This is an invited lecture from the AGM of the Royal College of Psychiatrists 2008. The topic is whether risk assessment scales and tools help clinicians who are assessing risk of suicide in vulnerable people.

1. Royal College of Psychiatrists, Annual Meeting, UCL, London, July 2008
Risk to Self in Psychiatry
Do suicide/self-harm scales help clinicians?
Alex Mitchell, Consultant in Liaison Psychiatry
Leicester General Hospital / University of Leicester

2. Content / Questions
• What guidelines exist?
• How to assess risk of suicide/self-harm?
– Role of scales / tools?
– How to assess scales / tools?
• How good are clinicians?
– How much better are clinicians with tools?
– Self-harm or suicide?

3. I: Guidelines

5. NICE Self-Harm Guidance (2004)
• “Only use a standardised risk
assessment scale to aid
identification of those at high
risk of repetition of self-harm
or suicide.”
• “Don’t use standardised risk
assessment scales to identify
service users of supposedly
low risk who are not then
offered services.”
Application of Scales =>

6. http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html
Application of Scales =>

7. II: Self-Harm Scales

8. Many Scales
SSI Scale for Suicidal Ideation(SSI; Beck et al., 1979)
SIS Suicide Intent Scale (Beck, Schuyler, & Herman, 1974)
LS Lethality Scales (LS; Beck, Beck & Kovacs, 1975)
BHS Beck Hopelessness scale (Beck & Steer, 1988)
HRDS Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960)
(Suicide item)
BDI Beck Depression Inventory (BDI; Beck & Steer, 1988)
(Suicide item)
SPS The Suicide Probability Scale (SPS; Cull & Gill, 1988) is a 36-
item self-report
SIS The Suicidal Ideation Scale (SIS; Rudd, 1989) is a 10-item self-
report scale
MSSI The Modified Scale for Suicide Ideation ( Miller, Norman, Bishop,
& Dow, 1986) is a revised version of the Scale for Suicide
Ideation

9. Simple Scales
• Kreitman & Foster “Edinburgh” Scale SAD PERSONS
Scale (11 items) (10 items)
– Previous Para-suicide S Sex
– Personality Disorder A Age
– Alcohol Abuse D Depression
– Previous Psychiatric Treatment P Previous Attempts
– Unemployment E Ethanol Abuse
– Social Class V R Rational Thinking Loss
– Drug Abuse S Social Support Lacking
– Criminal Record O Organised Plan
– Violence N No Spouse
– Age 25-54 yrs S Sickness
– Single, Divorced or Separated

10. Beck Suicide Intent Scale (15 items)

11. Measure Administration Predictive Study Setting
Validity Psyc Medical Community other
Self Interview Items
Scale for Suicidal No Yes 21 Yes Yes Yes Yes Yes
Ideation
Suicide Intent Scale No Yes 15 Yes Yes Yes No No
Lethality Scale No Yes 8 No Yes Yes No No
HRDS No Yes 1 Yes Yes No No No
(Suicide item)
Becks Yes No 20 Yes Yes Yes No No
Hopelessness scale
BDI Yes No 1 No Yes Yes No Yes
(Suicide item)
Linehan reason for Yes No 48 No Yes Yes Yes Yes
living

12. Difficulty Predicting Repetition

13. Possible Risk Factors for Repetition
• Previous DSH [Hall, O'Brien et al., 1998] [Morgan, 1975] [Buglass & Hawton, 1974] [Wilkinson & Smeeton, 1987]
• PPH [DeMoore & Robertson, 1996] [Slap, et al., 1989]
• Depression [Kerfoot, McNiven et al., 1997] [Scott, et al., 1997] [Pierce, 1996] [Qari, et al., 1995] [Martin, et al., 1995]
• Sociopathy [Kreitman & Casey, 1988] [Buglass & Hawton, 1974]
• Poor problem solving [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] [McLauchlin, Miller et al., 1996].
• Poor social adjustment [Kerfoot, McNiven et al., 1997]
• Hopelessness [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] [McLauchlin, Miller et al., 1996].
• Lack of confidants [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997]
• Internal locus of control [Tulloch, Blizzard et al., 1997]
• Alcohol abuse [Pierce, 1996] [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]
• Child abuse [Wurr & Partridge, 1996] [Romans, Martin et al., 1995] [Boudewyn & Liem, 1995]
• Poor parenting [Tulloch, Blizzard et al., 1997]
• Physical violence [Gupta, Sivakumar et al., 1995]
• Impulsiveness [Evans, Platts et al., 1996] [Slap, Vorets et al., 1989].
• Difficulty in sustaining relationships [Gupta, Sivakumar et al., 1995]
• Family dysfunction [Martin, Rozanes et al., 1995] [Slap, Vorets et al., 1989].
• Obesity [Sansone, Sansone et al., 1995]
• Deprivation [Inch, Rowlands et al., 1995]
• Situational factors [Inch, Rowlands et al., 1995]
• Psychological distress [Inch, Rowlands et al., 1995]
• Male gender [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]
• Low social class [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]
• Single Marital state [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]

14. Moderate Predictive Test
Point of Partial Rarity?
Number
of No Repetition
Individuals
Repetition
True -ve
True -ve
True +ve
True +ve
False -ve
False -ve False +ve
False +ve
Score on Hypothetical Predictive Test Optimum Cut-off value (hopelessness)

15. Poor Prognostic Test
Number
of No Repetition
Individuals
Repetition
True -ve
True -ve
True +ve
True +ve
False -ve
False -ve False +ve
False +ve
Score on Hypothetical Predictive Test Optimum Cut-off value (eg size of overdose)

16. 0
20
40
60
80
100
120
140
160
180
Ze
ro
O
ne
Tw
o
Th
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e
Fo
ur
Fi
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ev
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Th
irt
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Fo en
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fte
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Tw n
Tw en
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Tw -O
en ne
Tw ty
en -tw
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Tw thr
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Tw -fo
en ur
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Tw -fiv
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Tw n t
en y-
si
ty x
Tw -s
ev
en e
ty n
Tw -eig
en ht
Beck SIS Scores 24-48hrs after Self-Harm
ty
-n
in
e
Data from Allan House
Th
irt
y

17. III: Evidence from Prediction Studies
Leicester SH10 Study
Edinburgh Scale (Kreitman and Foster)
Beck Hopelessness Scale

19. Basic Demographics
• There were 567 cases included in the study
• The study period was between 18-April-04 to 27
June 2006
• The mean age in years was 39
• The follow-up period mean 254 days
• 144 cases were followed for more than 365
days

20. Results Basic Repetition Details
In the total sample
• 130 cases repeated self-harm out of 567 = 22.9% repetition
rate
• There were 0.70 repeat self-harm attempts per year on
average
• Av time to repeat = 90 days
If Follow up < 6 months
• 223 cases were followed up for less than 6 months.
• Of these 39 repeated = 17.5% repetition rate
If Follow up > one year
• 144 cases were followed for more than 365 days
• 39 cases repeated = 27.1% repetition rate
• There were 0.50 repeat self-harm attempts per year on
average

21. III3: Leicester SH10 Repetition Results

22. Leicester SH10 (sub-sample)
Repeater No Repeat
Test +ve 84 120 PPV 41%
Test -ve 3 44 NPV 94%
87 164 250
Prevalence
Sensitivity Specificity
35%
97% 27%
Predictive Summary Index
35%

23. Clinical Application of Predictors – Actual Risk
Predictor If Yes If No RR
Alcohol/illicit drug user 35.1 18 2.0
Difficult personal history 47.1 19 2.5
Housing problems 33.9 22 1.5
Intended to die 31.1 14 2.2
Mood/Perception 36.5 17 2.1
Past Medical history 34.9 20 1.7
Past Psychiatric History 32 10 3.2
Previous self harm 33.9 15.2 2.2

24. Kreitman and Foster Scale, 2002 Study
• 3 yr study 1,331 patients
• 180 repeaters within 365 days
• Logistic regression analysis
revealed only previous
parasuicide contributed to self
harm repetition.

25. Accuracy of Kreitman & Foster Scale
Repeater No Repeat
Test +ve 46 90 PPV 33%
Test -ve 134 960 NPV 87%
180 1137 1317
Prevalence
Sensitivity Specificity 13.6%
26% 84.4% Predictive Summary Index
20%

26. Beck Hopelessness Scale (20items)

27. BHS Meta-analysis
Predict
ed Predicte
Repea high No d Low
Reference Sample ted Risk Repeat Risk
Colman et al (2004) Self-harm popn, 1yr follow-up 92 65 277 150
Hawton et al (2003) Self-harm popn, 1.7yrs follow-up 34 26 77 23
Keller and Wolfersdorf
(1993) Inpatient popn, 1yr follow-up 10 8 51 15
Sidley et al (1999) 1 year outcome data reported 25 19 40 14
Tyrer et al (2003) Self-harm RCT 1 year follow-up 183 148 247 69
Adolescents followed for 1 year after hospital
Goldston et al (2001) discharge 45 38 135 66
Adolescents followed for 6mo after hospital
Huth-Bocks (2007) discharge 20 15 134 79

28. Accuracy of BHS Scale (n=7)
Repeater No Repeat
Test +ve 319 545 PPV 37%
Test -ve 90 416 NPV 82%
409 961 1370
Prevalence
Sensitivity Specificity
(repetition baseline)
78% 43%
30%

29. 1
Post-test Probability
0.9
Baseline Probability
0.8
BHS+ (meta)
0.7
BHS- (Meta)
0.6
0.5
0.4
0.3
0.2
0.1
Pre-test Probability
0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

30. 1.00
Post-test Probability
0.90
K&F+
0.80 K&F-
Baseline Probability
BHS+ (meta)
0.70 BHS- (Meta)
SH10+
SH10-
0.60
0.50
0.40
0.30
0.20
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

31. IV: Comparison with Clinicians (Unassisted)
Alone
Added Value

32. Accuracy of A&E Staff (high risk)
Repeated No Repeat
High Risk 207 764 PPV 21%
Not High Risk 439 3469 NPV 89%
646 4233 4879
Prevalence
Sensitivity Specificity
(repetition baseline)
32% 82%
13%

33. Accuracy of A&E Staff (low risk)
Repeated No Repeat
High+Med 533 2722 PPV 26%
Risk
Low Risk 113 1511 NPV 87%
646 4233 4879
Prevalence
Sensitivity Specificity
(repetition baseline)
82.5% 35.7%
13%

34. Scales vs Unassisted Ability (Low Risk Strategy)
1.00
Post-test Probability
0.90
Unassisted (Not low risk)
0.80 Unassisted (low risk)
Baseline Probability
BHS+ (meta)
0.70 BHS- (Meta)
SH10+
SH10-
0.60
0.50
0.40
0.30
0.20
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

35. Scales vs Unassisted Ability (High Risk Strategy)
1.00
Post-test Probability
0.90
Unassisted (high risk)
0.80 Unassisted (not high risk)
Baseline Probability
BHS+ (meta)
0.70 BHS- (Meta)
SH10+
SH10-
0.60
0.50
0.40
0.30
0.20
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

36. V: Suicide?

37. BHS in DSH vs Suicide
1.00
Post-test Probability
0.90
BHS+ (Suicide)
0.80
BHS- (Suicide)
Baseline Probability
0.70 BHS+ (meta)
BHS- (Meta)
0.60
0.50
0.40
0.30
0.20
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

38. Accuracy of BHS Scale (n=7 for DSH)
Repeater No Repeat
Test +ve 319 545 PPV 37%
Test -ve 90 416 NPV 82%
409 961 1370
Prevalence
Sensitivity Specificity
(repetition baseline)
78% 43%
30%

39. Accuracy of BHS Scale (n=4 for suicide)
Repeater No Repeat
Test +ve 46 1434 PPV 03%
Test -ve 12 1067 NPV 99%
58 2501 2559
Prevalence
Sensitivity Specificity
(repetition baseline)
79% 43%
02%

40. IV: Extras and Questions

41. Predictive Scales after DSH - Power
Repetition after DSH (Kreitman & Foster Scale)
70
Percentage
Repeating
60 Number
Repeating
50
Repetition (Number vs Proportion)
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12
Patients who score highly on the Kreitman & Foster scale are more likely to repeat,
Positive Predictive items
but the majority who repeat do not score highly

42. Advanced Suicide Intent Scales

43. Ranking (single Items)
P-value
Suicidal Plans or Conditional Threats? 1.65638E-05
Mood or Perceptions? 4.57034E-05
Previous Self-Harm? 0.000621875
Difficult Personal History? 0.001925556
Intended to die? 0.008459658
Housing problems? 0.113801724
Past Medical history? 0.171397338
Lack of social support? 0.202312118
Relationship problems? 0.234563323
Work or Financial problems? 0.267886875
Admission required (if so where)? 0.386619302
Past Psychiatric history? 0.391145703
Psychosis (odd thinking or beliefs)? 0.394990629
Antidote, sutures required? 0.411700936
Dementia (memory, odd behaviour)? 0.473154302
Appearance or Behaviour? 0.510764942
Unusual or risky circumstances? 0.730928415
Cognition or Insight? 0.903027575
Believed method was dangerous/fatal? 0.980425812
Alcohol or Illicit Drug User? 0.983364721
Depression (low interest, self-esteem)? 0.964452202
ICU/ITU or Resuscitation required? 0.910132669
Medical Complications or detoxification? 0.839234812
Personality (self-destructive, impulsive)? 0.755394419
Current Suicidal Intent? 0.675189743
Refuses assessment? 0.503519167
Delirium (poor orientation or attention)? 0.194075771
Hopeless or Suicidal Thoughts? 0.097861755
Attempts at concealment or Final acts? 0.068804974
Speech or Thoughts? 0.061774313

44. Combination Risk
Suicidal Plans or Conditional Threats?
+
Difficult Personal History? = 64% (if no
18%)
Past Psychiatric History
+
Intended to Die = 40% (if no 5%)
Past Psychiatric History
+

45. Alternative Cut-Off
• The 10 Step form can act as an accurate risk
predictor
• Optimal accuracy with a 50% referral rate =>
– 80% rule out and 50% rule in
• Using the simplest system (4 item) with 0/1 =>
– 93% rule out and 41% rule in (but we would receive
80% of referrals)

47. Summary of Factors Influencing Outcomes
Factor Predicts No. Of Repeats Predicts Time to Repeat
Suicidal plans/Threats Yes(1) No
Mood/Perceptions Yes(2) No
Previous Self Harm Yes(3) Yes(2)
Difficult Personal History Yes(4) No
Intended to Die Yes(5) Trend (p<0.1)
Past Psychiatric History No Yes(1)
Admission Required(Where) No Yes(3)
Refuses assessment No Yes(4)
Depression(low interest, No Yes(5)
self-esteem)

48. 0
10
20
30
40
50
60
70
80
90
100
0
Re
pe
tit
io
ns
437
1
Re
pe
tit
io
n
90
2
Re
pe
tit
io
ns
25
3
Re
pe
tit
io
ns
7
Frequency of Repetitions of Self Harm
4
Re
pe
tit
io
ns
5
5+
Re
pe
tit
io
ns
4

49. 0
5
10
15
20
25
1
Da
y
12
2-
Rate
7
Da
ys
14
8-
14
Da
ys
9
15
-2
8
Da
ys
17
29
-5
9
Da
ys
13
60
-9
0
Da
ys
Frequency distribution of Repetition
16
90
-1
80
Da
ys
23
18
1-
36
4
Da
ys
23
36
5
Da
ys
+
3