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There is little data on the accuracy of suicide screening in youth. According to the 2019 report of the U.S. Preventive Services Task Force on suicide risk assessment, an independent panel of subject matter experts, evidence is lacking, of poor quality, or conflicting. Further, the balance of screening benefits and harms cannot be determined.
The current American College of Emergency Physicians' clinical policy on suicidal patients states that screening tools, including the well-promoted, recently summarized six-question (C-SSRS) should not be used in isolation to guide disposition decisions of patients with suicidal ideation. Clinical impression alone and ideation-centric suicide screening tools continue to show poor predictive value for near-term events.
Data from these studies highlight the need for the development of ED, and other setting-based, suicide screening instruments capable of identifying persons at greatest risk. This mandates evaluating beyond the usual ideation query standard of care.
Broad suicide ideation and deliberate self-harm are not good surrogates or useful predictors for near-suicide death. Most ideators do not attempt, and most cutters do not die. Rather, near-death -- i.e., near-hanging, near-total blood loss persons, gasping, and in poor clinical status -- upon acute resuscitation, recovery, and careful query, provide high quality accounts of fresh suicide attempts and their antecedent thoughts and behaviors.
As a primer, ideation is not categorical, that is, present or absent, but rather dimensional. Similar to a vector, it has direction and strength. For example, suicidal ideation may be transient, fleeting, impermanent, enduring, or permanent. It can be further described as obvious, unobvious, absent, reversible, and, according to some, correctable.
In parallel, deliberate self-harm (DSH) also has frequency and duration components. It often ranges from fine to coarse cutting tissue injury, and generally possesses greater depressive, lower lethality, and impulsivity factors without death expectation. And, of course, these DSH individuals, resorting to self-mutilation as an ever-present recourse to conflict, may miscalculate and die.
Kelly Posner Gerstenhaber, a Columbia psychiatry professor (PhD) and lead scientist of the , developed a short six-plus item questionnaire, which the website claims has "an unprecedented amount of research [validating] the relevance and effectiveness of the questions," as a simple way to identify those at high risk for suicide.
The Columbia Suicide Severity Rating Scale is globally recommended or adopted by the CDC, FDA, DoD, and NIMH, and has become the gold standard for suicide monitoring. It is ubiquitous across the U.S and many international agencies.
Yet, the C-SSRS is an interview that is again ideation-centric, and 1) examines the predictive validity for future ED visits, and 2) assesses suicidal ideation severity and suicidal ideation intensity.
Herein lies the limitations: the accuracy of this categorical screening assessment logically attenuates with time; the presence or absence of ideation in the C-SSRS infers diagnostic validity; and knowledge deficits have not generated new research hypotheses.
Therefore, think differentially, Dr. Gerstenhaber. A diagnostic problem -- i.e., ideation-centric assessments have been of limited value in protecting diverse patient populations -- is a question for which a scientific answer is sought. For example, the 2017 Council on Behavioral Health Director's Report indicates that up to 50% of recent suicides occur within 30 days of last clinical contact. Of those, 50% denied ideation.
The evaluation of suicidal ideation as a risk factor, must consider strength, consistency, epidemiological plausibility, freedom from confounders, and contradict the logical fallacy that "If B follows A, then A caused B."
As an illustration, let's look at some categorical "Old Laws" and construct new, dimensional "If/Then" hypotheses:
- "Old Law": The world is flat! New hypothesis: If ships return from the New World, then the world may not be flat.
- "Old Law": Planets orbit the earth! New hypothesis: If there are phases of the moon and earth, then the sun may be at the center of our solar system.
- "Old Law": Ideation is the gold standard in suicide risk assessment! (Of course, it must be queried as one asks about chest pain). New hypothesis: If ideation-centric assessments are of poor predictive value, then others heretofore unrecognized factors may allow significance.
People who die by suicide occupy a phenotype with observable characteristics satisfying pathophysiological etiologies of causation. These subgroups, often representing an admixture or combination of factors, include toxic, acquired or developmental, congenitally present from birth, infectious, iatrogenic, metabolic, neurologic, and psychogenic.
For example, individuals with metabolic iron deficiency anemia often experience profound akathisia with suicide. This presentation is similar to psychogenic acute adjustment disorder with brief psychotic features, infectious Group A streptococcal Pediatric Autoimmune Syndrome, and iatrogenic SSRI induced akathisia.
Each of these categories jointly share restlessness, irrationality, autobiographical deficits, derailment, decomposition of rapid alternating movements, and compelled self-destructive behavior. The transition is rapidly progressive and, more likely than not, does not satisfy the two-arm test of rational intentionality, characterized by a considered appreciation and purposefulness of the act.
In the above instances, it is the absence of ideation that conveys uniquely important clinical information.
"Old Law": The patient denies ideation.
New hypotheses: If carefully queried, the absence of ideation in select cohorts may convey uniquely important clinical information.
- If rational thinking is suspended in particular phenotypes, then executive screening may reduce some suicide cohort rates.
- If acute stress changes the balance of cortical-subcortical circuits, then executive dysfunction may underlie nonideation attempts.
- If acute ideation is restored (and patient protected), then reestablishing executive function favors early and durable improvement.
Although suicidal ideation may be "correctable" in borderline personality disorder using dialectical behavioral therapy, it is not capable of control in specific, aforementioned autonomous, nonideated suicidal states. The acute gene induction and transcriptional changes in these phenotypes are prolonged for a few hours or days, hijacking rational executive function, and thus extending the period of acute vulnerability.
Acute absence of ideation, however, is reversible with appropriate emergency intervention. The reemergence of ideation signals restored cortical-subcortical balance. This is similar to cardiac reperfusion arrhythmias following stent placement and thrombolytic therapy.
The conventional definitional domain of suicidal ideation requires parsimonious inclusion of unusual, heretofore, unrecognized types. Otherwise, names of things, for example, the C-SSRS and other ideation-centric screeners, will not change what they are, yet another unencouraging, albeit well-funded and glossy assessment.
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 , an originator and distributor of violence assessments.