Developing a suicide risk prediction algorithm using electronic health record data in mental health care

Background:
Artificial intelligence (AI) offers potential solutions to address the challenges faced by a strained mental health care system, such as increasing demand for care, staff shortages, and pressured accessibility. While developing AI-based tools for clinical practice is technically feasible and has the potential to produce real-world impact, only a few are actually implemented into clinical practice. Implementation starts at the algorithm development phase, as this phase bridges theoretical innovation and practical application. The design and the way the AI tool is developed may either facilitate or hinder later implementation and use.

Objective:
This study aims to examine the development process of a suicide risk prediction algorithm using real-world electronic health record (EHR) data through a qualitative case study approach for clinical use in mental health care. It explores which challenges the development team encountered in creating the algorithm and how they addressed these challenges. This study identifies key considerations for the integration of technical and clinical perspectives in algorithms, facilitating the evolution of mental health organizations toward data-driven practice. The studied algorithm remains exploratory and has not yet been implemented in clinical practice.

Methods:
An exploratory, multimethod qualitative case study was conducted, using a hybrid approach with both inductive and deductive analysis. Data were collected through desk research, reflective team meetings, and iterative feedback sessions with the development team. Thematic analysis was used to identify development challenges and the team’s responses. Based on these findings, key considerations for future algorithm development were derived.

Results:
Key challenges included defining, operationalizing, and measuring suicide incidents within EHRs due to issues such as missing data, underreporting, and differences between data sources. Predicting factors were identified by consulting clinical experts; however, psychosocial variables had to be constructed as they could not directly be extracted from EHR data. Risk of bias occurred when traditional suicide prevention questionnaires, unequally distributed across patients, were used as input. Analyzing unstructured data by natural language processing was challenging due to data noise, but ultimately enabled successful sentiment analysis, which provided dynamic, clinically relevant information for the algorithm. A complex model enhanced predictive accuracy but posed challenges regarding understandability, which was highly valued by clinicians.

Conclusions:
To advance mental health care as a data-driven field, several critical considerations must be addressed: ensuring robust data governance and quality, fostering cultural shifts in data documentation practices, establishing mechanisms for continuous monitoring of AI tool usage, mitigating risks of bias, balancing predictive performance with explainability, and maintaining a clinician “in-the-loop” approach. Future research should prioritize sociotechnical aspects related to the development, implementation, and daily use of AI in mental health care practice.