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Brief report
a r t i c l e i n f o a b s t r a c t
Article history: Objective: To assess the predictive value of the Suicide Intent Scale in patients with high suicide
Received 13 October 2010 risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale may
Received in revised form 15 November 2010 offer a better predictive value in suicide risk detection. Finally a shorter version of the scale was
Accepted 15 November 2010 created after an item analysis.
Available online 8 December 2010
Method: Eighty-one suicide attempters were assessed with the Beck's Suicide Intent Scale (SIS).
All patients were followed up for cause of death. Receiver-operating characteristic (ROC)
Keywords: curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to
Suicide intent predict suicide.
Prediction Results: Seven patients committed suicide during a mean follow up of 9.5 years. The major finding
Suicide attempt
was that mean SIS scores distinguished between suicides and survivors. The positive predictive
Suicide
value was 16.7% and the Area Under Curve (AUC) was 0.74. Only the planning subscale reached
Scales
ROC statistical significance. Four items were used to test a shorter version of the SIS in the suicide
Karolinska Institutet prediction. The positive predictive value was 19% and the AUC was 0.82.
Conclusions: The Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a shorter
version of the scale may offer a better predictive value.
© 2010 Elsevier B.V. All rights reserved.
1. Introduction intent, and recently Misson et al. presented a four factor solution
of the SIS in suicide attempters. In a recent study by Antretter et
Over the past 30 years, Beck's Suicide Intent Scale (SIS) has al. only one factor: “subjective part” of the SIS consisting of items
been the prevailing psychometric scale for assessing suicide 9 to 14 (the same items as in factor lethal intent by Mieczkowski)
intent in suicide attempters (Freedenthal, 2008). In a recent was strongly supported, whereas an acceptable model fit for the
review article, five out of 13 studies showed a positive ‘objective part’ was not found in eleven clinical samples
relationship between SIS scores and suicide over a follow-up (Antretter et al., 2008). They concluded that possible future
period ranging from 10 months to 20 years (Freedenthal, revisions of ‘objective’ SIS items may be worth consideration.
2008). Only two earlier clinical studies have used receiver There is a need for validated clinical tools for suicide risk
operating characteristics (ROC) to assess the optimal threshold assessment that can be easily administered. To the best of our
of the SIS in suicide prediction (Niméus et al., 2002; Harriss and knowledge, only two studies have compared underlying factors
Hawton, 2005). of the SIS in suicide prediction (Niméus et al., 2002; Harriss and
Earlier studies of the factorial structure of the SIS have Hawton, 2005) and only one study has assessed the suicide
identified between two and four factors (Antretter et al., 2008). predictive validity of individual items of the scale (Niméus et al.,
Mieczkowski found two factors: planning subscale and lethal 2002). We hypothesized that high scores with Suicide Intent
Scale may predict future suicide after attempted suicide.
The aim of the present study was to assess the predictive
⁎ Corresponding author. Department of Clinical Neuroscience/Psychiatry,
Karolinska Institutet, R5, Karolinska University Hospital, Solna, SE-171 76
value of the Suicide Intent Scale in patients with high suicide
Stockholm, Sweden. Tel.: + 46 8 51776759; fax: + 46 8 303706. risk, i.e. patients admitted to a psychiatric clinic after a suicide
E-mail address: jussi.jokinen@ki.se (J. Jokinen). attempt. The secondary aim was to assess the predictive value
0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2010.11.016
168 J. Stefansson et al. / Journal of Affective Disorders 136 (2012) 167–171
of the factors of the Suicide Intent Scale to detect future suicide Åsberg, 1979). The mean score of MADRS was 16 (median 17,
in suicide attempters. Finally a shorter version of the scale was S.D. 9, range 0–37).
created after an item analysis. The Beck Hopelessness Scale is a 20-item true/false
instrument with statements of pessimistic beliefs about oneself
2. Methods and the future (Beck et al., 1974b). Mean level of hopelessness
was 10.4, (median 11, S.D. 6.2, range 0–20).
2.1. Study setting
2.4. Outcomes
Patients having their clinical follow-up after a suicide attempt
at the Karolinska University Hospital were asked to participate in By use of the unique personal identification number patients
a study of biological and psychological risk factors for suicidal were linked to the Cause of Death register, maintained by the
behaviour. The Regional Ethical Review Board in Stockholm National Board of Health and Welfare in Sweden (http://
approved the study protocols (Dnr 93-211) and the participants www.socialstyrelsen.se). Seven patients had committed suicide
gave their written informed consent to the study. before January 2009; suicides were ascertained from the death
certificates. Five patients committed suicide within 6 years, two
2.2. Subjects patients died of suicide after 11 years from entering to the study
(time to suicide: median 4 years, mean 6 years, range between
This is a cohort study involving 81 suicide attempters 1.7 and 12.8 years). The follow up time ranged between 10 and
(35 men, mean age 39 years, S.D.=11.8, range 20–69 and 46 15 years. There was no age difference between suicides and
women, mean age 35 years, S.D.=12.1, range 18–68). Patients survivors.
were included to the study between 1993 and 1998. Inclusion
criteria were a recent suicide attempt (a time limit of one month), 2.5. Data analysis
fair capacity to communicate verbally and in writing in the
Swedish language and an age of 18 years or older. Exclusion Characteristics of the population were described by
criteria were schizophrenia spectrum psychosis, dementia, using the mean, the median and the range for quantitative
mental retardation and intravenous drug abuse. Suicide attempt variables. Shapiro–Wilk test was used to test if data was
was defined as any nonfatal, self-injurious behaviour with some normally distributed. Parametric statistics, t-test one tailed
intent to cause death. The participants were interviewed by a was applied for between-group comparisons, suicide victims
trained psychiatrist using the SCID I research version interview to vs. survivors if data was normally distributed. If skewed,
establish diagnosis according to DSM-III (American Psychiatric nonparametric statistics (Kruskal–Wallis' test) in continuous
Association). Axis II diagnoses were established with SCID II variables was applied for between-group comparisons.
interview. An ad hoc ROC analysis was used to find optimal thresholds
Ninety-four percent of participants had at least one current for SIS and SIS factors to predict suicide. Receiver-operating
Axis I psychiatric diagnosis; 80% of patients fulfilled criteria for characteristic (ROC) curves and tables were created for scales to
mood disorder, 5% for adjustment disorder and 4% for anxiety establish the optimal cut-off values. ROC areas under the curves
disorders, one patient had substance related disorder, one (AUCs) were calculated as a measure of the diagnostic
patient had anorexia nervosa and one an unspecified psychiatric performance, and differences were calculated and tested
disorder (not psychotic). Twenty-one percent of the patients according to the methods of Hanley and McNeil. The cut-off
had a co morbid substance related disorder (mostly alcohol point that optimized sensitivity (proportion of suicides correctly
dependence). Among Axis II diagnoses, 39% of the patients identified) and specificity (proportion of survivors correctly
fulfilled criteria for a personality disorder. Fourteen patients identified) was used. Pearson Chi-square and Fisher's exact test
(17%) had used a violent suicide attempt method. were used for cross tabulations of categorical variables.
Statistical analyses were performed using JMP VI software,
2.3. Assessments SAS Institute inc., Cary, NC, USA. The p value was set at b0.05.
1,00
0,90
0,80
0,70
0,60
0,50
Sensitivity
0,40
0,30
0,20
0,10
0,00
0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00
1-Specificity
Fig. 2. ROC curve for Suicide Intent Scale in suicide prediction, AUC = 0.74.
Table 1
SIS planning 1–7, 15 10.1 10 2.5 7–15 7.3 7 3.8 0–15 Z = 2.0
p b 0.045
SIS lethal intent/Conception/“subjective part” 9–14 9.7 10 1.1 8–11 8.3 8.5 2.9 1–12 Z = 1.2
p b 0.22
Preparation 5, 6, 7, 15 3.9 3 2.1 2–8 0.98 2.6 2.4 0–8 Z = 1.3
p b 0.19
Precautions 1–3 4.4 5 1.5 2–6 3.5 4 1.9 0–6 Z = 1.3
p b 0.21
Communication 4, 8 2.1 2 0.4 2–3 1.5 2 0.9 0–4 Z = 1.9
p b 0.058
SIS shorter version 4, 7, 12, 13 7 7 1 6–8 5 5 1.9 0–8 Z = 2.8
p b 0.0046
170 J. Stefansson et al. / Journal of Affective Disorders 136 (2012) 167–171
Table 2
Positive predictive values of SIS, SIS planning subscale and SIS shorter version in suicide prediction.
Test Cut off Suicide+ Suicide− Sensitivity Specificity Positive predictive value AUC Test ⁎
2006; Niméus et al., 2002; Pierce, 1987; Suominen et al., 2004). We constructed a shorter version of the SIS with items 4, 7,
One study found a positive relationship for women only 12 and 13. When we used this shorter version of the SIS in
(Skogman et al., 2004). Two of the earlier positive reports suicide prediction we found that an optimal cut-off of 6 gave
studied elderly patients (Pierce, 1987; Hawton and Harriss, specificity of 59% and sensitivity of 100%. The positive predictive
2006). value was 19% and the AUC was 0.82 which gave a better
However there are several large negative studies. So far prediction by reducing the number of false positives.
seven studies, with follow-up periods from 113 days to 10 years, In the study of Niméus et al., shorter versions of the SIS or
did not find a statistically significant association between the SIS the factors were not superior to the original SIS scale in
scores and later suicide (see review by Freedenthal, 2008). One predicting suicide. Having a shorter test may increase the
of the negative studies showed that the total SIS score did not clinical utility of the scale. The utility and predictive value of
predict suicide whereas items 1, 2 and 3 measuring precaution the shorter version should be replicated in a larger cohort of
did so (Beck and Steer, 1989). suicide attempters.
Only two studies have compared the underlying factors of the Limitation of this study is a small number of patients;
Beck's Suicide Intent Scale in suicide prediction (Niméus et al., furthermore suicidal intentions are very difficult to measure per
2002; Harriss and Hawton, 2005). In the study of Niméus and his se (Freedenthal, 2007). A patient who tried to die may deny
coworkers all the subscales/factors were predictive for future suicidal intent to avoid hospitalization. Shame, ambivalence,
suicide. We found that only higher scores in the Planning confusion or intoxication can contribute to recall bias.
subscale were a significant predictor of future suicide. The In summary, our findings support the use of information
Planning subscale showed a very similar predictive value and the about suicidal intent as part of a clinical suicide risk assessment.
AUC compared with the SIS total score, whereas Lethal intent Further work needs to be done to test the utility of a shorter
factor scores did not predict suicide. The seven attempters who version of the SIS combined with other clinical rating scales
later killed themselves had reported more planning at the time of measuring other types of suicide risk factors such as violence.
their index attempt than the 74 patients who did not commit
suicide. This is partly in line with the results of Harris and Hawton Role of funding source
Funding for this study was provided by the Swedish Research Council
who found a stronger association between the circumstances
(Project number K2009-61P-21304-04-4) by Söderström-Königska Foundation
section of the SIS (items 1–8) and suicide especially in female and by the Thurings Foundation.
deliberate self harm patients. Interestingly the planning subscale The Swedish Research Council, Söderström-Königska Foundation and the
was associated with lower levels of CSF 5-HIAA, a replicated Thurings Foundation had no further role in study design; in the collection,
biomarker of suicide risk (Mann et al., 1996). We have earlier analysis and interpretation of data; in the writing of the report; and in the
decision to submit the paper for publication.
reported that CSF 5-HIAA was a short term predictor of suicide
compared to suicide intent and hopelessness assessed after a Conflict of interest
suicide attempt in male mood disorder inpatients (Samuelsson No conflicts of interests to declare for any of the co authors.
et al., 2006).
In this study, we found that the cut-off point of 16 was Acknowledgements
optimal and the positive predictive value was 16.7%, which is
higher than the PPV in the study of Niméus et al. who reported a We want to acknowledge Professor Marie Åsberg for inspiring
PPV of 9.7% in the whole sample. They also found that Suicide us with studies in suicidology Dr Kaj Forslund for careful clinical
Intent Scale may offer a better prediction if targeted in elderly assessments and Dr. Large who made helpful comments on the
suicide attempters with PPV of 22.5% for those 55 years or older. electronic version of the paper resulting in an improved final
Harris and Hawton reported a low PPV of 4.0% in a large group of paper version.
deliberate self harm patients. They concluded that the SIS cannot
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