Imprecise definitions make it impossible to assess medical situations, collaborate with colleagues, or make better critical decisions. Conversations are reduced to psychotic-equivalent word salad. On the other hand, really good definitions generate value and produce useful insights. Whether the pathophysiology of COVID-19 or suicide, getting to a good definition requires deliberative thinking, careful examination, and rigorous testing.
Consider, for example, "suicidal ideation." Can current endpoints of suicidal ideation serve as reliable surrogates of near-future suicide attempts?
Saving life is difficult. If it were easy, everyone would be doing it. Well, everyone is doing it, from the American Psychiatric Association, American Foundation for Suicide Prevention, Suicide Prevention Resource Center, coalitions, foundations, Columbia University Suicide Severity Rating Scale, NIMH, mental health first-aid, and suicide ideation therapists. And, where are we? A continuing and horrendous U.S. suicide trajectory! No flattening of the proverbial curve here.
Consider 'The Rule of 50'
- U.S. suicide rates are at 50-year historical highs across all age and work/occupational groups
- U.S. suicide rates have increased by 30% since 1999, with a 50% increase in women
- Youth suicide rate has skyrocketed over 50% in a decade
- 50% of mental health disorders are either misdiagnosed or unrecognized in clinical settings
- 50% of those who die by suicide were not diagnosed or recognized with a mental disorder at their most recent clinical encounter (hours, days, or few weeks)
- 50% of completed suicides occur within hours, days, or a few weeks of last clinical encounter
Suicide is a complicated and complex family of self-destructive behaviors.
Suicide is a model. As such, variables measure the model. Yet, currently, certain assumptions with face validity, rather than logical, construct, concurrent, or criterion validity are incorporated into assessments. And, until now, the difference between analytical and diagnostic sensitivity and specificity, and the usefulness of likelihood ratios, have not been considered.
For example, ideation-centric suicide assessments represent the current gold standard or best practices standard of care in suicide evaluation. Yet, the U.S. Preventive Services Task Force unequivocally states that these assessments, and their commonly applied binary statistical measures, are insufficient in defining children, youth, or adults at risk. In fact, these instruments may either (Type I and Type II errors).
Therefore, the independent value of ubiquitous ideation is not only hard to determine, it has not "flattened" the historically high U.S. suicide curve. Most ideators do not attempt -- an obvious fact. Not all attempters ideate -- an unobvious fact; not all MI patients experience chest pain.
Hypothesis: If single plane ideation-centric assessments have been of limited predictive value, then other multidimensional factors may hold significance. This is equivalent to asking, "Can a wind vane built with one compass point accurately show wind direction?"
In an airplane crash, the National Transportation Safety Board evaluates factors such as pilot, plane, and environmental variables. Focusing on the aircraft, an airplane's vector, either wings level flight or spin, are localized in three-dimensional flight or space (pitch, yaw, roll).
Now, think about a three-dimensional biopsychosocial vector in suicide danger analysis, let's term it DIM, with coordinates placed in three logically derived historical (predisposing), clinical (precipitating), and longitudinal (perpetuating) clusters, defining person "pilot" resilience or vulnerability.
Definition of Suicide
In this reconceptualizing or restructuring of a comprehensive suicide definition, were connected across neuroscience, neurosurgical, and ED psychiatry experiences. As Louis Pasteur opined, "In the field of observation, chance favors only the well prepared."
Now ask, is suicide simply self-inflicted murder? Of course not. Think about a tripartite definition or membership in this family of behaviors. This is not unlike the categorization of diabetes mellitus into type I, type II, and gestational categories rather than the superficial application of total hyperglycemia.
Thus, a multidimensional definition could include the following:
- It may be a purposeful (actus rea) and appreciated (mens rea) act that is "rational" and competent.
- It may be a response to established psychiatric illness and unusual motivations or disordered thinking, for example psychotic commands (not automatically incompetent).
- It may represent a heretofore unrecognized acute psychological, toxic, or infectious neurologic induction or (akathisia with incompetency).
It has taken years of patient-centered experiences and within a complex and challenging family of self-destructive behaviors.
The adversities of the COVID-19 pandemic will further add to this mental health storm. In many ways this has been a thankless pursuit. It has intimidated colleagues and other folks in search of a "quick-and-easy" reduction with few elements. However, this precision has also motivated conversations, constructive discussions, and focused outcomes.
Currently, parsimonious, 1- to 2-minute AI logic flow probabilistic (likelihood ratio-based) applications, that is, actual suicide assessment patient-doctor interactions, different from everything else in the suicide instrument market, may now naturally the "curve."
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. One of Copelan's four sons is an EMT/paramedic in Colorado Springs, and his daughter is a Denver-based physician assistant. Read more of his posts here.