Does the Suicide Assessment Scale predict risk of repetition? A prospective study of suicide attempters at a hospital emergency department

Efficacy and safety of venlafaxine hydrochloride combined with tandospirone citrate for patients with vascular depression accompanied by somatic symptoms: An open-labeled randomized control trial

AIMS

To explore the pharmacological treatment of vascular depression (VaDep) and whether the blood levels of neurotransmitters can reflect the VaDep severity.

METHODS

VaDep patients with somatic symptoms were enrolled and randomly received venlafaxine + tandospirone (Combined Group) or venlafaxine (Monotherapy Group). The treatment efficacy was assessed by Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), and Patient Health Questionnaire-15 (PHQ-15). The levels of blood monoamine neurotransmitters were measured by enzyme-linked immunosorbent assay.

RESULTS

Both groups reported a progressive decrease in HAMD, HAMA, and PHQ-15 scores to below the baseline after the respective treatment. Compared with the Monotherapy Group, the Combined Group reported a significant decrease in HAMD score at week 2 and markedly lower HAMA and PHQ-15 scores at weeks 1, 2, 4, and 8. Both groups showed a decrease in the levels of blood monoamine neurotransmitters at weeks 4 and 8 when compared with the baseline. A strong positive association was evident between the plasma 5-HT levels and the HAMD score.

CONCLUSION

The combined therapy rapidly acts on VaDep comorbid with anxiety and somatic symptoms and significantly alleviates the anxiety and somatic symptoms. The plasma levels of 5-HT may serve as potential objective candidates in evaluating VaDep severity and the efficacy of the undertaken treatment regimen.

Augmentation therapy with tandospirone citrate in vascular depression patients with mild cognitive impairment: A prospective randomized clinical trial

Cognitive impairment is a prominent clinical manifestation of vascular depression (VaDep). The current study aimed to assess the efficacy of tandospirone citrate in VaDep cases with mild cognitive impairment (VaDep-MCI) as well as the role of plasma monoamine neurotransmitters during the treatment. In this single-blind, randomized controlled study, 116 participants were randomly assigned to the tandospirone (tandospirone citrate-escitalopram) and control (escitalopram) groups. The primary endpoints were changes in cognitive test scores from baseline to Week 8, including the Rey Auditory Verbal Learning Test (RAVLT), Semantic Verbal Fluency (SVF) test, Trail Making Test (TMT), Digital Span Test (DST) and Clock Drawing Test (CDT) scores. Generalized estimating equation models were used to examine repeated measures. The results showed that compared with the changes in the control group from baseline to Week 8, the tandospirone group showed more significant changes in SVF score at Weeks 4 (p < 0.05) and 8 (p < 0.001), and TMT (B-A) score at Week 8 (p < 0.05). RAVLT, DST and DCT scores were relatively stable in both groups during the study period. Moreover, mediation analysis showed that these results were not mediated by the alleviation of depression symptoms. Partial Spearman correlation analysis showed that only plasma 5-hydroxytryptamine (5-HT) was positively correlated with Hamilton Depression Rating Scale score after Bonferroni correction (r = 0.347, p < 0.001). Augmentation therapy with tandospirone citrate improved the executive and language functions of VaDep-MCI patients. Additionally, plasma 5-HT levels may serve as a potential biomarker of VaDep severity. These findings may provide clinical insights into the treatment of vascular depression.

Attention deficit hyperactivity disorder in adults who present with self-harm: a comparative 6-month follow-up study

BACKGROUND

ADHD is common in psychiatric populations. This study aimed to compare clinical characteristics in adults with and without ADHD who presented with self-harm, and to compare later risk of suicidal behaviour within 6 months.

METHODS

Eight hundred four adults presented with self-harm (with and without suicidal intent) at psychiatric emergency services at three Swedish hospitals. Persons with a discharge ICD-10 diagnosis F90.0-F90.9 or a prescription for ADHD medication were considered to have ADHD (n = 93). Medical records were reviewed for evidence of subsequent suicide attempts (SA) within 6 months; suicides were identified by national register.

RESULTS

Recent relationship problems were more prevalent in the ADHD group. While the index episodes of those with ADHD were more often non-suicidal, and actual SAs more often rated as impulsive, medical lethality at presentation did not differ in attempters with and without ADHD. Subsequent SAs (fatal or non-fatal) were observed in 29% of the ADHD group and 20% in all others (P = .005). A logistic regression model showed elevated risk of suicidal behaviour during follow-up in the ADHD group (OR = 1.70, CI 1.05-2.76), although a final regression model suggested that this association was partly explained by age and comorbid emotionally unstable personality disorder.

CONCLUSIONS

Findings highlight the need for clinicians to take self-harm seriously in adults with ADHD.

25(OH)D levels are decreased in patients with difficult-to-treat depression

Objectives

The aims of the study are i) to compare 25-hydroxyvitamin D (25(OH)D) levels between clinically depressed individuals with insufficient treatment response and healthy controls and ii) to test the association between 25(OH)D levels and different affective disorder diagnoses (i.e., major depressive disorder (MDD) single episode, MDD recurrent episode, chronic MDD, and dysthymia), as well as grade of suicidal ideation.

Method

We quantified serum 25(OH)D in 202 individuals with difficult-to-treat depression (DTD) and 41 healthy controls. Patients were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition (DSM-IV-TR). ANCOVA was used to test differences in mean 25(OH)levels between depressed and controls, adjusting for sex, age, smoking, sampling season, ethnicity, somatic illness, and body mass index (BMI). Binary logistic regression models were used to test the association between depression and 25(OH)D levels.

Results

Patients with difficult-to-treat depression had significantly lower levels of 25(OH)D compared to healthy controls (ANCOVA, F = 4.89; p = 0.03). Thirty percent of the depressed patients were 25(OH)D deficient (<50 nmol/L) compared to 5% of the controls (Chi-squared test, χ² = 11.38; p < 0.01). The odds for being depressed decreased significantly with 17% per 10 nmol/L increase of 25(OH)D (Binary logistic regression, p < 0.05).

Limitations

The cross-sectional design of the study precludes any conclusions about causality. A large part of the patients took psychotropic drugs and/or had somatic illnesses, which might have affected the results.

Conclusion

The results of the present study add to the body of evidence linking 25(OH)D deficiency and depression. Further investigations are warranted to better understand any clinical implications of this association.

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Lower 25(OH)D levels in difficult-to-treat depression versus healthy controls.

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No difference in 25(OH)D levels between different affective disorder diagnoses.

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No associations between 25(OH)D and suicidality.

Prediction and network modelling of self-harm through daily self-report and history of self-injury

BACKGROUND

Self-harm is a significant public health issue, and both our understanding and ability to predict adverse outcomes are currently inadequate. The current study explores how preventative efforts could be aided through short-term prediction and modelling of risk factors for self-harm.

METHODS

Patients (72% female, M_age = 40.3 years) within an inpatient psychiatric facility self-reported their psychological distress, interpersonal circumstances, and wish to live and die on a daily basis during 3690 unique admissions. Hierarchical logistic regressions assessed whether daily changes in self-report and history of self-harm could predict self-harm, with machine learning used to train and test the model. To assess interrelationships between predictors, network and cross-lagged panel models were performed.

RESULTS

Increases in a wish to die (β = 1.34) and psychological distress (β = 1.07) on a daily basis were associated with increased rates of self-harm, while a wish to die on the day prior [odds ratio (OR) 3.02] and a history of self-harm (OR 3.02) was also associated with self-harm. The model detected 77.7% of self-harm incidents (positive predictive value = 26.6%, specificity = 79.1%). Psychological distress, wish to live and die, and interpersonal factors were reciprocally related over the prior day.

CONCLUSIONS

Short-term fluctuations in self-reported mental health may provide an indication of when an individual is at-risk of self-harm. Routine monitoring may provide useful feedback to clinical staff to reduce risk of self-harm. Modifiable risk factors identified in the current study may be targeted during interventions to minimise risk of self-harm.

Risk Assessment of Repeated Suicide Attempts Among Youth in Saudi Arabia

Introduction

Although the incidence of suicide attempts continues to increase among youth in Saudi Arabia, no risk assessment tool has been established for suicide attempt repetition in the country's youth population. The objective of the study was to develop risk assessment of suicide attempt repetition among youth in Saudi Arabia.

Methods

This is a retrospective study of youth (10-24 years) with intentional suicide attempt(s) who presented to the emergency departments (ED) at King Abdullah Specialist Children's Hospital (KASCH) and King Abdulaziz Medical City-Riyadh (KAMC-R), Saudi Arabia between 1 January 2015 and 31 December 2017. We excluded youth having unintentional suicide attempts. Data were retrieved for the 157 eligible as having attempted suicide.

Results

Forty-one of 157 (26.1%) had repeated suicide attempts (95% confidence limits: 19.433.7%). Four independent factors were identified that were associated with an increased risk of repeated suicide attempts: age (adjusted odds ratio [aOR] = 1.147, 95% confidence interval (CI) = 11.015-1.297, P=0.028), family problems (aOR = 4.218, 95% CI = 1.690-10.528, P=0.002), psychiatric disorders (aOR = 3.497, 95% CI = 1.519-8.051, P=0.003), and hospitalization (aOR = 5.143, 95% CI = 1.421-18.610, P=0.013). This risk model showed adequate utility with an area under the receiver operating characteristic (ROC) curve (AUC): 77.9%, 95% CI: 69.486.3% with optimism-corrected AUC = 71.8%. Youden index defined a probability of ≥0.38 to predict a high risk of repeated suicide attempts.

Conclusion

The risk of repeated suicide attempts among Saudi youth was high, compatible with what has been reported among youth in England and in France. Age, family problems, psychiatric disorders, and hospitalization are risk factors for repeated suicide attempts. A prevention program for suicide attempts in youth may take into account family problems, screening for psychiatric disorders, and suicidal behavior.

Exploring characteristics and risk of repetition in people who fail to report previous hospital presentations for self-harm: A case-control study using data from The Manchester Self-Harm Project

BACKGROUND

As a risk factor for future self-harm and suicide, questions about past self-harm are typically included in assessments that help inform management of people who self-harm. However, little is known about people with a history of self-harm who do not report it. This study aimed to describe and compare (i) characteristics of people who did or did not accurately report previous self-harm, and (ii) 12-month repetition of self-harm.

METHODS

Data on all self-harm presentations to three hospital emergency departments in England were collected from 2003 to 2015. A 1:5 matched case-control design included 374 cases where previous self-harm was not reported and 1,870 controls where previous self-harm was reported. Data were analysed using conditional logistic regression and survival analysis.

RESULTS

Cases were more likely to be male (OR 1.42; 95% CI 1.13-1.77), middle-aged (OR 1.41; 95% CI 1.08-1.83), employed (OR 1.51; 95% CI 1.15-1.98), and less likely be referred to psychiatric services (OR 0.53; 95% CI 0.35-0.80). Twelve-month repetition was similar in cases and controls (30% vs 31%).

LIMITATIONS

Self-harm not resulting in a hospital presentation could not be verified and individuals with a single episode in the study database were therefore excluded.

CONCLUSIONS

Previous self-harm is an important risk factor for repetition in people who accurately recall and report it and those who fail to report it. Those who do not report previous self-harm are less likely to be referred to psychiatric services, emphasising the need for careful assessment of every self-harm presentation to emergency departments.

A controlled study of the efficacy and safety of tandospirone citrate combined with escitalopram in the treatment of vascular depression: A pilot randomized controlled trial at a single-center in China

Vascular depression can respond poorly to antidepressants. This study aimed to explore the efficacy and safety of tandospirone plus escitalopram for treating vascular depression with anxiety. This pilot randomized controlled trial included consecutive inpatients/outpatients with vascular depression/anxiety at the Department of Neurology, Fujian Medical University Union Hospital, China (January 2014 to December 2016). Among 157 patients screened, 100 were randomly divided into the tandospirone + escitalopram (combination therapy) and escitalopram (monotherapy) groups equally, and then followed for 8 weeks. Efficacy was evaluated using the Hamilton Depression (HAMD), Hamilton Anxiety (HAMA), Clinical Global Impression (CGI) and Mini-Mental State examination (MMSE) scales. Adverse events (AEs) were assessed with the Treatment Emergent Symptom Scale (TESS). HAMD and HAMA scores decreased progressively, showing reductions versus baseline at 1, 2, 4 and 8 weeks in both groups (P < 0.001). HAMD and HAMA scores were lower in the tandospirone + escitalopram group than those in the escitalopram group at 1 and 2 weeks (P < 0.001), but not at 4 and 8 weeks. Improvements in CGI scores (severity, improvement and efficacy indexes) were greater in the tandospirone + escitalopram group than that in the escitalopram group at 1 and 2 weeks (P < 0.01), but not at 4 and 8 weeks. The tandospirone + escitalopram group had higher MMSE scores than that in the escitalopram group at 4 and 8 weeks (P < 0.01). All AEs were mild, and the rates were comparable between groups. Augmentation of escitalopram with tandospirone accelerates the onset of anti-depressive and anxiolytic effects and improves cognitive function in patients with vascular depression and anxiety.

Meta-analysis of suicide rates among people discharged from non-psychiatric settings after presentation with suicidal thoughts or behaviours

OBJECTIVE

To quantify the suicide rate among people discharged from non-psychiatric settings after presentations with suicidal thoughts or behaviours.

METHOD

Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours after discharge from emergency departments or the medical or surgical wards of general hospitals.

RESULTS

A total of 115 studies reported 167 cohorts and 3747 suicide deaths among 248 005 patients during 1 263 727 person-years. The pooled suicide rate postdischarge was 483 suicide deaths per 100 000 person-years (95% confidence interval (CI) 445-520, prediction interval (PI) 200-770) with high between-sample heterogeneity (I²  = 92). The suicide rate was highest in the first year postdischarge (851 per 100 000 person-years) but remained elevated in the long term. Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years) but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018 (329 per 100 000 person-years).

CONCLUSIONS

People with suicidal thoughts or behaviours who are discharged from non-psychiatric settings have highly elevated rates of suicide despite a clinically meaningful decline in these suicide rates in recent decades.

Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence

Background

Instruments have been developed to facilitate suicide risk assessment. We aimed to evaluate the evidence for these instruments including assessment of risk of bias and diagnostic accuracy for suicide and suicide attempt.

Methods

PubMed (NLM), PsycInfo, Embase, Cinahl and the Cochrane Library databases were searched until December 2014. We assessed risk of bias with QUADAS-2. The average sensitivity and specificity of each instrument was estimated and the certainty of the evidence was assessed with GRADE. We considered instruments with a sensitivity > 80% and a specificity > 50% to have sufficient diagnostic accuracy.

Results

Thirty-five relevant studies were identified but 14 were considered to have high risk of bias, leaving 21 studies evaluating altogether 15 risk assessment instruments. We could carry out meta-analyses for five instruments. For the outcome suicide attempt SAD PERSONS Scale had a sensitivity of 15% (95% CI 8–24) and specificity of 97% (96–98), and the Manchester Self-Harm Rule (MSHR) a sensitivity of 97% (97–97) and a specificity of 20% (20–21). ReACT, which is a modification of MSHR, had a similar low specificity, as did the Sodersjukhuset Self Harm Rule. For the outcome suicide, the Beck Hopelessness Scale had a sensitivity of 89% (78–95) and specificity of 42% (40–43).

Conclusions

Most suicide risk assessment instruments were supported by too few studies to allow for evaluation of accuracy. Among those that could be evaluated, none fulfilled requirements for sufficient diagnostic accuracy.

Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales

BackgroundPrediction of suicidal behaviour is an aspirational goal for clinicians and policy makers; with patients classified as 'high risk' to be preferentially allocated treatment. Clinical usefulness requires an adequate positive predictive value (PPV).AimsTo identify studies of predictive instruments and to calculate PPV estimates for suicidal behaviours.MethodA systematic review identified studies of predictive instruments. A series of meta-analyses produced pooled estimates of PPV for suicidal behaviours.ResultsFor all scales combined, the pooled PPVs were: suicide 5.5% (95% CI 3.9-7.9%), self-harm 26.3% (95% CI 21.8-31.3%) and self-harm plus suicide 35.9% (95% CI 25.8-47.4%). Subanalyses on self-harm found pooled PPVs of 16.1% (95% CI 11.3-22.3%) for high-quality studies, 32.5% (95% CI 26.1-39.6%) for hospital-treated self-harm and 26.8% (95% CI 19.5-35.6%) for psychiatric in-patients.ConclusionsNo 'high-risk' classification was clinically useful. Prevalence imposes a ceiling on PPV. Treatment should reduce exposure to modifiable risk factors and offer effective interventions for selected subpopulations and unselected clinical populations.

Computerized Adaptive Test vs. decision trees: Development of a support decision system to identify suicidal behavior

BACKGROUND

Several Computerized Adaptive Tests (CATs) have been proposed to facilitate assessments in mental health. These tests are built in a standard way, disregarding useful and usually available information not included in the assessment scales that could increase the precision and utility of CATs, such as the history of suicide attempts.

METHODS

Using the items of a previously developed scale for suicidal risk, we compared the performance of a standard CAT and a decision tree in a support decision system to identify suicidal behavior. We included the history of past suicide attempts as a class for the separation of patients in the decision tree.

RESULTS

The decision tree needed an average of four items to achieve a similar accuracy than a standard CAT with nine items. The accuracy of the decision tree, obtained after 25 cross-validations, was 81.4%. A shortened test adapted for the separation of suicidal and non-suicidal patients was developed.

CONCLUSION

CATs can be very useful tools for the assessment of suicidal risk. However, standard CATs do not use all the information that is available. A decision tree can improve the precision of the assessment since they are constructed using a priori information.

Predicting Risk of Suicide Attempt Using History of Physical Illnesses From Electronic Medical Records

BACKGROUND

Although physical illnesses, routinely documented in electronic medical records (EMR), have been found to be a contributing factor to suicides, no automated systems use this information to predict suicide risk.

OBJECTIVE

The aim of this study is to quantify the impact of physical illnesses on suicide risk, and develop a predictive model that captures this relationship using EMR data.

METHODS

We used history of physical illnesses (except chapter V: Mental and behavioral disorders) from EMR data over different time-periods to build a lookup table that contains the probability of suicide risk for each chapter of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes. The lookup table was then used to predict the probability of suicide risk for any new assessment. Based on the different lengths of history of physical illnesses, we developed six different models to predict suicide risk. We tested the performance of developed models to predict 90-day risk using historical data over differing time-periods ranging from 3 to 48 months. A total of 16,858 assessments from 7399 mental health patients with at least one risk assessment was used for the validation of the developed model. The performance was measured using area under the receiver operating characteristic curve (AUC).

RESULTS

The best predictive results were derived (AUC=0.71) using combined data across all time-periods, which significantly outperformed the clinical baseline derived from routine risk assessment (AUC=0.56). The proposed approach thus shows potential to be incorporated in the broader risk assessment processes used by clinicians.

CONCLUSIONS

This study provides a novel approach to exploit the history of physical illnesses extracted from EMR (ICD-10 codes without chapter V-mental and behavioral disorders) to predict suicide risk, and this model outperforms existing clinical assessments of suicide risk.

Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy

OBJECTIVES

The aims of this review were to calculate the diagnostic accuracy statistics of risk scales following self-harm and consider which might be the most useful scales in clinical practice.

DESIGN

Systematic review.

METHODS

We based our search terms on those used in the systematic reviews carried out for the National Institute for Health and Care Excellence self-harm guidelines (2012) and evidence update (2013), and updated the searches through to February 2015 (CINAHL, EMBASE, MEDLINE, and PsychINFO). Methodological quality was assessed and three reviewers extracted data independently. We limited our analysis to cohort studies in adults using the outcome of repeat self-harm or attempted suicide. We calculated diagnostic accuracy statistics including measures of global accuracy. Statistical pooling was not possible due to heterogeneity.

RESULTS

The eight papers included in the final analysis varied widely according to methodological quality and the content of scales employed. Overall, sensitivity of scales ranged from 6% (95% CI 5% to 6%) to 97% (CI 95% 94% to 98%). The positive predictive value (PPV) ranged from 5% (95% CI 3% to 9%) to 84% (95% CI 80% to 87%). The diagnostic OR ranged from 1.01 (95% CI 0.434 to 2.5) to 16.3 (95%CI 12.5 to 21.4). Scales with high sensitivity tended to have low PPVs.

CONCLUSIONS

It is difficult to be certain which, if any, are the most useful scales for self-harm risk assessment. No scales perform sufficiently well so as to be recommended for routine clinical use. Further robust prospective studies are warranted to evaluate risk scales following an episode of self-harm. Diagnostic accuracy statistics should be considered in relation to the specific service needs, and scales should only be used as an adjunct to assessment.

Risk Factors of Discharged Against Medical Advice among Adolescents Self-inflicted Injury and Attempted Suicide in the Korean Emergency Department

Suicide is a leading cause of death among Korean adolescents. Many suicide attempting adolescents often are discharged against medical advice in the emergency department. The aim of the present study was to determine the risk factors for discharge against medical advice (DAMA) after self-inflicted injury or attempted suicide in the emergency department. We extracted data on adolescents (10-19 yr old) from the national emergency department information system; we used data from 2007 and 2011. A total of 6,394 adolescents visited EDs after self-inflicted injury or attempted suicide. Among these patients, the median age was 17 yr (Interquatile range, 15-18 yr), 83.2% were between 15-19 yr of age, and 63.3% were female. Poisoning was the most common method of attempted suicide, while hanging and fall were the most common methods of fatality. The rate of DAMA from the ED was 22.8%. Independent risk factors for DAMA included female gender (odds ratio [OR], 1.49), older age adolescents (OR, 1.96), residence in a metropolitan/large city area (OR, 1.49), and discharge at night (OR, 1.38). These risk factors should be considered in establishing management and counseling plans for patients discharged against medical advice by community services and EDs.

Attitudes of acceptability and lack of condemnation toward suicide may be predictive of post-discharge suicide attempts

BACKGROUND

Suicide attempts (SA) after psychiatric hospitalization continue to be a major cause of morbidity. Implicit measures may enhance our ability to assess suicide risk. In this context, we describe the first use of the Suicide Opinion Questionnaire (SOQ) to identify post-discharge suicide attempters.

METHODS

Adult psychiatric inpatients admitted for suicidality (N = 91) were administered a battery of measures including the SOQ, and forty were reached and reassessed for SA at two months post-discharge. Exploratory factor analysis (EFA) on items associated with suicidality was performed to identify latent constructs. Linear discriminant analysis (LDA) was used to optimize factor combination for suicide identification. Results were compared with explicit measures of suicidality, and logistic regression was used to control for other risk factors. Finally, a simplified 9-item scale was derived from the results and its performance compared to that of the linear discriminant function.

RESULTS

Twenty items differed between patients with and without SA at intake or follow-up. EFA on these identified two factors: suicide attempters indicated greater acceptability and less moral condemnation of suicide. The LDA-derived discriminant function and 9-item scale was significantly sensitive and specific for post-discharge SA.

CONCLUSIONS

Attitudes of acceptability and lack of condemnation toward suicide may constitute an implicit measure of suicidality that could contribute to risk assessment in a high-risk population.

Risk stratification using data from electronic medical records better predicts suicide risks than clinician assessments

BACKGROUND

To date, our ability to accurately identify patients at high risk from suicidal behaviour, and thus to target interventions, has been fairly limited. This study examined a large pool of factors that are potentially associated with suicide risk from the comprehensive electronic medical record (EMR) and to derive a predictive model for 1-6 month risk.

METHODS

7,399 patients undergoing suicide risk assessment were followed up for 180 days. The dataset was divided into a derivation and validation cohorts of 4,911 and 2,488 respectively. Clinicians used an 18-point checklist of known risk factors to divide patients into low, medium, or high risk. Their predictive ability was compared with a risk stratification model derived from the EMR data. The model was based on the continuation-ratio ordinal regression method coupled with lasso (which stands for least absolute shrinkage and selection operator).

RESULTS

In the year prior to suicide assessment, 66.8% of patients attended the emergency department (ED) and 41.8% had at least one hospital admission. Administrative and demographic data, along with information on prior self-harm episodes, as well as mental and physical health diagnoses were predictive of high-risk suicidal behaviour. Clinicians using the 18-point checklist were relatively poor in predicting patients at high-risk in 3 months (AUC 0.58, 95% CIs: 0.50 - 0.66). The model derived EMR was superior (AUC 0.79, 95% CIs: 0.72 - 0.84). At specificity of 0.72 (95% CIs: 0.70-0.73) the EMR model had sensitivity of 0.70 (95% CIs: 0.56-0.83).

CONCLUSION

Predictive models applied to data from the EMR could improve risk stratification of patients presenting with potential suicidal behaviour. The predictive factors include known risks for suicide, but also other information relating to general health and health service utilisation.

Triglycerides as a biological marker of repeated re-hospitalization resulting from deliberate self-harm in acute psychiatry patients: a prospective observational study

BACKGROUND

Biological factors have been associated with deliberate self-harm (DSH) but have not been integrated with clinical factors in routine risk assessments.This study aimed to examine the incremental validity of lipid levels and platelet serotonin when combined with psychosocial factors in risk assessments for repeated admissions due to DSH.

METHODS

In this prospective observational study of 196 acutely admitted patients, results of blood tests performed upon admission and the MINI Suicidal Scale and psychosocial DSH risk factor assessments performed at discharge were compared with the incidence of DSH recorded during the first 3 and 12 months after discharge.

RESULTS

High triglyceride levels were found to be a significant marker for patients admitted 3 or more times due to DSH (repeated DSH, DSH-R) when tested against other significant risk factors. When all (9) significant univariate factors associated with 12-month post-discharge DSH-R were analyzed in a multivariate logistic regression, the MINI Suicidal Scale (p = 0.043), a lack of insight (p = 0.040), and triglyceride level (p = 0.020) remained significant. The estimated 12-month area under the curve of the receiver operator characteristic (ROC-AUC) for DSH-R was 0.74 for triglycerides, 0.81 for the MINI, 0.89 for the MINI + psychosocial factors, and 0.91 for the MINI + psychosocial factors + triglycerides. The applied multifaceted approach also significantly discriminated between 12-month post-discharge DSH-R patients and other DSH patients, and a lack of insight (p = 0.047) and triglycerides (p = 0.046) remained significant for DSH-R patients in a multivariate analysis in which other DSH patients served as the reference group (rather than non-DSH patients).

CONCLUSION

The triglyceride values provided incremental validity to the MINI Suicidal Scale and psychosocial risk factors in the assessment of the risk of repeated DSH. Therefore, a bio-psychosocial approach appears promising, but further research is necessary to refine and validate this method.

Risk factors for repetition of self-harm: a systematic review of prospective hospital-based studies

BACKGROUND

Self-harm entails high costs to individuals and society in terms of suicide risk, morbidity and healthcare expenditure. Repetition of self-harm confers yet higher risk of suicide and risk assessment of self-harm patients forms a key component of the health care management of self-harm patients. To date, there has been no systematic review published which synthesises the extensive evidence on risk factors for repetition.

OBJECTIVE

This review is intended to identify risk factors for prospective repetition of self-harm after an index self-harm presentation, irrespective of suicidal intent.

DATA SOURCES

PubMed, PsychInfo and Scirus were used to search for relevant publications. We included cohort studies which examining factors associated with prospective repetition among those presenting with self-harm to emergency departments. Journal articles, abstracts, letters and theses in any language published up to June 2012 were considered. Studies were quality-assessed and synthesised in narrative form.

RESULTS

A total of 129 studies, including 329,001 participants, met our inclusion criteria. Some factors were studied extensively and were found to have a consistent association with repetition. These included previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, drug abuse/dependence, and living alone. However, the sensitivity values of these measures varied greatly across studies. Psychological risk factors and protective factors have been relatively under-researched but show emerging associations with repetition. Composite risk scales tended to have high sensitivity but poor specificity.

CONCLUSIONS

Many risk factors for repetition of self-harm match risk factors for initiation of self-harm, but the most consistent evidence for increased risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of an index episode. The current review will enhance prediction of self-harm and assist in the efficient allocation of intervention resources.

Suicide reattempters: a systematic review

The aim of this study is to identify the characteristic features of suicide reattempters. The recognition of the suicide reattempters population as a distinct clinical population may encourage future preventive and clinical work with this high-risk subgroup and thus reduce deaths. A systematic literature review was carried out in order to identify the key demographic, psychological, and clinical variables associated with the repetition of suicide attempts. In addition, we wished to analyze the operational definitions of the repetition of suicide attempts proposed in the scientific literature. Studies published from 2000 to 2012 were identified in PubMed, PsycINFO, and Web of Science databases and were selected according to predetermined criteria. We examined a total of 1480 articles and selected 86 that matched our search criteria. The literature is heterogeneous, with no consensus regarding the operational definitions of suicide reattempters. Comparison groups in the literature have also been inconsistent and include subjects making a single lifetime attempt and subjects who did not reattempt during a defined study period. Suicide reattempters were associated with higher rates of the following characteristics: unemployment, unmarried status, diagnosis of mental disorders, suicidal ideation, stressful life events, and family history of suicidal behavior. Additional research is needed to establish adequate differentiation and effective treatment plans for this population.

Sense of coherence and suicidality in suicide attempters: a prospective study

The usefulness of the Sense of Coherence (SOC) scale in the nursing setting is well-established, and an association between SOC and suicidality has been suggested. The aim was to test whether low SOC at index attempt is an independent predictor of suicidality at 2-month follow-up and of risk for repeat attempt. The study, which had a prospective cross-sectional design, included patients admitted to hospital after a suicide attempt. They were interviewed by means of Structured Clinical Interview for DSM-IV. Participants (n=155) completed the SOC scale and the Comprehensive Psychopathological Self-rating Scale for Affective Syndromes. Suicidality was rated with the Suicide Assessment Scale. Instruments were employed again at follow-up. Non-fatal/fatal repetition within 3 years was determined by review of hospital records. Low SOC at baseline predicted high suicidality at follow-up. The association remained after adjustment for major depression and affective symptom burden. Repeat attempts were made by 54 persons. Low baseline SOC was associated with repeat attempt, but the association did not remain after adjustment for major depression and symptom burden. Low SOC ratings could be a marker of risk for high suicidality in the aftermath of a suicide attempt. The SOC scale could be incorporated in nursing assessments of suicide attempters.

Predictive validity of the MINI suicidal scale for self-harm in acute psychiatry: a prospective study of the first year after discharge

The aim of the study was to explore the predictive validity of the Suicidal Scale of the Mini-International Neuropsychiatric Interview as a screen for suicidal behavior and non-suicidal self-injury following discharge from an acute psychiatric ward. Using a prospective, naturalistic design, the patients were screened with the Suicidal Scale when discharged (n = 307). At 12 months post-discharge, the Suicidal Scale was a significant predictor of suicidal behavior (n = 48) and suicidal behavior+non-suicidal self-injury (n = 49) but not for non-suicidal self-injury (n = 15). For patients without any known previous suicide attempts (n = 180), the Suicidal Scale was a significant predictor of suicidal behavior (n = 21) and suicidal behavior+non-suicidal self-injury (n = 11). Further research is needed to determine the overall utility of the routine screening of self-harm.

Psychogenic nonepileptic seizures and suicidal behavior on a video/EEG telemetry unit: the need for psychiatric assessment and screening for suicide risk

Patients with epilepsy and psychogenic nonepileptic seizures (PNES) have an increased prevalence of psychiatric illness and risk for suicidal ideation/suicidal behavior/suicide compared with the general population. Recent literature suggests that antiepileptic drugs (AEDs) used to treat epilepsy, pain, and psychiatric disorders increase the risk of suicide and that this increased risk may be AED selective. This case analyzes a suicide attempt on a video/EEG telemetry unit. Specific risk factors associated with increased risk of suicidal behaviors pertinent to this case are reviewed: epilepsy, multiple psychiatric diagnoses including affective disorder, AEDs, PNES, prior medically serious suicide attempt, and suicide attempt within the past month. Specific psychometric rating scales to screen for both psychiatric illness and suicide risk and psychiatric assessment should be integral components of the evaluation and treatment of patients on video/EEG telemetry units.