The Columbia SuicideScreen: Validity and Reliability of a Screen for Youth Suicide and Depression

doi:10.1097/00004583-200401000-00016

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 43, Issue 1, January 2004, Pages 71-79

https://doi.org/10.1097/00004583-200401000-00016 Get rights and content

ABSTRACT

Objective

This study reports on the psychometric properties of a brief, self-administered screening questionnaire, the Columbia SuicideScreen® (CSS), intended to identify high school students at risk for suicide.

Method

Seventeen hundred twenty-nine 9th- to 12th-grade students completed the CSS and Beck Depression Inventory during school hours in 1991 to 1994. Three hundred fifty-six students who screened positively and 285, group matched on age, gender, and ethnicity, who screened negatively were examined on the Diagnostic Interview Schedule for Children (DISC), version 2.3, to assess validity. The DISC-based suicide risk criterion was suicidal ideation or prior suicide attempt and a DSM-III-R diagnosis of major depression or dysthymia or substance use. Test–retest reliability was assessed in a subsample of 85.

Results

The most balanced algorithm had a sensitivity of 0.75, specificity 0.83, and positive predictive value 16%. Suicidal ideation and prior attempt item reliabilities (κ) were 0.48 and 0.58, respectively. Eight-day test–retest reliability for the most balanced scoring algorithm was 0.32.

Conclusions

The CSS demonstrated good sensitivity and reasonable specificity identifying students at risk for suicide. A second-stage evaluation would be needed to reduce the burden of low specificity.

Section snippets

Study Design

A convenience sample of 2,583, 9th- to 12th-grade students from seven diverse high schools was identified from school attendance registers in the greater New York metropolitan area. Those who agreed to participate and were present on the screening day (n = 1,729) completed the CSS questionnaire and the BDI, embedded in a larger health survey, at the start of a regular class period during 1991 to 1994. The project and its procedures were presented to parents, school faculty, and administration

RESULTS

The demographic and symptom characteristics of the sample are shown in Table 1. The item prevalence of CSS questions in various population groups is shown in Table 2. Sensitivity, specificity, and positive and negative predictive values of the CSS and BDI in relationship to the DISC are shown in Tables 3 and 4, respectively.

DISCUSSION

This study of 1,729 high school students tested the reliability and validity of a brief screening questionnaire, the CSS, designed to allow adolescents to self-report the presence of the major risk factors for completed suicide. Different combinations and threshold values for individual CSS items were examined. The algorithm that afforded the best balance against the validity criterion (i.e., mood or substance use disorder on the DISC, coupled with suicidal ideation or prior attempt) was

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Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth.
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Citation Excerpt :
Screening: Although there is insufficient evidence to support the routine use of screening for suicide in all adolescents,63 the American Academy of Pediatrics recommends that pediatricians ask questions about depression, suicidal thoughts, mood disorders, bullying, sexual orientation, and other risk factors in their routine history taking at health maintenance visits.64 For those adolescents perceived to be at risk, there are a number of validated screening tools for depression and suicide validated in adolescents.65,66 The American Academy of Pediatrics also recommends routinely discussing the risk of adolescent suicide with parents and specifically asking about whether firearms are kept in the home.64
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Suicidality is a leading cause of death among adolescents. In addition to other psychiatric conditions, youths with attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (DBDs) are at heightened risk for suicide. Decision-making deficits are a hallmark symptom of ADHD and DBDs and are also implicated in suicidal behavior. We examined behavioral and neural differences in decision making among youths with ADHD and DBDs with (SI+) and without (SI−) histories of suicidal ideation.
The Balloon Analog Risk Task, a risky decision-making task, was completed by 57 youths with ADHD and DBDs (38% SI+) during functional magnetic resonance imaging. Mean stop wager (mean wager at which youths bank money) was the primary measure of risk taking. We conducted whole-brain and region-of-interest analyses in the anterior cingulate cortex and orbitofrontal cortex (OFC) during choice (win vs. inflate) and outcome (inflate vs. explode) contrasts using parametric modulators accounting for probability of balloon explosion.
There were no differences between SI+ and SI− youths in Balloon Analog Risk Task performance. SI+ youths showed decreasing activation in the right medial frontal gyrus when choosing inflate as explosion probability increased compared with SI− youths. During explosions, SI− youths showed increasing activation in the left OFC as explosions became more likely. SI+ showed increasing left medial OFC activity in response to inflations as explosion probability increased.
SI+ youths may show heightened sensitivity to immediate reward and decreased sensitivity to potential loss as evidenced by medial frontal gyrus activity. OFC findings suggest that SI+ youths may be drawn to reward even when there is high probability of loss.
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Functional alterations in the subregions of the anterior cingulate cortex (ACC) have been observed in patients with major depressive disorder (MDD). Studies have shown that higher depressive symptoms are associated with altered functional connectivity (FC) in different ACC sub-regions. Suicide is highly prevalent in patients with MDD; however, it is unclear whether suicidal behavior is associated with the FC alterations in the subregions of the ACC in these indibiduals. Seventy-six patients with MDD (41 with and 35 without a history of suicidal behavior) underwent functional magnetic resonance imaging (fMRI) and were assessed using the Hamilton Rating Scale for Depression (HAMD), the Scale for Suicide Ideation (SSI), and the Columbia Scale for Rating of Suicide Severity. We investigated the FC between the ACC subregions and other brain regions in young MDD patients with and without a history of suicidal behavior. The FC in the subregions of the ACC-superior frontal gyrus differed significantly between the two groups. Additionally, the anterior sgACC-right caudate FC and the pgACC-left insula FC were found to be abnormal in the suicidal MDD group. Interestingly, the suicidal ideation score positively correlated with decreased FC in the pgACC-superior frontal gyrus in both groups, but it negatively correlated with increased FC in the anterior sgACC-superior frontal gyrus in the non-suicidal MDD group. Our findings indicate that altered connections of subregions in the ACC may be involved in the neurological mechanisms underlying suicide in young adults with MDD.

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: This work was supported by Centers for Disease Control grant R49/CCR 202598, NIMH grants P30 MH 43878 and ST32MH-16434, and grants from the American Mental Health Foundation and the Joy and William Ruane Center at Columbia University.

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ARTICLESThe Columbia SuicideScreen: Validity and Reliability of a Screen for Youth Suicide and Depression

ABSTRACT

Objective

Method

Results

Conclusions

Section snippets

Study Design

RESULTS

DISCUSSION

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

Measurement of feelings using visual analog scales

Proc R Soc Med

Beck Depression Inventory Manual

Antidepressant medication and suicide in Sweden

Pharmacoepidemiol Drug Saf

Primary care pediatrics and child psychopathology: a review of diagnostic, treatment, and referral practices

Pediatrics

Psychiatric disorders in pediatric primary care

Arch Gen Psychiatry

Suicidality, hopelessness, and attitudes toward life and death in children

Death Stud

Suicide Probability Scale

A Measure of Adolescent Potential for Suicide (MAPS): development and preliminary findings

Suicide Life Threat Behav

Measuring Suicidal Behavior and Risk in Children and Adolescents

ARTICLES
The Columbia SuicideScreen: Validity and Reliability of a Screen for Youth Suicide and Depression