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 ] 100 as an adverse event (AE) or serious adverse event (SAE). 13 As we observe in a companion paper, the S-STS captures a more complete range of s uicidal ideation and behavior, reducing potential type II error (not capturing suicidal phenomena that do exist), and it is likely to have less type I error (identifying suicidal phenomena when they do not exist) because the S-STS avoids the flawed navigation instructions and hierarchical scaling assumptions inherent in the suicidal ideation section of the C–SSRS. 19 Clinical practice. With increasing media attention to recent high profile suicides, incidents of "death by cop," suicides associated with conjoint homicides or school killings, and the call for proper screening of those buying guns, suicide assessments cannot be haphazard. They need to be systematic, careful, and thoughtful, with the aim of helping the vulnerable in a humane, understanding way. The S-STS provides a useful screening and tracking tool in mental health, primary care, and emergency room settings. It allows clinicians to collect the documentation recommended in the prescribing information for most psychiatric medications for assessing and monitoring suicidality before and during the course of treatment. This serves both to protect patients and to protect clinicians and healthcare provider groups and institutions medico-legally. Unlike alternative scales, such as the C–SSRS, the S-STS can be self-rated on paper or by computer before each visit while the patient waits to see a clinician. This assists the clinician in routinely monitoring the patient's suicidality. Health maintenance and managed care organizations. Health maintenance and managed care organizations are taking increasingly active roles in suicide prevention to promote health and to contain costs associated with suicidal behaviors. The S-STS, with its sensitivity to signal detection and change, 13,21,22 has a potential role in this effort and can be integrated easily into an electronic medical record. Epidemiology research. The S-STS has applications in national epidemiology studies to investigate national suicide statistics beyond the u sual reporting of deaths by suicide. This may provide national health policy advisors with information to better plan and allocate funding in national efforts to reduce suicide. For example, S-STS is currently being used in adapted form, as noted above, in two major epidemiology initiatives—one in South Africa 2 4 and one in India (one of the largest epidemiology studies ever carried out in psychiatry 25,26 ). Military and military veterans. The increasing rate of suicide among members of the armed forces and veterans is another growing concern and has led to the implementation of programs to more carefully detect and monitor suicidality in these groups. 27 The ability to use the paper-based or electronic self-rated S-STS one page form provides a way to screen those from waiting lists with higher suicidality scores and to ensure they get higher priority and more urgent care. Criminal justice. It is estimated that more than 400 suicides occur each year in local jails at a rate three times greater than in the general population, and, according to some estimates, suicide is now the third leading cause of death in prisons. 28,29 The S-STS, with its companion the Sheehan- Homicidality Tracking Scale (S-HTS), 30 is a potentially valuable tool for screening and follow-up of the incarcerated and those on parole. The S-STS can be used to detect suicidality and the S-HTS can detect both homicidality alone and combination homicidality/suicidality (e.g., murder- suicide) in these populations. The S- HTS is the only scale the authors are aware of that tracks these homicidal or homicidal/suicidal impulses, ideations, or behaviors with the necessary level of detail. International security. The frequency of suicide terrorism is a growing concern internationally. While the determinants of suicide terrorist acts are complex, there is increasing evidence that antecedent suicidality may play a role in this phenomenon. 31 Surviving perpetrators are increasingly being apprehended and detained in hotspots, such as Israel, Palestine, A fghanistan, and Iraq, and some are being sent to rehabilitation programs (e.g., in programs in Saudi Arabia). 31 The third author of this article (I.S.) has called for international cooperation and sharing of information about this population as a preventative measure. 32 Consistent, systematic data collection on suicidality within this population using a tool such as the S-STS may be useful in detecting the extent to which antecedent and ongoing suicidality contributes to these acts. This could enable the international sharing and analysis of such data in order to better understand the suicide terrorist and to lead to better methods of prevention of such behavior. Because of its systematic collection of data 1 1 and its sensitivity to signal detection and change, 13,21,22 S-STS also has potential uses as a screening tool for victims of human security catastrophes, including war, famine, and displacement. Schools and colleges. High profile suicides at schools and colleges/universities have alerted the public to the need for sensitive evaluation of students at all levels. As discussed earlier, as many as one fifth of college students have suicidal ideation, 4.3 percent had made a suicide plan, and 2.6 percent have made a serious suicide attempt. 15 The probability of a suicide attempt among subjects who had suicidal ideation and had made a plan captured on the self- rated S-STS was 46.2 percent. 15 Routine tracking of suicidality in this population when they come to the attention of college counselors is prudent, and the S-STS provides a useful tool for this purpose because it can be self-rated. Concern about the need to monitor suicidality in vulnerable samples of children and adolescents, both on and off medications, persists. Indeed a recent study of automated healthcare claims from 11 health plans for 1.1 million adolescents, 1.4 million young adults, and 5 million adults from 2000 to 2010 found a significant, relative

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