Suicide Assessment Is ‘Damn Hard Writing’

I was recently invited by the distinguished emergency department (ED) faculty of AdventHealth, Orlando to lecture ED residents on the deception of suicidal ideation and improvements to ED workflow and staff morale.

In my introduction, I stated early the quote of Roman general Pliny the Elder who was vaporized by an energy wave from Mt. Vesuvius on the Bay of Naples in 79 A.D. — “I apologize for writing such a long letter. A shorter letter would have taken more time.” Eighteen centuries later and emphasized another way by the American writer Nathaniel Hawthorne, “Easy reading is damn hard writing.”

This was particularly evident in my attempt to reduce 4 decades of practice and investigation into a 45-minute presentation. The topic of suicide is complex, complicated, and dark, and systematizing what some consider the equivalent of Freudian Plinko into bite-size compartments is challenging.

So, what is “damn hard” writing in a structured, real-world person-based suicide assessment? I have published 18 articles on MedPage Today. I have tried to write informative, stimulating, and concise texts. Yet, the challenge to aptly inform and advise remains formidable. Here is another attempt, this time focusing on a new ED suicide assessment protocol.

Rather than thoughtlessly following the limitations of suicide meta-analysis with often reckless and wasteful search, selection, availability, confirmatory, and representative biases, I urge the readers to utilize accelerated and probabilistic (likelihood ratio) protocols. These provide a tiered and rational system for reasonable foreseeability of suicidal patients. The assessment cascade further evaluates the impact of ideation, non-ideation, and dysexecutive states on attempt rates with confirmatory bedside neurological tests. And, most critically, this fast-track protocol likely interrupts the awfulness of unrecognized, misdiagnosed cases based on valueless ideation-centric assessments, fraught with false-positive and false-negative outcomes. How many times do I need to emphasize this point?

The foundation for this validated, and now available accelerated diagnostic protocol in suicide assessment, a.k.a. EMED (emergency medical evaluation of dangerousness) was the substrate of my presentation. The participants were informed of its parallel to the HEART Pathway accelerated diagnostic protocol wherein the history, EKG, age, risk factors, and troponin cascade is designed to improve care for patients with acute chest pain. Fascinatingly, the individual protocol stages and comprehensive test positive likelihood ratios in the two accelerated “set of rules” are comparable.

The issue with current suicide screeners, such as the ubiquitous Patient Health Questionnaire-9 (PHQ-9) and other similar instruments (Columbia Suicide Risk Screener), is that they do not provide sufficient information for an ED clinician to make a valid risk stratification. But considering that my stated mission here is to write “a shorter letter,” we must similarly consider the role of brevity — only touching on the necessary questions — in such screeners.

What then is sufficient information? As an example, and similar to the HEART procedure, EMED differentiates the quality, duration, and degree of the currently monolithic ideation risk factor, in addition to other variables. In our work, the ideation construct is dimensionalized to include fleeting, transient, impermanent, enduring, permanent, correctible, containable, reversible, and “absent” variables. Furthermore, ideation modifiers include age, gender, ethnicity, country of origin, family adversity, religion, dysexecutive states, previous illness, past attempts, and substance abuse. And, motivators can be discriminated into ritual, rebirth, reunion, revenge, copycat, suicide by cop, dutiful or obligatory, and Werther effect, among other components.

To summarize, there is now an innovative, valid, and reliable computer-based solution to the deception of suicidal ideation with branching logic engines to provide ED clinicians (and other settings in which assessments are indicated) the answers they need to determine next steps in mental health patients.

The EMED system, therefore, digs beyond conventional suicide ideation. Unlike paper-based screenings, this EHR-compatible assessment does not need to ask questions unless they are necessary. This means that for most patients, testing is simple and short. Only patients that trigger critical thresholds require more extensive questioning and a physician interaction. The assessment can be serially repeated to evaluate ED clinical course, relieve lengthy boarding times, and assess improvement or lack thereof to early ED treatment.

EDs can now screen without slowing down their workflow. They can determine when patients need more assessment and care without increasing wait times of non-mental health ED patients. Most of all they can improve Joint Commission required evaluation and 72 discharge outcomes, develop staff confidence and morale, and expand a number of ED treatment and cost efficiencies.

Do you see now, the impact of a sharper, “shorter letter?”

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 eMed International, 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.