On the challenges of studying suicide

Nature has an important article on why virtually no-one is trying to develop treatments to prevent suicide because research with such high-risk patients is almost impossible to get approved.

Most psychiatric drug trials today—the majority of which are industry sponsored—exclude anyone expressing thoughts of suicide. This is for ethical as well as practical reasons: physicians consider it taboo to give people on the brink of suicide an experimental drug, let alone a placebo, if other options are available, and many additional safety precautions are required to run trials in this vulnerable population. To complicate matters, few mental health experts are trained in how to conduct suicide research, and those who do are often afraid of lawsuits.

As a result, institutional review boards aren’t always so amenable to this kind of high-risk research. “It takes forever to get anything approved to do suicide prevention research, and it’s incredibly frustrating,” says Marjan Holloway, a clinical psychologist who is running clinical trials with suicidal military personnel at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Kate Comtois, a psychologist at the University of Washington in Seattle who has run psychotherapy trials in people with borderline personality disorder (BPD), expresses a similar concern. “I hear many stories from other institutions where people have basically given up recruiting high-risk patients because their institutional review boards are so cautious that they throw up roadblocks,” she says.

Suicide research also suffers from a practical problem related to the development of risk-assessments.

Normally, if I want to develop a way of predicting who will develop depression or not, I can assess a group of people and I can return later and see whether my predictions were right or not.

If I do the same with a suicide assessment and it suggests that several people are at high-risk of suicide, I have a moral duty to intervene and help them.

What complicates the issue is that this often applies regardless of the quality of my assessment. In other words, imagine that my suicide assessment is useless but I don’t know it – I will still intervene.

This means it’s often hard to get the assessment ‘off the ground’ in terms of its testing and development and this is why most scales are based on research looking at less serious outcomes, like having suicidal thoughts, that aren’t a very good predictor of whether someone will actually try to kill themselves or not.

This is also one reason why ethical review boards, and indeed researchers, are reluctant to get involved in this research.

Who wants to be known as someone who had several patients kill themselves during a trial to test an experimental form of suicide prediction? Despite the fact that, actually, virtually all the established scales are equally as ‘experimental’ due to lack of data.

The Nature article does a fantastic job of tackling these delicate issues and highlighting the need for better research on a crucial issue.
 

Link to Nature article ‘The Ultimate Endpoint’ (via @Neuro_Skeptic)

7 Comments

  1. Posted March 30, 2012 at 11:51 am | Permalink

    “I have a moral duty to intervene and help them.”

    You also have a moral duty to refrain from coercing them.

  2. Posted March 30, 2012 at 12:20 pm | Permalink

    I’m looking forward to reading this, and the Nature article, soon.

    Suicide is a strange topic for me…

    I lost my mother to suicide- and I’m in the psych field. So, it’s a huge interest to me.

    Often I think of suicide being paradoxical in that; if I love someone, I will always want them to do exactly what they want to do.

    I wrote more about this here –

    http://jasonkirin.wordpress.com/2012/01/21/the-codependent-paradox-part-1/

    It’s something I want to follow up with more. And also something I’d love to discuss further.

    For now, however, the work day starts.

  3. Posted March 30, 2012 at 7:43 pm | Permalink

    Excellent article about suicide. I’ve had a TBI in 1991 & Neurotin offered significant pain relief after a subarachnoid hemorrhage. In 2008 some physicians decided to discontinue all my medications. After 2 months I didn’t want to live. (Florinef for autonomic instability as well) No one even checked into the fact that all my medications were discontinued…and I couldn’t tolerate the pain. Thank God for prayers…and 2 months later I was restarted on Neurotin 1200 mg tid at another healthcare facility Spinal Cord Injury and never experienced that “suicidal thoughts” again. Sad, that NOT one person helped identify this cause and effect. I can see that research would be difficult, but it probably would help instead of hurt!

  4. russhamel
    Posted March 30, 2012 at 8:55 pm | Permalink

    Mental illness is such a tough issue to deal with for EVERYONE. I’m speaking as a former husband/caretaker for a Schizophrenic woman for 19 out of the 23 years we were married. Thankfully, we have moved on with our lives while remaining good friends. I am very happily remarried while my former wife lives under the care of Public Guardianship which works out so well for everyone concerned. Schizophreniacs tend to target their caretakers (often family members) as they perceive them to be the ones in ‘control’.

    As for suicidal thoughts, it became the ‘trigger’ word towards the end of our marriage as it was one of the only ways to get my former wife into better care. She was always right on that fine-line cusp; not bad enough to be institutionalized, but just sick enough to be a public (not to mention) personal menace and health hazard.

    And to be totally honest, she wasn’t the ONLY one with suicidal thoughts – if you know what I mean. That particular thought crossed my own mind more than once as I struggled desperately – futilely – to get her into some type of program that would give her some kind of consistent relief. Did I mention that mental illness is hard on EVERYONE involved?

    The BIG QUESTION in our case was always, “If the mental patient is NOT in the right frame of mind to make rational, every day decisions at ALL times, how can you possibly rely on them to make the right decision about their care at ANY time?”

    My former wife was and still is a beautiful human being. I admire her incredible strength and courage to endure what she has been through and continues to suffer in this life time. Because of what we have gone through together, mental health issues will always be close to my heart.

    All the best from Toronto,
    Russ

  5. Annonymous
    Posted March 31, 2012 at 5:11 pm | Permalink

    Sadly, suicidal thoughts are part and parcel with some forms of mental illness. Ideation, is quite a relief even if not acted upon. It brings ease and may not be the healthiest thing to do but it does bring comfort. It is rather sad that it so taboo to speak of with your doctor (God forbid they get sued for something), in our most litigious society. I am a devout Catholic, so it is out of the question. But, it sure is nice, to think of it like a vacation, that there is always that option. Troubled minds do not always find relief in the awful drugs and it is kind of like day-dreaming or a wish for a way to find solace. I believe in a merciful God and know he/she would understand. Anguish is difficult and playing the perfect person and happy game can be exhausting. Just saying and MDs that deal with mental illness should know this!

    Thanks Mind Hack for bringing up a subject that is sometimes most terrible, but also a great relief. It will always be difficult to speak of, but the reality remains significantly different. Best

  6. graemedixon
    Posted April 3, 2012 at 1:43 am | Permalink

    i would have thought you had an ethical duty to make an intervention for depression screening as well.
    An excellent article and one that sadly is shrouded in political correctness.

  7. Brody
    Posted April 6, 2012 at 10:17 pm | Permalink

    I’ve had recurring depression over the years, which, with severe philosophy and substance abuse and severe radical politics, culminated in TBI. I’ve been told I have bi-polar disorder, manic depression, plain depression, substance abuse and/or BPD. The very last pseudo-scientist I saw claimed I had a mental disorder due to alcohol abuse, ignoring the breakdown or my 12 year relationship, a pregnancy termination, loss of job and home all in the space of the preceding month as well as the TBI for which I had had no treatment over two years. So, I’m either a complete idiot or as my previous employers assumed, by allowing me to implement a major IT Financial system project, reasonably capable, but fucked up by circumstance. Which is it? And why is my word less valuable than a pseudo-scientist, when my degree has more scientific grounding than that in a field created by a pervert from Vienna to hide/justify his own perversions?

    More simply. How about some blood tests disproving any bio-chemical imbalance before stating that my ‘issues’ are ‘purely’ psychological?


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