Emergency department assessment of self-harm risk using psychometric questionnaires

Suicidality and mood disorders in psychiatric emergency patients: Results from SBQ-R

Patients with mood disorders are at high risk of suicidality, and emergency departments (ED) are essential in the management of this risk. This study aims to (1) describe the suicidal thoughts and behaviours of patients with mood disorders who come to ED; (2) assess the psychometric properties of the Suicidal Behaviours Questionnaire-Revised (SBQ-R) in a psychiatric ED; and (3) determine the best predictors of suicidality for these patients. A total of 300 participants with mood disorders recruited for the Signature Bank of the Institut universitaire en santé mentale de Montréal (IUSMM) were retained. Suicidality was assessed using the SBQ-R. Other clinical and demographic details were recorded. Bivariate analyses, correlations and multivariate regression analyses were conducted. SBQ-R's internal consistency, construct and convergent validities were also tested. In the Patient Health Questionnaire-9 (PHQ-9), 53.3% of the sample stated they had suicidal or self-harm thoughts in the last 2 weeks. The mean score obtained at the SBQ-R was 8.3. Multivariate analysis found that SBQ-R scores were associated with depressive symptoms and substance use, especially alcohol, accounting for 44.3% of the model variance. Cronbach's alpha was 0.81 [0.78, 0.84] and factor loadings for items 1-4 were 0.68, 0.88, 0.54, and 0.85, respectively. The confirmatory factor analysis indicated that the model fit the data well. The SBQ-R is a brief and valid instrument that can easily be used in busy emergency departments to assess suicide risk. Depressive symptoms and alcohol use shall also be assessed, as they are determinants of increased risk of suicidality.

Risk Assessment of Self-Injurious Behavior and Suicide Presentation in the Emergency Department: An Integrative Review

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.

Accuracy of individual and combined risk-scale items in the prediction of repetition of self-harm: multicentre prospective cohort study

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.

Hopelessness is associated with repeated suicidal behaviors after discharge in patients admitted to emergency departments for attempted suicide

BACKGROUND

Hopelessness may be associated with an increased risk of suicide. However, findings regarding the long-term predictive ability of the Beck Hopelessness Scale (BHS) for suicide are inconsistent. This study investigated the long-term predictive ability of BHS scores for subsequent self-harm episodes in individuals admitted to an emergency department after attempting suicide.

METHODS

The BHS was administered to 805 adult patients with a DSM-IV-TR axis I disorder admitted to an emergency department following a suicide attempt. The patients were followed for at least 18 months and up to 5 years. The incidence of the first subsequent suicidal behavior (attempt or dying by suicide) was examined and the numbers per person-year of overall repeat self-harm episodes, suicide attempt episodes, and non-suicidal self-harm episodes were evaluated.

RESULTS

The total BHS scores showed significant associations with the overall number of self-harm episodes per person-year (incidence rate ratio [IRR], 1.05; 95% confidence interval [CI], 1.03-1.07; p < 0.0001), the number of suicide attempt episodes per person-year (IRR, 1.05; 95%CI, 1.03-1.08; p < 0.0001), and the number of non-suicidal self-harm episodes per person-year (IRR, 1.05; 95%CI, 1.03-1.07; p < 0.0001).

LIMITATIONS

The study excluded children and adolescents. The sample size, while large, was insufficient to ensure generalizability, or to allow subanalyses based on specific disorders.

CONCLUSIONS

Hopelessness scores assessed in the emergency department after a self-harming episode were associated with a rate of repetition of suicidal behaviors after discharge. Additional strategies to address hopelessness of these patients are warranted.

Predicting Future Suicide: Clinician Opinion versus a Standardized Assessment Tool

OBJECTIVE

To compare the effectiveness of clinician prediction of risk to a standardized assessment of presentation status.

METHODS

All adult psychiatry emergency department consults in the two main hospitals in Winnipeg, Canada, were assessed using a standardized form (n = 5,376). This form includes two risk scales for a gestalt physician assessment of risk (Suicide Likelihood scale, suicide Attempt Likelihood scale) and the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Regression determined whether assessments predicted future suicide attempts and deaths. The area under the curve (AUC) determined the prediction accuracy of these methods.

RESULTS

Although the regression results were significant, the AUCs were either moderate or poor. Clinician assessment was not effective at predicting deaths (AUC = .546, .36-.73), but moderately accurate at predicting future attempts (AUC = .728, .66-.79). C-CASA assessment was moderately accurate at predicting both attempts and deaths (AUC = .666 and .678).

CONCLUSIONS

Clinician assessment does not significantly outperform a simple assessment of the occurrence of suicidal thoughts and behaviors during presentation to the emergency department. Behavior-based standardized assessments should be further researched in this field. Assessment of suicidality at presentation using C-CASA or similar assessment should be standard for psychiatric patients assessed in the emergency department.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department

BACKGROUND

Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients.

METHODS

This prospective observational study enrolled a convenience sample of patients who answered "yes" to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated.

RESULTS

276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66-0.73).

CONCLUSION

Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

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

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

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

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

OBJECTIVES

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

DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Recent self-harm and psychological measures in the emergency department

The assessment of self-harm risk is a common, difficult, and perplexing task for many physicians, especially those working in emergency departments (ED). Attempts have been made to determine objective methods for assessing patients with suicidal ideation or self-harm though there is still a lack of knowledge about objective assessments of these patients. A study was conducted where 181 suicidal patients were enrolled in two EDs within the city of Edmonton, Canada. Initial interviews were conducted in the ED which collected basic demographics and medical history as well as psychometric measures including the Beck Hopelessness Scale, Barratt Impulsiveness Scale, Brief Symptom Inventory, Drug Abuse Screening Test 10, and CAGE questionnaire. The results of these measures were compared between those who presented to the ED with self-harm and those who presented only with ideation. Those with recent self-harm scored lower on many of the scales and subscales of distress and impulsivity measured compared to those with no recent self-harm. Possible explanations for this difference include differences in psychological traits between the two groups and possible cathartic effects of self-harm. The lower scores obtained by those that present with self-harm may complicate attempts to use psychometric tools to determine future self-harm risk.

Validation of the Chinese SAD PERSONS Scale to predict repeated self-harm in emergency attendees in Taiwan

BACKGROUND

Past and repeated self-harm are long-term risks to completed suicide. A brief rating scale to assess repetition risk of self-harm is important for high-risk identification and early interventions in suicide prevention. The study aimed to examine the validity of the Chinese SAD PERSONS Scale (CSPS) and to evaluate its feasibility in clinical settings.

METHODS

One hundred and forty-seven patients with self-harm were recruited from the Emergency Department and assessed at baseline and the sixth month. The controls, 284 people without self-harm from the Family Medicine Department in the same hospital were recruited and assessed concurrently. The psychometric properties of the CSPS were examined using baseline and follow-up measurements that assessed a variety of suicide risk factors. Clinical feasibility and applicability of the CSPS were further evaluated by a group of general nurses who used case vignette approach in CSPS risk assessment in clinical settings. An open-ended question inquiring their opinions of scale adaptation to hospital inpatient assessment for suicide risks were also analyzed using content analysis.

RESULTS

The CSPS was significantly correlated with other scales measuring depression, hopelessness and suicide ideation. A cut-off point of the scale was at 4/5 in predicting 6-month self-harm repetition with the sensitivity and specificity being 65.4% and 58.1%, respectively. Based on the areas under the Receiver Operating Characteristic curves, the predictive validity of the scale showed a better performance than the other scales. Fifty-four nurses, evaluating the scale using case vignette found it a useful tool to raise the awareness of suicide risk and a considerable tool to be adopted into nursing care.

CONCLUSIONS

The Chinese SAD PERSONS Scale is a brief instrument with acceptable psychometric properties for self-harm prediction. However, cautions should be paid to level of therapeutic relationships during assessment, staff workload and adequate training for wider clinical applications.

Suicidal behaviour and related risk factors among school-aged youth in the Republic of Benin

INTRODUCTION

Research on factors associated with suicidal ideation and suicide attempts has been conducted largely in developed countries. Research on West African countries in particular is lacking.

METHODS

Data were obtained from the Global School-based Health Survey conducted in Benin in 2009. This was a cross-sectional study of three grades, spanning Junior and Senior High, which sampled a total of 2,690 adolescents. Data on the occurrence of demographic, psycho-social and socio-environmental risk factors were tested using multinomial logistic regression for their association with suicidal ideation and suicide attempts.

RESULTS

The survey indicated that 23.2% had thought about suicide and 28.3% had made a suicide attempt in the previous year. Anxiety, loneliness, being bullied, alcohol misuse, illicit drug use, and lack of parental support were independently related to the ideation outcomes, suicidal ideation without planning and suicidal ideation with planning. Multinomial regression analysis, using one suicide attempt and multiple suicide attempts as outcomes, revealed that female sex, anxiety, loneliness, being physically attacked, and illicit drug use were associated these outcomes.

DISCUSSION

The prevalence of suicide attempts reported in the survey is relatively high. It is possible that there are cultural factors that could explain this finding. Our research indicates that many factors are related to the occurrence of suicidal ideation and suicide attempts among youth in Benin. Illicit drug use and violence in particular are associated with a high rate of suicide attempts in Benin. Measures to address these issues may reduce the risk of self-inflicted violence.

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

BACKGROUND

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

OBJECTIVE

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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