Comparison of clinical and research assessments of diagnosis, suicide attempt history and suicidal ideation in major depression

A number of studies have compared clinical diagnostic and suicide assessments to standardized schedules to determine the level of agreement. At best there is only moderate diagnostic agreement, but most often it is fair. There are only a few reports comparing clinical assessments for suicidal behavior with standardized schedules. We present the data from 201 inpatient admissions for major depression that had both clinical diagnostic and suicide evaluations by PGYII resident physicians under supervision from an attending psychiatrist and research evaluations using standardized schedules for diagnosis and suicide by at least masters' level clinicians. There was moderate agreement for diagnosis and suicide attempt history but only fair agreement for the presence of suicidal ideation using Cohen's kappa statistic. In regards to suicide attempt history a cross-tabulation demonstrated that 18.7% of those patients identified by a research schedule as having a past suicide attempt were not identified as such by the clinicians. A cross-tabulation demonstrated that 29.7% of those patients identified by structured interview as having suicidal ideation were not identified as such by the clinician. There was a statistically significant difference in the level of agreement for suicide attempt history between clinical and research assessments for attempts within a year of admission and those beyond a year. These findings suggest the importance of adding a structured diagnostic and suicide assessment to routine clinical care to improve the reliability and validity of clinical evaluations and to inform treatment planning to benefit our patients.

Are high-lethality suicide attempters with bipolar disorder a distinct phenotype?

Because Bipolar Disorder (BD) individuals making highly lethal suicide attempts have greater injury burden and risk for suicide, early identification is critical. BD patients were classified as high- or low-lethality attempters. High-lethality attempts required inpatient medical treatment. Mixed effects logistic regression models and permutation analyses examined correlations between lethality, number, and order of attempts. High-lethality attempters reported greater suicidal intent and more previous attempts. Multiple attempters showed no pattern of incremental lethality increase with subsequent attempts, but individuals with early high-lethality attempts more often made high-lethality attempts later. A subset of high-lethality attempters make only high-lethality attempts. However, presence of previous low-lethality attempts does not indicate that risk for more lethal, possibly successful, attempts is reduced.