1
|
Kolochowski FD, Kreckeler N, Forkmann T, Teismann T. Reliability of Suicide Risk Estimates: A Vignette Study. Arch Suicide Res 2024:1-12. [PMID: 39045846 DOI: 10.1080/13811118.2024.2382709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
OBJECTIVE Suicide risk assessments are obligatory when patients express a death wish in clinical practice. Yet, suicide risk estimates based on unguided risk assessments have been shown to be of low reliability. Since generalizability of previous studies is limited, the current study aimed to assess inter-rater and intra-rater reliability of risk estimates conducted by psychotherapists and psychology students using written case vignettes. METHOD In total, N = 256 participants (psychology students, psychotherapists) were presented with 24 case vignettes describing patients at either low, moderate, severe or extreme risk of suicide. Participants were asked to assign a level of risk to each single vignette at a baseline assessment and again at a follow-up assessment two weeks later. RESULTS Risk estimates showed a low inter-rater reliability, both for students (AC1 = .35) and for psychotherapists (AC1 = .44). Intra-rater reliability was moderate for psychotherapists (AC1 = .59) and rather low for psychology students (AC1 = .47). In general, intra- and intra-rater reliability were highest for vignettes displaying "low" and "extreme" risk. CONCLUSIONS The results highlight that the reliability of unguided suicide risk assessments is questionable. Standardized risk assessment protocols are therefore recommended. Nonetheless, even reliable risk estimation does not imply predictive validity of risk estimates for future suicidal behavior.
Collapse
|
2
|
Cantrell A, Sworn K, Chambers D, Booth A, Taylor Buck E, Weich S. Factors within the clinical encounter that impact upon risk assessment within child and adolescent mental health services: a rapid realist synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-107. [PMID: 38314750 DOI: 10.3310/vkty5822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Background Risk assessment is a key process when a child or adolescent presents at risk for self-harm or suicide in a mental health crisis or emergency. Risk assessment by a healthcare professional should be included within a biopsychosocial assessment. However, the predictive value of risk-screening tools for self-harm and suicide in children and adolescents is consistently challenged. A review is needed to explore how best to undertake risk assessment and the appropriate role for tools/checklists within the assessment pathway. Aims To map research relating to risk assessment for child and adolescent mental health and to identify features that relate to a successful risk assessment. Objectives To review factors within the clinical encounter that impact upon risk assessments for self-harm and suicide in children and adolescents: i. to conduct a realist synthesis to understand mechanisms for risk assessment, why they occur and how they vary by context ii. to conduct a mapping review of primary studies/reviews to describe available tools of applicability to the UK. Data sources Databases, including MEDLINE, PsycINFO®, EMBASE, CINAHL, HMIC, Science and Social Sciences Citation Index and the Cochrane Library, were searched (September 2021). Searches were also conducted for reports from websites. Review methods A resource-constrained realist synthesis was conducted exploring factors that impact upon risk assessments for self-harm and suicide. This was accompanied by a mapping review of primary studies/reviews describing risk-assessment tools and approaches used in UK child and adolescent mental health. Following piloting, four reviewers screened retrieved records. Items were coded for the mapping and/or for inclusion in the realist synthesis. The review team examined the validity and limitations of risk-screening tools. In addition, the team identified structured approaches to risk assessment. Reporting of the realist synthesis followed RAMESES guidelines. Results From 4084 unique citations, 249 papers were reviewed and 41 studies (49 tools) were included in the mapping review. Eight reviews were identified following full-text screening. Fifty-seven papers were identified for the realist review. Findings highlight 14 explanations (programme theories) for a successful risk assessment for self-harm and suicide. Forty-nine individual assessment tools/approaches were identified. Few tools were developed in the UK, specifically for children and adolescents. These lacked formal independent evaluation. No risk-screening tool is suitable for risk prediction; optimal approaches incorporate a relationship of trust, involvement of the family, where appropriate, and a patient-centred holistic approach. The objective of risk assessment should be elicitation of information to direct a risk formulation and care plan. Limitations Many identified tools are well-established but lack scientific validity, particularly predictive validity, or clinical utility. Programme theories were generated rapidly from a survey of risk assessment. Conclusions No single checklist/approach meets the needs of risk assessment for self-harm and suicide. A whole-system approach is required, informed by structured clinical judgement. Useful components include a holistic assessment within a climate of trust, facilitated by family involvement. Study registration This study is registered as PROSPERO CRD42021276671. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135079) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 1. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Anna Cantrell
- Health Economics & Decision Science (HEDS) School of Health and Related Research (ScHARR), Regent Court, Sheffield, UK
| | - Katie Sworn
- Health Economics & Decision Science (HEDS) School of Health and Related Research (ScHARR), Regent Court, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), Regent Court, Sheffield, UK
| | - Andrew Booth
- Health Economics & Decision Science (HEDS) School of Health and Related Research (ScHARR), Regent Court, Sheffield, UK
| | | | - Scott Weich
- School of Health and Related Research (ScHARR), Regent Court, Sheffield, UK
| |
Collapse
|
3
|
Arora A, Bojko L, Kumar S, Lillington J, Panesar S, Petrungaro B. Assessment of machine learning algorithms in national data to classify the risk of self-harm among young adults in hospital: A retrospective study. Int J Med Inform 2023; 177:105164. [PMID: 37516036 DOI: 10.1016/j.ijmedinf.2023.105164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 07/06/2023] [Accepted: 07/21/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Self-harm is one of the most common presentations at accident and emergency departments in the UK and is a strong predictor of suicide risk. The UK Government has prioritised identifying risk factors and developing preventative strategies for self-harm. Machine learning offers a potential method to identify complex patterns with predictive value for the risk of self-harm. METHODS National data in the UK Mental Health Services Data Set were isolated for patients aged 18-30 years who started a mental health hospital admission between Aug 1, 2020 and Aug 1, 2021, and had been discharged by Jan 1, 2022. Data were obtained on age group, gender, ethnicity, employment status, marital status, accommodation status and source of admission to hospital and used to construct seven machine learning models that were used individually and as an ensemble to predict hospital stays that would be associated with a risk of self-harm. OUTCOMES The training dataset included 23 808 items (including 1081 episodes of self-harm) and the testing dataset 5951 items (including 270 episodes of self-harm). The best performing algorithms were the random forest model (AUC-ROC 0.70, 95%CI:0.66-0.74) and the ensemble model (AUC-ROC 0.77 95%CI:0.75-0.79). INTERPRETATION Machine learning algorithms could predict hospital stays with a high risk of self-harm based on readily available data that are routinely collected by health providers and recorded in the Mental Health Services Data Set. The findings should be validated externally with other real-world, prospective data. FUNDING This study was supported by the Midlands and Lancashire Commissioning Support Unit.
Collapse
Affiliation(s)
- Anmol Arora
- School of Clinical Medicine, University of Cambridge, Cambridge, UK; Health Economics Unit, NHS Midlands and Lancashire Commissioning Support Unit, Leyland, UK.
| | - Louis Bojko
- Health Economics Unit, NHS Midlands and Lancashire Commissioning Support Unit, Leyland, UK
| | - Santosh Kumar
- Health Economics Unit, NHS Midlands and Lancashire Commissioning Support Unit, Leyland, UK
| | - Joseph Lillington
- Health Economics Unit, NHS Midlands and Lancashire Commissioning Support Unit, Leyland, UK
| | - Sukhmeet Panesar
- Senior Adviser, Office of Chief Data and Analytics Officer, NHS England and NHS Improvement, UK
| | - Bruno Petrungaro
- Health Economics Unit, NHS Midlands and Lancashire Commissioning Support Unit, Leyland, UK
| |
Collapse
|
4
|
Sariaslan A, Fanshawe T, Pitkänen J, Cipriani A, Martikainen P, Fazel S. Predicting suicide risk in 137,112 people with severe mental illness in Finland: external validation of the Oxford Mental Illness and Suicide tool (OxMIS). Transl Psychiatry 2023; 13:126. [PMID: 37072392 PMCID: PMC10113231 DOI: 10.1038/s41398-023-02422-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/20/2023] Open
Abstract
Oxford Mental Illness and Suicide tool (OxMIS) is a standardised, scalable, and transparent instrument for suicide risk assessment in people with severe mental illness (SMI) based on 17 sociodemographic, criminal history, familial, and clinical risk factors. However, alongside most prediction models in psychiatry, external validations are currently lacking. We utilised a Finnish population sample of all persons diagnosed by mental health services with SMI (schizophrenia-spectrum and bipolar disorders) between 1996 and 2017 (n = 137,112). To evaluate the performance of OxMIS, we initially calculated the predicted 12-month suicide risk for each individual by weighting risk factors by effect sizes reported in the original OxMIS prediction model and converted to a probability. This probability was then used to assess the discrimination and calibration of the OxMIS model in this external sample. Within a year of assessment, 1.1% of people with SMI (n = 1475) had died by suicide. The overall discrimination of the tool was good, with an area under the curve of 0.70 (95% confidence interval: 0.69-0.71). The model initially overestimated suicide risks in those with elevated predicted risks of >5% over 12 months (Harrell's Emax = 0.114), which applied to 1.3% (n = 1780) of the cohort. However, when we used a 5% maximum predicted suicide risk threshold as is recommended clinically, the calibration was excellent (ICI = 0.002; Emax = 0.005). Validating clinical prediction tools using routinely collected data can address research gaps in prediction psychiatry and is a necessary step to translating such models into clinical practice.
Collapse
Affiliation(s)
- Amir Sariaslan
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
| | - Thomas Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Joonas Pitkänen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Centre for Health Equity Studies (CHESS), Stockholm University and Karolinska Institutet, Stockholm, Sweden
- Max Planck Institute for Demographic Research, Rostock, Germany
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
| |
Collapse
|
5
|
Quinlivan L, Gorman L, Marks S, Monaghan E, Asmal S, Webb RT, Kapur N. Liaison psychiatry practitioners' views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study. BJPsych Open 2023; 9:e34. [PMID: 36803955 PMCID: PMC9970172 DOI: 10.1192/bjo.2023.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate. AIMS To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners. METHOD Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data. RESULTS Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services. CONCLUSIONS Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.
Collapse
Affiliation(s)
- Leah Quinlivan
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; and National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Louise Gorman
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; and National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Stephen Marks
- Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, UK
| | - Elizabeth Monaghan
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Sadika Asmal
- National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Roger T Webb
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; and National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - Nav Kapur
- Centre for Mental Health and Safety, University of Manchester, UK; Manchester Academic Health Science Centre, University of Manchester, UK; National Institute for Health and Care Research (NIHR) Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK; and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| |
Collapse
|
6
|
Fedorowicz SE, Dempsey RC, Ellis N, Phillips E, Gidlow C. How is suicide risk assessed in healthcare settings in the UK? A systematic scoping review. PLoS One 2023; 18:e0280789. [PMID: 36730243 PMCID: PMC10045566 DOI: 10.1371/journal.pone.0280789] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/09/2023] [Indexed: 02/03/2023] Open
Abstract
A high proportion of people contact healthcare services in the 12 months prior to death by suicide. Identifying people at high-risk for suicide is therefore a key concern for healthcare services. Whilst there is extensive research on the validity and reliability of suicide risk assessment tools, there remains a lack of understanding of how suicide risk assessments are conducted by healthcare staff in practice. This scoping review examined the literature on how suicide risk assessments are conducted and experienced by healthcare practitioners, patients, carers, relatives, and friends of people who have died by suicide in the UK. Literature searches were conducted on key databases using a pre-defined search strategy pre-registered with the Open Science Framework and following the PRISMA extension for scoping reviews guidelines. Eligible for inclusion were original research, written in English, exploring how suicide risk is assessed in the UK, related to administering or undergoing risk assessment for suicide, key concepts relating to those experiences, or directly exploring the experiences of administering or undergoing assessment. Eighteen studies were included in the final sample. Information was charted including study setting and design, sampling strategy, sample characteristics, and findings. A narrative account of the literature is provided. There was considerable variation regarding how suicide risk assessments are conducted in practice. There was evidence of a lack of risk assessment training, low awareness of suicide prevention guidance, and a lack of evidence relating to patient perspectives of suicide risk assessments. Increased inclusion of patient perspectives of suicide risk assessment is needed to gain understanding of how the process can be improved. Limited time and difficulty in starting an open discussion about suicide with patients were noted as barriers to successful assessment. Implications for practice are discussed.
Collapse
Affiliation(s)
- Sophia E. Fedorowicz
- Centre for Health and Development, Staffordshire University, Stoke-on-Trent, Staffordshire, United Kingdom
| | - Robert C. Dempsey
- Faculty of Health and Education, Department of Psychology, Manchester Metropolitan University, Manchester, United Kingdom
- * E-mail:
| | - Naomi Ellis
- Centre for Health and Development, Staffordshire University, Stoke-on-Trent, Staffordshire, United Kingdom
| | - Elliott Phillips
- Centre for Health and Development, Staffordshire University, Stoke-on-Trent, Staffordshire, United Kingdom
| | - Christopher Gidlow
- Centre for Health and Development, Staffordshire University, Stoke-on-Trent, Staffordshire, United Kingdom
| |
Collapse
|
7
|
Airey ND, Iqbal Z. Are Clinicians Confident in the Risk Assessment of Suicide?: A Systematic Literature Review. Arch Suicide Res 2022; 26:1-13. [PMID: 32669055 DOI: 10.1080/13811118.2020.1792019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Suicide reduction is recognized as a vital focus for mental health clinicians. Clinician confidence to undertake suicide risk assessment, though poorly understood, appears related to job performance, though overconfidence has also been evident in clinical practice. A systematic literature search was undertaken on PSYCinfo and MEDLINE using the terms: suicide risk assessment, confidence, clinician. Of 192 papers identified, 10 articles were deemed pertinent. These for the most part suggested clinician confidence above the 50% chance level though statistical evidence was lacking for all but two. The literature fails to provide sufficient and objective evidence of the impact of clinician confidence in practice. Recommendations are provided for future research.
Collapse
|
8
|
Stewart I, Lees-Deutsch L. Risk Assessment of Self-Injurious Behavior and Suicide Presentation in the Emergency Department: An Integrative Review. J Emerg Nurs 2021; 48:57-73. [PMID: 34782168 DOI: 10.1016/j.jen.2021.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 09/17/2021] [Accepted: 10/04/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Globally, there is a lack of clarity regarding the best practice to distinguish patients at the highest risk of suicide. This review explores the use of risk assessment tools in emergency departments to identify patients at high risk of repeat self-harm, suicide attempts, or death by suicide. METHODS The review question ("Does the use of risk assessment tools in emergency departments identify patients at high risk of repeat self-harm, suicide attempts, or death by suicide?") focused on exposure and outcome. Studies of any design were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used. Study characteristics and concepts were extracted, compared, and verified. An integrative approach was used for reporting through narrative synthesis. RESULTS Nine studies were identified for inclusion. Two risk assessment tools were found to have good predictive ability for suicide ideation and self-harm. Three had modest prediction of patient disposition, but in one study, the clinical impression of nurses had higher predictive ability. One tool showed modest predictive ability for patients requiring admission. DISCUSSION This review found no strong evidence to indicate that any particular risk tool has a superior predictive ability to identify repeat self-harm, suicide attempts, or death by suicide. Best practice lacks clarity to determine patients at highest risk of suicide, but the use of risk assessment tools has been recommended. Nevertheless, such tools should not be used in isolation from clinical judgment and experience to evaluate patients at risk. Education and training to augment risk assessment within the emergency department are recommended.
Collapse
|
9
|
Kimbrel NA, Beckham JC, Calhoun PS, DeBeer BB, Keane TM, Lee DJ, Marx BP, Meyer EC, Morissette SB, Elbogen EB. Development and validation of the Durham Risk Score for estimating suicide attempt risk: A prospective cohort analysis. PLoS Med 2021; 18:e1003713. [PMID: 34351894 PMCID: PMC8341885 DOI: 10.1371/journal.pmed.1003713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/23/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Worldwide, nearly 800,000 individuals die by suicide each year; however, longitudinal prediction of suicide attempts remains a major challenge within the field of psychiatry. The objective of the present research was to develop and evaluate an evidence-based suicide attempt risk checklist [i.e., the Durham Risk Score (DRS)] to aid clinicians in the identification of individuals at risk for attempting suicide in the future. METHODS AND FINDINGS Three prospective cohort studies, including a population-based study from the United States [i.e., the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study] as well as 2 smaller US veteran cohorts [i.e., the Assessing and Reducing Post-Deployment Violence Risk (REHAB) and the Veterans After-Discharge Longitudinal Registry (VALOR) studies], were used to develop and validate the DRS. From a total sample size of 35,654 participants, 17,630 participants were selected to develop the checklist, whereas the remaining participants (N = 18,024) were used to validate it. The main outcome measure was future suicide attempts (i.e., actual suicide attempts that occurred after the baseline assessment during the 1- to 3-year follow-up period). Measure development began with a review of the extant literature to identify potential variables that had substantial empirical support as longitudinal predictors of suicide attempts and deaths. Next, receiver operating characteristic (ROC) curve analysis was utilized to identify variables from the literature review that uniquely contributed to the longitudinal prediction of suicide attempts in the development cohorts. We observed that the DRS was a robust prospective predictor of future suicide attempts in both the combined development (area under the curve [AUC] = 0.91) and validation (AUC = 0.92) cohorts. A concentration of risk analysis found that across all 35,654 participants, 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. The DRS also performed well among important subgroups, including women (AUC = 0.91), men (AUC = 0.93), Black (AUC = 0.92), White (AUC = 0.93), Hispanic (AUC = 0.89), veterans (AUC = 0.91), lower-income individuals (AUC = 0.90), younger adults (AUC = 0.88), and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals (AUC = 0.88). The primary limitation of the present study was its its reliance on secondary data analyses to develop and validate the risk score. CONCLUSIONS In this study, we observed that the DRS was a strong predictor of future suicide attempts in both the combined development (AUC = 0.91) and validation (AUC = 0.92) cohorts. It also demonstrated good utility in many important subgroups, including women, men, Black, White, Hispanic, veterans, lower-income individuals, younger adults, and LGBTQ individuals. We further observed that 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. Taken together, these findings suggest that the DRS represents a significant advancement in suicide risk prediction over traditional clinical assessment approaches. While more work is needed to independently validate the DRS in prospective studies and to identify the optimal methods to assess the constructs used to calculate the score, our findings suggest that the DRS is a promising new tool that has the potential to significantly enhance clinicians' ability to identify individuals at risk for attempting suicide in the future.
Collapse
Affiliation(s)
- Nathan A. Kimbrel
- Durham Veterans Affairs (VA) Health Care System, Durham, North Carolina, United States of America
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, United States of America
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, United States of America
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Jean C. Beckham
- Durham Veterans Affairs (VA) Health Care System, Durham, North Carolina, United States of America
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, United States of America
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Patrick S. Calhoun
- Durham Veterans Affairs (VA) Health Care System, Durham, North Carolina, United States of America
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, United States of America
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, North Carolina, United States of America
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Bryann B. DeBeer
- Rocky Mountain Mental Illness Research, Education, and Clinical Center, Denver, Colorado, United States of America
| | - Terence M. Keane
- National Center for PTSD, Boston, Massachusetts, United States of America
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Daniel J. Lee
- National Center for PTSD, Boston, Massachusetts, United States of America
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Brian P. Marx
- National Center for PTSD, Boston, Massachusetts, United States of America
- VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Eric C. Meyer
- Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Sandra B. Morissette
- Department of Psychology, The University of Texas at San Antonio, San Antonio, Texas, United States of America
| | - Eric B. Elbogen
- Durham Veterans Affairs (VA) Health Care System, Durham, North Carolina, United States of America
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, United States of America
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, United States of America
| |
Collapse
|
10
|
Olfson M, Stroup TS, Huang C, Wall MM, Crystal S, Gerhard T. Suicide Risk in Medicare Patients With Schizophrenia Across the Life Span. JAMA Psychiatry 2021; 78:876-885. [PMID: 34037667 PMCID: PMC8156163 DOI: 10.1001/jamapsychiatry.2021.0841] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/15/2021] [Indexed: 11/14/2022]
Abstract
Importance Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span. Objective To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population. Design, Setting, and Participants Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021. Main Outcomes and Measures For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity. Results The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up. Conclusions and Relevance In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.
Collapse
Affiliation(s)
- Mark Olfson
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York
- Mailman School of Public Health, Columbia University, New York, New York
| | - T. Scott Stroup
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York
| | - Cecilia Huang
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Melanie M. Wall
- Department of Psychiatry, Columbia University Irving Medical Center, New York State Psychiatric Institute, New York
- Mailman School of Public Health, Columbia University, New York, New York
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Tobias Gerhard
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
| |
Collapse
|
11
|
Cassidy SA, Bradley L, Cogger-Ward H, Rodgers J. Development and validation of the suicidal behaviours questionnaire - autism spectrum conditions in a community sample of autistic, possibly autistic and non-autistic adults. Mol Autism 2021; 12:46. [PMID: 34154642 PMCID: PMC8218414 DOI: 10.1186/s13229-021-00449-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 05/25/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Autistic people and those with high autistic traits are at high risk of experiencing suicidality. Yet, there are no suicidality assessment tools developed or validated for these groups. METHODS A widely used and validated suicidality assessment tool developed for the general population (SBQ-R), was adapted using feedback from autistic adults, to create the Suicidal Behaviours Questionnaire-Autism Spectrum Conditions (SBQ-ASC). The adapted tool was refined through nine interviews, and an online survey with 251 autistic adults, to establish clarity and relevance of the items. Subsequently, 308 autistic, 113 possibly autistic, and 268 non-autistic adults completed the adapted tool online, alongside self-report measures of autistic traits (AQ), camouflaging autistic traits (CAT-Q), depression (PHQ-9), anxiety (ASA-A), thwarted belongingness and perceived burdensomeness (INQ-15), lifetime non-suicidal self-injury, and the original version of the suicidality assessment tool (SBQ-R). Analyses explored the appropriateness and measurement properties of the adapted tool between the groups. RESULTS There was evidence in support of content validity, structural validity, internal consistency, convergent and divergent validity, test-retest validity, sensitivity and specificity (for distinguishing those with or without lifetime experience of suicide attempt), and hypothesis testing of the adapted tool (SBQ-ASC) in each group. The structure of the SBQ-ASC was equivalent between autistic and possibly autistic adults, regardless of gender, or use of visual aids to help quantify abstract rating scales. LIMITATIONS The samples involved in the development and validation of the adapted tool were largely female, and largely diagnosed as autistic in adulthood, which limits the generalisability of results to the wider autistic population. The SBQ-ASC has been developed for use in research and is not recommended to assess risk of future suicide attempts and/or self-harm. The SBQ-ASC has been designed with and for autistic and possibly autistic adults, and is not appropriate to compare to non-autistic adults given measurement differences between these groups. CONCLUSIONS The SBQ-ASC is a brief self-report suicidality assessment tool, developed and validated with and for autistic adults, without co-occurring intellectual disability. The SBQ-ASC is appropriate for use in research to identify suicidal thoughts and behaviours in autistic and possibly autistic people, and model associations with risk and protective factors.
Collapse
Affiliation(s)
- Sarah A Cassidy
- School of Psychology, University of Nottingham, University Park, Nottingham, NG7 2RD, UK.
| | - Louise Bradley
- The International Centre, University of Bedfordshire, Luton, UK
| | - Heather Cogger-Ward
- School of Psychology, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
- School of Psychology, University of Lincoln, Lincoln, UK
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | - Jacqui Rodgers
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
12
|
Predicting self-harm within six months after initial presentation to youth mental health services: A machine learning study. PLoS One 2020; 15:e0243467. [PMID: 33382713 PMCID: PMC7775066 DOI: 10.1371/journal.pone.0243467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A priority for health services is to reduce self-harm in young people. Predicting self-harm is challenging due to their rarity and complexity, however this does not preclude the utility of prediction models to improve decision-making regarding a service response in terms of more detailed assessments and/or intervention. The aim of this study was to predict self-harm within six-months after initial presentation. METHOD The study included 1962 young people (12-30 years) presenting to youth mental health services in Australia. Six machine learning algorithms were trained and tested with ten repeats of ten-fold cross-validation. The net benefit of these models were evaluated using decision curve analysis. RESULTS Out of 1962 young people, 320 (16%) engaged in self-harm in the six months after first assessment and 1642 (84%) did not. The top 25% of young people as ranked by mean predicted probability accounted for 51.6% - 56.2% of all who engaged in self-harm. By the top 50%, this increased to 82.1%-84.4%. Models demonstrated fair overall prediction (AUROCs; 0.744-0.755) and calibration which indicates that predicted probabilities were close to the true probabilities (brier scores; 0.185-0.196). The net benefit of these models were positive and superior to the 'treat everyone' strategy. The strongest predictors were (in ranked order); a history of self-harm, age, social and occupational functioning, sex, bipolar disorder, psychosis-like experiences, treatment with antipsychotics, and a history of suicide ideation. CONCLUSION Prediction models for self-harm may have utility to identify a large sub population who would benefit from further assessment and targeted (low intensity) interventions. Such models could enhance health service approaches to identify and reduce self-harm, a considerable source of distress, morbidity, ongoing health care utilisation and mortality.
Collapse
|
13
|
Taylor AK, Steeg S, Quinlivan L, Gunnell D, Hawton K, Kapur N. Accuracy of individual and combined risk-scale items in the prediction of repetition of self-harm: multicentre prospective cohort study. BJPsych Open 2020; 7:e2. [PMID: 33261707 PMCID: PMC7791570 DOI: 10.1192/bjo.2020.123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/18/2020] [Accepted: 09/29/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide. AIMS To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items. METHOD We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression. RESULTS A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43-0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations. CONCLUSIONS No individual or combination of items outperformed patients' or clinicians' ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.
Collapse
Affiliation(s)
- Anna Kathryn Taylor
- Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Sarah Steeg
- Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Leah Quinlivan
- Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, UK; and NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| | - David Gunnell
- Department of Population Health Sciences, University of Bristol, UK
| | - Keith Hawton
- Centre for Suicide Research University Department of Psychiatry, Warneford Hospital, UK; and Oxford Health NHS Foundation Trust, Warneford Hospital, UK
| | - Nav Kapur
- Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, UK; and NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, UK
| |
Collapse
|
14
|
Graney J, Hunt IM, Quinlivan L, Rodway C, Turnbull P, Gianatsi M, Appleby L, Kapur N. Suicide risk assessment in UK mental health services: a national mixed-methods study. Lancet Psychiatry 2020; 7:1046-1053. [PMID: 33189221 DOI: 10.1016/s2215-0366(20)30381-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/30/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Risk assessments are a central component of mental health care. Few national studies have been done in the UK on risk assessment tools used in mental health services. We aimed to examine which suicide risk assessment tools are in use in the UK; establish the views of clinicians, carers, and service users on the use of these tools; and identify how risk assessment tools have been used with mental health patients before suicide. METHODS We did a mixed-methods study involving three components: collection and content analysis of risk assessment tools used by UK mental health services; an online survey of clinicians, service-users, and carers; and qualitative telephone interviews with clinicians on their use of risk assessment tools before a suicide death and their views of these tools. The online survey was advertised through the National Confidential Inquiry into Suicide and Safety in Mental Health's (NCISH) website and social media, and it included both quantitative and open-ended qualitative questions, and respondents were recruited through convenience sampling. For the telephone interviews, we examined the NCISH database to identify clinicians who had been responsible for the care of a patient who died by suicide and who had been viewed as being at low or no immediate risk of suicide. FINDINGS We obtained 156 risk assessment tools from all 85 National Health Service mental health organisations in the UK, and 85 (one per each organisation) were included in the analysis. We found little consistency in use of these instruments, with 33 (39%) of 85 organisations using locally developed tools. Most tools aimed to predict self-harm or suicidal behaviour (84 [99%] of 85), and scores were used to determine management decisions (80 [94%]). Clinicians described positive aspects of risk tools (facilitating communication and enhancing therapeutic relationships) but also expressed negative views (inadequate training in the use of tools and their time-consuming nature). Both patients and carers reported some positive views, but also emphasised little involvement during risk assessment, and a lack of clarity on what to do in a crisis. INTERPRETATION Assessment processes need to be consistent across mental health services and include adequate training on how to assess, formulate, and manage suicide risk. An emphasis on patient and carer involvement is needed. In line with national guidance, risk assessment should not be seen as a way to predict future behaviour and should not be used as a means of allocating treatment. Management plans should be personalised and collaboratively developed with patients and their families and carers. FUNDING The Healthcare Quality Improvement Partnership.
Collapse
Affiliation(s)
- Jane Graney
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK.
| | - Isabelle M Hunt
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Leah Quinlivan
- National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Manchester, UK
| | - Cathryn Rodway
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Pauline Turnbull
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Myrsini Gianatsi
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Louis Appleby
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK
| | - Nav Kapur
- National Confidential Inquiry into Suicide and Safety in Mental Health, Centre for Mental Health and Safety, School of Health Sciences, University of Manchester, Manchester, UK; National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre, Manchester, UK; Greater Manchester Mental Health National Health Service Foundation Trust, Manchester, UK
| |
Collapse
|
15
|
Leather JZ, O'Connor RC, Quinlivan L, Kapur N, Campbell S, Armitage CJ. Healthcare professionals' implementation of national guidelines with patients who self-harm. J Psychiatr Res 2020; 130:405-411. [PMID: 32891028 PMCID: PMC7450264 DOI: 10.1016/j.jpsychires.2020.08.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/22/2020] [Accepted: 08/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND National guidelines for the short-term management of self-harm are aimed at healthcare professionals who may be involved in the care of people who have self-harmed. However, evidence from small-scale studies globally suggest there is a lack of awareness of such guidelines among some groups of healthcare professionals. For the first time in a large representative sample of patient-facing healthcare professionals, we aimed to identify: (a) which healthcare professionals are aware of guidelines for the management of self-harm; (b) the perceived availability of training; (c) the use of risk screening tools; and (d) the extent to which healthcare professionals implement guidelines for the management of self-harm. METHODS 1020 UK healthcare professionals completed a cross-sectional survey online. RESULTS 85.6% (873/1020) of the sample had heard of the national guidelines, but only 24.3% (248/1020) knew "a fair amount" or more about them. Of the respondents who had previously encountered a patient who had self-harmed or was at risk of repeat self-harm, the guidelines were implemented in fewer than 50% (M = 43.89%, SD = 38.79) of encounters. 31% (312/1020) of the sample had received training in managing self-harm and, contrary to guidelines, 2.25% (23/1020) of the sample had used self-harm risk screening tools. CONCLUSIONS Our findings highlight a need to improve knowledge of self-harm management guidelines, and identifies professional groups where awareness and knowledge is currently low. Further work is required to develop interventions to change healthcare professional practice with respect to the implementation of self-harm management guidelines.
Collapse
Affiliation(s)
- Jessica Z Leather
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK; Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland 1, Oxford Road, Manchester, M13 9PL, UK.
| | - Rory C O'Connor
- Suicidal Behaviour Research Laboratory, Institute of Health & Wellbeing, University of Glasgow, Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow, G12 0XH, UK
| | - Leah Quinlivan
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK; Centre for Mental Health and Safety, University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Navneet Kapur
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK; Centre for Mental Health and Safety, University of Manchester, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK; Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK
| | - Christopher J Armitage
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK; Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Coupland 1, Oxford Road, Manchester, M13 9PL, UK; Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Oxford Road, Manchester, M13 9PL, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, The Nowgen Centre, 29 Grafton Street, Manchester, M13 9WL, UK
| |
Collapse
|
16
|
Brown S, Iqbal Z, Burbidge F, Sajjad A, Reeve M, Ayres V, Melling R, Jobes D. Embedding an Evidence-Based Model for Suicide Prevention in the National Health Service: A Service Improvement Initiative. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144920. [PMID: 32650466 PMCID: PMC7399800 DOI: 10.3390/ijerph17144920] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 12/11/2022]
Abstract
Despite the improved understanding of the determinants of suicide over recent decades, the mean suicide rate within the United Kingdom (UK) has remained at 10 per 100,000 per annum, with about 28% accessing mental health services in the 12 months prior to death. In this paper, we outlined a novel systems-level approach to tackling this problem through objectively differentiating the level of severity for each suicide risk presentation and providing fast-track pathways to care for all, including life-threatening cases. An additional operational challenge addressed within the proposed model was the saturation of local crisis mental health services with approximately 150 suicidality referrals per month, including non-mental health cases. This paper discussed a service improvement initiative undertaken within a National Health Service (NHS) secondary care mental health provider's open-access 24/7 crisis and home treatment service. An organisation-wide bespoke "suicide risk triage" system utilising the Collaborative Assessment and Management of Suicidality (CAMS) was implemented across all services. The preliminary impacts on suicidality, suicide rates and service user outcomes were described.
Collapse
Affiliation(s)
- Sophie Brown
- Department of Psychology, Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK; (S.B.); (F.B.)
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
| | - Zaffer Iqbal
- Department of Psychology, Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK; (S.B.); (F.B.)
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
- Correspondence: ; Tel.: +44-1472-806800
| | - Frances Burbidge
- Department of Psychology, Faculty of Health Sciences, University of Hull, Hull HU6 7RX, UK; (S.B.); (F.B.)
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
| | - Aamer Sajjad
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
| | - Mike Reeve
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
| | - Victoria Ayres
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
| | - Richard Melling
- NAViGO Health and Social Care Community Interest Company, Grimsby DN32 0QE, UK; (A.S.); (M.R.); (V.A.); (R.M.)
| | - David Jobes
- Department of Psychology, School of Arts and Sciences, Clinical Psychology Faculty, The Catholic University of America, Washington, DC 20064, USA;
| |
Collapse
|
17
|
Senior M, Burghart M, Yu R, Kormilitzin A, Liu Q, Vaci N, Nevado-Holgado A, Pandit S, Zlodre J, Fazel S. Identifying Predictors of Suicide in Severe Mental Illness: A Feasibility Study of a Clinical Prediction Rule (Oxford Mental Illness and Suicide Tool or OxMIS). Front Psychiatry 2020; 11:268. [PMID: 32351413 PMCID: PMC7175991 DOI: 10.3389/fpsyt.2020.00268] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/19/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Oxford Mental Illness and Suicide tool (OxMIS) is a brief, scalable, freely available, structured risk assessment tool to assess suicide risk in patients with severe mental illness (schizophrenia-spectrum disorders or bipolar disorder). OxMIS requires further external validation, but a lack of large-scale cohorts with relevant variables makes this challenging. Electronic health records provide possible data sources for external validation of risk prediction tools. However, they contain large amounts of information within free-text that is not readily extractable. In this study, we examined the feasibility of identifying suicide predictors needed to validate OxMIS in routinely collected electronic health records. METHODS In study 1, we manually reviewed electronic health records of 57 patients with severe mental illness to calculate OxMIS risk scores. In study 2, we examined the feasibility of using natural language processing to scale up this process. We used anonymized free-text documents from the Clinical Record Interactive Search database to train a named entity recognition model, a machine learning technique which recognizes concepts in free-text. The model identified eight concepts relevant for suicide risk assessment: medication (antidepressant/antipsychotic treatment), violence, education, self-harm, benefits receipt, drug/alcohol use disorder, suicide, and psychiatric admission. We assessed model performance in terms of precision (similar to positive predictive value), recall (similar to sensitivity) and F1 statistic (an overall performance measure). RESULTS In study 1, we estimated suicide risk for all patients using the OxMIS calculator, giving a range of 12 month risk estimates from 0.1-3.4%. For 13 out of 17 predictors, there was no missing information in electronic health records. For the remaining 4 predictors missingness ranged from 7-26%; to account for these missing variables, it was possible for OxMIS to estimate suicide risk using a range of scores. In study 2, the named entity recognition model had an overall precision of 0.77, recall of 0.90 and F1 score of 0.83. The concept with the best precision and recall was medication (precision 0.84, recall 0.96) and the weakest were suicide (precision 0.37), and drug/alcohol use disorder (recall 0.61). CONCLUSIONS It is feasible to estimate suicide risk with the OxMIS tool using predictors identified in routine clinical records. Predictors could be extracted using natural language processing. However, electronic health records differ from other data sources, particularly for family history variables, which creates methodological challenges.
Collapse
Affiliation(s)
- Morwenna Senior
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Matthias Burghart
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Rongqin Yu
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | | | - Qiang Liu
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Nemanja Vaci
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | | | - Smita Pandit
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Jakov Zlodre
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
18
|
Kessler RC, Bossarte RM, Luedtke A, Zaslavsky AM, Zubizarreta JR. Suicide prediction models: a critical review of recent research with recommendations for the way forward. Mol Psychiatry 2020; 25:168-179. [PMID: 31570777 PMCID: PMC7489362 DOI: 10.1038/s41380-019-0531-0] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 09/04/2019] [Accepted: 09/17/2019] [Indexed: 12/26/2022]
Abstract
Suicide is a leading cause of death. A substantial proportion of the people who die by suicide come into contact with the health care system in the year before their death. This observation has resulted in the development of numerous suicide prediction tools to help target patients for preventive interventions. However, low sensitivity and low positive predictive value have led critics to argue that these tools have no clinical value. We review these tools and critiques here. We conclude that existing tools are suboptimal and that improvements, if they can be made, will require developers to work with more comprehensive predictor sets, staged screening designs, and advanced statistical analysis methods. We also conclude that although existing suicide prediction tools currently have little clinical value, and in some cases might do more harm than good, an even-handed assessment of the potential value of refined tools of this sort cannot currently be made because such an assessment would depend on evidence that currently does not exist about the effectiveness of preventive interventions. We argue that the only way to resolve this uncertainty is to link future efforts to develop or evaluate suicide prediction tools with concrete questions about specific clinical decisions aimed at reducing suicides and to evaluate the clinical value of these tools in terms of net benefit rather than sensitivity or positive predictive value. We also argue for a focus on the development of individualized treatment rules to help select the right suicide-focused treatments for the right patients at the right times. Challenges will exist in doing this because of the rarity of suicide even among patients considered high-risk, but we offer practical suggestions for how these challenges can be addressed.
Collapse
Affiliation(s)
- Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
| | - Robert M Bossarte
- West Virginia University Injury Control Research Center and Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, WV, USA
- West Virginia and VISN 2 Center of Excellence for Suicide Prevention, Canandaigua, NY, USA
| | - Alex Luedtke
- Department of Statistics, University of Washington, Seattle, WA, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Alan M Zaslavsky
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Jose R Zubizarreta
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Statistics, Harvard University, Cambridge, MA, USA
| |
Collapse
|
19
|
Harris IM, Beese S, Moore D. Predicting future self-harm or suicide in adolescents: a systematic review of risk assessment scales/tools. BMJ Open 2019; 9:e029311. [PMID: 31494608 PMCID: PMC6731844 DOI: 10.1136/bmjopen-2019-029311] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE This systematic review aimed to evaluate the ability of risk tools to predict the future episodes of suicide/self-harm in adolescents. DESIGN Systematic review. DATA SOURCES MEDLINE, EMBASE, CINAHL and PsycINFO were searched from inception to 3 March 2018. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Cohort studies, case-control studies and randomised controlled trials of adolescents aged 10-25 who had undergone risk assessment in a clinical setting following an episode of self-harm were included. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. Data were grouped by tool and narrative synthesis undertaken, with studies appraised using a checklist combining the QUIPS (Quality In Prognosis Studies) and QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies) tools. RESULTS Of the 17 137 articles initially identified, 11 studies evaluating 10 separate tools were included. The studies varied in setting, population and outcome measure. The majority of the studies were rated as having an unclear risk of bias, and meta-analysis was not possible due to high variability between studies.The ability of the tools to correctly identify those adolescents going on to make a self-harm/suicide attempt ranged from 27% (95% CI 10.7% to 50.2%) to 95.8% (95% CI 78.9% to 99.9%). A variety of metrics were provided for 1-10 points increases in various tools, for example, odds and HRs. CONCLUSIONS This systematic review is the first to explore the use of assessment tools in adolescents. The predictive ability of these tools varies greatly. No single tool is suitable for predicting a higher risk of suicide or self-harm in adolescent populations. PROSPERO REGISTRATION NUMBER CRD42017058686.
Collapse
Affiliation(s)
| | - Sophie Beese
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David Moore
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| |
Collapse
|
20
|
Affiliation(s)
- Gregory Carter
- 1 Centre for Brain and Mental Health Research, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Matthew J Spittal
- 2 Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
21
|
McClatchey K, Murray J, Chouliara Z, Rowat A. Protective Factors of Suicide and Suicidal Behavior Relevant to Emergency Healthcare Settings: A Systematic Review and Narrative Synthesis of Post-2007 Reviews. Arch Suicide Res 2019; 23:411-427. [PMID: 30024351 DOI: 10.1080/13811118.2018.1480983] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Suicide is a major public health concern and, with recent societal changes, such as economic and technological changes, there may be emerging protective factors that mitigate suicide risk that are unrecognized in emergency healthcare. This systematic review aims to identify protective factors for suicide that can feasibly be assessed in time-limited emergency healthcare settings. A systematic review of reviews was conducted via PsycINFO, CINAHL and Medline (2007-2015). Reviews were assessed for methodological quality using AMSTAR. A total of 24 reviews met the inclusion criteria and 8 were assessed as high quality and included in a narrative synthesis. Known protective factors were identified (e.g., social support), along with emerging protective factors (e.g., internet support). The review synthesizes recent research evidence on protective factors and discusses their relevance to emergency healthcare.
Collapse
Affiliation(s)
- Kirstie McClatchey
- a Edinburgh Napier University , Edinburgh , United Kingdom of Great Britain and Northern Ireland
| | - Jennifer Murray
- a Edinburgh Napier University , Edinburgh , United Kingdom of Great Britain and Northern Ireland
| | - Zoë Chouliara
- a Edinburgh Napier University , Edinburgh , United Kingdom of Great Britain and Northern Ireland
| | - Anne Rowat
- a Edinburgh Napier University , Edinburgh , United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
22
|
Ebert DD, Franke M, Kählke F, Küchler A, Bruffaerts R, Mortier P, Karyotaki E, Alonso J, Cuijpers P, Berking M, Auerbach RP, Kessler RC, Baumeister H. Increasing intentions to use mental health services among university students. Results of a pilot randomized controlled trial within the World Health Organization's World Mental Health International College Student Initiative. Int J Methods Psychiatr Res 2019; 28:e1754. [PMID: 30456814 PMCID: PMC6877244 DOI: 10.1002/mpr.1754] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 09/28/2018] [Accepted: 10/12/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The majority of university students with mental health problems are untreated. Only a small empirical literature exists on strategies to increase mental health service use. AIMS To investigate the effects and moderators of a brief acceptance-facilitating intervention on intention to use mental health services among university students. METHOD Within the German site of the World Health Organization's World Mental Health International College Student (WMH-ICS) initiative, 1,374 university students were randomized to an intervention condition (IC; n = 664) or a control condition (CC; n = 710) that was implemented in the survey itself. Both conditions received the questions assessing mental disorders and suicidality that were included in other WMH-ICS surveys. The IC group then additionally received: Internet-based personalized feedback based on subject symptom severity in the domains of depression, anxiety, substance use, suicidal thoughts and behaviors, and nonsuicidal self-injury; psychoeducation tailored to the personal symptom profile; and information about available university and community mental health services. The primary outcome was reported intention to use psychological interventions in the next semester, which was the last question in the survey. A broad range of potential moderating factors was explored. RESULTS There was a significant main effect of the intervention with students randomized to IC, reporting significantly higher intentions to seek help in the next semester than students in the CC condition (d = 0.12, 95% CI: 0.02 to 0.23). Moderator analyses indicated that the intervention was more effective among students that fulfilled the criteria for lifetime (d = 0.34; 95% CI: -0.08 to 0.7) and 12-month panic-disorder (d = 0.32; 95% CI: -0.10 to 0.74) compared with those without lifetime (d = 0.11; 95% CI: 0.00 to 0.22) or 12-month panic disorder (d = 0.11; 95% CI: 0.00 to 0.22), students with lower (d = 0.37; 95% CI: -0.77 to 1.51) than higher (d = -0.01; 95% CI: -0.36 to 0.34) self-reported physical health, and students with nonheterosexual (d = 0.38; 95% CI: 0.08 to 0.67) compared with heterosexual (d = 0.06; 95% CI: -0.06 to 0.17) sexual orientation. The intervention had no effects among students who reported that they recognized that they had an emotional problem and "are already working actively to change it" (Stage 4 "stages of change"). CONCLUSIONS A simple acceptance-facilitating intervention can increase intention to use mental health services, although effects, are on average, small. Future studies should investigate more personalized approaches with interventions tailored to barriers and clinical characteristics of students. In order to optimize intervention effects, the development and evaluation should be realized in designs that are powered to allow incremental value of different intervention components and tailoring strategies to be evaluated, such as in multiphase optimization designs.
Collapse
Affiliation(s)
- David Daniel Ebert
- Department of Clinical Psychology and PsychotherapyUniversity of Erlangen‐NurembergErlangenGermany
| | - Marvin Franke
- Department of Clinical Psychology and PsychotherapyUniversity of Erlangen‐NurembergErlangenGermany
| | - Fanny Kählke
- Department of Clinical Psychology and PsychotherapyUniversity of Erlangen‐NurembergErlangenGermany
| | - Ann‐Marie Küchler
- Department for Clinical Psychology and PsychotherapyUlm UniversityUlmGermany
| | - Ronny Bruffaerts
- Public Health PsychiatryKU Leuven; Universitair Psychiatrisch Centrum KU LeuvenLeuvenBelgium
| | - Philippe Mortier
- Research Group Psychiatry, Department of NeurosciencesKU Leuven UniversityLeuvenBelgium
| | - Eirini Karyotaki
- Department of Clinical PsychologyVU Amsterdam and Amsterdam Public Health InstituteAmsterdamThe Netherlands
| | - Jordi Alonso
- Health Services Research UnitIMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain; Pompeu Fabra University (UPF), Barcelona, Spain; CIBER en Epidemiología y Salud Pública (CIBERESP)MadridSpain
| | - Pim Cuijpers
- Department of Clinical PsychologyVU Amsterdam and Amsterdam Public Health InstituteAmsterdamThe Netherlands
| | - Matthias Berking
- Department of Clinical Psychology and PsychotherapyUniversity of Erlangen‐NurembergErlangenGermany
| | - Randy P. Auerbach
- Department of PsychiatryColumbia University, New York, USA; Division of Clinical Developmental Neuroscience, Sackler InstituteNew YorkNew York
| | - Ronald C. Kessler
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusetts
| | - Harald Baumeister
- Department for Clinical Psychology and PsychotherapyUlm UniversityUlmGermany
| | | |
Collapse
|
23
|
Abstract
It is widely believed that suicide prevention involves the consideration of risk and protective factors and related interventions. Preventative interventions can be classified as “universal” (targeting whole populations), “selective” (targeting higher-risk groups), and “indicated” (protecting individuals). This review explores the range of preventative measures that might be used commensurately with different types of suicide prediction. The author concludes that the best prospects for suicide prevention lie in universal prevention strategies. While risk assessments do generate some information about future suicide, suicide risk categorization results in an unacceptably high false positive rate, misses many fatalities, and therefore, is unable to usefully guide prevention strategies. The assessment of suicidal patients should focus on contemporaneous factors and the needs of the patient, rather than probabilistic notions of suicide risk.
Collapse
Affiliation(s)
- Matthew Michael Large
- Mental Health Services, The Prince of Wales Hospitals, Barker Street, Randwick, NSW, 2031, Australia
| |
Collapse
|
24
|
Quinlivan L, Steeg S, Elvidge J, Nowland R, Davies L, Hawton K, Gunnell D, Kapur N. Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis. J Affect Disord 2019; 249:208-215. [PMID: 30772749 DOI: 10.1016/j.jad.2019.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/16/2019] [Accepted: 02/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Risk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk. METHOD Quality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions. RESULTS The formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0-£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk. LIMITATIONS Our primary model depended on the assumption that high-intensity care reduced patients' risk of further self-harm. CONCLUSION The use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities.
Collapse
Affiliation(s)
- Leah Quinlivan
- NIHR Greater Manchester Patient Safety Translational Research Centre, United Kingdom; Centre for Mental Health and Safety, University of Manchester, Jean McFarlane Building Oxford Road, Manchester M13 9PL, United Kingdom.
| | - Sarah Steeg
- Centre for Mental Health and Safety, University of Manchester, Jean McFarlane Building Oxford Road, Manchester M13 9PL, United Kingdom.
| | - Jamie Elvidge
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, United Kingdom
| | - Rebecca Nowland
- Centre for Mental Health and Safety, University of Manchester, Jean McFarlane Building Oxford Road, Manchester M13 9PL, United Kingdom
| | - Linda Davies
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, United Kingdom
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom
| | - David Gunnell
- School of Social and Community Medicine, University of Bristol, United Kingdom; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, United Kingdom
| | - Nav Kapur
- NIHR Greater Manchester Patient Safety Translational Research Centre, United Kingdom; Centre for Mental Health and Safety, University of Manchester, Jean McFarlane Building Oxford Road, Manchester M13 9PL, United Kingdom; Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| |
Collapse
|
25
|
Harris IM, Beese S, Moore D. Predicting repeated self-harm or suicide in adolescents and young adults using risk assessment scales/tools: a systematic review protocol. Syst Rev 2019; 8:87. [PMID: 30947743 PMCID: PMC6449918 DOI: 10.1186/s13643-019-1007-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/25/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Self-harm and suicide have been identified as serious public health problems in children, adolescents, and young people across the world. Suicide is a major cause of mortality in this population and is commonly preceded by self-harm. Both suicide and self-harm are difficult to predict, and several risk scales and tools are in use for this purpose. Currently, there is only a small amount of evidence available regarding their predictive ability in clinical practice, and no consensus as to which is the most suitable for particular populations or settings. The aim of this review is to evaluate the ability of risk scales to predict future episodes of suicide or self-harm in adolescents and young adults presenting to clinical services with attempted suicide or an episode of self-harm. METHODS A comprehensive search of electronic databases (MEDLINE, EMBASE, CINAHL, and PsycINFO) from inception will be conducted to identify studies that look at the ability of risk scales to predict suicide or future episodes of self-harm in adolescents and young adults presenting to clinical services with attempted suicide or an episode of self-harm. Two authors will independently carry out key methodological steps such as study screening and selection and data extraction. Quality assessment will be carried out using a checklist developed from the QUIPS and QUADAS-2 tools. Data will be grouped by tool and a narrative synthesis undertaken. For each tool, meta-analysis will be undertaken for ability to predict suicide or repeat self-harm where clinical and methodological homogeneity exists. DISCUSSION This systematic review will be the first to explore the use of assessment scales/tools in an adolescent population and will help to inform current practice regarding scales/tools with higher predictive ability. There is currently no evidence specifically for this population and a clear need with a high prevalence of self-harm and suicide in adolescents. Additionally, this review will help guide future research into suicide and self-harm prediction and prevention. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017058686.
Collapse
Affiliation(s)
- Isobel Marion Harris
- Institute of Applied Health Research, Public Health Building, University of Birmingham, Birmingham, B15 2TT UK
| | - Sophie Beese
- Institute of Applied Health Research, Public Health Building, University of Birmingham, Birmingham, B15 2TT UK
| | - David Moore
- Institute of Applied Health Research, Public Health Building, University of Birmingham, Birmingham, B15 2TT UK
| |
Collapse
|
26
|
McClatchey K, Murray J, Chouliara Z, Rowat A, Hauge SR. Suicide risk assessment in the emergency department: An investigation of current practice in Scotland. Int J Clin Pract 2019; 73:e13342. [PMID: 30859674 DOI: 10.1111/ijcp.13342] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/08/2019] [Accepted: 03/08/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Suicide is a global public health issue. Approximately one third of individuals who complete suicide have attended an emergency department in the year preceding their death. The aim of this study was to investigate current suicide risk assessment practices across emergency department clinicians in Scotland. METHODS A mixed-methods design was employed. A total of 112 surveys for emergency department clinicians were posted to 23 emergency departments in Scotland between March and September 2016. Follow-up semi-structured interviews were also conducted exploring clinician's experiences of suicide risk assessment. Interviews were analysed using thematic analysis. RESULTS Fifty-one emergency department clinicians across 17 emergency departments completed the survey. Thirty-five (68.6%) participants were currently using a suicide risk assessment tool; with most using locally developed tools and proformas (n = 20, 62.5%) or the SAD PERSONS scale (n = 13, 40.6%). Remaining participants (n = 16, 31.4%) did not use suicide risk assessment tools during assessment. Variation in practice was found both across and within emergency departments. Six clinicians participated in follow-up interviews, which identified four major themes: Clinician Experiences of Suicide Risk Assessment; Components of Suicide Risk Assessment; Clinical Decision-Making; and Supporting Clinicians. CONCLUSIONS There is substantial variation in current practice, with around two-thirds of clinicians using a variety of empirically and locally developed tools, and a third using their judgement alone. Clinicians find suicide risk assessment a challenging part of their role and discuss the need for increased training, and appropriate and helpful guidelines to improve practice.
Collapse
Affiliation(s)
- Kirstie McClatchey
- Usher Institute of Population Health Sciences & Informatics, University of Edinburgh, Edinburgh, UK
| | - Jennifer Murray
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Zoë Chouliara
- School of Social and Health Sciences, Abertay University, Dundee, UK
| | - Anne Rowat
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Samantha R Hauge
- Faculty of Arts and Social Sciences, The Open University, Milton Keynes, UK
| |
Collapse
|
27
|
Fazel S, Wolf A, Larsson H, Mallett S, Fanshawe TR. The prediction of suicide in severe mental illness: development and validation of a clinical prediction rule (OxMIS). Transl Psychiatry 2019; 9:98. [PMID: 30804323 PMCID: PMC6389890 DOI: 10.1038/s41398-019-0428-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/19/2019] [Accepted: 01/27/2019] [Indexed: 12/24/2022] Open
Abstract
Assessment of suicide risk in individuals with severe mental illness is currently inconsistent, and based on clinical decision-making with or without tools developed for other purposes. We aimed to develop and validate a predictive model for suicide using data from linked population-based registers in individuals with severe mental illness. A national cohort of 75,158 Swedish individuals aged 15-65 with a diagnosis of severe mental illness (schizophrenia-spectrum disorders, and bipolar disorder) with 574,018 clinical patient episodes between 2001 and 2008, split into development (58,771 patients, 494 suicides) and external validation (16,387 patients, 139 suicides) samples. A multivariable derivation model was developed to determine the strength of pre-specified routinely collected socio-demographic and clinical risk factors, and then tested in external validation. We measured discrimination and calibration for prediction of suicide at 1 year using specified risk cut-offs. A 17-item clinical risk prediction model for suicide was developed and showed moderately good measures of discrimination (c-index 0.71) and calibration. For risk of suicide at 1 year, using a pre-specified 1% cut-off, sensitivity was 55% (95% confidence interval [CI] 47-63%) and specificity was 75% (95% CI 74-75%). Positive and negative predictive values were 2% and 99%, respectively. The model was used to generate a simple freely available web-based probability-based risk calculator (Oxford Mental Illness and Suicide tool or OxMIS) without categorical cut-offs. A scalable prediction score for suicide in individuals with severe mental illness is feasible. If validated in other samples and linked to effective interventions, using a probability score may assist clinical decision-making.
Collapse
Affiliation(s)
- Seena Fazel
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK.
| | - Achim Wolf
- 0000 0004 1936 8948grid.4991.5Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Henrik Larsson
- 0000 0004 1937 0626grid.4714.6Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden ,0000 0001 0738 8966grid.15895.30School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Susan Mallett
- 0000 0004 1936 7486grid.6572.6School of Population and Health Sciences, University of Birmingham, Birmingham, UK
| | - Thomas R. Fanshawe
- 0000 0004 1936 8948grid.4991.5Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
28
|
Woodford R, Spittal MJ, Milner A, McGill K, Kapur N, Pirkis J, Mitchell A, Carter G. Accuracy of Clinician Predictions of Future Self-Harm: A Systematic Review and Meta-Analysis of Predictive Studies. Suicide Life Threat Behav 2019; 49:23-40. [PMID: 28972271 DOI: 10.1111/sltb.12395] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022]
Abstract
Assessment of a patient after hospital-treated self-harm or psychiatric hospitalization often includes a risk assessment, resulting in a classification of high risk versus low risk for a future episode of self-harm. Through systematic review and a series of meta-analyses looking at unassisted clinician risk classification (eight studies; N = 22,499), we found pooled estimates for sensitivity 0.31 (95% CI: 0.18-0.50), specificity 0.85 (0.75-0.92), positive predictive value 0.22 (0.21-0.23), and negative predictive value 0.89 (0.86-0.92). Clinician classification was too inaccurate to be clinically useful. After-care should therefore be allocated on the basis of a needs rather than risk assessment.
Collapse
Affiliation(s)
- Rachel Woodford
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, NSW, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Allison Milner
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Katie McGill
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, NSW, Australia.,Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
| | - Navneet Kapur
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - Jane Pirkis
- Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | - Alex Mitchell
- Cancer Studies & Molecular Medicine, University of Leicester, Leicester, UK
| | - Gregory Carter
- Centre for Brain and Mental Health Research, University of Newcastle, Newcastle, NSW, Australia
| |
Collapse
|
29
|
Horton MC, Dyer W, Tennant A, Wright NMJ. Assessing the predictability of self-harm in a high-risk adult prisoner population: a prospective cohort study. HEALTH & JUSTICE 2018; 6:18. [PMID: 30242541 PMCID: PMC6755554 DOI: 10.1186/s40352-018-0076-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 09/06/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Prisoners are at increased risk of self-harm and when either intent is expressed, or an act of self-harm carried out, prisoners in the UK are subject to self-harm/suicide monitoring (referred to as "open ACCT" monitoring). However, there is a paucity of validated instruments to identify risk of self-harm in prisoner populations. In response to the need to support prison staff to determine who is at increased risk of self-harm or repeat self-harm, the aim of this study was to determine whether any pre-existing, standardised instruments could usefully identify future self-harm events in prisoners undergoing ACCT monitoring. METHODS A multi-stage prospective cohort study was conducted, where the Prison Screening Questionnaire (PriSnQuest), a modified Borderline Symptom List-23 (BSL-23), Self-Harm Inventory (SHI), Patient Health Questionnaire-9 (PHQ-9) and Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) instruments were administered to prisoners aged 18 and above, who were judged to be at an increased risk of self-harm (on open ACCT monitoring) during the recruitment phase. A 6-month follow-up determined self-harm occurrence since baseline, and Area-Under-the-Curve (AUC) analysis examined the ability of the instruments to predict future self-harm. RESULTS Prison records established that 29.1% self-harmed during the follow up period, involving a total of 423 self-harm events reported from 126 individuals, followed up for 66,789 prisoner days (median 167 days; IQR 71-207.5 days). This translated to an 'event incidence' of 6.33 per 1000 prisoner days of those who had been placed upon an ACCT, or 'prisoner incidence' of 1.89 per 1000 days, with considerable variation for both gender and participating prisons. None of the summary scores derived from the selected instruments showed a meaningful ability to predict self-harm, however, exploratory logistic regression analysis of individual background and instrument items revealed gender-specific item sets which were statistically significant in predicting future self-harm. CONCLUSIONS Prospective self-harm was not predicted by any of the pre-existing instruments that were under consideration. Exploratory logistic regression analysis did reveal gender-specific item sets, producing predictive algorithms which were statistically significant in predicting future self-harm; however, the operational functionality of these item sets may be limited.
Collapse
Affiliation(s)
- Mike C. Horton
- Section of Rehabilitation Medicine, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Faculty of Medicine and Health, University of Leeds, D Floor, Martin Wing, LGI, LS1 3EX, Leeds, UK
| | - Wendy Dyer
- School of Arts and Social Sciences, Northumbria University, Lipman Building Room 216, Newcastle Upon Tyne, NE1 8ST UK
| | - Alan Tennant
- Swiss Paraplegic Research, Guido A. Zäch-Strasse 4, 6207 Nottwil, Switzerland
| | - Nat M. J. Wright
- Clinical Research Director Transform Research Alliance, Visiting Associate Professor Leeds University, Spectrum Community Health CIC, One Navigation Walk, Hebble Wharf, Wakefield, WF1 5RH UK
| |
Collapse
|
30
|
Pennel L, Quesada JL, Dematteis M. Neuroticism and anxious attachment as potential vulnerability factors of repeat suicide attempts. Psychiatry Res 2018; 264:46-53. [PMID: 29626831 DOI: 10.1016/j.psychres.2018.03.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 03/14/2018] [Accepted: 03/22/2018] [Indexed: 11/30/2022]
Abstract
The recurrence risk of suicide attempts can reach 50% in the first year, each attempt increasing suicide-risk by 32%. No screening tool efficiently identifies potential repeat suicide attempters who are too often regarded as borderline personality. Our aim was to identify individual and interpersonal psychopathological dimensions that could represent a vulnerability to repeat suicide attempts. Sixty first-time and repeat suicide attempters consecutively admitted in emergency rooms were compared for fundamental dimensions of personality, patterns of attachment, personality and mental disorders using standardized questionnaires. Confounding and significantly different factors were evaluated using univariate and multivariate logistic regressions. Repeat suicide attempters differed from first-attempters by higher neuroticism and anxious attachment. Combined in an 11-item measure, these two parameters identified a 3.99 times higher risk of repeat suicide attempt. These traits associated with the other two best predictors (non-suicidal self-injury history, current psychotropic drugs) provide a vulnerability model with better screening performance compared to each factor individually. Repeat suicide attempters have more psychological features impairing emotional stability and social interactions than first attempters. Cross-sectional study design, sample size, lack of independent sample and of fearful-avoidant attachment evaluation are the main limitations. The model needs to be validated in a prospective and controlled study.
Collapse
Affiliation(s)
- Lucie Pennel
- Univ. Grenoble Alpes, F-38042 Grenoble, France; CHU Grenoble Alpes, Department of Addiction Medicine, F-38043 Grenoble, France
| | - Jean-Louis Quesada
- CHU Grenoble Alpes, Clinical Investigation Center 1406, F-38043 Grenoble, France
| | - Maurice Dematteis
- Univ. Grenoble Alpes, F-38042 Grenoble, France; CHU Grenoble Alpes, Department of Addiction Medicine, F-38043 Grenoble, France.
| |
Collapse
|
31
|
Steeg S, Quinlivan L, Nowland R, Carroll R, Casey D, Clements C, Cooper J, Davies L, Knipe D, Ness J, O’Connor RC, Hawton K, Gunnell D, Kapur N. Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data. BMC Psychiatry 2018; 18:113. [PMID: 29699523 PMCID: PMC5921289 DOI: 10.1186/s12888-018-1693-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 04/16/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Risk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known. METHOD We compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months. RESULTS The episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24-29% and 9-12% respectively) and high specificity (76-77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm. CONCLUSIONS The scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.
Collapse
Affiliation(s)
- Sarah Steeg
- Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, Manchester, England.
| | - Leah Quinlivan
- 0000000121662407grid.5379.8Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Rebecca Nowland
- 0000000121662407grid.5379.8Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Robert Carroll
- 0000 0004 1936 7603grid.5337.2Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Deborah Casey
- 0000 0004 1936 8948grid.4991.5Centre for Suicide Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, England
| | - Caroline Clements
- 0000000121662407grid.5379.8Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Jayne Cooper
- 0000000121662407grid.5379.8Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, Manchester, England
| | - Linda Davies
- 0000000121662407grid.5379.8Institute of Population Health, University of Manchester, Manchester, England
| | - Duleeka Knipe
- 0000 0004 1936 7603grid.5337.2Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Jennifer Ness
- Centre for Self-harm and Suicide Prevention Research, Derbyshire Healthcare NHS Foundation Trust, Derby, England
| | - Rory C. O’Connor
- 0000 0001 2193 314Xgrid.8756.cSuicidal Behaviour Research Laboratory, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Keith Hawton
- 0000 0004 1936 8948grid.4991.5Centre for Suicide Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, England
| | - David Gunnell
- 0000 0004 1936 7603grid.5337.2Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - Nav Kapur
- 0000000121662407grid.5379.8Centre for Mental Health and Safety, Manchester Academic Health Science Centre, University of Manchester, Manchester, England ,Greater Manchester Mental Health NHS Foundation Trust, Manchester, England
| |
Collapse
|
32
|
Steeg S, Emsley R, Carr M, Cooper J, Kapur N. Routine hospital management of self-harm and risk of further self-harm: propensity score analysis using record-based cohort data. Psychol Med 2018; 48:315-326. [PMID: 28637535 DOI: 10.1017/s0033291717001702] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The care received by people presenting to hospital following self-harm varies and it is unclear how different types of treatment affect risk of further self-harm. METHOD Observational cohort data from the Manchester Self-Harm Project, UK, included 16 456 individuals presenting to an Emergency Department with self-harm between 2003 and 2011. Individuals were followed up for 12 months. We also used data from a smaller cohort of individuals presenting to 31 hospitals in England during a 3-month period in 2010/2011, followed up for 6 months. Propensity score (PS) methods were used to address observed confounding. Missing data were imputed using multiple imputation. RESULTS Following PS stratification, those who received a psychosocial assessment had a lower risk of repeat hospital attendance for self-harm than those who were not assessed [RR 0.87, 95% confidence interval (CI) 0.80-0.95]. The risk was reduced most among people less likely to be assessed. Following PS matching, we found no associations between risks of repeat self-harm and admission to a medical bed, referral to outpatient psychiatry or admission to a psychiatric bed. We did not find a relationship between psychosocial assessment and repeat self-harm in the 31 centre cohort. CONCLUSIONS This study shows the potential value of using novel statistical techniques in large mental health datasets to estimate treatment effects. We found that specialist psychosocial assessment may reduce the risk of repeat self-harm. This type of routine care should be provided for all individuals who present to hospital after self-harm, regardless of perceived risk.
Collapse
Affiliation(s)
- S Steeg
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - R Emsley
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - M Carr
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - J Cooper
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| | - N Kapur
- Division of Psychology and Mental Health,Centre for Suicide Prevention, University of Manchester, Manchester Academic Health Science Centre,Manchester,UK
| |
Collapse
|
33
|
Katz C, Randall JR, Sareen J, Chateau D, Walld R, Leslie WD, Wang J, Bolton JM. Predicting suicide with the SAD PERSONS scale. Depress Anxiety 2017; 34:809-816. [PMID: 28471534 DOI: 10.1002/da.22632] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 03/09/2017] [Accepted: 03/14/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Suicide is a major public health issue, and a priority requirement is accurately identifying high-risk individuals. The SAD PERSONS suicide risk assessment scale is widely implemented in clinical settings despite limited supporting evidence. This article aims to determine the ability of the SAD PERSONS scale (SPS) to predict future suicide in the emergency department. METHODS Five thousand four hundred sixty-two consecutive adults were seen by psychiatry consultation teams in two tertiary emergency departments with linkage to population-based administrative data to determine suicide deaths within 6 months, 1, and 5 years. RESULTS Seventy-seven (1.4%) individuals died by suicide during the study period. When predicting suicide at 12 months, medium- and high-risk scores on SPS had a sensitivity of 49% and a specificity of 60%; the positive and negative predictive values were 0.9 and 99%, respectively. Half of the suicides at both 6- and 12-month intervals were classified as low risk by SPS at index visit. The area under the curve at 12 months for the Modified SPS was 0.59 (95% confidence interval [CI] range 0.51-0.67). High-risk scores (compared to low risk) were significantly associated with death by suicide over the 5-year study period using the SPS (hazard ratio 2.49; 95% CI 1.34-4.61) and modified version (hazard ratio 2.29; 95% CI 1.24-2.29). CONCLUSIONS Although widely used in educational and clinical settings, these findings do not support the use of the SPS and Modified SPS to predict suicide in adults seen by psychiatric services in the emergency department.
Collapse
Affiliation(s)
- Cara Katz
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jason R Randall
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jitender Sareen
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dan Chateau
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada.,Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Randy Walld
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - William D Leslie
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - JianLi Wang
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - James M Bolton
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada.,Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
34
|
Quinlivan L, Cooper J, Meehan D, Longson D, Potokar J, Hulme T, Marsden J, Brand F, Lange K, Riseborough E, Page L, Metcalfe C, Davies L, O'Connor R, Hawton K, Gunnell D, Kapur N. Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. Br J Psychiatry 2017; 210:429-436. [PMID: 28302702 PMCID: PMC5451643 DOI: 10.1192/bjp.bp.116.189993] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 10/05/2016] [Accepted: 11/13/2016] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Leah Quinlivan
- Leah Quinlivan, PhD, Jayne Cooper, PhD, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, Manchester; Declan Meehan, RMN, Damien Longson, FRCPsych, Greater Manchester Mental Health and NHS Foundation Trust, Manchester; John Potokar, MRCPsych, Avon & Wiltshire Mental Health Foundation Trust, Bristol, University Hospitals Bristol, NHS Foundation Trust, Bristol and School of Social and Community Medicine, University of Bristol, Bristol; Tom Hulme, MSc, University Hospitals Bristol, NHS Foundation Trust, Bristol, Bristol; Jennifer Marsden, BA, Derbyshire Healthcare NHS Foundation Trust, Derby; Fiona Brand, RMN, Kezia Lange, MRCPsych, Oxford Health NHS Foundation Trust, Oxford; Elena Riseborough, RMN, Lisa Page, PhD, Sussex Partnership NHS Foundation Trust, Worthing; Chris Metcalfe, PhD, School of Social and Community Medicine, University of Bristol, Bristol; Linda Davies, Institute of Population Health, University of Manchester, Manchester; Rory O' Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow; Keith Hawton, DSc, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford; David Gunnell, DSc, School of Social and Community Medicine, University of Bristol, Bristol; Nav Kapur, MBChB, MMedSci, MD, FRCPsych, Centre for Suicide Prevention, Manchester Academic Health Science Centre, University of Manchester, and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Chan MKY, Bhatti H, Meader N, Stockton S, Evans J, O'Connor RC, Kapur N, Kendall T. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry 2016; 209:277-283. [PMID: 27340111 DOI: 10.1192/bjp.bp.115.170050] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 03/21/2016] [Indexed: 11/23/2022]
Abstract
BACKGROUND People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex. AIMS To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm. METHOD We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable. RESULTS Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the meta-analysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38-2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91-3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16-3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70-2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%. CONCLUSIONS The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.
Collapse
Affiliation(s)
- Melissa K Y Chan
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Henna Bhatti
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Nick Meader
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Sarah Stockton
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Jonathan Evans
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Rory C O'Connor
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Nav Kapur
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| | - Tim Kendall
- Melissa K. Y. Chan, MSc, Centre for Suicide Research and Prevention, University of Hong Kong, Pok Fu Lam, Hong Kong; Henna Bhatti, MSc, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Nick Meader, PhD, Centre for Reviews and Dissemination, The University of York, York, UK; Sarah Stockton, BA(Hons), National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK; Jonathan Evans, MRCPsych, Centre for Academic Mental Health, School of Social & Community Medicine, University of Bristol, Bristol, UK; Rory C. O'Connor, PhD, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK; Nav Kapur, FRCPsych, Centre for Suicide Prevention, Centre for Mental Health and Safety, University of Manchester, and Manchester Mental Health and Social Care Trust, Manchester, UK; Tim Kendall, FRCPsych, National Collaborating Centre for Mental Health, Royal College of Psychiatrists' Research and Training Unit, London, UK
| |
Collapse
|
36
|
Lopez-Morinigo JD, Ayesa-Arriola R, Torres-Romano B, Fernandes AC, Shetty H, Broadbent M, Dominguez-Ballesteros ME, Stewart R, David AS, Dutta R. Risk assessment and suicide by patients with schizophrenia in secondary mental healthcare: a case-control study. BMJ Open 2016; 6:e011929. [PMID: 27678536 PMCID: PMC5051464 DOI: 10.1136/bmjopen-2016-011929] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/09/2016] [Accepted: 07/11/2016] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To investigate the role of risk assessment in predicting suicide in patients with schizophrenia spectrum disorders (SSDs) receiving secondary mental healthcare. We postulated that risk assessment plays a limited role in predicting suicide in these patients. DESIGN Retrospective case-control study. SETTING Anonymised electronic mental health record data from the South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM) (London, UK) linked with national mortality data. PARTICIPANTS In 242 227 SLaM service users up to 31 December 2013, 635 suicides were identified. 96 (15.1%) had a SSD diagnosis. Those who died before 1 January 2007 (n=25) were removed from the analyses. Thus, 71 participants with SSD who died from suicide over the study period (cases) were compared with 355 controls. MAIN OUTCOME MEASURE Risk of suicide in relation to risk assessment ratings. RESULTS Cases were younger at first contact with services (mean±SD 34.5±12.6 vs 39.2±15.2) and with a higher preponderance of males (OR=2.07, 95% CI 1.18 to 3.65, p=0.01) than controls. Also, suicide occurred within 10 days after last contact with services in half of cases, with the most common suicide methods being hanging (14) and jumping (13). Cases were more likely to have the following 'risk assessment' items previously recorded: suicidal history (OR=4.42, 95% CI 2.01 to 9.65, p<0.001), use of violent method (OR=3.37, 95% CI 1.47 to 7.74, p=0.01), suicidal ideation (OR=3.57, 95% CI 1.40 to 9.07, p=0.01) and recent hospital discharge (OR=2.71, 95% CI 1.17 to 6.28, p=0.04). Multiple regression models predicted only 21.5% of the suicide outcome variance. CONCLUSIONS Predicting suicide in schizophrenia is highly challenging due to the high prevalence of risk factors within this diagnostic group irrespective of outcome, including suicide. Nevertheless, older age at first contact with mental health services and lack of suicidal history and suicidal ideation are useful protective markers indicative of those less likely to end their own lives.
Collapse
Affiliation(s)
- Javier-David Lopez-Morinigo
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Rosa Ayesa-Arriola
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Department of Psychiatry, Marqués de Valdecilla University Hospital, IFIMAV, School of Medicine, University of Cantabria, Santander, Spain
| | | | - Andrea C Fernandes
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Hitesh Shetty
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Matthew Broadbent
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | | | - Robert Stewart
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Anthony S David
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Rina Dutta
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| |
Collapse
|
37
|
Wang Y, Bhaskaran J, Sareen J, Bolton SL, Chateau D, Bolton JM. Clinician Prediction of Future Suicide Attempts. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:428-432. [PMCID: PMC4910410 DOI: 10.1177/0706743716645287] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
Objective: Established risk assessment tools are often inaccurate at predicting future suicide risk. We therefore investigated whether clinicians are able to predict individuals’ suicide risk with greater accuracy. Method: We used the SAFE Database, which included consecutive adult (age ≥18 years) presentations (N = 3818) over a 22-month period to the 2 tertiary care hospitals in Manitoba, Canada. Medical professionals assessed each individual and recorded his or her predicted risk for future suicide attempt (SA) on a 0-10 scale—the clinician prediction scale. The SAD PERSONS scale was completed as a comparison. SAs within 6 months, assessed using the Columbia Classification Algorithm for Suicide Assessment, were the primary outcome measure. Receiver operating characteristic curve and logistic regression analyses were conducted to determine the accuracy of both scales to predict SAs, and the scales were compared with z scores. Clinician prediction scale performance was stratified based on level of training. Results: Clinicians were able to predict future SAs with significantly greater accuracy (area under the curve [AUC] = 0.73; 95% CI, 0.68 to 0.77; P < 0.001) compared with the SAD PERSONS scale (z = 3.79, P < 0.001). Both scales nonetheless showed positive predictive value of less than 7%. Analyses by level of training showed that junior psychiatric residents and non–psychiatric residents did not accurately predict SAs, whereas senior psychiatric residents and staff psychiatrists demonstrated greater accuracy (AUC = 0.76 and 0.78, respectively). Conclusions: Clinicians are able to predict future attempts with fewer false positives than a conventional risk assessment scale, and this skill appears related to training level. Predicting future suicidal behaviour remains very challenging.
Collapse
Affiliation(s)
- Yunqiao Wang
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba
| | - Joanna Bhaskaran
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba
| | - Jitender Sareen
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Shay-Lee Bolton
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| | - Dan Chateau
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba
| | - James M. Bolton
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
| |
Collapse
|
38
|
Gale TM, Hawley CJ, Butler J, Morton A, Singhal A. Perception of Suicide Risk in Mental Health Professionals. PLoS One 2016; 11:e0149791. [PMID: 26909886 PMCID: PMC4766090 DOI: 10.1371/journal.pone.0149791] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 02/04/2016] [Indexed: 01/21/2023] Open
Abstract
This study employed an independent-groups design (4 conditions) to investigate possible biases in the suicide risk perception of mental health professionals. Four hundred participants comprising doctors, nurses and social workers viewed a vignette describing a fictitious patient with a long-term mental illness. The case was presented as being drawn from a sample of twenty similar clinical case reports, of which 10 were associated with an outcome of suicide. The participant tasks were (i) to decide whether the presented vignette was one of those cases or not, and (ii) to provide an assessment of confidence in that decision. The 4 conditions were used to investigate whether the presence of an associated face, and the nature of the emotional state expressed by that face, affected the response profile. In fact, there were no significant differences between conditions, but there was a significant bias across all conditions towards associating the vignette with suicide, despite the base rate being pre-determined at 50%. The bias was more pronounced in doctors and in male respondents. Moreover, many participants indicated substantial confidence in their decisions. The results are discussed in terms of availability bias and over-confidence bias.
Collapse
Affiliation(s)
- Tim M. Gale
- Department of Research, Hertfordshire Partnership University NHS Foundation Trust, Hatfield, United Kingdom
- Department of Psychology, University of Hertfordshire, Hatfield, United Kingdom
| | - Christopher J. Hawley
- Department of Post-graduate Medicine, University of Hertfordshire, Hatfield, United Kingdom
| | - John Butler
- School of Health, University of Central Lancaster, Preston, United Kingdom
| | - Adrian Morton
- Reigate Psychology Service, Reigate, Surrey, United Kingdom
| | - Ankush Singhal
- Psychological Medicine Service, The Royal Oldham Hospital, Oldham, United Kingdom
| |
Collapse
|
39
|
Quinlivan L, Cooper J, Davies L, Hawton K, Gunnell D, Kapur N. Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy. BMJ Open 2016; 6:e009297. [PMID: 26873046 PMCID: PMC4762148 DOI: 10.1136/bmjopen-2015-009297] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 09/16/2015] [Accepted: 10/21/2015] [Indexed: 11/06/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- L Quinlivan
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - J Cooper
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
| | - L Davies
- Institute of Population Health, University of Manchester, Manchester, UK
| | - K Hawton
- Department of Psychiatry, Centre for Suicide Research, University, Warneford Hospital, Oxford, UK
| | - D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - N Kapur
- Centre for Mental Health and Safety, University of Manchester, Manchester, UK
- Manchester Mental Health and Social Care Trust, Manchester, UK
| |
Collapse
|
40
|
Townsend E, Ness J, Waters K, Kapur N, Turnbull P, Cooper J, Bergen H, Hawton K. Self-harm and life problems: findings from the Multicentre Study of Self-harm in England. Soc Psychiatry Psychiatr Epidemiol 2016; 51:183-92. [PMID: 26499114 DOI: 10.1007/s00127-015-1136-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/13/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Self-harm is a major clinical problem and is strongly linked to suicide. It is important to understand the problems faced by those who self-harm to design effective clinical services and suicide prevention strategies. We investigated the life problems experienced by patients presenting to general hospitals for self-harm. METHODS Data for 2000-2010 from the Multicentre Study of Self-harm in England were used to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status. RESULTS Of 24,598 patients (36,431 assessed episodes), 57% were female and with a mean age of 33.1 years (SD 14.0 years), 92.6% were identified as having at least one contributing life problem. The most frequently reported problems at first episode of self-harm within the study period were relationship difficulties (especially with partners). Mental health issues and problems with alcohol were also very common (especially in those aged 35-54 years, and those who repeated self-harm). Those who repeated self-harm were more likely to report problems with housing, mental health and dealing with the consequences of abuse. CONCLUSIONS Self-harm usually occurs in the context of multiple life problems. Clinical services for self-harm patients should have access to appropriate care for provision of help for relationship difficulties and problems concerning alcohol and mental health issues. Individualised clinical support (e.g. psychological therapy, interventions for alcohol problems and relationship counselling) for self-harm patients facing these life problems may play a crucial role in suicide prevention.
Collapse
Affiliation(s)
- Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, University Park, Nottingham, NG72RD, UK.
| | - Jennifer Ness
- Centre for Self-Harm and Suicide Prevention Research, Research and Development Centre, Derbyshire Healthcare NHS Foundation Trust, Kingsway, Derby, DE22 3LZ, UK
| | - Keith Waters
- Centre for Self-Harm and Suicide Prevention Research, Research and Development Centre, Derbyshire Healthcare NHS Foundation Trust, Kingsway, Derby, DE22 3LZ, UK
| | - Navneet Kapur
- Centre for Suicide Prevention, University of Manchester, Centre for Mental Health and Safety, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Pauline Turnbull
- Centre for Suicide Prevention, University of Manchester, Centre for Mental Health and Safety, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Jayne Cooper
- Centre for Suicide Prevention, University of Manchester, Centre for Mental Health and Safety, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, UK
| | - Helen Bergen
- Centre for Suicide Research, University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
| |
Collapse
|
41
|
de Cates AN, Broome MR. Can We Use Neurocognition to Predict Repetition of Self-Harm, and Why Might This Be Clinically Useful? A Perspective. Front Psychiatry 2016; 7:7. [PMID: 26858659 PMCID: PMC4728206 DOI: 10.3389/fpsyt.2016.00007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/11/2016] [Indexed: 12/13/2022] Open
Abstract
Over 800,000 people die by suicide each year globally, with non-fatal self-harm 20 times more common. With each episode of self-harm, the risks of future self-harm and suicide increase, as well as personal and healthcare costs. Therefore, early delineation of those at high risk of future self-harm is important. Historically, research has focused on clinical and demographic factors, but risk assessments based on these have low sensitivity to predict repetition. Various neurocognitive factors have been associated with self-harming behavior, but it is less certain if we can use these factors clinically (i) as risk markers to predict future self-harm and (ii) to become therapeutic targets for interventions. Recent systematic reviews and meta-analyses of behavioral tasks and fMRI studies point to an emerging hypothesis for neurocognition in self-harm: an underactive pre-frontal cortex is unable to respond appropriately to non-emotional stimuli, or inhibit a hyperactive emotionally-/threat-driven limbic system. However, there is almost no imaging data examining repetition of self-harm. Extrapolating from the non-repetition data, there may be several potential neurocognitive targets for interventions to prevent repeat self-harm: cognitive training; pharmacological regimes to promote non-emotional neurocognition; or other techniques, such as repetitive transcranial magnetic stimulation. Hence, there is an urgent need for imaging studies examining repetition and to test specific hypotheses. Until we investigate the functional neurocognitive basis underlying repetition of self-harm in a systematic manner using second-generational imaging techniques, we will be unable to inform third-generational imaging and potential future clinical applications.
Collapse
Affiliation(s)
- Angharad N. de Cates
- Unit of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew R. Broome
- Unit of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| |
Collapse
|
42
|
Joory K, Farroha A, Moiemen N. Is a self-inflicted burn part of a repeated self-harm pattern? ANNALS OF BURNS AND FIRE DISASTERS 2015; 28:223-227. [PMID: 27279811 PMCID: PMC4883609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 03/08/2015] [Indexed: 06/06/2023]
Abstract
Self-inflicted burns (SIB) consistently account for a small proportion of burn injuries. There is a wide spectrum of SIB, from minor burns through to major life threatening burn injuries in suicidal patients who have committed self-immolation. Non-fatal deliberate self-harm (DSH) is a common reason for presenting to hospital. This occurs in many forms including wounding, burning and poisoning to name a few. Such behaviours are commonly repeated, sometimes with increasing severity. DSH is a major risk factor for subsequent suicide. We had observed patterns of repeated self harm behaviours in patients presenting to our centre with SIB. Patterns of repeated DSH in those presenting with self-inflicted burns have not previously been described in the literature. In a five-year period (2008 to 2012) 84 patients presented to our burns centre with SIB. Within this population, 39 patients (46%) were identified on a national database as having been admitted to an acute National Health Service (NHS) trust somewhere in the UK with sequelae of deliberate self-harm. There had been a total of 128 additional hospital admissions. In the majority of cases (85%) another admission preceded the presentation to our service with SIB. Only four out of the 17 SIB patients (24%) who died of their injuries had previous hospital admissions with DSH. This lends weight to the need for thorough holistic assessment of any patient admitted to hospital with sequelae of deliberate self-harm in order to try and provide appropriate support and interventions for these vulnerable individuals to prevent recurrent self-harm or suicide.
Collapse
Affiliation(s)
- K. Joory
- Burns Centre, Queen Elizabeth Hospital Birmingham, UK
| | - A. Farroha
- Burns Centre, Queen Elizabeth Hospital Birmingham, UK
| | - N. Moiemen
- Burns Centre, Queen Elizabeth Hospital Birmingham, UK
| |
Collapse
|
43
|
Abstract
Suicide is a serious public health problem, with more than 800,000 deaths taking place worldwide each year. Mental disorders are associated with increased risk of suicide. In schizophrenia and other psychotic disorders, the lifetime risk of suicide death is estimated to be 5.6%. The risk is particularly high during the first year of the initial contact with mental health services, being almost twice as high as in the later course of the illness. The most consistently reported risk factor for suicide among people with psychotic disorders is a history of attempted suicide and depression. Suicide risk in psychosis in Denmark decreased over time, most likely because of improved quality of inpatient and outpatient services. There is a high proportion of young people with first-episode psychosis who attempted suicide before their first contact with mental health services. This finding suggests that the mortality rates associated with psychotic disorders may be underreported because of suicide deaths taking place before first treatment contact. However, currently, no data exist to confirm or refute this hypothesis. Attempted suicide can be an early warning sign of later psychotic disorder. Data from different studies indicate that the risk of suicide attempt during the first year of treatment is as high as 10%. The most important risk factors for attempted suicide after the first contact are young age, female sex, suicidal plans, and a history of suicide attempt. Early intervention services are helpful in first-episode psychosis, and staff members should, in collaboration with the patients, monitor the risk of suicide and develop and revise crisis plans.
Collapse
|
44
|
|