Innovations In Clinical Neuroscience

SEP-OCT 2014

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

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Do the Five Combinations of Suicidal Ideation in the FDA 2012 Draft Guidance Document and the C–SSRS Adequately Cover All Suicidal Ideation Combinations in Practice? A Case Study..........................172 ABSTRACT: Objective: The United States Food and Drug Administration's newest classification system for suicidality assessment anchors suicidal ideation to various combinations of passive suicidal ideation, active suicidal ideation, method, intent, and plan. This is based upon the suicidal ideation categories in the Columbia–Suicide Severity Rating Scale. Although there are 32 possible combinations of these suicidal ideation phenomena, the Food and Drug Administration's 2012 system and the Columbia–Suicide Severity Rating Scale accommodate six combinations. We use a case study to explore the impact of possible type II errors on suicidality classification posed by not including remaining 26 possible categories. Methods: A suicidal subject kept detailed daily records of her experience of suicidality over two separate intervals of eight- months' and nine-months' duration. These records permitted classification of individual events into each of the possible 32 suicidal ideation combinations. Results: Although only a small percentage of all events of suicidality from either collection period fell outside of the Food and Drug Administration's classification system and the Columbia –Suicide Severity Rating Scale categories, those that were not so categorized constituted a large percentage of the time this subject experienced suicidality. When these two timeframes were aggregated, more than half of the subject's time spent experiencing suicidality fell into the suicidal ideation combinations not captured by the Food and Drug Administration's classification system and the Columbia–Suicide Severity Rating Scale categories. Conclusion: This case study suggests that type II errors in the Food and Drug Administration's classification system and in the Columbia–Suicide Severity Rating Scale categories for suicidal ideation may represent important omissions. Is a Count of Suicidal Ideation and Behavior Events Useful in Assessing Global Severity of Suicidality? A Case Study.........................................................179 ABSTRACT: Objective: Regulatory agencies and suicidality scales have focused on the value of a count of suicidal ideation and behavior events, even though the clinical usefulness and predictive value of the count of events in the global assessment of suicidality is unclear. This case study explores the value of this event count and offers a more sensitive alternative to tracking the count of events. Methods: One subject documented her suicidality daily for 366 days. This documentation included the global severity of suicidality, the count of suicidal events, and the time spent experiencing those events. The relationship between both the count of events and the time spent were each compared to the global severity rating. Results: We found the relationship between the time spent experiencing suicidality and the global severity of suicidality was much stronger than the relationship between the count of suicidal events and global severity. Conclusion: This case study suggests that tracking the time a patient spends experiencing suicidality may be more clinically useful and may have more value in assessing global severity of suicidality than tracking the count of events of suicidal ideation and behavior. Is There Value in Asking the Question "Do you think you would be better off dead?" in Assessing Suicidality? A Case Study ...182 ABSTRACT: Objective: The author of the widely used suicidality scale, the Columbia–Suicide Severity Rating Scale, has repeatedly made the claim that asking the question, "Do you think you would be better off dead?" in suicidality assessment delivers false positive results. This case study investigates the value of this question as an immediate antecedent to impulsive suicidality and as a correlate of functional impairment. Method: One subject with daily suicidality and frequent impulsive suicidality rated five passive suicidal ideation phenomena and impulsive suicidality daily on a 0 to 4 Likert scale and rated weekly functional impairment scores for 13 weeks on a 0 to 10 Discan metric. Results: Each of the five passive suicidal ideation phenomena studied frequently occurred at a different severity level, and the five phenomena did not move in synchrony. Most passive suicidal ideation phenomena were very low on dates of impulsive suicidality. Thoughts of being better off dead were a frequent antecedent to impulsive suicidality and were related to an increase in functional impairment. Conclusion: The relationship to both functional impairment and impulsive suicidality suggest that it is potentially dangerous to ignore thoughts of being better off dead in suicidality assessment. How the Timing of a Patient's Self-ratings of Suicidality and the Relationship to the Recipient Affect Patient Responses: A Case Study ...........................................191 ABSTRACT: Objective: This case study explores to what extent, if any, a subject's reporting varies depending upon whom the subject believes will view the data and the relationship the subject has with the reviewer. It also explores the variance in reporting if several days pass between the timeframe in question and the time of data collection. Method: The subject answered three suicidality-related scales (the Sheehan-Suicidality Tracking Scale, the Suicidality Modifiers, and the Alphs Dichotomous Impulsivity and Hopelessness Two Questions) for 24 distinct timeframes. The scales were rated three different ways for each timeframe. The first was for only the patient. Immediately afterward, the scales were answered for the subject's therapist. A few days later, the scales were again answered by the patient, but only for the patient. The three different interviews for the same timeframe were compared to investigate any deviations. Results: This case study found clinically relevant deviations between the three ratings completed for the same timeframe. Conclusion: This case study illustrates that a patient's reporting of his or her symptoms of suicidality using a patient- rated scale can vary depending upon the context, distance from timeframe in question, and the patient's relationship with the reviewer of the data. RESEARCH TO PRACTICE Assessment of Suicidal Behavior in the Emergency Department for Clinical Trial Results ......................................................194 SUMMARY: The author discusses the assessment of suicidal patients in the emergency department of Tufts Medical Center with Drs. Frank Friedman and Manuel N. Pacheco. A N N O T A T E D T A B L E O F C O N T E N T S [ 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 9

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