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 77 thoughts, thereby undermining the meaning of the category and potentially inflating the rate intended for capture in this category ( type I error). This C–SSRS flaw is exposed in the cross-validation study of three suicidality scales by Sheehan et al. 29 " Active Suicidal Ideation With Any Methods (Not Plan) Without Intent to Act." This C–SSRS category should match the FDA-CASA 2012 category, "Active suicidal ideation: method, but no intent or plan." 6 The definitions and examples appear to correspond. However, the C–SSRS probe, "Have you been thinking about how you might do this?" 1 has the potential to elicit responses that do not directly relate the FDA category and could go beyond it. The problem here is the use of the word "this," a word that in the context is ambiguous and could refer to any number of phenomena, causing either type I or type II errors. "Active Suicidal Ideation With Some Intent to Act, Without Specific Plan." This C–SSRS category differs from the FDA-CASA 2012 category, "Active suicidal ideation: method and intent, but no plan." 6 in three ways. First, the C–SSRS title does not indicate the need for a method, a requirement that is clearly made on the FDA-CASA 2012. Second, the title requires the absence of a "specific" plan, whereas the corresponding FDA-CASA 2012 title and definition only require the absence of a plan. This difference could lead to under-identification of this category, a type II error. Third, the C–SSRS probe question is so broad that it has the potential to capture suicidal phenomena well beyond that covered by the definition, leading to over- identification of this category, a type I error. "Active Suicidal Ideation With Specific Plan and Intent." The title for this C–SSRS category should match the title for the FDA-CASA 2012 category, "Active suicidal ideation: method, intent, and plan." 6 However, in contrast to the FDA- CASA 2012 title, it does not indicate the need for a method. Additionally, the C–SSRS probe questions, "Have you started to work out or worked o ut the details of how to kill yourself?" and "Do you intend to carry out this plan?" 1 do not correspond with the FDA-CASA 2012 definition, which indicates that the patient would need to have gone beyond merely starting to work out the details and "have details of [a] plan fully or partially worked out." 6 This difference could lead to over- identification of cases in this category. "Actual Attempt." The definition for this C–SSRS category should match that for the FDA category "Suicide attempt." However, the C– SSRS definition requires the behavior to be "thought of as a method to kill oneself" 1 while the FDA definition does not include this requirement. Further potential incompatibility is introduced by the C–SSRS qualification that the behavior be "in part" thought of as a method to kill oneself. 1 This could mean at least in part or wholly in part. It should specifically have stated "at least in part" to avoid to this ambiguity. This qualification not only affects the interpretation of the C–SSRS category, but it also distances it further from the FDA- CASA 2012. "Self-Injurious Behavior Without Suicidal Intent." This C–SSRS category is tucked into a probe, "Has subject engaged in non-suicidal self- injurious behavior?" under "Actual Attempt." 1 To find the definition, one needs to review another probe, one that may or may not be asked depending on the answer to the first question under the "Actual Attempt" category. This probe asks if the attempt was done "purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better, get sympathy, or get something else to happen)?" 1 Compared to the FDA definition ("Self-injurious behavior associated with no intent to die. The behavior is intended purely for other reasons, either to relieve distress [often referred to as self-mutilation [e.g., superficial cuts or scratches, hitting or banging, or burns]] or to effect c hange in others or the environment."), 6 the C–SSRS definition is somewhat more expansive, adding behaviors "feel better," "get sympathy," and the rather ambiguous "to get something else to happen." 1 " Aborted" or "Self-Interrupted Attempt. " As described in above in section 3, use of the word "themselves" in the definition for the C–SSRS category, "Aborted Suicide Attempt," 1 is ambiguous and may be interpreted by some that more than one person has to be engaged for the act to be an aborted attempt. This is not the case with the corresponding FDA-CASA 2012 category, "Aborted Suicide Attempt," where no ambiguity is present. 6 "Preparatory Acts or Behavior." The C–SSRS category, "Preparatory Acts or Behavior," 1 differs from the FDA-CASA 2012 category, "Preparatory acts toward imminent suicidal behaviors," 6 in its placement and hence emphasis on the word "imminent." Whereas the FDA-CASA 2012 category has this word in the title, the C–SSRS only has it in the definition. Furthermore, while the FDA-CASA 2012 definition clearly differentiates this category from other categories, indicating that the acts or behaviors stop short of a suicide attempt, an interrupted suicide attempt, or an aborted suicide attempt, the C–SSRS probe question does not make this distinction clearly. As a result patients who start an attempt, even if the attempt is interrupted or aborted, may be included in this category on the C–SSRS, thereby inflating its endorsement. This C–SSRS probe question wording conflicts with the definition wording. "Completed Suicide" or "Suicide." Although this category (labeled "Suicide") is provided in the current version (downloaded from C–SSRS website on February 5, 2014 15 ) of the

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