Opinion | Advice to the Field of Suicidology: A Way Home When ‘Bad Lost’

Last week, the CDC reported that U.S. suicide deaths reached an 80-year high. The increase in deaths by suicide in 2022 for women was double that of men. Although some take comfort in the modest youth improvement within the data, I believe that any superficial improvement — which is skewed, in part, by data censoring and miscoding (as is all suicide reporting) — is eclipsed by rising rates of opioid overdose mortality among 10-19-year-olds, 41% of whom had a preexisting mental disorder. It isn’t a stretch, in my opinion, to say suicide and opioid overdose coupled with a mental health diagnosis are two sides of the same coin in many cases.

Furthermore, consider the American Foundation for Suicide Prevention’s aspirational goal, launched in 2016, to reduce the annual U.S. suicide toll 20% by 2025. Since the initiative began, there has instead been a 10% increase in suicide deaths. We should be nothing short of appalled and dismayed by these numbers.

Perhaps it is now best to consider the advice of Davy Crockett to young hunters: “Whenever a fellow gets bad lost, the way home is just the way he don’t think it is.” The field of suicidology is indeed “bad lost.” We are in urgent need of a new “way home.” So let’s get out our compasses and make directions based on where we are standing, our present state. Don’t walk aimlessly.

I will provide readers “just the way he don’t think it is.”

Here is a starting point. Saving life is difficult. If it were easy, everyone would be doing it. Well, in suicide prevention and research, everyone is trying to do it. And yet, the escalating press of self-directed death marches on. For foundations, alliances, and associations, the definitional issues, fragmentary data, ubiquitous risk training, interdisciplinary squabbling, coroner misclassifications, stale statistical methods, and entrenched leadership make it difficult to determine a true North Star without intricate probabilities. It is currently equivalent to the blind leading the blind — and falling in a ditch.

Furthermore, ideation-centric assessments have continued to be promoted as “best practices.” Under mounting evidence of insensitivity to risk, statistical inefficiencies, unreliable patient recruitment, miscoding, data censoring, construction of danger, minimization of risk, and confirmatory bias, should these assessments continue to serve as surrogates or the “gold standard” in suicide risk evaluation? None of these instruments have been sufficiently accurate.

It should now be obvious that risk determinations require intricate observational processes with resultant diagnostic efficiencies. In simpler terms, it is a process by which reasonable foreseeability, in this case risk assessment, can be made regarding future outcomes based solely on a person’s present risk state. Importantly, such predictions — these goodness-of-fit, time-to-event determinations — are often more precise when based on specific yet parsimonious executive function suicide crisis criteria rather than the predictions made by knowing a person’s full history.

Furthermore, where is the proactive management to identify the root causes of our current and miserable predicament? Where is the preparatory understanding of the basic elements of the “map” that could have empowered the field of suicidology to stay found?

Let me ask again: Is conventional suicide prevention practice good enough? No. Unequivocally, no! What medical specialty would tolerate such a recurring — indeed “80-year high” — disaster?

So, what is my valued direction? What is my new “way home”?

I want to emphasize that the continuing advancement of bad suicide science has resulted in weaker findings and perpetually tragic outcomes. Suicide risk assessment is a challenge in that suicidal thoughts and behavior represent a complicated family of presentations. Therefore, a validated, dimensional assessment requires evidence-informed definitions across medical, neurologic, and psychiatric observations. Furthermore, it requires suspension of biases; utilization of precision data-driven protocols; understanding that the absence of ideation is not benign; suspending the bias that ideation-centric assessments are reliable surrogates of risk; and courageously administering old, but fitting (Bayes’ theorem) statistical methods and Markov chain, one-step probabilities.

The emphasis on specific, rather than universal, inclusion criteria documents the process of medical decision-making. Such specific considerations include suspected, new-onset, or worsening suicidal or violent thoughts; abrupt change in thinking or behavior because of psychological, medical, or medication events; and medically cleared resuscitated suicide attempters.

The foundation for this new and useful validated, accelerated diagnostic protocol in suicide assessment is 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 HEART and suicide coding accelerated “set of rules” are comparable. Similar diagnostic sets appear in the efficient diagnostic testing of pulmonary embolus, cancer, and STEMI in myocardial infarction.

So how can this be applied? Consider in your work a dimensional, differential tripartite definition or membership in this family of destructive behaviors — that is, a matrix of phenotypes. This is not unlike the categorization of diabetes mellitus into type 1, type 2, and gestational categories as opposed to assigning the superficial category of hyperglycemia. Each of these classifications requires distinct diagnostic and treatment approaches.

Thus, a multidimensional definition of suicide may well include the following:

• It may be a purposeful (actus reus) and appreciated (mens rea) act that is a rational and competent two-armed action
• It may be a response to established psychiatric illness and unusual motivations or disordered thinking
• It may represent a heretofore unrecognized acute neurologic induction, suicide crisis syndrome or anaphylactic suicide, or dysexecutive function syndrome consisting of agitation, inattention, disorientation, “brain fog,” or dissociative movements as a reaction to subcortical hijacking (incompetent to provide informed consent for medical procedures or refuse treatment).

I have wrestled with suicide studies for some time. The topic of suicide is complex, complicated, and dark, and attempting to systemize and communicate improved risk probability stratification is considered by many either too difficult or a lost proposition. But you must fight with implacable doggedness, challenge old laws, and test new hypotheses. Demonstrate the miracles of good sense, connected observations, and strong convictions. Maximize your cause and seize your direction. As Louis Pasteur stated: “In the field of observation, chance favors the well-prepared mind.”

This compass can provide a level of accuracy that won’t be achieved with current suicide risk assessment methods. No longer walk aimlessly in this work.

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