Screening for suicide: a comment on Steeg et al. [Letter]
Christopher Ryanvisibility
…
description
2 pages
link
1 file
In their recent paper, Steeg et al. (2012) introduced ReACT, ‘a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an emergency department self-harm presentation ’. The paper’s abstract reported that ReACT: performed with 95% sensitivity [95%confidence interval (CI) 94–95] and 21% specificity (95% CI 21–22), and had a positive predictive value of 30% (95% CI 30–31) and a negative predictive value of 91% (95% CI 90–92) in the derivation centres ; it identified 83/92 of all subsequent suicides. Some readers may have misinterpreted this sentence to mean that the researchers had found a way of predicting suicide with only two false positives for every true positive. In fact the figures in the clause before the semicolon in the quoted sentence above are ReACT’s metrics for any form of repeated self-harm. After the semicolon, the 83 of 92 suicides that ReACT was able to ‘ identify ’ were associated with approximately 16 600 false positives with a positive predictive value of 0.5%.
Related papers
Clinicians Should Not Adopt a Single Self-Reported Item as a Screener for Suicide
The Journal of clinical psychiatry, 2016
Letters to the Editor Clinicians Should Not Adopt a Single Self-Reported Item as a Screener for Suicide To the Editor: In their recent article, Green and associates state that item 9 of the Beck Depression Inventory, an item that pertains to suicide ideas and plans, should be used as "a brief, efficient screen for suicide risk in routine clinical care" 1(p1683) and that "clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen." 1(p1683) They imply that psychiatric outpatients and patients seen in the emergency department after a suicide attempt who do not self-report suicide ideas (with a score of 0 on item 9) do not need a "suicide risk assessment and corresponding risk management plan." While we acknowledge that item 9 might distinguish between high-and low-risk groups for suicide in a statistical sense, we believe the authors have overstated the case for its use as a routine screening tool in these populations. The World Health Organization (WHO) has very well-established guidelines outlining when screening is worthwhile. 2,3 WHO suggests that a specific diagnostic test should be available to follow a sensitive but nonspecific screening procedure like item 9. 2,3 However, there are no tests for future suicide that are specific enough to usefully divide patients into those at high or low likelihood of future suicide. 4,5 Further, according to WHO, a useful intervention should be available to justify screening. 2,3 However, there are no highly effective treatments that specifically prevent suicide or suicide attempts, and certainly none that have effectiveness over the very long period of follow-up described in the recent study. Finally, WHO recommends that screening should be shown to reduce overall morbidity or mortality. 2,3 Despite over 50 years of suicide risk research, it has never been shown that allocating treatment resources on the basis of suicide risk assessment results in fewer suicides. The thoroughness of a psychiatric assessment in these populations should never be determined by the simple presence or absence of self-reported suicidality. Every psychiatric outpatient and every patient seen in an emergency department after a suicide attempt should be thoroughly, sympathetically, and personally assessed by a mental health professional who should then be in a position to offer treatment in line with the patient's needs and wishes. 6 Unfortunately, there are no shortcuts in this realm of clinical practice.
Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales
British Journal of Psychiatry, 2017
Mental health clinicians treat patients who are at much greater risk of suicide, suicide attempts or non-fatal self-harm than the general population. 1,2 Clinicians would like to be able to predict with acceptable accuracy, for a clinically meaningful time frame, which individual patients will subsequently die by suicide or have a further episode of non-fatal self-harm so that preventive interventions can be preferentially allocated to those classified as 'high risk' for those outcomes. 3 Historically, there have been three generations of prediction approaches: unassisted clinician prediction (first), standardised scales or biological tests (second) and scales derived from statistical modelling (third). Many clinical instruments have been utilised for prediction including: psychological scales such as versions of the Beck Depression Inventory (BDI) 4 or the SADPERSONS scale; 5 biological tests such as the dexamethasone suppression test (DST) 6 and the cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HIAA) concentration test; 7 and scales derived from statistical models such as the ReACT Self-Harm Rule 8 and the Repeated Episodes of Self-Harm (RESH) score. 9 At the policy level, the use of risk assessment classification to determine treatment allocation has been strongly endorsed in the USA. The (US) National Action Alliance for Suicide Prevention's Research Prioritization Task Force has made a recommendation to 'find ways to assess who is at risk for attempting suicide in the immediate future'. This recommendation is specifically 'related to the task of identifying and predicting near-term suicide risk at the individual patient level'. 10 Similarly, the (US) National Strategy for Suicide Prevention stated the need to 'Fund the development of suicide screening and assessment tools that will be non-proprietary and widely available' (Objective 7.4); and 'Develop standardized protocols for use within emergency departments based on common clinical presentation to allow for more differentiated responses based on risk profiles and assessed clinical needs' (Objective 9.6). 11 There have been clear objections about the clinical utility of this approach, based on the inaccuracy of predictive 'tests' used as the basis for allocation of treatment. 12 In the UK, the National Institute for Health and Care Excellence (NICE) guidelines have instead suggested 'Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm' and emphasised a shift in recommendations from 'risk assessment' to 'needs assessment' to determine allocation of clinical aftercare. 13 The relevant accuracy statistics for clinicians are the positive predictive value (PPV) and the negative predictive value (NPV) of a test; and as a basis for allocation of treatment, the PPV is the key statistic. Simply put: 'The positive predictive value. .. expresses the proportion of those with positive test results who truly have disease'. 14 Unlike sensitivity and specificity, the PPV and NPV are highly dependent on the prevalence of the outcome of interest, which means that the values for these measures are not simply transferable from one clinical population to another with different prevalence of disease. 14 A few systematic reviews of predictive instruments have reported sensitivity and specificity ranges for specific tests or scales. 15,16 A recent review explored a wide range of diagnostic accuracy measures for a small number of risk scales used to assess patients after presentation for self-harm. 17 However, there have been no meta-analyses to produce pooled estimates for the PPV for predictive instruments in mental health patient populations. Method Key questions Our key question for the review was: is the classification of mental health patients as being 'high risk' for subsequent suicide death or 26.1-39.6%) for hospital-treated self-harm and 26.8% (95% CI 19.5-35.6%) for psychiatric in-patients. Conclusions No 'high-risk' classification was clinically useful. Prevalence imposes a ceiling on PPV. Treatment should reduce exposure to modifiable risk factors and offer effective interventions for selected subpopulations and unselected clinical populations. Declaration of interest N.K. chaired the NICE guidelines for the longer term management of self-harm in England but the views in this paper are the author's own and not those of NICE or the Department of Health (UK). G.C. chaired the Royal Australian and New Zealand College of Psychiatrists' (RANZCP's) Clinical Practice Guidelines for Deliberate Self Harm but the views in this paper are the author's own and not those of the RANZCP.
The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule
Psychological Medicine, 2012
Background. Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation.
Advances In The Assessmentof Suicide Risk-Craig JBryanand MDavid Rud
This article reviews and integrates empirically grounded advances in the assessment of suicidality. The practices discussed are consistent with existing standards of care, practice guidelines, and applicable research. The authors differentiate between risk assessment and prediction and then emphasize the important role of time in risk assessment. We present and illustrate a continuum of suicidality for risk assessment and offer practical recommendations for clinical decision making and treatment.
Validation of suicide and self‐harm records in the C linical P ractice R esearch D atalink
British Journal of Clinical Pharmacology, 2013
The UK Clinical Practice Research Datalink (CPRD) is increasingly being used to investigate suicide-related adverse drug reactions. No studies have comprehensively validated the recording of suicide and nonfatal self-harm in the CPRD. We validated general practitioners' recording of these outcomes using linked Office for National Statistics (ONS) mortality and Hospital Episode Statistics (HES) admission data. METHODS We identified cases of suicide and self-harm recorded using appropriate Read codes in the CPRD between 1998 and 2010 in patients aged Ն15 years. Suicides were defined as patients with Read codes for suicide recorded within 95 days of their death. International Classification of Diseases codes were used to identify suicides/hospital admissions for self-harm in the linked ONS and HES data sets. We compared CPRD-derived cases/incidence of suicide and self-harm with those identified from linked ONS mortality and HES data, national suicide incidence rates and published self-harm incidence data. RESULTS Only 26.1% (n = 590) of the 'true' (ONS-confirmed) suicides were identified using Read codes. Furthermore, only 55.5% of Read code-identified suicides were confirmed as suicide by the ONS data. Of the HES-identified cases of self-harm, 68.4% were identified in the CPRD using Read codes. The CPRD self-harm rates based on Read codes had similar age and sex distributions to rates observed in self-harm hospital registers, although rates were underestimated in all age groups. CONCLUSIONS The CPRD recording of suicide using Read codes is unreliable, with significant inaccuracy (over-and under-reporting). Future CPRD suicide studies should use linked ONS mortality data. The under-reporting of self-harm appears to be less marked. WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT • The Clinical Practice Research Datalink (CPRD), formerly known as the General Practice Research Database (GPRD), is being increasingly used to investigate suicide-related adverse drug reactions, although no previous studies have comprehensively validated the recording of suicide and nonfatal self-harm in the CPRD. Recent linkages of CPRD General Practices with Office for National Statistics mortality data and Hospital Episode Statistics data provide new opportunities for validation. WHAT THIS STUDY ADDS • Use of diagnostic codes ('Read codes') recorded by general practitioners for suicide identification has low sensitivity and positive predictive value compared with Office for National Statistics-confirmed suicides obtained by record linkage (the gold standard). • Approximately 31.6% of hospital-admitted cases of self-harm are not recorded in the CPRD. Compared with estimates derived from registers of hospital attendance for self-harm, CPRD underestimates the incidence of self-harm by approximately 54.5%. The lack of a gold standard for nonfatal self-harm makes it difficult to validate this outcome fully.
Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data
BMC psychiatry, 2018
Risk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known. We compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months. The episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low...
Advances in the assessment of suicide risk
Journal of Clinical Psychology, 2005
This article reviews and integrates empirically grounded advances in the assessment of suicidality. The practices discussed are consistent with existing standards of care, practice guidelines, and applicable research. The authors differentiate between risk assessment and prediction and then emphasize the important role of time in risk assessment. We present and illustrate a continuum of suicidality for risk assessment and offer practical recommendations for clinical decision making and treatment. © 2005 Wiley Periodicals, Inc. J Clin Psychol: In Session 62: 185–200, 2006.
ROC analysis of dexamethasone suppression test threshold in suicide prediction after attempted suicide
Journal of Affective Disorders, 2008
Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis function is associated with suicidal behavior. In suicide attempters with mood disorder, the non-suppressor status in the dexamethasone suppression test (DST) is associated with suicide indicating that HPA-axis hyperactivity is a biological risk factor for suicide and may be a useful predictor. The threshold of 5 μg/dl for cortisol levels measured at 08:00 a.m. or 4:00 p.m. following dexamethasone at 11:00 p.m. to define the DTS nonsuppression was derived as being optimal for the separation of melancholia and nonmelancholic conditions rather than the prediction of suicide. A different threshold may offer a better identification of suicide.
Psychological Medicine, Page 1 of 3.
f Cambridge University Press 2012
Correspondence
Psychological Medicine (2012).
doi:10.1017/S0033291712001377
Letter to the Editor
Screening for suicide : a comment on Steeg et al.
In their recent paper, Steeg et al. (2012) introduced
ReACT, ‘ a clinical tool to help identify patients at
higher risk of repeat self-harm, or suicide, within 6
months of an emergency department self-harm presentation ’. The paper’s abstract reported that ReACT :
performed with 95 % sensitivity [95 % confidence interval (CI)
94–95] and 21 % specificity (95 % CI 21–22), and had a positive
predictive value of 30 % (95 % CI 30–31) and a negative predictive value of 91 % (95 % CI 90–92) in the derivation centres ;
it identified 83/92 of all subsequent suicides.
Some readers may have misinterpreted this sentence to
mean that the researchers had found a way of predicting suicide with only two false positives for every true
positive. In fact the figures in the clause before the
semicolon in the quoted sentence above are ReACT’s
metrics for any form of repeated self-harm. After the
semicolon, the 83 of 92 suicides that ReACT was able to
‘ identify ’ were associated with approximately 16 600
false positives with a positive predictive value of 0.5 %.
Despite using the words ‘ predict ’ and ‘ identify ’, the
authors describe ReACT as a ‘ screening ’ test rather
that a predictive or diagnostic test. However, we do not
believe it can be usefully used as a way to screen for
future suicide. The World Health Organization (WHO)
has issued guidelines outlining when screening is
worthwhile (Wilson & Jungner, 1968). These include
the recommendation that a specific diagnostic test
should be available to follow a sensitive but nonspecific test like ReACT. Well-known examples from
other areas of medicine include faecal occult blood tests
that may be followed by endoscopy for bowel cancer
and mammograms that may be followed by biopsy for
breast cancer. The authors imply that ReACT might be
used as ‘ a guide or adjunct to the wider assessment of
risk ’, perhaps with another form of suicide risk assessment. We doubt that any further more sensitive
and specific risk categorization is really possible, particularly because the items in ReACT (including recent
self-harm and treatment for a mental disorder) cannot
be used to further discriminate within a group of people who have already been defined by possession of
these characteristics.
More broadly, if we assume that there is an intervention that is likely to decrease the likelihood of
future suicide, then categorizing patients by their
likelihood of suicide within 6 months might be justified if the proportion of true positives (suicide victims)
among the whole ‘ high-risk ’ group were sufficiently
high to justify the intervention for the whole ‘ highrisk ’ group. Such justification would only be present if
the intervention were sufficiently effective and sufficiently benign (in terms of side-effect burden), as
to mean that any down side to health or welfare of
patients who were ‘ high-risk ’ false positives was
clearly outweighed by the benefits accrued to patients
who were ‘ high-risk ’ true positives. Even under these
circumstances, categorization of patients by their likelihood of suicide within 6 months would hardly be
necessary if it were feasible to also provide the benign,
effective intervention to ‘ low-risk ’ patients as well.
After all, these ‘ low-risk ’ patients are still at very high
risk for future suicide compared to the general population. In the Steeg et al. (2012) study there were nine
suicides within 6 months among 13 000 people classified by ReACT as at ‘ low-risk ’. This translates into an
annual rate of suicide among the ‘ low-risk ’ of 138 per
100 000 which can be compared to figures for population of England of about 10 suicides per 100 000 per
year (NMHDU, 2009). We doubt that any form of risk
categorization can lead to any intervention that can
be ethically provided to ‘ high-risk ’ patients, the
vast majority of whom will not attempt suicide, yet be
denied to patients classified as ‘ low-risk ’.
The authors suggest that ‘ some ’ patients who
present to the emergency department after a suicide
attempt or act of self-harm and who are classed as
‘ low-risk ’ by ReACT could be ‘ followed up for an assessment at a more convenient time and place, perhaps in the community ’. If this is to imply that ReACT
‘ low-risk ’ patients could have the ‘ full mental health
and social needs assessment ’ that NICE recommends
be offered in the emergency department (NICE, 2004)
be delayed and completed more conveniently in the
community, we would strenuously disagree. It is quite
feasible to offer such assessments in the emergency
department to all patients presenting with self-harm.
The assessments place little burden on the patient and,
combined with the formation of an appropriate management plan, are likely to decrease the likelihood of
future suicide.
ReACT may offer a statistically valid way of discriminating between patients on the basis of their
likelihood of suicide within 6 months, but even so
we cannot see how using this tool will have any clinical utility and are concerned that it might be
2
Correspondence
inappropriately used to deny some patients a timely
and comprehensive assessment of their illness and
circumstances.
Declaration of Interest
None.
References
NICE (2004). Self-harm : the short-term physical and
psychological management and secondary prevention of
self-harm in primary and secondary care. Clinical
Guideline 16. National Institute for Clinical Excellence
(http://www.nice.org.uk/nicemedia/pdf/
CG016NICEguideline.pdf). Accessed 16 March 2012.
NMHDU (2009). National Suicide Prevention Strategy for
England Annual Report on Progress 2008. National Mental
Health Development Unit (http://www.suicideprevention.
ca/wp-content/uploads/2010/10/England-6th-annualreport-2010.pdf). Accessed 16 March 2012.
Steeg S, Kapur N, Webb R, Applegate E, Stewart SL,
Hawton K, Bergen H, Waters K, Cooper J (2012). The
development of a population-level clinical screening tool
for self-harm repetition and suicide : the ReACT Self-Harm
Rule. Psychological Medicine. Published online : 7 March
2012. doi :10.1017/S0033291712000347.
Wilson JMG, Jungner G (1968) Principles and practice of
screening for disease. Geneva : WHO. (http://whqlibdoc.
who.int/php/WHO_PHP_34.pdf). Accessed 16 March
2012.
MATTHEW LARGE
1,2
BSc(Med), MBBS, FRANZCP,
3,4 ,5
MBBS, FRANZCP
CHRISTOPHER JAMES RYAN
1
The Prince of Wales Hospital, Barker Street, Randwick,
Sydney, Australia
2
School of Psychiatry, University of New South Wales,
Sydney, Australia
3
Centre for Values, Ethics and the Law in Medicine,
University of Sydney, Australia
4
Discipline of Psychiatry, University of Sydney,
Australia
5
Department of Psychiatry, Westmead Hospital,
Westmead, Australia
Address for correspondence :
Dr M. Large,
The Euroa Centre, The Prince of Wales Hospital,
Barker Street, Randwick, NSW, Australia 2031,
(Email : [email protected])
Psychological Medicine (2012).
doi:10.1017/S0033291712001389
Screening for suicide - Reply
The Letter by Large & Ryan (2012) correctly points out
that the positive predictive value of 30 % is for both
non-fatal and fatal repeat self-harm acts, which is
the outcome we based our performance measures on.
We hope that this will not be misinterpreted as the
measure for suicide alone. We acknowledge that suicide is a rare outcome and that aiming to predict only
those repeat acts that end fatally would not be feasible.
Throughout the development of ReACT we were
mindful that there needed to be a balance between
correctly identifying the relatively small number of
suicides and the large proportion that re-attended
with non-fatal self-harm. We acknowledged that ‘ no
risk assessment measure can be accurate enough to
assume a patient assessed as low risk will not repeat
self-harm or complete suicide ’ (Steeg et al. 2012) and
the risk of suicide is markedly elevated for anyone
within the self-harming population relative to the
general population (Cooper et al. 2005).
However, we proposed that a tool drawing together
risk factors from a large prospective cohort, based on
population-level data and real outcomes provides
some evidence to inform risk categorization according
to a patient’s likelihood of further self-harm. We support the NICE guidance (NICE, 2004) that this is only a
part of a wider assessment of a patient’s psychological
and social needs. With any clinical decision tool it is
important to be clear about the proposed utility as well
as its statistical validity and performance. With tools
designed for use in mental health settings, such as the
ReACT tool, discussion around the proposed clinical
use becomes more important than with those designed
for physical conditions. As Large & Ryan highlight,
specific diagnostic tests are often carried out following
the result of screening tools. While the course of action
is not so clear-cut when treating self-harm patients
presenting in an emergency situation, the use of
screening tools as part of mental health risk assessment has been recommended (DoH, 2007). We therefore welcome the opportunity to expand on this
further.
Screening is the beginning of a process and we were
not suggesting a four-question tool can be used alone
to determine a patient’s outcome in terms of non-fatal
repetition or suicide. The four factors identified
may act as a ‘ red flag ’ to emergency-department (ED)
staff treating the patient in the early stages of the
presentation. We agree that specific interventions
would not be determined solely on the basis of the
ReACT tool. Any intervention would be based on a
comprehensive assessment of psychological and social
needs. Risk is an important area to consider as part
of the wider assessment, particularly when considering immediate management, but would not inform
decisions on interventions alone. However, mental
health clinicians may use this awareness in consideration of the potential benefits of certain treatments
Related papers
EL CONVENIO DE LA VILLA DE SAN FERNANDO: UN ACUERDO ENTRE ESPAÑA Y LOS APACHES
REFLEXIONES SOBRE PODER, GUERRA Y RELIGIÓN EN LA HISTORIA DE ESPAÑA, 2011
Eski Yunan Tiyatrosu ve Agon Kültürü
Journal of Theatre Criticism and Dramaturgy, 2022
A regenerative tourism approach for the development of marginalised areas. Insights from two best practices in Southern Italy
Turistica - Italian Journal of Tourism, 2023
The Effect of Conceptual Factors on Small and Medium-Sized Enterprises Business Success in Malaysia
Information Management and Business Review, 2023
Human Factors, Extreme Events and Floods in the Lower Po Plain (Northern Italy) in the 16th Century
Environment and History, 1998
Ποια Ελλαδα ηθελαν τα πρωτα κομματα
Καθημερινή, 13 Ιουνίου 2021
Characterisation of black skin stratum corneum by digital macroscopic images analysis
Healthcare Technology Letters, 2020
A Lightweight Secure Cyber Foraging Infrastructure for Resource-Constrained Devices
Sixth IEEE Workshop on Mobile Computing Systems and Applications
Folates: Key Nutrients to Remember
Asian Journal of Pharmaceutical Research and Health Care, 2017
Four Cases of Pediatric Photokeratitis Present to the Emergency Department After Watching the Same Theater Show
Türk Oftalmoloji Dergisi, 2015
The transition from informal to formal understanding of the concept of order in abstract mathematics
2015