ments are based on hindsight bias and use of terms akin to 'predictable' really mean 'can be understood in retrospect'. Hence, in these two important settings ...
Australasian Psychiatry 20(6)
then share this information with AHPRA. Ten percent of psychiatrists’ CPD submissions will be audited by the College – essentially, this means the College asks for documented proof that the activity has indeed occurred. There is a minimum requirement of 55 credits (50 hours) to be accrued during the year, including at least 15 credits (10 hours) of peer-reviewed activity and at least 20 credits (20 hours) of self-guided learning. This can be averaged over a triennium, with the latest triennium ending in December 2012. Minimum requirements are adjusted for part-timers. The College website provides a log book (and also several supporting documents) which can be amended via word processing. The log book starts with the professional developmental plan (PDP) template, followed by tables detailing different categories. Tables can be completed on any word processor. I was keen to keep a contemporaneous record, ideally with the possibility of writing notes whilst I attend CPD events. An aide memoire can assist later when referring to the contents of a presentation. Further more, I believe that in the present economic climate, with an increasing need for efficiency savings, any assistance with the streamlining of processes, even CPD, is welcome. I also believe that it is best to avoid sanctions due to unsatisfactory fulfilment of CPD requirements. Hence I was looking for an IT interface that would enable dealing with all the above issues at once, but without any extra demands on time. I have found the RANZCP website helpful for these purposes, and especially for the end of year summary. However, I did not find the software on the College website as adjustable as the online Australian Medical Association (AMA) CPD tracker.3 The latter offers an interface that allows customisation of the College template, categories and umbrella terms; contents can be edited any time; and records can be printed. The AMA CPD tracker interface also allows for contemporaneous note-keeping. Of
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course, keeping online records does not negate the importance of collecting invitations, records of attendance and other relevant material we may receive in relation to a CPD activity, should evidence be required at audit. Although I am generally impressed with the ease of use of the AMA’s interface, I have found the box for record-keeping too small, particularly if I have attended a seminar where I wished to take more than a few notes. Further, after saving data, I have found that scrolling back down to the bottom of my notes can take an excessive period of time, as again the box is very small. I have also had the experience of ‘losing’ what I have typed if I kept using the interface but the internet connection became disrupted. The AMA CPD tracker is available for free to AMA members, and is also available to non-AMA members at relatively low cost. For readers’ information, I now use both: the CPD log on the RANZCP website and the AMA CPD tracker contemporaneously when at CPD. How many minutes are you going to log after reading this letter? References 1. Australian Health Practitioner Regulation Agency. Continuing Professional Development Registration Standard, http://www.medicalboard.gov.au/Registration- Standards.aspx (accessed 20 July 2012). 2. Royal Australian and New Zealand College of Psychiatrists. The CPD Program Outline, http://www.ranzcp. org/Fellowship/CME-CPD/The-CPD-Program-Outline. aspx (accessed 20 July 2012). 3. Australian Medical Association. AMA Continued Professional Development (CPD) recording service, https:// cpd.ama.com.au (accessed 20 July 2012).
Klaus Beckmann Waterford, Queensland DOI: 10.1177/1039856212465024
Suicide is preventable but not predictable Dear Sir, In a recent editorial, Walter and Pridmore rightly question the politically correct view that suicide is preventable.1 We agree with their
conclusion that good clinical care can prevent suicide in many, but by no means all cases. Here we focus on the related question of whether suicide is predictable. The Australian Concise Oxford Dictionary defines a prediction as ‘a statement about the future; foretell, prophesy’.2 Following from this definition, a meaningful prediction must fulfill three criteria: i) it must be about the future, ii) it must be true, and iii) it must be specific. In suicide research, the term ‘predictive’ rarely relates to future events but is used in retrospective studies that examine the characteristics of people who have committed suicide. Very few studies of suicide have collected data prospectively, and fewer still set out a predictive model at the beginning of the study. In retrospective studies and studies that collect clinical data before the suicides, the ‘predictive’ power of multivariate suicide risk models are usually inflated by chance findings.3,4 In legal settings such as a coroner’s court, suicide risk factors are often identified and can be used to imply that a suicide was predictable or was reasonably foreseeable.5 In reality, these judgments are based on hindsight bias and use of terms akin to ‘predictable’ really mean ‘can be understood in retrospect’. Hence, in these two important settings suicide prediction lacks the crucial element of being about the future. It is unfortunate that terms like prediction and predictable have lost their common English language meaning where suicide is concerned. In peer reviewed papers, the term ‘predictive’ is often used where ‘association’ would be more appropriate. The use of the term predictive ignores the reality that strong statistical associations – such as the association between male gender and suicide, are of next to no value in making a prediction. The only meaningful measure of the ‘truth’ dimension of a suicide prediction and the only correct use of the term ‘predictive’ is the positive predictive value (PPV). In this context, PPV is the proportion of suicides among
Correspondence
the patients who are considered to be at high-risk of suicide. PPVs in suicide risk-assessment are universally discouraging – for example, a recent study suggested that as few as 0.14% of those categorized as at high-risk of suicide in hospital will go on to kill themselves.6 However, even if a PPV of 100% could be achieved, this would tell you nothing about the specifics of the time and place of the suicide. This sort of accuracy of prediction is the stuff of science fiction and fantasy and not of science or medicine. It might be possible to make an accurate judgment about a suicide if a potentially lethal suicide attempt is directly observed, but otherwise there is no scientific evidence to support the concept of ‘imminent suicide’.6 Moreover, long-term suicide risk assessment generally has a higher PPV than short-term suicide risk assessment because the base rate of suicide is higher over a longer period of time. Where suicide is concerned, the use of the term ‘prediction’ is a dangerous misnomer. It is a misnomer because suicide predictions lack the crucial dimensions of being about the future, true and specific. It is dangerous because courts have come to believe that we as a profession have abilities that we do not possess. Disclosure Dr Large and Dr Nielssen have received speakers’ fees from Astra-Zeneca.
References 1. Walter G and Pridmore S. Suicide is preventable, sometimes. Australas Psychiatry 2012; 20: 271–273. 2. The Australian Concise Oxford Dictionary. Melbourne, Australia: Oxford University Press, 2004. 3. Large M, Ryan C and Nielssen O. The validity and utility of risk assessment for inpatient suicide. Australas Psychiatry 2011; 19: 507–512. 4. Large M, Smith G, Sharma S, et al. Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatr Scand 2011; 124: 18–29. 5. Large M, Callaghan S and Ryan C. Hindsight bias and the overestimation of suicide risk in expert testimony. The Psychiatrist 2012; 36: 236–237. 6. Large M and Nielssen O. Risk factors for inpatient suicide do not translate into meaningful risk categories-all
psychiatric inpatients are high-risk. J Clin Psychiatry 2012; 73: 1034. 7. Simon R. Imminent suicide: the illusion of short-term prediction. Suicide Life Threat Behav 2006; 36: 296–301.
Matthew Large, Olav Nielssen Sydney, NSW DOI: 10.1177/1039856212464912
Chaos theory and suicide Dear Sir, ‘Something as small as the flutter of a butterfly’s wing can ultimately cause a typhoon halfway around the world.’ (Chaos theory) There are two types of system in the world that can explain various natural phenomenons – linear and nonlinear systems. A non-linear system is one whose output is not directly proportional to its input, while a linear system fulfills these conditions. A non linear system is any problem where the dependent variable(s) to be solved cannot be written as a linear combination of independent components. Small differences in initial conditions yield widely diverging outcomes for chaotic systems, rendering long-term prediction generally impossible.1 This happens even though these systems are deterministic, meaning that their future behavior is fully determined by their initial conditions, with no random elements involved.1 In other words, the deterministic nature of these systems does not make them predictable.1 This behavior is known as chaos. One of the properties of a chaotic system is that sensitivity to initial conditions means that each point in such a system is arbitrarily closely approximated by other points with significantly different future trajectories. Thus, an arbitrarily small perturbation of the current trajectory may lead to significantly different future behaviors. It can be speculated that suicides in a population affected by mental health issues are chaotic events. Various factors can influence suicidal behaviors and these include complex interactions between biological vulnerability, psychological stressors, episodic
disinhibition due to substance use, problem-solving and coping skills, psychosocial supports, and presence and accessibility of psychosocial services. Any minor perturbation in any of these factors can result in significant change, leading to significantly drastic consequences. As mental health professionals, we are aware of the challenges and limitations of the risk assessment tools in predicting suicides in a population with mental health issues. It may be speculated that this limitation is probably similar to prediction in other chaotic systems, like the prediction of weather and earthquakes which are again chaotic systems. Reference 1. Kellert SH. In the wake of chaos: unpredictable order in dynamical systems. Chicago, IL: University of Chicago Press, 1993; 32, 52, 56.
Vinit Sawhney Brisbane, Queensland DOI: 10.1177/1039856212464911
Protest suicide It has been proposed that unacceptable predicaments may lead to suicide. These predicaments may arise from untreated/unresponsive mental disorders or social/environmental stressors.1 Protest suicide has received little attention. For the purposes of homogeneity, we have excluded suicide with homicidal intent, such as the suicide of Samson, Kamikaze pilots and suicide bombers. Also excluded, is the suicide of Lucretia, a noblewoman who was raped by the son of the last king of Rome and whose suicide led to the replacement of the monarchy with a Republic; it is unclear whether her action was a form of a protest. Most protest suicides involve selfimmolation. There may be a connection with the ancient Hindu practice of ‘suttee’ (or ‘sati’), in which the widow threw herself on the pyre of her husband, but self-immolation also has a long tradition among Buddhist monks.
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