Letters COMMENT & RESPONSE to identify cases of suicidal behavior that are documented in the medical record but are not reflected in the diagnostic code. In Reply We would like to thank Pennap and colleagues for their thoughtful letter. We completely agree that the use of diag- DavidA.Brent,MD nostic data are likely to greatly underestimate the prevalence Kwan Hur, PhD of suicide attempts, and we should have stated that explicitly Robert D. Gibbons, PhD in our article as a possible limitation. To emphasize this point, Author Affiliations: Department of Psychiatry, University of Pittsburgh, we cite a recent study of postpartum women that demon- Pittsburgh, Pennsylvania (Brent); Center for Health Statistics, University of strated that detection of suicidal behavior through natural lan- Chicago, Chicago, Illinois (Hur, Gibbons); Department of Medicine, University of guage processing of clinical notes resulted in an 11-fold greater Chicago, Chicago, Illinois (Gibbons); Department of Public Health Sciences, estimate of suicide attempts than in those based solely on di- University of Chicago, Chicago, Illinois (Gibbons); Department of Psychiatry, University of Chicago, Chicago, Illinois (Gibbons). agnostic data. However, as Pennap and colleagues note in their Letter, while this underestimate most assuredly affects an es- Corresponding Author: Robert D. Gibbons, PhD, Department of Public Health Sciences, University of Chicago, 5841 S Maryland Ave, Room W260, timate of the risk difference, it may not affect the relative risk Mail Code 2000, Chicago, IL 60637 (firstname.lastname@example.org). of suicide attempts. Therefore, we believe that it is safe to con- 1 Published Online: September 4, 2019. doi:10.1001/jamapsychiatry.2019.2342 clude that while the diagnostic data reported in our study most Conflict of Interest Disclosures: Dr Brent reported receiving royalties from likely underestimate the true prevalence of suicide attempts Guilford Press, eRT, and UpToDate and reported serving as a consultant for and the risk difference, it is probably a reasonable estimate of Healthwise and McKeeson (although in the latter, not related to issues of opioid the relative risk of suicide attempts in the children of parents abuse). Dr Gibbons reported being a founder of Adaptive Testing Technologies, who use opioids on a regular basis. We also note that our sample which distributes the CAT-MH suite of computerized adaptive tests and reported serving as an expert witness in cases related to suicide for the was based on parents and children with private health insur- US Department of Justice and Pfizer, Wyeth, and GSK. These activities have ance and the rate is likely to be lower than in a general emer- been reviewed and approved by the University of Chicago in accordance with gency department sample, which includes patients with pub- its conflict of interest policies. No other disclosures were reported. lic health insurance and no health insurance. For example the 1. Brent DA, Hur K, Gibbons RD. Association between parental medical claims background rate of acute liver injury based on International for opioid prescriptions and risk of suicide attempt by their children [published online May 22, 2019]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.0940 Classification of Diseases, Ninth Revision code 570 was 4 times 2. Zhong QY, Mittal LP, Nathan MD, et al. Use of natural language processing in higher in Medicaid claims data relative to claims based on electronic medical records to identify pregnant women with suicidal behavior: people with private health insurance (ie, the same Market- towards a solution to the complex classification problem. Eur J Epidemiol. 2019; Scan data used in our article). Future work that studies sui- 34(2):153-162. doi:10.1007/s10654-018-0470-0 cidal behavior using medical records may benefit from aug- 3. Gibbons RD. OxyElite Pro and liver disease: statistical assessment of an menting estimates of the prevalence of suicidal behavior from apparent association. J Stat Theory Pract. 2018;12(1):42-47. doi:10.1080/ diagnostic codes with the use of natural language processing 15598608.2017.1305923 jamapsychiatry.com (Reprinted) JAMA Psychiatry Published online September 4, 2019 E1 © 2019 American Medical Association. All rights reserved.
JAMA Psychiatry – American Medical Association
Published: Sep 4, 2019
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