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 41 with the C–SSRS endorsing these categories 20 or more times as often with 55 percent or more of subjects mapping to these categories c ompared to 2.6 percent or less on the other two scales. These discrepancies could be interpreted to mean that the ISST- Plus and S-STS both under-endorse certain categories of active ideation or they could be interpreted to mean, conversely, that the C–SSRS over-endorses these phenomena. We suspect that the latter interpretation is more plausible for the following reason: The C–SSRS has a logical flaw in that it requires that a subject answer "Yes" to question 2 ("Non- specific Active Suicidal Thoughts") to proceed to subsequent active ideation questions. However, if the subject answers "Yes" to question 2, questions on active ideation (3, 4, and 5) should theoretically be answered "No." This is because the "Yes" to question 2 is predicated on not having "thoughts of ways to kill oneself / associated methods, intent, or plan during the assessment period." 4 In addition, the probe question for "Non-Specific Active Suicidal Thoughts" is, "Have you actually had any thoughts of killing yourself?" A "Yes" response to this question could, we think, map to very specific rather than non- specific active suicidal thoughts in clinical practice. That it does not in this case is likely to lead to substantial inflation of false positives on this category in the C–SSRS. 8 Neither the S-STS nor the ISST-Plus have such navigation flaws or mismatches between probe questions and FDA-CASA 2012 categories. There is an additional problem. Not all combinations of active suicidal ideation are captured in the C–SSRS and by extension the FDA-CASA 2012. As pointed out here and in two companion articles, as many as 26 combinations of suicidal ideation out of 32 possible combinations are excluded in the C–SSRS and FDA- CASA 2012. 7,8 These combinations are captured by the other two scales. In different words, it is not that the ISST- Plus and S-STS under-endorse active ideation; rather, they are more specific. On the S-STS and the ISST- Plus, the components that make up these combinations are disaggregated at the interview and data acquisition level. They are later aggregated into all 32 possible combinations by the computer after entry. This is not the case on the C–SSRS, which does not capture all the components making up the combinations separately. It only captures six of the possible 32 combinations directly on the scoring form, rather than disaggregating all the elements and later recombining them. Raters have told the authors of this article that they and the patients encountered difficulties in rating the complex combinations of suicidal FIGURE 4. Sensitivity of the ISST-Plus and the S-STS by FDA-CASA 2012 category using the C–SSRS ISST-Plus: InterSePT Scale for Suicidal Thinking-Plus; S-STS (Patient): Sheehan-Suicidality Tracking Scale patient-rated version; S-STS (Clinician): Sheehan-Suicidality Tracking Scale clinician-rated version; S-STS (Reconciled): Sheehan-Suicidality Tracking Scale reconciled version; C–SSRS: Columbia–Suicide Severity Rating Scale F IG U R E 5. Speci f i ci t y of I SST- Pl us and S- STS by FDA- CASA cat egory usi ng t he C – SSRS ISST- Plus : InterSePT Scale for Suicidal Thinking-Plus; S-STS (Patient): Sheehan-Suicidality Tr a c k ing Scale patient-rated version; S-STS (Clinician): Sheehan-Suicidality Tracking Scale c linic ia n- r ated version; S-STS (Reconciled): Sheehan-Suicidality Tracking Scale reconciled v e r s ion; C – SSRS: Columbia – Suicide Severity Rating Scale

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