Introduction
Recently, juxtaposed with for youth mental health, the American Academy of Pediatrics (AAP) recommended suicide risk screening for its for preventative care amid skyrocketing rates of depression in young people. However, given the by the U.S. Preventive Services Task Force (USPSTF) on the current ineffectiveness of youth suicide screeners, what now is the standard of care to be funded?
Years of wasted money, imprecise definitions, inadequate training, bad science, the consequent construction, or minimization of findings, and increasing criticism of sensitivity/specificity statistics will likely perpetuate the same old problematic, proverbial wheel with tragic outcomes.
In my writing and research, I have made myself vulnerable and have taken risks to improve the assessment landscape. The risk in this essay is to go out on a ledge (I have literally been there) and attempt to find a mathematical expression of suicide lethality, irrespective of ideation, in a unique subsample. In so doing, I extrapolate beyond an earlier described and homogenous ideated cross factor product of deadliness, that is death expectation "x plan" with tissue injury. However, this new thesis is not a final, unifying theory of everything suicidal.
Background
I am now preoccupied with rewriting my theory of nonideated anaphylactic suicide. I am attempting to apply a tangible and clean rule or theorem to quantify a series of specific, parsimonious, common pathway states and reducing its final expression to a simpler form or equation.
In 2006, I and highlighted the evaluation and specific treatment of this group of patients, and proposed a neurological algorithm with bedside testing to expedite its diagnosis. I have continued this investigation of quantifiable, less abstract violence states. I encouraged continuing curiosity to help identify an implicated risk locus biomarker and pathway that contribute to understanding this small tail distribution of extreme suicide vulnerability.
Moreover, I have earlier emphasized the innovative likelihood ratio process for tests and stages of suicide risk. These likelihoods, used in other areas of medicine, will now serve as a substrate to a proposed novel . Often employed in HIV transmission and AIDS progression, the chain will be reasoned to link the fatal sequence or transition probability from a present and specific stress reaction suicide cohort.
The "Wobbler's Walk"
In this discussion of transition probabilities, an illustrative example is the famous Markov chain case, or so-called "Wobbler's Walk," also known as the "Drunkard's Walk." Here, a vulnerable person walks on a line where, at each step, the person's position may falter, leading to a "cracked" skull. Clearly, this is not a fair walk, as in rolling a fair die.
In our example, the transition probabilities of our impaired protagonist depend only on his present position, not on the manner in which his position was reached while enjoying the pub. That is, the probability of moving or stumbling to the intracranial hematoma state depends only on the present exposed state and not on the previous state. The future depends only on the present, not the past. Only the most recent point in the trajectory affects what happens next. That is: Meet patients where they are because "you can observe a lot by just watching" (Yogi Berra).
To repeat, this transition is independent of the way in which the present state of the individual arose. For example, in this case, for the probability of a person to go from a present state to a future outcome in one step, let P probability equal pij = P(X1 = j)|X0 = i). This equation denotes that the conditional probability of the person will be in state "j" after exactly one transition, independent of time and given that he is presently in state "i."
The Equation of Suicidal Lethality
As I have warned this audience many times, broad suicide ideation is not a good surrogate or useful predictor for near-suicide death. Most youth ideators do not attempt, and most cutters do not die. And not all attempters ideate, specifically those in the excruciating throws of an acute stress or adjustment disorder. Rather, near-death -- i.e., near-hanging, near-total blood loss persons, gasping, and in poor clinical status -- upon acute resuscitation, recovery, and the author's careful management and query of other cases, provide high quality accounts of fresh suicide attempts and their immediate antecedent thoughts and behaviors where ideation is absent or "."
Earlier research by the author has also been consistent with the aforementioned discussion. Specifically, the indicated a strong relationship between early and late appearing dysexecutive factors in nonideated states (state "i") and risk for near future lethal attempt (state "j") within 24-48 hours (r=0.89, P=0.001; and r=0.90, P=0.001). Nowhere is another quote of the inimitable Yogi Berra more appropriate: "It's getting late early."
Furthermore, in youth experiencing a salient interpersonal stressor without a previously documented mental disorder, strong correlations between dysexecutive syndrome, such as disorganized thought, mental inflexibility, rapid alternating movement difficulties (dysdiadochokinesia), and poor problem solving demonstrated increases in lethal attempts as a function of the frequency of these factor occurrences. Moreover, the transition probability in a statistically significant subset of this group (n=43) 79.1% of those who reported no ideation attempted at a startling rate of 97.7%.
Other recorded and associated dysexecutive features in this sample included memory or autobiographical deficits with confusion, mutism, stereotypic motor movements, and intense inner distress. There was frequently diurnal variation in that symptoms were often most intense at night.
The Theorem in Principal and Practice
Therefore, the theorem is as follows: The identification of a dysexecutive element "i" -- early or late, alone or in combination -- in the presence or absence of a pure disorder, with or without ideation, signals a significant and current transition probability to lethality "j."
In practice, the evaluation of acute dysexecutive states according to this theorem, in carefully selected youth suicidal cohorts, suggest the early identification of seized neurocognitive capacity. Well-timed utilization of rapid alternating movement tests, including the finger-to-nose, alternating palm, or impromptu alpha-numeric trail making examinations, as an enrichment to not substitute for clinical judgment and diagnosis, holds the benefit of rapidly unveiling previously inaccessible ideation equivalents and facilitating early life-saving intervention.
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. He is a reviewer for Academic Psychiatry and founder of EMED Logic, a non-profit originator and distributor of violence assessments.