of Excellence. He has a doctorate in clinical psychology and a master's degree in theology.

Dr. Bush is an experimental psychologist who has done extensive research in the areas of technology and mental health as well as on suicide. He is chief of the Research Branch at the Psychological Health Center of Excellence.