Thursday, July 31, 2014

Blood Test for Suicide - Are We Humble Enough for Such a Tool?

People are afraid to even say the word suicide, none the less ask a suffering person if they've thought about it. And now they have a blood test for it? 

Is our world ready?

Well, John's Hopkins psychiatric researchers are developing one.

The researchers have discovered a mutation in the SKA2 gene that predicts suicidal thoughts and behaviors. To grossly simplify what this means (for a more complete explanation, see this Science Daily article: Blood Test for Suicide). The gene SKA2 works in the prefrontal cortex, the part of the brain in charge of decision making and impulse control, keep cortisol - the stress hormone - from flooding this important part of the brain. When the mutation is present, there is too little SKA2 and the cortisol is able to flood the prefrontal cortex, keeping the brain from suppressing negative thoughts and dangerous impulses.

In a recent trial, low levels of SKA2 predicted with 96% accuracy whether a participant had attempted suicide or not. Levels of SKA2 were highly related - 80% - to thoughts and attempts of suicide in earlier trials.

An assistant professor at John's Hopkins, Dr. Zachary Kaminsky, summarized it well"We have found a gene that we think could be really important for consistently identifying a range of behaviors from suicidal thoughts to attempts to completions."

The Science Daily article indicates the use for such a test would span from tests of military personnel to emergency room visits. The military could test for the genetic mutation to see if a individual is vulnerable and have them monitored after deployment. Emergency room personnel could use the test to help assess risk of suicide in making decisions about hospitalization.

Sounds great, right?

It is easy to make the assumption here that one suicide prevention is solely predicting "a range of behaviors from suicidal thoughts to attempts to completions," but this is the farthest from the truth. 

Suicidality is not a constant state. Just because a test can predict with 96% accuracy whether a person has attempted suicide in the past does not mean they will attempt the day the test was taken. 

Suicidal thoughts do not equal suicide attempts. Most people in their lives think about suicide at least once in their lives. Only 38,000 people in the United States die by suicide in 2010 according to the Center for Disease Control. The Los Angeles Suicide Prevention Center, one of the National Suicide Prevention Lifeline centers, gets 70,000 callers from suicidal individuals or their loved ones every year. Only about 5% of those callers would fall under the category of high risk, and even fewer require a visit to the emergency room or hospitalization.

Further, hospitalizations are not always therapeutic for a suicidal individual. A prominent psychiatric stigma researcher, David Roe, warned of the pervasive "culture of 'doctor/judge/lawyer always knows best'’’ when all too often the patients' experience of hospitalization is not taken into consideration or simply not well understood (Roe & Ronen, 2003, p. 322).

The article goes one to describe the experiences participants shared in his study:
            "Describing the impact his hospitalization had on him, Ron said 'It shook my foundation, made me uncertain about everything.' On the most basic level, leaving the familiar environment in which one lives, the routine and activities in which one is engaged, and becoming a patient in a hospital with its novel set of rules and expectations can be quite traumatic. Furthermore, hospitalization bears a powerful statement about one’s limited competence and capacity for independence. In addition, the experience can threaten one’s self-concept by promoting negative appraisals of self" (Roe & Ronen, 2003, p. 322-3).

So can we blame people for not wanting to be hospitalized?

It is important to keep in mind that a blood test is not the only way to find out about suicidal thoughts and behaviors. When working for two years on a suicide prevention hotline I could get this information on a phone call or even an online chat. Just. By. Asking.

Is this because I'm special in some way? While I have had a lot of training and experience, the act of asking a person if they are suicidal can be done by anyone. And in my experience people will generally answer with more detail than one would expect.

What a blood test provides is hard evidence - it takes out the guesswork. It's a number on a paper. Researchers like this. People who offer research grants like this. Insurance companies like this. This is a test that satisfies the powers that be. (Which, frankly, we need. Funding for this kind of research is vital and if this helps get it, more power to you.)

What a blood test does not do is treat suicidal thoughts, behaviors, or attempts. But asking about them can. 

Talking to a person about suicide can help them relieve stress, show them desperately needed support, and actually helps to reduce risk in and of itself. No blood test can do that.

The only time asking about suicide does not give the same information as a blood test is when the individual decides to lie. Definitely good information, but it is vital to know why a person would lie about suicidal thoughts or behaviors. 

The most common reason a person won't admit to them is when they believe that admitting to them would result in a police officer at their front door - to involuntarily commit them, as it were. (Though this very rarely happens.) It can also lead to prejudice or discrimination.

In fact, some job, government, and school applications require that applicants report any involuntary commitments. (It is notable that this question usually is asked in the criminal record section of applications.) Involuntary commitments can therefore lead to blatant discrimination.

So is a suicide blood test useless? By no means. But we must always keep in mind that the reason for it is to benefit the patient. We have to be humble enough to know what a blood test can do and what it can't do. We have to keep in mind that even experts may not know what is best for a patient and that bureaucratic decision can result in traumatic experiences. 

A suicide blood test must be used with humility. And I'm not certain we have that yet. 

Based on the article in Science Daily:

Roe, D & Ronen, Y, (2003). Hospitalization as experienced by the psychiatric patient: A therapeutic jurisprudence perspective. International Journal of Law and Psychiatry, 26: 317–332.

CDC Fact Sheet on Suicide: