Suicide new views on risk assesment and prevention
We have included two recent abstracts pertaining to suicide. The first from the U.S. is about a new approach to risk with a focus on prevention rather than prediction.
The second from Denmark addresses the ongoing controversy about SSRIs and the risk of suicide attempts and completed suicide in young people.
REFORMULATING SUICIDE RISK FORMULATION: FROM PREDICTION TO PREVENTION.
Acad Psychiatry. 2016 Aug;40(4):623-9. doi: 10.1007/s40596-015-0434-6. Epub Dec 2015
Pisani AR, Murrie DC, Silverman MM.
(1)University of Rochester, Rochester, NY, USA.
[email protected]. (2)University of Virginia, Charlottesville, VA. (3)University of Colorado-Denver, Denver, CO, USA.
Psychiatrists-in-training typically learn that assessments of suicide risk should culminate in a probability judgment expressed as “low,” “moderate,” or “high.”
This way of formulating risk has predominated in psychiatric education and practice, despite little evidence for its validity, reliability, or utility. We present a model for teaching and communicating suicide risk assessments without categorical predictions. Instead, we propose risk formulations which synthesizedata into four distinct judgments to directly inform intervention plans:
(1) risk status (the patient’s risk relative to a specified subpopulation),
(2) risk state (the patient’s risk compared to baseline or other specified time points),
(3) available resources from which the patient can draw in crisis, and
(4) foreseeable changes that may exacerbate risk.
An example case illustrates the conceptual shift from a predictive to a preventive formulation, and we outline steps taken to implement the model in an academic psychiatry setting.
Our goal is to inform educational leaders, as well as individual educators, who can together cast a prevention-oriented vision in their academic programs.
SSRIS AND RISK OF SUICIDE ATTEMPTS IN YOUNG PEOPLE – A DANISH OBSERVATIONAL
REGISTER-BASED HISTORICAL COHORT STUDY, USING PROPENSITY SCORE.
Nord J Psychiatry. 2016;70(3):167-75. doi: 10.3109/08039488.2015.1065291. Epub
Christiansen E, Agerbo E, Bilenberg N, Stenager.
(1) Erik Christiansen, Department of Child and Adolescent Mental Health Odense and Institute of Regional Health Services Research , University of Southern Denmark (2) Esben Agerbo, Centre for Integrated Register-based Research, Aarhus University Denmark. (3) Niels Bilenberg, University of Southern Denmark. (4) Elsebeth Stenager, Department of Psychiatry , Odense and Institute of Regional Health Services Research, University of Southern Denmark.
BACKGROUND: SSRIs are widely used in the treatment of mental illness for both children and adults. Studies have found a slightly increased risk of suicidal thoughts and suicide attempts in young people using SSRIs but SSRIs’ impact on risk for suicides in youth is not well-established.
AIM: Is there indication that SSRIs might raise risk for suicide attempts in
METHODS: We used an observational register-based historical cohort design, a large cohort of all Danish individuals born in 1983-1989 (n = 392,458) and a propensity score approach to analyse the impact from SSRIs on risk for suicideattempts. Every suicide attempt and redeemed prescription of SSRIs was analysed by Cox regression.
RESULTS: We found a significant overlap between redeeming a prescription of SSRIs and subsequent suicide attempt. The risk for suicide attempt was highest in the first 3 months after redeeming the first prescription. The hazard ratio for suicide attempts after redeeming a prescription was estimated to 5.23, 95% CI 4.82-5.68.
CONCLUSION: We conclude that the risk of suicide attempt is higher for young people in the first months after redeeming their first prescription for SSRIs, compared to non-users. For SSRI users with lower propensity score (fewer risk factors for SSRIs) the risk of suicide attempt is estimated to be highest.
Although the design may miss some explicit reason for prescription of SSRIs and SSRIs might be a marker for those in high risk rather than a causal risk factor, we would recommend systematic risk assessment in the period after redeeming the first prescription.