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

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This is an invited lecture from the AGM of the Royal College of Psychiatrists 2008. The topic is whether risk assessment scales and tools help clinicians who are assessing risk of suicide in vulnerable people.

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

  1. 1. Royal College of Psychiatrists, Annual Meeting, UCL, London, July 2008 Risk to Self in Psychiatry Do suicide/self-harm scales help clinicians? Alex Mitchell, Consultant in Liaison Psychiatry Leicester General Hospital / University of Leicester
  2. 2. 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?
  3. 3. I: Guidelines
  4. 4. 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 =>
  5. 5. http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html Application of Scales =>
  6. 6. II: Self-Harm Scales
  7. 7. Many Scales SSI Scale for Suicidal Ideation(SSI; Beck et al., 1979) SIS Suicide Intent Scale (Beck, Schuyler, & Herman, 1974) LS Lethality Scales (LS; Beck, Beck & Kovacs, 1975) BHS Beck Hopelessness scale (Beck & Steer, 1988) HRDS Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960) (Suicide item) BDI Beck Depression Inventory (BDI; Beck & Steer, 1988) (Suicide item) SPS The Suicide Probability Scale (SPS; Cull & Gill, 1988) is a 36- item self-report SIS The Suicidal Ideation Scale (SIS; Rudd, 1989) is a 10-item self- report scale MSSI The Modified Scale for Suicide Ideation ( Miller, Norman, Bishop, & Dow, 1986) is a revised version of the Scale for Suicide Ideation
  8. 8. 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
  9. 9. Beck Suicide Intent Scale (15 items)
  10. 10. Measure Administration Predictive Study Setting Validity Psyc Medical Community other Self Interview Items Scale for Suicidal No Yes 21 Yes Yes Yes Yes Yes Ideation Suicide Intent Scale No Yes 15 Yes Yes Yes No No Lethality Scale No Yes 8 No Yes Yes No No HRDS No Yes 1 Yes Yes No No No (Suicide item) Becks Yes No 20 Yes Yes Yes No No Hopelessness scale BDI Yes No 1 No Yes Yes No Yes (Suicide item) Linehan reason for Yes No 48 No Yes Yes Yes Yes living
  11. 11. Difficulty Predicting Repetition
  12. 12. 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]
  13. 13. Moderate Predictive Test Point of Partial Rarity? Number of No Repetition Individuals Repetition True -ve True -ve True +ve True +ve False -ve False -ve False +ve False +ve Score on Hypothetical Predictive Test Optimum Cut-off value (hopelessness)
  14. 14. Poor Prognostic Test Number of No Repetition Individuals Repetition True -ve True -ve True +ve True +ve False -ve False -ve False +ve False +ve Score on Hypothetical Predictive Test Optimum Cut-off value (eg size of overdose)
  15. 15. 0 20 40 60 80 100 120 140 160 180 Ze ro O ne Tw o Th re e Fo ur Fi ve Si x Se ve n Ei gh t N in e Te n El ev e Tw n el ve Th irt e Fo en ur te en Fi fte e Si n xt Se ee ve n nt ee Ei n gh te N en in et ee Tw n Tw en en ty ty Tw -O en ne Tw ty en -tw ty o - Tw thr en ee ty Tw -fo en ur ty Tw -fiv e e Tw n t en y- si ty x Tw -s ev en e ty n Tw -eig en ht Beck SIS Scores 24-48hrs after Self-Harm ty -n in e Data from Allan House Th irt y
  16. 16. III: Evidence from Prediction Studies Leicester SH10 Study Edinburgh Scale (Kreitman and Foster) Beck Hopelessness Scale
  17. 17. 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
  18. 18. 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
  19. 19. III3: Leicester SH10 Repetition Results
  20. 20. Leicester SH10 (sub-sample) Repeater No Repeat Test +ve 84 120 PPV 41% Test -ve 3 44 NPV 94% 87 164 250 Prevalence Sensitivity Specificity 35% 97% 27% Predictive Summary Index 35%
  21. 21. 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
  22. 22. 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.
  23. 23. Accuracy of Kreitman & Foster Scale Repeater No Repeat Test +ve 46 90 PPV 33% Test -ve 134 960 NPV 87% 180 1137 1317 Prevalence Sensitivity Specificity 13.6% 26% 84.4% Predictive Summary Index 20%
  24. 24. Beck Hopelessness Scale (20items)
  25. 25. BHS Meta-analysis Predict ed Predicte Repea high No d Low Reference Sample ted Risk Repeat Risk Colman et al (2004) Self-harm popn, 1yr follow-up 92 65 277 150 Hawton et al (2003) Self-harm popn, 1.7yrs follow-up 34 26 77 23 Keller and Wolfersdorf (1993) Inpatient popn, 1yr follow-up 10 8 51 15 Sidley et al (1999) 1 year outcome data reported 25 19 40 14 Tyrer et al (2003) Self-harm RCT 1 year follow-up 183 148 247 69 Adolescents followed for 1 year after hospital Goldston et al (2001) discharge 45 38 135 66 Adolescents followed for 6mo after hospital Huth-Bocks (2007) discharge 20 15 134 79
  26. 26. Accuracy of BHS Scale (n=7) Repeater No Repeat Test +ve 319 545 PPV 37% Test -ve 90 416 NPV 82% 409 961 1370 Prevalence Sensitivity Specificity (repetition baseline) 78% 43% 30%
  27. 27. 1 Post-test Probability 0.9 Baseline Probability 0.8 BHS+ (meta) 0.7 BHS- (Meta) 0.6 0.5 0.4 0.3 0.2 0.1 Pre-test Probability 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  28. 28. 1.00 Post-test Probability 0.90 K&F+ 0.80 K&F- Baseline Probability BHS+ (meta) 0.70 BHS- (Meta) SH10+ SH10- 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  29. 29. IV: Comparison with Clinicians (Unassisted) Alone Added Value
  30. 30. Accuracy of A&E Staff (high risk) Repeated No Repeat High Risk 207 764 PPV 21% Not High Risk 439 3469 NPV 89% 646 4233 4879 Prevalence Sensitivity Specificity (repetition baseline) 32% 82% 13%
  31. 31. Accuracy of A&E Staff (low risk) Repeated No Repeat High+Med 533 2722 PPV 26% Risk Low Risk 113 1511 NPV 87% 646 4233 4879 Prevalence Sensitivity Specificity (repetition baseline) 82.5% 35.7% 13%
  32. 32. Scales vs Unassisted Ability (Low Risk Strategy) 1.00 Post-test Probability 0.90 Unassisted (Not low risk) 0.80 Unassisted (low risk) Baseline Probability BHS+ (meta) 0.70 BHS- (Meta) SH10+ SH10- 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  33. 33. Scales vs Unassisted Ability (High Risk Strategy) 1.00 Post-test Probability 0.90 Unassisted (high risk) 0.80 Unassisted (not high risk) Baseline Probability BHS+ (meta) 0.70 BHS- (Meta) SH10+ SH10- 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  34. 34. V: Suicide?
  35. 35. BHS in DSH vs Suicide 1.00 Post-test Probability 0.90 BHS+ (Suicide) 0.80 BHS- (Suicide) Baseline Probability 0.70 BHS+ (meta) BHS- (Meta) 0.60 0.50 0.40 0.30 0.20 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  36. 36. Accuracy of BHS Scale (n=7 for DSH) Repeater No Repeat Test +ve 319 545 PPV 37% Test -ve 90 416 NPV 82% 409 961 1370 Prevalence Sensitivity Specificity (repetition baseline) 78% 43% 30%
  37. 37. Accuracy of BHS Scale (n=4 for suicide) Repeater No Repeat Test +ve 46 1434 PPV 03% Test -ve 12 1067 NPV 99% 58 2501 2559 Prevalence Sensitivity Specificity (repetition baseline) 79% 43% 02%
  38. 38. IV: Extras and Questions
  39. 39. Predictive Scales after DSH - Power Repetition after DSH (Kreitman & Foster Scale) 70 Percentage Repeating 60 Number Repeating 50 Repetition (Number vs Proportion) 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Patients who score highly on the Kreitman & Foster scale are more likely to repeat, Positive Predictive items but the majority who repeat do not score highly
  40. 40. Advanced Suicide Intent Scales
  41. 41. Ranking (single Items) P-value Suicidal Plans or Conditional Threats? 1.65638E-05 Mood or Perceptions? 4.57034E-05 Previous Self-Harm? 0.000621875 Difficult Personal History? 0.001925556 Intended to die? 0.008459658 Housing problems? 0.113801724 Past Medical history? 0.171397338 Lack of social support? 0.202312118 Relationship problems? 0.234563323 Work or Financial problems? 0.267886875 Admission required (if so where)? 0.386619302 Past Psychiatric history? 0.391145703 Psychosis (odd thinking or beliefs)? 0.394990629 Antidote, sutures required? 0.411700936 Dementia (memory, odd behaviour)? 0.473154302 Appearance or Behaviour? 0.510764942 Unusual or risky circumstances? 0.730928415 Cognition or Insight? 0.903027575 Believed method was dangerous/fatal? 0.980425812 Alcohol or Illicit Drug User? 0.983364721 Depression (low interest, self-esteem)? 0.964452202 ICU/ITU or Resuscitation required? 0.910132669 Medical Complications or detoxification? 0.839234812 Personality (self-destructive, impulsive)? 0.755394419 Current Suicidal Intent? 0.675189743 Refuses assessment? 0.503519167 Delirium (poor orientation or attention)? 0.194075771 Hopeless or Suicidal Thoughts? 0.097861755 Attempts at concealment or Final acts? 0.068804974 Speech or Thoughts? 0.061774313
  42. 42. 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 +
  43. 43. 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)
  44. 44. 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, No Yes(5) self-esteem)
  45. 45. 0 10 20 30 40 50 60 70 80 90 100 0 Re pe tit io ns 437 1 Re pe tit io n 90 2 Re pe tit io ns 25 3 Re pe tit io ns 7 Frequency of Repetitions of Self Harm 4 Re pe tit io ns 5 5+ Re pe tit io ns 4
  46. 46. 0 5 10 15 20 25 1 Da y 12 2- Rate 7 Da ys 14 8- 14 Da ys 9 15 -2 8 Da ys 17 29 -5 9 Da ys 13 60 -9 0 Da ys Frequency distribution of Repetition 16 90 -1 80 Da ys 23 18 1- 36 4 Da ys 23 36 5 Da ys + 3

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