Abstract: Traditional approaches to the prediction of suicide attempts have limited the accuracy and scale of risk detection for these dangerous behaviors. We sought to overcome these limitations by applying machine learning to electronic health records within a large medical database. Participants were 5,167 adult patients with a claim code for self-injury (i.e., ICD-9, E95x); expert review of records determined that 3,250 patients made a suicide attempt (i.e., cases), and 1,917 patients engaged in self-injury that was nonsuicidal, accidental, or nonverifiable (i.e., controls). We developed machine learning algorithms that accurately predicted future suicide attempts (AUC = 0.84, precision = 0.79, recall = 0.95, Brier score = 0.14). Moreover, accuracy improved from 720 days to 7 days before the suicide attempt, and predictor importance shifted across time. These findings represent a step toward accurate and scalable risk detection and provide insight into how suicide attempt risk shifts over time.
Discussion: Accurate and scalable methods of suicide attempt risk detection are an important part of efforts to reduce these behaviors on a large scale. In an effort to contribute to the development of one such method, we applied ML to EHR data. Our major findings included the following: (a) this method produced more accurate prediction of suicide attempts than traditional methods (e.g., ML produced AUCs in the 0.80s, traditional regression in the 0.50s and 0.60s, which also demonstrated wider confidence intervals/greater variance than the ML approach), with notable lead time (up to 2 years) prior to attempts; (b) model performance steadily improved as the suicide attempt become more imminent; (c) model performance was similar for single and repeat attempters; and (d) predictor importance within algorithms shifted over time. Here, we discuss each of these findings in more detail. ML models performed with acceptable accuracy using structured EHR data mapped to known clinical terminologies like CMS-HCC and ATC, Level 5. Recent metaanalyses indicate that traditional suicide risk detection approaches produce near-chance accuracy (Franklin et al., 2017), and a traditional method—multiple logistic regression—produced similarly poor accuracy in the present study. ML to predict suicide attempts obtained greater discriminative accuracy than typically obtained with traditional approaches like logistic regression (i.e., AUC = 0.76; Kessler, Stein, et al., 2016). The present study extends this pioneering work with its use of a larger comparison group of self-injurers without suicidal intent, ability to display a temporally variant risk profile over time, scalability of this approach to any EHR data adhering to accepted clinical data standards, and performance in terms of discriminative accuracy (AUC = 0.84, 95% CI [0.83, 0.85]), precision recall, and calibration (see Table 1). This approach can be readily applied within large medical databases to provide constantly updating risk assessments for millions of patients based on an outcome derived from expert review. Although short-term risk and shifts in risk over time are often noted in clinical lore, risk guidelines, and suicide theories (e.g., O’Connor, 2011; Rudd et al., 2006; Wenzel & Beck, 2008), few studies have directly investigated these issues. The present study examined risk at several intervals from 720 to 7 days and found that model performance improved as suicide attempts became more imminent. This finding was consistent with hypotheses; however, two aspects of the present study should be considered when interpreting this finding. First, this pattern was confounded by the fact that more data were available naturally over time; predictive modeling efforts at point of care should take advantage of this fact to improve model performance as additional data are collected. Second, due to the limitations of EHR data, we were unable to directly integrate information about potential precipitating events (e.g., job loss) or data not recorded in routine clinical care into the present models. Such information may have further improved short-term prediction of suicide attempts. Future studies should build on the present findings to further elucidate how risk changes as suicide attempts become more imminent.