Suicidality includes suicidal ideation, plans, actual suicide attempts and completed suicide. Suicidality is considered a calamity in mental health care, general health care and society in general. In developed countries, the prevalence of suicidal ideation, plans and attempts in the adult population over 12 months is respectively 2.1%, 0.7%, 0.4% [1]. Suicidality is an erratic pattern of behaviour that serves as a precursor to suicide. Suicide is the leading cause of non-natural death worldwide and the second leading cause of mortality in individuals aged 15–29 years [2]. Suicide is widely considered the worst possible outcome within mental health care. The precursor of suicide -suicidality - is complex and multifactorial, and the result of a wide range of interacting psychological, psychiatric, genetic, social, economic, cultural, and other risk factors operating at multiple levels (societal, community, relationship, and individual) [1].
Suicidality is a heterogeneous, seemingly non-consistent phenomenon [3-6] and it is not a clearly well-defined psychiatric symptom. Officially, it only occurs as a symptom in two psychiatric classifications: major depressive disorder and borderline personality disorder [7, 8]. For a number of psychiatric diagnoses though, suicidality is a frequently occurring symptom as is the case for PTSD, sleep disorders and adjustment disorders [9, 10]. Despite the great complexity involved in the assessment and risk taxation of suicidality, there is little empirical research on the differentiation or subtypes of this phenomenon [11, 12].
From a clinical mental health care perspective, several forms of suicidality can be distinguished, while availability of a demarcated description is lacking in scientific literature [4].
To what extent (mental) health workers, the suicidal patient or society are able to take responsibility for safety of a patient during the recovery from a suicidal condition, is something improved differentiation may be able to distinguish ([6] and figure 1).
Guidelines pay much attention to general aspects of the diagnosis and treatment of suicidality, but, apart from making a distinction between an acute and chronic type, they lack a clear differentiation of suicidality [13, 14].
Clinical differentiation of somatic disorders and/or symptoms is important as it contributes to the development and improvement of general medicine and somatic care. Examples are the differentiation and classification of diabetes [15], breast cancer [16] and dementia [17]. More specific subdivisions of somatic symptomatology also exist, like the subcategories of diarrhoea: watery, fatty or inflammatory [18]. Differentiation of disorders has resulted in improved diagnosis, more effective treatment and targeted counselling strategies. Along this line we Extending the concept of differentiation to suicidality: we believe differentiation of suicidality will support improved clinical practice, better risk assessment, prognosis, etiological knowledge, more accurate scientific research and more effective treatment. Formulation of different levels of responsibility for (mental) health workers will be improved with differentiation of suicidality [19-22].
The experience of entrapment seems to play a crucial role for the aetiology of suicidality as described in the Integrated model of stress vulnerability [23] and the integrated[24] stress-entrapment model developed for the Dutch suicide prevention guideline [25]
So far, we have developed a differentiation model for suicidality, based on both clinical practice [4, 6] and on a theoretical dimensional approach of psychopathology and personality [26]. We discussed the model extensively, tested it with colleagues and patient experts at several conventions, including with a discussion forum in which 50 psychiatrists took part [27], and revised the model accordingly. To be able to research the model, the SUICIdality DIfferentiation(SUICIDI-2) [6]) questionnaire was developed and updated over the recent years into version 2 with a 0, 1 and 2 score, see: https://suicidaliteit.nl/SUICIDI/SUICIDI%20translation.pdf
The differentiation model of suicidalitydifferentiates 4 subtypes of suicidality (figure 1) [4, 6]:
1) perceptual disintegration (PD); originated from the context of disturbed perceptions and/or behaviours,
2) primary depressive cognition (PDC); in the context of (a) depressive cognition(s),
3) psychosocial turmoil/“entrapment” (PT); in the context of acute reactivity to a (deemed or actual) loss, offence, adversity or doom,
4) inadequate communication/coping (IC) (Emphasizing Emotional Pain); in the context of communicating about intense suffering.
Figure 1 Hypothetical model for 4 suicidal subtypes.
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Outreaching psychiatric emergency services often become involved in assessment of suicidality when it is recognized -or suspected- as a critical event by society, patient himself, significant other and/or healthcare professionals . Acute emergency services are required to set up policies around suicidality, appropriate treatment and safety planning [28]. In the Netherlands, the employees of these services are almost exclusively medical doctors or specialized consultant psychiatrists and (specialised) nurses. Psychologists are rarely present within these services [29].
An independent, consultant psychiatrist decides which policy to follow, based on the assessment of the crisis service, for example whether or not to move a person will be voluntarily or involuntarily to a psychiatric emergency facility [30]. Crisis services and acute admission wards are frequently confronted with serious suicidal behaviour and make a significant contribution to the prevention of suicide [31, 32]. These services though do not differentiate between different types of suicidality [28]. In a former position paper we described the study protocol [6].
Aim
In this first study we examine the feasibility and validity of a clinical differentiation model of suicidality[6]. We aim to answer the following questions:
1) Is the differentiation model workable for a selection of mental health care workers?
2) Can conclusions of patient records of suicidal high risk patients assessed by the outreach psychiatric emergency services, be rated in an absolute/discrete and gradual way?
3) Can clinicians allocate validly most/all cases to the proposed subtypes (PD, PDC, PT and IC)?
4) How are subtypes distributed?
5) Are these subtypes gradual delineated by using two different modes of gradual scoring (according SUICIDI questionnaire and an alternative 0-4 score per subtype), and is there consensus when different clinicians/investigators independently score them? What is de reliability of the different modes of scoring?
6) Which choice can be made in which form of gradual scoring? And is there any way to improve the SUICIDI-II questionnaire?
7) Can we perform a qualitative analysis after getting the results? When performing a qualitative analysis of scoring for the model can we provide feedback to the raters if there is any indication that incorrect scoring may have occurred?