Partnering with Policymakers to Design Suicide Care Research: Maximizing Impact in Adolescent Mental Health Policy

Abstract

Outpatient medical settings are a critical source of mental health care for adolescents and young adults. This is due to the familiarity and accessibility of those settings and challenges accessing mental health care elsewhere. Adolescents and young adults who die by suicide are more likely to have seen a medical provider in the prior month than a mental health specialist, but few suicide care interventions have been developed to specifically address the challenges of working in these outpatient medical settings. This paper provides the perspective of the University of Washington Suicide Care Research Center on the importance of incorporating evidence into public policy decisions regarding workforce development and standards of care for adolescents and young adults experiencing suicidal thoughts and behaviors, their families, and their outpatient medical setting providers; and the equal importance of integrating policy and funding perspectives in clinical services and implementation science. The paper will review the trends in suicide care policy and funding structures as relevant to adolescents and young adults in outpatient medical settings, provide recommendations to advance the translation of research into evidence-based policy decisions for adolescents and young adults at risk of suicide, and recommendations for researchers on incorporating policy perspectives in the development and evaluation of evidence-based interventions. We will share how the University of Washington Suicide Care Research Center is operationalizing these recommendations.

Introduction

Suicide is the fourth leading cause of death for 15–29-year olds globally (World Health Organization, 2021). However, in the US, suicide is the second leading cause of death among 10–14-year olds and 25–34-year olds and a close third for 15–24-year olds, with over 25% of youth deaths being suicide deaths (Centers for Disease Control and Prevention Injury Center, n.d.). Further, there is an even greater number of adolescents and young adults (AYA) experiencing suicidal thoughts and behaviors (STB). For example, in 2021 among US adolescents aged 12–17, at least 12.7% (3.3 million) had serious thoughts of suicide, 5.9% (1.5 million) made a suicide plan, and 3.4% (892,000) attempted suicide in the past year (Substance Abuse and Mental Health Services Administration, 2022).

Outpatient medical settings (OMS) are a critical intervention point to identify AYA at risk for suicide. Eighty percent of youth who died by suicide visited a healthcare provider in the year before their death and 38% in the month prior (Ahmedani et al., 2019; Hua et al., 2023). Further, AYA who die by suicide are more likely to have seen a medical provider in the prior month than a mental health specialist (Ahmedani et al., 2014, 2019; Luoma et al., 2002). However, in 2019, only 61.2% of mental health facilities with outpatient settings provided outpatient suicide prevention programs (Hung et al., 2021), and this number is not likely to be higher among general OMS (Shi, 2023). Thus, it is important for suicide prevention policymakers to recognize the critical role of OMS in identifying and addressing suicide risk among AYA to help reduce this gap.

In this paper, we focus on healthcare policies including public policies, such as legislation, regulation, financing, and publicly funded programs, as well as policies enacted by private entities, such as those set by healthcare systems and insurance companies, which are particularly relevant in the US given the absence of a single national health system. While the University of Washington Suicide Care Research Center (SCRC) focuses on OMS, healthcare policy is rarely specific to this context, and we thus address suicide healthcare policies generally. Erismann et al. (2021) define key strategies that nurture research uptake into policies and practices broadly as: (1) policy and decision makers directly engage with and seek evidence from researchers; (2) policy and decision makers are involved throughout the life of a research project and (3) engagement in transdisciplinary research approaches to coproduce knowledge and inform policy (emphasizing the benefits as co-learning to balance power dynamics). This manuscript will discuss the development and policy priorities of SCRC funded by a grant from the National Institute of Mental Health. We will review the trends in suicide care policy as relevant to AYA in OMS and the funding structures to pay for policy-related changes to care. We will then provide recommendations to advance the translation of research into evidence-based policy decisions for AYA at risk for suicide and provide recommendations for the integration of policy and funding perspectives in services and implementation research. We will conclude with a description of how these perspectives are integrated within SCRC, by engagement with policymakers in the research and co-design of evidence-based suicide care interventions for OMS.

Translation of research into evidence-based policy decisions

Suicide prevention within healthcare has often been organized around a suicide care pathway (see Figures 1 and 2) (Coffey, 2007; Hogan & Grumet, 2016; Layman et al., 2021). The pathway approach is predicated on the readiness of the system to advance individuals to higher levels of care at the time of need. Unfortunately, there is little to support the assumption that we are working within an outpatient healthcare system that can receive and respond to patients who present with STB (Hooper et al., 2012; Jobes & Barnett, 2024; Pfefferle, 2007; Taliaferro & Borowsky, 2011). Within the US, this been addressed most prominently through Zero Suicide and The Joint Commission although multiple systems such as Veteran Health Affairs, the Department of Defense, and Substance Abuse and Mental Health Service Administration (SAMHSA) have provided both guidance and funding. In suicide prevention, there are unique challenges in generating evidence-based policy recommendations. For example, low base rates of both suicides and suicide attempts require rigorous trials to have very large sample sizes for which there is limited funding – this leads to a much smaller research base than is desirable to develop evidence-based practice guidelines (The Assessment and Management of Suicide Risk Workgroup, 2024; O’Connor & Portzky, 2018). Research to predict suicide deaths or attempts in the near term (90 days or next hours to days) has been extremely limited which also limits clear guidance for healthcare professionals (Gutierrez et al., 2021; Mughal et al., 2023; O’Connor & Portzky, 2018; U.S. Preventive Services Task Force et al., 2022), although a recent controlled pragmatic trial suggests that an integrated pathway of screening, EHR clinical decision-making tools, and safety planning can reduce suicide attempts in a large health system – thus providing a scientific reason other than risk prediction to pursue such efforts (Angerhofer Richards et al., 2024). In addition, there is a lack of services and implementation research on how to transfer innovative research solutions into practice (Comtois et al., 2020; O’Connor & Portzky, 2018).

Figure 1.

Suicide care pathways from the U.S. Department of health and human services 2024 national strategy for suicide prevention. Materials from the National Strategy on Suicide Prevention (US Department of Health and Human Services, 2024) are in the public domain.

Figure 2.

Suicide care research center vision of suicide care pathway in outpatient medical settings.

There are four primary areas of research (identification of risk, behavioral health integration, treatment, and training) that have created substantive changes in suicide care pathway adoption for youth who present with suicide risk in the outpatient medical setting. Screening is an improvement from the status quo as it has been estimated that primary care providers recognize only 24–45% of all those adolescents who have high levels of suicidal ideation and/or psychological distress (Taliaferro & Borowsky, 2011). Based on these findings, some researchers and practitioners recommend universal screening, a practice that includes screening all patients for suicide risk regardless of the reason they are seeking care, across medical settings including primary care for AYA over age 12 (Bridge et al., 2023; Hua et al., 2023; Kemper et al., 2021). In a contrasting opinion, the US Preventative Services Task Force concluded there are insufficient data either for or against universal screening (U.S. Preventive Services Task Force et al., 2022). Despite inconclusive data, both the Joint Commission and the Det Norske Veritas (DNV) accreditation have issued guidance to support identifying and responding to individuals at risk for suicide through suicide risk screening, and some experts suggest depression screening is becoming so ubiquitous that the question is how and not whether to screen universally (Simon et al., 2023). Additional research is needed to determine the relative advantage of screening methods and the most effective measurement strategy, frequency and follow-up as well (Bryan et al., 2023; Simon et al., 2023).

The integration of behavioral health into outpatient medical settings is the second primary area of research on the suicide care pathway. The importance of behavioral health integration is highlighted by multiple logistic and systemic barriers cited by AYA and their primary care providers as impediments to seeking mental health treatment. These include inadequate knowledge of services available, insurance restrictions, long waiting lists, financial barriers, transportation issues, high staff turnover in mental health agencies, and not fitting the eligibility criteria for treatment (Moskos et al., 2007; Samargia et al., 2006; Solorio et al., 2006). The U.S. Department of Health and Human Services (HHS) introduced the HHS Roadmap for Behavioral Health Integration, which emphasizes bold policy action to meaningfully increase access to care (Bagalman et al., 2022; HealthcareNOWradio, 2022). Behavioral health integration policies have the potential to make a meaningful impact on suicide prevention, as research has linked integrated behavioral health consultation combined with screening in AYA OMS to a reduction in suicide risk levels (Wellen et al., 2023). Behavioral health integration that incorporates brief psychological interventions have been associated with small significant reductions in suicidal ideation (Grigoroglou et al., 2021), but few programs incorporate principles and components of suicide-specific care (Dueweke & Bridges, 2018).

The third area is suicide-specific psychotherapy for which there are abundant data but limited implementation. If AYA do navigate the medical to behavioral health transition, it is unlikely they will receive an adequate dose of evidence-based treatment (Goldstein Grumet & Jobes, 2024). Engagement challenges in mental health treatment have historically been documented, with 11–50% of individuals who attempt suicide refusing treatment or dropping out very quickly (Kurz & Möller, 1984; Rudd et al., 1999) and estimates of 60–77% of adolescents demonstrating noncompliance with treatment recommendations (Burns et al., 2008; Trautman et al., 1993). More recent studies suggest high mental health service utilization among adolescents experiencing STB but poorer treatment adherence. Specifically, a recent meta-analysis documented mental health service utilization estimates ranging from 29% to 86.2%, with the highest rates among clinical samples (e.g., post-hospitalization). However, the same study documented treatment adherence rates across samples ranging from 32% to 96%, but with several studies reporting adherence rates below 50% (Rufino et al., 2021). Evaluation of efforts to increase engagement in recommended care have failed to identify effective strategies (Asarnow et al., 2015; Milner et al., 2017). However, clinical trials evaluating suicide-specific care show better engagement and retention even in effectiveness and pragmatic trials with externally valid samples (Bornovalova & Daughters, 2007; Chang et al., 2023; Comtois et al., 2023; Jobes et al., 2017; McCauley et al., 2018; Mehlum et al., 2014). These findings highlight the need to identify new ways to augment participation, adherence to recommendations, treatment alliance, and engagement to optimize suicide-specific treatments, all of which also apply to behavioral health integration programs.

The final area is the preparation, training, and support of outpatient medical providers to plan for and respond to AYA with STB. Prior work has demonstrated significant training gaps in the assessment and management of suicide risk (Institute of Medicine U.S. Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide, 2002; Schmitz et al., 2012; Stuber et al., 2023) and this combined with the frequency of AYA presenting to healthcare settings prior to their death has compelled adoption of continuing education policies. In fact, 18 states encourage or require health care providers in the state to take some form of suicide prevention training. In Washington state, all licensed general medical and behavioral health care professionals are required to complete training in suicide assessment, management, and treatment (Revised Code of Washington § 43.70.442, 2024; Stuber et al., 2023). These policies align with longstanding evidence that training health care professionals, such as general practitioners, can be an effective tool in suicide prevention. One study found that training primary care physicians focusing on screening for suicide risk decreased patient suicides by 22–73% (Mann et al., 2005). While few examples exist demonstrating return on investment for training costs, a case study by Chickasaw Nation showed changes in care practices following suicide care training led to 200 diversions from inpatient care leading to an estimated $200,000 in cost savings (Dial et al., 2019) and at The Betty Hardwick Center, there was a comparable 8% decrease in hospital admissions for a savings of $23,400 (Elliot, 2020). There remain several empirical questions regarding the way to best teach and sustain the uptake of evidence-based suicide care practices to a broad range of providers to ensure perceptual and behavioral outcomes of aligning practice with current evidence. Ultimately, by aligning discipline-specific or state-based policies related to training mandates with best and research supported practices, there is potential to improve the identification and management of suicide risk in outpatient medical settings.

A core tenet of community participatory research is based on the premise that the involvement of key end users, in this case AYA, their families, and providers, increases the quality of clinical questions asked and the likelihood that interventions are developmentally appropriate, effective, sustainable, and meaningful (Frank et al., 2014; Hom et al., 2020). To identify and address AYAs’ and families’ priorities, preferences, and the contextual factors affecting their priorities and preferences, researchers use mixed qualitative and quantitative approaches. Hjelmeland and Knizek (2010) recommend the use of qualitative methodologies focused on increasing understanding as a means to move the suicidology field forward. The authors suggest that an overreliance on quantitative methodology focused on explanation has resulted in a “dead end of repetitious research” (p. 74) and research focused on the views and needs of those affected by STB ought to be prioritized to improve our understanding of these things in context. Unfortunately, since their publication it appears that mixed methods and co-design processes are rarely deployed in the development and evaluation of suicide care pathway processes (Pearce et al., 2022).

SCRC has integrated two primary approaches to maximize the utility of our research for the AYAs experiencing STB and the OMS, where they are served – human-centered design and optimization. Human-centered design focuses on novel interventions in the suicide care pathway having maximum usability for AYA patients, their families, and their providers (Lyon et al., 2020) and optimization to assure the best balance effectiveness, affordability, scalability, and efficiency (EASE) using the multiphase optimization strategy (MOST) (Collins et al., 2007) (see Figure 3). Attending to the needs, barriers, and constraints of primary end users (AYA, their families, and their providers) and considering implementation outcomes is critical in the development and evaluation of suicide care interventions for OMS for scientific results to be meaningful and serve as a basis for more effectively solving healthcare challenges, benefiting end users, and result in faster translation of evidence-based policymaking.

Figure 3.

Suicide care research center methodology using discover design build test framework and multiphase optimization strategy framework. The Suicide Care Research Center adapted the DDBT diagram and uses with permission from the University of Washington Alacrity Center.

Funding structures to support suicide care pathway development

In addition to the significant toll that suicide has on families and communities, there is a negative impact on society and health systems. The economic cost of suicide and nonfatal self-harm in the US has been averaged at $510 billion (in 2020 USD) annually, including from costs of life years ($484 billion), medical spending ($13 billion), injury morbidity reduced quality of life ($10 billion), and work loss due to nonfatal injuries ($3 billion) (Peterson et al., 2024). However, despite evidence for effective strategies to prevent suicide, gaps in funding for effective suicide care are repeatedly cited as a barrier for implementing these programs (Suicide Prevention Resource Center, 2019). The funding landscape typically involves a combination of federal, state, and private sources. For instance, findings from the National Council for Behavioral Health and the Suicide Prevention Resource Center have revealed that organizations delivering suicide prevention services use different payor sources including Medicaid, Medicare, commercial insurance, state and federal grants, philanthropy, and others to support provision of services, with variation across providers and organizations (Suicide Prevention Resource Center, 2019). The Joint Commission and Commission on Accreditation of Rehabilitation Facilities (CARF) updated their standards for suicide prevention (CARF International, 2019; The Joint Commission, 2019) signaling the availability and importance of the best practices health care providers must use to identify and care for people at risk for suicide. Despite these requirements, studies reveal they are poorly met. Only 8% of hospitals have instituted all of the key evidence-based practices recommended and one in four are not conducting any of the best practices (Jobes & Barnett, 2024). Further, one study found that even when hospitals documented that they were doing safety planning, review of the safety plan indicates that few of the hospitals were actually conducting the safety plan key components with fidelity (Chitavi et al., 2024).

There is now sufficient evidence regarding best implementation practices for identifying and treating people at risk for suicide (The Assessment and Management of Suicide Risk Workgroup, 2019), but providers have little training in using the interventions to treat people at risk for suicide. Neither do health care systems have routine checks and balances in place to ensure that this care is provided. Providers report anxiety and discomfort treating people with STB and little training or support is provided that successfully allays this fear (Jobes & Barnett, 2024).

Within a health care system, consistent, high-fidelity use of evidence-based practices underpin the Zero Suicide model. Zero Suicide is a quality improvement model that focuses on not just what care providers deliver to people at risk, but also how they deliver care, and most importantly, how that care is working to reduce suicide. As Zero Suicide has emerged as a best practice in health care and the realization that additional training is needed to adopt suicide care practices and systemwide change management strategies, more health care systems have sought training and support. Health care systems can utilize the free and publicly available Zero Suicide toolkit and many other resources, webinars, worksheets and case studies to launch and sustain their efforts (https://zerosuicide.edc.org/). Some health care systems have sought the services of the Zero Suicide Institute (https://solutions.edc.org/solutions/zero-suicide-institute) to provide expert consultation and training in how to adopt Zero Suicide. The in-person Zero Suicide Academy^® is a two-day training led by Zero Suicide Institute staff and faculty to learn about the Zero Suicide framework and seven elements (see Figure 4), begin strategic implementation planning, and prepare for commonly faced challenges.

Figure 4.

Seven elements of the zero suicide framework. Reproduced with permission from Zero Suicide Institute at the Education Development Center.

Funding for changes to the suicide care pathway like Zero Suicide vary nationally. In the US, some health care systems have been able to pay for training and technology through foundation grants such as the Blue Cross Blue Shield Foundation. There are federal grants available to support adoption of Zero Suicide and suicide interventions, mostly from SAMHSA, including the Zero Suicide grants focused on adults aged 25 and older and the Garrett Lee Smith (GSL) grants for states, tribes, campuses, and communities, that focus on youth ages 10–24. GLS grants fund development and implementation of suicide prevention in education, training programs including gatekeeper training, screening activities, infrastructure for improved linkages to services, crisis hotlines, and community partnerships (Goldston et al., 2010).

Block grant dollars to states can fund suicide prevention efforts as well. A block grant is a noncompetitive, formula grant mandated by the U.S. Congress. Eligible recipients are all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and some other entities such as a tribe or Pacific jurisdiction. Grantees can use block grant funds for prevention, treatment, recovery support, and other services to supplement Medicaid, Medicare, and private insurance services such as funding (a) priority treatment and support services for individuals without insurance, (b) treatment and support services that demonstrate success but are not covered by insurance, (c) universal, selective, and indicated prevention, or (d) collection of performance and outcome data to determine the ongoing effectiveness of behavioral health promotion, treatment, and recovery support services (Substance Abuse and Mental Health Services Administration, 2023).

The 2024 National Strategy for Suicide Prevention Federal Action Plan in the US has outlined several goals for fiscal years 2024–2026, including a goal to build and sustain suicide prevention infrastructure at the state, tribal, local, and territorial levels. This goal includes an objective to establish and sustain public and private funding streams for implementation and evaluation of effective suicide prevention programming, with attention to populations disproportionately affected by suicide (US Department of Health and Human Services, 2024). This is the first time the National Strategy for Suicide Prevention has been a White House level program and included an explicit federal action plan that identifies over 200 actions to be taken across the federal government to facilitate and provide resources for implementation of the national strategy. For instance, Goal 8 of the National Strategy, “Implement effective suicide prevention services as a core component of health care,” identifies over 25 actions to be taken by a range of federal entities including the Assistant Secretary for Planning and Evaluation (the principal advisor to the Secretary of the US Department of Health and Human Services on policy development), Veterans Affairs, the Department of Defense, Department of Homeland Security, CDC, Center for Medicare and Medicaid Services, HSRA, SAMHSA, NIH, AHRQ, and USDA. Aligning suicide care and research to improve suicide care with these funding mandates can speed implementation of evidence-based treatments by building them into mandated improvements.

Incorporating public policy perspectives into development and evaluation of interventions

Unless researchers work together with policymakers and funders in the development and evaluation of suicide care interventions, there will continue to be a major gap between research and sustained implementation in healthcare systems. This is because many interventions designed by researchers in academic departments or well-resourced academic medical centers include components that are beyond the scope of the healthcare settings where they are needed. Alternatively, they are feasible but designed with a different model of care that requires substantial changes in philosophy or infrastructure to successfully implement. For instance, the use of mental health apps or web pages is often a minimal burden for trained clinicians in theory – but if implemented in a system that expects all interventions to be linked to the electronic health record or be sanctioned through organizational leadership or risk management who aren’t motivated to do so, a highly effective, simple to use, and well-liked app becomes too unwieldy and burdensome for the system to implement.

Another suicide care related example is the implementation of evidence-based psychotherapies in community mental health or integrated behavioral health programs in primary care. These treatments are premised on providing substantial amounts of care over a limited time (e.g., 4–16-weeks for acute suicidality, 52 weeks for chronic suicidality). Compared to usual care, evidence-based suicide care has shown cost-effectiveness (Bernecker et al., 2020; Denchev et al., 2018; Lebenbaum et al., 2020; McCutchan et al., 2022; Park et al., 2018). Unfortunately, the savings are often in reduced emergency or inpatient care and the actual costs for the clinics providing the evidence-based care are higher and savings are not or cannot be passed on to them. In addition, healthcare systems tasked with assuring all care requests receive an intake within 2 weeks are not staffed to also provide weekly services and patients often receive sporadic “next available” slots for follow-up sessions. As a result, evidence-based treatments are not implemented or are implemented with long breaks between sessions that impair their effectiveness. Thus, patients either stop coming to treatment or continue to use high levels of health care services due to undertreated STB. Without a sufficient workforce to both intake new patients and provide evidence-based suicide interventions to existing patients, treatment has become focused on the possible (e.g., safety planning and other one session interventions). This means that AYAs are chronically underserved, and their continued suicidality increases the burnout of the workforce.

There is a dialectic with the need for effective services on one side and possible services on the other. Thus, it is critical that researchers co-design with AYAs, their families, and their providers as well as with policy leaders and funders of suicide care. A synthesis must be found where (1) researchers do not focus on and develop interventions that are never going to be possible in healthcare, (2) researchers are aware of policy and funding directions so they can develop interventions well fitted to the coming health care environment and funded services, and (3) public and private policy leaders and funders are aware of where the evidence-base is going and can design funding and policy to support it.

There are several policy questions that would have a substantive impact to align current practice with the evidence-based strategies. For instance, a critical problem in the field includes providers describing a paralyzing fear of blame and malpractice litigation impacting clinical decision-making when treating suicidal patients (Jobes & Barnett, 2024; Pope & Tabachnick, 1993; Rudd et al., 2008). Clinicians find managing suicide risk the most anxiety provoking task required by their position (Pope & Tabachnick, 1993; Rudd et al., 2008). What are policy considerations to reduce the perceived risk of liability? Many clinicians don’t know when they have done “enough.” They live in the realm of the possible where there is little they can do but also in the realm of anxiety that they haven’t done enough and could face terrible consequences, however unlikely? Policy recommendations from the guilds where providers are members (e.g., American Medical Association, American Psychiatric Association, American Psychological Association, American Academy of Pediatrics) could be used to direct practice changes and mitigate liability. Another critical impact would be to alter funding to coincide with periods of high risk and incentivize treatments that are well established over those with limited, mixed, or no empirical support. Are there ways to pivot funding mechanisms to provide more outpatient dollars for the one to four months immediately after discovering acute risk? Alternatively, could federal or payor policy shift to allow for alternatives to hospitalization or partial hospitalization to allow for more evidence-based individual psychotherapy and less reliance on group focused programs?

Innovative programs utilizing technology are beginning to demonstrate promise for use with AYA who have STB (Malakouti et al., 2020); however, reach will not occur without shaping incentives for healthcare to incorporate the use of new technologies with acutely suicidal patients. Additionally, there will be organizational, industry-related, and fiscal policy questions around broad implementation for responding to and tolerating known risks such as patients reporting STB outside of work hours or using mental health apps that are outside of the electronic health record.

Finally, if advances in policy and funding strategies are not viable, it is critical for these decisions to be conveyed back to the researchers who are focusing on these areas. Instead, researchers should be provided with information about funding options that are available so innovation can move in that direction.

Prioritizing policy at the suicide care research center

The challenge of research uptake into health policy and practice is nothing new but is often seen as someone else’s responsibility by academia. By contrast, the Suicide Care Research Center (SCRC) Policy Core (see Figure 5) integrates policy and non-academic perspectives to maximize the likelihood that effective interventions from the center are both used and scaled. The Policy Core is coordinated through the Educational Development Center (EDC) and led by the directors of the Zero Suicide Institute and the National Action Alliance for Suicide Prevention along with SCRC’s Director and Manager. The Policy Core connects SCRC to a national perspective on suicide prevention and is the key to maximizing the responsiveness of findings to the emerging public and private policy and financing opportunities (and barriers) for suicide care for AYA. The Policy Core provides strategic direction as members of the steering committee, nominating members for our lived experience, outpatient medical setting network and policy/financing advisory boards, delivering training to SCRC researchers and scholars on how policy and financing in suicide care works, and convening panels of people with lived experience of suicidality, suicide prevention advocates, as well as program and policy leaders to contextualize SCRC interventions and research studies in the bigger and real-world picture. This integration of policy and other non-academic perspectives provided throughout the first four years of the center will culminate with a National Policy Briefing in the fifth year at which researchers will present their research and discuss broader dissemination strategy with key legislative, health policy, insurance, and financing leaders gathered by the Policy Core. Activities will be described below.

Figure 5.

Suicide care research center policy core relationship to other organizational structures.

Training is critical for academics who have a range of (and often quite limited) exposure to how suicide care is funded nor understanding of the levers of change to increase funding. Without this perspective, researchers cannot aim their intervention development or optimization toward the key determinants of widespread implementation (i.e., barriers, facilitators, constraints) if they don’t understand what they are. To convey critical knowledge, our Policy Core presents or facilitates learning in the monthly SCRC Public talks and within center meetings. Recent presentations covered how suicide prevention policy is developed, a review of the 2024 National Strategy for Suicide Prevention, and instruction on how to brief policymakers. In addition, new suicide prevention policies and funding opportunities are regularly disseminated to all center members.

Active learning is SCRC’s primary focus; however, SCRC also creates spaces where non-academics can review and provide input on research throughout the process – particularly through the Advisory Boards and Contextualizing Panels. Three non-academic advisory boards and one research board have guided the work of the center, starting with a Kickoff Retreat. The Lived Experience Advisory Board includes individuals with a history of experiencing STB themselves or caring for a family member with these experiences. The Outpatient Medical Setting Advisory Board consists of leaders of outpatient medical provider networks where center research is designed to be used. The Policy and Financing Advisory Board consists of policymakers, leaders in agencies that fund research, and advocates who promote suicide care funding or programs. Boards provided feedback to SCRC on its principles, plans, and structure. This has led to subsequent training in areas where there was insufficient understanding, including a seminar on effectively incorporating the voices of people with lived experience in the research process. SCRC hosted a two session Kickoff Retreat where research teams received feedback from Board members on their interventions and research approach. This was considered a highlight of the retreat by teams and forms the basis of our Contextualizing Meetings.

The Contextualizing Meetings are hosted three times each year to provide the opportunity for researchers to have conversations about their suicide care interventions and research approach with two different panels. One panel brings a policy, financing, and outpatient medical network perspective and the other brings a lived experience perspective. Two SCRC research teams prepare a presentation to discuss with each panel for the virtual meeting. Each panel has a breakout room. Research teams spend 45 minutes in each breakout room. Facilitated by Policy Core leadership, teams present (or re-present) their work and receive input on the appeal of their intervention, how the work fits into the suicide care landscape and the OMS context, as well as soliciting guidance on new directions and solutions to barriers identified by the panel. Other SCRC researchers and scholars are encouraged to attend the panels but based on advice from our Lived Experience Advisory Board, stay with the policy, financing, and outpatient medical setting panel to ensure a more private and comfortable setting for people with lived experience to speak with individual research teams. Other SCRC attendees keep cameras off and remain muted to maximize communication between the panel and the research team. Over time, as research teams share progress on their interventions and research in subsequent panel presentations, they will share with the panels how previous guidance informed their work and continue to learn how their work fits in the ever-changing suicide care landscape. Presenting at least every other year is expected of all SCRC research teams.

Advisory Boards also influence SCRC through twice yearly meetings on the strategic directions, specific research studies, and to advise on trends in the field. One meeting is focused on the SCRC leadership providing updates on center progress and gathering input to address concerns and better align with directions in the field and the other meeting a presentation by Advisory Board members on such directions to educate the center. One member of each Board serves on an Advisory Council that annually reviews the center’s small grant applications to prioritize grants given high scientific ratings on their level of innovation and potential impact. This input is used along with scientific review to determine which grant proposals are funded.

In a final step to bring research to policymakers and funders, the Policy Core will host a National Briefing 5 years into the center when study interventions and research findings have been developed. Modeled on joint research and policy institutes hosted by the Military Suicide Research Consortium also developed by the first author, this meeting will provide SCRC investigators the opportunity to brief an audience of policymakers and funders from national and regional public and private organizations as well as legislative staff. Our goal is that the ongoing training and input from the Advisory Boards and Contextualizing Meetings will prepare researchers to provide effective briefings that will increase interest in their specific interventions by those in the position to recommend, finance, disseminate, or implement then to key AYA suicide prevention constituencies including youth behavioral health programs, tribal programs, military and young veteran programs, perinatal and maternal and child programs, African American youth programs, and programs focused on rural and frontier health. The integration of our Policy Core leaders from the Zero Suicide Institute and the National Action Alliance for Suicide Prevention – a partnership of public programs and private companies – with leaders from all of these programs at the national, state, and regional levels will maximize the audience and potential for SCRC interventions to be scaled through one of these systems or to create partnerships for pragmatic or hybrid implementation trials to evaluate interventions needing further data prior to widespread implementation.

Conclusion

The integration of policy and research is critical to maximize implementation and scale of evidence-based care, and this should be bi-directional with research influencing policy and policy influencing research. As described above, Erismann et al. (2021) provide three strategies to integrate research and policy for more success: (1) policy and decision makers to directly engage with and seek evidence from researchers; (2) policy and decision makers are involved throughout the lifecycle of a research project and (3) engagement in transdisciplinary research approaches to coproduce knowledge and inform policy. In the area of suicide care, there are multiple barriers and opportunities for innovation in suicide care and scaling these interventions. In response, the Suicide Care Research Center has incorporated a Policy Core to maximize the responsiveness of the research to emerging policy and financing barriers and opportunities for suicide prevention for AYA, accelerate dissemination and implementation of research, and train and mentor researchers and scholars in the policy and financing of suicide care and assure their ability to disseminate their findings effectively to policymakers.

Data availability statment

No datasets were generated or analyzed during the development of this manuscript.