Self-harm subscale of the Schedule for Nonadaptive and Adaptive Personality (SNAP): predicting suicide attempts over 8 years of follow-up

Maladaptive personality traits and the course of suicidal ideation in young adults with bipolar disorder: Cross-sectional and prospective approaches

BACKGROUND

Childhood-onset bipolar disorder (BD) has considerable morbidity and mortality, including suicide. Many risk factors have been identified for suicidality, but the potential role of personality traits as assessed by a computer-assisted self-report measure remains unclear.

AIMS

To address this gap in knowledge, we tested relations between pathological-range personality traits and suicidal ideation among young adults whose childhood-onset BD was prospectively confirmed by enrollment in the Course and Outcome of Bipolar Youth study (COBY) as children (n = 45) and a newly enrolled group of typically developing controls (TDCs; n = 52) both cross-sectionally and longitudinally after 1.5 years of follow up.

MATERIALS & METHODS

Personality traits were assessed with the computerized Schedule for Nonadaptive and Adaptive Personality-2 (SNAP-2).

RESULTS

Cross-sectionally, we found that participants with BD had elevated Suicide Proneness and Low Self-esteem versus TDCs at baseline. Furthermore, longitudinal analyses in the BD participants for whom we had 1.5 years of prospectively collected illness-course data showed that greater Suicide Proneness and Low Self-esteem prospectively predicted greater levels, shorter time until occurrence, and greater frequency of suicidal ideation during the follow-up.

CONCLUSION

Our findings suggest the role of specific personality-related vulnerabilities in the course of BD that, pending replication, could contribute to development of interventions focused on personality traits among individuals with BD.

Predicting suicide with the SAD PERSONS scale

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.

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.

Evaluating chronic suicide risk with the Personality Assessment Inventory: Development and initial validation of the Chronic Suicide Risk Index (S_Chron)

The current study sought to develop and validate a new measure of chronic suicide risk (the S_Chron) from the Personality Assessment Inventory in a mixed sample of psychiatric inpatients and outpatients. In an initial development sample (N=397), hierarchical logistic regression identified six PAI variables uniquely associated with multiple versus single/no prior suicide attempts after controlling for sample demographics: Negative Impression Management, Situational Stress, Mania - Grandiosity, Borderline - Negative Relationships, Borderline - Self-Harm, and Antisocial Behaviors. These indicators were then aggregated into a single index (S_Chron) and evaluated in terms of validity in an independent clinical sample (N=398). Results indicated the S_Chron effectively differentiated between groups with multiple versus single/no prior suicide attempts, even after controlling for the effects of the PAI Suicidal Ideation (SUI) and Suicide Potential (SPI) indices, with moderate to large effect sizes observed (range of Cohen's d's=0.30-0.91). Further, the S_Chron incremented all other PAI indices and SUI in predicting multiple suicide attempts. The potential clinical application and ways in which the S_Chron may augment other existing measures of suicide risk are discussed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of suicide threats in patients with borderline personality disorder over 16 years of prospective follow-up

Despite their impact on interpersonal relationships and health resources, suicide threats are not often studied in those with borderline personality disorder (BPD). The primary aim of this study was to examine clinically relevant predictors of suicide threats in this patient group. Two-hundred and ninety inpatients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and a self-report measure. These subjects were then reassessed using the same instruments every 2 years for 16 years. All variables in the bivariate analyses were found to be significant. In multivariate analyses, four predictors were found to be significant: feeling abandoned and hopeless, and being demanding and manipulative. The results of this study suggest that suicide threats are often related to emotions connected with interpersonal relationships. Suicide threats may function, albeit maladaptively, to regulate these emotions aroused by interpersonal relationships and bring needed support.

DSM-5 Pathological Personality Traits and the Personality Assessment Inventory

Section 3 of the DSM-5 will include a pathological personality trait system rooted in the quantitative epistemology of personality and clinical psychology. This system has the potential to enhance the clinical utility of the diagnostic nosology by providing a means for the dimensional assessment of individuals with psychopathology. However, there is limited research on the associations of DSM-5 traits with common mental disorders and related clinical phenomena as measured by currently popular assessment instruments. The purpose of this article was to evaluate the convergence of the DSM-5 trait system with a well-validated broadband clinical instrument, the Personality Assessment Inventory (PAI). Bivariate correlations were examined and factor analytic methods were used to examine the degree to which the DSM-5 traits and PAI capture common variance in personality and mental health. In a student sample ( N = 1,001), we found broad convergence between the DSM-5 traits and PAI, which could be organized effectively using five factors. The implications of these findings for using traits to address issues related to diagnostic co-occurrence and heterogeneity in routine clinical assessment are discussed.

Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up

BACKGROUND

It is clinically important to understand the factors that increase the likelihood of the frequent and recurrent suicide attempts seen in those with borderline personality disorder (BPD). Although several studies have examined this subject in a cross-sectional manner, the aim of this study was to determine the most clinically relevant baseline and time-varying predictors of suicide attempts over 16 years of prospective follow-up among patients with BPD.

METHOD

Two-hundred and ninety in-patients meeting Revised Diagnostic Interview for Borderlines (DIB-R) and DSM-III-R criteria for BPD were assessed during their index admission using a series of semistructured interviews and self-report measures. These subjects were then reassessed using the same instruments every 2 years. The generalized estimating equations (GEE) approach was used to model the odds of suicide attempts in longitudinal analyses, controlling for assessment period, yielding an odds ratio (OR) and 95% confidence interval (CI) for each predictor.

RESULTS

Nineteen variables were found to be significant bivariate predictors of suicide attempts. Eight of these, seven of which were time-varying, remained significant in multivariate analyses: diagnosis of major depressive disorder (MDD), substance use disorder (SUD), post-traumatic stress disorder (PTSD), presence of self-harm, adult sexual assault, having a caretaker who has completed suicide, affective instability, and more severe dissociation.

CONCLUSIONS

The results of this study suggest that prediction of suicide attempts among borderline patients is complex, involving co-occurring disorders, co-occurring symptoms of BPD (self-harm, affective reactivity and dissociation), adult adversity, and a family history of completed suicide.