A team of experts in neuroscience, psychology and psychiatry has issued an urgent call to policy makers, funding agencies and peers in the field of psychiatry, to mitigate a serious public health crisis. In a commentary published by JAMA Psychiatry, the experts identify suicidality as a bio-psychosocial “system collapse,” and call for prioritization of deep phenotyping, a comprehensive look at things like behavior and biology over time, to accelerate the study, understanding and prevention of suicidal behavior. Authors include Greg Witkop of Renaissance Philanthropy and the Uniformed Services University of Health Sciences, Richard J. Davidson, founder and director of University of Wisconsin–Madison’s Center for Healthy Minds and Kerry Ressler and Matthew Nock of Harvard. 

Suicide is the lethal outcome of mental illness, addiction and psychological trauma, as well as a leading cause of death worldwide, and the third leading cause of death in teens and young adults aged 15-29 years. In addition to emotional and social impacts for individuals and their families, in the US alone, suicide and non-fatal self-harm contribute to an annual economic cost of $510 billion. Yet, suicide receives only 0.7% of mental health research funding.

The team says that every field of medicine has prioritized the study of critically ill patients in order to reduce mortality. A central part of that research has been to study the moment of organ “system collapse” - like a heart attack in cardiology - to understand, treat and prevent crisis. The team believes that by caring for people who have survived a suicide attempt there is a threefold opportunity: save lives now through more effective interventions for those at greatest risk; accelerate precision care by identifying the biological and functional mechanisms underlying mental health crises and recovery; and eliminate shame and stigma by recognizing that suicidal behavior can reflect a collapse in the brain's capacity to adapt, leaving individuals unable to see another way to end their suffering.

Just as cardiology transformed outcomes by studying and treating patients at the point of heart failure, the experts believe psychiatry has an opportunity to do the same. 

Lead author Greg Witkop emphasizes another JAMA Psychiatry viewpoint article from earlier this year by Kleinmen et al. “‘Updating Psychological Treatment During Inpatient Psychiatric Care’ calls for using the inpatient period for both stabilization and treatment instead of stabilization alone, as often happens today,” he says. Individually, patients who receive inpatient care for suicidal behaviors are at high risk for self-harm when discharged, without undergoing the type of physical and biological assessments used in other areas of medicine. “When a person goes to the hospital for suicidal behavior, the primary goal is to stop them from physical self-harm, verbally assess them, and send them home with a plan to try to stay safe,” Davidson adds. The team identifies inpatient treatment as an opportunity to reduce immediate danger and integrate interventions with measurable goals. After discharge, patients could receive strength-based supports and would be monitored for potential relapse for at least a year. 

The team calls for intensive, longitudinal studies of patients with suicidal behaviors, as an ethical imperative to addressing the critical rate of suicidality in the US, and to develop precision treatments, or individualized plans of care. “Over the past decade, psychiatry has developed the tools to move beyond verbal assessments of patients with suicidal behaviors, and we have a scientific responsibility to prioritize implementing them as a standard of care,” says Davidson.  

Furthermore, the researchers point to scientific evidence that these tools show promise. Recent research shows intensive digital monitoring can improve understanding and prediction of suicidal thoughts and behaviors over short time spans, and genetic and brain imaging work have identified potential treatment targets. The team suggests that integrating these tools with an existing framework called the Precision Psychiatry Roadmap (PPR), could build on these findings and operationalize emerging recommendations in the field. 

The Roadmap includes deep phenotyping, multimodal integration, ecological measurement, longitudinal trajectories and biology-informed frameworks that move beyond diagnostic categories. The team believes that accelerating the integration and implementation of this plan with intensive digital monitoring, genetic and brain imaging with this population would immediately exceed the current standard of care for the field of psychiatry.

However, the team states that implementing this plan requires fundamental changes to current psychiatric research methods, deepening and lengthening studies by integrating the identified tools and following patients through admission following a suicide attempt, inpatient treatment and at least a year of recovery. “We know that patients are at highest risk within a month of hospitalization,” says Davidson, referring to research that shows that risk to be 270-fold. “We have an opportunity to not only prevent immediate harm, but to continuously monitor recovery trajectories, including the effectiveness of strength-based interventions that can enhance qualities such as resilience and help prevent relapse,” he says. 

The commentary additionally calls for a reframing of ethical frameworks, supported by existing NIH consensus around safely researching people at risk for suicide. “Right now studies often exclude people with suicidal thoughts and behaviors despite the fact they have a high risk of dying by suicide and are the most scientifically informative population to study because of the density and intensity of signals associated with system collapse and recovery. It needs to change,” says Witkop. 

The team’s ultimate goal is to shepherd adaptive preventive care in the field. Witkop says that “to accomplish that goal, we must implement both the European College of Neuropsychopharmacology's PPR and the American College of Neuropsychopharmacology's Consensus statement for actionable biomarkers to answer the call from the ENIGMA-STB Consortium for longitudinal studies to determine if their findings of subtle differences in diffusion tensor imaging studies between people with recent suicidal ideation and a prior suicide attempt are valid risk factors.” He went on to say that “we believe caring for the post suicide attempt population also responds to the PPR’s guidance for an initial implementation focus area based on emerging science, assessment of relative clinical unmet need and available technology. We have to start somewhere to change the field, and this is the ideal starting point where we can simultaneously save lives, accelerate the move toward precision mental health care and build resilience for prevention.”

By Heather Harris

Featured photo credit: pocketlight