Abstract
The expression of suicidal ideation is considered to be an important warning sign for suicide. However, the predictive properties of suicidal ideation as a test of later suicide are unclear.AimsTo assess the strength of the association between suicidal ideation and later suicide measured by odds ratio (OR), sensitivity, specificity and positive predictive value (PPV). We located English-language studies indexed in PubMed that reported the expression or non-expression of suicidal ideation among people who later died by suicide or did not. A random effects meta-analysis was used to assess the pooled OR, sensitivity, specificity and PPV of suicidal ideation for later suicide among groups of people from psychiatric and non-psychiatric settings. There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n=71, OR=3.41, 95% CI 2.59-4.49, 95% prediction interval0.42-28.1, I2=89.4, Q-value=661, d.f.(Q)=70, P≤0.001). Studies conducted in primary care and other non-psychiatric settings had similar pooled odds to studies of current and former psychiatric patients (OR=3.86 v. OR=3.23, P=0.7). The pooled sensitivity of suicidal ideation for later suicide was 41% (95% CI 35-48) and the pooled specificity was 86% (95% CI 76-92), with high between-study heterogeneity. Studies of suicidal ideation expressed by current and former psychiatric patients had a significantly higher pooled sensitivity (46% v. 22%) and lower pooled specificity (81% v. 96%) than studies conducted in non-psychiatric settings. The PPV among non-psychiatric cohorts (0.3%, 95% CI 0.1%-0.5%) was significantly lower (Q-value=35.6, P<0.001) than among psychiatric samples (3.9%, 95% CI 2.2-6.6). Estimates of the extent of the association between suicidal ideation and later suicide are limited by unexplained between-study heterogeneity. The utility of suicidal ideation as a test for later suicide is limited by a modest sensitivity and low PPV.Declaration interestM.M.L. and C.J.R. have provided expert evidence in civil, criminal and coronial matters. I.B.H. has been a Commissioner in Australia's National Mental Health Commission since 2012. He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to Headspace. I.B.H. has previously led community-based and pharmaceutical industry-supported (Wyeth, Eli Lily, Servier, Pfizer, AstraZeneca) projects focused on the identification and better management of anxiety and depression. He is a Board Member of Psychosis Australia Trust and a member of Veterans Mental Health Clinical Reference group. He was a member of the Medical Advisory Panel for Medibank Private until October 2017. He is the Chief Scientific Advisor to, and an equity shareholder in, InnoWell. InnoWell has been formed by the University of Sydney and PricewaterhouseCoopers to administer the $30M Australian Government Funded Project Synergy. Project Synergy is a 3-year programme for the transformation of mental health services through the use of innovative technologies.
Highlights
The expression of suicidal ideation is considered to be an important warning sign for suicide
There was a moderately strong but highly heterogeneous association between suicidal ideation and later suicide (n = 71, odds ratio (OR) = 3.41, 95% CI 2.59–4.49, 95% prediction interval 0.42–28.1, I2 = 89.4, Q-value = 661, d.f.(Q) = 70, P ≤0.001)
The pooled sensitivity of suicidal ideation for later suicide was 41% and the pooled specificity was 86%, with high between-study heterogeneity
Summary
Multiple search strategies were initially explored using the databases Medline, Embase and PsycINFO from inception to January 2017. These searches yielded an excessive number of titles when the term ‘suicide’ was used as a keyword (>200 000) or in the title (>70 000). PubMed indexed all but one Englishlanguage publication located by searches of multiple databases in earlier studies.[7,8] and in order to obtain a large and representative sample of relevant studies, one author (M.M.L.) examined the titles of English-language publications with an accompanying abstract that contained variants of the single term ‘suicide’ (suicid*) in their title and were published in PubMed from inception to 14 September 2017 and hand searched the references list of relevant review articles.[7,8,9,10,13,14] Two authors (M.M.L. and C.M.M.) winnowed the resulting abstracts and full-text publications (Fig. 1)
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