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Is Suicide Risk Assessment ‘Some Good’ Enough?

Riddle: You see a boat filled with people. It has not sunk, but when you look again you don’t see a single person on the boat. (Hint: Think of the famous Sherlock Holmes quote, “There is nothing more deceptive than an obvious fact.” See the answer to the riddle at the end of the op-ed.)…

Riddle – You can see a boat full of people. Although it hasn’t sunk, you can still see people on the boat. (Hint) Think about the Sherlock Holmes quote: “There is nothing more deceitful than an obvious fact.” The answer to the riddle is at the end. )

Last month, the U.S. Preventive Services Task Force (USPSTF) restated what it had summarized for several years: “The current evidence is insufficient to assess the balance of benefits and harms of screening suicide risk in children and adolescents. “

Again, again, and again, the USPSTF evidence reviews on screening for suicide risk include:

  • More randomized trials are needed on the benefits and harms of screening for suicide risk among children and adolescents in primary care settings compared with no screening or usual care
  • More information is needed on the performance characteristics of screening tests for suicide risk
  • Treatment studies are needed in populations with screen-detected suicide risk, in all age groups
  • Evidence on screening and treatment is lacking in populations defined by sex, race and ethnicity, sexual orientation, and gender identity, such as American Indian/Alaska Native youth (who are at increased risk for suicide)

Any discussion of “best practices” or “a gold standard,” including the glossy and well publicized Columbia-Suicide Severity Rating Scale (C-SSRS), Computerized Adaptive Screen for Suicidal Youth (CASSY), and countless other ideation-centric assessments, is currently meaningless.

Can ideation still be used as a proxy or surrogate for near-term suicide events? roughly 50% of patients “deny” the ideation of it, other factors3_ are significant. The USPSTF’s latest recommendation might be seen as a significant step backwards by some, particularly those with fragile reputational and financial interests. However, this finding is an opportunity to “be more than good.” By exploring new questions, factors, and methods, the standard of assessment care, practices, and ethics may be elevated. What should the standard of care be? It is not prediction. It is not mathematical certainty. It is a reasonable, probabilistic expectation of risk that is based on a systematic review and analysis of both conventional and unconventional factors. It can be considered a complement to the legal standards for evidence. For example, it may be considered preponderance, convincing and beyond reasonable doubt.

Rather than following the limitations of metaanalysis with reckless and wasteful search and selection, confirmatory and representative biases and often reckless and wasteful searching, selection, availability and confirmatory searches, I encourage readers to use accelerated and probabilistic likelihood (LR) protocols in clinical practice and research. I suggested this model in 2006 in the American Journal of Emergency Medicine, “Adolescent Violence Screening in the ED.” This screening version offered a rational and tiered system that allowed for reasonable foreseeability for suicidal patients. It had successive stages and a final score LR.

LRs have been used in:

  • The deception of epidural hematoma in anemia
  • The deception of myocardial pain
  • The deception of flank fullness in overweight patients

Similar to the HEART emergency department protocol (history, ECG, age, risk factors, initial troponin), a suicide assessment cascade of this new type evaluates the impact of ideation, non-ideation, and dysexecutive states on attempt rates with confirmatory bedside neurological tests. The deception of ideation, for example in adjustment disorder with dysexecutive features, can be answered within reasonable medical certainty, i.e., an LR >10, in specific suicidal youth cohorts (P value lower than 0.05).

And, perhaps most importantly, this fast-track process will likely stop the terribleness of misdiagnosed, unrecognized cases that are based on valueless ideation-centric assessment, which is fraught with false positive and false negative outcomes. This point needs to be repeated a few times.

The USPSTF suggests that screening for anxiety and depression may be a temporary solution to the assessment landscape. However, imprecise definitions, 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. We urgently need new tools and instruments.

What has this terrible proposition cost? In that we are at a historic 50-year high in suicide deaths and attempts, and a mystifying rise of youth suicides without traditional “red flags,” the consequences to a civil society when either danger is normalized (false negative) or violence constructed (false positive) are immense. Consider the tens to thousands of lives that are being lost, the damage to reputations, dysfunctional family relationships, severe ED boarding times, and the medico-legal consequences for hospitals and providers.

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