Suicide Prevention Tool Useful in Teens, Adults

Rating scale can help predict who may attempt suicide.

Nov. 9, 2011— -- A short suicide questionnaire used millions of times by jails, schools, hospitals, police and defense forces worldwide not only identifies suicidal thoughts and behavior, but also helps predict which people are likely to try ending their lives, researchers announced.

By asking a series of direct questions, beginning with: "Have you wished you were dead or wished you could go to sleep and not wake up?" followed by "Have you actually had any thoughts of killing yourself?" the Columbia-Suicide Severity Rating Scale (C-SSRS) ranks suicidal thoughts and plans on a 5-point scale, ranging from 1, the wish to die; through 5, having a plan and intent to commit suicide.

Researchers put the tool to the test in three groups of people vulnerable to suicide: 124 teenage suicide attempters in a treatment study; 312 depressed teens in a medication study; and 237 adults who visited hospital emergency rooms for psychiatric reasons. The results were analyzed by the tool's Columbia University developers, along with colleagues from several other institutions, who released their findings online Wednesday in the American Journal of Psychiatry.

Lead study author Kelly Posner, director of Columbia's suicide risk assessment program, said the idea behind the questionnaire was to improve suicide prevention by more precisely identifying those youngsters and adults at risk of ending their lives before they can carry out their plans.

"What this paper has done is give us prediction, which is a national priority for prevention," Posner told Study participants who had "worrisome answers" to the questions "were 50 percent more likely to attempt suicide," during the year they were followed, she said.

The suicide questionnaire assesses more than just whether someone had attempted suicide.

"In the past, people would only ask about a suicide attempt," Posner said. "You would miss the person who bought the gun yesterday or put the noose around their neck, (or the person) collecting or buying pills, writing a will or suicide note."

By more precisely identifying a range of suicidal thoughts and behaviors, the tool is finding "the people at risk we would have missed before," Posner said. The questionnaire also assesses "how much medical damage was there when they attempted suicide? Did they take two pills, or try to shoot themselves in the head? Were they in the hospital intensive care unit?" Posner said. All of that information "tells you something about the level of severity of risk."

"Having a proven method to assess suicide risk is a huge step forward in our efforts to save lives," said Dr. Michael Hogan, commissioner of the N.Y. State Office of Mental Health. He called the scientific validation of the rating scale "a critical step in putting this tool in the hands of health care providers and others in a position to take steps for safety."

Dr. Jeffrey Lieberman, psychiatry chairman at Columbia, noted the tool's potential to make a dent in the current volume of suicides.

"The public health benefits in terms of lives saved could be enormous," he said.

Simple Screening Tool Can Be Used by Non-Professionals

Given that "50 percent of suicides see their primary care doctor in the month before they die," Posner said doctors should be asking their patients about suicide "the way we monitor for blood pressure."

One of the advantages of having a simple question-based tool, most of which can be administered in "a minute or two," is that it can be used by non-professionals, such as peer counselors, she said. In addition, men and women can complete an electronic version in the privacy of their own homes.

Suicide is the third leading cause of death among people under the age of 24, many of whom may not have regular access to a doctor, let alone mental health counseling.

"We know prevention depends upon appropriate screening," Posner said. To that end, she said her ultimate goal is "universal screening" for suicide risk in the schools, which "helps us to identify those people who really need intervention or further evaluation."

Targeted interventions could not just save lives, but save scarce resources, she said. Already, the Columbia rating scale is being used in schools around the country, including New York City public schools.

Dr. Adam Kaplin, assistant professor of psychiatry and neurology at Johns Hopkins Medical institutions in Baltimore, welcomed the new study, calling it "the most comprehensive effort to actually validate this scale in three different settings and to really hammer away at how good a scale (it is)."

The scale represents an attempt to distinguish between "the millions of people who have thoughts in any given year about wanting to call it quits and commit suicide," and the estimated 30,000 who die by their own hands.

"For my money, this is the best application of a scale from one of the best groups studying suicide in the country," he said. "It is the best-tested tool out there."

"I think it's promising. It's worth people trying in their practices and in their research and seeing how it works for them," said adolescent suicide specialist Nadine Kaslow, chief psychologist at the Emory University School of Medicine in Atlanta. "We could certainly benefit from better tools. No question, our assessment armamentarium needs to be strengthened."

Despite decades of public health agency discussions about lowering suicide rates, suicides and attempted suicides remain "a serious public health problem," Koslow said.

"One of the things you want to know is who are people at risk for suicidal behavior?" she said. "You find out somebody's at risk and then you can employ useful prevention and intervention strategies. We have some hopeful strategies in prevention and intervention, but we still have a long way to go."