Emergency Room Validation of the Revised Suicide Trigger Scale (STS-3): A Measure of a Hypothesized Suicide Trigger State

Abstract

BackgroundThe Suicide Trigger Scale (STS) was designed to measure the construct of an affective ‘suicide trigger state.’ This study aims to extend the inpatient setting validation study of the original Suicide Trigger Scale version 2 to the revised Suicide Trigger Scale version 3 (STS-3) in an acute psychiatric emergency room setting.MethodsThe 42-item STS-3 and a brief psychological test battery were administered to 183 adult psychiatric patients with suicidal ideation or attempt in the psychiatric emergency room, and re-administered to subjects at 1 year follow up. Factor analysis, linear and logistic regressions were used to examine construct structure, divergent and convergent validity, and construct validity, respectively.ResultsThe STS-3 demonstrated strong internal consistency (Cronbach’s alpha 0.94). Factor analysis yielded a three-factor solution, which explained 43.4% of the variance. Principal axis factor analysis was used to identify three reliable subscales: Frantic Hopelessness, Ruminative Flooding, and Near-Psychotic Somatization (Cronbach’s alphas 0.90, 0.80, and 0.76, respectively). Significant positive associations were observed between Frantic Hopelessness and BSI depression and anxiety subscales, between Ruminative Flooding and BSI anxiety and paranoia subscales, and Near Psychotic Somatization and BSI somatization subscales. Suicidal subjects with suicide attempt history had mean scores 7 points higher than those without history of suicide attempts. Frantic hopelessness was a significant predictor of current suicide attempt when only attempts requiring at least some medical attention were considered.ConclusionThe STS-3 measures a distinct clinical entity, provisionally termed the ‘suicide trigger state.’ Scores on the STS-3 or select subscales appear to relate to degree of suicidality in terms of severity of ideation, history of attempt, and presence of substantive current attempts. Further study is required to confirm the factor structure and better understand the nature of these relations.

Functional domains as correlates of suicidality among psychiatric inpatients

“…Addressing this challenge, the Research Domain Criteria (RDoC) project was launched where systems based on cognitive, behavioral and neuronal mechanisms are the focus of investigation rather than a DSM classified psychiatric disorder (Cuthbert, 2015). Relatedly, several suicide studies from our laboratory and others have examined specific symptoms that reflect corresponding disturbances in functional domains, such as anhedonia (Bradley et al, 2015; Fawcett et al, 1990; Gabbay et al, 2015; Kollias et al, 2008; Nock and Kazdin, 2002; Spijker et al, 2010; Winer et al, 2014), anxiety/entrapment (Goldston et al, 1996; Goldston et al, 2006; Hendin et al, 2010; O’Connor et al, 2013; Ohring et al, 1996; Panagioti et al, 2012; Sareen et al, 2005a; Sareen et al, 2005b; Yaseen et al, 2012; Yaseen et al, 2014), and attachment disturbances (Adam et al, 1996; Grunebaum et al, 2010; Lessard and Moretti, 1998; Lizardi et al, 2011; Palitsky et al, 2013). In particular, anhedonia reflects disturbance in reward processing including reward motivation (Auerbach et al, 2015; Gold et al, 2013), attainment (Liu et al, 2016), and learning (Pizzagalli et al, 2008; Pizzagalli et al, 2005); entrapment reflects response to acute threat in the context of frustrative nonreward (Gilbert and Allan, 1998); state and trait anxiety reflect acute sensitivity to and chronic vigilance for threat, respectively (Bishop, 2009; Jusyte et al, 2015); finally, fearful attachment represents disturbance in the social systems involved in affiliation (Safran, 1990; Yaseen et al, 2016).…”

Assessing Risk for Imminent Suicide

“…In our previous work, 11,13 we identified a distinctive panic-like state found in suicide attempters and patients presenting to the emergency department with suicidality. 17,23 From these studies, we developed a 42-item self-report measure, the Suicide Trigger Scale, version 3 (the STS-3) to assess this "suicide trigger" state.…”

“…The evidence that a patient's transition from suicidal ideation (SI) to SA may be marked by a distinct pre-suicidal state [10][11][12][13][14] is central to the idea of a "trigger state" that mediates the transition to suicidal action. Results by Fawcett 14 indicate that suicidal individuals often experience increased anxiety and agitation, a combination of symptoms that he has termed "psychic pain," before a serious suicide attempt.…”

Double RASS cutpoint accurately diagnosed suicidal risk in females with long-term conditions attending the emergency department compared to their male counterparts

“…A number clinical scales have been developed to assess suicidal risk including the Beck Scale for Suicidal Ideation (BSS) [14], the Beck Hopelessness Scale (BHS) [15], the Sad Persons Scale (MSPS) [16] and recently the Patient Safety Screener for adults in the ED setting [17]. Standardized sort term risk assessment tools such as the High-Risk Construct Scale (NEW) [13] or the Suicide Trigger Scale (STS-3) [18][19][20] may also be an effective way to detect suicidality in the ED. Nevertheless, although most scales have been shown to have high sensitivity and negative predictive value, they also have variable specificity and positive predictive value, with rates ranging from 38 to 90% and 28% to 71%, respectively.…”