Innovations In Clinical Neuroscience

SEP-OCT 2014

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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[ V O L U M E 1 1 , N U M B E R 9 – 1 0 , S E P T E M B E R – O C T O B E R 2 0 1 4 ] Innovations in CLINICAL NEUROSCIENCE 183 including the Sheehan-Suicidality Tracking Scale (S-STS), 1 InterSePT Scale for Suicidal Thinking (ISST), 2 Patient Health Questionnaire (PHQ- 9 ), 3 a nd the Montgomery–Åsberg Depression Rating Scale (MADRS) 4 routinely include this question. Other groups 5–7 have taken a different position. One author, for example, has repeatedly stated, "We do not consider thoughts that you would better off dead to be anything." 8,9 This author asserts that questioning patients about the thought that they would be "better off dead" delivers "false positive results," 10-–14 adding that these patients "should not have been called suicidal." 1 2 This latter advice was given to and accepted by the United Stated Food and Drug Administration (FDA) and is reflected in the FDA suicidal ideation category, "Passive suicidal ideation: wish to be dead" (line 470). 7 In support of this claim, Posner 5 cited a study by Katzan et al 15 at the International Academy of Suicide's World Congress on Suicide 2013. That study 1 5 investigated the relationship between question 9 in the PHQ-9 ("thoughts that you would be better off dead or of injuring yourself in some way" 3 ) and the Columbia–Suicide Severity Rating Scale 5 (C–SSRS). In a sample of 1,461 subjects, question 9 on the PHQ-9 was positive in 269 cases when the C– SSRS was negative, and was positive in only 78 cases when the C–SSRS was positive. The positive predictive value for question 9 on the PHQ-9 against the C–SSRS was 22.5 percent. Because of this poor relationship, the author 15 concluded that question 9 on the PHQ-9 lacked any value as a screening question in suicidality assessment. Another equally plausible and alternative explanation of the same data, however, is that the C– SSRS is incomplete in assessing passive suicidal ideation. In a follow-up, structured, telephone interview of 330 cancer patients who responded positively to question 9 on the PHQ-9, Walker et al 16 found that one third reported still " having thoughts that they would be better off dead, but not of suicide, and another third reported clear thoughts of committing suicide." In light of these findings, it appears potentially dangerous to dismiss the q uestion about "thoughts that you would be better off dead" as having no value. The purpose of the following case study is to investigate the value of including the question, "Do you think you would be better off dead?" in the assessment of passive suicidal ideation, as an immediate antecedent to impulsive suicidality, and as a correlate of functional impairment associated directly with suicidality. METHODS This case study presents a prospectively collected, self-report data series on five passive suicidal ideation phenomena and one measure of impulsive suicidality over a 13- week period. A 31-year-old female subject diagnosed with Asperger syndrome collected detailed daily data on her events of suicidality. The subject had some suicidality on a daily basis for several years. She rated the severity of these six suicidal phenomena daily on a 0 to 4 (5- point) Likert scale with descriptive anchors (0=not at all, 1=mild, 2=moderate, 3=severe, 4=extreme). These phenomena were 1) the thought "I would be better off dead," 2) the thought "I need to be dead," 3) the thought "I wish I were dead," 4) the thought "I wish I could go to sleep and not wake up," 5) the thought "I wish I was not alive anymore," and 6) impulsive suicidality. Of the six phenomena assessed, we view impulsive suicidality as the greatest danger. Data for all five of the above passive ideation phenomena were then plotted against the impulsive suicidality to highlight the relationship between each of these phenomena and the impulsive suicidality. The results from this analysis are shown in Figures 1 through 9. The subject collected weekly tracking on the functional impairment and quality of life experienced due to suicidality over the same timeframe using a 0 to 10 (11-point) Discan metric. The functional impairment questions were 1) "The suicide s ymptoms have disrupted your work / school work," 2) "The suicide symptoms have disrupted your social life / personal relationships / leisure activities," and 3) "The suicide symptoms have disrupted your family life / home responsibilities" followed by the quality of life question 4) "The suicide symptoms have disrupted the quality of your life." The subject also recorded her responses to these functional impairment questions daily over the last month of the timeframe under study, using a 0 to 10 (11-point) Discan metric to more precisely study the relationship between daily fluctuations in impairment, quality of life, the five passive suicidal ideations, and impulsive suicidality. These questions and metric (adapted from the Discan metric used in the Sheehan Disability Scale 2009 17 ) were taken from page 9 of the 11/12/13 version of the S-STS Clinically Meaningful Change Measure (CMCM). 1 Result 1. Figure 1 illustrates the subject's daily severity ratings of "I would be better off dead" and impulsive suicidality. It shows that in the days before the impulsive suicidality, she had 2 to 5 days of feeling that she would be better off dead before the onset of the impulsive suicidality. Discussion. The findings in this case study suggest that the thought "I would be better off dead" can be an important and recurrent antecedent of more serious suicidality in some patients. The subject of this case study had a lifetime history of 33 non-halted suicide attempts. Of these attempts, 31 were episodes of impulsive suicidality. The "better off dead" thought/feeling occurred prior to 31 of these episodes of impulsive suicidality. The "better off dead" thought/feeling occurred prior to or during 32 of the non-halted attempts. The most serious attempt resulted in Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 1 , N U M B E R 9 – 1 0 , S E P T E M B E R – O C T O B E R 2 0 1 4 ]

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