TSA, thorough suicide assessment, is an acronym that predated the Transportation Security Administration’s creation following 9/11. Yet, as ghastly as that slaughter was, nearly one million children, youth, and adults have died by suicide in the two decades since that early fall day. And who can deny the now likely contributions of the porpoising COVID-19 pandemic on this escalating suicide epidemic? There will likely be carnage by direct and indirect effects of the virus, including exhausted antidepressant supplies limiting helpful use in some, and untoward, often unobvious side effects in others.
“Thorough suicide assessment” — promoted, financed, and taught by academicians, resource centers, coalitions, foundations, mental health first-aid advocates, et al. — has not been effective to stem the decades-old suffering experienced by individuals and their surviving loved ones. Where are the vowed, yet shifting time-stamped reduction goalposts promoted by the Zero Suicide framework and others? Why should their current models hold any hope for even a small, timely reduction in these awful upon awful events? Is it possible to construct a technological and psychological foreseeable suicide model equivalent to the best security in airline travel?
As stated in this suicide-watch post (and referenced) over, and over, and over again, meticulous, systematic suicide assessment of a diverse, complex, and complicated family of self-destructive behaviors is tough. It requires the unusual ability to connect observations across subject disciplines and specialties, remodel hypotheses with often unfamiliar and uncomfortable questions, and challenge stale statistical methods of assessment, definitional domains, and risk factors analysis. It may also put at risk an oddly bold investigator’s financial and reputational security.
For example, what represents an “old law” and “new hypothesis”? Well, “if ships return from the new world, then the world may not be flat.” Similarly, “if there are phases of the moon and Venus, then the earth may not be the center of our solar system.” And, here it is, wait for it — “if ideation-centric assessments are of poor predictive value in suicide assessment, then other factors and definitions may hold significance.”
New Definition of Suicide
In this remedial lesson plan, in the reconceptualizing or restructuring of a comprehensive suicide definition, hundreds of observations and factors 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 differentially about a tripartite definition or membership in this family of behaviors. This is not unlike the categorization of diabetes mellitus (mellitus first differentiated by Thomas Willis — Willis’ disease), into Type I, Type II, and gestational categories rather than the superficial application of total hyperglycemia. Better yet, consider first-, second-, and third-degree murder categories.
Thus, a multidimensional definition of suicide requires the flexible and often unpredictable assessment, the cause and manner, the what and how physical or psychic injury leads to self-inflicted death. Therefore, the definition includes 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 dysexecutive function syndrome (akathisia with incompetency).
Is ‘TSA’ Enough?
Security at El Al, the flag carrier of Israel, is a model for airlines. No Israeli carrier or airport has had a major security issue since 1973. The airline’s strategy is to screen passengers by observation techniques. It is the secret to thwarting terrorism. Technology, airline staff, agents in uniform and out are necessary. Scanning passengers for voluntary and involuntary behavior and psychological reactions may signal stress, fear, or deception. El Al’s passenger successive screening is quite aggressive and includes computerized lists, vetting when reservations are made, payment methods, holiday observances and practices, passport-stamped safety measures, and sticker assigned threat levels, among others.
This multilevel security system may also serve as a model for systematic suicide foreseeability or a new “thorough suicide assessment” across age groups and diverse populations. Yet, is this comprehensive enough? Is the goal reasonable anticipation or prediction of suicidal events with mathematical certainty?
In essence, security measures, whether airport or suicide evaluation, can basically be placed into two categories; standardized or universal screening techniques, and elevated risk screening for which a small subset of individuals are selected. For example, metal detectors possess high sensitivity, that is, they “Rule In” large numbers of people entering airport security. This is also, unfortunately, the realm of the current and myopic standard of ideation-centric assessment. On the other hand, increasingly sensitive magnetic and x-ray imaging, as well as “puffer” technology can “Rule Out” metallic and molecular objects, similar to likelihood/probabilistic intelligent suicide analytics in selected subgroups.
A New ‘TSA’ Method
An innovative complementary neurologic suicide risk assessment with biometric deployment can now identify conventional as well as unobvious suicide cohorts. This method represents a successive series of specificity, sensitivity, and likelihood ratio filters, the final distillate of which is an increasingly accurate AI analytic test that informs safety protocols and treatment utilizing cognitive and motor biomarkers.
Practically speaking, this new work is a process of considering expanded definitional domains as well as obvious and non-obvious risk factor study. These components are analyzed according to strength, consistency, epidemiological plausibility, and freedom from confounders. Non-obvious risk symptoms — a category addressing a much-underserved population of patients whose symptoms often go overlooked, minimized, deferred, or dismissed in clinical settings — includes the presence of stress- and drug-induced dysexecutive function syndrome. This is often difficult to recognize and rapidly progressive with tragic consequences.
I encourage MedPage Today readers to review previous posts that are intended to be utilized across research, clinical, and educational settings. Importantly, the workflow generally described provides cost-effective and well-organized access to patients and clinicians. It is used as an adjunct to, not substitute for clinical judgment to determine a person’s risk for violent mental health events that often epigenetically transition from minutes to hours. The assessments are designed to be utilized in concert, yet they can also be administered individually or conjointly to inform effective treatment, enlighten administrative protocols, and encourage the day when reasonable suicide burden lessened.
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 Inc., 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.
Source: MedicalNewsToday.com
