APA: Simple Screen Improves Suicide Risk Assessment

SAN DIEGO, May 25 -- Emergency department patients who may be suicidal can be identified with a simple tool designed for use by health professionals without a mental health background.

The risk-assessment tool, which goes by the tortuous acronym SAD PERSONS, assigns one point to each of 10 items on a risk-factor scale, reported Brian P. Miller, M.D. and Roseann Giordano, R.N., M.S., both of Grossmont Hospital in Costa Mesa, Calif. A score on the scale from seven to 10 indicates that the patient is at high risk for attempting suicide.

"We use this in a community-based hospital," said Dr. Miller, clinical director of Grossmont Hospital, at the American Psychiatric Association meeting here.

"It's designed for non-mental health professionals to use, so in our setting, the triage nurse in the emergency department uses this scale," he continued. "When people come into the emergency department and they've got a psychiatric complaint, or known substance abuse history, we give them the scale and it gives the triage nurse the ability to direct the patient at that point."

The test could also be administered by a social worker or other health care professional, he noted.

Dr. Miller and colleagues adopted and tested the scale in response to a mandate from the Joint Commission of Accreditation of Healthcare Organizations, which requires that hospitals provide a "documented suicide-risk assessment of patients in a psychiatric hospital and patients being treated for emotional or behavioral disorders in general hospitals."

After a literature review to determine existing knowledge on suicide risk assessment instruments, they settled on the modified SAD PERSONS scale.

The scale, which has items that spell out the acronym, assigns one point to each of 10 items identified as risk factors for suicide:

• Sex (male)
• Age less than 19 or greater than 45 years
• Depression (patient admits to depression or decreased concentration, sleep, appetite and/or libido
• Previous suicide attempt or psychiatric care
• Excessive alcohol or drug use
• Rational thinking loss: psychosis, organic brain syndrome
• Separated, divorced, or widowed
• Organized plan or serious attempt
• No social support
• Sickness, chronic disease

A score of one or two points indicates low risk, three to five points indicates moderate risk, and seven to 10 signals high risk.

Dr. Miller said that the cumulative score can tell the triage nurse whether the patient "is just someone who can just go into the waiting room, as most patients do, or is going to need a sitter or security, and how soon is going to need a psychiatric consultation."

Before the hospital implemented the SAD PERSONS, emergency department nurses were tested on their suicide risk assessment skills and knowledge of risk factors, as well as what they should do when a patient is identified as a high suicide risk,

The nurses were tested again after the computerized risk-assessment tool was put in place. The authors found that their knowledge of suicide risk factors and how to use the information provided by the screening tool improved significantly.

"The idea is that someone without a whole lot of psychiatric sophistication can use it and have an idea of where to direct the patient so they can have a more thorough evaluation," Dr, Miller said.