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Can We Really Predict Suicide?
Prof. Gil Zalsman M.D.Deputy Director, Geha Mental Health Center
Psychiatry DepartmentSackler Faculty of Medicine
Tel Aviv University, Israel&
Chair, National Council for Suicide Prevention, Israel&
Associate Research Scientist
Molecular Imaging and Neuropathology DivisionPsychiatry DepartmentColumbia University
New York, NY
ESSSB15 Tall inn A ug 29 16-18:00 Room A002
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Prediction in medicine
Perform benefit/risk assessments of theinterventions and intervene only when benefitsunequivocally exceed the risks .
The scope of prediction (diagnosis) is to limitthe intervention to those affected by thecondition , thus improving the benefit/risk ratio.
If you can predict and you didnt - you areresponsible for the results
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The Prediction Paradox
We teach risk assessment
We try to control riskfactors
BUT we can not predictbetter than flipping a coin
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Confused?
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Stadium with 100 K citizens ofTallinn
17 will commit suicide Data from
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Stadium of 100 K males in Tallinn
32 will commit suicide
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Stadium of 100 K depressed inTallinn
5000 will commit suicide
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Stadium of 100 K depressed inTallinn
Is this guy is one of the 5000?
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1 . Suicide is a high impact, low probabilityevent2. The prediction power of the demographic and
phenomenological variables is very low3. No data exists to support prediction orpreventive intervention at the individual level*(which is what doctors care about)
4 . Therefore the clinician cannot be heldresponsible
Limiting availability of fire arms and gate gatekeeper educationhas had moderate effects at the population level (Mann et al., 2005)
My Message
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Game Theory
"the study of mathematical models of conflictand cooperation between intelligent rationaldecision- makers(Mayerson 1991)
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Irrational prediction
Prof. Daniel Kahnman2002 Nobel price winner ineconomics
Prof. Dan ArielyAuthor of
predictably irrational
Behavioral economics
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Biases and difficulties in risk-benefit assessment
Event available in the recent memory Attributing causality to natural course of disease
or to randomness
Ignoring low base rate Overweight small probabilities and underweight
moderate and large ones.
Statistical illiteracy Loss aversion The tendency to personalize and be influenced by
anecdotes
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At the individual level, are characteristics (risk factors)for suicide consistent and reliable?
low IQ
high impulsivity active psychosis low socio-economic status unemployment increases risk
Young age
high IQ
low impulsivity remission of psychosis high socio-economic status unemployment decreases risk
Old age
*Depression and previous attempts (common in clinical sample)(Pokorny 1983 Arch Gen Psychiatry; Hunt et al 2007 Psychological Medicine 37; 831-837; Valenstein et al 2008; Bowers et al 2010;Journal of Affective disorders Bolton et al 2012 J Clin Australasian Psychiatry; Peuskens et al 1997;Fenton 2000; Madsen et al2012 J Clin Psychiatry Osborn et al 2007 Schizophrenia research ; Hunt et al 2007; Agerbo 2005).
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Why is suicide so hard to predict?A rare event (low base rate) is always hard to predict
It is easier to predict how many days it willrain in May of 2015 in London than in Dubai
Buying 10 lottery tickets rather than 1 willincrease the chances of winning the lotteryX10, yet very low chance to win.
It is easy to predict who, out of 100psychiatric patients who are very high-risk forsuicide, will not commit suicide than who
will.
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