Innovations In Clinical Neuroscience

SEP-OCT 2014

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

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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 ] 24 of reports of suicidal behavior. Reports of lifetime suicidal behaviors at baseline also predicted subsequent suicidal behavior, and m ultiple lifetime behaviors monotonically increased prospective risk of suicidal behavior. Baseline suicidal ideation and behavior predicted future suicidal behavior in both psychiatric and non-psychiatric trials. Conclusions: Lifetime reports of suicidal ideation and/or behavior at baseline significantly increased risk of prospectively reporting suicidal behavior during research trial participation in both psychiatric and nonpsychiatric patients. Lifetime prevalence of suicidal ideation and behavior is higher among psychiatric patients, but also presents a safety concern among nonpsychiatric patients when reported. INTRODUCTION Suicide is the major preventable mortality of psychiatric disorders. 1 Many who commit suicide have seen primary care or mental health specialists shortly before their deaths. 2 Recognition of risk is a prerequisite for medical intervention to prevent suicide attempts and manage subsequent risk. Evaluation of risk conventionally rests with clinicians caring for patients. In suicide risk assessment, as with any human endeavor, variability in assessment ability is inevitable. Differences in aptitude, training, skill, experience, time pressure, fatigue, illness, beliefs, and biases are among factors affecting reliability and accuracy of clinician assessment. In a study of "sources of unreliability in depression ratings" with the Hamilton Depression Rating Scale (HDRS), 92 percent of variance was attributable to raters and eight percent to respondents. 3 Another study provided and evaluated HDRS training for 31 raters from 15 United States clinical trial sites. 4 After training and three rating trials, seven percent of raters could not qualify. After rating in trials for one year, 42 percent of qualified raters were no longer qualified. The common misconception that a sking about suicide might evoke it can lead to critical assessment omissions. 5 Worry about managing identified suicide risk may also inhibit thorough interviewing. 6 Sensitivity of patients and professionals regarding suicide stigma may dampen inquiry and response. Candor with sensitive subjects is often compromised. Catholic confessionals have a screen between priest and penitent while analysts sit at the head of the couch. Both arrangements reduce eye contact to facilitate difficult disclosures. As Isaac Marks observed more broadly, "Fear of two staring eyes is widespread throughout the animal kingdom." 7 Long ago it was recognized that indirect assessment of suicide risk factors had greater sensitivity than direct assessment, 8 an observation confirmed repeatedly. 9–12 Despite these observations, there is no doubt that the clinician's role in suicide risk assessment and management is essential and pivotal. Only clinicians can implement the range of treatments and caring that reduce suicides. The best suicide risk assessment comes from combining systematic indirect interviewing of demonstrated prospective value with astute follow- up by clinicians. The electronic Columbia-Suicide Severity Rating Scale (eC-SSRS) is a fully-structured, computer-administered, clinical interview designed to systematically query patients regarding past and current suicidal ideation and behavior (SIB) in complete adherence to the clinical conventions of the Columbia- Suicide Severity Rating Scale (C- SSRS). 13 The psychometric characteristics of the patient- reported eC-SSRS have been assessed in multiple contexts. It has demonstrated convergent validity with the clinician-based C-SSRS when both were administered. 14 The eC-SSRS has also been shown to improve patient candor regarding SIB in epilepsy patients. 8 From clinical and validation perspectives, it is also critically important to demonstrate that i deation and behavior ratings at one point predict ideation and behavior at a future time. However, this is difficult to accomplish with data from a single trial where base rates of ideation and behavior are low. We conducted a meta-analysis of over 35,000 eC-SSRS assessments accumulated from clinical trials conducted between 2009 and 2011. Summary indices of lifetime ideation and behavior predicted suicidal behaviors in short-term follow-up and in an additive fashion. Having both lifetime history of ideation and behavior more strongly predicted future behavior than either alone. 14 The previous studies provide compelling initial evidence supporting the psychometric characteristics of the eC-SSRS. However, open questions remain regarding the performance of the eC- SSRS. For example, although commonly used in psychiatric populations, it is unclear if the instrument predicts future behavior in nonpsychiatric populations. Additionally, although summary indices of ideation and behavior predict subsequent behavior, it is not clear that different severity levels of ideation and behavior have predictive value. We would expect more severe ideation and greater numbers of behaviors to predict subsequent behavior more robustly. The present study expands on the prior findings by 1) examining generalizability of the prior findings to studies involving non-psychiatric patients and 2) drilling deeper into the specific ideation and behavior items assessed by the eC-SSRS to evaluate their independent predictive relationships with prospective risk of reporting suicidal behavior during study participation. METHODS The initial anonymized, pooled dataset for this meta-analysis included 74,884 eC-SSRS

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