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Three Part Question

In [an adult who presents with suicidal ideation or self-harm] is [a risk tool] available to [detect those who are at medium to high risk of further self-harm if discharged]

Clinical Scenario

A 42-year-old woman presents to the emergency department stating she has suicidal ideation. She denies any overdose or intoxication. She states in the past few days she has been planning to end her life.

Search Strategy

Pubmed search:
Search terms [("adult suicide risk tool emergency department”)]
14 papers identified; 3 relevant, 6 irrelevant and 5 discussed the validity of the tools mentioned below.

Pubmed search:
Search terms [("adult self-harm risk tool emergency department”)]
9 papers identified; 3 relevant (as already included), 6 irrelevant

Pubmed search:
Search terms [("mental health triage tool”)]
42 papers identified; 0 relevant (of note 3 discuss paediatric mental health triage tools)

BestBETS
0 Reviews

Web of Science
Search terms [("adult suicide risk tool emergency department”)]
11 paper; 1 relevant (already included), 10 irrelevant
Web of Science
Search terms [("adult self-harm risk tool emergency department”)]
9 papers identified; 9 irrelevant

Web of Science
Pubmed search:
Search terms [("mental health triage tool”)]
42 papers identified; 0 relevant (of note 2 discuss paediatric mental health triage tools)

Pubmed search:
Search terms [("self-harm risk score”)]
122 papers identified; 1 relevant (as below) 121 irrelevant

Pubmed search:
Search terms [("self-harm risk score”)]
27 papers identified; 3 relevant (as below) 24 irrelevant

Also references of papers included searched. No additional papers found.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Spittal MJ1, Pirkis J, Miller M, Carter G, Studdert DM. 12th March 2014 Australia	All patients admitted to hospital for deliberate self-harm in two Austrailian States. 350 hospitals, 84,659 episodes of self-harm included.	Retrospective analysis of patient records	Development of a tool to identify those who are at risk of repeated self-harm (defined as any subsequent episode of hospital-treated deliberate self-harm or suicide within 6 months)	Development of a risk calculator (RESH: Repeated episodes of self-harm) showing good discrimination (AUC=0.75) and high specificity. Patients with scores of 0-3 had 14% risk of repeat episodes, whereas patients with scores of 20-25 had over 80% risk	Poor sensitivity thus can’t be used for ruling people out. This is inpatient data not emergency department patients. Possibly not generalizable to other populations
Steeg S, Kapur N, Webb R, Applegate E, Stewart SLK, Hawton K, Bergen H, Waters K, Cooper J March 2012 Manchester, UK	All patients admitted to 5 emergency departments over 16 years old. 18680 people included, with 29571 episodes of self-harm.	Multicentre prospective cohort study	Development of a tool to identify those who are at risk of repeated self-harm (defined as any subsequent episode of hospital-treated deliberate self-harm or suicide within 6 months)	Development of a clinical risk tool ReACT (Recent self-harm, Alone or homeless, Cutting as a method of harm, T for current psychiatric disorder) Self-harm tool. 95% Sensitivity and 21% Specificity 30% PPV and 91% NPV Identified 83/92 (90%) of subsequent suicides.	Possibly not generalizable to other populations as only validated to one population set. Low specificity.
Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K, October 2006 Manchester, UK	Patients who self-harmed in 5 emergency departments. 9086 patients	Multicentre prospective cohort study	Development of a risk-stratification model for use by emergency department clinical staff in the assessment of patients attending with self-harm and identify those who are at risk of repeated self-harm (defined as any subsequent episode of hospital-treated deliberate self-harm or suicide within 6 months)	Development of a 4 question rule with a sensitivity of 94% and specificity of 25% was derived to identify the patients at higher risk of repetition or suicide.	Patients who attended with cutting may have been under represented. May not be applicable to rural EDs or EDs on the USA. Possible that not all re-attenders data was captured – possible to attend one of the other EDs. Variability in psychiatry resources available in each of the EDs. May have affected results.

Comment(s)

These 3 tools have large numbers of patients included and have produced tools with good specificity. However, all have commented on the low specificity and the fact that their tool is not validated in other populations.

Clinical Bottom Line

These tools are not currently validated, therefore all patients with suicidal ideation should be referred to mental health services as per national guidance.

References

1. Spittal MJ, Pirkis J, Miller M, Carter G, Studdert DM. The Repeated Episodes of Self-Harm (RESH) score: A tool for predicting risk of future episodes of self-harm by hospital patients. Journal of Affective Disorders 161(2014)36–42.
2. Steeg S, Kapur N, Webb R, Applegate E, Stewart SLK, Hawton K, Bergen H, Waters K, Cooper J The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule Psychological Medicine (2012), 42, 2383-2394
3. Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K A Clinical Tool for Assessing Risk After Self-Harm. Annals of Emergency Medicine (2006), 48(4), 459- 466.