1. SUICIDALITY CLASSIFICATION PROJECT Kelly Posner, Ph.D. Maria A. Oquendo, M.D.

2. The Problem : Limitations in Suicide Assessment and Nomenclature Lack of agreement on common terminology Lack of agreement on common terminology –In clinical descriptions of suicidal acts –In research descriptions of suicidal acts (even among experts in suicidal behavior) Importance of reliability (all define/assess the same way) and validity (some truth to dfn) Importance of reliability (all define/assess the same way) and validity (some truth to dfn)

3. Suicide Attempt A self-injurious act committed with at least some intent to die. A self-injurious act committed with at least some intent to die. Intent does not have to be explicit. Eg: patient denies intent to die, but thought that the behavior could be lethal. Intent can be inferred. Intent does not have to be explicit. Eg: patient denies intent to die, but thought that the behavior could be lethal. Intent can be inferred.

4. Other Classifications: Suicidal Behavior w/o Injury Interrupted Attempt: individual is stopped by an outside circumstance from starting the self-injurious act Aborted Attempt: individual takes steps towards making a suicide attempt, but stops himself before engaging in any potentially self-destructive behavior

5. Suicidal Intent Presence of intent to die differentiates suicidal acts from self-injury Presence of intent to die differentiates suicidal acts from self-injury -Determine whether self-injurious act was thought of as a means of causing or facilitating death - Support for validity of using intent to define suicidality: Completed suicide predicted by previous intent measures (Beck et al, 1989)

6. Examples of Non-Suicidal Self- Injury Teenage girl reported mother was being cruel and neglectful and she wanted to escape from mother’s home. States she researched lethal doses of ibuprofen to make sure she took an amount that would not be life-threatening. Took 6, feeling certain it was not enough to kill her, she definitely did not want to die, only to escape from mother’s home. Taken to ER and then admitted to psych. hospital Teenage girl reported mother was being cruel and neglectful and she wanted to escape from mother’s home. States she researched lethal doses of ibuprofen to make sure she took an amount that would not be life-threatening. Took 6, feeling certain it was not enough to kill her, she definitely did not want to die, only to escape from mother’s home. Taken to ER and then admitted to psych. hospital Person described 12 incidents of cutting himself. States he did this only “to relieve tension” and “to play with danger to see how far I would go” and no part of him wanted to die. Thought about it for hours before acting on the urge and felt relieved of tension afterwards. Did not feel pain while cutting self. Person described 12 incidents of cutting himself. States he did this only “to relieve tension” and “to play with danger to see how far I would go” and no part of him wanted to die. Thought about it for hours before acting on the urge and felt relieved of tension afterwards. Did not feel pain while cutting self.

7. Research Support of Classifications Reliability excellent reliability (kappa=.97) utilizing classification system in NIMH- funded treatment, biological, and genetic trials excellent reliability (kappa=.97) utilizing classification system in NIMH- funded treatment, biological, and genetic trials Multi-site reliability with other centers in family genetic studies and treatment of adolescent suicide attempters trial Multi-site reliability with other centers in family genetic studies and treatment of adolescent suicide attempters trial

8. Validity of Classifications Individuals classified as suicide attempters have as much as 2.5X risk of future attempts or completions (Dorpat, 1967, Nordstrom, 1995, Oquendo, in press) Individuals classified as suicide attempters have as much as 2.5X risk of future attempts or completions (Dorpat, 1967, Nordstrom, 1995, Oquendo, in press) Interrupted attempters are reported to be 3X more likely to commit suicide than uninterrupted attempters (Steer et al 1988) Interrupted attempters are reported to be 3X more likely to commit suicide than uninterrupted attempters (Steer et al 1988) Aborted attempters are at risk for eventual attempts and were more likely to have made an actual attempt in the past (Marzuk et al 1997) Aborted attempters are at risk for eventual attempts and were more likely to have made an actual attempt in the past (Marzuk et al 1997)

9. Classification Methodology Expert Panel with 9 members Review of cases N = x Subgroup Reviews x/3 + 5 +5 cases Subgroup Reviews x/3 + 5 + 5 cases Subgroup Reviews x/3 + 5 +5 cases Blinding of data by experienced child psychiatrist not on panel Determination of event classification based on reliable and valid constructs Training on classification system to establish reliability of panel members Consensus discussion of non-concordant cases (additional cases to prevent stratification bias) Generate Classified Cases

10. Classifications SuicidalNon Suicidal Suicide Attempt Suicidal Ideation Self-Injury/ Mutilation Other: -Accidental - other sxs (eg. akathesia) Indeterminate Non- consensus Unable to Classify Due To Limited Data Suicidal Behavior without injury: Aborted attempt Interrupted attempt

11. Future Directions Develop guidelines as to how to better capture data, enabling appropriate classification of suicidality: Develop guidelines as to how to better capture data, enabling appropriate classification of suicidality: Utilization of research assessment tools (what questions to ask, how to ask, and what measures aid this) Consistency of Nomenclature and Classification Improved, More Valid Identification and Documentation Of Suicidality Also describes 12