Back to top Open menu arrow
Download Reprints
Sections
METHODS RESULTS DISCUSSION Clinical Points
The Journal of Clinical Psychiatry The Journal of Clinical Psychiatry

The Journal of
Clinical Psychiatry
Access icon

Meta-Analysis Focus on Suicide November 16, 2022

Tools to Detect Risk of Death by Suicide: A Systematic Review and Meta-Analysis

Natalie B. Riblet, MD, MPH; Sarah Matsunaga, BA; Younji Lee, BA; Yinong Young-Xu, ScD; Brian Shiner, MD, MPH; Paula P. Schnurr, PhD; Maxwell Levis, PhD; Bradley V. Watts, MD, MPH

J Clin Psychiatry 2023;84(1):21r14385

ABSTRACT

Objective: There is limited knowledge about the ability of instruments to detect risk of suicide in a range of settings. Prior reviews have not considered whether the utility of instruments depends on prior probability of risk. We performed a systematic review to determine the diagnostic accuracy of instruments to detect risk of suicide in adults using likelihood ratio analysis. This method aids evaluation of prior probabilities of risk.

Data Sources: We searched MEDLINE, Cochrane Database of Systematic Reviews, PsycINFO, EMBASE, and Scopus from inception through January 19, 2021.

Study Selection: We included clinical trials, observational studies, and quasi-experimental studies assessing the diagnostic accuracy of instruments to detect risk of suicide in adults. There were no language restrictions.

Data Extraction: Three reviewers in duplicate assessed full texts to determine eligibility and extracted data from included studies. Positive (LR+) and negative likelihood ratio (LR–) and 95% CIs were calculated for each instrument.

Results: Thirty studies met inclusion criteria. Most instruments showed minimal utility to detect or rule out risk of suicide, with LR+ ≤ 2.0 and LR– ≥ 0.5. A few instruments had a high utility for improving risk detection in emergency department, inpatient mental health, and prison settings when patients scored above the cutoff (LR+ > 10). For example, among patients discharged from an emergency department, the Columbia Suicide Severity Rating Scale–Clinical Practice Screener had a LR+ of 10.3 (95% CI, 6.3–16.8) at 3-month follow-up. The clinical utility of the instruments depends on the pretest probability of suicide in the setting. Because studies spanned over 6 decades, the findings are at risk for secular trends.

Discussion: We identified several instruments that may hold promise for detecting risk of suicide in emergency department, inpatient mental health, or prison settings. The utility of the instrument hinges, in part, on baseline suicide risk.

Registration: PROSPERO: CRD42021285528

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

  1. Brown G. A review of suicide assessment measures for intervention research with adults and older adults. SPRC website. https://www.sprc.org/resources-programs/review-suicide-assessment-measures-intervention-research-adults-older-adults. Accessed December 9, 2021.
  2. The Joint Commission. National Patient Safety Goal for suicide prevention. R3 Report. The Joint Commissiion website. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_18_suicide_prevention_hap_bhc_cah_11_4_19_final1.pdf. Accessed December 9, 2021
  3. Large M, Kaneson M, Myles N, et al. Meta-analysis of longitudinal cohort studies of suicide risk assessment among psychiatric patients: heterogeneity in results and lack of improvement over time. PLoS One. 2016;11(6):e0156322. PubMed CrossRef
  4. Runeson B, Odeberg J, Pettersson A, et al. Instruments for the assessment of suicide risk: a systematic review evaluating the certainty of the evidence. PLoS One. 2017;12(7):e0180292. PubMed CrossRef
  5. Saab MM, Murphy M, Meehan E, et al. Suicide and self-harm risk assessment: a systematic review of prospective research. Arch Suicide Res. 2021:1–21. PubMed CrossRef
  6. Chan MK, Bhatti H, Meader N, et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry. 2016;209(4):277–283. PubMed CrossRef
  7. Carter G, Milner A, McGill K, et al. Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales. Br J Psychiatry. 2017;210(6):387–395. PubMed CrossRef
  8. O’Connor E, Gaynes BN, Burda BU, et al. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the US Preventive Services Task Force. Ann Intern Med. 2013;158(10):741–754. PubMed CrossRef
  9. Johnson KM. Using Bayes’ rule in diagnostic testing: a graphical explanation. Diagnosis (Berl). 2017;4(3):159–167. PubMed CrossRef
  10. Johnson KM. Erratum to: Using Bayes’ rule in diagnostic testing: a graphical explanation. Diagnosis (Berl). 2018;5(2):89. PubMed CrossRef
  11. Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. BMJ. 2004;329(7458):168–169. PubMed CrossRef
  12. Aitken C, Mavridis D. Reasoning under uncertainty. Evid Based Ment Health. 2019;22(1):44–48. PubMed CrossRef
  13. Cai W, Zhu D, Byanju S, et al. Magnetic resonance spectroscopy imaging in diagnosis of suspicious prostate cancer: a meta-analysis. Medicine (Baltimore). 2019;98(14):e14891. PubMed CrossRef
  14. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347(dec11 1):f7095. PubMed CrossRef
  15. Glenn CR, Nock MK. Improving the short-term prediction of suicidal behavior. Am J Prev Med. 2014;47(3 suppl 2):S176–S180. PubMed CrossRef
  16. Whiting PF, Rutjes AW, Westwood ME, et al; QUADAS-2 Group. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med. 2011;155(8):529–536. PubMed CrossRef
  17. McInnes MDF, Moher D, Thombs BD, et al. The PRISMA-DTA Group. Preferred reporting items for a systematic review and meta-analysis of diagnostic test accuracy studies: the PRISMA-DTA Statement. JAMA. 2018;319(4):388–396. PubMed CrossRef
  18. Macaskill P, Gatsonis C, Deeks J, et al. Analysing and presenting results. In: Deeks JJ, Bossuyt PM, Gatsonis C, eds. Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy Version 1.0, Chapter 10. The Cochrane Collaboration. https://methods.cochrane.org/sdt/handbook-dta-reviews. 2010. Accessed December 9, 2021.
  19. van de Loo KJ, Diekstra RW. The construction of a questionnaire for the prediction of subsequent suicidal attempts: a preliminary study. Ned Tijdschr Psychol. 1970;25(2):95–100. PubMed
  20. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan—a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210. PubMed CrossRef
  21. Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: sample size estimation for diagnostic test studies. J Clin Epidemiol. 1991;44(8):763–770. PubMed CrossRef
  22. Stengel D, Bauwens K, Sehouli J, et al. A likelihood ratio approach to meta-analysis of diagnostic studies. J Med Screen. 2003;10(1):47–51. PubMed CrossRef
  23. Dwamena B, Sylvester R, Carlos RC. MIDAS: meta-analysis of diagnostic accuracy studies. BC.EDU website. http://fmwww.bc.edu/repec/bocode/m/midas.pdf. Accessed October 21, 2021.
  24. Reitsma JB, Glas AS, Rutjes AWS, et al. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol. 2005;58(10):982–990. PubMed CrossRef
  25. Jaeschke R, Guyatt GH, Sackett DL. Users’ Guides to the Medical Literature, III: how to use an article about diagnostic test B: what are the results and will they help me in caring for my patients? JAMA. 1994;271(9):703–707. PubMed CrossRef
  26. Lindh ÅU, Dahlin M, Beckman K, et al. A comparison of suicide risk scales in predicting repeat suicide attempt and suicide: a clinical cohort study. J Clin Psychiatry. 2019;80(6):18m12707. PubMed CrossRef
  27. Randall JR, Sareen J, Chateau D, et al. Predicting future suicide: clinician opinion versus a standardized assessment tool. Suicide Life Threat Behav. 2019;49(4):941–951. PubMed CrossRef
  28. Steeg S, Kapur N, Webb R, et al. The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychol Med. 2012;42(11):2383–2394. PubMed CrossRef
  29. Buglass D, Horton J. A scale for predicting subsequent suicidal behaviour. Br J Psychiatry. 1974;124(0):573–578. PubMed CrossRef
  30. Frottier P, König F, Matschnig T, et al. VISCI-Viennese Instrument for suicidality in correctional institutions. (Das Wiener Instrument für Suizidgefahr in Haft). Psychiatr Prax. 2008;35(1):21–27. PubMed CrossRef
  31. Frottier P, Koenig F, Seyringer M, et al. The distillation of “VISCI”: towards a better identification of suicidal inmates. Suicide Life Threat Behav. 2009;39(4):376–385. PubMed CrossRef
  32. Kuerz A, Moeller HJ, Torhorst A, et al. Validation of Six Risk Scales for Suicide Attempters. Current Issues of Suicidology; 1988:174–178.
  33. Pallis DJ, Gibbons JS, Pierce DW. Estimating suicide risk among attempted suicide, II: efficiency of predictive scales after the attempt. Br J Psychiatry. 1984;144(2):139–148. PubMed CrossRef
  34. Buglass D, McCulloch JW. Further suicidal behaviour: the development and validation of predictive scales. Br J Psychiatry. 1970;116(534):483–491. PubMed CrossRef
  35. Katz C, Randall JR, Sareen J, et al. Predicting suicide with the SAD PERSONS scale. Depress Anxiety. 2017;34(9):809–816. PubMed CrossRef
  36. Motto JA. Preliminary field-testing of a risk estimator for suicide. Suicide Life Threat Behav. 1985;15(3):139–150. PubMed CrossRef
  37. Motto JA, Heilbron DC. Development and Validation of Scales for Estimation of Suicidal Risk. Suicidology; 1976:166–199.
  38. Motto JA, Heilbron DC, Juster RP. Development of a clinical instrument to estimate suicide risk. Am J Psychiatry. 1985;142(6):680–686. PubMed CrossRef
  39. Simpson S, Goans C, Loh R, et al. Suicidal ideation is insensitive to suicide risk after ED discharge: performance characteristics of the Columbia-Suicide Severity Rating Scale Screener. Acad Emerg Med. 2021;28(6):621–629. PubMed CrossRef
  40. Braucht GN, Wilson LT. Predictive utility of the revised suicide potential scale. J Consult Clin Psychol. 1970;35(3):426. PubMed CrossRef
  41. Dean RA, De Cook R, Maley RF, et al. Prediction of suicide in a psychiatric hospital. J Clin Psychol. 1967;23(3):296–301. PubMed CrossRef
  42. Wang AG, Nielsen B, Bille-Brahe U, et al. Attempted suicide in Denmark, III: assessment of repeated suicidal behaviour. Acta Psychiatr Scand. 1985;72(4):389–394. PubMed CrossRef
  43. GRADEpro GDT: GRADEpro Guideline Development Tool [Software]. McMaster University and Evidence Prime. Gradepro website. https://www.gradepro.org. Accessed December 14, 2021.
  44. Schünemann H, Brożek J, Guyatt G, et al, eds. GRADE Handbook for Grading Quality of Evidence and Strength of Recommendations. Updated October 2013. The GRADE Working Group. guidelinedevelopment.org/handbook. 2013. Accessed December 14, 2021.
  45. Beck AT, Brown GK, Steer RA, et al. Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav. 1999;29(1):1–9. PubMed
  46. Brown GK, Beck AT, Steer RA, et al. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68(3):371–377. PubMed CrossRef
  47. Joiner TE Jr, Steer RA, Brown G, et al. Worst-point suicidal plans: a dimension of suicidality predictive of past suicide attempts and eventual death by suicide. Behav Res Ther. 2003;41(12):1469–1480. PubMed CrossRef
  48. Ducher JL, Terra JL. Is the suicidal risk assessment scale RSD of predictive value? (L’échelle d’évaluation du risque suicidaire RSD possède-t-elle une valeur predictive?) LEncphale. 2006;32(5Pt1):738–745. CrossRef
  49. Clark DC, Young MA, Scheftner WA, et al. A field test of Motto’s risk estimator for suicide. Am J Psychiatry. 1987;144(7):923–926. PubMed CrossRef
  50. Cooper J, Kapur N, Dunning J, et al. A clinical tool for assessing risk after self-harm. Ann Emerg Med. 2006;48(4):459–466. PubMed CrossRef
  51. Harriss L, Hawton K. Suicidal intent in deliberate self-harm and the risk of suicide: the predictive power of the Suicide Intent Scale. J Affect Disord. 2005;86(2–3):225–233. PubMed CrossRef
  52. Harriss L, Hawton K, Zahl D. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Br J Psychiatry. 2005;186(1):60–66. PubMed CrossRef
  53. Lindh AU, Waern M, Beckman K, et al. Short term risk of non-fatal and fatal suicidal behaviours: the predictive validity of the Columbia-Suicide Severity Rating Scale in a Swedish adult psychiatric population with a recent episode of self-harm. BMC Psychiatry. 2018;18(1):319. PubMed CrossRef
  54. Lindh ÅU, Beckman K, Carlborg A, et al. Predicting suicide: a comparison between clinical suicide risk assessment and the Suicide Intent Scale. J Affect Disord. 2020;263:445–449. PubMed CrossRef
  55. Lopez-Morinigo JD, Fernandes AC, Shetty H, et al. Can risk assessment predict suicide in secondary mental healthcare? findings from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Case Register. Soc Psychiatry Psychiatr Epidemiol. 2018;53(11):1161–1171. PubMed CrossRef
  56. Naud H, Daigle MS. Predictive validity of the suicide probability scale in a male inmate population. J Psychopathol Behav Assess. 2010;32(3):333–342. CrossRef
  57. Niméus A, Alsén M, Träskman-Bendz L. The suicide assessment scale: an instrument assessing suicide risk of suicide attempters. Eur Psychiatry. 2000;15(7):416–423. PubMed CrossRef
  58. Skogman K, Alsén M, Ojehagen A. Sex differences in risk factors for suicide after attempted suicide-a follow-up study of 1,052 suicide attempters. Soc Psychiatry Psychiatr Epidemiol. 2004;39(2):113–120. PubMed CrossRef
  59. Niméus A, Alsén M, Träskman-Bendz L. High suicidal intent scores indicate future suicide. Arch Suicide Res. 2002;6(3):211–219. CrossRef
  60. Probert-Lindström S, Berge J, Westrin Å, et al. Long-term risk factors for suicide in suicide attempters examined at a medical emergency in patient unit: results from a 32-year follow-up study. BMJ Open. 2020;10(10):e038794. PubMed CrossRef
  61. Samuelsson M, Jokinen J, Nordström AL, et al. CSF 5-HIAA, suicide intent and hopelessness in the prediction of early suicide in male high-risk suicide attempters. Acta Psychiatr Scand. 2006;113(1):44–47. PubMed CrossRef
  62. Steeg S, Quinlivan L, Nowland R, et al. Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data. BMC Psychiatry. 2018;18(1):113. PubMed CrossRef
  63. Stefansson J, Nordström P, Jokinen J. Suicide Intent Scale in the prediction of suicide. J Affect Disord. 2012;136(1–2):167–171. PubMed CrossRef
  64. Stefansson J, Nordstrom P, Jokinen J. Suicide intent scale in the prediction of suicide. Eur Psychiatry. 2011;26(S2):1649. CrossRef
  65. Stefansson J, Nordström P, Runeson B, et al. Combining the Suicide Intent Scale and the Karolinska Interpersonal Violence Scale in suicide risk assessments. BMC Psychiatry. 2015;15(1):226. PubMed CrossRef
  66. Dahle K-P, Lohner JC, Konrad N. Suicide prevention in penal institutions: validation and optimization of a screening tool for early identification of high-risk inmates in pretrial detention. Int J Forensic Ment. 2005;4(1):53–62. CrossRef
  67. Farberow NL, MacKinnon D. A suicide prediction schedule for neuropsychiatric hospital patients. J Nerv Ment Dis. 1974;158(6):408–419. PubMed CrossRef
  68. Geulayov G, Casey D, Bale L, et al. Suicide following presentation to hospital for non-fatal self-harm in the multicentre study of self-harm: a long-term follow-up study. Lancet Psychiatry. 2019;6(12):1021–1030. PubMed CrossRef
  69. Brådvik L. Suicide risk and mental disorders. Int J Environ Res Public Health. 2018;15(9):2028. PubMed CrossRef
  70. Kajeepeta S, Mauro PM, Keyes KM, et al. Association between county jail incarceration and cause-specific county mortality in the USA, 1987–2017: a retrospective, longitudinal study. Lancet Public Health. 2021;6(4):e240–e248. PubMed CrossRef
  71. Bukten A, Stavseth MR. Suicide in prison and after release: a 17-year national cohort study. Eur J Epidemiol. 2021;36(10):1075–1083. PubMed CrossRef
  72. Zhong S, Senior M, Yu R, et al. Risk factors for suicide in prisons: a systematic review and meta-analysis. Lancet Public Health. 2021;6(3):e164–e174. PubMed CrossRef
  73. Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(7):694–702. PubMed CrossRef
  74. Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999–2018. NCHS Data Brief. 2020;362:1–8. PubMed
  75. Naghavi M; Global Burden of Disease Self-Harm Collaborators. Global, regional, and national burden of suicide mortality 1990 to 2016: systematic analysis for the Global Burden of Disease Study 2016. BMJ. 2019;364:l94. PubMed CrossRef
  76. McKeown RE, Cuffe SP, Schulz RM. US suicide rates by age group, 1970-2002: an examination of recent trends. Am J Public Health. 2006;96(10):1744–1751. PubMed CrossRef
  77. Mann JJ, Michel CA, Auerbach RP. Improving suicide prevention through evidence-based strategies: a systematic review. Am J Psychiatry. 2021;178(7):611–624. PubMed CrossRef
  78. Riblet NBV, Shiner B, Young-Xu Y, et al. Strategies to prevent death by suicide: meta-analysis of randomised controlled trials. Br J Psychiatry. 2017;210(6):396–402. PubMed CrossRef
  79. Haroz EE, Kitchen C, Nestadt PS, et al. Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: a preliminary analysis. Suicide Life Threat Behav. 2021;51(6):1189–1202. PubMed CrossRef
  80. Snowdon J, Choi NG. Undercounting of suicides: where suicide data lie hidden. Glob Public Health. 2020;15(12):1894–1901. PubMed CrossRef
Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

Save Save

Share Share

Cite Cite

Vol 85 • 2024 • Number 3

Read the Current Issue

Editorial

Focus on Women’s Mental Health: Twenty Years and Counting

Original Research

Esmethadone in Patients With Major Depressive Disorder and Inadequate Response to Standard Antidepressants

Commentary

Can Our Collective Experiences As Clinicians Improve Mental Health Care?

Original Research

Prescription Opioid Use Disorder in US Adults Reporting Prescription Opioid Use

Original Research

Symptomatic Disorders Comorbid with Borderline Personality Disorder Over Time

Original Research

Aripiprazole Lauroxil Initiation Regimens
View current Issue

Celebrating
85 Years

Read the Journal of Clinical Psychiatry

Subscribe to read
more articles

Subscribe