Journal Pre-proof

Predicting suicide: a comparison between clinical suicide risk

assessment and the Suicide Intent Scale

Åsa U Lindh MD, PhD , Karin Beckman MD, PhD ,

Andreas Carlborg MD, MBA, PhD , Margda Waern MD, PhD ,
Ellinor Salande Renberg PhD , Marie Dahlin MD, PhD ,
Bo Runeson MD, PhD

PII: S0165-0327(19)31849-X
DOI: https://doi.org/10.1016/j.jad.2019.11.131
Reference: JAD 11378

To appear in: Journal of Affective Disorders

Received date: 17 July 2019

Revised date: 27 October 2019
Accepted date: 29 November 2019

Please cite this article as: Åsa U Lindh MD, PhD , Karin Beckman MD, PhD ,
Andreas Carlborg MD, MBA, PhD , Margda Waern MD, PhD , Ellinor Salande Renberg PhD ,
Marie Dahlin MD, PhD , Bo Runeson MD, PhD , Predicting suicide: a comparison between clini-
cal suicide risk assessment and the Suicide Intent Scale, Journal of Affective Disorders (2019), doi:
https://doi.org/10.1016/j.jad.2019.11.131

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 1

Highlights

 The predictive accuracy of a clinical suicide risk assessment has only been evaluated in a few
studies
 In a self-harm cohort, the clinical suicide risk assessment performed very similar to the
Suicide Intent Scale in predicting suicide during one-year follow-up
 The positive predictive value for both methods was 6%
 2

Predicting suicide: a comparison between clinical suicide risk

assessment and the Suicide Intent Scale

Åsa U. Lindh1a MD, PhD; Karin Beckmana MD, PhD; Andreas Carlborga MD, MBA, PhD;
Margda Waernb MD, PhD; Ellinor Salander Renbergc PhD; Marie Dahlina MD, PhD; Bo
Runesona MD, PhD.

From the aCentre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska
Institutet, & Stockholm Health Care Services, Region Stockholm, S:t Görans Hospital,
Stockholm, Sweden; the bDepartment of Psychiatry and Neurochemistry, University of
Gothenburg & Region Västra Götaland, Sahlgrenska University Hospital, Psychosis
Department, Gothenburg, Sweden and the cDepartment of Clinical Sciences, Division of
Psychiatry, University of Umeå, Sweden

1
Corresponding author. Email address: asa.lindh@ki.se. Postal address: Vårdvägen 1, SE-112 19 Stockholm,
Sweden. Telephone: +46735688860.
 3

Abstract

Background
How suicide risk should be assessed is under discussion with arguments for both actuarial
and clinical approaches. The aim of the present study was to compare the predictive
accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in
predicting suicide within one year of an episode of self-harm with or without suicidal intent.

Methods
Prospective clinical study of 479 persons assessed in a psychiatric emergency department
after an episode of self-harm. The clinical risk assessment and the SIS rating were made
independently of each other. Suicides within one year were identified in the National Cause
of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal
cut-offs were identified and accuracy statistics were calculated.

Results
Of 479 participants, 329 (68.7%) were women. The age range was 18–95 years. During one-
year follow up, 14 participants died by suicide. The area under the curve (AUC) for the
clinical risk assessment and the SIS score were very similar, as were the accuracy statistic
measures at the optimal cut-offs of the respective methods. The positive predictive value
(PPV) of each assessment method was 6%.

Limitations
The clinical suicide risk assessment is not standardized. The number of suicides is small, not
allowing for stratification by e.g. gender or diagnosis.

Conclusion
Predictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to
guide treatment allocation.

Key words
Self-harm, suicide attempt, suicide, suicide risk assessment, Suicide Intent Scale.
 4

Introduction
How accurate are clinicians’ suicide risk assessments, and how do they perform compared to
a risk assessment instrument? It has been argued that actuarial assessments are superior to
clinical judgment, not only in psychiatry but in medicine in general (Dawes et al., 1989,
Marchese, 1992), and the large number of existing suicide risk assessment instruments and
rating scales indicate that there has been a perceived need for a complement to clinical risk
assessment. However, it has also been argued that such instruments will never be able to
pick up dynamic risk factors and that clinicians could outperform them, were they
adequately trained in assessment based on a broad range of relevant factors (Berman and
Silverman, 2014). In a British multicentre self-harm monitoring study, the global clinical risk
assessment was compared to the Manchester Self-Harm Rule (MSHR) regarding prediction
of repeat self-harm during a six-month follow-up. The MSHR had a higher sensitivity and a
lower specificity, and it was suggested that the clinical assessment could be improved with
the addition of this instrument (Cooper et al., 2007). In another study, clinicians’ risk
assessment was compared to several structured instruments (the MSHR, the SAD PERSONS
scale and the Barratt Impulsiveness Scale); the formal risk scales did not perform better
than the clinical risk assessment in predicting repetition of self-harm within six months
(Quinlivan et al., 2017). The authors of that study suggested that risk scales have limited
clinical utility. In a recent review on the evidence base for risk scales in suicide risk
assessment, it was noted that there were no studies evaluating whether clinical risk
assessment improved with the addition of a structured instrument (Runeson et al., 2017).

The aim of the present study was to assess the predictive accuracy of a clinical suicide risk
assessment and to compare it to that of the Suicide Intent Scale (SIS) in predicting suicide
within a year of an index episode of self-harm with or without suicidal intent. The SIS covers
15 items concerning the aspects of a recent suicide attempt in terms of the risk of being
found, the planning involved, the perceived lethality of the method and the wish to die from
the attempt (Beck, 1974). The instrument was chosen for this comparison since it has been
extensively used and researched, and since high scores have been shown to better correlate
with future suicide than with repeat suicide attempt (Freedenthal, 2008). A second aim was
to determine whether accuracy could be improved by combining data from both
evaluations.
 5

Method
Setting and participants
From April 2012 to April 2016, patients seeking or being referred to a psychiatric assessment
at the psychiatric emergency (PE) department in Stockholm, Sweden after an episode of self-
harm could be evaluated for participation in a study of suicide risk assessment instruments.
The PE department is the only psychiatric emergency service that is open twenty-four hours
a day, seven days a week in Stockholm County, serving a population of about 2.2 million. It is
also the only service that accommodates patients arriving by ambulance or police transport.
The index episode could be either a suicide attempt, i.e. a potentially self-injurious
behaviour where there is evidence that the person wanted to die as a result (O'Carroll et al.,
1996) or a non-suicidal self-injury, i.e. a deliberate self-injury without intent to die (Nock et
al., 2007). All participants were ≥18 with no upper age limit. There were no exclusion criteria
regarding specific diagnoses, but patients had to be able to understand the information
given about the study and to take part in the interview, thereby excluding patients who did
not speak Swedish as well as those with symptoms seriously interfering with verbal
communication (psychotic symptoms, severe cognitive impairment, pronounced drowsiness,
and aggressiveness). The research staff collaborated closely with the regular staff, to get
information about potential study participants at the psychiatric emergency department or
patients who had recently been admitted. Patients who were transferred to another clinic or
discharged directly after emergency ward assessment were less likely to be available for
study participation. A fully structured manual with fixed-response questions and validated
rating scales was used for the research interview, which was carried out within a week of the
index episode by a psychiatrist or an experienced psychiatric nurse not presently engaged in
the clinical management of patients in the PE department. Training in the application of the
interview manual as well as supervision was provided. Participants could be included on one
occasion only; repeated self-harm episodes did not render a new inclusion in the study. This
was part of a multicentre study described in previous publications (Haglund et al., 2016,
Lindh et al., 2018, Beckman et al., 2018).
As part of the routine clinical assessment, a suicide risk assessment is registered for all
patients assessed at the PE department. The clinical assessment is made on a four point
scale with a fixed-response format where 1: minimal risk, suicide risk need not be addressed
 6

in treatment plan; 2: moderate risk, treatment plan needs to address increased risk if
situation/illness changes; 3: high risk, needs to be addressed in treatment plan and 4: very
high risk, inpatient treatment and close monitoring needed. The time frame is not specified.
The risk assessment is based on the information at hand during the PE visit, which can differ
from patient to patient. The clinicians at the PE department have varying levels of
experience, but junior doctors are specifically encouraged to consult with a senior colleague
regarding suicide risk assessment. All study participants were clinically evaluated before
being informed about the study, and the doctors who had made the clinical suicide risk
assessment were not involved in data collection or analysis in the research project. The
clinical suicide risk assessment was extracted from the medical record after the research
interview was completed.

Statistical analyses
Analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version
24.0 and R. P-values below 0.05 were considered statistically significant. Receiver operating
characteristics (ROC) curves were constructed and the area under the curve (AUC) was
assessed as a summary measure of predictive accuracy.
A SIS total score ≥16 has been associated with an increased risk of future suicide in a cohort
of suicide attempters (Stefansson et al., 2012) and this cut-off was tested in our sample. In
addition, we identified cut-offs for the clinical risk assessment and for SIS that maximized the
sum of sensitivity and specificity in this sample. Accuracy statistics were calculated for 1) SIS
score ≥16, 2) the optimal cut-offs for the respective assessments, 3) being identified as high
risk by both methods and 4) being identified as high risk by either method. These four
predictors were entered as independent variables in separate bivariate logistic regression
models to yield odds ratios for suicide during one-year follow-up.
Interviews with paired raters were performed using the research interview manual, and
interrater reliability was assessed with intra-class correlation for the SIS total score.
Assessment of interrater reliability of the clinical risk assessment was beyond the scope of
this study.
 7

Outcome
The electronic medical record system used at the PE department is linked via the Swedish
personal identity number (Ludvigsson et al., 2009) to the Population Register in which
virtually all deaths occurring in Sweden, or in Swedish citizens abroad, are registered within
30 days (Ludvigsson et al., 2016). Deaths within a year of the index episode were thus
identified via the medical record, and cause of death for all deceased persons was obtained
from the National Cause of Death Register (CDR). Suicides were identified by ICD-10 codes
X60–X84 and Y10–Y34.

Ethics approval
Ethical approval was obtained from the Gothenburg Regional Ethics Committee (589-10,
T034-12). All participants gave written informed consent.

Results
Of 726 patients informed about the study, 26 were excluded due to interfering symptoms or
inability to understand study information. Of 700 eligible patients, 479 (68%) took part in the
study. Baseline data are presented in Table 1. Two thirds were women, and some level of
intent to die was reported in four fifths of the total group. Anxiety and mood disorders were
the most common clinical diagnoses. A clinical risk assessment was present for 422
participants (88%) with the following distribution: minimal risk: 22 (4.6%), moderate risk 236
(49.3%), high risk 150 (31.3%) very high risk 14 (2.9%). There were 457 (95%) SIS ratings with
a range of 2–27 and a median score of 15 (interquartile range 10–19). The intra-class
correlation coefficient for the SIS total score was 0.94 (95% CI 0.85–0.90). Spearman’s rho
for the correlation between the clinical risk and SIS total score was 0.217 (p<0.001).
During the one-year follow-up 14 (2.9%) participants (10 men [6.7% of all men], 4 women
[1.2% of all women]) died by suicide. All deaths described as suicides in the medical record
had an ICD-10 code of either X60–X84 (n=11) or Y10–Y34 (n=3). The most common suicide
methods were hanging (n=7) and poisoning (n=4). Complete clinical risk assessments were
available for the index episode for all these, and 13 of the 14 suicides had complete SIS
ratings.
The ROC curves are presented in Figure 1. The AUC for the clinical assessment was 0.68 (95%
CI 0.53–0.82, p=0.031). For SIS the AUC was 0.72 (95% CI 0.54–0.89, p=0.008). Accuracy
statistics are shown in Table 2. The optimal cut-off for the clinical assessment was ≥3, giving
 8

a sensitivity/specificity of 71.4%/62.3% and a positive predictive value (PPV) of 6.1%. At this

cut-off the false negative rate (proportion patients assessed as low risk among those who
died by suicide during follow-up) was 4/14 (28.6%). Regarding SIS, the suggested cut-off ≥16
was not a significant predictor but a total score ≥18 was optimal, with a sensitivity/specificity
of 69.2%/69.4%, a PPV of 6.2% and a false negative rate of 4/13 (30.8%). With these cut-offs,
seven participants who died by suicide were classified as having a high risk by both methods,
two were classified as high risk by the clinical assessment only, two by SIS only and two
participants who died by suicide were identified as high-risk patients by neither method. The
latter two were young (<25 years) and their index episodes lacked suicide intent.
When high risk was defined as being identified on both assessments, specificity increased to
87.5% combined with a sensitivity of 53.8%. The PPV was 11.5%, and the false negative rate
was 6/13 (46.2%). If high risk was defined as being identified on either assessment,
sensitivity was 85.7% and specificity 43.8% with a PPV of 4.8% and a false negative rate of
2/14 (14.3%). A high clinical risk was associated with an OR of 4.1 for suicide during one-year
follow-up (Table 2). A SIS total score ≥ 18 yielded an OR of 5.1.

Discussion
In this prospective study of 479 persons with a recent episode of self-harm, the clinical risk
assessment and the Suicide Intent Scale yielded very similar results regarding prediction of
suicide during a one-year follow-up with an AUC of 0.68 for the clinical assessment and 0.72
for SIS, with almost identical confidence intervals. Sensitivity and specificity were ca. 70 %
and 62–69 %. Combining the assessments could improve either sensitivity or specificity but
not both.
In this sample 2.9% of the participants died by suicide during the first year of follow-up. This
proportion is slightly higher than in other studies on fatal repetition (Pokorny, 1983, Owens
et al., 2002), but it is still based on a small number of outcome events making the estimates
more uncertain and not allowing stratification on e.g. age or specific diagnoses. The results
for SIS are in line with previous research on this instrument, where high scores have been
associated with suicide during follow-up times of 1 to 20 years (Harriss and Hawton, 2005,
Harriss et al., 2005, Niméus et al., 2002, Stefansson et al., 2012).
The AUC and accuracy statistics of the clinical assessment were very similar to that of SIS,
contrary to the notion of actuarial approaches being more reliable than clinical judgment.
 9

Regarding the clinical assessment, clinicians are instructed to take both static and dynamic
risk factors into account. If and how these should be weighted is up to the individual
clinician. Clinicians were not expected to formulate a risk estimate in terms of a probability
for suicide within a specified time frame but rather to choose one of four risk levels on a
Likert-like scale, a common format for this kind of assessment (Berman and Silverman,
2014). Previous research has shown that there is little consensus on what numerical
probabilities correspond to the different risks categories, and that “high risk” can be
interpreted as the probability for a specific event, or the severity of that event regardless of
its probability (Cahill and Rakow, 2012). It follows, and is a limitation of this study, that we
do not know the exact basis of the clinical risk assessment – it might be highly structured, or
highly intuitive. A recent study indicates that psychiatrists find little use for formal risk scales
and that intuition or “gut feeling” plays an important part in risk assessment (Waern et al.,
2016). Another limitation concerns the naturalistic setting, where all study participants were
treated according to the clinical assessment of their needs. While this is the only ethically
acceptable study design, it might have had a negative impact of the accuracy of predictions.
Since potential study participants who were discharged directly after the clinical assessment
were less likely to be included in the study, it could be assumed that a majority of the study
sample has a more pronounced psychiatric illness, higher perceived suicide risk and/or
medically more severe self-harm than the self-harm population as a whole. Thus, the results
would not be generalizable to all persons who self-harm. It is also possible that the study
sample has been given more extensive treatment and, at least initially after the self-harm
event, had fewer opportunities for repetition. This could lessen the impact of the risk factors
on the outcome studied. Patients with symptoms interfering with verbal communication
were excluded from the study and as a consequence the results might not be valid for all
diagnostic categories.
This study has some notable strengths, one of the more important being the independent
ratings of the clinical risk on one hand and SIS on the other. In a previous study the clinician
made the global assessment of risk and rated the instruments (Quinlivan et al., 2017), which
could imply that the clinical risk assessment was influenced by the information from the
instruments. This would not be the case in the present study as SIS was not part of the
routine clinical assessment but performed separately as part of the research interview.
 10

How a clinical suicide risk assessment should be performed is still under debate. Some
researchers argue that an actuarial assessment could be preferable to a clinical one if their
predictive properties are similar, because of the low risk of heterogeneity in an actuarial
assessment as seen in the excellent interrater reliability of the SIS in the present study. Using
an actuarial instrument would ensure that some specific aspects of suicidality are always
assessed, and it could also improve communication of risk across transitions in care. An
actuarial assessment could also free time for the clinician to engage in risk management
rather than assessment (Fazel and Wolf, 2017). Others, however, state that suicide risk
assessment and stratification of patients in different risk categories should be avoided,
regardless of method (Murray, 2016, Large, 2018). The positive predictive value is generally
low (e.g. in this study between 4 and 11 % depending on assessment method) while the false
negative rate is not negligible (14 to 46% in this sample) and it follows that it would be
questionable to reserve some interventions for the high risk group under such
circumstances.

Conclusion
This study does not support the notion that a structured instrument such as SIS has better
predictive accuracy than the clinical risk assessment. Sensitivity or specificity can be
improved if the methods are combined and what is desired is ultimately a question of what
further actions are to be taken based on the assessment. The most important task however
would be to prevent suicides rather than predicting them accurately. A possible focus for
future studies could be a direct comparison of risk assessment and risk management
strategies, where a low rate of suicide would be the desired goal rather than an impediment
to achieving excellent predictive accuracy.
Contributors
ÅL and BR designed the study in close collaboration with all other authors and ÅL wrote
the study protocol. ÅL undertook the statistical analyses and wrote the first draft of the
manuscript. All authors contributed to interpretation of the results and to the manuscript,
and have approved the final manuscript.

Role of the Funding Source

The funding sources had no role in study design, data collection, analysis or
interpretation of results nor in writing the manuscript or submitting it for publication.
 11

Funding
The study was financed by grants from the Swedish Research Council [grant number 521-
2011-299], the Bror Gadelius Foundation and the Swedish state under the agreement
between the Swedish government and the county councils, the ALF agreement [grant
numbers ALFGBG-147361, ALFGBG-715841, Stockholm County Council ALF 20120225, ALF
20150290, and Västerbotten County Council ALFVLL-225251, ALFVLL-549931]. The funding
sources had no role in study design, data collection, analysis or interpretation of results nor
in writing the manuscript or submitting it for publication.
 12

Acknowledgements
None

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Figure 1.
 14

Table 1. Baseline characteristics

Of 479 patients being assessed after self-harm in Stockholm 2012–2016.

Age Median (IQR): 33 years (23 - 49)

N %

Women 329 68.7%

Men 150 31.3%

Suicide attempt at index 386 80.6%

Non suicidal self-injury (NSSI) at 93 19.4%

index

Self-harm method

Intoxication 280 58%

Cutting 130 27%

Hanging 55 11%

Previous suicide attempt 331 69.1%

Previous NSSI 252 53.2%

Clinical diagnosis at index

Anxiety disorder (F40-48) 189 39.5%

Mood disorder (F30-39) 139 29%

Personality disorder (F60) 107 22.3%

Substance use disorder (F10-19) 86 18%

Disturbance of activity and attention 53 11.1%

(F90.0)

Autism spectrum disorder 42 8.8%

(F84-89)
 15

Psychotic disorder (F20-29) 15 3.1%

IQR=interquartile range. Clinical diagnoses are in both first and secondary position, not
mutually exclusive. More than one self-harm method possible.
 16

Table 2
Clinical risk assessment and Suicide Intent Scale, performance in prediction of suicide within
a year of an index episode of self-harm. All proportions are presented with 95 % confidence
intervals.

Clinical risk assessment SIS SIS Clinical risk ≥3

High risk=total score ≥3 High risk=total score ≥16 High risk=total score ≥18 SIS score ≥1
n=422 n=457 n=457 n=446

Alive Dead by suicide Alive Dead by suicide Alive Dead by suicide Alive Dead by s
Low risk 254 4 245 4 308 4 378 6
High risk 154 10 199 9 136 9 54 7
Total 408 14 444 13 444 13 432 13
Sensitivity 71.4% (42.0 – 90.4) 69.2% (38.9 – 89.6) 69.2% (38.9 – 89.6) 53.8 (26.1 – 79
Specificity 62.3% (57.3 – 66.9) 55.2% (50.4 – 59.9) 69.4% (64.8 – 73.6) 87.5 (83.9 – 90
PPV 6.1% (3.1 – 11.2) 4.3% (2.1 – 8.3) 6.2% (3.1 – 11.8) 11.5 (5.1 – 22
NPV 98.4% (95.8 – 99.5) 98.4% (95.7 – 99.5) 98.7% (96.5 – 99.6) 98.4 (96.5 – 99
Proportion
38.9% (34.2 – 43.7) 45.5% (40.8 – 50.2) 31.7% (27.5 – 36.2) 13.7 (10.7 – 17
high risk
Odds ratio 4.1 (1.3 – 13.4) 2.7 (0.8 – 9.1) 5.1 (1.5 – 16.8) 8.2 (2.6 – 25.

p-value 0.018 0.094 0.008 <0.001

PPV=positive predictive value, NPV=negative predictive value

 17

Declarations of interest: None