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Why predicting suicide is a difficult and complex challenge

 

Who is going to die by suicide? This terrible mystery of human behavior takes on particular poignancy in the wake of suicides by high-profile and much-beloved celebrities Kate Spade and Anthony Bourdain. It is only natural that people want to know why such tragedies occur. Those closest to those who take their lives are often tormented, wondering if there is something they could have – or should have – known to prevent their loved one’s suicide.

As a scientist who has focused on this question for the past decade, I should have a pretty good idea of who is and isn’t going to die by suicide. But the sad truth is, I don’t. The sadder truth is, neither do any other suicide experts, psychiatrists or physicians. The sum of the research on suicide shows that it does not matter how long we’ve known someone or how much we know about them. In my research, my colleagues and I have shown that we can only predict who is going to die by suicide slightly more accurately than random guessing.

The need for answers

The fact that suicide is so hard to predict unfortunately took about 50 years for most scientists to appreciate. About the same time that this recognition became widespread a few years ago, a new hope emerged: a form of artificial intelligence called machine learning. As several research groups have demonstrated in recent years, machine learning may be able to predict who is going to attempt or die by suicide with up to 90 percent accuracy.

To understand why this is, and why we humans won’t ever be able to accurately predict suicide on our own, one needs to take a step back and understand a little more about the nature of human cognition, suicide and machine learning.

As humans, we love explanations that have two qualities. First, explanations should be simple, meaning that they involve one or a small number of things. For example, depression is a simple explanation for suicide.

Second, explanations should be determinate, meaning that there is one set explanation that accounts for all or most of something. For example, the idea that depression causes most suicides is a determinate explanation. This simple and determinate explanatory style is highly intuitive and very efficient. It’s great for helping us to survive, procreate, and get through our days.

But this style of thinking is terrible for helping us understand nature. This is because nature is not simple and determinate. In recent decades, scientists have come to recognize that nearly everything – from physics to biology to human behavior – is complex and indeterminate. In other words, a very large number of things combined in a complex way are needed to explain most things, and there’s no set recipe for most physical, biological or behavioral phenomena.

I know that this latter idea of indeterminacy is especially counterintuitive, so let me provide a straightforward example of it. The math equation X plus Y equals 1 is indeterminate. As humans, we instinctively try to find one solution to this equation (e.g., X equals 1, Y equals 0). But there is no set recipe for solving this equation; there are nearly infinite solutions to this equation. Importantly, however, this does not mean that “anything goes.” There are also near infinite values for X and Y that do not solve this equation. This indeterminate middle ground between “one solution” and “anything goes” is difficult for most humans to grasp, but it’s how much of nature works.

The sum of our scientific evidence indicates that, just like most other things in nature, the causes and predictors of suicide are complex and indeterminate. Hundreds, and maybe thousands, of things are relevant to suicide, but nothing predicts suicide much more accurately than random guessing. For example, depression is often considered to be an extremely important predictor of suicide. But about 2 percent of severely depressed people eventually die by suicide, which is only slightly higher than the 1.6 percent of people from the general United States population who eventually die by suicide. Such a pattern is consistent with complexity because it suggests that we must put a lot of factors together to account for suicide.

Empathy will always matter

So how should we put all of these factors together? One intuitive solution is to add many of these factors together. But even when summing hundreds of factors, this doesn’t work – prediction is still only slightly more accurate than random guessing.

A much better solution would be to somehow find an optimized combination of tens or even hundreds of factors. How can we do this? One promising answer is machine learning. In short, machine learning programs can process a large amount of data and learn an optimal combination of factors for a given task. For example, most existing machine learning studies have used data from electronic health records, spanning hundreds of factors related to mental health diagnoses, physical health problems, medications, demographics and hospital visit patterns. Results from several groups in recent years have shown that this approach can consistently predict future suicide attempts and death with 80-90 percent accuracy. Multiple groups are currently working on applying these algorithms to actual clinical practice.

One important thing to keep in mind is that there isn’t, and never will be, a single algorithm or recipe for suicide prediction. This is because suicide is indeterminate, much like the X plus Y equals 1 equation. There are likely near-infinite algorithms that could predict suicide with 80-90 percent accuracy, as a number of studies have shown. Research has already demonstrated that no particular factors are necessary for a good algorithm, and many different types of algorithms can produce accurate prediction. But again, this indeterminacy also means that there are near-infinite bad algorithms, too.

About 2 percent of severely depressed people die by suicide.
Fure/Shutterstock.com

All of this research shows that suicide is unfortunately too complex and indeterminate for humans to predict. Neither I nor anyone else can accurately predict who is going to die by suicide or truly explain why a particular person died by suicide (this includes the suicide decedents themselves). Machine learning can do a much better job of approximating the complexity of suicide, but even it falls far short. Although it can accurately predict who will eventually die by suicide, it cannot yet tell us when someone will die by suicide. This “when” dimension of prediction is critical, and we are likely still many years away from accounting for it.

In the meantime, what can we humans do? While we don’t have the ability to know whether someone is going to die by suicide or not, we do have the ability to be supportive and caring. If you believe that someone may be struggling, talk with them and let them know about resources such as the US National Suicide Prevention Lifeline (1-800-273-8255).

The ConversationIf this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 14.

Joseph Franklin, Assistant professor of Psychology, Florida State University

This article was originally published on The Conversation. Read the original article.

Federal money announced for doctors’ mental health

Health Minister Greg Hunt will work directly with doctors to develop a mental health care package for the medical profession.

Addressing the AMA National Conference on May 26, Mr Hunt (pictured) said a recent spate of young doctor suicides – including that of Deputy Chair of the AMA Doctors-in-Training Council Dr Chloe Abbott – has been a cause for great concern.

The Minister said that after speaking with AMA President Dr Michael Gannon and former President Dr Mukesh Haikerwal, he was determined to develop a mental health package targeting doctors.

“One of the main things we introduced in the Budget was prioritising mental health. For the first time, this has been raised to the top level as one of the four pillars of the long-term national health Plan,” Mr Hunt said.

“And we were able to invest significantly in mental health, both in the election, but in particular, in the Budget as well. There’s a very strong focus on suicide prevention with support for suicide prevention hotspots and an $11 million initiative, but also complementing that with the rural telehealth initiative for psychological services.

“Much of this is deeply important preventive health work on the mental health side and it goes with what has to happen in, I think, the medical work force. The case of Chloe Abbott was outlined and I’m aware that many people have been affected by Chloe’s loss, as well as others.

“And Michael and I have been speaking this week, and also been speaking in recent weeks with Mukesh Haikerwal, and I am determined to offer a partnership with the Government and the AMA for us to provide new investment directly into caring for carers.

“And so I want to announce that we will offer a partnership going forward and we will develop the suicide prevention, mental health programs with the AMA and the broader medical work force for suicide prevention and mental health support, specifically for doctors and other medical work force professionals.

“One of the critical roles that you have is psycho-social services. There’s the clinical work with those with mental health issues, but then there is the support services.”

The Minister offered few details of the partnership, stressing that it was still in its conception stage.

But he was determined to take action.

Following his address to the conference, he spoke more to the media about the plan.

“There have been some terrible tragedies in the sector. Michael Gannon and other doctors, Mukesh Haikerwal, have talked to me about that,” he said.

“What we’ll be doing is developing a caring for carers package which will be assisting with specialist channels, because sometimes, and this is what’s been explained to me, those who are doctors or nurses (a) will feel that they shouldn’t be seeking help even though they’re just the same as everybody, and (b) they might feel professionally uncomfortable. Even though they might be in the depths of despair they’ll still feel that professional discomfort at reaching out.

“And so if they have some specialised services for them then they will feel more comfortable, we hope, and that’s what’s been proposed by the profession.”

He did not know if the plan would address the mandatory reporting lines, where doctors might fear they would be reported to the Medical Board when they seek help.

He also promised funds to the partnership, but could not say how much at this stage.

“There’s been no proposal put to me yet, but as I’ve said, in designing of this, what I really want to do is work with the AMA and the GPs,” he said.

“What we’re doing is we’re designing together, and from that we’ll have the outcome.”

This article was originally published in Australian Medicine. Read the original piece here.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

Why don’t we speak openly about doctor suicides?

Why don’t we speak openly about doctor suicides?

 

Just over a week ago, I read an obituary in a medical publication about a young talented and clearly lovely junior doctor. Her life and achievements were celebrated, but no mention was made of the cause of her untimely death. Some colleagues and I surmised it was suicide, but then we wondered why it was it was not mentioned in the obituary.  Subsequently, suicide was confirmed, but at the time it felt as though there was an embargo on talking about doctor suicide. There is a shame about discussing it in public, and if this is the case, how can we possibly learn about the things that lead to suicide in our colleagues? We discuss medical cases openly so that we might learn, but why not of our colleagues who reach a point of no return?

It is well known that doctors do have a higher rate of suicide than the general public. These results have been reported as being up to 5.7 times higher than the general public. Female doctors are at the greatest risk with rates 2.27 – 5.7 times higher.

These results are staggering, but the fact that we have suicide at all in the profession is indicative of a deep dis-ease in our profession.

How is it that we can have people who are caring by nature, who choose to do medicine to care for people, but ending up so despairing that they take their own life?

And worse, that their colleagues and medical friends do not notice their decline to that point and are often completely surprised to hear of the death of a colleague in such a fashion?

These suicide statistics have been known for some time, yet until now, no true action has been undertaken.

In response to recent matters, last month the NSW Health Minister Brad Hazzard, instructed his staff that they have one month to come up with a plan for the doctor suicide crisis. It is great to see urgency brought to this matter, but is one month really enough and will it really get to the root of the cause?

What we are looking at here are ingrained issues, where for so long suicide has been accepted as a “sad yet inevitable”, or an “occupational hazard”. I was taught the statistics as though it was an inevitability that could not be altered. But is this really the case, and is this the way we would or ought to approach other health issues?

As doctors, we care about the health of people in medicine, yet we do not appear to be taking the same care and attention to the health of people in our own medical community.

Doctor suicide occurs within the context of the health care system and culture

Increasingly the culture of medicine is being revealed as replete with bullying and harassment. Far from caring for health care professionals, the culture of medicine is that of judgement, critique, condemnation, blaming and shaming. There is no true care and attention brought to the health and well-being of doctors and we are not trained in any suitable way how to deal with the emotional demands of the job, nor are we taught how to look after our own health and well-being.

Medicine is not a culture of peer support, but rather of peer competition and judgement. Any sign of human vulnerability and feelings is seen as a sign of failure. Medicine teaches you to be a “doctor” and not who you are as a human being. You are taught to “toughen up”. You learn that only the tough survive. There is stigma for those with mental health issues. People become isolated, hiding what they are going through. There are definitely some cultural factors that need addressing.

I have heard it said more than once that medicine is more stressful than being in the army or in a war zone, and that there is more compassion for your well-being when you are a soldier. In such a harsh environment, does it really surprise us that people do not survive?

As health care experts, why are doctors ‘surviving’ and not thriving?

Doctor suicide is the end of a long line of health issues for doctors, who are well known to have worse mental health than the general population on a number of counts. For every doctor who actually dies by suicide there are many who make an attempt but survive. Statistics show that  40-55% of the profession are burnt out with all of the personal health issues that entails such as higher rates of cardiovascular disease, anxiety, depression, diabetes, musculoskeletal disorders and suicidal thoughts. 25% of the profession have thought about killing themselves.

Doctor suicide exists in a longstanding culture that is well established to be uncaring and, at times, frankly abusive towards its own professionals. Suicide is an absolute tragedy but the day-to-day ill health of the medical profession is also a serious issue that needs to be recognised.

If we are serious about dealing with doctor suicide, we need to address the entire medical culture and system including the educational, medico-legal and regulatory aspects as well as personal factors at play. We need to be willing to make the needed changes. But we cannot do that until we are completely open about it and willing to examine the issue in absolute fullness.

Given the long association of suicide with the medical profession, there is clearly something amiss and thus something that can potentially be rectified. Let’s not look for short term solutions. Let’s aim to truly address the situation in full and get to the roots of the matter. Lives depend on it.

Dr Maxine Szramka is a Sydney-based rheumatologist and Clinical Senior Lecturer at the University of Wollongong. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support and information about suicide prevention in the medical community.

For support and information about suicide prevention, call Lifeline on 13 11 14