Author's Note
The reader will notice that the study discussed in this piece does not use conceptually confusing sensitivity/specificity, exclusion bias in logistic regression, or unstable predictive value typically employed in suicide analyses. Instead, a multilayer neural network model with interval likelihood ratios (LR), based on Bayes' theorem of event probability, are applied for the first time to differentiate extreme risk categories.
This paradigm shift is new to mental health but not new to medicine. For example, it is utilized in the diagnostic effectiveness for point-of-care streptococcal pharyngitis, myocardial infarction protocol (HEART), S3 heart sound in cardiac failure, ventilation perfusion scan in pulmonary embolus, and the swirl sign in acute intracranial hemorrhage.
This essay may help you to think innovatively about where accurate assessment and stratification of suicide risk is essential. Please demonstrate a willingness to surrender preconceptions.
Introduction
I have wrestled with suicide studies for some time. The topic of suicide is complex, complicated, and dark, and attempting to systemize risk stratification for the emergency department (ED) clinician is considered by many the equivalent of Freudian Plinko.
However, given its unique nature, consensus on suicide research continues to face a series of obstacles that limit progress. The field is a gathering of "experts" in several disciplines with competing foundations, alliances, and associations, definitional issues, fragmentary data, interdisciplinary squabbling, coroner miscoding, stale statistical methods, and entrenched leadership. This continues to pose conflicts in communication and progress.
Yet recently, appeared in the peer-reviewed scientific literature. It independently validated this author's earlier publications and central pillar, emphasizing that current ideation-centered suicide screeners, such as the glossy and well-funded Columbia-Suicide Severity Rating Scale (C-SSRS), are insensitive to suicide risk in the ED. At last, on the basis of evidence, this ubiquitous "gold standard" has received a deserved and objective narcissistic self-injury.
Well then, Dr. Copelan, please tell us, what is a sufficient, if only just one, suicide examination?
An Ideation Fact Pattern
In my writing, I have occasionally used, or revised an analogy to explain some unfamiliar concepts and to link these ideas to something familiar to you. For example, I have used this technique to help get a point across relating to anaphylactic suicide and an equation for suicidal lethality. Let's employ this method once again.
As an example, and similar to the , assessment must differentiate, and admirably quickly, the quality (X), duration (Y), and degree (Z) of the currently monolithic ideation risk factor (or in this discussion, the equivalent of chest pain).
In this configuration, the ideation structure is dimensionalized to include fleeting, transient, impermanent, enduring, permanent, correctible, containable, "absent" and "reversible" variables. Furthermore, ideation modifiers should include age, gender, ethnicity, country of origin, family adversity, religion, dysexecutive states, previous illness, past attempts, and substance abuse. And motivators can be discriminated into ritual, rebirth, reunion, revenge, copycat, , dutiful or obligatory, and Werther effect, among other components.
To complete this structure, "absence of ideation" is included here in that the lack of ideation, similar to the absence of chest pain, may convey uniquely important clinical information in carefully parsed patients. "Reversible ideation" is associated with a characterized by breathtakingly rapid transition to death in minutes. This is underlined in the Violence Ideation and Suicidality Treatment Algorithm (VISTA), or what I will deem, "The Little Construct That Could," a rewording from the ""
Publication History and the Study
"What's past is prologue" is a quotation by William Shakespeare from his play . In contemporary use, the phrase stands for the idea that history sets the context for the present. In 2006, I published an in the American Journal of Emergency Medicine. A follow-up was issued in Pediatrics In Review. These and other papers highlighted the specific evaluation of a heretofore unrecognized youth cohort, and proposed a based on likelihood ratios and Markov chain probabilities to expedite its diagnosis.
Most suicide ideators do not attempt. Not all attempters ideate. A positive correlation between extreme suicidal risk youth without ideation, alternatively referenced as anaphylactic suicide, and impaired ability to perform rapid alternating movements (RAM) has been observed. Could a specific RAM test, analogous to carotid sinus message in tachyarrhythmias, temporarily "distract" or reset, acutely hijacked implicated cortical circuits following an acute adjustment or stress reaction? Might the RAM test temporarily restore seized neurocognitive capacity and facilitate early life-saving treatment in this cohort?
examined a consecutive series of 43 carefully assessed, drug naïve, first episode youth patients who were admitted to a high-volume ED. After satisfying strict DSM-IV, pattern recognition, and behavioral diagnostic inclusion criteria, the patients were randomly assigned to initial ED or modified ED treatment. There was a matched, non-lethal, deliberate self-harm control group. For all patients with dire presentations, safeguards included ethical and quality improvement requirements, social value, prospect of clinical benefit, detailed informed consent, independent research advocate, trained staff, and secure in-patient setting. The subjects were administered a new neurocognitive test and standardized RAM measure and evaluated for errors, logical rigidity, and reemerging ideation. Statistical analysis included the interval likelihood ratio to determine magnitude of abnormality in categorical data.
A small, yet statistically significant (interval likelihood ratios 7.5-17; CI 95%) sample result suggested that well-timed RAM confirms and conditionally restores seized neurocognitive capacity in acute stress disorder by activating neural patterns of attentional control. The rapid unveiling of previously inaccessible ideation, although alarming, may signal improving short-term functioning that facilitates early stabilization.
The Value of Hard Work
It takes a lot of battered confidence and depleted energy to continue this fight, even when you know you're on the right "medical need" track. No matter what barriers exist to promising research approaches, this validated work, this single study now extended across diverse populations, must count in favor of something. It meets accepted diagnostic standards. It balances risks and benefits. Perhaps someday the same benefits that entities have provided to other disease initiatives can be expected for suicide.
Russell Copelan, MD (Ret.), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed residency and fellowship in emergency department psychiatry at UC, Irvine and University of Colorado, Denver. He is a reviewer for Academic Psychiatry and founder of eMed Logic, a non-profit originator and distributor of violence assessments. Copelan is also a presenter for the National Association of School Psychologists (NASP) Speaker's Bureau.