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Letter to the Editor

Greater Than "Even Greater" Need?

John H. Greist, MD

Published: July 27, 2016

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Greater Than "Even Greater" Need?

To the Editor: Eric A. Youngstrom’s commentary in the October 2015 issue of the Journal1 highlights the value of assessment standardization demonstrated in Brown and colleagues’ excellent article "Detection and Classification of Suicidal Behavior and Nonsuicidal Self-Injury Behavior in Emergency Departments."2

The goal of all assessment is to gather reliable and accurate data to guide clinical decisions. Unfortunately, reliability and accuracy of clinician assessment data are reduced by variability in clinician interviewing. Even "calibrated" interviewers using standardized interview guides vary substantially after training and retraining in use of an assessment.3,4

Brown et al compared data from "patients’ admission notes written in the context of routine clinical care"2(p1399) with data collected by "master’s – or doctoral-level research staff" using "standardized assessments."2(p1398)

Consensus suicide attempt and nonsuicidal self-injury behavior diagnoses were assigned on the basis of the standardized assessments. Overall, the unusually high diagnostic agreement found between unstandardized assessment by clinicians during routine care and standardized assessment by trained research staff interviewers focused on suicidal ideation and behavior (SIB) was attributed to "reliance on clinicians at academic institutions with a culture of excellence in research and evaluation of suicidal ideation and behavior. In the larger context, those findings represent a best-case scenario’ ¦.’ "1(p e1331)

Still, 18% of patients classified as having made a recent suicide attempt by standardized assessment were not identified as suicide attempters during clinical assessment. In half of these disagreements, clinicians diagnosed nonsuicidal self-injury behavior or other nonattempt behaviors, such as attempt interruption by self or others. In the other half of disagreements, the clinicians missed all suicidal or nonsuicidal self-injury behaviors identified by standardized assessment.

All data in this study on which SIB diagnoses depended were mediated from patients through clinicians or specially trained raters in face-to-face interviews. However, there is another possible medium of communication between patient and clinician. McLuhan’s aphorism "The medium is the message" is applicable. Consistent evidence spanning 40 years indicates that standardized patient self-reports identify more suicidal and nonsuicidal self-injury behavior than face-to-face clinician or research staff assessments. Six research groups conducted 7 studies of self-report versus clinician assessment of SIB employing 6 different SIB assessments.5-11 Three standardized self-report assessments were administered by paper and pencil; 4, by computer interview (3 using text and 1 using interactive voice response). All studies reported greater disclosure of SIB with standardized patient self-report than with clinician face-to-face assessment. This greater sensitivity remained in the 4 studies in which standardized self-report assessment was compared with standardized clinician or research staff assessment.8-11

The Catholic confessional has a screen separating priest and penitent. Stigmatized behaviors, sinful or not, are less likely to be disclosed face-to-face than indirectly. How patient data are collected matters with regard to sensitive subjects (people and topics). Patients often want clinicians to know about stigmatized thoughts and behaviors that have been completed or, with suicidal ideation and behavior, contemplated, but they have greater difficulty disclosing them directly. Clinicians equipped with standardized patient self-report assessments regarding SIB will provide better care for patients at risk of suicide. Forewarned is forearmed.


1. Youngstrom EA. Using standardized methods to assess suicidal behavior: the need is even greater than it looks. J Clin Psychiatry. 2015;76(10):e1331-e1332. PubMed doi:10.4088/JCP.14com09573

2. Brown GK, Currier GW, Jager-Hyman S, et al. Detection and classification of suicidal behavior and nonsuicidal self-injury behavior in emergency departments. J Clin Psychiatry. 2015;76(10):1397-1403. PubMed doi:10.4088/JCP.14m09015

3. Kobak KA, Brown B, Sharp I, et al. Sources of unreliability in depression ratings. J Clin Psychopharmacol. 2009;29(1):82-85. PubMed doi:10.1097/JCP.0b013e318192e4d7

4. Kobak KA, Lipsitz J, Williams JBW, et al. Are the effects of rater training sustainable? results from a multicenter clinical trial. J Clin Psychopharmacol. 2007;27(5):534-535. PubMed doi:10.1097/JCP.0b013e31814f4d71

5. Greist JH, Gustafson DH, Stauss FF, et al. A computer interview for suicide-risk prediction. Am J Psychiatry. 1973;130(12):1327-1332. PubMed doi:10.1176/ajp.130.12.1327

6. Erdman HP, Greist JH, Gustafson DH, et al. Suicide risk prediction by computer interview: a prospective study. J Clin Psychiatry. 1987;48(12):464-467. PubMed

7. Levine S, Ancill RJ, Roberts AP. Assessment of suicide risk by computer-delivered self-rating questionnaire: preliminary findings. Acta Psychiatr Scand. 1989;80(3):216-220. PubMed doi:10.1111/j.1600-0447.1989.tb01330.x

8. Bridge JA, Barbe RP, Birmaher B, et al. Emergent suicidality in a clinical psychotherapy trial for adolescent depression. Am J Psychiatry. 2005;162(11):2173-2175. PubMed doi:10.1176/appi.ajp.162.11.2173

9. Vitiello B, Silva SG, Rohde P, et al. Suicidal events in the Treatment for Adolescents with Depression Study (TADS). J Clin Psychiatry. 2009;70(5):741-747. PubMed doi:10.4088/JCP.08m04607

10. Trivedi MH, Wisniewski SR, Morris DW, et al. Concise Health Risk Tracking scale: a brief self-report and clinician rating of suicidal risk. J Clin Psychiatry. 2011;72(6):757-764. PubMed

11. Hesdorffer DC, French JA, Posner K, et al. Suicidal ideation and behavior screening in intractable focal epilepsy eligible for drug trials. Epilepsia. 2013;54(5):879-887. PubMed doi:10.1111/epi.12128

John H. Greist, MDa

aDepartment of Research, Healthcare Technology Systems, Inc, Madison, Wisconsin

Potential conflicts of interest: Dr Greist is a shareholder in Healthcare Technology Systems, Inc, which receives royalties for 1 self-report assessment of suicidal ideation and behavior (the eC-SSRS) studied in 1 published paper referenced in the manuscript; however, this does not seem to be a conflict of interest as the eC-SSRS is only 1 of 6 standardized self-report assessments referenced in publications cited, none of which is specifically recommended in the letter. Further, the eC-SSRS is not mentioned in this letter or in the title of the published article in which it was studied (reference 11).

Funding/support: None.

J Clin Psychiatry 2016;77(7):e902

© Copyright 2016 Physicians Postgraduate Press, Inc.

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