Child Psychiatry Hum Dev (2007) 38:17–29

DOI 10.1007/s10578-006-0040-7

ORIGINAL PAPER

Suicide Probability Scale and its Utility with

Adolescent Psychiatric Patients

Michael Eltz Æ Allison Schettini Evans Æ Mark Celio Æ

Jennifer Dyl Æ Jeffrey Hunt Æ Laura Armstrong Æ
Anthony Spirito

Published online: 16 November 2006

Ó Springer Science+Business Media, LLC 2006

Abstract This study examined the factor structure, reliability, and validity of the
Suicide Probability Scale (SPS) in a sample of 226 (80 male, 146 female) adolescent
psychiatric inpatients. Confirmatory factor analyses provided only some support for
the original subscales. Exploratory factor analyses revealed some overlap with the
original scales, but the factors differed by gender. Internal consistency of the original
factors was somewhat better than the factors derived from this sample. A negative
change in SPS scores over the course of the inpatient admission was related to risk
for readmission due to repeat suicidal behavior.

Keywords Suicide prediction Æ Adolescents Æ Suicide probability scale

Introduction

Suicidal ideation and behavior are primary reasons adolescents are admitted to
inpatient psychiatric care. Unfortunately, continued suicidal behavior following
discharge from inpatient care is not uncommon. For example, one study found that
after an inpatient psychiatric admission, repeat suicide attempts were evident in
more than one third of adolescents at 3-month follow-up [1]. Given the high risk
nature of this population, measures that assess risk for subsequent suicidal behavior
in adolescents who have been psychiatrically hospitalized would be quite useful.
One existing measure to assess suicide risk is the Suicide Probability Scale (SPS),
which is a 36-item self-report measure. This measure was initially devised to assess

M. Eltz Æ M. Celio Æ J. Dyl Æ J. Hunt Æ L. Armstrong Æ A. Spirito

Bradley Hospital, East Providence, RI, USA

A. S. Evans Æ J. Dyl Æ J. Hunt Æ A. Spirito (&)

Brown Medical School, Box G-BH, Providence, RI 02912, USA
e-mail: anthony_spirito@brown.edu

A. S. Evans
Memorial Hospital of Rhode Island, Pawtucket, RI, USA
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suicidal risk in clinical and non-clinical adolescent and adult populations [2]. Factor
analysis, using a varimax solution, from the original validation sample initially re-
vealed six factors accounting for 38.6% of the variance. Follow-up analyses then
identified two major factors: Suicide Ideation and Negative Self-Evaluation, with four
lower-level factors, namely, Hostility, Angry Impulsiveness, Interpersonal Closeness,
and Positive Outlook. Given the exploratory nature of the measure, the researchers
then conducted an oblique factor analysis to examine whether the factor structure
differed when the solution was non-orthogonal. This solution also resulted in six
factors, accounting for 48.3% of the variance. Again, two main factors emerged, with
several lower-level factors. The two main factors were slightly different and were
labeled, Suicide Ideation and Hopelessness. The remaining factors were merged into
three factors: Interpersonal Closeness, Negative Self-Evaluation (also termed, Posi-
tive Outlook), and Hostility.
The measure developers concluded that four main factors should be included in
the formal scoring of the measure: Hopelessness, Suicide Ideation, Negative Self-
Evaluation, and Hostility. However, the rationale for selecting these factors is un-
clear. This selection procedure raises concerns as to whether other factors not ac-
counted for by this larger 4-factor structure are relevant, particularly when the
measure is used with different populations.
Given that the measure has excellent face validity and that it seems to measure
factors that are inherent to understanding and predicting suicidal behavior, the SPS
warrants continued consideration. Nonetheless, additional research with the SPS has
been limited. Research that has been conducted in this area suggests the need to
revisit the proposed factor structure of the SPS. For example, research by Bagge and
Osman [3] revealed that there was a poor fit between the original factor structure
and that derived from a sample of undergraduate students. Based on their results,
they argued for revision of the subscales. Furthermore, the use of the SPS, and
whether the factor structure holds up in different populations is, as of yet, largely
unknown. Although the information from the standardization provides valuable
preliminary information, further research is necessary to determine whether there
are critical differences in the use of this scale in different populations (i.e., clinic
setting, inpatient setting, and outpatient setting).
The current study examined the factor structure, reliability, and validity of the
SPS in an adolescent psychiatric inpatient population.

Method

Participants

Participants consisted of 226 inpatient adolescents (80 males and 146 females) at a
psychiatric hospital located in the Northeast. They were selected from a larger
sample of 419 adolescents admitted over a year long time period, with participants
excluded if they did not complete both intake and discharge ratings on the SPS, e.g.,
due to unexpected discharge, or refusal to cooperate with the assessment. Partici-
pants ranged in age from 11 to 18 years, with the mean age being approximately
15 years, (M = 14.8; SD = 1.5). The hospital mainly serves patients of lower and
middle socioeconomic status. The racial distribution of the hospital population is as
follows: approximately 81% Caucasian, 8% Hispanic, 5% African American, and
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the remainder are Asian, Native American, or multiracial. The average length of
stay was 10.5 days but with considerable variability (SD = 14.0).

Procedures

The SPS and other measures noted below were administered by a trained mental
health worker as part of an assessment battery given to patients upon admission to
the hospital. All participants received their assessment within 1 week of their
admission, typically within the first 3 days. Subsequently, the SPS and RADS were
re-administered at discharge, and information on treatment (e.g., length of stay,
participation in groups) and demographic information was also collected at this time
via chart reviews. A subset of data from 15% of charts were reviewed by two raters
and then subsequently assessed for inter-rater reliability, which was high (0.92 based
on Cohen’s Kappa). Permission to use this clinical data was obtained from the
hospital Human Subjects Review Committee.

Measures

The Suicide Probability Scale (SPS)

The SPS [2] consists of 36 statements, e.g., ‘‘I feel isolated from people’’, rated on
a four-point scale based on how often they feel the statement is true for them
(ranging from ‘‘none or a little of the time’’ to ‘‘most or all of the time’’). These
ratings are then weighted selectively by item and totaled to achieve a Total
Weighted Score and four subscale scores. The scale developers validated the scale
using a sample of ‘‘normals,’’ a psychiatric inpatient group, and a suicide attempter
group. Adolescents made up 16.6% of the three samples. Good evidence for item
content validity, criterion validity, and discriminant validity has been reported [2].
They also reported excellent internal consistency for the Total Scale with an alpha
coefficient of 0.93 and internal consistency ranging from fair to good for the
remaining scales (0.62 for Negative Self-Evaluation, 0.78 for Hostility, 0.80 for
Hopelessness, and 0.89 for Suicide Ideation). Similarly, there was fair to excellent
split-half reliability ranging from 0.58 (Negative Self-Evaluation) to 0.93 (Total
Scale).

Reynolds Adolescent Depression Scale (RADS)

The RADS [4] is a 30-item self-report questionnaire of depressive symptoms, which

is completed by adolescents. Adolescents rate statements on a 4-point scale ranging
from 1 (almost never) to 4 (most of the time). The RADS has shown satisfactory to
excellent test–retest reliability, internal consistency, and convergent/discriminant
validity in both clinical and community samples [4].

Hopelessness Scale for Children (HSC)

The HSC [5] consists of 17 true/false statements designed to measure negative

expectancies toward oneself and one’s future. The HSC has shown adequate reli-
ability and internal consistency with a sample of adolescent suicide attempters [6].
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The State-Trait Anger Expression Inventory (STAXI)

The STAXI [7] consists of 44 items designed to measure both the experience and
expression of anger. Items are rated on 4-point Likert scales, with higher scores
indicating greater intensity or frequency of anger experienced or expressed. The
STAXI has been used with adolescents [8], and adequate internal consistency and
construct validity have been reported for the subscales [7].

The Trauma Symptom Checklist for Children (TSCC)

The TSCC [9] is a 54 item scale that measures trauma-related symptomatology and
generates 10 subscale t-scores for specific symptoms as well as under-reporting and
hyper-reporting scales which indicate the validity of the self-report. The TSCC was
designed for use with children aged 6–18 and adequate validity has been reported in
several studies on the impact of child abuse [10, 11].

Results

Preliminary Analyses

A series of t-tests and chi-square analyses were conducted on the original sample of
419 participants to determine if there were any differences between participants who
completed the SPS and those who did not. There were no differences on age, gender
or race between the two samples.
Table 1 presents data on the means and standard deviations of the primary study
variables broken down by gender. Correlations and t-tests were used to assess the
relationship between race, gender, and age with the outcomes measures, including
the standardized SPS change score, the standardized RADS change score, length of
stay, participation in groups. The relationship between race with outcome variables

Table 1 Means and standard deviations of primary study variables for girls and boys

Variable Girls n = 146 Boys n = 80

Mean SD Mean SD

RADS t-score at admission 72.72 30.46 66.85 28.99

RADS t-score at discharge 48.80 33.71 45.60 30.87
SPS total t-score at admission* 67.40 10.72 63.64 8.84
SPS total t-score at discharge 59.75 11.51 58.20 9.64
SPS Hopelessness Scale t-score at admission** 64.16 10.36 59.42 10.19
SPS suicide t-score at admission* 65.12 11.74 60.08 11.06
SPS Negative Self-Evaluation t-score at admission* 64.39 10.63 61.19 10.23
SPS hostility t-score at admission 59.85 11.55 61.12 9.89
Length of stay in days 9.81 11.92 12.00 17.89
Days between discharge and first readmission 188.25 222.23 174.48 248.31
Total number readmissions 1.62 1.03 1.26 0.44

RADS = Reynolds Adolescent Depression Scale; SPS = Suicide Probability Scale

* Gender difference significant at P < 0.05 level
** Gender difference significant at P < 0.01 level

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were all non-significant. Age was significantly correlated with both length of stay
(r = –0.16, P < 0.01) and frequency of readmission (r = –0.36, P < 0.01), i.e., youn-
ger patients had shorter lengths of stay and faster readmissions than older patients
while females showed a higher rate of readmissions (X = 1.64, SD = 0.96) than
males (X = 1.18, SD = 0.39); t = –2.57, P < 0.05). No significant ethnicity differences
were found on any measure.

SPS Analyses

After reviewing the items, one item on the SPS, ‘‘I feel/felt close to my mate’’ was
not answered by 36% of participants in this sample and, therefore, it was elimi-
nated from further analyses. See Table 2 for means and standard deviations of SPS
items by gender. Gender differences were explored using t-tests. The results
indicated that males and females differed significantly on 13 of 36 items (P < 0.01),
with females scoring significantly higher than males. Given that there were dif-
ferences by gender on more than one-third of the items, all factor analyses were
conducted by gender.

Internal Consistency

Chronbach’s alpha was used to calculate the internal consistency of the total scale
and the original subscales of the SPS for this population. An alpha coefficient of 0.91
was obtained for the total scale. Alphas from the original SPS scales were: suicide
ideation 0.82, hopelessness 0.86, negative self-evaluation 0.66, and hostility 0.68.

Factor Analyses by Gender

In order to further assess the validity of the original scales, confirmatory factor
analyses (CFAs), i.e., factor analyses performed to confirm the hypothesized sub-
scales of the SPS, were individually conducted on the four main subscales of the SPS
in order to determine their structural integrity within a psychiatric sample. Chi
square tests as well as other fit indices (e.g., GFI, Tucker-Lewis Index, RMSEA)
were used. These tests are used to determine if the model derived from the factor
analysis is correct. The chi square tests should be non-significant for the model to be
confirmed.
Exploratory factor analyses were conducted on each gender separately because of
the differences found in the preliminary analyses. Results can be seen in Table 3.

Factor Analyses: females only

Confirmatory factor analysis was used to determine whether the four originally
proposed scales of the SPS would hold up statistically in this psychiatric sample.
Results indicated poor model fit for three of the four scales (e.g., suicide scale
(X2 = 77.65, df = 20, P = 0.00), hostility scale (X2 = 115.67, df = 14, P = 0.00), and
hopelessness scale (X2 = 91.97, df = 54, P = 0.01). The negative-self evaluation scale
held up relatively well statistically (X2 = 38.44, df = 27, P = 0.07; GFI = 0.96;
TLI = 0.93; RMSEA = 0.05). The original 6-scale model of the SPS did not hold up
well statistically either.
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Table 2 Means and standard deviations of individual suicide probability scale items for girls and
boys

Item Girls n = 146 Boys n = 80

Mean SD Mean SD

When I get mad, I throw things. 2.20 1.13 2.01 1.09

I feel many people care for me deeply.** 2.25 1.31 1.70 1.04
I feel I tend to be impulsive. 1.50 0.75 1.56 0.77
I think of things too bad to share with others. 1.82 1.22 1.86 1.21
I think I have too much responsibility. 1.47 0.97 1.26 0.71
I feel there is much I can do which is worthwhile. 2.38 0.93 2.08 1.00
In order to punish others, I think of suicide.** 2.19 1.66 1.51 1.16
I feel hostile towards others. 1.87 1.10 1.70 0.93
I feel isolated from people. 2.27 1.45 2.13 1.45
I feel people appreciate the real me. 1.98 1.02 1.99 0.92
I feel many people will be sorry if I die. 1.84 0.37 1.85 0.36
I feel so lonely I cannot stand it.** 1.91 1.48 1.32 1.50
Others feel hostile towards me. 1.84 1.18 1.89 1.14
I feel, if I could start over, I would make many changes in my life. 2.62 1.53 2.27 1.57
I feel I am not able to do many things well.** 2.38 1.06 1.86 0.96
I have trouble finding and keeping a job I like. 2.08 1.52 2.15 1.34
I think that no one will miss me when I am gone.** 2.11 1.18 1.64 0.95
Things seem to go well for me. 2.80 1.44 2.44 1.51
I feel people expect too much of me. 1.69 1.07 1.62 1.05
I feel I need to punish myself for things I have done and thought. 2.01 1.20 1.74 1.11
I feel the world is not worth continuing to live in.** 2.76 1.55 2.10 1.40
I plan for the future very carefully. 2.12 0.68 2.08 0.62
I feel I don’t have many friends I can count on. 2.04 1.17 1.78 0.96
I feel people would be better off if I were dead.** 2.93 1.80 2.05 1.59
I feel it would be less painful to die.** 2.87 1.58 2.06 1.50
I feel/felt close to my mother. 1.80 0.88 1.66 0.84
I feel/felt close to my mate. 1.80 0.89 1.85 0.94
I feel hopeless that things will get better.** 1.93 1.42 1.34 1.4
I feel people do not approve of me or what I do.** 2.42 1.09 2.03 0.98
I have thought of how to do myself in.** 2.61 1.53 1.98 1.38
I worry about money. 1.38 0.66 1.51 0.77
I think of suicide.** 2.86 1.74 2.25 1.47
I feel tired and listless. 2.17 1.65 1.73 1.32
When I get mad, I break things. 1.87 1.29 2.11 1.44
I feel/felt close to my father. 1.71 0.456 1.62 0.49
I feel I can’t be happy no matter where I am.** 2.26 1.70 1.34 1.68

** Gender difference significant at P < 0.01 level

Given that the proposed 4-scale and 6-scale models did not adequately capture
the data for this sample, exploratory factor analyses (EFAs), i.e. factor analyses
without a prior hypothesis about the factor structure, were conducted in order to
determine whether more structurally sound scales could be developed. It was
hypothesized that the lack of structural integrity of the scales might be due to items
that were either no longer relevant for this group, or rather, items that were char-
acteristic of the group as a whole. Therefore, a number of EFAs were conducted in
order to (a) eliminate items that loaded on several factors and (2) construct revised
scales that were similar to the original scales but with, perhaps, some minor differ-
ences that better fit an adolescent psychiatric sample.

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 Table 3 Revised suicide probability scale factor analyses broken down by sex

Revised scale items for girls Weight Revised scale items for boys Weight

Revised suicide scale Revised suicide scale

I think of suicide. 0.97 I think of suicide. 0.85
I have thought of how to do myself in. 0.84 I have thought of how to do myself in. 0.78
I feel it would be less painful to die 0.83 I feel it would be less painful to die than 0.74
than to keep living the way things are. to keep living the way things are.
I feel the world is not worth continuing to live in. 0.80 I feel the world is not worth continuing 0.74
to live in.
I feel people would be better off if I were dead. 0.63 Suicide/punishment scale
In order to punish others, I think of suicide. 0.50 In order to punish others, I think 0.71
of suicide.
I feel I need to punish myself for things 0.50 I feel I need to punish myself for 0.72
I have done and thought. things I have done and thought.
Child Psychiatry Hum Dev (2007) 38:17–29

Others feel hostile towards me.c 0.80

Revised negative self-evaluation scale Revised negative self-evaluation scale
I feel/felt close to my father. 0.67 I feel there is much I can do which is worthwhile. 0.72
I feel people appreciate the real me. 0.63 I feel people appreciate the real me. 0.57
I feel/felt close to my mother. 0.62 Things seem to go well for me. 0.65
I feel many people care for me deeply. 0.55 I feel many people care for me deeply. 0.71
Closeness scale
I feel/felt close to my father. 0.89
I feel/felt close to my mother. 0.64
Angry impulsivity scale Angry impulsivity scale
When I get mad, I break things. 0.88 When I get mad, I break things. 0.82
When I get mad, I throw things. 0.84 When I get mad, I throw things. 0.83
Revised hopelessness scale
Revised hostility scale I feel people do not approve of me or what I do. –0.90
I feel I don’t have many friends I can count on.a –0.75 I feel hopeless that things will get better. –0.74
Others feel hostile towards me. –0.74 I feel I can’t be happy no matter where I am. –0.56
I feel isolated from people. –0.69
I have trouble finding and keeping a job I like. –0.51
I think of things too bad to share with others.b –0.48

Note: a indicates that item was originally part of hopelessness scale; b indicates that item was originally part of suicide scale; c indicates that item was originally part
of hostility scale.

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An initial principal components analysis using an Oblimin Rotation with Kaiser

Normalization was performed on the sample of girls. This analysis is designed to
explain the maximum amount of variance in variables that are correlated. (All
remaining EFAs used this extraction and rotation method; varimax rotations, which
assume uncorrelated data, yielded the same results). The pattern matrix failed to
converge in 25 iterations. Initial inspection of the component matrix indicated
groupings of items that were relatively similar to the original 4 scales of the SPS.
Therefore, EFAs were conducted on each of the original scales individually. In order
to restrict potential factors to a reasonable number, by convention, an eigenvalue
greater than one is required to extract a factor.
An EFA on the items originally comprising the suicide scale extracted one
component with an eigenvalue greater than 1, accounting for 55.31% of the variance.
Three factors with eigenvalues greater than 1 were extracted by an EFA on the items
in the hopelessness scale. Items with high cross loadings were eliminated, leaving two
components with eignevalues greater than 1 (accounting for 56.65% of the variance).
An EFA on the original items in the negative self-evaluation scale resulted in a three-
factor solution. Items with high cross loadings were eliminated and a follow-up EFA
was conducted on the five remaining items. This analysis resulted in a two-factor
solution made up on a 3-item and a 2-item solution. However, the items in the latter
factor highly loaded on both components. Therefore, these items were eliminated,
leaving a 3-item negative self-evaluation component. Two factors with eigenvalues
greater than 1 were extracted for the hostility factor (accounting for 58.79% of the
variance).
Once this smaller set of items was identified, those items remaining were then
subjected to a combined EFA. Four items with high cross-loadings were eliminated.
Follow-up analyses resulted in the final 4-factor structure: a 7-item (revised) suicide
scale, a 4-item (revised) negative-self evaluation scale, a 2-item angry-impulsivity
scale, and a 5-item (revised) hostility scale. Notably, this last scale included one
original suicide item (‘‘I think of things too bad to share with others’’). Final items
can be seen in Table 3.

Factor Analyses: males only

The same confirmatory and exploratory factor analysis procedures were used to
analyze the scales for the boys in the sample. Again, confirmatory factor analysis
suggested inadequate fit for the original 4-factor and 6-factor solutions. Exploratory
factor analysis (using the same method as described above) was used to determine
structurally sound scales. As was seen with the girls, an EFA on all items failed to
converge. Therefore, individual EFAs were conducted on items in each of the ori-
ginal scales.
An EFA on the suicide factor resulted in two factors with eigenvalues greater
than 1 (accounting for 70.49% of the variance). Four factors with eigenvalues greater
than 1 were extracted for the hopelessness factor; however, three of the four com-
ponents had several items with multiple cross-loadings. Therefore, only the items
extracted as part of the first component were as used in subsequent analyses. Four
factors with eigenvalues greater than 1 were extracted for the negative self-evaluation
factor. Three items with high cross loadings were eliminated, resulting in a more
parsimonious two-factor structure (accounting for 58.99% of the variance). Three
factors with eigenvalues greater than 1 were extracted for the hostility factor. One
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item that loaded relatively equally on two of three components was eliminated,
resulting in a more parsimonious three-factor structure (accounting for 74.86% of
the variance).
Once this smaller sample of items was identified, these remaining items were
subjected to a combined EFA. Eight factors with eigenvalues greater than 1 were
extracted, accounting for 73.52%. Six items had multiple cross-loadings and con-
tributed relatively little to their main components; therefore, these items were
eliminated. A final follow-up EFA resulted in a 6-factor structure: a 4-item (revised)
suicide scale, a 3-item suicidal/punishing scale (which included one hostility item), a
3-item (revised) hopelessness scale, a 2-item angry-impulsivity scale, a 4-item, (re-
vised) negative self-evaluation scale, and a 2-item closeness scale (2 items originally
part of negative self-evaluation). See Table 3 for individual items.

Scale Summary and Internal Consistency

The analyses indicate that while many final scale items overlap between the boys and
girls, there are some items that are more specific to boys versus girls and vice versa.
Moreover, items that may cohere as one scale for girls may actually be indicative of
two different factors for boys (such as can be seen with the suicide scale). Chron-
bach’s alpha scores for the revised factors were as follows: Suicide 0.84 for males,
0.88 for females; Negative Self-Evaluation 0.65 males, 0.63 female; and Angry
Impulsivity 0.77 male, 0.76 female. Scales that were only identified for one gender
had the following Chronbach’s alphas: Hostility, 0.65 female; Suicidal Punishing, 0.60
male; Hopelessness, 0.73 male; and Closeness, 0.76 male.

Validity Data

To assess the validity of the SPS within an inpatient setting, the subscale scores from
a smaller subset of patients who had all available measures, were compared through
a series of correlations to other measures assessing related constructs. Specifically,
the original and revised hopelessness subscale was compared to the Hopelessness
Scale for Children (HSC) and the Reynold’s Adolescent Depression Scale (RADS)
at admission, the original and revised Negative Self-Evaluation subscales were
compared to the RADS item ‘‘ I am no good’’, the original and revised Suicide scale
were compared to the RADS item ‘‘I have thoughts of hurting myself’’, and the
original and revised Hostility subscale was compared to the t-scores of the State and
Trait anger subscales of both the State-Trait Anger Expression Inventory (STAXI)
and the t-score for anger from the Trauma Symptom Checklist for Children (TSCC).
The results for all comparisons indicated similar or higher correlations for the
revised scales as compared to the original scales (see Table 4).
Correlations were also used to assess how the primary outcome variables related
to SPS scores, particularly, length of stay, participation in group treatment, stan-
dardized change in SPS t-score from admission to discharge, standardized change
in RADS t-scores from admission to discharge, and number of readmissions (see
Table 5). Over the course of hospitalization, patients showed symptom improve-
ment on several clinical measures. For example, SPS t-scores decreased an average
of 6.9 points (SD = 10.6) and RADS t-scores decreased an average of 23.4
(SD = 30.3) points. Examination of the data also indicates that 29% of the sample
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Table 4 Correlations between Original and Revised SPS Scales and Measures of Depression,
Hopelessness, and Anger

Hopeless- Negative Suicide Hostilityb

nessª self-eval (n = 139) (n = 108)
(n = 57) (n = 139)
Orig Revd Orig Revd Orig Revd Orig Revd

1. RADS total t-score at admission 0.30 0.33

2. Hopelessness scale for children total t-score 0.45 0.50
3. RADS item ‘‘I am no good’’ at admission 0.44 0.48
4. RADS item ‘‘I hurt myself’’ at admission 0.72 0.74
5. STAXI state anger t-score 0.35 0.32
6. STAXI trait anger t-score 0.38 0.45
7. TSCC anger scale t-score 0.31 0.51

RADS = Reynolds Adolescent Depression Scale; STAXI = State-Trait Anger Expression Inven-
tory; TSCC = Trauma Symptom Checklist for Children
b
ª Only males; Only females
All Correlations significant at the 0.01 level (2-tailed)

was readmitted after discharge and that the average number of readmissions was
1.5 (SD = 0.9). The average time between discharge and re-hospitalization for the
29% of the sample readmitted was 183 days (SD = 230.5). The number of read-
missions was negatively correlated with SPS change. There were also significant
positive correlations between the SPS change and RADS change, and between
frequency of group therapy participation and SPS change and RADS change.
Additionally, stepwise regressions were conducted on the number of psychiatric
readmissions, and RADS change to determine the relative contribution of the SPS to
these primary outcome variables. The variables entered into the equation for the
RADS change regression included: age, initial level of SPS, length of stay, and
frequency of group participation. Only initial SPS score was related to RADS
change (0.19, P < 0.01).
For psychiatric readmissions, the variables entered were age, RADS change, SPS
change, length of stay, frequency of group participation, and length of time to first
readmission. Two variables produced a small combined R2 change (0.27, P < 0.01):
age and SPS change.

Table 5 Correlations among outcome variables (n = 146)

1 2 3 4 5

1. Standardized change in RADS from admission to discharge

2. Standardized change in SPS from admission to discharge 0.63**
3. Length of stay 0.10 0.10
4. Days between discharge and first readmission 0.05 0.01 –0.13
5.Total number of readmissions –0.20* –0.21* 0.12 0.12
6. Number of group therapy sessions 0.22* 0.29* 09 –0.15 –0.14

RADS = Reynolds Adolescent Depression Scale; SPS = Suicide Probability Scale

** Correlation is significant at the 0.01 level (2-tailed)
* Correlation is significant at the 0.05 level (2-tailed)

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Discussion

This study provides support both for the use of the current SPS scale with an ado-
lescent inpatient population and for some revisions to the current SPS scale. The
original factor analytic structure of the SPS did not demonstrate a good fit, with only
the general suicide factor holding up well across this and other studies. The Negative
Self-Evaluation factor also shows some viability across factor analyses; however, it
shows only fair internal consistency, less than most other scales. In contrast, the SPS
Hopelessness subscale did not hold up in this sample as well as it did in the original
study sample. One explanation for this may be that hopelessness is a universal
characteristic of adolescents entering an inpatient stay, and therefore, there would
be no meaningful variability in the factor. This would essentially eliminate this
factor, which could, in turn, statistically change the factor structure for the remaining
items. Moreover, while the reliability estimates for the current scales are generally
good to excellent, they are not particularly better than those found for the revised
subscales.
Our analyses indicate that while 13 items on the SPS overlap between the boys and
girls, there are some items that are differentially responded to by boys versus girls.
Items that may cohere as one scale for girls may actually be indicative of two different
factors for boys (such as can be seen with the suicide scale). In general, the factor
analysis for the girls is similar to that for the sample combined, with the exception of 2
items (‘‘things go well for me’’ and ‘‘I tend to be impulsive,’’) that drop out. The items:
‘‘people would be better off if I were dead’’, ‘‘I think of things too bad to share with
others’’, and ‘‘I feel I don’t have many friends I can count on’’ emerge as contributing
to the suicide scale rather than the other scales. This difference, perhaps, reflects a
shift in emphasis from personal attributes to concerns regarding relationships.
For boys, the differences appear to be more substantial. Interestingly, the Hos-
tility subscale drops out while the hopelessness scale emerges. It may be that hostility
is also very common among psychiatrically hospitalized boys and therefore, it no
longer is a discriminating factor for them. In contrast, level of hopelessness may be
more variable in boys and therefore may be a more critical factor in differentiating
boys with and without suicidal ideation.
Age was also found to be related to length of stay and readmission but not SPS
scores. Younger patients had shorter lengths of stay and faster readmissions than
older patients. Girls were found to have higher scores on the SPS, as is consistent
with the literature, and had more readmissions than boys. Thus, age and gender
differences were found with regard to inpatient hospitalization factors. With regard
to the SPS, gender differences discussed above need to be considered but clinicians
can use the SPS equally well with both younger and older adolescents.
Results such as these lend support to the use of the SPS for use in an adolescent
inpatient setting, but with revisions. Additionally, the superior correlations for the
revised scales with indicators of validity may also argue for revisions of the original
scales. As noted, the revised scales consistently showed higher correlations with
external measures than did the original scales, albeit showing slightly poorer internal
consistency. Thus, while they may need some utility, it is possible that they still
require some alteration. It would be interesting to see how well the different versions
of the scales predict more meaningful aspects of suicidal behavior, such as continuing
ideation or repeated attempts.

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Moreover, this study also provides limited but important evidence that psychiatric
intervention does reduce the level of suicidal beliefs and depressive symptoms.
Similarly, there was also a reduction in the number of readmissions due to suicidal
behavior for adolescents who had demonstrated improvement as assessed by the
SPS, suggesting that the treatment effects may be stable over time. Thus, targeting
suicidal behavior during the course of a hospital stay may be an effective way to
reduce reoccurrence. Also, pre/post assessment with a standardized measure such as
the SPS may provide a way to measure effectiveness of treatment in reducing su-
icidality over the course of an inpatient stay. However, given that there was such a
strong correlation between change on the SPS and on the RADS, it is unclear as to
whether the lower readmissions were a result of decreased suicidality, decreased
depression, or both.
A relationship was also found between frequency of group participation and SPS
change; however, this relationship needs to be qualified in two ways. First, group
participation was not random, but rather participants were often selected for group
participation based on probability of this intervention being successful (e.g., ado-
lescents showing motivation for treatment). Therefore, the statistical relationship
may reflect other qualities of the individuals that led to change in suicidal behavior
rather than effectiveness of the intervention. Secondly, the group participation effect
was not statistically significant in the regression for re-admissions, suggesting that the
variance may have been better accounted for by the change in suicidal symptoms
whether or not it was related to group participation.
This study provides informative data on the use of a structured measure in
understanding the presentation and change in suicidal symptoms across the course of
treatment, yet there were some limitations that should be considered. There were a
substantial number of excluded participants in this study and while there were no
differences on demographic variables there may well have been meaningful differ-
ences in symptom presentation or severity. Thus, a more complete sample may serve
to better elucidate scale interpretation. Moreover, the population studied here may
be sufficiently different enough to warrant different scale results than found in the
original study. While this may be a limitation for generalizability, it is also important
because the scale has applicability to psychiatric inpatient samples. Finally, the
limited availability of validity data reduces the ability to understand true differences
among the original and revised scales. Nonetheless, given the results showing poor
support for the original factor analytic structure, the question of need for revision of
this measure for adolescent inpatients remains.

Summary

Psychometric properties of the SPS were examined in a sample of 266 adolescent

psychiatric patients. Factor analyses provide some support for the SPS subscales,
both in their original form and with revisions. Exploratory factor analyses were
particularly helpful in revealing some potentially meaningful gender differences in
scale structure. Internal consistency of the original scale factors was somewhat better
than the factors derived from this sample. Moreover, preliminary evidence was
found to suggest the beneficial role of inpatient treatment in reducing future suicidal
behavior. These results collectively argue for both further use and further investi-
gation of the utility of the SPS in inpatient settings.
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Child Psychiatry Hum Dev (2007) 38:17–29 29

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