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Three Part Question

[In adult patients presenting to the ED with recent self harm] does [the SADPERSONS scale] accurately predict [further self harm risk]

Clinical Scenario

A 28 year old male with known depression attends the Emergency Department (ED) six hours after a small overdose of benzodiazepines. He is threatening to leave the ED prior to mental health assessment. You wonder whether the SADPERSONS scale is useful in predicting his risk of further self harm or completed suicide.

Search Strategy

Medline 1966 to 02/2011 using the OVID interface
PsycINFO 1806 to 02/2011using the OVID interface
CINAHL(R) 1982 to 02/2011 and EMBASE 1974 to 02/2011 (EMZZ) using the OVID interface
[exp depression OR self harm] AND [SAD PERSONS OR SADPERSONS] AND [assessment] LIMIT to English language.

Search Outcome

Altogether 10 articles were found, of which four were relevant to the study question. These are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bullard MJ 1993, Taiwan	96 adult patients presenting to an ED in Taiwan following known or perceived self-harm.	Prospective cohort study using a "suicide risk evaluation form" including a subjective assessment and formal SADPERSONS scale.	Completed suicide and disability following further self harm.Compliance of healthcare staff with recommended management plan according to measured risk	The SADPERSONS scale underestimated suicide risk and placed patients in a lower risk group than subjective assessment.Healthcare staff rarely complied with the recommended management plan.	Pattern of self-harm may be different to other countries (e.g. main cause of completed suicide was agricultural poisoning). Most patients were sent home, even those considered intermediate and high risk. Follow-up was incomplete.
Hockberger RS, Rothstein RJ 1998 USA	100 consecutive adult patients attending Los Angeles County Harbor-UCLA Medical Center Emergency Department	Prospective cohort study. The assessment of ED medical staff, using a modified SADPERSONS scale (MSPS), was compared to an immediate formal psychiatric evaluation, from which a second MSPS score and disposition decision (admit or discharge) were determined.	Comparison between the ED assessment and formal psychiatric evaluation, including the MSPS score and disposition decision. Patients were also followed up to determine compliance with future appointments, further hospitalization and completed suicide.	There was reasonable agreement between the ED and psychiatry MSPS scores, but neither accurately predicted patient disposition. A weighted MSPS was developed and prospectively validated in a further 82 patients, with a sensitivity of 31% and specificity of 94% for hospitalization. No patient died during 6 month follow-up.	Small sample sizes, particularly in the second validation cohort. The outcome of most clinical interest (completed suicide) did not occur during the study.
Cochrane-Brink KA, et al, 2000 Canada	55 non-consecutive adults requiring psychiatric evaluation in a Canadian ED setting.	Semi-structured interviews using the modified SADPERSONS scale (MSPS) and five other scales designed to assess the risk of further self-harm	Admission to hospital as a result of assessed suicide risk was used as a proxy measure for further self harm or completed suicide.	All clinical rating scales had high sensitivity (92 -100%) and negative predictive value (96% - 100%), but lower specificity (38% to 90%). The MSPS predicted hospital admission (p<0.5), but other scales performed more effectively.	Small and non-consecutive sample excluding intoxicated patients. No follow-up to determine actual risk of further self-harm.
Herman SM 2006 USA	271 veteran patients at a large Midwest Veterans Affairs Medical Center (VAMC)	Semi structured interviews using the SADPERSONS scale.	Results of SADPERSONS scale were compared to other assessments of suicide risk	A cutoff score of five (recommended by the scale's developers) resulted in failure to identify 14% of individuals considered to be actively suicidal, with a false positive rate of 87%.	Veterans population only, so of limited generalisability. Single evaluation relying on self-reported data. No follow-up to determine actual risk of further self-harm

Comment(s)

Assessing the risk of suicide is a difficult and challenging task, especially in the Emergency Department. Paterson et al arranged a number of factors into a mnemonic that they suggested could be used to assess potentially suicidal patients and help determine the need for hospitalization.[Hockberger] By allocating one point to each of ten factors the SADPERSONS score was created, but no high quality validation studies of the score have been published to date.[Bullard]. Assessments in Taiwan and a North American veteran's population have not been particularly supportive of the scale,[Cochrane-Brink, Juhnk] and modified versions have been derived.[Herman, Patterson] However evidence to support these modified scales is also limited.

Editor Comment

Research into assessing suicide risk is notoriously difficult as suicide is relatively rare. Large scale studies are required to achieve any meaningful results, this generally would require a cohort of tens of thousands and above.

Clinical Bottom Line

The modified SAD PERSONS scale may be helpful in assessing suicide risk in the ED, but evidence to support its use is limited, and it is not sufficiently reliable to be applied in isolation.

References

1. Bullard MJ The problems of suicide risk management in the emergency department without fixed, full time emergency physicians. Changgeing yi xue za zhi 1993;16:30-38
2. Hockberger RS, Rothstein RJ Assessment of suicide potential by non psychiatrists using the SAD PERSONS Score J Emerg Med 1998;6:99-107
3. Cochrane-Brink KA, Lofchy JS, Sakinosfsky I Clinical rating scales in suicide risk assessment General Hospital Psychiatry 2000;22:445-451
4. Herman SM Is the SADPERSONS Scale Accurate for the Veterans Affairs Population? Psychological Services 2006;3:137-141
5. Patterson WM, Dohn HH, BirdJ, Patterson GA Evaluation of suicidal patients: The SADPERSONS Scale Psychosomatic 1983;24:343–349
6. Juhnke GA SAD PERSONS scale review. Measurement and Evaluation in counselling and development 1994;27:325-327