Jerrold Pollak, PhD

Modern medicine has achieved considerable success in containing and, in some cases, eradicating epidemics of debilitating and lethal infectious illness. In recent decades there has also been significant progress in the prevention, diagnosis, and treatment of major psychiatric disorders. Yet, major psychiatric illness 

highly associated with significant morbidity and mortality.

 Suicide is among the most frequent lethal outcomes of major psychiatric illness.

Since the start of this century, suicide rates have increased dramatically across the age range. Among the many disturbing trends, the suicide rate among pre-adolescents and younger adolescents has increased 178% from 2007 to 2017. During this period the incidence of suicide has increased 76% among older adolescents.

 Suicide is now a formidable public health epidemic.

Evidence-based harm reduction suicidology has arisen in response to this alarming development. This conceptual framework emphasizes the importance of prevention, by restricting access to lethal means and through psychoeducation, including reducing stigma and heightening public awareness of prodromal and/or warning signs. It also involves risk assessment screening and/or evaluation and case formulation, as well as safety and treatment planning. Finally, this approach includes strategic outreach to patients and their families, offering timely access to care that is specifically tailored to the needs of the suicidal patient. The goals of programs based on this model include improved safety, reduced risk, and amelioration of comorbid medical and psychiatric conditions that contribute to elevated risk.

 is a complex multi-determined biopsychosocial phenomenon, and the suicidal patient remains an elusive 

 for effective prevention, identification, and intervention.

Substantial barriers to suicidal harm reduction remain. At-risk patients have a high incidence of concurrent mental illness, personality disorder, and substance abuse. They are often beset by difficult and seemingly intractable life circumstances. The considerable demoralization and hopelessness that characterizes a substantial percentage of patients at risk for suicide contributes to a high level of skepticism and mistrust of the mental health care system and reluctance to engage and remain in treatment. This constellation of difficulties has a negative impact on efforts to reduce death by suicide.

Formal risk assessment, a cornerstone of contemporary evidence-based clinical practice, is notoriously unreliable with respect to predictive validity, regardless of approach and thoroughness. It generates low hit rates: unacceptably high rates of false positives and false negatives.

 Moreover, there are mixed findings with respect to the efficacy of safety planning in reducing the incidence of suicidal behavior.

Despite the recent developments in evidence-based suicidology, which include several promising risk assessment models and diagnostic tools, suicide remains unpredictable in each case. Consequently, many patients with concerning risk factors for serious self-harm are discharged from inpatient, outpatient, and emergency department settings. Psychiatrists and other mental health specialists. keep their fingers crossed that this turns out to have been a reasonable decision and that the patient remains safe—at least in the short term.

, which is the most well-known and influential harm reduction initiative to date. This training and consultation program is a multipronged effort to incorporate best practices from evidence-based suicidology as outlined above. It has successfully integrated these practices in ways which are relatively easy for psychiatrists and other health care professionals to learn and execute. It has made a substantial contribution to improving the standard of care for suicide prevention, evaluation, and treatment.

Fostering hope while not raising unrealistic expectations regarding outcome should be a key objective of any public health care initiative. Regrettably, the term Zero Suicide implies the perfect outcome of irrevocably eliminating suicide. At the same time the literature promulgated on Zero Suicide states only in passing that this is an aspirational goal but is otherwise silent as to its attainability. Despite this quiet qualification, the very name Zero Suicide implies that suicide is a condition that can be eradicated, much like some infectious disease epidemics, and that this is the ultimate objective of this program.

Suicide, however, is a very different societal ill then the 

 of this century. Advances in medical technology and treatment have significantly curtailed these diseases. Unfortunately, there is no evidence that methods can be devised that would entirely eliminate suicide, despite the powerful human need to attain maximal control over existential threats.

The moniker of Zero Suicide runs the distinct risk of raising false hope for patients, their loved ones, and their health care providers. Suicide assessment and treatment, for the foreseeable future, is likely to continue to be more art than science. Advances in suicidology may well succeed at lowering the incidence of suicide, perhaps even on a sustained basis, but are quite unlikely to eliminate it.

There is a substantial evidence regarding the negative effects of patient suicide on loved ones and their health care providers. These include potentially destabilizing and protracted feelings of anxiety, depression, anger, loss, shame, guilt, and failure.

 One can only hope that the concept of Zero Suicide does not have the unintended consequence of exacerbating these reactions in people who have lost someone to suicide by virtue of its utopian vision of a society free from death by suicide.

The developers and promoters of Zero Suicide need to rethink their brand and consider that such a title, although uplifting in some respects, is also misleading. A name change would be highly desirable, one that reflects a greater appreciation for the unrelenting human penchant for self-destruction but also instills hope that evidence-based research and practice can eventually result in better outcomes. Short of a name change, the literature on Zero Suicide ought to include a clear and unequivocal statement that the goal of this initiative is limited to finding increasingly effective ways to save lives by sharply reducing the occurrence of suicide, but not trying to extirpate it.

The views expressed in this article are those of the author and do not necessarily reflect the opinions of

 is a clinical and neuropsychologist, Emergency Services, Seacoast Mental Health Center, Portsmouth, NH; and an allied health professional, Department of Medical Services, Section of Psychiatry, Exeter Hospital, Exeter, NH. He reports no conflicts of interest regarding the subject matter of this article.

This article was originally posted on September 18, 2020, and has since been updated. Scroll down for the 

Premature mortality across most psychiatric disorders

2. Frankl R. Suicide deaths rising in children 10-19 years. 

3. O’Connor RC, Nock MK. The psychology of suicidal behavior. 

4. Murray D, Devitt P. Suicide risk assessment doesn’t work. 

. March 28, 2017. Accessed September 17, 2020. 

https://www.scientificamerican.com/article/suicide-risk-assessment-doesnt-work

5. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revised: 10-year systematic review. 

6. Milner A, Witt K, Pirkis J, et al. The effectiveness of suicide prevention delivered by GPs: a systematic review and meta-analysis. 

7. Miller IW, Camargo CA Jr, Arias SA, et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. 

8.Stanley B, Brown GK, Brenner LA, et al. Comparison of the Safety Planning Intervention With Follow-up vs Usual Care of Suicidal Patients Treated in the Emergency Department. 

9. Gutkin NJ. Losing a patient to suicide: what we know. 

Articles

A well-meaning mental health initiative may be setting unrealistic expectations.

What’s in a Name: The Problem with Zero Suicide

    Based on the “normal curve,” the distribution of various psychological characteristics in the general population, nearly 23 out of 100 individuals can be classified as having below average intellectual functioning-IQ’s that range from 70 to 89 but fall above what is generally considered mild mental retardation. 
    Borderline Intellectual Functioning is a significant correlate and risk factor for the development of a broad spectrum of neuropsychiatric disorders treated by psychiatrists and, more specifically, is quite common among patients with autistic and psychotic spectrum disorders.

 It is also a significant risk factor for less favorable treatment outcomes. As well, it is a robust predictor of limited educational/vocational attainment and is associated with persistent problems with adaptive coping.
    Psychopharmacologic interventions may need to be modified in keeping with the reduced cognitive capacities of these patients. In many cases, certain interventions may be contraindicated, including some forms of psychodynamically-based psychotherapy. 
     Many patients with Borderline Intellectual Functioning can be expected to have difficulty comprehending the rationales for various treatment plans/recommendations, leading to lowered adherence/compliance. Hence, treatment interventions in this subpopulation should be modified to take into account the cognitive limitations of Borderline Intellectual Functioning.
     Because of its high prevalence within various neuropsychiatric groups and potential for significantly affecting treatment planning and outcome, the 

 Task Force should consider removing Borderline Intellectual Functioning as a V code and including this designation as a possible separate axis, specifier, and/or part of a “dimension” germane to cognitive competence/disability.
     When in doubt about such a designation in a particular case, referral to a psychologist for cognitive/neuropsychological testing and assessment of adaptive capabilities/functioning would be appropriate. 
 


1. Frances A. Advice to DSM-V: Change deadlines and text, keep criteria stable. Psychiatric Times. 2009;XXVI:1,7-8.
2. Wechsler D, Coalson DL, Raiford SE. WAIS-IV technical and interpretive manual. San Antonio, Texas, Pearson; 2008.
3. Harvey, P, Keefe R. Clinical neuropsychology of schizophrenia. In: Grant I, Adams K, eds. Neuropsychological Assessment of Neuropsychiatric and
Neuromedical Disorders. New York, Oxford, 2009;507-522.

Borderline Intellectual Functioning is rarely included in clinical reports and case/treatment team reviews except indirectly when, as part of the mental status examination, mention is sometimes made that the patient’s intellect appears to fall below average limits.

Jerrold Pollak, PhD

Articles

What’s in a Name: The Problem with Zero Suicide

A Call to DSM-V to Focus on the Designation of Borderline Intellectual Functioning