SUICIDALITY SUICIDALITY CLASSIFICATION CLASSIFICATION

PROJECTPROJECT

Kelly Posner, Ph.D.Kelly Posner, Ph.D.

Maria A. Oquendo, M.D.Maria A. Oquendo, M.D.

The Problem : Limitations in The Problem : Limitations in Suicide Assessment and Suicide Assessment and NomenclatureNomenclature

Lack of agreement on common terminology Lack of agreement on common terminology – In clinical descriptions of suicidal actsIn clinical descriptions of suicidal acts– In research descriptions of suicidal acts (even In research descriptions of suicidal acts (even

among experts in suicidal behavior)among experts in suicidal behavior)

Importance of reliability (all define/assess the Importance of reliability (all define/assess the same way) and validity (some truth to dfn)same way) and validity (some truth to dfn)

Suicide AttemptSuicide Attempt

A self-injurious act committed A self-injurious act committed with at least some intent to die.with at least some intent to die.

Intent does not have to be Intent does not have to be explicit. Eg: patient denies intent explicit. Eg: patient denies intent to die, but thought that the to die, but thought that the behavior could be lethal. Intent behavior could be lethal. Intent can be inferred.can be inferred.

Other Classifications: Other Classifications: Suicidal Behavior w/o InjurySuicidal Behavior w/o Injury

Interrupted Attempt: Interrupted Attempt: individual is individual is stopped by an outside circumstance stopped by an outside circumstance from starting the self-injurious actfrom starting the self-injurious act

Aborted Attempt: Aborted Attempt: individual takes individual takes steps towards making a suicide steps towards making a suicide attempt, but stops himself before attempt, but stops himself before engaging in any potentially self-engaging in any potentially self-destructive behaviordestructive behavior

Suicidal IntentSuicidal Intent

Presence of intent to die differentiates Presence of intent to die differentiates suicidal acts from self-injurysuicidal acts from self-injury

-Determine whether self-injurious act -Determine whether self-injurious act was thought of was thought of as a means of causing or as a means of causing or facilitating deathfacilitating death

--Support for validity of using intent to Support for validity of using intent to define suicidality: Completed suicide define suicidality: Completed suicide predicted by previous intent measures predicted by previous intent measures (Beck et al, 1989) (Beck et al, 1989)

Examples of Non-Suicidal Self-Examples of Non-Suicidal Self-InjuryInjury

Teenage girl reported mother was being cruel and Teenage girl reported mother was being cruel and neglectful and she wanted to escape from mother’s neglectful and she wanted to escape from mother’s home. States she researched lethal doses of ibuprofen home. States she researched lethal doses of ibuprofen to make sure she took an amount that would not be to make sure she took an amount that would not be life-threatening. Took 6, feeling certain it was not life-threatening. Took 6, feeling certain it was not enough to kill her, she definitely did not want to die, enough to kill her, she definitely did not want to die, only to escape from mother’s home. Taken to ER and only to escape from mother’s home. Taken to ER and then admitted to psych. hospitalthen admitted to psych. hospital

Person described 12 incidents of cutting himself. Person described 12 incidents of cutting himself. States he did this only “to relieve tension” and “to States he did this only “to relieve tension” and “to play with danger to see how far I would go” and no play with danger to see how far I would go” and no part of him wanted to die. Thought about it for hours part of him wanted to die. Thought about it for hours before acting on the urge and felt relieved of tension before acting on the urge and felt relieved of tension afterwards. Did not feel pain while cutting self.afterwards. Did not feel pain while cutting self.

Research Support of Research Support of ClassificationsClassifications

ReliabilityReliability excellent reliability (kappa= .97) excellent reliability (kappa= .97)

utilizing classification system in NIMH- utilizing classification system in NIMH- funded treatment, biological, and funded treatment, biological, and genetic trialsgenetic trials

Multi-site reliability with other centers Multi-site reliability with other centers in family genetic studies and in family genetic studies and treatment of adolescent suicide treatment of adolescent suicide attempters trialattempters trial

Validity of ClassificationsValidity of Classifications

Individuals classified as suicide attempters Individuals classified as suicide attempters have as much as 2.5X risk of future attempts have as much as 2.5X risk of future attempts or completions or completions (Dorpat, 1967, Nordstrom, 1995, (Dorpat, 1967, Nordstrom, 1995, Oquendo, in press)Oquendo, in press)

Interrupted attempters are reported to be 3X Interrupted attempters are reported to be 3X more likely to commit suicide than more likely to commit suicide than uninterrupted attempters uninterrupted attempters (Steer et al 1988)(Steer et al 1988)

Aborted attempters are at risk for eventual Aborted attempters are at risk for eventual attempts and were more likely to have made attempts and were more likely to have made an actual attempt in the past an actual attempt in the past (Marzuk et al 1997)(Marzuk et al 1997)

Classification MethodologyClassification Methodology

Expert Panelwith 9 membersReview of cases

N = x

Subgroup Reviewsx/3 + 5 +5 cases

Subgroup Reviewsx/3 + 5 + 5 cases

Subgroup Reviewsx/3 + 5 +5 cases

• Blinding of data by experienced child psychiatrist not on panel • Determination of event classification based on reliable and valid constructs• Training on classification system to establish reliability of panel members• Consensus discussion of non-concordant cases

(additional cases to prevent stratification bias)

Generate Classified Cases

ClassificationsClassifications

Suicidal Non Suicidal

Suicide Attempt

Suicidal Ideation

Self-Injury/Mutilation

Other:-Accidental

-other sxs (eg. akathesia)

Indeterminate

Non-consensus

Unable toClassify Due

To Limited Data

Suicidal Behavior without injury:Aborted attemptInterrupted attempt

Future DirectionsFuture Directions

Develop guidelines as to how to better capture data, Develop guidelines as to how to better capture data, enabling appropriate classification of suicidality:enabling appropriate classification of suicidality:

Utilization of research assessment toolsUtilization of research assessment tools

(what questions to ask, how to ask, and what measures (what questions to ask, how to ask, and what measures aid this)aid this)

Consistency of Nomenclature and ClassificationConsistency of Nomenclature and Classification

Improved, More Valid Identification andImproved, More Valid Identification and

Documentation Of SuicidalityDocumentation Of Suicidality