At-risk subjects in research studies are often asked to rate their suicidality in interviews or questionnaires. However, there seems to be little literature on using a self-administered screening or assessment tool to gauge inpatients' thoughts or feelings on factors bearing on the level of suicide risk present prior to D/C that may leave with them as they enter the high risk period that may persist for 30 days or more after leaving the hospital. The risk is so high during this period that every means for determining and addressing risk must be considered. What I have in mind would complement rather than replace the pre-D/C suicide risk assessment that should be done by a psychiatrist or other appropriate member of the treatment team. It would be used with all patients, irrespective of presenting problem at admission. Joiner's Interpersonal Psychological Theory could be the basis for such a tool, e.g., I feel that I belong, I feel that I am connected to others whom I care about, I do not feel that I am a burden to others, etc.
Perhaps you are familiar with these papers. They shed some light on this issue. Based on the literature the nature of the self-assessment tool for suicidal ideation does not seem to be of great importance.
Longitudinal trajectories and predictors of adolescent suicidal ideation and attempts following inpatient hospitalization. Prinstein, Mitchell J.; Nock, Matthew K.; Simon, Valerie; Aikins, Julie Wargo; Cheah, Charissa S. L.; Spirito, Anthony Journal of Consulting and Clinical Psychology, Vol 76(1), Feb 2008, 92-103.
Near-term predictors of the intensity of suicidal ideation: An examination of the 24h prior to a recent suicide attempt. Bagge, Courtney L.; Littlefield, Andrew K.; Conner, Kenneth R.; Schumacher, Julie A.; Lee, Han-Joo. Journal of Affective Disorders165 (Aug 20, 2014): 53-58.
Thank you for your reply. The two reference that you offer seem very pertinent. I am not acquainted with them and will follow up. Perhaps I was influenced by Kuhn at too early an age but I often feel that a "paradigm" holds forth in suiciological research that influences what gets studied. In any case, if you use the "literature" as a measure there are a many subjects related to suicide risk that are not of great importance.
I'd suggest using the same measure at admission and discharge. This way you can track how much change has occurred, and have the clinical discussion with the patient at admission (e.g. 'We want to help you feel better and think about suicide less') and at discharge (e.g. 'It is good to see that you are thinking about suicide so much less frequently/are less distressed, etc.'). One measure that is helpful for pre- and post- inpatient treatment is Reynold's Adult Suicide Ideation Questionnaire (ASIQ). Reynold's followed people post-discharge; ASIQ that didn't decline sigificantly with inpatient treatment had a much higher risk than those who showed declines. David Jobe's SSF tracks initial drivers to suicide and assesses post-treatment changes; it is tied to a treatment process that is focused on reducing suicide risk. I wouldn't rely on Joiner's ITS measures (INQ and ACSS) personally; they are measures of proximal causes of desire for suicide. More direct measures (e.g. ASIQ, the Beck Scale for Suicidal Ideation) are better for the purpose you describe.
I really appreciate your thoughts on this matter. Would you be willing to share your thoughts on using post-discharge contact such as this publication discusses, in addition to assessment at the time of discharge? (And does it need to be limited to the "young"?) It is difficult to see a downside, yet I wonder if it is practical in the already overworked environment of a psychiatric hospital.
Article Can receipt of a regular postcard reduce suicide-related beh...
Corrina: Thank you for your comments and citation. It is interesting that when a psych hospital has a "sentinel event" weeks, months, even years, may be spent retrospectively on one case. However, as you note, at other times suicide prevention is given less attention because of "too busy." Inpatient facilities "own" post-D/C suicides in the first days/weeks after the patient leaves their care. Other providers are typically slow to re-engage, families think the patient is "cured," and some patients feel they need a break from treatment after their inpatient stay. Yet the hospital obviously must have made a bad D/C decision when a high risk person completes suicide in a high risk period. I'm for follow-up by any means (post cards, e-mail, calls, visits). For the next year we're having a psych nurse make a home visit or two or three to high risk individuals to do some mental health wellness coaching and bridge that transition period when patients are on their own. Other patients will be referred to a mobile crisis team. However, the real issue is building suicide prevention into D/C planning and getting everyone involved with community-based care to play a part.
Dear Tony,
Here at the Menninger Clinic in Houston I work with patients daily who we discharge and are considered high risk over the longer term, and who have come to us in a suicidal crisis. We use the Columbia Suicide Severity Scale, which has a lot of terrific items for capturing even subtle signs of carelessness towards one's life. All patients are administered this before discharge. We also use a measure that assesses the "Wish to Live" and "The Wish to Die," as well as general measures of functionality. Interestingly, we have found that the WHO-DAS,a measure of functional impairment, is a sensitive indicator of how much felt progress a person has made--and that this has bearing on a person's sense of suicidality. Those who experience themselves as functionally limited, and see little change in that experience, are the folks (4 to 6%) that show the least response to treatment and who require are most intensive follow-up.
Great question, and one I think about frequently. I think this is a multimodal assessment process (I love Shawn Shea's CASE approach, and have found my training in it invaluable).
Michael:
Thank you for your comments. I fully concur with the value of Dr. Shea's approach and I make sure that some of our clinicians get to any of his trainings within 100 miles of our facility. I guess the basic point is that post-D/C suicide risk is not one dimensional so our efforts must be comparably multidimensional. Our situation is compounded by the fact that 65%-75% of our admissions are involuntary and an average of 85%-90% of them involve imminent risk of suicide.
Tony
The Sheehan-Suicidality Tracking Scale Clinically Meaningful Change Measure version (S-STS CMCM) could be used for this purpose. (See the first following link that gives a 2014 update on the S-STS and has the CMCM version on the appendices.) Just change the timeframe as appropriate. The S-STS CMCM version covers a wide spectrum of suicidal ideation and behavior phenomena, both risk and protective factors, compounding features, and impairment that all go into a clinician's judgement of risk and judgement of treatment the patient needs. The S-STS CMCM allows patients or clinicians to rate the severity of the suicidal phenomena present. It also does not assume that 'factors' present in a patient's history or presentation of symptoms are "risk" factors. It allows for the potential of them being "protective" factors as well. This makes it unlike the other scales out there that assume any of the factors contribute to risk which is not necessarily true. If a patient experienced sexual assault, the traditional 'risk' model of suicidality assumes this will contribute to the patient's suicidality. However, this event may in fact be a protective factor for a patient that plans to seek justice through the court system. The CMCM version allows the patient to indicate the severity of compounding features (e.g. hopelessness, ability and willingness to cope, ability and willingness to stay safe, quality of life, suicidal impulsivity) and the severity of impairment from their suicidality. It also asks the patient for input on immediate treatment needs.
One of the other scales previously mentioned in the answers above has some serious design flaws. See the second link for a review of that scale.
http://innovationscns.com/status-update-on-the-sheehan-suicidality-tracking-scale-s-sts-2014/
http://innovationscns.com/the-columbia-suicide-severity-rating-scale-c-ssrs-has-the-gold-standard-become-a-liability/
Jennifer: Thank you for this information. This aspect of the scale would be especially applicable to the purpose that we have in mind: " It also does not assume that 'factors' present in a patient's history or presentation of symptoms are "risk" factors. It allows for the potential of them being "protective" factors as well." Regards!
As a police officer trained in Crisis Intervention I responded a large number of self-report and third party reports of individuals with ideation and outward expressions of suicide. What was intriguing was the degree of self report and symptoms that were vividly expressed by the person who was feeling suicidal. Many times the discussions were straightforward and demonstrated an unusual awareness on the part of the client. A large portion of the population I encountered in the last five years of my job were Lakota Sioux. There is a remarkably high rate of incidence of completed suicides, attempts and verbalization/outward expression of ideation within that community. Directly on the heels of this population were incidents of family members who had committed suicide and incidents of child abuse which included sexual assault. While I can't definitively point to any known studies which show relative factors to child abuse/sex assault and suicide ideation and attempts, there does appear to be a correlation. What's more is the cultural aspect of acceptance of suicide within this segment of the population. Hence, in terms of risk factors, there was almost always an outward expression followed closely by statements.
Furthermore, officers screened for risk factors using a standardized line of questioning to determine whether the individual was a candidate for a voluntary out-patient style contact with a practitioner (Crisis Care Center) or an officer driven committal to a hospital. In South Dakota only law enforcement and medical doctors are authorized to make such petitions in a "Crisis" situation. The standardized criteria was aimed at the officers perception of the degree of risk and lack of extensive training in assessment and risk identification.
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