MHEI transcript 4 specific screening for suicidal risk

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PODCAST TRANSCRIPT 4:
SPECIFIC SCREENING FOR SUICIDE RISK
Neubauer, David N., M.D.
Associate Professor
Psychiatry and Behavioral Sciences
Johns Hopkins Bayview Medical Center
Hello, this is David Neubauer and I would like to welcome you back to this podcast series
focusing on the issues surrounding the suicide risk associated with the use of
medications, particularly antidepressant and antiepileptic agents, and particularly
among children, adolescents, and young adults. This is the 4th and last of these
podcasts. The first installment examined the history of the concern about medications
possibly increasing “suicidality” –– especially following the 2004 FDA Black Box warning
for antidepressants prescribed for children and adolescents and the subsequent
extension to young adults and to the warnings about antiepileptic agents. While
“suicidality” was the term initially used in these warnings, now it wisely has been
replaced by the less ambiguous phrase “suicidal ideation and behavior.”
The first podcast dealt primarily with antidepressants and the second with antiepileptics
and the third with general issues and FDA updates regarding suicide risk screening. Now
in this final installment we will explore some practical issues related to screening for
suicide risk.
Since this podcast series has been concerned primarily with the potential increased
suicide risk in the context of patients being prescribed antidepressants and
antiepileptics, our immediate interest here is with screening in outpatient settings –
primary care and specialty offices and clinics – or by other healthcare providers who
might be reviewing patients’ medications.
Recall that the FDA warnings for these medications, whether or not in a black box in the
PI – the Prescribing Information, suggest first education to patients, caregivers, and
families, that there is a possibility of increased symptoms of depression and even

suicidal thoughts and behaviors. So, all should be alert to any changes in mood or
behavior indicative of worsening depression or harmful behaviors. And, any behaviors of
concern should be reported immediately to healthcare providers. Secondly, patients
prescribed these medications should be monitored for worsening depression and
suicidal thoughts and behaviors. So, that suggests a baseline assessment and future
reassessments – perhaps screening questions on scheduled follow up visits and perhaps
by some method between visits – possibly by telephone or through online approaches.
No matter what strategy is employed in asking questions regarding suicide risk,
consistency in the use of screening questions, in the regularity of screening, and in the
ongoing documentation of the evaluation process should be maintained. Employing a
routine system will make it quick and easy for nearly all patient encounters.
At this point, let me dispel one common misconception – that asking about suicide
might actually lead people – children, adolescents, and young adults – to think about it
more or even act on the thoughts – as though the question planted a seed. The
extensive research on suicide assessment has shown that this simply isn’t the case. In
fact, studies have specifically shown that after being asked suicide risk questions, the
subjects had neither greater distress nor an increase in suicidal thoughts.
One key – and easy to overlook – element in the suicide risk assessment process is
having a plan of what to do when patients do offer positive responses – that they report
feeling more depressed, think that life isn’t worth living, now are having thoughts of
ending their lives, or actually have a suicide plan. Of course, these symptoms range in
urgency, so there should be a corresponding range of possible interventions.
Some positive responses should be expected – especially regarding suicidal ideation. A
very recent study by Nock and colleagues published in JAMA Psychiatry examined data
from the National Comorbidity Survey Replication Adolescent Supplement on a national
sample of 13 to 18 years olds. The objective of the study was to estimate the lifetime
prevalence of suicide ideation, suicide plans, and suicide attempts. This large study
involved detailed interviews with 6,483 adolescents and questionnaires completed by
their parents. The findings were impressive: 12.1% of this general population adolescent

sample endorsed a history of suicidal ideation and about 4% reported past suicidal plans
and 4% said that they had attempted suicide. Here is the article conclusion: “Suicidal
behaviors are common among US adolescents!”
So, don’t be surprised or unprepared when patients say they have had suicidal thoughts.
Make sure you have emergency contact information for patients and family, and make
sure that you have established local resources for further consultations and referrals,
and information for emergency psychiatric evaluations and hospitalizations.
The potential strategies for suicide risk screening are quite varied with a spectrum from
a question or two to a detailed and structured questionnaire or interview. On the most
basic level patients simply may be asked whether they have had thoughts that life was
not worth living or actual thoughts of harming themselves or ending their lives. That
might take 5 or 10 seconds, unless, of course, the reply is yes, in which case further
questioning will be necessary and treatment interventions may be warranted.
And since suicidal thoughts and behaviors so often occur in the context of depressive
symptoms and since suicidal behavior may be impulsive and not premeditated, it also
may be useful to assess the potential for suicidal acts with inquiries about changes in
mood, sleep, appetite, interest in usual activities, and the ability to enjoy life. Of course,
reports by parents or other caregivers will be invaluable with younger children, and
these other informants may be useful with patients of any age.
The gold standard for suicide risk screening is the Columbia-Suicide Severity Rating Scale
(C-SSRS) developed by Kelly Posner and colleagues at Columbia University, the
University of Pennsylvania, and the University of Pittsburgh. The C-SSRS was designed as
a highly structured interview; although computer assisted self-assessments have been
developed and tested. The scale evolved from the definitions in the Columbia Suicide
History Form and the Columbia Classification Algorithm of Suicide Assessment (C-CASA)
that we discussed in the first podcast.
It should be pointed out here that the C-SSRS is intended to be used by individuals
trained in administering the scale. The scale disclaimer also notes that the
determination of suicidal ideation or behavior depends on the judgment of the person

administering the scale. The complete scale, information about training, and lots of
other resources are readily available at the scale website: www.cssrs.columbia.edu.
The goals in creating the C-SSRS included 1) incorporating clear definitions of suicidal
ideation and behavior, as well as nonsuicidal self-injurious behavior, 2) a way to quantify
the spectrum and severity of suicidal ideation and behavior, and 3) a mechanism to
separately identify lifetime and past month history symptoms. The last issue really is
important since the worst degree of lifetime suicidal ideation may be especially
predictive of eventual suicide.
The C-SSRS has four key constructs or subscales. These are the severity subscale, the
intensity subscale, the behavior subscale, and the lethality subscale. It has been
extensively evaluated and has been found to have excellent psychometric properties
including convergent, divergent, and predictive validity; sensitivity to change; sensitivity
and specificity; and internal consistency. It also has been successfully employed in
widely divergent settings. And, there are several different versions available. There is
the Lifetime/Recent version that is valuable as a baseline assessment, but also highlights
recent ideation or behavior. There is a Since Last Visit version that can be used when the
person previously has completed the Lifetime version. And there also is a specific Risk
Assessment version for acute care settings that is designed to estimate a person’s
immediate suicide risk.
In addition, there are pediatric versions of the Lifetime/Recent and the Since Last Visit
assessments.
And the C-SSRS has been translated into 103 languages.
All of this may make it sound lengthy and unwieldy and impractical in a busy office
setting, but the C-SSRS structure allows a relatively quick assessment with scores that
can be used for comparison with other visits, and with scales that certainly help to
stratify severity and highlight what patients will need further interventions.
The C-SSRS has two primary sections: Suicidal Ideation and Suicidal Behavior.

The Suicidal Ideation section comprises five potential levels of severity. Each of these
five levels has a definition and a corresponding sample question to address this degree
of suicidal thinking. With increasing severity the five categories are:
1. Wish to be Dead
a. Have you wished you were dead or wished you could go to sleep and not
wake up?
2. Non-Specific Active Suicidal Thoughts
a. Have you actually had any thoughts of killing yourself?
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act
a. Have you been thinking about how you might do this?
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
a. Have you had these thoughts and had some intention of acting on them?
5. Active Suicidal Ideation with Specific Plan and Intent
a. Have you started to work out or worked out the details of how to kill
yourself? Do you intend to carry out this plan?
If subjects say “no” or offer similar negative responses to the first two questions, then
you move on to the next section – Suicidal Behavior. If there are positive responses, the
subjects are asked to elaborate, and there is a further assessment of the intensity of
ideation – all precisely defined in terms of frequency, duration, controllability,
deterrents, and reasons for ideation. However, the most common situation with the
first two “no” responses will take just a matter of seconds.
The Suicidal Behavior assessment in the C-SSRS comprises five categories:
1. Actual attempt
2. Interrupted attempt
3. Aborted or self-interrupted attempt
4. Preparatory acts or behavior

5. As well as a yes/no item noting whether there were any of these suicidal behaviors
during the assessment period, which could be the baseline lifetime history or the
intervening period since the last assessment.
6. There also is a place to note whether the individual has engaged in non-suicidal self-
injurious behavior.
As with the Suicidal Ideation section, the C-SSRS incorporates detailed definitions and
sample questions for these suicidal behavior categories.
For instance, a suicide attempt is defined as a potentially self-injurious act committed
with at least some wish to die as a result of the act. There does not need to have been
any injury or harm from the attempt, and the intent to die does not have to have been
100% to qualify as a suicide attempt. Among the sample questions are, “Have you made
a suicide attempt; have you done anything to harm yourself?” And other questions
follow up with further detail depending on the responses to the above questions.
The question associated with the Interrupted Attempt category is: “Has there been a
time when you started to do something to end your life but someone or something
stopped you before you actually did anything?” An example presented is initiating a
medication overdose with pills in one’s hand, but then being stopped from swallowing –
at which point it would become an attempt. The key element in this Interrupted
Attempt category is that outside circumstances interfere with the planned attempt.
The Aborted or Self-Interrupted Attempt, as the name suggests, represents situations
when subjects stop themselves from continuing with steps they have made toward a
suicide attempt. The associated question is, “Has there been a time when you started to
do something to try to end your life but you stopped yourself before you actually did
anything?”
The last of these Suicide Behavior options is Preparatory Acts or Behavior with this
associated question: “Have you taken any steps toward making a suicide attempt or
preparing to kill yourself (such as collecting pills, getting a gun, giving valuables away or
writing a suicide note)?”

There are two further possible ratings. The first rates the Actual Lethality or Medical
Damage and on a zero to five scale ranges from none or very minor physical damage all
the way to death. And when there was no actual lethality a subsequent potential
lethality rating can be applied with estimates that the behavior 1) would not likely result
in injury, 2) likely would result in injury but not death, 3) likely would result in death
despite available medical care.
So, the C-SSRS has lots of advantages. It is standardized and employed in a wide range of
settings. It incorporates clear definitions and associated questions for each section. It
can be done very quickly for most patients. And it helps stratify which subjects may
require different levels of intervention. And, there is the electronic eC-SSRS, as well as
an Interactive Voice Response System (IVRS).
Here’s the website again: www.cssrs.columbia.edu
Although I’ve emphasized the C-SSRS, it certainly isn’t the only efficient and well-studied
suicide risk assessment scale. There is a 17-item Suicidal Ideation Questionnaire – the
SIQ, and the ASQ – Ask Suicide-Screening Questions with 4 questions. These and several
others are easy to locate online.
The bottom line here is that screening for symptoms of depression and suicide risk can
be done quickly in an organized manner that satisfies the guidelines of the FDA for
people (especially children, adolescents, and young adults) taking antidepressants and
antiepileptic medications – and perhaps others in the future.
Thank you for joining us for this podcast series on suicide risk assessment.

MHEI transcript 4 specific screening for suicidal risk

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MHEI transcript 4 specific screening for suicidal risk