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Alex Mitchell, Consultant in Liaison PsychiatryLeicester General Hospital / University of Leicester
Royal College of Psychiatrists, Annual Meeting, UCL, London, July 2008
Risk to Self in PsychiatryDo suicide/self-harm scales help clinicians?
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?
I: Guidelines
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 =>
http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html
Application of Scales =>
II: Self-Harm Scales
Many Scales
The Suicide Probability Scale (SPS; Cull & Gill, 1988) is a 36-item self-report
SPS
The Suicidal Ideation Scale (SIS; Rudd, 1989) is a 10-item self-report scale
SIS
The Modified Scale for Suicide Ideation ( Miller, Norman, Bishop, & Dow, 1986) is a revised version of the Scale for Suicide Ideation
MSSI
Beck Depression Inventory (BDI; Beck & Steer, 1988)BDI(Suicide item)
Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960)HRDS(Suicide item)
Beck Hopelessness scale (Beck & Steer, 1988)BHS
Lethality Scales (LS; Beck, Beck & Kovacs, 1975)LS
Suicide Intent Scale (Beck, Schuyler, & Herman, 1974)SIS
Scale for Suicidal Ideation(SSI; Beck et al., 1979)SSI
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
Beck Suicide Intent Scale (15 items)
Measure Administration
Self Interview Items
Predictive Validity
Study SettingPsyc Medical Community other
Scale for Suicidal Ideation
No Yes 21 Yes Yes Yes Yes Yes
Suicide Intent Scale No Yes 15 Yes Yes Yes No No
Lethality Scale No Yes 8 No Yes Yes No No
HRDS(Suicide item)
No Yes 1 Yes Yes No No No
BecksHopelessness scale
Yes No 20 Yes Yes Yes No No
BDI(Suicide item)
Yes No 1 No Yes Yes No Yes
Linehan reason for living
Yes No 48 No Yes Yes Yes Yes
Difficulty Predicting Repetition
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]
Moderate Predictive Test
No Repetition
Repetition
Number ofIndividuals
Optimum Cut-off value (hopelessness)
False +veFalse +veFalse -veFalse -ve
True -veTrue -ve
True +veTrue +ve
Point of Partial Rarity?
Score on Hypothetical Predictive Test
Poor Prognostic Test
No Repetition
Repetition
Number ofIndividuals
Optimum Cut-off value (eg size of overdose)
False +veFalse +veFalse -veFalse -ve
True -veTrue -ve
True +veTrue +ve
Score on Hypothetical Predictive Test
Beck SIS Scores 24-48hrs after Self-Harm
0
20
40
60
80
100
120
140
160
180
Zero OneTwoThree Four
Five SixSev
enEightNine
TenEleve
nTwelv
eThirt
een
Fourtee
nFifte
enSixtee
nSev
entee
nEightee
nNinete
enTwen
tyTwen
ty-One
Twenty-
two
Twenty-
three
Twenty-
fourTwen
ty-fiv
eTwen
ty-six
Twenty-
seve
nTwen
ty-eig
htTwen
ty-nin
eThirt
y
Data from Allan House
III: Evidence from Prediction Studies
Leicester SH10 Study
Edinburgh Scale (Kreitman and Foster)
Beck Hopelessness Scale
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
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
III3: Leicester SH10 Repetition Results
Leicester SH10 (sub-sample)
25016487
NPV 94%443Test -ve
PPV 41%12084Test +ve
No RepeatRepeater
Sensitivity97%
Specificity27%
Prevalence35%Predictive Summary Index35%
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
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.
Accuracy of Kreitman & Foster Scale
13171137180
NPV 87%960134Test -ve
PPV 33%9046Test +ve
No RepeatRepeater
Sensitivity26%
Specificity84.4%
Prevalence13.6%Predictive Summary Index20%
Beck Hopelessness Scale (20items)
BHS Meta-analysis
791341520Adolescents followed for 6mo after hospital dischargeHuth-Bocks (2007)
661353845Adolescents followed for 1 year after hospital dischargeGoldston et al (2001)
69247148183Self-harm RCT 1 year follow-upTyrer et al (2003)
144019251 year outcome data reportedSidley et al (1999)
1551810Inpatient popn, 1yr follow-upKeller and Wolfersdorf(1993)
23772634Self-harm popn, 1.7yrs follow-upHawton et al (2003)
1502776592Self-harm popn, 1yr follow-upColman et al (2004)
Predicted Low
RiskNo
Repeat
Predicted
high Risk
RepeatedSampleReference
Accuracy of BHS Scale (n=7)
1370961409
NPV 82%41690Test -ve
PPV 37%545319Test +ve
No RepeatRepeater
Sensitivity78%
Specificity43%
Prevalence(repetition baseline)30%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post
-test
Pro
babi
lity
Baseline Probability
BHS+ (meta)
BHS- (Meta)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Pos
t-tes
t Pro
babi
lity
K&F+K&F-Baseline ProbabilityBHS+ (meta)BHS- (Meta)SH10+SH10-
IV: Comparison with Clinicians (Unassisted)
Alone
Added Value
Accuracy of A&E Staff (high risk)
48794233646
NPV 89%3469439Not High Risk
PPV 21%764207High Risk
No RepeatRepeated
Sensitivity32%
Specificity82%
Prevalence(repetition baseline)13%
Accuracy of A&E Staff (low risk)
48794233646
NPV 87%1511113Low Risk
PPV 26%2722533High+MedRisk
No RepeatRepeated
Sensitivity82.5%
Specificity35.7%
Prevalence(repetition baseline)13%
Scales vs Unassisted Ability (Low Risk Strategy)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post
-test
Pro
babi
lity
Unassisted (Not low risk)Unassisted (low risk)Baseline ProbabilityBHS+ (meta)BHS- (Meta)SH10+SH10-
Scales vs Unassisted Ability (High Risk Strategy)
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Post
-test
Pro
babi
lity
Unassisted (high risk)Unassisted (not high risk)Baseline ProbabilityBHS+ (meta)BHS- (Meta)SH10+SH10-
V: Suicide?
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
1.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Pre-test Probability
Pos
t-tes
t Pro
babi
lity
BHS+ (Suicide)
BHS- (Suicide)
Baseline Probability
BHS+ (meta)
BHS- (Meta)
BHS in DSH vs Suicide
Accuracy of BHS Scale (n=7 for DSH)
1370961409
NPV 82%41690Test -ve
PPV 37%545319Test +ve
No RepeatRepeater
Sensitivity78%
Specificity43%
Prevalence(repetition baseline)30%
Accuracy of BHS Scale (n=4 for suicide)
2559250158
NPV 99%106712Test -ve
PPV 03%143446Test +ve
No RepeatRepeater
Sensitivity79%
Specificity43%
Prevalence(repetition baseline)02%
IV: Extras and Questions
Predictive Scales after DSH - PowerRepetition after DSH (Kreitman & Foster Scale)
0
10
20
30
40
50
60
70
0 1 2 3 4 5 6 7 8 9 10 11 12
Positive Predictive items
Rep
etiti
on (N
umbe
r vs
Prop
ortio
n)
PercentageRepeating
NumberRepeating
Patients who score highly on the Kreitman & Foster scale are more likely to repeat, but the majority who repeat do not score highly
Advanced Suicide Intent Scales
Ranking (single Items)
0.061774313Speech or Thoughts?0.068804974Attempts at concealment or Final acts?0.097861755Hopeless or Suicidal Thoughts?0.194075771Delirium (poor orientation or attention)?0.503519167Refuses assessment?0.675189743Current Suicidal Intent?0.755394419Personality (self-destructive, impulsive)?0.839234812Medical Complications or detoxification?0.910132669ICU/ITU or Resuscitation required?0.964452202Depression (low interest, self-esteem)?0.983364721Alcohol or Illicit Drug User?0.980425812Believed method was dangerous/fatal?0.903027575Cognition or Insight?0.730928415Unusual or risky circumstances?0.510764942Appearance or Behaviour?0.473154302Dementia (memory, odd behaviour)?0.411700936Antidote, sutures required?0.394990629Psychosis (odd thinking or beliefs)?0.391145703Past Psychiatric history?0.386619302Admission required (if so where)?0.267886875Work or Financial problems?0.234563323Relationship problems?0.202312118Lack of social support?0.171397338Past Medical history?0.113801724Housing problems?0.008459658Intended to die?0.001925556Difficult Personal History?0.000621875Previous Self-Harm?4.57034E-05Mood or Perceptions?1.65638E-05Suicidal Plans or Conditional Threats?
P-value
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+
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)
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, self-esteem)
No Yes(5)
Frequency of Repetitions of Self Harm90
25
75 4
0
10
20
30
40
50
60
70
80
90
100
0 Rep
etitio
ns
1 Rep
etitio
n
2 Rep
etitio
ns
3 Rep
etitio
ns
4 Rep
etitio
ns
5+ Rep
etitions
437
12
14
9
17
13
16
23 23
3
0
5
10
15
20
25
1 Day
2-7 Da
ys
8-14 D
ays
15-28
Days
29-59
Days
60-90
Days
90-18
0 Day
s
181-36
4 Day
s
365 Days
+Frequency distribution of Repetition Rate