Promising new suicide assessment tool in ED setting

A new tool could have the potential to identify which suicidal patients presenting to the emergency department should be admitted to the hospital and which patients can be safely discharged, new research suggests.

The investigators found that 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,” the investigators found. study co-author Lisa Cohen, PhD, clinical professor of psychiatry, Carl Icahn School of Medicine, Mount Sinai Beth Israel, New York, said Medscape Medical News.

Suicidal crisis syndrome (SCS) is an “acute negative affect state” predictive of suicidal behavior (SB), even in patients who do not express suicidal ideation (SI). SCS is currently under review for inclusion as a specific diagnosis for suicide in the updates of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

The study was published online May 1 in The journal of clinical psychiatry.

New diagnosis

The SCS concept was “largely pioneered” by study co-author Igor Galynker, MD, a 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 is at risk; but as doctors, we don’t just want to know who is at risk, we want to know when particularly high-risk populations are at risk, like in emergency rooms,” she said.

SCS is a “new pre-suicidal diagnosis that has been strongly associated with short-term suicidal behaviors,” the authors note.

Criterion A Intense and persistent feeling of frantic hopelessness/trapping (a need to escape a perceived unavoidable life situation)
Criterion B
  1. Affective disorder

  2. Loss of cognitive control

  3. Hyperarousal

    • Shaking

    • Hypervigilance

    • Irritability

    • Insomnia

  4. Acute social withdrawal

Patients must meet criterion A and have 1 symptom for each domain of criterion B to be diagnosed with SCS.

“We do not specify IS, although IS increases risk and cannot be ignored, but it cannot be considered a primary indicator of suicide risk,” Cohen said.

Additionally, a large percentage of individuals with SCS do not have a prior psychiatric diagnosis, although “mental illness increases risk, but a stressor can throw a person [without mental illness] in that state,” he noted.

Cohen’s group studied SCS in outpatient and inpatient psychiatric patients, but not in psychiatric ED, “to see if it can be used to decide whether or not to admit a patient to the plan.”

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

They tested the clinical utility of the A-SCS-C in two stages, with disposition decision as the outcome variable, entering the major disorders of SI, SB, and psychosis/agitation in stage 1, and the diagnosis A-SCS-C in phase 2.

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

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

Primordial state

The researchers studied 212 patient encounters. Of these, 57.5% involved inpatient stays. Among these patients, 37.26% received “positive” or “extreme” A-SCS-C ratings.

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

“Overall, the diagnosis of SCS was concordant with 73.1% of hospitalization/discharge decisions,” the authors report. When the main complaint of psychosis/agitation was excluded, the percentage 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 hospital admission, while neither SI nor SB were a significant predictor. Indeed, the presence of SI reduced the probability of hospitalization (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 “markedly increased” 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 hospitalization/discharge decisions; and SCS status was highly associated with admissions decision in both genders, with no statistically significant differences.

“Pay attention to your patient’s emotional states,” Cohen advised. “The presence or absence of self-reported SI is informative but not the only indicator of suicide risk.”

SCS symptoms have been identified across multiple continents and countries, he noted. “It arrives at primal affective states unaffected by culture.”

Promising clinical utility

Commenting for Medscape Medical NewsKelly Green, PhD, senior investigator, Penn Center for the Prevention of Suicide, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, said that adopting an acute suicide-specific diagnosis such as SCS “has promising clinical utility, by 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 results were “particularly impressive” because they “demonstrate the feasibility of incorporating assessment of an acute suicide risk diagnosis” into the ED, “which can be a challenging environment in which to implement new practices, due to its fast-paced nature, said Green, who was not involved in the study.

However, “Green’s enthusiasm … is tempered by the state of the science on acute suicide risk,” as there is “still much that is unknown. There is much work underway in this area that will be able to inform the criteria for a potential acute risk diagnosis, so it is important not to implement the diagnostic criteria prematurely.”

The study received no funding. Cohen and coauthors 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 consulting firm 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 memoirs of two brave Afghan sisters who told their story).

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