Modified SAD PERSONS Research Articles

A Comparison of The Modified Sad Persons Scale with Psychiatric Recommendations for Deciding On Hospitalization In Patients Admitted To Ed Due To Suicide

Objective: There are scales to decide hospitalization or follow up in patients presenting to the emergency department after suicide attempt. Modified SAD PERSONS scale (MSPS) is the scaling system for adult suicide generated using the initials of 10 major demographic risk factor in the literature. The aim of our study is to investigate the reliability of the MSPS patients who are evaluated in the emergency department after suicide attempt for deciding admission or discharging of patients in our population. Material-Method: Patients admitted to our emergency department with suicide attempts was evaluated by MSPS. All patients were evaluated by MSPS also consulted to a psychiatrist concurrently. MSPS suggestions are compared with psychiatry decisions. All data were inputted into SPSS analyzed statistically. Results: There were 205 patients totaly and 147of them were female. Psychiatrics decide hospitalization for 95% of patients MSPS score higher than 8. 131 patients MSPS score less than 6 are evaluated by psyhiatrics and 5 (3.8%) of them were decided for hospitalization. MSPS has sensitivity 90%, specificity 84%, positive predictive value 67%, negative predictive value 96% for deciding hospitalization when compared with psychiatric evaluation. Conclusion: Giving the decision of discharging or hospitalization of patients presenting in the emergency department after suicide attempt is a serious dilemmas for doctors working in the emergency department. There is a need for objective evaluation of such patients of in the emergency department. Although MSPS does not meet all of the requirements but can be used in the emergency department.

Accuracy of individual and combined risk-scale items in the prediction of repetition of self-harm: multicentre prospective cohort study.

Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide. To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items. We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression. A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43-0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations. No individual or combination of items outperformed patients' or clinicians' ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.

Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis

BackgroundRisk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk. MethodQuality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions. ResultsThe formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0–£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk. LimitationsOur primary model depended on the assumption that high-intensity care reduced patients’ risk of further self-harm. ConclusionThe use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities.

Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data

BackgroundRisk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known.MethodWe compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months.ResultsThe episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24–29% and 9–12% respectively) and high specificity (76–77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm.ConclusionsThe scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.

Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk.

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n=153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n=67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n=114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.

Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study.

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Long-term validation of the SAD PERSONS scale for prediction of repeat self-harm in A&E patients with and without a prior self-harm history

ObjectiveRepeated self-harm is difficult to predict particularly in the long-term. Scales that help identify risk of repetition are widely used, and the most popular is the modified SAD PERSONS scale (mSPS). We aimed to clarify the accuracy of the mSPS in first time and non-first time patients presenting with self-harm with an extended follow-up period of observation.MethodWe conducted the UK's first long-term prospective risk prediction study of patients to an Accident and Emergency (A&amp;E) department. We followed up 774 patients for a mean period of 7.4 years. At the time of study 429 patients presented with their first episode of self-harm and 345 had a hospital record of past history of self-harm.ResultsDuring 7.4 years of follow-up 54.7% of those who initially presented with self-harm represented with a repeat self-harm episode. Four hundred and twenty-one patients had a mSPS score less than 6 (low risk), 260 had a score between 6 and 8 (moderate risk) and 94 scored 9 or higher usually notated as high risk. The clinical utility of the mSPS was “poor” for predicting future self-harm but at cut-offs ≥7 it was “fair” for predicting non-repetition. Of the individual questions in the mSPS, a positive answer to “stated future wishes” was a true positive in 74.0%.ConclusionsWe found the mSPS was a relatively poor indicator of future self-harm risk in a long term follow-up of patients who self-harmed regardless of hospital record of previous self-harm history. However, mSPS did have modest value in predicting non-repetition.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Predicting Suicide Attempts With the SAD PERSONS Scale

The SAD PERSONS scale is a widely used risk assessment tool for suicidal behavior despite a paucity of supporting data. The objective of this study was to examine the ability of the scale in predicting suicide attempts. Participants consisted of consecutive referrals (N=4,019) over 2 years (January 1, 2009 to December 31, 2010) to psychiatric services in the emergency departments of the 2 largest tertiary care hospitals in the province of Manitoba, Canada. SAD PERSONS and Modified SAD PERSONS (MSPS) scale scores were recorded for individuals at their index and all subsequent presentations. The 2 main outcome measures in the study included current suicide attempts (at index presentation) and future suicide attempts (within the next 6 months). The ability of the scales to predict suicide attempts was evaluated with logistic regression, sensitivity and specificity analyses, and receiver operating characteristic curves. 566 people presented with suicide attempts (14.1% of the sample). Both SAD PERSONS and MSPS showed poor predictive ability for future suicide attempts. Compared to low risk scores, high risk baseline scores had low sensitivity (19.6% and 40.0%, respectively) and low positive predictive value (5.3% and 7.4%, respectively). SAD PERSONS did not predict suicide attempts better than chance (area under the curve =0.572; 95% confidence interval [CI], 0.51-0.64; P value nonsignificant). Stepwise regression identified 5 original scale items that accounted for the greatest proportion of future suicide attempt variance. High risk scores using this model had high sensitivity (93.5%) and were associated with a 5-fold higher likelihood of future suicide attempt presentation (odds ratio =5.58; 95% CI, 2.24-13.86; P<.001). In their current form, SAD PERSONS and MSPS do not accurately predict future suicide attempts.

The Adult Suicide-Prone Patient: A Review of the Medical Literature and Implications for Oral and Maxillofacial Surgeons

Suicide is the 11th most common cause of death among American adults. Some individuals who commit suicide may have been treated by oral and maxillofacial surgeons in the days preceding the event. Because suicide often is preventable, in this report we review methods that are useful in identifying individuals at risk of imminent suicide and give suggestions for obtaining interventional assistance. A Medline search using the key terms "suicide," "adult," and "oral surgery" was conducted. Articles selected were published in peer-reviewed journals. Individuals who have told their surgeon they have no further reason to live, have developed a suicide plan, have secured a lethal device, and have previously made such an attempt are at extreme risk and require immediate intervention. Additional risk factors include being white, aged older than 45 years, and unemployed; living alone, with poor social supports; having a current mental illness or history of mental illness, including substance abuse; and having a family history of suicide. Specialty-specific patients at highest risk are those treated for oral cancer and cosmetic issues and those with adverse surgical outcomes. With regard to assessment of these individuals, the modified SAD PERSONS acronym can assist surgeons in documenting the presence of major risk factors associated with adult suicide and in facilitating communication with emergency personnel. Suicide is a potentially preventable public health problem. Oral and maxillofacial surgeons can be key in elucidating clinically significant suicide potential in their patients and referring them for timely intervention.

Clinical rating scales in suicide risk assessment

This study explores the usefulness of clinical rating scales in the assessment of suicidal risk in an urban psychiatric teaching hospital. Admission for clinically evaluated suicide risk was the outcome variable because actual suicide occurs rarely. Six clinical scales identified high-risk patients: the Modified SAD PERSONS scale, revised Beck Depression Inventory, Beck Anxiety Inventory, Beck Hopelessness Scale, Beck Scale for Suicidal Ideation (BSS), and the High-Risk Construct Scale (NEW). It was hypothesized that patients who scored highly on the clinical scales were more likely to be admitted. Five of the scales had previously established psychometric properties, while one was new and untested. For our patient population, the established scales had 100% sensitivity and negative predictive value, but lower specificity and positive predictive value (range = 38–90% & 28–71%). We performed a correlation matrix and regression analysis to determine which scale(s) best predicted admission based upon suicidal concerns. The previously untested NEW scale was the best predictor followed by the BSS. Clinical rating scales cannot predict suicide in the individual and strict cut-off scores should not be used to dictate admission to hospital. However, the information provided can be a valuable adjunct to suicide risk assessment in psychiatric and non-psychiatric emergency settings