Here we are again.
In 2018, in response to yet another historically high Colorado suicide death count, I published an article imploring Colorado suicide prevention administrators and practitioners to heed the alert, “It is going to get worse before it gets worse.” In reaction to this alarm, and many earlier words of warning, some readers accused me of suffering from the ‘Chicken Little Syndrome.’
With the advantage of hindsight, it is now fitting to paraphrase a popular quote from Miguel de Cervantes, the author of Don Quixote: “Facts are the enemy of [your perceived] truth.”
As factual evidence, last week, Becker’s Hospital Review published a daily briefing titled, “Overrun with kids attempting suicide: Children’s Hospital Colorado (CHC) declares state of emergency.” The CEO and CMO of Children’s Hospital Colorado said pediatric emergency departments and inpatient units are being “overrun with kids attempting suicide and suffering from other forms of major mental health illness.”
Moreover, in the last two years, CHC has seen a 90% increase in demand for behavioral health treatment. Isolation and stress amid the pandemic exacerbated low-level anxiety and depression among pediatric patients into suicide attempts, according to hospital officials.
Further, the Joint Commission collected data on compliance with standards, National Patient Safety Goals, and Accreditation and Certification Participation Requirements to identify trends surrounding challenging requirements. The number one most difficult requirement for hospitals in 2020, as written by the Joint Commission, was to reduce the risk for suicide.
According to the U.S. Preventive Services Task Force, current ideation-centric assessments do not meet clinical and safety needs. U.S. suicide rates are at 50-year historical highs across all age and work groups. There has been a 50% increase in suicide among women since 1999.
The youth suicide rate also skyrocketed more than 50% in the last decade. In a recent CDC study, 25% of 18- to 24-year-olds acknowledged suicidal ideation within the last 30 days prior to the survey. Furthermore, 50% of completed suicides occur within hours, days, or a few weeks of the last hospital, emergency department, or other clinical encounter.
Updating Suicide Science
Here, it is important to emphasize that the continuing advancement of bad suicide science — characterized by imprecise definitional domains, poor design, underrepresentation of seriously suicidal persons, and data misinterpretation — has resulted in weaker findings and perpetually tragic outcomes. In what other medical field would this endless and rotten investigatory practice with soaring death rates be tolerated?
In other medical specialties definitions have progressed. Precise definitions make it possible to accurately assess medical situations, collaborate with colleagues, and make better critical clinical decisions and research analyses. Who can deny the systematic category improvements with better-quality patient outcomes in ST-Elevation Myocardial Infarction (STEMI) and non-STEMI myocardial infarction, genomic cancer types, pain classifications, brain death criteria, metabolic obesity, and diabetes mellitus?
This is not so in the current definition and taxonomy of suicide. In a single plane, suicide is self-inflicted murder. However, consider a 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 I, type II, and gestational categories as opposed to assigning it 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, for example psychotic commands (not automatically incompetent)
- It may represent a heretofore unrecognized acute neurologic induction 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)
Therefore, this objective definitional hierarchy represents a strict index of clinical suspicion beyond archaic intuition and clairvoyance. It requires definite analytical, therapeutic, and prognostic methodologies.
However, the decades-old support for short-sighted, ideation-based suicide assessment methods with imprecise classification have had long-term and tragic repercussions. These include poorly balanced, statistically underpowered, and biased assessments that either normalize violence, construct risk, or overlook often unobvious and unconventional, yet likely significant temporal factors.
Those at higher risk of preventable harm include patients (definition number three above) with unconventional or unrecognized physical and psychological complaints such as anxiety, agitation, restlessness, poor concentration, and insomnia, with or without ideation. The immediate danger in these persons is evaluated and confirmed neurologically using rapid alternating movement tests with likelihood ratios, not psychiatrically with an often endless, ever-deepening ride into the unconscious.
While these complex physiological and psychological etiologic categories (i.e., iatrogenic, metabolic, infectious, acute stress, adjustment disorder) may represent a high-risk population individually (i.e., thin tail distribution), collectively, it is from this shared dysexecutive syndrome population that many suicide deaths are likely occurring. Therefore, this group — including COVID-19 era people — needs extra attention and analysis to identify those dimensional historical and clinical risk factors that accelerate transition to near-term suicide endings.
Failing to Reverse Suicide Trends
In years past and more recently, I proposed that those untrained in emergency psychiatry (which includes most psychiatrists, let alone other mental health types) cannot possibly align disciplines to formulate ethical and innovative suicide research hypotheses and designs in high-risk persons. Therefore, no matter which “best practices” have been identified up to this point, including well-commercialized products, none have yet interrupted the trajectory of historically elevated suicidal events across our country, and perpetually in Colorado.
It is here that heretofore unrecognized, yet well-designed suicidality research — including studies on medication side effects, deadly adjustment disorder, and other neurologic stress dysfunctions, for example COVID-19 — offers more than a mere glimmer of hope. If you cannot speak this new investigation language directly, without data censoring, publication bias, or statistician ghostwriters, you cannot formulate the research questions, cannot connect observations and commonalities, and cannot help the acutely mentally ill.
If you cannot imagine yourself in dynamic research and clinical settings, if you cannot think clearly as violent, horrid, unsightly, or resuscitated patients are whirling about you, “you shouldn’t speak” on this difficult subject matter. Learning superficial suicidology vocabulary, and parroting this twaddle, no more creates an emergency clinician or relevant researcher than a scalpel placed in the hand makes a surgeon.
In 2021, it is horribly “sad before it gets sadder.”
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.