Columbia-Suicide Severity Rating Scale Screen Version: initial screening for suicide risk in a psychiatric emergency department

Abstract

Background Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to evaluate the association between the novel Colombia Suicide Severity Rating Scale Screen Version (C-SSRS Screen) and subsequent clinical management and suicide within 1 week, 1 month and 1 year from screening. Methods Consecutive patients (N = 18 684) attending a PE department in Stockholm, Sweden between 1 May 2016 and 31 December 2017 were assessed with the C-SSRS Screen. All patients (52.1% women; mean age = 39.7, s.d. = 16.9) were followed-up in the National Cause of Death Register. Logistic regression and receiver operating characteristic curves analyses were conducted. Optimal cut-offs and accuracy statistics were calculated. Results Both suicidal ideation and behaviour were prevalent at screening. In total, 107 patients died by suicide during follow-up. Both C-SSRS Screen Ideation Severity and Behaviour Scales were associated with death by suicide within 1-week, 1-month and 1-year follow-up. The optimal cut-off for the ideation severity scale was associated with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7, 95% confidence interval 1.5–14.8). Both scales were also associated with short-term clinical management. Conclusions The C-SSRS Screen may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide risk. Future research may investigate the utility of combining the C-SSRS Screen with a more thorough assessment.

The Brief Suicide Cognitions Scale: Development and Clinical Application

“…Recent findings have highlighted the limited predictive value of traditional approaches to assessing suicidal thinking and behaviors in real-world clinical settings, specifically the limitations of relying on endorsement of suicidal thinking. Both Bjureberg et al ( 1 ) and Simpson et al ( 2 ), utilizing large samples from psychiatric emergency departments with suicide outcomes at 30 and 365-days post-discharge, found the Columbia Suicide Severity Rating Scale (C-SSRS) screener to have poor predictive value. Similarly, ( 3 ) found that prior suicidal thoughts and behaviors only provided “marginal improvement in diagnostic accuracy above chance (p. 2).” In the largest meta-analysis to date, covering a span of 50 years, ( 4 ) similarly found: (a) that predictive value has not improved, (b) predictive values are only slightly better than chance across all outcome measures, (c) and ultimately called for fundamental changes in approach to suicide risk assessment, particularly across real-world clinical settings.…”

Suicide Models and Treatment Models Are Separate Entities. What Does It Mean for Clinical Suicide Prevention?

“…By their nature, risk factor models can only provide information on mid-term or long-term risk, but not on the risk in a time frame of hours and days. In clinical practice, risk-factor-based suicide screening can be used as an initial step leading to a person-centered risk assessment [ 33 , 34 ].…”

Hospital staff at most psychiatric clinics in Stockholm experience that patients who self-harm have too long hospital stays, with ensuing detrimental effects

“…Suicide risk assessment is often mandatorily used in psychiatry to predict and prevent suicides. However, suicide risk assessment has such low positive predictive value and limited sensitivity that the clinical value is limited in individual cases and does not justify highly interfering interventions such as admission to inpatient care [30][31][32]. Also, admitting a patient assessed as having high suicide risk to inpatient care has not shown to reduce the incidence of suicides over time and admission to hospital itself has been argued to possibly play a causal role in a proportion of inpatient suicides [32,33].…”

“…However, suicide risk assessment has such low positive predictive value and limited sensitivity that the clinical value is limited in individual cases and does not justify highly interfering interventions such as admission to inpatient care [30][31][32]. Also, admitting a patient assessed as having high suicide risk to inpatient care has not shown to reduce the incidence of suicides over time and admission to hospital itself has been argued to possibly play a causal role in a proportion of inpatient suicides [32,33]. These unrealistic expectations from society when it comes to psychiatrists' ability to predict and prevent suicides may explain why many psychiatrists experience work-related anxiety related to handling suicidality, sometimes to the extent that it affects their clinical practise negatively [34,35].…”