"No. no! The adventures first. Explanations take such a dreadful time."
– Lewis Carroll, Alice's Adventures in Wonderland
"I don't think . . . then you shouldn't talk," said the Hatter.
– Lewis Carroll, Alice's Adventures in Wonderland
Here we are again. Last week, the 2017 Colorado suicide statistics were released by the Colorado Department of Public Health and Environment (CDPHE). Once more, Colorado experienced historically high suicide absolute numbers. Several counties attained national ranking base rates. Tragically, these figures represent only a fraction of the true figures, which may be one-third to one-half as large.
I trained long ago in the intensely disturbed and disturbing world of the psychiatric emergency room. Whatever the personal or professional challenges, danger required quantification. Acute psychological pain demanded differentiation from absence of personality health. There were persons admitted who had self-amputated body parts, driven stakes through victims' hearts, or engaged in unusual strangulation.
What factors represent components of imminent danger in these diverse populations? For example, is drop hanging equivalent to horizontal hanging? Does motor restlessness suggest impending suicidality? Do homicidality and suicidality share a final common pathway? Is suicide rationally purposeful or neurologically compelled? Do some neurologic examinations correlate with acute suicidality?
Without fail, the first question asked when presenting death statistics is: What are suicide risk factors?
The common, head numbing affirmation of many is: Some factors include rugged individualism, lack of available psychiatric beds and psychiatrists, substance use, accessible guns, and economic or personal loss.
This is a democratic, socially equal answer. Anyone can speak this language. Although based in factor analysis, it only reflects the most superficial appreciation. Learning high-priced psychiatric vocabulary no more creates an emergency clinician then a scalpel placed in the hand makes a surgeon.
Therefore, there is a distinction between mere description and in-depth understanding. More complex contributing factors to persistent, high base-rate suicides include calcified administrators, fossilized psychiatrists, and resistance to anything but ideation-centric research.
It is here that heretofore unrecognized suicidality research, including medication side effects, deadly adjustment disorder, and other neurologic stress dysfunctions, offers more than a mere glimmer of hope. If you cannot speak this new investigation language forthrightly, you cannot formulate the research questions, cannot connect observations and commonalities, and cannot help the acutely mentally ill.
Although there is some documented and diligent suicide research by non-physicians, the questions that need to be honestly and directly asked of these principal investigators are:
- What are the operational definitions of suicide beyond intentional self-annihilation?
- What variables define high-risk suicidal patients in non-meta-analysis designs?
- What factors, other than depression and ideation, are involved in the study?
The retort is often: Well, most suicidologists are not medical doctors. They don't go to medical school.
That is literally dead-on. Without intense study in neurology and emergency psychiatry, I propose that those untrained in these fields (which includes most psychiatrists) cannot possibly align disciplines to formulate innovative research hypotheses and designs.
For example, recent research suggests that up to 20 percent of acute suicide cases represent unusual presentations. Among these are unobvious side effects to antidepressant medications, various forms of akathisia, and dissociative acute stress disorders. Additionally, 10 percent of those who commit suicide do so within hours or days (and 30 percent within weeks) after last clinical contact, emergency department, hospital, or clinic discharge.
Therefore, whatever "best practices" have been identified up to this point, including well-commercialized products, none have yet interrupted the trajectory of historically high suicidal events in Colorado. Unless and until unobvious (yet significant) conditions are included in a complete and psychometrically advanced assessment, no meaningful reduction in suicide absolute numbers or base rates, regionally or nationally, will consistently follow for "explanations take such a dreadful time."
Nevertheless, perhaps the best hands-on approach for now is not in the consulting room but in the lecture hall. Herein counselors and clinicians alike, from diverse backgrounds and disciplines, could share the classroom, "flood the zone," and engage in collaborative continuing education. In this way, school, judicial, law enforcement, first responder, nursing, and hospital personnel could expand their knowledge base, bridge the training divide, and cross-pollinate to secure competent training for psychiatric emergencies where other fragmented programs have failed.
If you cannot imagine yourself in this setting, if you cannot think clearly as violent, horrid, or unsightly patients are whirling about you, "you shouldn't speak." Listen to the trained and experienced—albeit older—research-innovator: "Lead or get out of the way" of vital, life-saving violence research and application.
Russell Copelan, MD (retired) lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery, completed residency and fellowship in emergency room and adolescent psychiatry, and practiced, with headwinds, in Colorado. He was a certified NIMH principal investigator. He is currently a reviewer for Academic Psychiatry, and founder of eMed International, Inc. (www.emedcolorado.org), an originator and distributor of violence assessments, now reaching 100,000 worldwide clinical evaluations.
