A suicide risk assessment tool developed by a team of University of Vermont researchers is making its way into the prison and the military systems. It’s in the early stages of a rollout that the creators hope will significantly aid health care providers in identifying and saving people who are in crisis.
The Systematic Expert Risk Assessment for Suicide, or SERAS, is a questionnaire that can be administered on an iPad. It was developed at UVM as a clinical assessment of the acute risk of suicide within 72 hours, and has been tested in a clinical setting in hospital emergency departments.
SERAS is the work of psychiatrists Isabelle Desjardins, who now works as the UVM Medical Center’s chief medical officer; Sanchit Maruti, an addiction specialist who runs UVM’s suboxone program; and Robert Althoff, an associate professor at UVM. They were joined by William Cats-Baril, a professor at UVM’s Grossman School of Business who founded the school’s MBA on Sustainable Entrepreneurship. The four, with other partners, were answering a call from the Joint Commission – the national health care accrediting body – that called for hospitals to carry out suicide risk assessments for more patients.
The four set out to create a tool that could stand in for the judgment of psychiatrists in assessing a patient’s risk of suicide within the next 72 hours.
An app that thinks like an expert
The group met with panels of nationally recognized experts on suicide in 2015 and came up with the series of questions that is the basis of the tool, SERAS. SERAS can provide the kind of expert screening that isn’t always available, not only in a regular health appointment but in settings such as institutional health services, said Desjardins.
Answering the questions is quick – it takes just two minutes – and, because it’s on an iPad and not administered personally, it can eliminate some of the barriers that stop patients from telling health care providers if they are considering harming themselves.
“Often, people have suicidal thoughts, or are thinking about dying by suicide, but they feel ashamed of talking about it, or they feel inhibited to reach out,” said Desjardins. “They feel embarrassed to even bring it up, or they don’t want to scare their loved ones. So, they don’t really disclose the extent of the distress they are experiencing.”
A worrying increase in suicide risk
Suicide is a major public health problem in the United States that is getting worse. The Centers for Disease Control ranked suicide No. 10 among causes of death nationwide in 2017, saying more than 47,000 people died of suicide that year. Firearms were used in nearly half of those deaths, the CDC said. The rate has increased 33% from 1999 through 2017, according to the American Psychological Association.
Suicide is also something of a mystery to health officials, who are trying to do a better job of identifying both causes and warning signs so more acts of self-harm can be prevented. Desjardins said that one outcome of the research she did to help create SERAS was her discovery that she shouldn’t assume suicide risk is directly developed to a diagnosis of major depression.
“It only comes as a byproduct of major depression,” she said. “Suicide risk is really decoupled from the presence of psychiatric illness.” Environmental and personal factors play a larger role than previously thought – factors that the tool accounts for. For example, it’s known that male veterans in their 60s who are divorced and experience alcohol abuse are at higher risk of suicide.
“However, what is the difference between one individual who has all those characteristics today compared to the other one who has the same characteristic?” said Desjardins. “That’s in the tool. We’re assessing level of pain — it could be physical or emotional pain; they are both really drivers – one’s wish to live and one’s wish to die.”
The tool is adaptive, meaning that a patient’s answers and their own risk factors determine what other questions they will see. It’s also designed to become more precise and better at assessing risk as more data is entered for the algorithm to use over coming years.
Assessing short-term risk
The tool assesses the risk of suicide within the next 72 hours, not over the longer term. Its development was prompted by the fact that researchers saw most of the people who died of suicide had been in contact with a health care provider 30 days prior to the suicide, and not necessarily for a psychiatric complaint. It was those patients that health professionals wanted to reach.
“The tool we have designed is going at the essence of the drivers of taking action to take one’s life in the very short term,” Desjardins said. “It does not assess whether you are suffering from a major psychiatric mental health diagnosis; the questions are there to assess how much emotional distress you are in currently, and how much of that emotional distress is driving a wish for you to end your life right now.”
A long road to commercialization
Vermont’s suicide rate of 22 deaths per 100,000 population put it squarely in the middle of the CDC’s most recent state-by-state report on suicide; the rates were highest in the Intermountain West.
For that reason, SERAS was first tested in a clinical setting at a health center with offices in Idaho and Montana. Those states have a suicide rate of 24 and 25 deaths per 100,000, according to the CDC.
“The combination of guns, no access to mental health, and a culture of ‘I don’t need help:’ it’s deadly,” said Cats-Baril of the Intermountain West.
The UVM group formed a business called Wiser and contracted with a Hanover, N.H. company called Voi to market the tool. UVM, which owns the intellectual property, hasn’t sought a patent for SERAS. The four developers hold the license and they will receive royalties if Voi does sell it commercially.
Voi’s CEO, William Hudenko, is a psychologist whose company has developed several health assessment tools. Hudenko has a PhD in clinical psychology and works as a researcher and professor of psychological and brain science at Dartmouth College.
Hudenko said he’s now talking to a state prison system and the U.S. military about ways they could use the tool to assess suicide risk.
“A huge problem with suicide is there are so many people out there who die by suicide but don’t actually reach out for help,” Hudenko said.
Without an inexpensive tool like SERAS, it can take weeks before a qualified person can carry out a thorough risk assessment in many settings, Hudenko said. Identifying risk quickly would spur psychiatric intervention or treatment. The tool incorporates new outcomes and demographic data to hone its predictive algorithm. With time, Hudenko expects the screening tool to be as good as a professional at helping people who are at risk.
“We do everything we can to promote suicide prevention, and SERAS and Wiser is one part of that equation,” he said. “We have established a suite of technologies that has the capability to reduce suicide rates in the US. It’s very much my mission to get those into peoples’ hands and make a difference.”
Desjardins said she expects her peers in psychiatry to be receptive. Many recognize that while major depression can be a risk for suicide, there are other very complex factors at work, she said.
“The field recognizes that we haven’t been as good at preventing suicide as we could be because the suicide rates are going up,” she said. “So there is a humility in the field in recognizing that we need to think differently.”
And the shift in thinking away from major depression as the primary suicide risk factor is reflected in the SERAS tool, which was designed to evaluate the risk with the expert’s cognitive process in mind, Desjardins said.
“When everything else is equal, the shift is really the realization that in the end, it really doesn’t matter what the diagnosis is,” she said. “It’s really about the emotional state and the emotional experience in the moment of the individual.”
If you need help, the National Suicide Hotline is available 24 hours a day at 800-273-8255 and the Vermont Crisis Text Line is available at 741741. You can also find local organizations in your area here.