Suicidal ideation is insensitive to suicide risk after emergency department discharge: Performance characteristics of the Columbia‐Suicide Severity Rating Scale Screener

Abstract

Objectives We describe the Columbia‐Suicide Severity Rating Scale (C‐SSRS)–Clinical Practice Screener’s ability to predict suicide and emergency department (ED) visits for self‐harm in the year following an ED encounter. Methods Screening data from adult patients’ first ED encounter during a 27‐month study period were analyzed. Patients were excluded if they died during the encounter or left without being identified. The outcomes were suicide as reported by the state health department and a recurrent ED visit for suicide attempt or self‐harm reported by the state hospital association. Multivariable regression examined the screener’s correlation with these outcomes. Results Among 92,643 patients analyzed, eleven (0.01%) patients died by suicide within a month after ED visit. The screener’s sensitivity and specificity for suicide by 30 days were 0.18 (95% confidence interval [CI] = 0.00 to 0.41) and 0.99 (95% CI = 0.99 to 0.99). Sensitivity and specificity were better for predicting self‐harm by 30 days: 0.53 (95% CI = 0.42 to 0.64) and 0.97 (95% CI = 0.97 to 0.97), respectively. Multivariable regression demonstrated that screening risk remained associated with both suicide and self‐harm outcomes in the presence of covariates. Suicide risk was not mitigated by hospitalization or psychiatric intervention in the ED. Conclusions The C‐SSRS screener is insensitive to suicide risk after ED discharge. Most patients who died by suicide screened negative and did not receive psychiatric services in the ED. Moreover, most patients with suicidal ideation died by causes other than suicide. The screener was more sensitive for predicting nonfatal self‐harm and may inform a comprehensive risk assessment. These results compel us to reimagine the provision of emergency psychiatric services.

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.…”

“…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.…”

Observing time effect of SSRIs on suicide risk and suicide-related behaviour: a network meta-analysis protocol

“…8 Columbia-Suicide Severity Rating Scale also failed to estimate suicide risk with suicide ideation in Simpson's study. 9 Antidepressant has been used to alleviate depressive symptoms and prevent suicide in a wide spectrum of psychiatric disorders including depression, attention deficit hyperactivity disorder, bulimia, premenstrual dysphoric disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder. [10][11][12][13] It is thought to function by upregulating levels of different mood-related neurotransmitters, such as serotonin, dopamine and norepinephrine.…”

“… 8 Columbia-Suicide Severity Rating Scale also failed to estimate suicide risk with suicide ideation in Simpson’s study. 9 …”

Broken promise: Challenges in achieving effective universal suicide screening

“…The hope that death from suicide and injuries from suicidal behavior can be reduced from routine screening in emergency departments (EDs) is a promising hypothesis. The most recent study by Simpson et al 1 casts renewed doubt on the promise and practicality of that approach. Ostensibly, the Columbia Suicide Severity Rating Scale (C‐SSRS) has promise for use in EDs: it is simple to read, results in stratified categories of risk, and is a relatively brief tool.…”