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 95 The CMCM version of the S-STS has four parts. The first section can be either patient-rated or clinician-rated. This section is identical to the first two p ages of the standard S-STS. The second section is patient-rated. It provides patients with a series of additional ratings. These include 1) an opportunity to rate a series of risk or protective factors that might be important aggravating or relieving factors in the subject's suicidal ideation and behaviors; 2) a series of 11-point (0–10) discretized visual analog (DISCAN) scales on which patients can rate their ability and willingness to cope with their suicidality, their ability and willingness to "stay safe," the extent to which their suicidality is deliberate, the extent to which it is impulsive, the extent to which it has impacted the quality of their lives, and the extent to which it has impaired their work, social, or family lives; and 3) a patient-rated global severity of suicidal impulses, thoughts, and behaviors rating and an opportunity to provide a self-assessment of treatment needs. The third section of the CMCM version is clinician-rated. This section gives the clinician an opportunity to rate his or her judgment of the patient's suicide risk and a judgment of level of management required for the patient's suicidal ideation and behavior. It also captures a global assessment of suicidality based on all the information collected in the earlier sections of the scale with additional input from others and from any additional probe questions the clinician deems necessary to complete the assessment. The fourth section is completed by the clinician only if the patient misses a follow up appointment and is unavailable, which allows completion of the scale. It is identical to page 3 of the S-STS standard version. The Pediatric versions of the S-STS. The Pediatric versions of the S- STS were developed specifically for children and adolescents. There are currently three pediatric forms of the S-STS. One is for 6- to 8-year-olds, one for 9- to 12-year-olds, and one for 13- to 17-year-olds. A novel method of linguistic validation was used in the development of these versions. To our knowledge, this makes these three pediatric S-STS versions the first l inguistically validated versions of a suicidality scale in children and adolescents. The Pediatric versions of the S-STS are the subject of a separate article. 9 SCALE PROPERTIES Response format. To capture the seriousness and intensity of each suicidality phenomenon, the S-STS uses a Likert-like response format ranging from "not at all" (0), "a little" (1), "moderately" (2), "very" (3), to "extremely" (4). This response format allows the scale to capture finer discriminations for tracking than the dichotomous yes/no format used in the suicidality module of the MINI and in the scale's most widely used alternative, the Columbia–Suicide Severity Rating Scale (C-SSRS). 10 The C–SSRS, in contrast, captures an intensity rating on the highest-rated single combination of a limited number of six of 32 possible suicidal ideation combinations. The S-STS captures the seriousness of all suicidal phenomena. Scale structure. The C–SSRS has features of a Guttman scale structure, where the suicidal ideation items are ordered so that an individual who agrees to a particular item (e.g., suicidal method, intent, or plan) is assumed to have agreed with a lower ordered item (e.g., active suicidal ideation). In contrast, the S-STS scale structure treats each item separately without any assumptions of inherent order or cumulativeness. The S-STS structure makes it possible for the scale to capture a wider range of combinations of suicidal ideation and behavior than the C–SSRS and to assess the seriousness of each ideation item separately. Time frames. The S-STS accommodates a wide range of time frames. In clinical trials, the frequently used variants are "in the past week," "in the past month," "since the last visit," "lifetime look back," and "in the past day." In emergency room settings, the scale can be adapted to cover all phenomena relating to "your most recent attempt" or to "what brought you here." A shorter adaptation can be used to assess suicidality in the past 15 m inutes, in the past hour, or for other shorter times frames that might be needed for testing efficacy of medications with rapid anti-suicidal properties. These are all outlined in the scoring instructions (Appendix C) and in the instructions for use in acute rapid onset of action studies (Appendix D). Administration time. In a clinical sample of 34 patients with reported suicidal ideation or behavior, the average time taken to administer the standard S-STS was 9.1 minutes. 1 1 While this duration was slightly longer than that reported for the C-SSRS (8.1 minutes) in the same study, it was comparable to the duration reported for suicidal subjects in another study of the C–SSRS (9.6 minutes) 12 and somewhat shorter than that for the InterSePT Scale for Suicidal Thinking- Plus (ISST-Plus) (14.5 minutes). 11 The patient-rated version of the S-STS took 8.3 minutes and the reconciliation version took 2.5 minutes in the same study. In a sample of generalized anxiety disorder patients in a clinical trial who did not have active suicidal ideation at study entry, the original eight-item version of the S-STS took 1 to 2 minutes to complete. 13 Screening, study exclusion, and monitoring alert rules. As shown in Appendix C, the standard S-STS can be used to determine if a patient should be excluded from a study at the screening visit or alternatively after the study start and/or if a monitor should be alerted. Although different protocols have different needs, we provide suggestions based on item scores for these contingencies. Appendix E provides suggested guidelines on study stopping rules to be used with the S-STS. Scoring. As shown in Appendix C, the standard S-STS can be used to generate a summated score (total score), individual factor scores for suicidal ideation, suicidal intent, suicidal planning, suicidal behavior, and non-suicidal self-injury. Counts for

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