Academic journal article Indian Journal of Psychiatry

A Psychometric Cut-Point to Separate Emergently Suicidal Depressed Patients from Stable Depressed Outpatients

Academic journal article Indian Journal of Psychiatry

A Psychometric Cut-Point to Separate Emergently Suicidal Depressed Patients from Stable Depressed Outpatients

Article excerpt

Byline: W. McCall, Nicolas. Batson, Megan. Webster, Indu. Joshi, Todd. Derreberry, Adam. McDonough, Suzan. Farris

Context: The design of safe clinical trials targeting suicidal ideation requires operational definitions of what degree of suicidal ideation is too excessive to allow safe participation. Aims: We examined the Scale for Suicide Ideation (SSI) to develop a psychometric cut-point that would identify patients having a suicidal emergency. Settings and Design: The Emergency Department (ED) and the out-patient clinic of a university hospital. Materials and Methods: We used the SSI to contrast 23 stable, depressed adult out-patients versus 11 depressed adult ED patients awaiting psychiatric admission for a suicidal emergency. Statistical Analysis: The performance of the SSI was examined with nominal logistic regression. Results: ED patients were older than out-patients (P<0.001), with proportionally more men (P<0.05), and were more ethnically diverse than the outpatients (P<0.005). Compared to out-patients, ED patients were more depressed (Patient Health Questionnaire-9 score 23.1[+ or -]3.8 vs. 11.7[+ or -]7.3, P<0.005) and reported a greater degree of suicidal ideation (SSI scores 25.7[+ or -]7.3 vs. 4.2[+ or -]8.4, P<0.0001). Nominal logistic regression for the univariate model of SSI score and group yielded a score of 16 (P<0.0001) as the best cut-point in separating groups, with a corresponding Receiver Operating Characteristic Area Under the Curve = 0.94. Of 34 patients in the total sample, only two were misclassified by SSI score = 16, with both of these being false positive for ED status. Thus, the sensitivity of the cut-point was 100% with specificity of 91%. When the model was expanded to include SSI along with age, gender, ethnicity, sedative-hypnotic use, and over-the-counter use, only SSI score remained significant as a predictor. Conclusions: A SSI score ≥16 may be useful as an exclusion criterion for out-patients in depression clinical trials.


In preparation for an out-patient clinical trial to reduce suicidal ideation, we developed a psychometric cut-point to identify depressed patients with emergent suicidal ideation needing Emergency Department (ED) services. In general, design of clinical trials for suicide risk-reduction faces both practical and ethical dilemmas. On one hand, there is the need to include patients with some degree of suicidal ideation while on the other hand there is a need to exclude patients with unmanageable risk. Thus, it would be useful to define a cut-point assisting in identifying emergent levels of suicidal ideation of patients that should be excluded from clinical trial participation.

We previously reported on the relationship between sleep distress and suicidal ideation. [sup][1] In this secondary analysis, our goal was to devise a psychometric cut-point with good sensitivity and specificity and thus formulate an operational rule for an exclusion criterion for emergent suicidality for a clinical trial designed to reduce suicidal ideation.

Materials and Methods

Study setting and population

Inclusion criteria

Participants were sought from a convenience sample of psychiatric out-patients and psychiatric ED patients who were consecutively recruited over the calendar year 2011. Participants were literate, English-speaking adults ≥18 years old, with a chart diagnosis of one of the following depressive illnesses with nil, mild, moderate or a severe degree of overall symptoms: Major depressive disorder without psychotic features, major depressive disorder with psychotic features, depressive disorder not otherwise specified, bipolar disorder type I-most recent episode depressive or bipolar disorder type II-most recent episode depressive. [sup][2] Out-patients were consented during a routine, follow-up out-patient visit for mood disorder, with the clinical judgment that the patient was sufficiently stable that their next follow-up visit would also be an out-patient visit. …

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