Role of Mental Health Treatment in Preventing Suicide

September 1, 2014

The tragic death of comedian Robin Williams left much of the country in shock. Inevitably, the public discussion turned to depression in general and the role of mental health treatment in preventing suicides. Could Williams’ suicide have been predicted? And if so, could it have been prevented?

I would like to discuss the role of personality assessment in this issue. First of all, let me state that there is no ‘magic bullet’ when it comes to predicting suicide. No matter how sophisticated we are at the development of psychometric instruments, we are unlikely to ever come up with a foolproof (or even nearly foolproof) method. This is true for two reasons. In the first place, suicide remains a relatively rare event. Most surveys place the rate at somewhere between 10 and 12 per 100,000 in the US population. Any prediction method that can accurately identify those 10 or 12 individuals is likely to mis-identify many times that number as being potentially suicidal when they are not (what scientists call “false positives”). While the number of false positives can obviously be reduced by limiting assessment to individuals with known risk factors (e.g., major mental illness, alcoholism, etc.) they will likely still outnumber “true” positives by a large margin.

The second reason is that even if one identifies individuals with a high suicidal risk, the actual act is influenced by events that cannot be predicted, e.g. a fight with a significant other, financial reversal, physical illness, etc.). Mental health professionals have long known that even among chronically depressed individuals, there is usually a specific trigger that leads to a suicidal attempt.

Nonetheless, careful assessment of potentially suicidal individuals is of paramount importance in treatment and prevention of suicides. In this area, careful personality assessment is a crucial component. While there are scales that try to “predict” suicide, these are of only limited value. What is of much greater importance is the articulation of the nature of the suicidal threat, the likely triggers, etc. For instance, a careful assessment might reveal that an individual for whom suicide risk is suspected is highly impulsive. This suggests that this person is may make a suicidal attempt with relatively little warning, because s/he acts on sudden impulse. On the other hand, s/he is unlikely to remain at high risk for long. Or an assessment might point out that a person’s depression and hopelessness tends to spike when threatened with separation or abandonment. Thus, particular caution needs to be paid at times of impending separation (e.g., when a spouse or therapist is going on vacation). Another individual’s risk may be associated with blows to her or his self-esteem, so they need to be watched carefully when reversals in personal fortune occur (e.g., a poor grade on an exam or failure to secure a job that s/he applied for). While this kind of information may not tell exactly who is going to make an attempt on their life or when that attempt might occur, it does provide valuable insight into the motivations of the depressed individual and can go a long way toward saving a life.

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