Expert witness question about life span prediction and lawsuit valuation

[nexus73]

I had a recent call with a plaintiff attorney representing family of mid 20s female with schizophrenia who committed suicide while inpatient. They asked if I would be able to refute defense expert's claims that the patient was high risk and had a significantly reduced life expectancy on the order of less than 5 years due schizophrenia and history of suicide attempts. Plaintiff attorney said this prediction was based on a sophisticated predictive model of people with severe mental illness. The defense argument is basically that the total years of life lost is low, so value of lawsuit is minimal.

I told the plaintiff attorney I was aware of research finding people with SMI have reduced life spans on the order of 5-15 years vs general population, not 40-50 years shorter which would be the case with the patient in this scenario. My understanding is the data is informative at the population level but shouldn't be used to say any one individual has a certain expected life span. And said I was not aware of predictive models that could be used to determine the life expectancy of an individual in this way.

I'm just curious if predictive models like this exist and are actually used in court. Are they in the realm of expert psychiatrists vs PhD statisticians? Do they stand up to Daubert challenges?

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[PsyDr]

It’s lifecare planning stuff. They have databases on it

 

[Bartelby]

I think referencing studies that show typical outcomes would be best, and would probably not be consistent with that five year estimate (concluding suicide in that timeframe would be more likely than not). I have not seen such models used this way before.

 

[WisNeuro]

Yeah, we see this stuff all the time in personal injury, years of work, type stuff. Usually when someone is alleging that a questionable mild TBI with no LOC, PTA, or AMS somehow led to catastrophic cognitive decline.

 

[nexus73]

Yeah, we see this stuff all the time in personal injury, years of work, type stuff. Usually when someone is alleging that a questionable mild TBI with no LOC, PTA, or AMS somehow led to catastrophic cognitive decline.

I've definitely heard of it in personal injury cases. It's just a novel application I wasn't expecting, to argue an extremely short life expectancy to reduce damages.

What type of experts testify on this information. It seems outside scope for psychiatry/psychologist experts.

 

[WisNeuro]

I've definitely heard of it in personal injury cases. It's just a novel application I wasn't expecting, to argue an extremely short life expectancy to reduce damages.

What type of experts testify on this information. It seems outside scope for psychiatry/psychologist experts.

I've seen psychologists, psychiatrists, voacational experys (masters level), and various other physician specialties. I guess it'd be up to the opposing counsel to argue how FRE 702 applies there.

 

[nexus73]

Are life tables data accessible somewhere? Standing up to daubert challenge is certainly a question

 

[Candidate2017]

I had a recent call with a plaintiff attorney representing family of mid 20s female with schizophrenia who committed suicide while inpatient. They asked if I would be able to refute defense expert's claims that the patient was high risk and had a significantly reduced life expectancy on the order of less than 5 years due schizophrenia and history of suicide attempts. Plaintiff attorney said this prediction was based on a sophisticated predictive model of people with severe mental illness. The defense argument is basically that the total years of life lost is low, so value of lawsuit is minimal.

Very interesting.

Is this a state with a non-economic cap on malpractice? In which case, this is an attempt to increase the payout based on economic damages by using 40 years' worth of earning capacity (I assume suicide on a psych ward always leads to a payout, but not as high as you'd think).

But schizophrenics generally have limited earning capacity and don't commit suicide. At least, not in their mid-20s. So, this must be a college educated, higher intelligence schizophrenic? Anyway, even with higher functioning and a well-paying occupation, it wouldn't be hard to get someone to testify that a steep downward trajectory in function and occupation (i.e., earnings) is par for the course.

In sum, it probably won't succeed.

 

[WisNeuro]

Very interesting.

Is this a state with a non-economic cap on malpractice? In which case, this is an attempt to increase the payout based on economic damages by using 40 years' worth of earning capacity (I assume suicide on a psych ward always leads to a payout, but not as high as you'd think).

But schizophrenics generally have limited earning capacity and don't commit suicide. At least, not in their mid-20s. So, this must be a college educated, higher intelligence schizophrenic? Anyway, even with higher functioning and a well-paying occupation, it wouldn't be hard to get someone to testify that a steep downward trajectory in function and occupation (i.e., earnings) is par for the course.

In sum, it probably won't succeed.

Depends on what "success" means, most attorneys are just looking for a settlement.

 

[Sushirolls]

Talk with an insurance agent who sells life insurance.
They might be able to put you in touch with their underwriter who has data for actuarial tables.

 

[whopper]

The science to predicting lifespans is not emphasized in residency training. Yes there's science with actuarials AND YOU WERE NOT TRAINED IN IT, yes there's data showing schizophrenics don't live as long, but if you give any hard numbers, unless you got solid reasoning, and if I were a forensic psychiatrist on the opposing side, I'd happily tell my hiring attorney that you just opened yourself up for claiming to use a crystal ball and that all of your testimony is a load of $hit, demand you show how it meets the Daubert criteria, that it should be tossed out, and that your entire testimony be considered $hit given that you were willing to testify on an area that is not part of general psychiatry training.

At best I'd go with the following
1-An actuarial could be used, but only as a guide with lots of room for debate.
2-Schizophrenics, there's data they don't live as long
But given all of this there's factors we don't have that are up in the air such as the person's genetics, modifiable risk factors that might've not been taken into account, and this is outside of usual psychiatric training and therefore EVEN EXPERTISE. So I can point out the risks, but I'd rather leave it at that.

You start doing actuarials with no experience, oh oh oh I'd love to get you into a cross-examination and will have an explosion of glee when we see your facial expression when you admit you've never done this before ever. We could then make pic of your "oh $hit" facial expression into a 6 foot tall poster. I'd love it. So many fellows did the above and were cross examined for hours being told up to their face by a lawyer they don't know WTF they're doing.

Lawyer: Why did you testify you were an expert but you've never done this before?

 

[FlowRate]

But schizophrenics generally have limited earning capacity and don't commit suicide. At least, not in their mid-20s. So, this must be a college educated, higher intelligence schizophrenic?

Are you implying that by mid-20's you think function should be so reduced that they can't organize or that they're so far gone that they don't care anymore?

Psychotic disorders have the highest rate of suicide.

 

[Candidate2017]

Are you implying that by mid-20's you think function should be so reduced that they can't organize or that they're so far gone that they don't care anymore?

Psychotic disorders have the highest rate of suicide.

Yes, psychotic disorders have a higher risk. But I'm referring only to schizophrenia.

The only schizophrenics I've had who commit suicide were previously high functioning and college age or slightly post-college age (in addition to low med compliance in the setting of intrafamily conflicts). And yes, their cognition precipitously declines after a handful of episodes due to noncompliance. It's very sad to witness.

For schizophrenics with previous low functioning, half stay on the carousel of inpatient-noncompliance-back to inpatient with nary a suicide attempt. They generally expire from poor health in their 50s and 60s. They other half are compliant and do very well, have relationships, and work menial jobs like Door Dash. They also die from medical issues, rather than suicide, but 10 years later than noncompliant schizophrenics. This comports with the data that shows a 10-15 year reduction in life expectancy for most schizophrenics.

 

[clausewitz2]

Yes, psychotic disorders have a higher risk. But I'm referring only to schizophrenia.

The only schizophrenics I've had who commit suicide were previously high functioning and college age or slightly post-college age (in addition to low med compliance in the setting of intrafamily conflicts). And yes, their cognition precipitously declines after a handful of episodes due to noncompliance. It's very sad to witness.

For schizophrenics with previous low functioning, half stay on the carousel of inpatient-noncompliance-back to inpatient with nary a suicide attempt. They generally expire from poor health in their 50s and 60s. They other half are compliant and do very well, have relationships, and work menial jobs like Door Dash. They also die from medical issues, rather than suicide, but 10 years later than noncompliant schizophrenics. This comports with the data that shows a 10-15 year reduction in life expectancy for most schizophrenics.

Lifetime suicide rate in people with schizophrenia is about 10%. This compares to 0.3% in gen pop. Where is this idea that people with schizophrenia don't attempt suicide coming from?

 

[Bartelby]

Lifetime suicide rate in people with schizophrenia is about 10%. This compares to 0.014% in gen pop. Where is this idea that people with schizophrenia don't attempt suicide coming from?

That's why it would surprise me to hear an opinion that a person with schizophrenia was more likely than not to die of suicide within the next five years. That is the kind of prognosis we typically associate with metastatic cancer, not a chronic psychotic disorder.

I would not try to pretend to be an actuary in this case. I would, though, share what we know about suicide rates and characteristics for people with schizophrenia and what type of course we would generally expect with adequate treatment. I believe that falls well within the scope of a psychiatric expert witness.

 

[splik]

Lifetime suicide rate in people with schizophrenia is about 10%. This compares to 0.014% in gen pop. Where is this idea that people with schizophrenia don't attempt suicide coming from?

I thought it was closer to 5-6%? I'm not up to date but that was the consensus about 10yrs ago, that it was lower than previously thought (which was the 10% number).
e.g.:

The Lifetime Risk of Suicide in Schizophrenia

Background The psychiatry literature routinely quotes a lifetime schizophrenia suicide prevalence of 10% based on 1 meta-analysis and 2 studies of chronic schizophrenics.Objectives To build a methodology for extrapolating lifetime suicide prevalence estimates from published cohorts and...

jamanetwork.com

Suicide and schizophrenia: a systematic review of rates and risk factors

Risk assessment is a core skill in psychiatry. Risk prediction for suicide in schizophrenia is known to be complex. We undertook a systematic review of all original studies concerning suicide in schizophrenia published since 2004. We found 51 data-containing ...

www.ncbi.nlm.nih.gov

 

[clausewitz2]

I thought it was closer to 5-6%? I'm not up to date but that was the consensus about 10yrs ago, that it was lower than previously thought (which was the 10% number).
e.g.:

The Lifetime Risk of Suicide in Schizophrenia

Background The psychiatry literature routinely quotes a lifetime schizophrenia suicide prevalence of 10% based on 1 meta-analysis and 2 studies of chronic schizophrenics.Objectives To build a methodology for extrapolating lifetime suicide prevalence estimates from published cohorts and...

jamanetwork.com

Suicide and schizophrenia: a systematic review of rates and risk factors

Risk assessment is a core skill in psychiatry. Risk prediction for suicide in schizophrenia is known to be complex. We undertook a systematic review of all original studies concerning suicide in schizophrenia published since 2004. We found 51 data-containing ...

www.ncbi.nlm.nih.gov

Fair enough, but we can agree that it is a two digit integer multiple of the general risk, right?

 

[Stagg737]

Are you implying that by mid-20's you think function should be so reduced that they can't organize or that they're so far gone that they don't care anymore?

Psychotic disorders have the highest rate of suicide.

Last I checked bipolar disorder is typically cited as having the highest suicide rate and eating disorders have the highest rates of all-cause mortality, and possibly highest suicide rate too, but they often aren't included in larger studies on completed suicide when looking at multiple disorders.

Schizophrenia is a huge risk factor, but the crown sits elsewhere.

 

[futureapppsy2]

Last I checked bipolar disorder is typically cited as having the highest suicide rate and eating disorders have the highest rates of all-cause mortality, and possibly highest suicide rate too, but they often aren't included in larger studies on completed suicide when looking at multiple disorders.

Schizophrenia is a huge risk factor, but the crown sits elsewhere.

I think it's very important to consider relative versus actual risk here. 6% (or even 10%) is much higher than the general population rate, yes, but the vast, vast majority of people with schizophrenia won't die by suicide, and that's also a critical point here. To say that the patient had schizophrenia ergo they were all but guaranteed to kill themselves soon, like the attorney in the OP wants to say, is patently false.

 

[Stagg737]

I think it's very important to consider relative versus actual risk here. 6% (or even 10%) is much higher than the general population rate, yes, but the vast, vast majority of people with schizophrenia won't die by suicide, and that's also a critical point here. To say that the patient had schizophrenia ergo they were all but guaranteed to kill themselves soon, like the attorney in the OP wants to say, is patently false.

I was just pointing out that psychotic disorders don't actually have the highest rate of suicide from the literature I've looked at (and per multiple boards review sources).

 

[clausewitz2]

I was just pointing out that psychotic disorders don't actually have the highest rate of suicide from the literature I've looked at (and per multiple boards review sources).

Right, but "psychotic disorders have a lower suicide rate than bipolar disorder" does not imply "schizophrenics don't commit suicide", just in the same way that "breast cancer is 4 times more common than stomach cancer" does not imply "no one gets stomach cancer."

 

[FlowRate]

Last I checked bipolar disorder is typically cited as having the highest suicide rate and eating disorders have the highest rates of all-cause mortality, and possibly highest suicide rate too, but they often aren't included in larger studies on completed suicide when looking at multiple disorders.

Schizophrenia is a huge risk factor, but the crown sits elsewhere.

Psychiatry Online

ps.psychiatryonline.org

Study was US pop and very large (MHRN).
Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men.

Comparison of Suicide Risk by Mental Illness: a Retrospective Review of 14-Year Electronic Medical Records

Korea is one of the countries with the highest rate of suicide, while suicidality is known to be closely related to mental illnesses. The study aimed to evaluate the suicide rates in psychiatric patients, to compare it to that of the general population, ...

www.ncbi.nlm.nih.gov

Recent korean study.

Suicide rates among people with serious mental illness: a systematic review and meta-analysis
Paywalled, I accessed the fulltext:

The suicide rates of bipolar disorder were available from 16 studies and varied from 125.0 per 100 000 person-years (95% CI 34.1–319.7 per 100 000 person-years) in Oceania to 291.9 (95% CI 198.4–403.0 per 100 000 person-years) in Europe, with a pooled estimate of 237.0 per 100 000 person-years (95% CI 159.9–328.5 per 100 000 person-years). The suicide rates of major depression were available from four studies and varied from 180.3 per 100 000 person-years (95% CI 116.2–256.2 per 100 000 person-years) in North America to 1282.1 (95% CI 32.5–6937.3 per 100 000 person-years) in Asia, with a pooled estimate of 534.3 per 100 000 person-years (95% CI 30.4–1448.7 per 100 000 person-years). The suicide rates of schizophrenia were available from 24 studies and varied from 260.6 per 100 000 person-years (95% CI 71.0–665.8 per 100 000 person-years) in Africa to 421.1 (95% CI 244.3–642.6 per 100 000 person-years) in Asia, with a pooled estimate of 352.2 per 100 000 person-years (95% CI 239.3–485.7 per 100 000 person-years) (Table 2; online Supplementary eFig. 3).

It depends on the exact study you look at as to whether MDD, BPAD, or schizophrenia is on top. Would be fair to say all three are roughly tied.

 

[Stagg737]

Psychiatry Online

ps.psychiatryonline.org

Study was US pop and very large (MHRN).
Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men.

Comparison of Suicide Risk by Mental Illness: a Retrospective Review of 14-Year Electronic Medical Records

Korea is one of the countries with the highest rate of suicide, while suicidality is known to be closely related to mental illnesses. The study aimed to evaluate the suicide rates in psychiatric patients, to compare it to that of the general population, ...

www.ncbi.nlm.nih.gov

Recent korean study.
View attachment 377371

Suicide rates among people with serious mental illness: a systematic review and meta-analysis
Paywalled, I accessed the fulltext:

The suicide rates of bipolar disorder were available from 16 studies and varied from 125.0 per 100 000 person-years (95% CI 34.1–319.7 per 100 000 person-years) in Oceania to 291.9 (95% CI 198.4–403.0 per 100 000 person-years) in Europe, with a pooled estimate of 237.0 per 100 000 person-years (95% CI 159.9–328.5 per 100 000 person-years). The suicide rates of major depression were available from four studies and varied from 180.3 per 100 000 person-years (95% CI 116.2–256.2 per 100 000 person-years) in North America to 1282.1 (95% CI 32.5–6937.3 per 100 000 person-years) in Asia, with a pooled estimate of 534.3 per 100 000 person-years (95% CI 30.4–1448.7 per 100 000 person-years). The suicide rates of schizophrenia were available from 24 studies and varied from 260.6 per 100 000 person-years (95% CI 71.0–665.8 per 100 000 person-years) in Africa to 421.1 (95% CI 244.3–642.6 per 100 000 person-years) in Asia, with a pooled estimate of 352.2 per 100 000 person-years (95% CI 239.3–485.7 per 100 000 person-years) (Table 2; online Supplementary eFig. 3).

It depends on the exact study you look at as to whether MDD, BPAD, or schizophrenia is on top. Would be fair to say all three are roughly tied.

I've seen the Korean paper, I think the cultural differences there are significant enough that it likely plays a very significant role there. I'll have to look at the other study as I'm not sure I've seen it or may have just forgotten. Neither includes information about eating disorders though, which is an area I'd love to see good data on as they're some of the most challenging patients in general.

 

[FlowRate]

I've seen the Korean paper, I think the cultural differences there are significant enough that it likely plays a very significant role there. I'll have to look at the other study as I'm not sure I've seen it or may have just forgotten. Neither includes information about eating disorders though, which is an area I'd love to see good data on as they're some of the most challenging patients in general.

Better formatting links for the two (not one) referenced non-Korean studies above:
Diagnosed Mental Health Conditions and Risk of Suicide Mortality Hsueh-Han Yeh, Ph.D. et al (MHRN study)
Suicide rates among people with serious mental illness: a systematic review and meta-analysis Xue-Lei Fu et al (large meta-analysis, didn't include a direct link earlier)