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 ] 72 order item. 35 There is an implicit assumption in the C–SSRS that there is a severity hierarchy of suicidality going from passive to active ideation t o method to intent to plan to preparatory behavior to attempt— much like going up the steps of stairs. However, according to some of our patients who have chronic suicidal ideation, this is a flawed and potentially dangerous assumption, with many exceptions, though we could not find any reference to this concern by others in the literature. Some of our patients told us that this assumption contributes to the poor ability to predict suicidal behavior. Guttman scaling is not appropriate for the assessment of suicidality. The flawed navigation instruction on C– SSRS item 2 compounds this problem further by violating established Guttman scaling procedures. Mismatches in titles, definitions, and probes. Complicating the above issues is the potential for further classification error because of mismatches in the C–SSRS's titles, definitions, and probes. Ideally, categories should be well defined to avoid overlap. But as shown in Table 2, probe questions for suicidal ideation do not fully align with their corresponding titles and definitions for any of the five ideation categories, while those for suicidal behavior only align for two of the four categories with definitions. These mismatches have the potential to create type I and II errors. For example, for the category, "Non-specific Active Suicidal Thoughts," the probe, "Have you actually had any thoughts of killing yourself?" 1 could elicit either specific or non-specific thoughts or both. If the probe generates a "yes" because of the presence of specific thoughts and the rater opts to use the probe rather than the definition (referring to non-specific thoughts), the result will be a type I error (over- identification of this C–SSRS category). As another example, while the title and probe for category #3, "Active Suicidal Ideation With Any Methods (Not Plan) Without Intent to Act," requires thought associated with a method, the example within t he definition appears to exclude thoughts of method— "I never made a specific plan as to when, where or how I would do it." 1 At the very least, the patient is likely to be confused by the nuances of this example. We, the authors of this paper, regularly encounter this confusion in clinical settings. For the category, "Preparatory Acts or Behavior," the following probe, "Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or writing a suicide note)?" 1 could similarly elicit a "yes" that conflicts with the definition, one that requires "imminence." Depending on whether the probe or definition or title is used (and it isn't clear which should be used), a type I or a type II error could ensue. The horizontal alignment of the yes/no response check boxes with the probe questions in most (but not all) versions of the C–SSRS suggests that the response options relate more to the probe question than to the title or definition. On the interactive voice recognition software (IVRS) version of C–SSRS (the eC–SSRS 18 ), the IVRS response is mapped directly to the C– SSRS probe question. To the extent that the response check boxes on the paper version might be mapped to the title or the definition or the probe question, this makes the paper and the IVRS versions not infrequently inconsistent. 3. Is the instrument's wording unambiguous? As Guilford reminds us, categorizations should be "univocal" (i.e., unambiguous). 23 The possibility of misclassification (type I or II error) is enhanced on the C– SSRS by unclear and imprecise wording and the frequent presence of words, phrases, and sentences that are ambiguous (have more than one meaning). Examples follow. "Active Suicidal Ideation With Any Methods (Not Plan) Without Intent to Act." The rater has to keep in mind two positives (active suicidal ideation + any method) along with two negatives (no plan or intent). B ut then the rater is told in the definition, "This is different than a specific plan with time, place or method details worked out (e.g. [sic] thought of method to kill self but not a specific plan)." 1 To what does "this" refer? To what does the example refer? And how does the rater differentiate between "thought of method" and "method details worked out?" Presumably, there is a fine distinction here, but the wording is susceptible to different interpretations. To further compound this ambiguity is the probe, "Have you been thinking about how you might do this?" 1 Again, "this" has no referent and is susceptible to more than one interpretation. Depending on whatever interpretation the rater uses, there could be over- identification or under-identification of this category. "Active Suicidal Ideation With Some Intent to Act, Without Specific Plan." Here the definition requires "active suicidal thoughts" with "some intent to act on such thoughts," but the last phrase is qualified with the phrase "as opposed to 'I have thoughts but I definitely will not do anything about them'." 1 This phrase is ambiguous because it can have very different meanings. One interpretation of "will not do anything about them" 1 is that the patient will not attempt suicide. Another way to interpret it, however, is that patient will do nothing in the way of getting any assistance in coping with these thoughts or seek treatment for the thoughts. In the latter instance, someone who does want to get help could be improperly identified as having suicidal intent and classified in this category (type I error) when the opposite is the case (i.e., the person intends to act on the thoughts by getting help). The clinician- and patient-rated versions C-SSRS could easily provide opposite ratings on this point, depending on

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