RCPsych AGM08 - Risk of Self Harm Evidence for Scales (July08)

Alex Mitchell, Consultant in Liaison PsychiatryLeicester General Hospital / University of Leicester

Royal College of Psychiatrists, Annual Meeting, UCL, London, July 2008

Risk to Self in PsychiatryDo suicide/self-harm scales help clinicians?

Content / Questions

• What guidelines exist?

• How to assess risk of suicide/self-harm?– Role of scales / tools?– How to assess scales / tools?

• How good are clinicians?– How much better are clinicians with tools?– Self-harm or suicide?

I: Guidelines

NICE Self-Harm Guidance (2004)

• “Only use a standardised risk assessment scale to aid identification of those at high risk of repetition of self-harm or suicide.”

• “Don’t use standardised risk assessment scales to identify service users of supposedly low risk who are not then offered services.”

Application of Scales =>

http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html

Application of Scales =>

II: Self-Harm Scales

Many Scales

The Suicide Probability Scale (SPS; Cull & Gill, 1988) is a 36-item self-report

SPS

The Suicidal Ideation Scale (SIS; Rudd, 1989) is a 10-item self-report scale

SIS

The Modified Scale for Suicide Ideation ( Miller, Norman, Bishop, & Dow, 1986) is a revised version of the Scale for Suicide Ideation

MSSI

Beck Depression Inventory (BDI; Beck & Steer, 1988)BDI(Suicide item)

Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960)HRDS(Suicide item)

Beck Hopelessness scale (Beck & Steer, 1988)BHS

Lethality Scales (LS; Beck, Beck & Kovacs, 1975)LS

Suicide Intent Scale (Beck, Schuyler, & Herman, 1974)SIS

Scale for Suicidal Ideation(SSI; Beck et al., 1979)SSI

Simple Scales • Kreitman & Foster “Edinburgh” Scale SAD PERSONS

Scale (11 items) (10 items)

– Previous Para-suicide S Sex– Personality Disorder A Age– Alcohol Abuse D Depression– Previous Psychiatric Treatment P Previous Attempts– Unemployment E Ethanol Abuse– Social Class V R Rational Thinking Loss– Drug Abuse S Social Support Lacking– Criminal Record O Organised Plan– Violence N No Spouse– Age 25-54 yrs S Sickness– Single, Divorced or Separated

Beck Suicide Intent Scale (15 items)

Measure Administration

Self Interview Items

Predictive Validity

Study SettingPsyc Medical Community other

Scale for Suicidal Ideation

No Yes 21 Yes Yes Yes Yes Yes

Suicide Intent Scale No Yes 15 Yes Yes Yes No No

Lethality Scale No Yes 8 No Yes Yes No No

HRDS(Suicide item)

No Yes 1 Yes Yes No No No

BecksHopelessness scale

Yes No 20 Yes Yes Yes No No

BDI(Suicide item)

Yes No 1 No Yes Yes No Yes

Linehan reason for living

Yes No 48 No Yes Yes Yes Yes

Difficulty Predicting Repetition

Possible Risk Factors for Repetition• Previous DSH [Hall, O'Brien et al., 1998] [Morgan, 1975] [Buglass & Hawton, 1974] [Wilkinson & Smeeton, 1987]• PPH [DeMoore & Robertson, 1996] [Slap, et al., 1989]• Depression [Kerfoot, McNiven et al., 1997] [Scott, et al., 1997] [Pierce, 1996] [Qari, et al., 1995] [Martin, et al., 1995]• Sociopathy [Kreitman & Casey, 1988] [Buglass & Hawton, 1974]• Poor problem solving [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] [McLauchlin, Miller et al., 1996].• Poor social adjustment [Kerfoot, McNiven et al., 1997]• Hopelessness [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997] [McLauchlin, Miller et al., 1996].• Lack of confidants [Kerfoot, McNiven et al., 1997] [Scott, House et al., 1997]• Internal locus of control [Tulloch, Blizzard et al., 1997]• Alcohol abuse [Pierce, 1996] [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]• Child abuse [Wurr & Partridge, 1996] [Romans, Martin et al., 1995] [Boudewyn & Liem, 1995]• Poor parenting [Tulloch, Blizzard et al., 1997]• Physical violence [Gupta, Sivakumar et al., 1995]• Impulsiveness [Evans, Platts et al., 1996] [Slap, Vorets et al., 1989].• Difficulty in sustaining relationships [Gupta, Sivakumar et al., 1995]• Family dysfunction [Martin, Rozanes et al., 1995] [Slap, Vorets et al., 1989].• Obesity [Sansone, Sansone et al., 1995]• Deprivation [Inch, Rowlands et al., 1995]• Situational factors [Inch, Rowlands et al., 1995]• Psychological distress [Inch, Rowlands et al., 1995]• Male gender [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]• Low social class [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]• Single Marital state [Kreitman & Casey, 1988] Horton [Buglass & Hawton, 1974]

Moderate Predictive Test

No Repetition

Repetition

Number ofIndividuals

Optimum Cut-off value (hopelessness)

False +veFalse +veFalse -veFalse -ve

True -veTrue -ve

True +veTrue +ve

Point of Partial Rarity?

Score on Hypothetical Predictive Test

Poor Prognostic Test

No Repetition

Repetition

Number ofIndividuals

Optimum Cut-off value (eg size of overdose)

False +veFalse +veFalse -veFalse -ve

True -veTrue -ve

True +veTrue +ve

Score on Hypothetical Predictive Test

Beck SIS Scores 24-48hrs after Self-Harm

0

20

40

60

80

100

120

140

160

180

Zero OneTwoThree Four

Five SixSev

enEightNine

TenEleve

nTwelv

eThirt

een

Fourtee

nFifte

enSixtee

nSev

entee

nEightee

nNinete

enTwen

tyTwen

ty-One

Twenty-

two

Twenty-

three

Twenty-

fourTwen

ty-fiv

eTwen

ty-six

Twenty-

seve

nTwen

ty-eig

htTwen

ty-nin

eThirt

y

Data from Allan House

III: Evidence from Prediction Studies

Leicester SH10 Study

Edinburgh Scale (Kreitman and Foster)

Beck Hopelessness Scale

Basic Demographics

• There were 567 cases included in the study• The study period was between 18-April-04 to 27

June 2006• The mean age in years was 39 • The follow-up period mean 254 days• 144 cases were followed for more than 365

days

Results Basic Repetition Details

In the total sample• 130 cases repeated self-harm out of 567 = 22.9% repetition

rate• There were 0.70 repeat self-harm attempts per year on

average• Av time to repeat = 90 days

If Follow up < 6 months• 223 cases were followed up for less than 6 months.• Of these 39 repeated = 17.5% repetition rate

If Follow up > one year• 144 cases were followed for more than 365 days• 39 cases repeated = 27.1% repetition rate• There were 0.50 repeat self-harm attempts per year on

average

III3: Leicester SH10 Repetition Results

Leicester SH10 (sub-sample)

25016487

NPV 94%443Test -ve

PPV 41%12084Test +ve

No RepeatRepeater

Sensitivity97%

Specificity27%

Prevalence35%Predictive Summary Index35%

Clinical Application of Predictors – Actual Risk

Predictor If Yes If No RR

Alcohol/illicit drug user 35.1 18 2.0

Difficult personal history 47.1 19 2.5

Housing problems 33.9 22 1.5

Intended to die 31.1 14 2.2

Mood/Perception 36.5 17 2.1

Past Medical history 34.9 20 1.7

Past Psychiatric History 32 10 3.2

Previous self harm 33.9 15.2 2.2

Kreitman and Foster Scale, 2002 Study

• 3 yr study 1,331 patients• 180 repeaters within 365 days

• Logistic regression analysis revealed only previous parasuicide contributed to self harm repetition.

Accuracy of Kreitman & Foster Scale

13171137180

NPV 87%960134Test -ve

PPV 33%9046Test +ve

No RepeatRepeater

Sensitivity26%

Specificity84.4%

Prevalence13.6%Predictive Summary Index20%

Beck Hopelessness Scale (20items)

BHS Meta-analysis

791341520Adolescents followed for 6mo after hospital dischargeHuth-Bocks (2007)

661353845Adolescents followed for 1 year after hospital dischargeGoldston et al (2001)

69247148183Self-harm RCT 1 year follow-upTyrer et al (2003)

144019251 year outcome data reportedSidley et al (1999)

1551810Inpatient popn, 1yr follow-upKeller and Wolfersdorf(1993)

23772634Self-harm popn, 1.7yrs follow-upHawton et al (2003)

1502776592Self-harm popn, 1yr follow-upColman et al (2004)

Predicted Low

RiskNo

Repeat

Predicted

high Risk

RepeatedSampleReference

Accuracy of BHS Scale (n=7)

1370961409



No RepeatRepeater

Sensitivity78%

Specificity43%

Prevalence(repetition baseline)30%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

Baseline Probability

BHS+ (meta)

BHS- (Meta)

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Pos

t-tes

t Pro

babi

lity

K&F+K&F-Baseline ProbabilityBHS+ (meta)BHS- (Meta)SH10+SH10-

IV: Comparison with Clinicians (Unassisted)

Alone

Added Value

Accuracy of A&E Staff (high risk)

48794233646

NPV 89%3469439Not High Risk

PPV 21%764207High Risk

No RepeatRepeated

Sensitivity32%

Specificity82%


Accuracy of A&E Staff (low risk)

48794233646

NPV 87%1511113Low Risk

PPV 26%2722533High+MedRisk

No RepeatRepeated

Sensitivity82.5%

Specificity35.7%


Scales vs Unassisted Ability (Low Risk Strategy)

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Post

-test

Pro

babi

lity

Unassisted (Not low risk)Unassisted (low risk)Baseline ProbabilityBHS+ (meta)BHS- (Meta)SH10+SH10-

Scales vs Unassisted Ability (High Risk Strategy)

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Post

-test

Pro

babi

lity

Unassisted (high risk)Unassisted (not high risk)Baseline ProbabilityBHS+ (meta)BHS- (Meta)SH10+SH10-

V: Suicide?

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Pos

t-tes

t Pro

babi

lity

BHS+ (Suicide)

BHS- (Suicide)

Baseline Probability

BHS+ (meta)

BHS- (Meta)

BHS in DSH vs Suicide

Accuracy of BHS Scale (n=7 for DSH)

1370961409



No RepeatRepeater

Sensitivity78%

Specificity43%


Accuracy of BHS Scale (n=4 for suicide)

2559250158



No RepeatRepeater

Sensitivity79%

Specificity43%


IV: Extras and Questions

Predictive Scales after DSH - PowerRepetition after DSH (Kreitman & Foster Scale)

0

10

20

30

40

50

60

70

0 1 2 3 4 5 6 7 8 9 10 11 12

Positive Predictive items

Rep

etiti

on (N

umbe

r vs

Prop

ortio

n)

PercentageRepeating

NumberRepeating

Patients who score highly on the Kreitman & Foster scale are more likely to repeat, but the majority who repeat do not score highly

Advanced Suicide Intent Scales

Ranking (single Items)

0.061774313Speech or Thoughts?0.068804974Attempts at concealment or Final acts?0.097861755Hopeless or Suicidal Thoughts?0.194075771Delirium (poor orientation or attention)?0.503519167Refuses assessment?0.675189743Current Suicidal Intent?0.755394419Personality (self-destructive, impulsive)?0.839234812Medical Complications or detoxification?0.910132669ICU/ITU or Resuscitation required?0.964452202Depression (low interest, self-esteem)?0.983364721Alcohol or Illicit Drug User?0.980425812Believed method was dangerous/fatal?0.903027575Cognition or Insight?0.730928415Unusual or risky circumstances?0.510764942Appearance or Behaviour?0.473154302Dementia (memory, odd behaviour)?0.411700936Antidote, sutures required?0.394990629Psychosis (odd thinking or beliefs)?0.391145703Past Psychiatric history?0.386619302Admission required (if so where)?0.267886875Work or Financial problems?0.234563323Relationship problems?0.202312118Lack of social support?0.171397338Past Medical history?0.113801724Housing problems?0.008459658Intended to die?0.001925556Difficult Personal History?0.000621875Previous Self-Harm?4.57034E-05Mood or Perceptions?1.65638E-05Suicidal Plans or Conditional Threats?

P-value

Combination Risk

Suicidal Plans or Conditional Threats?+Difficult Personal History? = 64% (if no

18%)

Past Psychiatric History+Intended to Die = 40% (if no 5%)

Past Psychiatric History+

Alternative Cut-Off

• The 10 Step form can act as an accurate risk predictor

• Optimal accuracy with a 50% referral rate =>– 80% rule out and 50% rule in

• Using the simplest system (4 item) with 0/1 =>– 93% rule out and 41% rule in (but we would receive

80% of referrals)

Summary of Factors Influencing Outcomes

Factor Predicts No. Of Repeats Predicts Time to Repeat

Suicidal plans/Threats Yes(1) No

Mood/Perceptions Yes(2) No

Previous Self Harm Yes(3) Yes(2)

Difficult Personal History Yes(4) No

Intended to Die Yes(5) Trend (p<0.1)

Past Psychiatric History No Yes(1)

Admission Required(Where) No Yes(3)

Refuses assessment No Yes(4)

Depression(low interest, self-esteem)

No Yes(5)

Frequency of Repetitions of Self Harm90

25

75 4

0

10

20

30

40

50

60

70

80

90

100

0 Rep

etitio

ns

1 Rep

etitio

n

2 Rep

etitio

ns

3 Rep

etitio

ns

4 Rep

etitio

ns

5+ Rep

etitions

437

12

14

9

17

13

16

23 23

3

0

5

10

15

20

25

1 Day

2-7 Da

ys

8-14 D

ays

15-28

Days

29-59

Days

60-90

Days

90-18

0 Day

s

181-36

4 Day

s

365 Days

+Frequency distribution of Repetition Rate

RCPsych AGM08 - Risk of Self Harm Evidence for Scales (July08)

Education

Transcript of RCPsych AGM08 - Risk of Self Harm Evidence for Scales (July08)