Results of largest trial of suicide intervention in emergency departments ever conducted in USA

[RogerBlack]

Results of largest trial of suicide intervention in emergency departments ever conducted in US

http://blogs.plos.org/mindthebrain/...n-emergency-departments-ever-conducted-in-us/

Looks very similar to PACE and CBT in many ways.

A trial of an intervention that 'should' work, based on theories with little evidence, RCTs spun based on outcome switching and weak evidence that should really be regarded as null, leading to rollout of the intervention in some places.

More evidence that screening for suicide doesn’t improve outcomes
This study adds to an accumulation of a lack of evidence that routine screening for suicide is either efficient or leads to less suicides.

Previously, I blogged about the SEYLE trial of a school-based intervention to prevent teen suicide. It was a large RCT, but failed to demonstrate that screening affected the likelihood of a suicide attempt. The null findings for the Screening by Professionals programme (ProfScreen) of SEYLE are generally downplayed.

Another blog post Use of scales to assess risk for a suicide attempt wastes valuable clinical resources discussed a large UK study that found none of the commonly used screening scales were clinically useful in predicting subsequent suicide.

That study concluded

Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Nonetheless there is:

The Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;(56):1-7.

The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization[1] that accredits more than 21,000 health care organizations and programs in the United States. The Joint Commission recommends that hospitals routinely screen patients for risk of suicide.

 

[anciendaze]

I want to point out one small high-quality study by Naviaux et al. of patients with "treatment-resistant depression" who had survived suicide attempts. A significant portion of these had objectively-measurable metabolic abnormalities, some of which were already treatable. Others appear to be potentially treatable in the near term.

A second illness driving patients to suicide is misdiagnosed and mistreated Postural Orthostatic Tachycardia Syndrome (POTS). (There was a spectacular case locally in which a patient jumped off an airport parking garage.) It is by no means necessary for a patient with POTS to suffer from depression, but some form of dysautonomia is essential. It should come as no surprise that people make very bad decisions when their brains are deprived of oxygenated blood. There is plenty of research on the effects of hypoxia that should be relevant to behavioral response to episodic hypoxia, especially when the patient does not know what is going on. Telling patients with organic problems their illness is psychological, with no efforts to confirm organic causation, should be counted as malpractice.

There are any number of hypotheses on the cause of POTS which do not include any physiological causes. These belong in the wastebasket. There is however one cause which can be verified by MRI and partially corrected by surgery: cervical spinal stenosis. You might ask Dr. Peter Rowe of Johns Hopkins University about this. He will not have much good to say about treating spinal stenosis with counseling. Some of his patients had been through years of totally ineffective treatment, at considerable expense.

What I'm going to ask other readers to contribute to this discussion is a careful reading of material about screening for suicidal ideation to see if there is any mention of screening for cerebral hypoxia, metabolic abnormalities or organic autonomic problems, even from such direct mechanical causes as cervical spinal stenosis.