ENCORE! We Can't Predict Suicide, So What Should We Do? With Dr. Matthew Large

In this encore presentation, Dan and Dr. Matthew Large, a Conjoint Professor in the School of Psychiatry at UNSW Sydney, discuss the progresses and changes in the field of mental health.

Dan and Dr. Large delve into the limitations of Suicide Risk Assessment, the closure of asylums, and the improvement in the treatment of mental illness. Dr. Large discuss on how risk assessment is not clinically helpful and how suicide is a complex and unpredictable phenomenon. 

🎞️ Video version of the show@PsychotherapyAppliedPsychology on YouTube
🛜 Check out the website: Listen to every episode on your podcast player of choice

Connect with Dan
☏ Leave a voice message on Speakpipe
🔗 LinkedIn
📬 TheAppliedPsychologyPodcast@gmail.com

🦋@danielwcox.bsky.social

Chapters

• 0:00 Introduction & Episode Overview
• 5:00 Early Clinical Experiences and Impact of a Patient Suicide
• 8:00 Shifts in Psychiatric Practice Over the Decades
• 11:00 The Rise and Flaws of Risk Assessment Tools
• 15:45 Statistical Reality of Suicide Prediction
• 20:00 Short-Term Risk Prediction and Its Limitations
• 25:00 The Ethics and Utility of Hospitalization
• 33:00 Clinical Practice Without Risk Categories
• 41:40 Documentation, Liability, and Legal Myths

Transcript

0:00

[Music] A large part of my job is training the next generation of mental health practitioners. Because of this and because I do research on suicide, I often find myself in conversations about what people have done, will do, or should do when they're working with someone who's contemplating taking their life. Despite many people's best efforts, very thoughtful and bright folks continue to believe that suicide risk assessment is an ethical obligation and a useful tool for predicting suicide. So today, we're going to have an encore presentation of one of our early and most listened to episodes. I was very fortunate to speak with my guest, a leading researcher, if not the leading researcher, in understanding the clinical utility or lack of utility of suicide risk prediction. In this conversation, we dig into the predictive capabilities of suicide risk assessments. What practitioners can do instead, and how to appropriately document the proposed against the grain practices? But first, if you're new here, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, where I dive deep with leading researchers to uncover practical insights, pull back the curtain, and hopefully have a little bit of fun along the way. If you enjoy the show, do me a huge favor, and subscribe on your podcast player, or if you're watching one YouTube, hit the like and subscribe button. It's one of the best ways to help us keep these conversations going. This episode starts with my guest responding to my question about how he got into studying suicide. So without further ado, here's my very special guest, Dr. Matthew Larch. So I started my career in mental health as a teenager. I got into med school, but I really wasn't sure whether or not I was doing medicine. So, hopped on my bicycle and became a nurse at a local hospital. So I was a training nurse and at that stage, there were very few male nurses and the hospital was very unused to us. There was this sort of suggestion that we were all gay, which about half of us were. But we got shunted down to the psychiatry world. And it's always difficult to know why you've done something much later, but I do think this experience was quite formative. My job was really just to sort of herd the patients and chat to them. I don't know what the psychiatrist's job was. They seemed to smoke a lot of cigarettes and drink a lot of coffee and play chess. And there's a lot of psychoanelitic pronouncements and a lot of stylizing prescribed. So our job was really just to talk to the patients. And then one morning, I was coming into the ward through a back entrance through a workshop area, recreation area underneath the ward. And there was a young man hanging with a rope from the workshop from exposed plumbing. And my job, I was with another nurse. My job was to pick this young fellow up so that the other nurse could remove the noose from his neck. And then it was absolutely shambola cross-acetation. And it had a bad outcome. And I really thought lots of things about that I have to say. And had no deep briefing. I didn't really talk about it for about 10 years. I was really quite shocked by it. It was one of the things that sort of said, okay, like maybe I will go to medical school after all. Because I just don't think I can do this. And then, and this is in the late 70s, early 80s, the atmosphere was very much one of anti-secretary that psychiatric syndromes were an invention of psychiatrists and a product of culture. And then, and I'm getting to the second part here, I wanted to do infectious diseases and I went to southern India. And there in the Jewande Highlands saw a whole group of patients in a very remote area who had very much the same presentations as people in Sydney in suburban Sydney, OCD, Arexia, Paranoia, Mania. And it dawned on me that these people were actually, that it just really basically weren't well. And I suppose I maybe I didn't swallow a whole biomedical model of psychiatry, but I certainly loosened my view that it was a social problem. And I've had a strong interest in suicide really after this event, as I think it was 19. So there too, why I became a psychiatrist, I think, and where my interest in suicide comes from, I think it's always hard to reflect on your motivation. You said that, just listening to your story, I was sort of like, man, as a very impactful story, very impactful experience. You said that when that happened, you said, I don't know if I, something like, I don't know if I can do this or something like that. And then that was what led to your decision to go to medical school. Yeah, yeah, I thought being a nurse was an extraordinary experience. Actually, you're at the bottom of the social hierarchy. People didn't listen to you at all, didn't really matter to them that you'd had this dreadful experience. And as a teenager and no one spoke to me about it afterwards, you just expected to carry on the next day. And of course, I didn't tell the people I was working with that I could have gone to medical school. So it was probably one of the experiences that may be think. And I went to medical school with no view of doing psychiatry at that point. I was quite angry about how psychiatrists treated patients and their failure, I suppose, to save this young man who was only a year or two older than me, and their failure to protect me from having this experience. That makes any sense. Yeah, in Australia, do you feel like I would imagine that everything is of course culturally based things, but I imagine there's a lot of similarity. What's been your experience of how things have changed? Look, things have changed. There's, I suppose, much less stigma about mental illness. And the asylum system has been taken apart, and the patients are treated more respectfully and they have more rights. I mean, a very classic example is how we used to treat. How I saw people with anorexia nervosa being treated. So if you were a 16-year-old girl presenting with a low body mass index in the late 1970s, a kindly psychologist would talk to you about all the things you liked and make an inventory of all the things that you liked without telling you that all of those will be stripped from you and returned contingent on weight gain. And in the meantime, you would have to lie in bed with no visitors, no contact with the outside world. And it was really extraordinarily cruel form of treatment. And I mean, obviously we don't do that anymore. But I think, you know, so the psychiatry treatment of mental illness in hospital has progressed. Perhaps nowhere near as far as I would like it to. But it certainly has progressed. Do you think that there are one or two specific events that really help to push the field forward? Or do you think it's been a slow progression? I mean, it's been slow, but you know what I mean. So I guess one of the mandates very much without our topic in that, you know, obviously in 1975 or kind of versus Donaldson, the US Supreme Court ruled that it was unconstitutional to detain a person in hospital merely because they were mentally ill and that there must be something more. And that something more was, you know, widely interpreted as in the US, the term is dangerousness. Outside the US, the term is lead for protection from serious harm. And I think that, you know, in the 1970s and early '80s, you know, coincided with the sort of, you know, fiscal conservatism. So the human rights angle and fiscal conservatism collided, you know, allowing the closure of hospitals. Now what's happened later is not universally good by any means. But I think that's been a big change from, you know, my training in the '80s, training and experience in the '80s and my practice these days. So what got you into the study of suicide prediction? So I was a junior consultant and again with the caveat that it's I think it's hard to know, all your motivations really. We've very complicated creatures. I was a junior consultant and in the wash up of the, you know, Christopher, there's a death in England, the Christopher death of Christopher Clunus, death of Jonathan Zito by Christopher Clunus, the NHS introduced a requirement that there be a risk assessment at the point of entry to discharge into psychiatric services and that was introduced in New South Wales. And that would have been in, I suppose about 1997 or something like that by the time it washed up on our shores. And I'd had, some years earlier, not when it was released, I read Alex Bacorni's paper about the prediction of suicide. He did this really wonderful and very advanced study for the early '80s where he collected an awful lot of information about 480, consecutively admitted veterans, psychiatrically admitted veterans and then followed them up for five years and had lots and lots of data points, hundreds and hundreds of data points, including all the things that you would conventionally think might matter. And, metrically, the study showed that his high risk categories, however he defined them picked up fewer than around 50% of the future suicides, but also captured a very large number of people who were not going to suicide. And so it had a low sensitivity and and even low positive predictive value. And the strange thing about that paper and I remember reading it at the time, he said, well these are the results but risk assessment seems to work so we should continue to do it anyway. And I always found that rather jarring. So if you view yourself as a scientist and I view myself as a social scientist to some extent, you have to follow the data. And that was that megal to me. And then a few years later I did some studies of risk categorisation in psychiatric hospitals. I mostly work in psychiatric hospitals and found very similar result to percordies. And then I realised that no one had actually done a met or analysis of longitudinal prospective studies of risk categorisation. I was very surprised that no one had done it and as it happened there were two other groups working on it at the same time. My paper came out first by a few weeks so I was very pleased with myself. And it had results that were so similar to percordies. We found 53 studies. The odds ratio of suicide of higher risk patients compared to low risk patients was 4.84 which is quite a modest odds ratio. Not that much greater from greater than the association between male gender and suicide which in Australia and the US is about 3.5. The positive predictive value was very low. I think it was about 5% over five years so we've got 1% per year. And the sensitivity was only 50%. So you know 50% of the suicides occurred in the low risk group. And that really also got me thinking about that my earlier one particular thing in my earlier in my medical career. So when I finally finished medicine and was working as an intern in a major hospital it was right at the peak of the AIDS epidemic. And Sydney was a he was like San Francisco to a very gay city and we had lots and lots of patients. And we were told at the beginning of the year that we should wear gloves if we were drawing blood from you know, Hayations, heroin addicts, homosexuals and hemophiliax. And that was the risk that we, they were the risk groups and everybody else we would draw blood without wearing gloves. And about halfway through the year, I can't remember who it was but it wasn't me said this is ridiculous. Anyone can get AIDS. Let's just adopt universal precautions. And so I think that we need to, you know if you've got a test that only picks up 50% of future suicides and we want to prevent suicide. We can't be satisfied that low risk patients are not at risk of suicide. And that's particularly true among, you know, kind of hospital treated patients who I've classified as those presenting to emergency departments with suicidal thoughts and behaviors. Those who are admitted and those who are discharged, they have extraordinarily high rates of suicide. And even, you know, patients who are at low risk of suicide, you know, or at lower risk of suicide, according to our instruments still have very elevated suicide rates. And I just that thing, I think it's bad medicine to be, you know, allocating resources and only worrying about people who we think are high risk. So I want to sort of, you've said, you said a lot right there and I want to delve a little bit deeper into it. And so, and particularly when we're talking and talking about odds ratios and positive predictive values and things to try to help, you know, particularly the clinician who might be listening make sense of what that means in the real world. But let me sort of set you up with sort of my experience, my clinical experience and my clinical training in terms of what I was supposed to do when I suspected a client, when I suspected a patient was, you know, suicidal. So what I was trained to do is when you suspect a client's suicidal after you sort of ask an initial question, you know, are you thinking of potentially ending your life, you're potentially killing yourself and they they indicate yes or sort of something like that. Then what I was taught to do is get out some sort of a form and depending on where I was working, the form varied. And it had a handful of questions, well, I should say, I shouldn't say a handful anywhere from a half a dozen to 20 probably, a lot of variability to ask the client to assess their suicide risk. And based on how they answered the question, it was never quite clear what the exact algorithm was that if they were categorized as high risk, then that meant potentially that I should talk to them about hospitalization or the possibility of hospitalization because they might die by suicide, or they might they're at higher risk for a suicide attempt. And I think that that training experience for people in my field is very common. So what is what's wrong with that approach? So I think that is a very common approach still. And I mean, there are literally hundreds of these different forms that you're talking about. And no form has ever gathered momentum as the way to do this because they're all equally modest in their abilities. And if you look at NHS trust, and also health services in Australia, they're a generically, they're a locally derived non-imperial form that is used. And so what's wrong with that? Well, there might be some right things about it. You can gather a bit of information, make sure your history is a little bit more complete. But going back to those metrics, the sensitivity of this sort of form is about 50%. So the sensitivity is the proportion of future cases that you'll capture in your higher risk group. So they miss out on about half the patients. And the positive. So sorry, so of the people who do end up dying by suicide about half of those folks are in the high risk group and about half of those folks are in the low risk group. That's right. That's correct. So really then, so then, right, so that calls into question these categories overall. Yeah. And so, and if you look at the other metrics, so for high risk patient, very few high risk patients will die by suicide. That's the positive predictive value. The proportion of high risk patients will die by suicide. It's a different measure. But it's of the order of 1% per year and commensurately lower over shorter periods of time. And so that means if you were, for example, to hospitalise all your high risk patients, you would be hospitalising 99 patients. Many of them may not want to be hospitalised or may not benefit from being hospitalised. In order to potentially capture one person who may go onto suicide. And the other statistic that I mentioned is the odds ratio, which roughly translates into a multiplied probability of the likelihood of high risk patients versus lower risk patients suiciding. So the meta-analytic figure appears to be around 5. So higher risk patients are about 5 times more likely to suicide than lower risk patients. So suicide risk assessment does give you a little bit of information. And I think that he's generalizable to the patient. It does tell you something about the patient. It just isn't enough to make a clinical decision. And I mean, if you talk about, you spoke about asking people about suicidal ideations. Well, I've done some studies of suicidal ideation as well as some meta-analyses and some primary research. And only in community samples, only about 20% of future suicidal people who pass away by suicide have disclosed suicidal ideation of a specific earlier time. It's a very insensitive test. And the odds of suicidal ideators, suicidal ideators, isn't much higher than the odds of suicide among non-ideaters, particularly if you have depression, doesn't seem to make any difference at all. And if you would have played desert island risk assessment where you were only allowed one risk factor. And you could choose between suicidal ideation and gender. I would argue that you should choose gender, because they're equally statistically related with future suicide. And gender is a lot easier to ascertain. And suicidal ideation. I know partly it's an exaggerated case, but I do think there is a point a valid point about the weakness of the association between suicidal ideation and suicide. And that's not to say that you shouldn't ask patients about suicidal ideation. I mean, obviously, someone who's telling you that they're feeling suicidal is you don't need, there's no element of prediction in that. They're telling you that they're feeling so bad that they're thinking of ending their life. And obviously those people need care and treatment and the attention. You need to alleviate that somehow. But there are lots of very distressed people, equally distressed people, who also need care and attention, but don't disclose suicidal ideation. And I'm just suggesting that kind of rather naive, positive, instinct view of who will die by suicide shouldn't really be the guide to how we interact with people. I think we need to interact with people in a way that is much more like universal precautions. We need to be careful in all our interactions with every patient and no patient should go home and empty handed. And I mean, my own personal view and practice is that suicidal ideation, even quite severe, suicidal ideation isn't sufficient remit to compel a person into hospital care. There does need to be something more than that. But most people are happier and better treated in their homes. I want to come back to the hospitalization thing. I actually want to come back to a couple of things you said, but I want to go before we leave some of the sort of more data aspects of this. So you talked about for folks in the high risk group that about 1% of them per year will die by suicide. But for most clinicians, outpatient clinicians, I should just talk about psychologists because that's what I'm really familiar with. That's not what what they're interested in. And what I was interested in is what's the probability that this person is going to attempt in the next really, honestly, 24 hours, maybe up to 72 hours. Really, I'm thinking about if I let this person leave my office, will he attempt suicide tonight? What do we know? So that year figure for most of the psychologists in practice, the therapist in practice, it's actually not what they're concerned about when they're doing the assessment. So what do we know about that 24, 48, 70, whatever that really short timespan in terms of this predictive ability? Okay, so firstly, that figure of 1% comes from hospital treated patients. So they're a little bit different to patients who you might see as an outpatient. They're much lower than that. I mean, the suicide rate in the general community is one in 10,000, not one in 1% and presumably patients who we know that having contact with the hospital is arguably the risk factor for suicide associated with odds of 20 to 50 depending on what study you look at. So it would be lower than 1%. Remarkably, very little is known about the term immediate suicide risk is used very widely. But there is no evidence that shorter timeframes in assessments work any better than longer timeframes. I was just recently reading a study at one of the few studies that uses the Columbia Suicide Suburitory Rating Scale over time. And actually their scale is more accurate over longer period of time. And the positive predictive value of a high risk category in the first few days associated with essentially suicide-ladiational plans on the Columbia scale is 1 in 1600. That's the figure. The PPV was.006 which translates to 1 in 1600. And so 1600 people is a lot of people to do something restrictive for. It's a lot of people to do anything for actually to try and capture or try to treat one person. And this really comes down to the what I think is the real problem with risk assessment is not really the metrics. So the question is the metrics obviously impact on it. What would you do for a high risk patient that you wouldn't do for a lower risk patient? And you have to think of something that can be morally and ethically and practically delivered to a high risk patient that should be morally ethically and practically denied to a low risk patient. And so whether you do a risk classification is a human enterprise. So if you're making violins I imagine that you collect wood very differently to if you're making a bonfire or a barbecue. You know we classify things for human purposes. And so how we classify things depends on what range of tools we have available to us. And I sometimes like to think about a hypothetically excellent suicide prevention pill. And so you had a pill that you could give a patient that would stop them from taking their life for the next I don't know two months or so. And the only justification I can think of for only giving that to high risk patients would be cost. So there might be some instances where you know if you had a limited supply of these high risk suicide pills that you could deliver them on the basis of a risk assessment. But I actually just don't think we've got those instruments to us. Those instruments available to us. I mean there's a very thorough meta analysis by Fox published a few years ago looking at the you know randomized trials of suicide prevention that have been published in the last 50 years a very sobering study. And it shows that you know our ability psychotherapeutically and pharmacologically to prevent suicide is actually quite modest. So you know disturbingly models. So why do we keep doing this? That's a great question. And of course by this I mean just for the listener by this I mean why do we keep why do we keep using these risk assessment tools that are terrible at well just to be clear these tools actually do increase our ability to predict. However they don't do it in a clinically helpful way because as you just articulated I think it was the one in 1600 or I think that was right. That's that's still when you're dealing with this patient who's hanging across me right now. The they're in the high risk group but the only one in 1600 will go on to I don't know if that study was attempt or die by suicide that yeah that's closer than one in 10,000 or whatever you know the lowest group might be but it's still really not clinically useful but we continue to collect these data and make very serious consequential decisions based on these data. Why do we keep doing that? So I think it's a central question. Firstly I do think it takes medicine you know and psychology I think it takes a long time to change there's some evidence that there's a paper that says it takes 20 years to reforms to happen in medicine and I remember when I was a nurse if you had a big heart attack we'd force you into bed rest for 10 days and we literally pushed people into bed stop them from getting up and walking around and if you had a small heart attack it was a week but we now know that that actually kills people and that practice you know went on in the absence of evidence for years so but I think risk assessment is a little bit different in that we I think we have our own you know risk assessment mechanisms we worry about other people so we've got our own internal you know risk instruments and we're I think a little bit aware that those instruments are imperfect and we would like some external help to help us with that. I think it's also it's a baguiling idea that we can see into the future suicide I think is a very very complicated and disturbing problem I don't think it's any I don't think it's really whole there's much contention that to be or not to be as one of the most well-known phrases in the English language but you know it's a very complicated problem and having a simple solution to it is attractive and baguiling and of course wrong and then there's this you're actual feedback that you get so I've mostly worked in emergency departments and inpatient units but a lot of time in emergency departments so you see a patient in the emergency department and you think they're high risk and you admit them to hospital and of course hardly any of them suicide so you think you've done the right thing and then you send another group home and hardly any of them suicide so you think you've done the right thing so you don't actually get any real feedback about your decision and you can be just very satisfied with yourself until such time as you actually do have a suicide and I mean this one thing that I'm always concerned about in my role is the welfare of people who are junior to me in the system and time and time again I've seen young doctors and young psychologists and social workers in a see a patient fill in these forms that you describe in perfect handwriting make a totally correct categorization as to low medium or risk and then the patient passes away from suicide and happens in a big hospital happens once or twice a year to either an outpatient or an inpatient and the vast majority of those young people will have a very nice people that want to work in mental health for caring people and most of them will have some sort of mood disorder maybe only an adjustment disorder but I've certainly seen more severe disorders follow and there's always a presumption that the risk assessment was incorrect just you know by virtue of the fact of this suicide I mean it's crazy thinking I mean at one level I mean a winning or a losing lottery ticket is no more likely to win before the you know balls pop out of the little thing but that is the way people think about it and so I think I've got off topic a little bit but I've been very concerned about the effects of of of investing too much in these sorts of forms for young people and the end at the beginning of every year when we have a group of new people start I give a talk about suicide prediction and I tell them that probably one of you in this group we have run a big hospital see thousands and thousands of patients a year will will probably have a suicide and you will have done a risk assessment and the patient will pass the way and and when that happens it's very useful to be able to go back and say look out unfortunately this is very unlucky that this has happened to you and of course I'm lucky that it happened to your patient and their family as well but yeah I sometimes worry that I've got inordinate concern about the welfare of my colleagues but we do have to march on and treat people the next day often that afternoon even if I'm if I'm seeing patients in an outpatient context and I'm concerned about their suicide risk often the expectation is to hospitalize them what do you think about what are your thoughts about hospitalization in terms of treatment for suicidality well some years ago I did a meta-analysis of rights of suicide in psychiatric hospitals and so I looked at all the available data I think up until about 2011 and it showed a few things and one of them is that rates of suicide in psychiatric hospitals have actually gone up and they're quite high in more recent studies 600 per 100,000 per annum about 60 times out of global suicide rates so if if nothing else we're not you know our ability to protect people is imperfect there was some other things that were very interesting in that study and there was enormous heterogeneity statistical heterogeneity between the highest hospitals with the highest suicide rate and the lowest suicide rates and there were some clues to why that might be the hospital with the very highest suicide rate ever recorded was some hospital in Australia in a kind of top floor of a brutalist building was a ward that was in a run by a university and not a health department the authors of the paper you know wrote saying that they thought that it was due to low nursing numbers the absence of psychologists and social workers on the ward really did sound like a terrible ward and you know it was promptly closed so I think wards can be better or worse but the rate of suicide in hospitals is high and I've got three sort of things that I think about that so we know in the general community that stigma trauma and dissociation from your normal social role are things that have some association with suicide and a hospital does all of those things so something like globally something like I think we found in another study 17% of of psychiatric we admitted people are violent to another person and that's almost always other patients it's not known what proportion of patients are actually traumatized by an assault but psychiatric wards are horrible frightening places and then there's the stigma of being a psychiatric patient then often being an involuntary psychiatric patient and the patient people come in and they look around and they see the other patients some of them are extremely unwell they think this is their future so they're self stigma and stigma and then you know being admitted to a psychiatric hospital for the first time often will result in you know losing your place at university or losing your job or you know losing some standing even with your friends and family so the we the I don't think we've concentrated enough on the adverse aspects of psychiatric hospitalization and then of course there's precious little data that hospitalization prevents suicide in the Fox meta analysis they said there was no data subsequently there's one paper that suggests a very modest reduction in long-term suicide if you are admitted for suicidal that is emerged you know within the immediate immediate period but it's a very modest reduction and that suicidal in general is not reduced by psychiatric hospitalization this is a complex machine learning paper and I've got some doubts as to whether it'll be replicated but that is the only data there's really no data about hospitalization it's a contingent accident of history that we we put people in hospital and and not a no it's not an evidence-based treatment I mean having said that it's not all that long ago and I remember you know admitting a patient involuntarily with essentially no no suicide risk factors and so I perhaps won't talk about the details of this but she'd discuss how to in a catastrophic event in her social environment and just absolutely couldn't think and you couldn't take a history from her and unless you didn't have a mental illness she was highly educated and children was well off I just couldn't you know release her from hospital because I didn't know what she was thinking or what would happen next and there I thought epistemically she was a person who I regarded as something as a kind of suicidal person in a way not that I thought that it was particularly likely that she would suicide but there was a judgment that I made about her at that moment and of course when she settled down it was very easy to release her from hospital and she's very grateful and so that touches on this issue of what is the uncertainty about suicide and John Manard Kane said that there were two sorts of uncertainty there was uncertainty stemming from lack of knowledge or epistemic uncertainty and then there was uncertainty due to chance factors and so if you see a 16-year-old smoker they may or may not develop lung cancer and further information isn't really going to tell you whether they will but two decades later if they present coughing up blood then they may or may not have lung cancer but you can work that out by a chest X-ray CT scan and ultimately by biopsy and so I use those sorts of concepts to try to think about suicide prediction so I've done a few studies of this now so in three studies I've looked at the number of risk factors in cooperating in the suicide in the used in the high risk model and the strength of the suicide prediction and collecting more information suicide models that have more information don't work any better than suicide models that have rely on less information and in my 2016 study the odds of suicide was some to mention earlier is you know 4.84 which is not really any higher than any individual risk factors so collecting more information isn't necessarily going to help you know what the patient's going to do next and that has a lot of clinical implications the big one it has for me is if you've got a patient who's distressed and who you're having difficulty establishing rapport with and you've find you've got a choice between taking a complete history that will satisfy other people when they read it or getting along with the patient you should definitely choose getting along with the patient you shouldn't choose interrogation because that information isn't going to help you about the most significant outcome that might occur just to highlight that point and there is some writing on this that when you're doing this risk assessment but I always how I sort of communicated to folks is like well if I'm doing a risk assessment I'm I'm paying attention to this assessment making sure I collect the information but I'm not like I think almost no clinician is their therapeutically best right it sort of takes you out of that moment and sort of some of those skills that we have and that are so therapeutic sort of evaporate as we focus on collecting these data I couldn't agree with you more and I've got a specific way of thinking about this and so I think you know we're risk assessing the patients and the patients are risk assessing us they're risk assessing our likelihood of putting them in hospital and you know it's almost like the prisonist dilemma and and this is obviously for mentally competent patients you know for patients who are hallucinated or severely depressed they may not think too much about what you're thinking a lot of patients do think about what you're thinking and we think about what they're thinking and I always try to find some kind of humorous way if I can of getting past that and one way is to reassure the patient that probably earlier than most people that you know my intention is definitely not to put you in hospital but to help you and that usually cuts past it and we spend a lot of time doing suicide assessments and mental health resources are are very scarce I personally think I feel much more freed up as a clinician not I don't feel any forms anymore I've obviously given it up a long time ago I don't criticize other people who do because people do it for their own reasons interestingly I've never been a sort of issue entrepreneur saying to health citizens look you must remove all these forms but actually almost not doing that has been more powerful than doing it so in my own service people have given up the forms although I never asked them to and but they're very aware that the amount of you know that I've given lots of talks on this so in New South Wales there are some little things about high medium and low done by the nurses but the doctors are not required to do to to make a categorization about that but we are required to you know take a full history from everyone and you know to talk with their family to give information about suicide risk if they want it to provide something for everybody and you know if someone wants to come into hospital it's a completely different matter I mean we may not always be able to accommodate them but that's a very different matter to compelling someone you know into hospital so what do you do when clinicians say to you but I'm required to do a suicide risk assessment how do you respond to that so I don't ever think I've seen a low risk patient in my whole career I really don't think I have seen severely mental ill people in hospital so that kind of strikes out low risk and we know that the positive prediction value of high risk is quite small so I'm very spearing about low risk so if you have to do it medium you can't be more than one wrong so if you have to do it and I'm not being facetious here actually I would just choose medium go on and try to be helpful to the patient not spend too much time agonizing over it just try to do something that will be helpful and the patients all have things you know their things they're upset about the substance use can be you know assisted with their housing that patients usually have lots of targets for things that will be helpful for them so when working with a suicidal patient how much do you think that's a very broad question I know there's not a one size fits all but how much do you think that we should be prioritizing the suicidality in our treatment I don't think we should be prioritizing categorizing the patient obviously a patient who is feeling so awful that they've made an attempt on their life or are expressing suicidal ideas that's a very important piece of you know psychological almost philosophic information about the person and I think you know we should prioritize those patients but actually lots of our patients don't have suicide ideation and in a way you know I'm more concerned about those people being excluded from care then I am about I mean my concern about high risk patients is really is that we um in act far too quickly to put them in hospital or against their will my concern about low risk patients is that we don't give them anything very much so I think we just have to be modest the amount of information that we get from a suicide risk assessment is modest and therefore we should only pay a moderate amount of attention to it if that makes sense so what sort of pushback have you gotten? Well it's an ongoing controversy academically there are two prominent international groups who are still very much pushing their own like instrument I'm not going to mention names particularly but you know they're on both sides of the Atlantic but the metrics of their instruments are no better than percording study in 1983 and there has not been a big breakthrough in this field but what I have noticed is it's much easier for me to get things published these days so I had an extraordinary experience actually not too long ago where I wrote a very nice paper and I sent it to a good journal and the editor wrote back to me without sending it to review said look Matthew um very nice paper very convincing but you know as a journal we've moved on from risk assessment nobody believes this anymore put it somewhere else so that was kind of gratifying but a number of years before then I had difficulty getting things published because people were skeptical so that's that's in an academic in an academic thing I've it's become easier um I I've never had a pushback from patients or their families I I mean the stakeholders involved in this are the patients the families the clinicians the third-party providers the courts and ultimately in some instances even government and you know talking through all of those you know patients hate the idea that you're going to assess their idea of what they might do without really discussing exactly how you've done that they they don't like it um patients families are reassured by absolute estimates and um you know by by actual knowledge they don't really want to hear that their child is high or low risk um colleagues you know it was very um you know there were a lot of people very invested in it and actually interestingly the metrics of violence risk assessment are very similar to the metrics of suicide risk assessment but violence risk assessment no one's really like taken it on um so you get some pushback from forensic psychiatrists that realize that if there's real insight into the weakness of suicide risk assessment that that will uh call into question one of the central tenants of their profession so I do have some pushback from other psychiatrists um the third-party providers are when you explain it to them are remarkably fine and I mean I've been giving evidence in coroner's cases um you know across the country for two decades now and um you know I've given probably rather too many statistics lessons on the stand um but the courts I mean we have a duty as mental health professionals and evidentiary duty um to you know explain things to the courts um and you know the standard of medical practice everywhere is reasonableness and scientific um you know providence and results you know central to reasonableness so I you know I've seen some horrible cross-examinations of people but ultimately um the court decisions in at least in Australia have been all quite reasonable but do you have any advice I one of the one of the anxieties I hear from clinicians when I talked to them about this is if I don't do this and document it that that I um I could be held liable yeah yeah yeah yeah I think I heard that at the APA I just don't buy it um you I mean I suppose you might be if if the wrong experts gave evidence but doing a risk assessment um categorising the patient as high risk and then sending them home I mean we do that all the time we can't do anything about it then you know that actually causes a liability doctor why did you classify this person as high risk and then send them home um if you classify them as low risk and then something happens then there's the liability of you potentially getting the having gotten the assessment wrong um so there is you know there is if you have a suicide there's always a potential for um you know some sort of litigation but uh you know I'm in my mid 60s I've been a psychiatrist for a really long time I've never had to give evidence um to a court about a death of a patient under my own care and I think part of the reason for that is I've been very careful to talk with families um it's not that I haven't had any suicides unfortunately I've had um you know handful over the years um um but communicating with the family communicating with the patient um I mean I would like to think that a risk assessment could be replaced by a kind of risk communication really um in which we can give actual real knowledge and um and we need to emphasize that it is a very unpredictable um event with a lot of chance in it knowing more about the patient isn't necessarily gonna help you so when uh a clinician says to me when they ask me that question like so what should I do to help protect me from being sued what are your bullet points? Oh look documentation documentation and documentation and I mean um uh when um the thing doctors don't do and presumably psychologists is we collect a lot of information but we often don't explain why we've done something so I think it's quite okay to have yourself in the notes you know I've considered this person could be classified under some schemes as having an elevated risk of suicide but you know they're mentally competent um I'm aware that the you know positive predictive value of a high risk categorization over the next week is less than one in a thousand um patient really doesn't want to be in hospital um I can provide some further out patient care I've discussed this with their mum um you know that that's a standard of mental health practices to be a reasonable person and so um I think my one bullet point really would be to inject your decision making process into your documentation and that's much more powerful than a form and in fact when you see these cases they're sadly um often they've had hundreds of risk assessments and then the patients are equally deceased um and no one's explained how they used it um how to inform their treatment and often I don't think it did it's a little it's a little ritual that we do um that you know may reduce our anxiety a little bit stop us from thinking about you know the uncertainties um that the patient faces and I mean life's pretty uncertain for all of us and um and um I think one of the problem with suicide risk assessment it does um give a sort of sense of otherness um whereas you know we all stand a definable um risk of of of suicide I was in a lecture the other day and you know I I I had a period when I wasn't well many decades ago and I did my own Columbia Suicide Severity Rating Scale and on the basis of you know suicidal thoughts years and years ago I came up as moderate and I was thinking oh that's ridiculous I've got absolutely zero suicidal ideas um you know I've been a very happy person for you know for any of 30 years um uh so I don't know if that's helpful to you to to talk about that particularly but I do think you'd need to be skeptical about about um a simple solution to you know very complex and ultimately centrally human problem yeah and I've also read uh folks who make the argument that I write that if you if you engage in doing a safety plan doing means restriction counseling those sorts of things and note that that that is also you know you can fit you can note the things that you are doing yes of course um and uh I think the evidence for safety planning is not as good as some people make it out to be but obviously um it shows that you're um interested in the patient and helping them think it through and um so um I'm a term advocate of safety planning I think safety planning has been in advance um uh mean restrictions are very you know it's a very um like important population measure um we're very lucky in Australia and that we've had um you know very rigorous regulation of um handguns um and rules about storage and use of long guns and I mean female suicide by firearm has disappeared as a category of Australian suicide uh suicide by firearm is a rare cause it's no more common than jumping um um and it has been associated I think with the genuine decrease in the suicide rate um most of our suicides are by hanging um it's very difficult to regulate hanging I don't think we've really thought about how that might happen outside a hospital situation but um you know absolutely well Matthew I can't tell you how much I appreciate this conversation um I think that when you said that uh that the journal said oh nobody nobody really buys this uh risk assessment thing um I was sort of like wow that's you know uh perhaps the readers of that journal I don't know uh if that's true uh uh it's not true across the board at all no no it isn't it isn't um but I do you know if you want to read something to read some of the stuff that I've written or stuff nav capoe or Greg Carter has written or anything written by Franklin or Robino is very well you won't waste a minute reading them um there's a great paper and I think it's in jama psychiatry by um uh Belcher um from a few years ago um don't take it from me um just actually you know as a mental health responsive um professional you have a responsibility to know the literature and the literature is pretty clear now yeah no yeah absolutely and I it would also struck me when you were talking about folks who have developed risk assessments and I think a lot of very well meaning and intelligent people have put a put a lot of time and energy into the development of these tools and I think that there's something to just you know I mean there's some cost right and I think that it's difficult for folks to let go of that and I understand that at the human level I really do and at the same time and there there's an intuitive appeal there's a logic to it but then when you sort of to me anyway and part of it was reading your work reading other people's work listening to people talk when you peek under the hood of suicide work is the risk assessment and that in fact you need barely any data at all that this really is very much there's a logical argument here which is that this is such a low probability event uh that there's no way that I'm going to be able to collect data you know from a handful of questions to be able to predict this incredibly low probability event is going to happen in the next 24 hours it's just it's irrational it can't be done right it can't be done look I still do my own suicide risk assessment studies I'm not opposed to studying risk assessment I think that we have a lot to be thankful for the people who spend a lot of time you know trying to work this out we we're only at the position of knowing about the general weakness of suicide prediction because of the efforts of a really large number of people in lots of different countries in the last 50 years and of course I'm very grateful for those researchers that's a wrap on our conversation as I noted at the top of the show be much appreciated if you spread the word to anyone else who you think might enjoy it until next time