For example: There were those who confidently predicted with assured certainty the actual arrival time of the ill-fated RMS TITANIC.

The latest news is that it has yet to arrive.

Others predicted a most memorable and decisive victory for General George Armstrong Custer and his invincible 7th Cavalry. 

Unfortunately, War Chief Sitting Bull wasn't one of them. 

Predicting tsunamis, earthquakes, volcanic eruptions, landsides or any other natural disasters really isn't one of our most noteworthy successes either.

Let's face it we are just not very good at predicting things. If we were - then we would all be lottery winners I suppose.

With our collective inability to 'predict' in mind, the prediction of suicide would seem to be a particularly unlikely undertaking for anyone of us to contemplate undertaking.

But some of us (not me of course) are required to do this for a living, dealing with groups of us (called patients) who are classed as being at high risk of suicide.

Suicide Prediction

Health service professionals, researchers and others whose livelihood involves suicide prediction begin by looking for tell tale signs such as failed suicide attempts or acts of deliberate self-harm (so called parasuicidal activity) in the past.

This is required because painstaking scientific research suggests that a failed act of suicide (in the past) is regarded as a strong ‘predictor’ of suicide (in the future).

From the results of this research, it is calculated that a person with a history of parasuicide (or attempted suicide) is said to increase the risk of his or her death by suicide by as much as 40 times.

Recap

Research is instructing us that if one of us has attempted suicide in the past, we are now 40 TIMES more likely to die by suicide, than someone who has never attempted suicide in his or her life.

Not 39 Times, nor 41 Times but a nice well rounded 40 TIMES.

This sounds so professional and so assured, that it simply has to be flawed. For like so many things, it is dependent upon too many other factors.

For example what happens when any prior suicidal activity is not known by the medical authorities who are then totally unaware of such suicidal attempts.

What if such activity was misclassified?

Such assertions requires than any prior (suicidal) activity was correctly identified and not misclassified because of someone elses gut feeling.

 has been to imply a higher risk of suicide than having a mental disorder such as major depression, personality disorder, or dependence on alcohol.

The theory being I suppose, that if he or she has tried once - the likelihood is that he or she will try again.

The risk of suicide is generally most prominent during the first months after psychiatric care.

The risk of repetition and consequently of suicide is believed to be highest during the first one or two years after an episode of parasuicide.  Follow up studies of hospitalised patients who have attempted suicide show that the initial high risk declines each year.  But recent studies of people who have harmed themselves deliberately and attempted suicide show that the risk persists for a long time.  In a retrospective study of suicide we found that the interval between first suicidal behaviour and the suicide was related to the patient's sex and mental disorder. For example, in patients with borderline personality disorder or schizophrenia the suicidal process can take a long time. Follow up studies of parasuicide would improve if diagnostic subgroups were taken into consideration.

Severity of the attempt indicates higher risk. Extra caution is also warranted in situations with repeated parasuicide, especially when these occur with increasing frequency. More extensive planning of the current parasuicide may indicate a high risk. Mental disorder in general and depressive disorder in particular, if present at the index parasuicide, strengthens the risk for poor outcome. Likewise, the presence of substance abuse at the time of parasuicide increases the danger. Comorbidity such as substance abuse and another mental disorder is also noteworthy. Concomitant somatic illness should be assessed, especially in elderly people

The view that parasuicide and suicide involve totally different populations has been found to be inaccurate The prevalence of parasuicide is high also in retrospective systematic interview studies of suicide victims. In a study of young adults, previous parasuicide was found in 60% of young men and 80% of young women. This is a higher rate than among adults in general. Among men of all ages, previous parasuicide was found in about a third and among women of all ages in about two thirds. Irrespective of age, women have higher rates of parasuicide even among those who eventually die by suicide. Expectedly, repeated parasuicide is common in people who commit suicide. Three or more parasuicides occurred in 17% of men and 56% of women.

Can we rely on the answers that patients give when we question them about suicidal ideation in emergencies? Certainly, an empathic interview with the patient yields an honest answer in most instances. Further, the circumstances of the parasuicide are well worth exploring in the encounter with the patient. To what extent the verbal presentation of suicidal thoughts is valid in assessing the risk of suicide is still doubtful. Most people who commit suicide have communicated such ideation in a more obvious or disguised manner. Fewer than half of them did communicate their intention to family members during their previous suicidal episode.  In a study of suicide in elderly people, the doctors responsible for treating them were less aware of the suicidal thoughts than the family members In relation to this week's paper there is a good reason to point at previous acts of suicidal behaviour as the most reliable issue to penetrate in the clinical interview.

To pay attention to previous parasuicide in the assessment of the patient in the emergency department is crucial, because it may indicate a serious risk even if the act was committed several years ago.