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For instance, identification of suicidal outcomes by means of ICD codes registered during routine clinical practice databases has been associated with a slight under-registration of cases, which may result in underestimation of the association between drug exposure and SIS outcomes [35], and studies validating suicidal classification have concluded that ICD codes have good positive predictive value but low specificity [36]

The direction of future research emphasizes a need for applying hybrid methodologies to address time and space constraints, level of participation, and integration of tools