Notice of Intent to Publish a Funding Opportunity Announcement for Suicide Prevention Across the Life Span in Low- and Middle-Income Countries (R34 Clinical Trial Optional)

Key Dates

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National Institute of Mental Health (NIMH)

The National Institute of Mental Health intends to publish a Funding Opportunity Announcement (FOA) to solicit applications to encourage formative research and pilot testing of culturally appropriate innovative preventive, therapeutic, and service interventions to reduce the risk of suicide and suicide ideation and behavior (SIB), and/or non-suicidal self-injury (NSSI) and promote resilience for people across the life span in Low- and Middle-Income Countries (LMICs). During the development and testing of interventions, attention to implementation factors is strongly encouraged. This could include formative work to measure and understand the feasibility, acceptability, adoption, fidelity, and costs of interventions to reduce the risk of suicide and SIB and/or NSSI and promote resilience for people across the life span in LMICs.

This Notice is being provided to allow potential applicants sufficient time to develop meaningful collaborations and responsive projects. The FOA is expected to be published in Spring 2023 with an expected application due date in Summer 2023. This FOA will utilize the R34 activity code. Clinical trials will be optional. Details of the planned FOA are provided below.

Suicide is a significant global public health problem and a major contributor to the global burden of disease. Around 700,000 people die by suicide annually, with a global age-standardized suicide rate of 9.0 per 100,000. It is estimated that 77% of the world's suicides occur in LMICs, where most of the world's population lives^1. However, the overall suicide rate in LMICs is likely substantially underestimated since many LMICs lack a national suicide surveillance system and a systematic reporting system. Local and cultural factors may also contribute to under-reported suicide and suicidal behavior statistics, such as stigma, religious beliefs, and judicial and legal practices.

Suicide occurs throughout the lifespan. Nearly one-third of all suicides occur among young people, and suicide is the fourth leading cause of death in 15 19 years old. However, suicide rates are higher globally among individuals aged 50-69 (16.2 per 100.000) and those aged 70 and over (27.4 per 100.000).

Mental illnesses are associated with suicide attempts. However, there are significant gaps in our understanding of the factors that contribute to suicide in LMICs, such as health system barriers (e.g., access to care), economic (e.g., financial insecurity), societal (e.g., discrimination), community (e.g., social isolation), relationship (e.g., sexual violence), and individual risk factors (e.g., abuse and trauma). Understanding protective and risk factors for suicide is critical to identify effective preventive and intervention targets and implementation strategies that should be prioritized and implemented in different contexts.

Gaps and Opportunities to Advance Suicide Prevention, Therapeutic and Service Interventions Applying Implementation Science Approach

A vital gap in advancing suicide prevention globally is the lack of reliable data on suicide rates. For most LMICs, suicide rate estimates are modeled, and national reports may not be accurate.

Therefore, there is a need to create and/or strengthen community and/or national suicide surveillance systems in many LMIC settings. While NIMH expects projects to pilot-test culturally appropriate preventive, therapeutic, and/ or service interventions, it is also expected to enhance research capacity and country-led efforts to address the lack of reliable data on suicide rates.

Globally, there is a critical need to implement and evaluate a combination of 1) culturally adapted multilevel preventive approaches at the population level (universal prevention) and the individual level (selective and indicated prevention), and 2) therapeutic and service interventions with a focus on multiple risk factors and protective factors across various settings, such as primary care, education, employment, social welfare, and justice settings.

This is critical in order to develop and implement a comprehensive national strategy for suicide prevention that include culturally appropriate multilevel prevention approaches at the community and/or the system level. Therefore, this FOA encourages applications that aim to refine and test scalable and sustainable approaches that could be part of a national strategy to inform future research on testing and implementation of multi-level approaches.

Research Objectives

This FOA aims to stimulate research that will refine and test culturally scalable and sustainable approaches and interventions to reduce the risk of suicide. SIB, and/or NSSI and promote resilience for people across the life span in LMICs. This FOA is also expected to contribute to the long-term goals of strengthening the sustainable research capacity in LMICs and enhancing the potential for multidirectional knowledge and the exchange of research advancements. All projects must propose a research pilot study and a research capacity element.

All projects must propose a research pilot study and a research capacity element. NIMH expects the research to contribute to the long-term goals of strengthening the sustainable research capacity in LMICs and enhancing the potential for multidirectional knowledge and the exchange of research advancements. The potential for reciprocal learning will be considered an added value.

Pilot studies submitted to this FOA should be structured to inform future studies on whether and how the intervention strategy reduces SIB and/or NSSI in LMICs. Relevant pilot work might include and combine:

1. Pilot testing of interventions, including formative mixed methods research;
2. Adaptation and/or pilot testing of interventions with demonstrated efficacy for use in broader scale effectiveness trials; or
3. Pilot test implementation science and services research methodologies

NIMH strongly encourages the collection of preliminary data regarding feasibility, acceptability, adoption, fidelity and implementation cost, and target outcomes such as measuring change in the targeted proximal factors (e.g., consumer- or provider-behaviors and or organizational-/system level factors); fidelity in the delivery of the intervention; improvement in the intended outcomes in the populations served, or any other factors that will strengthen the success of a future larger-scale study and determine the mechanisms of action of the intervention.

Opportunities for the detection and prevention of SIB and /or NSSI in people across the lifespan may occur at various points of contact across an array of health and non-health settings. Given the importance of cultural, social, and contextual factors, the intervention should consider the individual-, family-, community-, provider-, and organizational-level factors to optimize effectiveness, feasibility, acceptability, rapid uptake, and sustained delivery.

A variety of methodologically rigorous approaches may be used, and pilot studies should be designed to inform and test the feasibility of the research design for a subsequent, adequately powered test of the intervention strategy.

NIMH will consider supporting multidisciplinary research teams that establish and/or expand meaningful collaborations with at least one or more key stakeholders, such as multisectoral collaborations across government (e.g., health, finance, education, labor, agriculture), international development agencies (i.g., United States Agency for International Development (USAID), United Nations Children's Fund (UNICEF), World Health Organization (WHO)), non-government partners, and/or other key stakeholders (e.g., health systems, provider, communities, advocates and users). Collaborations should consider current local strategic plans and infrastructure investments.

The application/scope of work should be formulated following NIMH requirements for clinical trials (see: https://www.nimh.nih.gov/funding/opportunities-announcements/clinical-trials-foas/index.shtml) and should address the following elements: 1) empirical/conceptual basis for the selection of the proximal targets of the implementation strategy, 2) plans for assessing preliminary changes in those proximal targets, and 3) plans for preliminary examination of whether changes in the targets are associated with more distal changes in clinical and functional outcomes that contribute to reducing disparities. Studies should be consistent with the NIMH experimental therapeutics approach.

Examples of relevant research topics include but are not limited to:

The general scope of the research includes, but is not limited to:

• Studies pilot testing and adapting universal prevention interventions such as safe storage of lethal means, media coverage for responsible suicide reporting, addressing social determinants of health, and implementing effective mental health policies.
• Studies pilot testing and adapting media guidance curricula and policies in multiple settings to reduce the risk of suicide and SIB and/or NSSI and promote resilience for people across the lifespan.
• Studies pilot testing and adapting effective suicide prevention selective and indicative efforts (e.g., safety planning and follow-up contacts after an attempt; community-based prevention programs; crisis intervention and management of SIB)
• Studies pilot testing and adapting effective youth and adult resilience socio-emotional life skills building programs, such as problem-solving, coping with stress, anti-bullying programs, and strengthening links to support services. The interventions and programs can be delivered across many different settings, such as the school, juvenile services, employment, training programs, worksite, and other community settings.
• Studies testing and adapting a chain of care (universal screening for high-risk groups, assessment, engagement, referral, and tracking of individual outcomes) in the healthcare system (primary care centers; pediatric and perinatal clinics) and community-level platforms (e.g., community services; school system, work-sites, juvenile services, and adult detention). Such research could inform or pilot-test patient-, provider-, organizational-, or policy-level services interventions to improve care quality, coordination, or delivery.
• Studies to develop innovative models of integrated prevention and treatment services to health systems and community platforms.
• Studies pilot testing and adapting scalable and sustainable strategies for training, supervising, and supporting providers, including technology-assisted training and competency assessments to improve reach (accurate detection) and quality of care in delivering research-supported suicide prevention and treatment interventions.
• Acceptability or feasibility studies that complement an ongoing effectiveness trial of preventive, treatment, and /or service intervention.

Applicants are also encouraged to consider one or more of the topics below:

• Pilot work that would build the evidence for approaches described in the World Health Organization LIVE LIFE and /or Zero Suicide.
• Employ the United Nations Human Rights and intersectional lens when designing interventions and strategies.
• Engage with stakeholders and propose a multisectoral partnership to collaboratively address the research questions, study designs, and dissemination.
• Employ a multidisciplinary research approach, which may also be reflected in the composition of the study team.
• Consider innovations from conventional means of service delivery, especially conventional approaches that are not effectively addressing the needs of the highest-burden communities.
• Consider the policy context in the design of the project.
• Utilize methods to optimize intervention components.
• Develop broad, generalizable knowledge that will extend beyond the specific implementation sites included in the application.

Research Capacity Element

Applicants are expected to describe a plan and one or more activities to strengthen research capacity in LMICs and enhance the potential for the exchange of multidirectional knowledge and research advancements. Applicants should describe how the research capacity activity could strengthen significant country-led efforts to prevent suicide.

Activities may include but are not limited to: Training for community/ hospital surveillance systems, civil registration, and vital statistics; training and strengthening the media professionals on best practices to report suicide; training for improving communication between researchers and policymakers, developing and disseminating implementation science programs to support the development of future studies and others.

Eligibility

For applications proposing a single PD/PI, the PD/PI will be required to have a primary academic appointment in an LMIC or HIC institution. Research projects must be conducted in the LMIC in which the single PD/PI or at least one PD/PI has a primary appointment. Research projects must be conducted in the LMIC in which the single PD/PI or at least one PD/PI has a primary appointment.

Applications proposing MPIs are required to include at least one PD/PI who has a primary academic appointment in an LMIC institution where the projects occur.

TBD

Public/State Controlled Institution of Higher Education
Private Institution of Higher Education
Small Business
For-Profit Organization (Other than Small Business)
State Government
Indian/Native American Tribal Government (Federally Recognized)
County governments
Independent school districts
Public housing authorities/Indian housing authorities
Indian/Native American Tribally Designated Organization (Native American tribal organizations (other than Federally recognized tribal governments)
U.S. Territory or Possession
Indian/Native American Tribal Government (Other than Federally Recognized)
Non-domestic (non-U.S.) Entity (Foreign Organization)
Regional Organization
Eligible Agencies of the Federal Government

Applications are not being solicited at this time.

Please direct all inquiries to:

Andrea Horvath Marques, M.D., Ph.D., MPH
National Institute of Mental Health (NIMH)
Telephone: 301-646-7320
Email: [email protected]