Are false positives in suicide classification models a risk group? Evidence for “true alarms” in a population-representative longitudinal study of Norwegian adolescents

Introduction: False positives in retrospective binary suicide attempt classification models are commonly attributed to sheer classification error. However, when machine learning suicide attempt classification models are trained with a multitude of psycho-socio-environmental factors and achieve high accuracy in suicide risk assessment, false positives may turn out to be at high risk of developing suicidal behavior or attempting suicide in the future. Thus, they may be better viewed as “true alarms,” relevant for a suicide prevention program. In this study, using large population-based longitudinal dataset, we examine three hypotheses: (1) false positives, compared to the true negatives, are at higher risk of suicide attempt in future, (2) the suicide attempts risk for the false positives increase as a function of increase in specificity threshold; and (3) as specificity increases, the severity of risk factors between false positives and true positives becomes more similar. Methods: Utilizing the Gradient Boosting algorithm, we used a sample of 11,369 Norwegian adolescents, assessed at two timepoints (1992 and 1994), to classify suicide attempters at the first time point. We then assessed the relative risk of suicide attempt at the second time point for false positives in comparison to true negatives, and in relation to the level of specificity. Results: We found that false positives were at significantly higher risk of attempting suicide compared to true negatives. When selecting a higher classification risk threshold by gradually increasing the specificity cutoff from 60% to 97.5%, the relative suicide attempt risk of the false positive group increased, ranging from minimum of 2.96 to 7.22 times. As the risk threshold increased, the severity of various mental health indicators became significantly more comparable between false positives and true positives. Conclusion: We argue that the performance evaluation of machine learning suicide classification models should take the clinical relevance into account, rather than focusing solely on classification error metrics. As shown here, the so-called false positives represent a truly at-risk group that should be included in suicide prevention programs. Hence, these findings should be taken into consideration when interpreting machine learning suicide classification models as well as planning future suicide prevention interventions for adolescents.