Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study

Craig J. Bryan; Michael H. Allen; Cynthia J. Thomsen; Alexis M. May; Justin C. Baker; AnnaBelle O. Bryan; Julia A. Harris; Craig A. Cunningham; Kara B. Taylor; Michelle D. Wine; Johnnie Young; Sean Williams; Kirsi White; Logan Smith; W. Cole Lawson; Timothy Hope; William Russell; Kent D. Hinkson; Tyler Cheney; Kimberly Arne

doi:10.1370/afm.2729

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RE: Could imprecise suicide assessment methods actually increase suicide risk?
Shauna Springer

Published on: 01 December 2021
RE: Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
M. David Rudd

Published on: 16 November 2021
RE: Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
Michael F Hogan

Published on: 11 November 2021

Published on: (1 December 2021)
Page navigation anchor for RE: Could imprecise suicide assessment methods actually increase suicide risk?
RE: Could imprecise suicide assessment methods actually increase suicide risk?
Shauna Springer, Psychologist, Hidden Ivy Consulting
Primary care suicide screenings commonly rely on imprecise questions that are distal from suicidal ideation or intent. Current approaches aim to capture as many at-risk patients as possible. As these authors emphasize, this may result in misallocation of treatment resources or unnecessary hospitalizations.

In addition to these considerations, there are other factors to weigh.

Might harm result from imprecise measures of risk?

Being flagged as “at risk” has consequences for some individuals, particularly those in certain occupations. For example, a military service member’s career may be derailed if he or she is “med-boarded” out of the service.(1) In fact, some marines refer to mental health providers as “wizards” because they have the power to “make service members disappear (from the Marine Corps).”
Further, hospitalization is not always therapeutic. In the worst cases, imprecise measures can result in poor decisions that break therapeutic trust and dissuade those who suffer from engaging in care in the future.

In this article, Bryan and colleagues demonstrated gains in discerning suicide risk from the addition of two items from the Suicide Cognitions Scale (SCS) that:

1) Bring the focus to the individual in a way that PHQ-2 items do not and
2) Are more specific (i.e., “proximal”), to suicidal intent as they home in on the tolerability of distress.

The performance of this combined PHQ/SCS items approach was act...
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Primary care suicide screenings commonly rely on imprecise questions that are distal from suicidal ideation or intent. Current approaches aim to capture as many at-risk patients as possible. As these authors emphasize, this may result in misallocation of treatment resources or unnecessary hospitalizations.

In addition to these considerations, there are other factors to weigh.

Might harm result from imprecise measures of risk?

Being flagged as “at risk” has consequences for some individuals, particularly those in certain occupations. For example, a military service member’s career may be derailed if he or she is “med-boarded” out of the service.(1) In fact, some marines refer to mental health providers as “wizards” because they have the power to “make service members disappear (from the Marine Corps).”
Further, hospitalization is not always therapeutic. In the worst cases, imprecise measures can result in poor decisions that break therapeutic trust and dissuade those who suffer from engaging in care in the future.

In this article, Bryan and colleagues demonstrated gains in discerning suicide risk from the addition of two items from the Suicide Cognitions Scale (SCS) that:

1) Bring the focus to the individual in a way that PHQ-2 items do not and
2) Are more specific (i.e., “proximal”), to suicidal intent as they home in on the tolerability of distress.

The performance of this combined PHQ/SCS items approach was actually superior to complex suicide prediction models derived from like machine learning algorithms.

Adding just a couple SCS items will better equip clinicians to accurately discern risk. This matters because discerning risk accurately is meaningfully related to decreasing risk, both for those who need care now, and those who may need urgent care in the future.

(1) The grief of losing the life one always wanted to lead as a career military service member is both substantial and often unaddressed in treatment settings where veterans are seen.
Show Less

Competing Interests: None declared.
Published on: (16 November 2021)
Page navigation anchor for RE: Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
RE: Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
M. David Rudd, President and Distinguished University Professor of Psychology, University of Memphis
The results of this study are important for a number of reasons, particularly given recent findings using traditional screening and assessment tools like the C-SSRS, and others asking direct and specific questions about suicide. It's not just about another scale assessing suicidality, it's about how these items assess suicidality by targeting core beliefs about self and enduring risk around three themes of unbearability, unlovability and unsolvability, without asking directly about suicide. Recent findings using the C-SSRS reveal a broader problem with direct assessment of suicide risk. As with many instruments assessing suicidality in direct and specific fashion, the C-SSRS demonstrated poor predictive value in two studies with very large samples in healthcare settings (Simpson, Loh, & Goans, 2021). There is emerging data to support the conclusion that a large percentage of patients in healthcare and clinical settings are either unwilling or unable to reveal active suicidal thoughts and motivation to die when answering direct questions (Rudd, 2021).

It's not that we need better screening tools. We need to recognize the limited predictive value of tools that assess suicidality in direct and specific ways. We need tools that complement these traditional approaches, adding unique predictive power. Additionally we need approaches that recognize that there are great and frequent variations in suicidal thinking for many, as ecological momentary asses...
Show More

The results of this study are important for a number of reasons, particularly given recent findings using traditional screening and assessment tools like the C-SSRS, and others asking direct and specific questions about suicide. It's not just about another scale assessing suicidality, it's about how these items assess suicidality by targeting core beliefs about self and enduring risk around three themes of unbearability, unlovability and unsolvability, without asking directly about suicide. Recent findings using the C-SSRS reveal a broader problem with direct assessment of suicide risk. As with many instruments assessing suicidality in direct and specific fashion, the C-SSRS demonstrated poor predictive value in two studies with very large samples in healthcare settings (Simpson, Loh, & Goans, 2021). There is emerging data to support the conclusion that a large percentage of patients in healthcare and clinical settings are either unwilling or unable to reveal active suicidal thoughts and motivation to die when answering direct questions (Rudd, 2021).

It's not that we need better screening tools. We need to recognize the limited predictive value of tools that assess suicidality in direct and specific ways. We need tools that complement these traditional approaches, adding unique predictive power. Additionally we need approaches that recognize that there are great and frequent variations in suicidal thinking for many, as ecological momentary assessment studies are illustrating, and that many existing tools are simply not sensitive to such profound and frequent shifts in suicidal thoughts. It is also important to recognize that there are some elements of enduring risk that are simply missed by traditional screening approaches. These findings confirm that a few items targeting underlying core beliefs about self, revolving around the themes of unlovability, unbearability, and unsolvability can add meaningful power to our ability to understand, anticipate and target individual vulnerability for suicide risk. I would suggest we need more work like this and continued innovation targeting how best to assess and understand enduring vulnerability for suicide.
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Competing Interests: None declared.
Published on: (11 November 2021)
Page navigation anchor for RE: Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
RE: Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
Michael F Hogan, Consultant, Court Monitor, CWRU Psychiatry
This is a report of a well conducted study to test use of items from the Suicide Cognitions Scale to improve specificity of item 9 on the PHQ9 screener to better predict suicidal behavior. This item, on a scale used widely in primary care, “overpredicts” suicide risk.

Improving performance of the PHQ9 item 9 is a good goal, even if the field of suicidology is a bit hung up on prediction. Common screeners for CVD risk, by the same measure, overpredict heart attacks. But preventive interventions like managing hypertension, like new interventions for moderate suicide risk (e.g. safety or crisis planning, supportive “caring contacts”) significantly reduce risk, are feasible in any professional healthcare setting and are relatively inexpensive.

However we already have screeners (e.g. Columbia Suicide Severity Rating Scale, Ask Suicide-Screening Questions) that perform adequately and are widely used to improve results of PHQ9. They do this by exploring other dimensions of risk than simply having thoughts of suicide, as this study demonstrates is useful. Not a research expert, this commentator wonders why we meet yet another scale, versus working harder to put effective ones to use in primary care.

Competing Interests: None declared.