CLINICAL INSTRUMENTS FOR THE EVALUATION OF SUICIDE RISK – AN OVERVIEW

INTRODUCTION

Suicide is a serious health-problem world-wide and one of the main emergencies in psychiatric practice. Completed suicide is responsible of 1% of all deaths and is included, in most regions of the world, in the first ten causes of death (1). It is even higher in rank in adolescents and young adults: in ages 15-29 it is the second cause of death and in ages 30-49 the fifth (1). More than that, suicide and suicidal behaviour have serious social, economic and psychological influences impacting both the persons who commit them, their families and other people close to them.

In most instances, suicide is a complication of psychiatric disorders. Approximately 90% of those who die by suicide have, at the time of death, a psychiatric diagnosis (1, 2), most of them a diagnosis of mood disorder (2, 3). Yet, most people who suffer from a mental illness never even attempt suicide. A study published in 2003 estimated that the suicide rate of affective disorders is

193:100.000, meaning that over 99.000 people suffering from a mood disorder will never die by suicide (4). Therefore it is very important to be able to distinguish those few who are at risk.

Up to date there is no available method that can accurately distinguish those who will commit suicide from those who will not.

The importance and the difficulty of the task of identifying those who are at risk for suicide has lead to an extensive research on the subject, and to the elaboration of numerous clinical instruments meant for this purpose. This review aims to describe some of those instruments, focusing on those that have proven psychometric properties, in order to guide clinicians searching for an aid in evaluating suicide risk. The author does not presume to be comprehensive in this review, since the number of instruments available is extensive and many of these are not sustained by a significant evidence basis.
The instruments are presented in several categories: checklists, clinician-rated instruments, self- report instruments, combined administration instruments, measures of suicide attempt lethality, brief screening measures and scales relating to protective factors. No instruments created for specific populations (adolescents, elderly etc.) were included.

CHECKLISTS

This type of instrument is the first to appear in clinical practice and, most of these early tools have little or no documented reliability and validity. Among these we can include: the Scale for Predicting Subsequent Suicidal Behaviour (5), the Instrument for the Evaluation of Suicide Potential (6) and the Scale for Assessing Suicide Risk (7). At present, the existence of these instruments has more of a historical importance than a clinical one.

1.CLINICIAN-RATED INSTRUMENTS
1.1 Scale for Suicide Ideation (SSI)
This is one of the most widely used instruments for assessing suicide risk, partly due to its extensive documentation regarding validity and reliability.
It was published in 1979 by Beck et al. (8). It contains 21 items, of which 5 are screening items (3 regarding the wish to die – passive suicidal ideation and 2 regarding the wish to attempt suicide – active suicidal ideation) and 2 are additional items which assess the incidence and frequency of prior suicide attempts (these items are not scored). The total score is calculated by adding the scores of each item, ranging from 0 (none) to 2 (moderate to strong).
Factorial analysis has determined 3 significant dimensions: active suicidal desire, specific plans regarding suicide and passive suicidal desire (8).
It has Cronbach coefficient alphas that show moderately high internal consistency – 0.84 (9) to 0.89 (8). It also has high interrater reliability, with a correlation of up to 0.98 (8, 9).
The validity of the SSI was established repeatedly. In the original work, Beck et al found a significant correlation with the self-harm items from the Beck Depression Inventory (BDI) (8). Other studies found significant correlations with previous suicide attempts, severity of depression and daily self-monitoring of suicidal ideation (9, 10). It has been proven that the SSI can discriminate suicide attempters from nonattempters (11).
It was found that a total score higher than 2 includes the patient in a higher risk category and suggests a likelihood of suicide that is 7 times higher than for those with scores of 2 or less (12).
Main advantages of this instrument are: extensive use in research, well documented validity and reliability in a variety of populations, and, according to some authors the fact that it is administered as an interview (13, 14) . One possible disadvantage is the fact that it has to be administered by trained clinicians (14).
1.2 Scale for Suicide Ideation – Worst (SSI-W)
This scale was published in 1999 by Beck et al. and contains 19 items scored 0 to 2, according to suicidal intensity. The SSI-W measures suicidality (behaviors, thoughts, emotions) at its worst point in the patient’s life. As with SSI, the total score ranges from 0 to 38 (15).
Factorial analysis has found two factors:
preparation and motivation (15).
The Cronbach alpha was found to be 0.88, representing moderately-high internal consistency (9). The instrument has high interrater reliability (9). Its validity was established by correlation with the suicide item from Hamilton Depression Rating Scale (HAM-D) and the suicide item of the BDI (9).
It was found that a score higher than 10 delineated a group of patients who were 14 times more likely to commit suicide, than those with lower scores (15).
1.3 Suicide Intent Scale (SIS)
This instrument is comprised of 15 items designed to measure the seriousness of the intent to die regarding the most recent suicide attempt. It rates behaviour and communication prior to and during this suicide attempt (preparation, execution, setting of the attempt, whether or not there were attempts to communicate the intention – directly or indirectly, purpose, expectations).
Factor analysis have reported between 2 and 6 factors (16, 17).
The Cronbach alpha showed high internal reliability (0.95) (15).
Predictive validity has been studied in two prospective studies that had a 10 years follow-up period. In neither of these studies the SIS was able to predict completed suicide (18, 19).
1.4 Suicide trigger scale (STS-3)
This is a 42-item clinician-administered questionnaire, with answers ranging from 0 (not at all) to 2 (a lot). It was devised to assess a clinical entity named by the authors “suicide trigger state” as a measure of acute suicide risk (20).
It has demonstrated a high internal consistency
(Cronbach alpha 0.94) (20).
Factor analysis lead to the identification of 3 subscales: frantic hopelessness (12 items), ruminative flooding (10 items) and near psychotic somatisation (7 items) (20).
The STS-3 total score correlated with the severity of current suicide ideation. Scores were also higher in those with a history of suicide (20).
A very recent study has shown that a transformed scoring (a distance from median of the initial scoring) was able to predict suicide attempts following discharge in a high-risk group of suicidal inpatients (21).

2.SELF-REPORT INSTRUMENTS
2.1 Beck Scale for Suicide Ideation (BSI)
This is a 21-item self-administered version of the SSI. It assesses the patient’s suicidality during the week prior to evaluation (22). As for the SSI, there are 19 scored items (0 to 2) which yield a total score of up to 38, and 2 additional items which document the existence of previous suicide attempts and the level of intent regarding these attempts.
Factorial analysis has delineated 3 factors: desire for death, preparation for suicide and actual suicide desire (23). There are two additional items that did not load any factor: deterrents to death and deception/concealment (23).
Cronbach alpha coefficients have been found to be high (up to 0.97) (22, 23). Regarding validity, it has been found that it correlates highly with SSI (22), but only moderately with the suicide item in the BDI.
Predictive validity has not been studied.
This instrument holds an advantage compared to the SSI, for patients who are more comfortable answering difficult questions in self-report format than in an interview (14).
2.2 Beck Hopelessness Scale (BHS)
This instrument was created by Beck and Steer and includes 20 statements which are rated as true or false. It assesses negative beliefs (pessimism) about the future (24).
Factorial analysis has revealed 2 factors: pessimism about the future and resignation. A later study has found that many of the items are redundant, and most of the variation of scores is due to a single statement: “The future appears dark to me” (25).

The validity of the BHS has been proven by the findings of higher scores in suicide attempters versus nonattempters (11, 26). Also, significant correlations were found between BHS scores and SIS scores (27, 28).
The predictive validity of the scale has been well documented. Beck et al. found, in 1989, that a score of 9 or above on the BHS suggested a suicide risk 11 times higher than for scores below 8 (18). A study published in 1990 has found that BHS scores are the best predictors of eventual suicide in the long term (over 1 year) (29).

2.3 Self-Monitoring Suicide Ideation Scale (SMSI)
This instrument was developed by Clum and Curtin in 1993 (30). It consists of 3 items adapted from the SSI: “Today I have had thoughts of making an actual suicide attempt” scored 0 (none) to 3 (strong), “Today I have thought about making an active suicide attempt” scored 0 (not at all) to 4 (continuously) and “Today I have felt that the control I have over making an active suicide attempt was” scored (strong; no doubt I had control) to 3 (absent; no sense of control).
It is designed to be used on a daily basis and to document fluctuations in level of suicidal ideation (30).
The SMSI items were moderately correlated with scores on the SSI, and significantly correlated with the Beck Hopelessness Scale (BHS) (30).
2.4 Suicide Probability Scale (SPS)
It was developed by Cull and Gill and published in 1988 (31). It consists of 36 items scored from 1 (“None, or a little of the time”) to 4 (“Most of the time”). It has 4 subscales: hopelessness, suicidal ideation, negative self- evaluation and hostility.
Factor analysis has delineated 7 factors: ideation, hopelessness, positive outlook, interpersonal closeness, hostility and angry impulsivity (31).
Cronbach alpha coefficients shows high internal reliability (0.93) (31).
The authors have shown that the SPS can differentiate among normals, psychiatric inpatients and suicide attempters (31). The total score was significantly correlated with the BHS and the BDI (32).
Its predictive value has not been tested.
2.5 Positive and Negative Suicide Ideation Inventory
(PANSI)
This is an instrument that evaluates positive and negative thoughts related to suicide attempts in the form of a 20 item self-report. Each item is scored taking into account symptoms present the previous 2 weeks, from 1 (none of the time) to 5 (most of the time) (33).
Factorial analysis has proven the presence of two factors: positive and negative ideation (33).
Coefficient alphas ranged from 0.80 to 0.93 for both factors, underlining a high internal reliability (33).
The authors have documented a generally moderate correlation to items from the Suicide Behaviours Questionnaire, but the psychometric properties of this scale need further research (33).
2.6 Adult Suicidal Ideation Questionnaire (ASIQ)
This instrument was developed by Reynolds and was published in 1991. It consists of 25 items scored from
0 (never had the thought) to 6 (almost every day). It measures frequency of suicidal thoughts and behaviour in the month prior to evaluation and the perceived response of others to a suicide attempt and, also, the degree of belief in suicide as a solution to problems (34).

Factorial analysis has proven that this instrument evaluates a single dimension of suicidality (35).
The ASIQ has high internal consistency – Cronbach alpha 0.96-0.98 (34, 35). Regarding validity, it was shown that there is significant correlation with the suicide item of HAM-D (34).
The predictive validity has been studied in 1999, and it was found that ASIQ significantly predicted suicides in a sample of psychiatric inpatients (35).
2.7 Suicide Ideation Scale (SIS)
This is a 10-item self-report scale that evaluates severity of suicidal ideation during the year preceding assessment. The total score ranges from 10 to 50, each item being scored from 1 (“Never or none of the time”) to
5 (“Always or a great many times”) (36).
Cronbach alpha coefficient shows high level of internal consistency (0.86) (36).
SIS scores were moderately correlated with the
BHS (36).
Psychometric properties of this scale have insufficiently been tested. Also there is no study regarding predictive value.
2.8 Firestone Assessment of Self-Destructive Thoughts(FAST)
This is a 84 item instrument assessing current frequency of self-destructive thoughts. Each item is rated from 0 (never) to 4 (most of the time). It contains 4 subscales: self-defeating, addictions, self-annihilating and suicide intent (37).
Factor analysis has found three factors: self- defeating (includes: self-depreciation, self-denial, cynical attitudes, isolation, self-contempt), addictions (consists of
8 addiction items) and self-annihilating (includes: hopelessness, giving up, self-harm, suicide plans and suicide injections) (37).
Cronbach’s alpha coefficients have shown high internal consistency of the total score and the four subscales (0.84 to 0.97) (37).
Total scores and scores on subscales have been significantly correlated with BDI, BHS and BSI (37).
Further research is required to assess FAST’s predictive ability.
2.9 Suicide Behaviours Questionnaire (SBQ)
The current version of the SBQ is an abbreviated version of a 7-page clinician-rated interview (developed by Linehan, unpublished), described by Cole in 1988 (38). It consists of 4 items: “Have you ever thought about or attempted to kill yourself?” (scores 1-6); “How often have you thought about killing yourself in the past year?” (scores 1-5); “Have you ever told someone that you were going to commit suicide, or that you might do it?” (scores
1-3) and “How likely is it that you will attempt suicide someday?” (scores 1-5).
Internal consistency is adequate (Cronbach alpha 0.75-0.80) (39).
Validity has been tested and it was shown that scores correlated significantly with the SSI scores (39). Also it was shown that there was a significant inverse correlation with RLI scores (14, 39).
There is no data available on predictive validity.
A 34 item revised version of the SBQ (SBQ-14) was created in 1996 by Linehan (unpublished). The SBQ-
14 assesses 14 suicidal behaviours in 5 areas: past suicidal ideation, future suicidal ideation, past suicide threats, future suicide attempts and likelihood of dying in a future suicide attempt. The questionnaire also evaluates: lifetime suicidal behaviour, current suicide plan, availability of lethal methods, social deterrents, attitudes towards suicide and distress tolerance.
Factor analysis has shown that SBQ-14 is one- dimensional (39).
Internal reliability is high (Chronbach alpha 0.73-0.92) and validity was proven by a significant correlation with the RLI (negative correlation) (39).
The main advantage of this instrument is its simplicity and its clarity, which make it a viable screening tool. This is also its greatest disadvantage, because it is very easy to conceal suicidality should the patient decide to do so.
2.10 Life Orientation Inventory (LOI)
This instrument was developed by Kowalchuk and King in 1988 and has two variants: one for screening which consists of 30 questions and one for profiling which consists of 113 questions (grouped in six subscales: self- esteem vulnerability, overinvestment, overdetermined misery, affective domination, alienation and suicide tenability). All items have answers ranging from 0 (I am sure I disagree) to 4 (I am sure I agree) (14).
The Cronbach alpha is high (0.90), showing a high internal consistency (14).
Validity has been shown by the instrument’s ability to discriminate between controls, depressed persons, possibly suicidal patients and high risk suicidal patients (14).
There is no proven predictive value.
This instrument has a unique advantage in that its long version has three validity indices: positive bias, column responses indicative of inattentiveness to the content of the items and spoiled or missing (14).

3.COMBINED RATING SCALES
3.1 Inventory of Potential Suicide (IPS)
It is a checklist type instrument that was published by Zung in 1974 (40). It contains 69 items of which 50 are clinical and its main advantage is the fact that it has 3 different versions: one clinical report (physician rated), one self-report and one reported by significant other (40).
It has little to none published research on validity and reliability, but the different versions make it worth mentioning.
3.2 Suicide Status Form (SSF)
This instrument measures psychological pain, external stressors, emotional upset, hopelessness, low self-regard and overall risk of suicide, using 12 items – 6 self-report and 6 clinician-administered. Each item is scored 1 (low) to 5 (high) (41).
It was reported that there is a high level of agreement between clinician-administered and self-report items (42). But there was only a moderately inverse correlation with the Reasons for Living Scale. Nevertheless, the SSF was able to differentiate significantly suicidal ideation that had resolved from chronic one (41).
There is no data regarding the predictive ability of the instrument. Its main advantage is the combination of clinician-rated and safe-report in the assessment of suicide risk.

4 . M E A S U R E S O F S U I C I D E A T T E M P T LETHALITY
We include in this review some examples of measures used for suicide attempt lethality because of the importance of this element has been proven in the evaluation of suicide risk (43).
Risk-Rescue Rating (44, 45) – a clinician- administered 10 item scale that measures the lethality and the suicidal intent of a suicide attempt.
Self-Inflicted Injury Severity Form (46) – a clinician-administered 7 item interview designed for use in emergency departments in order to identify self- inflicted injuries that are life-threatening.
Lethality of Suicide Attempt Rating Scale (47) – a clinician-administered scale designed to measure the lethality of a suicide attempt. It has 11 items. The total score ranges from 0 (death is impossible as a result of the suicidal behaviour) to 10 (death is almost certain regardless of the intervention of an outside agent; most people will die quickly after such an attempt). It is generally considered that a score above 3 signifies that the attempt is a medically serious one (14).

5.BRIEF SCREENING MEASURES
5.1 Sad Persons
It was published by Patterson et al in 1983 and it comprises 10 items, several of which are known demographic risk factors (sex, age and not living with family or a partner). Other items are: depression, previous suicide attempts, alcohol abuse, loss of rational thinking, lack of social support, organised plan of suicide and somatic illness. Items are scored as 0 – absent or 1 – present (48).
A modified version of the scale was published in
1988 (MSPS – Modified SAD PERSONS score). It also has 10 items, some different from the original version. The main difference is due to the assignment of scores 0-2 to some items (depression or hopelessness, rational thinking loss and stated future intent – determined to repeat or ambivalent). The importance of this version is that it was validated for use in screening of patients who require psychiatric hospitalisation due to suicide risk. Thus a score of 6 or more suggests the need for hospital admission. The authors found that this cut-off score resulted in 94% sensibility and 71% specificity (49).
5.2 Paykel Suicide Items
This is a 5-question interview. The questions have increasing levels of suicidal intent: 1) “Have you ever felt that life was not worth living?”; 2) “Have you ever wished you were dead? – for instance, that you could go to sleep and not wake up?”; 3) “Have you ever thought of taking your life, even if you would not really do it?”; 4) “Have you ever reached the point where you seriously considered taking your life or perhaps made plans how you would go about doing it?” and 5) “Have you ever made an attempt to take your life?”. The level of the last question with a positive answer is the score of the scale (50).
Internal consistency, validity and predictive value have not been adequately assessed.
5.3 Hamilton Depression Rating Scale (Suicide Item)
It is a clinician-reported item, scored from 0 to 4, as follows: “absent”, “feels life is not worth living or any thoughts of possible death to self”, “wishes he were dead”, “suicidal ideas or gestures”, “attempts at suicide” (51).
The validity was established by a significant correlation with the SSI score and with the sore of the suicide item on the BDI (14).
Brown et al found that patients with scores of 2 or higher were almost 5 times more likely to commit suicide, thus establishing predictive validity (12).
5.4 Beck Depression Inventory (Suicide Item)
This is a self-report item with a 4 point rating: 1 – “I don’t have any thoughts of killing myself”, 2 – “I have thoughts of killing myself, but I would not carry them out”, 3 – “I would like to kill myself” and 4 – “I would kill myself if I had the chance” (12).
Brown et al found that patients with scores of 2 or higher were almost 7 times more likely to commit suicide (12).

6 . S C A L E S R E L AT I N G T O P R O T E C T I V E FACTORS
6.1 Reasons for Living Inventory (RLI)
This is the most widely used instrument assessing protective factors against suicide. It consists of
48 items and is a self-report clinical tool. The items are grouped in 6 subscales: survival and coping beliefs, responsibility to family, child-related concerns, fear of suicide, fear of social disapproval and moral objections to suicide. Each item is scored from 1 (“not at all important”) to 6 (“extremely important”) (52).
The RLI has shown high internal reliability
(Cronbach alpha 0.89 for the total score) (52).
The survival and coping subscale was compared to BDI, BHS (53) and SSI (54) and it was found that there was a significant negative correlation. Also it was found that the RLI can distinguish between suicide attempters and ideators and between suicide attempters and psychiatric controls (11, 35).
There are also available an extended 72-item version and a brief 12-item version (55).

CONCLUSIONS
There are numerous clinical suicide assessment instruments described in the literature. Many of them have been studied, some more extensively than others, regarding their psychometric properties.
The main difficulty encountered when using clinical instruments is a low degree of specificity (meaning many false positive cases). Another disadvantage is the high reliance on the patient’s sincerity. Also, many of the scales or questionnaires described do not differentiate between acute and chronic suicide risk.
Another conclusion that can be drawn from this work is that, although, many of the instruments presented evaluate the suicidal process, meaning that, to some extent they are complementary and not interchangeable. This is why it is important to make an informed choice when applying a certain clinical instrument to an individual situation. This choice has to take into account the specific reason for the evaluation, the viability and reliability of the instrument regarding this evaluation, whether or not it has been applied to the population the patient pertains to etc.
One instrument seems to stand out: the STS-3. It is a newly developed interview, the only one that was created specifically for the evaluation of acute suicide risk. Also, it tries to resolve another major problem encountered by other clinical instruments: the reliance on the patient’s sincerity.
Further research is needed in the assessment of suicidal crises (acute suicide risk) since this

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