The clinical use of objective measures of suicidal ideation

[Rivi]

---

Members do not see this ad.

Hello everyone,

As many of you are aware, there are several scales designed to measure suicidal ideation, such as the Beck Suicidal Ideation Scale (see website below for a brief description of several):

http://www.hawaii.edu/hivandaids/Review%20of%20Suicide%20Assess%20for%20Interven%20Res%20w%20Adults%20and%20Older%20Adults.pdf

Despite the prevalence of these scales, a few of which have decent reliability and validity, I have rarely seen them used in clinical settings. The general consensus amongst clinicians seems to be that we should rely on interviewing techniques, rapport, safety plan, etc. This makes sense to me with some patients, but there are a few groups of patients I worry about:

-Inpatients that attempt suicide, are frustrated that they didn't complete, and under-report in an attempt to leave the hospital.

-Patients of therapists that are prone to over-react or under-react to the mention of suicide.

-Patients that are "on the fence." An objective measure may help give a clearer sense of severity and urgency.

Are these scales at all clinically useful? Do they add information that will be clinically relevant? Is SI something that is currently beyond our capacity to objectively measure to a degree that is clinically relevant?

 

[szymk1sm]

Have you looked up the Columbia Suicide Severity Rating Scale (CSSRS)? I have just begun reading about it, but it accounts for both ideation and behavior. Here's the website... http://www.cssrs.columbia.edu/

 

[Maedothin]

The clinic I've worked at does not make use of any SI scales. We use a suicide contract with the client, and a very simple means of recording in the client file the degree of danger to self we would rate the client is at. In response to your question, my sense (admittedly as an unlicensed student) is that if I have a client who is expressing some degree of suicidal ideation, I'm not going to run to the back room and grab an instrument to measure it. I am going to ask the critical questions (e.g. presence of plan, degree of specificty, etc) and make a judgment call on the spot. I can see liability insurance companies mandating the use of SI instruments to protect their own assets, and it may possibly be valuable for research, but I don't see much clinical value. A client with SI doesn't care about their SI t-score, and a licensed psychologist should have enough clinical judgment to protect their clients.

 

[docma]

Designing, testing, and revising measures is something psychologists do and it is useful to become familiar with formal scales as it helps you learn what the elements of good suicide assessment are and questions to include in a good interview and risk assessment. But I think they are probably implemented more as an institutional risk-management effort than because they are actually effective in prevention. How they are used in the context of the personal contact is clearly an important moderating variable in how the evaluation is itself an effective intervention. Basically, it is the quality of the personal contact and the thoroughness of the clinical interview that are really important. Many of the people most at risk will either not be motivated to do a scale in a valid way or they will be so intent on their plan that they will not be honest which effects validity too.

 

[cara susanna]

We look at the "suicide items" on the BDI. There is a great article on suicide assessment that I read for a class that discusses these issues, can't think of the citation though.

 

[Maedothin]

We look at the "suicide items" on the BDI. There is a great article on suicide assessment that I read for a class that discusses these issues, can't think of the citation though.

Hmm, I guess in that sense we do too. Didn't think about pre-treatment measures. We do that, I guess. Odd spikes can prompt direct inquiry in tx

 

[psychology24]

Hmm, I guess in that sense we do too. Didn't think about pre-treatment measures. We do that, I guess. Odd spikes can prompt direct inquiry in tx

I would HIGHLY recommend looking into the work by Jobes and colleagues with the Collaborative Assessment and Management of Suicidality (CAMS). They also have an assessment instrument called the Suicide Status Form.

 

[Therapist4Chnge]

I would HIGHLY recommend looking into the work by Jobes and colleagues with the Collaborative Assessment and Management of Suicidality (CAMS). They also have an assessment instrument called the Suicide Status Form.

He's done some interesting work. A quick overview of CAMS can be found here: http://www.dcoe.health.mil/event_do...09_JOBES_1520-1600_DOD_VA_CAMS_PPT_edited.pdf

--

Rivi, you are right to have those concerns, as they are quick applicable to the discussion. About 4 years ago I did some side research into the use/misuse of no harm contracts, and I came across quite a bit in the literature that touches on your questions. I can get you some citations (or the journal articles if I still have them) to address some of your concerns.

Inpatients that attempt suicide, are frustrated that they didn't complete, and under-report in an attempt to leave the hospital.

There can be an attempt to under-report and deny suicidal ideation with the goal of getting off of precautions....so they can try again.

Clinicians tend to over-estimate their clinical judgment, which allows for the opportunity for a patient to make an attempt (or attempt again) to suicide. Further complicating matters is that most doctoral training programs (per student report) do not sufficiently prepare students to fully assess and treat an at-risk patient. IIRC, a former colleague did her dissertation (or thesis?) on this exact issue. I can't remember if she also surveyed doctoral programs to see if they over-estimated their training...but that'd be interesting.

I'm not sure anything has been shown to be more effective than a solid clinical interview and continued followup by a licensed MH provider to re-assess as appropriate. While there are some common factors in a suicidal patient, I think the diversity of presentation makes it very difficult to really quantify and predict the straw that breaks the camel's back. A colleague of mine has done some work with the PHQ-9, suicidal ideation, and a rehab population...though that was looking more at initial flagging for risk, not followup.

 

[4410]

The clinic I've worked at does not make use of any SI scales. We use a suicide contract with the client, and a very simple means of recording in the client file the degree of danger to self we would rate the client is at. In response to your question, my sense (admittedly as an unlicensed student) is that if I have a client who is expressing some degree of suicidal ideation, I'm not going to run to the back room and grab an instrument to measure it. I am going to ask the critical questions (e.g. presence of plan, degree of specificty, etc) and make a judgment call on the spot. I can see liability insurance companies mandating the use of SI instruments to protect their own assets, and it may possibly be valuable for research, but I don't see much clinical value. A client with SI doesn't care about their SI t-score, and a licensed psychologist should have enough clinical judgment to protect their clients.

I went to a VA workshop last year covering suicide. We don't use suicide contracts anymore in my work setting, corrections, and the psychologists who is with the VA and developing a suicidality scale does not recommend using a suicide contract. For some reason, ethic and liability come into play and if it is severe enough to use a suicide contract, then the person needs to be in a hospital for treatment. I believe using a suicide contract increases your liability if the person commits suicide. We used to use contracts when I was working at a mental health center back in the 80's and 90's, and I have had two clients who successfully committed suicide despite at the time signing a contract and contacting family for supervision. Once they leave your office you do not know what the person will encounter. If you believe a written contract is necessary then the person should be protected in a hospital setting. Although it is a difficult decision for a psychologists to make, the client does not have the capacity to protect themselves once they are at this point.

The VA psychologist talked about the Golden Gate Bridge Phenomenon. There is a camera or video of people attempting or commiting suicide on the Golden Gate Bridge. Ironically, people who have suicidal thoughts frequently go to the Bridge when it is busiest rather then when no one is there. People who are thinking about killing themselves want to be discovered and they want to be rescued. I've had clients cuss me out with extreme anger when I am recommending they go to a psychiatric hospital due to suicidal ideations and a short time later they are very thankful that I recognized that they needed help now and not in a week because they signed a piece of paper. After you have had clients who have successfully committed suicide many have a different perspective on the subject of suicidal intervention and need for hospital admissions.

It was the CAMS workshop that I attended in Fort Worth, Texas last year. The presenter was B. Christopher Frueh, Ph.D. from University of South Carolina Medical Center. They had three or four presenters and one of them was a lady who wrote a book on living with bipolar disorder and her input on her numerous suicide attempts. Seems that the main presenter was from a VA in South Carolina, but the project is a collaborative effort among many agencies. He absolutely did not recommend using a written contract but he did recommend using objective measures.

 

[AcronymAllergy]

Research has shown that assessment measures (self-reports and semi-structured interviews) outperform clinical judgment in assessing suicide risk (and also in classifying suicide attempts, which is an important component of assessing future risk). Nock and colleagues are also working on implicit behavioral measures, that while not ready for use clinically, have been shown to predict suicide attempts better than clinician judgment in longitudinal study. Clinical judgment alone is not sufficient. The reality is that many programs do not adequately train students to assess for suicide risk. There was a paper out several years ago that actually found that MD's were the most competent as a degree group in assessing for suicide risk.

Also, "suicide contracts" are basically the worst thing ever. They are ineffective at best and harmful at worst. The standard of care is collaborative safety planning.

I haven't read the paper, so this may have been addressed, but I wonder if the this finding is owing to MD's being more ok with (and used to) making the decision to hospitalize patients than are psychologists. Perhaps data on overall rates/frequencies of hospitalizations by provider could shed some light on that.

At the same time, MD's typically do see a larger sheer number of severely mentally ill and/or suicidal individuals during their training than do psychologists, which may help the former to develop more astute heuristics.

 

[nitemagi]

Everyone is bad at predicting human behavior, in general. Even the best measures probably aren't going to do better than 70% predictability in the short run.

Psychiatrists get a Lot of exposure at assessing suicidality. Still there's wide variation amongst clinicians. I believe standardized self-report measures are useful in teaching risk factors, but that's about it. We might be at best OK at predicting someone's acute risk over the next day. But what about the next week? Month? Year? There's way too many variables that could occur that could substantially escalate the risk. Hence the importance of follow-up. There are evidence based interventions that can reduce risk, like of all things postcards. In far too many institutions they're not implemented.

Scales are useful to measure risk factors, but someone intent on beating the system to complete suicide can just as easily lie. There are just as many currently unmeasured variables that are observed in a clinical interview that may indicate defensiveness (minimizing sx's). Might be nice to try to standardize those factors, but even that would only go so far. In the end we're all pretty bad at predicting suicide.

We should use the evidence, but recognize its limitations. "Objective" measures based on self-report is still quite fallible, especially when the risks are so high.

 

[4410]

No suicide contracts should never be used, as they are not an effective intervention, so it has nothing to do with the decision to hospitalize someone.
If a person is at imminent risk for suicide, they should be hospitalized for their safety. If someone is not at imminent risk, I would be cautious with hospitalization, given that inpatient stays have no evidence of actually reducing suicide risk (other than temporary means restriction) and the days following discharge from a hospital are very high risk (something like 50x increase in suicide risk following discharge).

If someone is not at imminent risk, a collaborative safety plan is warranted, in addition to a treatment regimen that is evidence-based for suicide (DBT and CT for Suicide are the two most researched; CAMS is quickly getting there).

Some of the responses to this post really scare me, because people are getting poor and in some cases negligent training out there in how to assess and treat suicidal patients.

I agree that a risk assessment is needed. However, a written contract is not recommended anymore as it increases your liability and it does not protect the safety of the client. If you believe a written contract is necessary, than hospitalization is warranted. Informed consent covers this before beginning a treatment process.

 

[PsychBrownBag]

" People who are thinking about killing themselves want to be discovered and they want to be rescued."

This is inaccurate and, in my opinion, dangerous thinking. Intent levels certainly vary, however, the data solidly refute the notion that individuals with suicidal ideation generally "want" to be caught. Being glad after the fact that intervention occurs does not speak to the individuals desire prior to that intervention. The Golden Gate Bridge is actually a great example of that point. Approximately 97% of the individuals who jump from the bridge die. The few who survive the fall speak about their clear desire for death prior to the fall and their sense of regret immediately upon jumping. The shift - that impulsive urge to preserve life - is an important thing to note clinically, but it does not change the script that came before that moment.

Read some of Joiner's work on the acquired capability and the stoicism and fearlessness about death involved in serious and lethal suicidal behavior in particular.

 

[4410]

" People who are thinking about killing themselves want to be discovered and they want to be rescued."

This is inaccurate and, in my opinion, dangerous thinking. Intent levels certainly vary, however, the data solidly refute the notion that individuals with suicidal ideation generally "want" to be caught. Being glad after the fact that intervention occurs does not speak to the individuals desire prior to that intervention. The Golden Gate Bridge is actually a great example of that point. Approximately 97% of the individuals who jump from the bridge die. The few who survive the fall speak about their clear desire for death prior to the fall and their sense of regret immediately upon jumping. The shift - that impulsive urge to preserve life - is an important thing to note clinically, but it does not change the script that came before that moment.

Read some of Joiner's work on the acquired capability and the stoicism and fearlessness about death involved in serious and lethal suicidal behavior in particular.

Well from my recollection at this workshop, the emphasis was that there are numerous attempts by people contemplating suicide to be rescued. This does not mean that they want to intentionally or consciously be caught or discovered. If people did not want to be rescued then why would they talk about their feelings to hurt themselves? They would just do it and get it over with, they would not discuss these feeling with a family member or a therapist. Most suicide autopsies indicate there were numerous warning signs of something seriously being wrong where people did not intervene. Even in the Golden Gate Bridge Phenomenon, people climb over the rail and look and wait to see if other people will notice what they are doing. There is a sort of dissociative experience in that they may want to kill themselves but at the same moment they want help or recognition that they need help. Yes, survivors frequently indicate that once they have dropped off the bridge that they have a moment of epiphany and regret leting go but it is too late now, or at the time they thought it was too late.

 

[PsychBrownBag]

I haven't seen the data presented in that workshop, so I won't speak directly to that, but what I can say is that the preponderance of data out there do not support the notion that the majority of suicide attempts are engaged in with the aim of being rescued. In fact, the operational definition of suicidal behavior in some cases involves clear intent for death as a result of that specific behavior (not death in general), which is entirely incompatible with the desire for rescue (unlike the desire for death in general, which could, in theory, be present along side the desire for rescue). We can certainly argue about whether or not individuals have unconscious desire to be rescued, but that is an unfalsifiable idea. Furthermore, the frequency with which attempts are made in isolation and without overt communication to others regarding the intent to engage in the behavior speaks to something far different.

With respect to the question as to why people would speak about their desire to harm themselves if they did not want to get caught: they would do so for the same reason we speak about other behaviors and outcomes we wish for that we do not want others to stop. We talk about what is on our mind, particularly when people ask about the topic. Speaking about something does not mean you do not want that outcome to occur.

One last point: it is unclear where you are getting the notion that individuals have a dissociative experience just prior to engaging in suicidal behavior. In fact, plenty of emerging data demonstrate that it is individuals who are able to remain focused on their desired outcome (death) in the face of the physical and emotional discomfort associated with suicide attempts that are more likely to engage in the behavior.

I don't question that there are individuals who are unclear on their intent for death and who would prefer to have an individual intervene and demonstrate that they care for them. That simply does not characterize this behavior on the whole.

 

[cara susanna]

I've heard that suicide contracts are useless, too. I think people just use them because it makes them feel better, and maybe they feel it will also help them legally in terms of liability.

 

[nitemagi]

An alternative interpretation of the golden gate bridge situation is that they want witnesses for other reasons than to be dramatic, such as an interest to harm their loved ones. Probably useful to point out that there are many sub-populations of those that're suicidal and those that complete suicide. Some do rehearsal behaviors and then ultimately complete it, maybe by accident some of the time. Others can do it as retaliation (I can't count the number I've seen who escalate to a SA after not being admitted to the hospital). Others just want relief from suffering and couldn't give a damn about other people or a desire to be rescued. Lumping everyone together neglects the heterogeneity of the population and the need to account for their individual risks.

 

[nitemagi]

I've heard that suicide contracts are useless, too. I think people just use them because it makes them feel better, and maybe they feel it will also help them legally in terms of liability.

People definitely think that it protects them, though in truth it's the opposite.

http://www.ncbi.nlm.nih.gov/pubmed/19767501

 

[Therapist4Chnge]

People definitely think that it protects them, though in truth it's the opposite.

http://www.ncbi.nlm.nih.gov/pubmed/19767501

I can dig up a bunch of other citations if people are interested in reading more about this. My side research looked specifically at the implications of using a no harm contract in a clinical setting. I did a brief review of the legal implications of its use. I never got around to publishing it, though I think it is still worthwhile information.

 

[wigflip]

I can dig up a bunch of other citations if people are interested in reading more about this. My side research looked specifically at the implications of using a no harm contract in a clinical setting. I did a brief review of the legal implications of its use. I never got around to publishing it, though I think it is still worthwhile information.

I'd be interested in reading more (thanks for the abstract link, nitemagi). Nice offer, T4C.

 

[psychology24]

The VA psychologist talked about the Golden Gate Bridge Phenomenon. There is a camera or video of people attempting or commiting suicide on the Golden Gate Bridge. Ironically, people who have suicidal thoughts frequently go to the Bridge when it is busiest rather then when no one is there. QUOTE]

There is a documentary made about this. I believe it is titled, "The Bridge"

 

[psychology24]

Even in the Golden Gate Bridge Phenomenon, people climb over the rail and look and wait to see if other people will notice what they are doing. There is a sort of dissociative expereince in that they may want to kill themselves but at the same moment they want help or recognition that they need help. Yes, survivors frequently indicate that once they have dropped off the bridge that they have a moment of epiphany and regret leting go but it is too late now, or at the time they thought it was too late.

I wouldnt deem this a disassociative experience, but rather it reflects the ambivalence with suicide of wanting to live vs. wanting to die. Jobes talks about this ambivalence and the CAMS approach and SSF (instrument) reflect this ambivalence as well. Also, there was an article awhile back, I think by Beck and Kovacs on suicide and ambivalence: I think it was called "The Wish to Die and the Wish to Live," maybe.

 

[Therapist4Chnge]

I can't find the article I first though of, but here are a few citations worth reading.

American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Psychiatric Association Practice Guidelines. Arlington, VA.

Simon RI. (1999). The suicide prevention contract: clinical, legal, and risk management issues. Journal of the American Academy of Psychiatry and the Law. 27:445-450.

Williams, H.R. (2005). Contracting for safety redux. Law and Psychiatry. (11)1: 54-57.

 

[wigflip]

I can't find the article I first though of, but here are a few citations worth reading.

American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Psychiatric Association Practice Guidelines. Arlington, VA.

Simon RI. (1999). The suicide prevention contract: clinical, legal, and risk management issues. Journal of the American Academy of Psychiatry and the Law. 27:445-450.

Williams, H.R. (2005). Contracting for safety redux. Law and Psychiatry. (11)1: 54-57.

How thoughtful. Thank you.