Can a Suicide Scale Predict the Unpredictable?
Can a Suicide Scale Predict the Unpredictable?
Seeking to find an instrument for predicting imminent suicide attempts, Igor Galynker, MD, PhD, from Beth Israel Medical Center, and his research team are developing a scale to measure a clinically identified emotional “trigger state” that puts individuals with suicidal ideation at increased risk of acting on their ideations.
Dr Galynker is Associate Chairman of Psychiatry and Director of the Bipolar Family Treatment Center at Beth Israel Hospital and also Professor of Clinical Psychiatry at the Albert Einstein College of Medicine in New York. He gave a progress report on the Suicide Trigger Scale at the annual meeting of the American Psychiatric Association.
In 2007, there were 34,598 reported suicide deaths in the US, according to the latest available data released by the CDC. Galynker noted that the nation’s suicide rate has not declined for the last several years, and that 60% of the completed suicides are successful on the first attempt.
“We can identify those individuals with highest risk for potential suicide, but we can’t identify those who will commit suicide in the near future. In part, this is because the duration between the suicidal thought and attempt is usually only about 10 minutes,” said Galynker.
Suicide risk factors, Galynker said, include psychiatric disorders, chronic physical illness, suicidal ideation, a history of suicide attempts, and poor social supports.
Galynker acknowledges that suicidal ideation is a thinking process, but contends that the “suicidal act itself is not a thinking process. Rather, it is an affective state.”
In their clinical work, Galynker said, the team has identified repeated themes. These include fear of entrapment and distorted and confused thinking. The team has also identified a distinct psychopathologic state or syndrome related to panic and psychosis.
In a 2010 article, Galynker and his coauthors1 described the state as being “marked by ‘ruminative flooding’ (a confusing, uncontrollable and overwhelming profusion of negative thoughts) coupled with an acute ‘frantic hopelessness,’ in which not only is there a fatalistic conviction that life cannot improve, but also an oppressive sense of entrapment and imminent doom.”
All of this builds, they added, to an intolerable, confused state in which patients feel that suicidal action is the only conceivable route of escape. In this state of severe distress, many patients have also reported the experience of “near-psychotic somatization” characterized by feeling as if their thoughts are creating head pressure (eg, feeling as if the head was going to explode), as well as some somatic distortions (eg, change in body size or shape).
As part of our research strategy, we wanted to create a scale (now called the Suicide Trigger Scale) that would reflect that state, Galynker told APA attendees. So far, the research team has found that patients with higher scores on the Suicide Trigger Scale are more likely to have had prior suicide attempts. Those with low scores are likely to have only suicidal ideation.
He reported that the researchers are now on the fourth iteration of the Suicide Trigger Scale. It is being tested as a predictive instrument
“It is important to mention,” Galynker added, “that there is not a single question on the scale that asks if you are planning to attempt suicide. We hope it prevents malingerers from lying and helps identify patients who deliberately conceal or unconsciously repress suicidal ideation.” Funded by the American Association of Suicide Prevention, the current study, Galynker said “is ongoing and prospective.”
“We see people within 24 hours of their admission to an inpatient program,” he explained. “We administer detailed scales assessing suicidal behavior as well as the Suicide Trigger Scale, and plan to follow up with telephone calls and meetings at 2 months after admission and then 1 year after admission to see if the STS predicts imminent suicide attempts.”
Galynker said they hope to complete the study within about a year and a half.
The ability to predict an imminent suicide is both a critical professional and personal issue for many of the psychiatrists attending the APA Symposium on suicide and anxiety. The majority of psychiatrists in the audience had lost at least 1 patient to suicide. Galynker said he had lost 4 during his 25-year career.
References
1. Yaseen Z, Katz C, Johnson MS, et al. Construct development: The Suicide Trigger Scale (STS-2), a measure of a hypothesized suicide trigger state. BMC Psychiatry. 2010;10:110.
How can I get a copy of the Suicide Trigger Scale? Dr. Snider
This could be a great tool to assist psychiatrists in discharging high risk patients from their practices to minimize risk of wrongful death suits or being blamed when patients kill others as well as themselves.
Dr Galynker comments: The STS-2 version of the Suicide Trigger Scale is freely available on this web site:
Still issues with aetiology as only 25% of those who complete suicide (in the UK) have been in contact with specialist mental health services in the previous 12 months. There is risk related awareness in areas such as schizophrenia, personality disorder, depression and some relationship with self-harm (although this is somewhat tenuous). The challenge is with those who apparently 'suddenly' attempt or complete suicide with little or no indication. It is important to recognise that not everyone is disorganised and/or chaotic in their thinking or so distressed that they see no alternative. Some individuals have made a conscious choice and prepare and/or plan accordingly.
The multifaceted nature of suicide requires both formal (as indicated here) tools but also greater awareness through education of changes in the person (outlook, behaviour, attitude) that may indicate an issue. We either become more involved in the lives of people that we know and risk some accusations of interference or we rely on later intervention by which time it may be more serious and potentially damaging to not only the person but everyone associated with that person.
I am glad to hear this report. It confirms another similar report published recently. I agree whole heartedly that suicide intents/plans are circumscribed and short lived. All the "scales"may just indicate the potential for suicide and is not going to predict who will kill self in any absolute certainty. Just like in any other branches of medicine, we the mental health people somehow think we can predict events and have a cure for almost everything. Moreover, a person who wants to kill self will do so quietly and will not go to ER, doctors office or family members and announce he/she will kill self. It does not make sense to announce it when one knows something will be done to prevent it. If it does not make sense it is not real.