Multi-Informant Assessment of the Suicide Crisis Syndrome in Adolescents Presenting to an Emergency Department

Suicide is the second leading cause of death in adolescents and self-harm is one of the strongest predictors of death by suicide. There has been an alarming increase in the rates of adolescents presenting to Emergency Departments (ED) with suicidal thoughts and behaviors (STB). The weeks following ED admission is of the highest risk for suicide. Accordingly, there is a need for a valid and reliable measure of imminent suicide risk, which focuses on youth's suicide risk specific characteristics. The measures proposed in this study build on the conceptualization and empirical evidence suggesting that adolescent suicidal behaviors are often episodic, preceded by brief but intense suicidal ideation. Recently suggested candidate proximal predictors of youth STB include emotional pain and entrapment, irritability, lack of cognitive control, interpersonal dysfunction, and sleep disturbances. However, there is no prospective study that assesses these risk factors in a comprehensive and unified manner. To address this lack of evidence, the proposed project tests a suicide risk assessment instrument comprising multi-informant assessments by patient, parent, and clinician to capture pre-suicidal mental state preceding suicidal behaviors: The Suicide Crisis Syndrome. The Suicide Crisis Syndrome, as measured by the Suicide Crisis Inventory, captures aspects of episodic crisis-like mental state predictive of imminent suicidal behavior among adults but has yet to be tested in adolescents. The assessment instrument developed in this study evaluates the proposed proximal predictors of imminent suicide risk among adolescents, including perceived and observed specific disturbances in affect, cognition, arousal, and interpersonal behavior, and does not rely on self-reports of suicidal ideation. 

Building on our promising pilot results among 60 adolescents evaluated post-discharge, in the proposed project, we will administer the Suicide Crisis Inventory measures adapted to youth to 110 suicidal adolescents aged 11-18 in a pediatric hospital ED. We will assess STB one week, one month, and six months later. Led by Dr. Shira Barzilay (PI) and a collaborative team comprised of recognized international leaders in the assessment and treatment of youth suicidal behaviors, this project will pursue two aims: 
First, we will evaluate suicide crisis severity as a strong predictor of imminent suicidal outcomes. We will examine associations with STB measured at one- and six-month follow-up. We expect the Suicide Crisis inventory to be an independent predictor of imminent risk over and beyond initial suicidal ideation and other psychopathological symptoms, based on traditional and novel statistical techniques.

Second, we will validate the adapted Suicide Crisis Inventories, including patient, parent, and clinician versions as reliable instruments for assessing suicidal adolescents. We will examine psychometric properties as well as associations with established implicit and explicit psychosocial and suicidal measures. Additionally, we will determine the differential contribution of the multiple information resources and examine their optimal integration.

The proposed study will encourage further large-scale research into optimizing and disseminating these risk assessments. This novel suicide risk instrument can aid clinical assessment and inform decision-making in emergency settings, ultimately preventing young people's suicidal behaviors and saving lives.