Background
The Suicide Trends in At-Risk Territories (START) study is the outcome of discussions held at the WHO-WPRO meeting held from 15 to 19 August 2005 in Manila, Philippines. This forum included the participation of government-nominated participants from 22 countries within the WHO Western Pacific Region.
Suicide was identified as a leading cause of mortality in all countries of the region. Participants to this meeting advocated addressing this problem using an integrative and collaborative approach.
This meeting identified four specific areas for action. These were as follows:
- to develop a reliable mortality registry system;
- to conduct research on the causes, risks and protective factors for suicide within the different countries and areas of the region;
- to encourage the development of national suicide prevention strategies; and
- to develop a network of researchers with knowledge and skills specific to suicidal behaviours.
The WHO/START study was officially launched in Brisbane, Australia on 2 March 2006, at the Australian Institute for Suicide Research and Prevention, a WHO Collaborating Centre.
The size of the problem
Suicide in the WHO Western Pacific Region comprises nearly 38% of all suicides occurring the world (World Health Organization, 2006). This figure is predicted to increase in the coming years.
Objectives
- Improved knowledge about the incidence and trends of both fatal and non-fatal suicidal behaviour at the local, regional and/or national levels through standard monitoring procedures.
- The development of appropriate and effective cross-cultural treatment interventions for individuals engaging in non-fatal suicidal behaviour in different cultural contexts.
- Increased understanding of the factors preceding both fatal and non-fatal suicidal behaviour in different cultural contexts.
- Improved knowledge about the impact of longitudinal follow-up on individuals who have engaged in non-fatal suicidal behaviours.
Components of the START Study
The WHO/START Study has four main components:
- Monitoring of Suicide Deaths and Attempts, including deliberate self-harm;
- Randomized-Controlled Intervention with Suicide Attempters (the Brief Intervention Project);
- Psychological Autopsy Cross-Cultural Study; and
- Follow-up Medically Serious Suicide Attempters.
All components but the Monitoring component are optional, and their implementation depends on the resources and infrastructure available in each participating country.
Component One
Component One of START (the monitoring component) intends to develop a database for suicidal behaviours (both fatal and non-fatal suicidal behaviours) using a standardized collection procedure. This same collection process will be replicated in all study locations, which will ensure standardized and comparable data across a diverse number of countries.
Data on both fatal and non-fatal suicidal behaviours will be recorded using the standardized monitoring forms developed for the project. These forms use a cross-culturally acceptable definition of suicide and standardized questions on demographic details, as well as the International Classification of Disease (ICD) codes for recording suicide methods. The monitoring study also aims to record ‘intent’, an aspect recognized as important in classifying suicidal behaviours (De Leo, et al., 2004).
The monitoring component aims to collect the following basic information:
Essential information:
- Age: date of birth (e.g. day/month/year);
- Sex (e.g. male or female);
- Location of suicide: where the person was found or carried out the suicidal behaviour (e.g. at home, at place of work, river, roadside, bushland);
- Date of suicide: (e.g. day/month/year);
- Time of suicide: in 24-hour time (e.g. 00:50);
- Method of suicide: using ICD-10 codes for suicide methods;
- Ethnicity: ethnic origin adapted to the local context.
If possible, the following information should also be collected:
- Statement of intent (either indirect or direct);
- The presence of alcohol or illicit/prescription drugs.
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Component Two
Component Two of START intends to:
- Expand current knowledge of both risk and protective factors connected to non-fatal suicidal behaviours; and
- Conduct a randomized-controlled trial comparing two treatment conditions.
Increased knowledge about the contributing and protective factors involved in the suicidal act will be examined through an in-depth interview with suicide attempters following treatment in a hospital setting. The START Assessment Battery has been developed for this purpose and contains a variety of psychological scales as well as questions pertaining to personal and family history, physical health, previous suicidal behaviours and critical life factors which may have contributed to the attempt. The START Assessment Battery is a standardized form that has been previously approved and distributed to all participants in the study.
Component two also involves a randomized-controlled trial, which adheres to WHO guidelines stipulating that research studies need to improve existing systems and treatments. Consequently, this part of the study replicates the successful template of the SUPRE-MISS Study (the SUicide PREvention - Multisite Intervention Study on Suicidal Behaviours) and will compare Brief Intervention and Contact (BIC) and treatment as usual (TAU) for suicide attempters in emergency units (Bertolote et al., 2005; Fleischmann et al., 2005; Fleischmann et al., 2008). Using a randomized-controlled trial methodology, the goal of this intervention is to examine the impact of BIC on suicide mortality and repeated suicide attempts. A similar intervention has been successfully used in past research with high suicide risk psychiatric patients refusing treatment (Motto & Bostrom, 2001; Motto et al., 1981). The advantage of the BIC intervention is that it contains little or none of the skilled training required by cognitive-behavioural or other psychological or medical treatments. The BIC is also low in cost, and can be carried out with very modest resources of space, equipment and personnel. This model of intervention fits very well with the outstanding variety of approaches and clinical facilities operating in the different participating locations of START. These features are also beneficial for those researchers conducting the study in low- and middle-income countries. As in the case of the SUPRE-MISS Study, the BIC in the START is intended as an add-on to the treatment a patient would usually receive, making sure that a patient is not deprived of any usual treatment.
[Methodology flowchart of Component Two]
[Timeline of follow-up of Component Two]
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Component Three
The third component of START is comprised of two parts. The first seeks to investigate the circumstances preceding fatal suicidal behaviours through the ‘Psychological Autopsy’ interview method. This technique gathers information about the events and circumstances occurring prior to suicide deaths by interviewing proxies of the deceased. The interview includes an adapted version of the Structured Clinical Interview for DSM–IV TR (non-patient version) - SCID (Spitzer, Williams & Gibbon, 1987) and also seeks to gather information on family history, physical health and significant life events.
The START Study offers an immense opportunity for refinement of the Psychological Autopsy technique. With regard to inter-rater reliability between interviewers, the co-rating of at least 10% of interviews is necessary, with audio/video recording of interviews and re-rating of items. Eligible interviewees must have had a history of regular contact with the deceased in the six months leading up to the death, and a minimum of two informants are required per case. For consent purposes, one of the informants needs to be a next of kin (local definition) and, when possible, the health care professional that regularly treated the deceased. All informants will be interviewed within 12 months of the occurrence of a suicide. The interview schedule is based on a bereavement counselling model (similar to Structured Clinical Interview for DSM IV-TR).
The second part of component three is the Community Description. This aims to illustrate the basic sociocultural characteristics of each participating site. This will permit an appropriate contextualization of the study and complement the multidisciplinary dimension of the START study. This survey instrument should be given to an expert or researcher who has extensive knowledge of the cultural, social, political, religious and economic environment in the country. Candidates most suitable for this would be a cultural psychologist, anthropologist or sociologist.
The START Community Description Form contains socio-cultural indices on:
- The external socio-cultural context (including the population and gender structure);
- The socio-cultural and linguistic structure;
- Social and economic context;
- Religious systems;
- Communications, media and entertainment;
- Health and medical dynamics;
- Social deviancy patterns according to demographic markers;
- Mental health and wellbeing;
- General socio-cultural context; and
- The socio-cultural context of suicide (the cultural attitudes toward suicide).
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Component Four
Component Four of START (the Follow-Up of Medically Serious Suicide Attempters) is a longitudinal study that, starting from standardized baselines and definitions, will concentrate on subjects that are most exposed to repetition of suicidal behaviour. This is an area of importance as these people have been identified as being of higher subsequent risk of suicide morbidity or mortality (Beautrais, 2003; 2004; O’Donnell, Arthur & Farmer, 1994; O’Donnell, Farmer & Catalan, 1996).
START will base the definition of medically serious non-fatal behaviour on the lethality of the chosen suicide method used (Maris, Berman & Silverman, 2000). Participants will be identified in Component One and Two of the START study through the clinical notes made about the patient in emergency departments and medical wards, as well as the Self-Inflicted Injury Severity Form (SIISF) which is contained in the START Assessment Battery. Lethality refers to the probability or medical certainty that an action, method or condition will in fact lead to a fatal outcome. For example, a high-calibre hand gun shot to the brain would have almost a 100% lethality, whereas trying to hold your breath until you die has virtually a zero lethality (Maris et al., 2000). The definition of near-lethal non-fatal suicidal behaviour are those cases where methods were used with a high case fatality ratio (Douglas et al., 2004) such as:
- hanging, drowning, self-poisoning with car exhaust fumes, or jumping from a high place;
- self injury to a vital body area such as the throat, chest or abdomen (not wrists or arms); or
- self poisoning that requires admission to an intensive care unit or is judged to be potentially lethal by a doctor (or other health care worker).
[Time schedule for contacting medically serious cases of Component Four]
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