Novel Suicide Assessment Tool Promising in the ED Setting

Batya Swift Yasgur, MA, LSW

June 06, 2023

A novel tool may have the potential to identify which suicidal patients who present to the emergency department (ED) should be admitted to hospital and which patients can be safely discharged, new research suggests.

Investigators found the Abbreviated Suicide Crisis Syndrome Checklist (A-SCS-C) "shows robust clinical utility and may actually reduce the limitations of relying on self-reported suicidal ideation to determine suicide risk," study co-author Lisa Cohen, PhD, clinical professor of psychiatry, Carl Icahn School of Medicine, Mount Sinai Beth Israel, New York, told Medscape Medical News.

Suicide crisis syndrome (SCS) is an "acute negative affect state" predictive of suicidal behavior (SB), even in patients who don't express suicidal ideation (SI). SCS is currently under review for inclusion as a suicide-specific diagnosis in updates to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

The study was published online May 1 in The Journal of Clinical Psychiatry.

Novel Diagnosis

The concept of SCS was "largely pioneered" by study co-author Igor Galynker, MD, professor of psychiatry, Icahn School of Medicine, and director of the Suicide Research and Prevention Lab, Cohen said.

"Decades of research have made us good at identifying chronic risk factors [for suicide] and who's at risk; but as clinicians, we don't just want to know who's at risk, we want to know when they're at risk — particularly high-risk populations, such as in emergency rooms," she said.

SCS is a "novel, pre-suicidal diagnosis that has been robustly associated with near-term suicidal behavior," the authors note.

Criterion A Intense and persistent feeling of frantic hopelessness/entrapment (an urge to escape a perceived inescapable life situation)
Criterion B
  1. Affective disturbance

    • Emotional pain

    • Rapid spikes of negative emotions

    • Extreme mood swings

    • Extreme anxiety

    • Acute anhedonia

  2. Loss of cognitive control

    • Ruminations/ruminative flooding

    • Cognitive rigidity

    • Failed thought suppression

  3. Hyperarousal

    • Agitation

    • Hypervigilance

    • Irritability

    • Insomnia

  4. Acute social withdrawal

Patients must meet criterion A and have ≥1 symptoms from each domain of criterion B to be diagnosed with SCS.

"We don't specify SI, although SI increases risk and can't be ignored; but it can't be relied on as a primary indicator of suicide risk," Cohen said.

Moreover, a large percentage of individuals with SCS have no prior psychiatric diagnosis, although "mental illness increases the risk — but a stressor can throw a person [without mental illness] into that state," she noted.

Cohen's group has studied SCS in psychiatric outpatients and inpatients, but not in the psychiatric ED, "to see whether it can be used in deciding whether or not to admit a patient to the floor."

The researchers turned to data from NorthShore University Health System in Chicago from December 1 to December 31, 2020. In March 2020, NorthShore implemented use of a tool combining the A-SCS-C with questions from the Columbia–Suicide Severity Rating Scale (C-SSRS)–Screening Version.

They tested the clinical utility of the A-SCS-C in two steps, with disposition decision as the outcome variable, entering the chief complaints of SI, SB, and psychosis/agitation into step 1 and A-SCS-C diagnosis into step 2.

They then performed a sensitivity analysis that used another two-step multiple logistic regression model, entering SI from C-SSRS into step 1 and A-SCS-C diagnosis into step 2.

Finally, they performed two additional sensitivity analyses, one with patients younger than 18 years, and one in which male and female patients were analyzed separately.

Primordial State

The researchers studied 212 patient encounters. Of these, 57.5% resulted in admissions to the inpatient unit. Among these patients, 37.26% received "positive" or "extreme" A-SCS-C ratings.

Chief complaints included SI, SB, and psychosis or agitation (39%, 10.4%, and 28%, respectively).

"Overall, SCS diagnosis was concordant with 73.1% of admission/discharge decisions," the authors report. When the chief complaint of psychosis/agitation was excluded, the proportion rose to 86.9%.

Multivariate analysis showed that for A-SCS-C, the adjusted odds ratio (AOR) was 65.9 (95% CI, 18.79 – 231.07) for inpatient admission, while neither SI nor SB was a significant predictor. In fact, the presence of SI reduced the likelihood of admission (AOR, 0.29).

When calculated in isolation, SCS had "very high specificity" (0.92) but not high sensitivity. Sensitivity and specificity were both "inadequate" in step 1 of the first logistic regression, but both "increased markedly" in step 2 (to 0.87 and 0.76, respectively).

The relationship was significant in minors (P < .001), with SCS status accounting for 82.9% of total admission/discharge decisions; and SCS status was highly associated with admission decision in both sexes, with no statistically significant difference.

"Pay attention to your patient's emotional states," Cohen advised. "The presence or absence of self-reported SI is a piece of information but not the sole indicator of suicidal risk."

SCS symptoms have been identified across multiple continents and countries, she noted. "It gets to primordial affective states not influenced by culture."

Promising Clinical Utility

Commenting for Medscape Medical News, Kelly Green, PhD, senior research investigator, Penn Center for the Prevention of Suicide, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, said adopting an acute suicide-specific diagnosis such as SCS "has promising clinical usefulness, helping clinicians better distinguish acute from chronic suicide risk, which is important for selecting appropriate evidence-based treatments to address a patient's specific needs."

The findings were "particularly impressive" because they "demonstrate the feasibility of incorporating the assessment of an acute suicide risk diagnosis" in the ED, "which can be a difficult setting in which to implement new practices, due to its fast-paced nature," said Green, who was not involved with the study.

However, Green's " tempered by the state of the science on acute suicide risk," since there's "still much that is unknown. There's a lot of ongoing work in this area that will be able to inform criteria for a potential acute risk diagnosis, so it's important not to implement diagnostic criteria prematurely."

The study received no funding. Cohen and co-authors and Green report no relevant financial relationships.

J Clin Psychiatry. Published online May 1, 2023. Abstract

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom(the memoir of two brave Afghan sisters who told her their story).

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