1. PSYCHOMETRIC PROPERTIES OF THE TURKISH VERSION OF COLUMBIA-SUICIDE SEVERITY RATING SCALE AMONG YEAR-OLD ADOLESCENTS IN TURKEY
Adem Gunes1, M.D., Ayse Kilincaslan1, M.D., Mehmet Eskin2, M.S.
1Department of Child and Adolescent Psychiatry, Istanbul School of Medicine, Istanbul University
2Department of Psychiatry, Aydin School of Medicine, Aydin University
We warrant that we have no conflict of
interest in general or in connection with
this poster and no financial relationship
with any pharmaceutical company.
Poster ID24036
One Way ANOVA *p<0,05 **p<0,01
Group 1: Suicidal attempts in the last month
Group 2: Major Depression
Group 3: Clinical Sample
Group 4: Community Sample
CONCLUSIONS
INTRODUCTION
RESULT
METHOD
The Turkish version of the C-SSRS is a reliable and valid instrument that can be used for the assessment of suicide risk among adolescents between 12 and 18 years of age. The inter-rater reliability and internal consistency coefficients, and correlation values with other standard instruments are high. Current suicidal ideation subscale scores distinguish the last-month suicidal attempters from the other groups (depression, non-depressive psychiatric outpatient and non-psychiatric patient groups). Current suicidal ideation scores and current/lifetime intensity of suicide ideation subscale scores of the last month suicide attempters are different from non-depressive psychiatric and non-psychiatric samples, but similar to that of the depressive sample.
Suicide and suicidal attempts are accepted as an important public health problem both in Turkey and worldwide. According to State Statistics Institute data, annual suicide rate in Turkey was 4.19/ in 2013 (1). Studies done in Turkey showed that prevalence of suicidal attempts is still low in Turkey, however rate of increase is strikingly high (2). After the geriatric population (>75 years), the prevalence rates are the highest among adolescents between 15 and 19 years of age (1). Adolescent suicide attempts have become one of the most common psychiatric emergencies in recent years and there is a great need for studies investigating screening and treatment of suicide in this population (3,4).
Clinical interview is very important to assess the suicide risk and structured assessment of suicidal ideation and behavior significantly improves identification of high-risk groups relative to a routine clinical interview (5). Although there is a few number of Turkish self-report suicide scales, there exist no standardized and structured assessment tools to evaluate suicidal risk in Turkey. Columbia-Suicide Severity Rating Scale (C-SSRS) is one of the few and most commonly used standard measures that assesses both suicidal ideation and behavior. The aims of the present study are to assess the validity and reliability of the Turkish version of the Columbia-Suicide Severity Rating Scale (C-SSRS) and to determine the distinguishing properties of C-SSRS for the suicidal risk in different adolescent samples.
Table 1. Descriptive data and suicidal ideation rates for each group
Statistical analyses were performed using SPSS Kappa and Cronbach-alpha values were calculated for the assessment of inter-rater agreement and internal consistency, respectively. Pearson test was used for correlations. The scores of the four clinical groups were assessed with One-Way Analysis of Variance (ANOVA) test, and Tukey HSD test was used for post-hoc comparisons. A p value of< 0.05 was accepted for statistical significance.
Group 1
(n=41)
Group 2
(n=50)
Group 3
Group 4
(n=70) p
Gender (n/%)
Male
3 (7.3)
18 (36)
28 (56)
31 (44.3)
0.001**
Female
38 (92.7)
32 (64)
22 (44)
39 (55.7)
Age (mean/SD)
15.63 (1.33)
15.06 (1.63)
14.38 (1.56)
14.88 (1.72)
C-SSRS Suicide Ideation (n/%)
No Ideation
Last Month
9 (20.9)
7 (14)
43 (86)
61 (87.1)
Lifetime
8 (19.5)
5 (10)
37 (74)
56 (80)
Passive Ideation
4 (9.8)
19 (38)
2 (4)
3 (4.3)
5 (12.2)
11 (22)
7 (10)
Active Ideation
0 (0)
10 (20)
5 (7.1)
6 (12)
Ideation + Method
1 (2.4)
3 (6)
1 (1.4)
1 (2)
Ideation + Intent
24 (58.5)
8 (16)
18 (16)
Ideation + Plan
0,049*
0.049*
RESULT
The study sample included 131 females and 80 males. The mean age of the whole group was ± Age, gender and the most severe ideation of the participants according to groups are shown in Table 1.
Concerning inter-rater reliability, kappa values for the most severe ideation scores in the last month and lifetime, were found to be 0.91 and 0.76, respectively. Cronbach alpha coefficients for intensity of ideation in the last month and lifetime were 0.91 and No elevation was observed in these values when any of the items was removed.
Most severe ideation scores of the C-SSRS were highly correlated with the suicide item of the CDI (last month: r=0.88 p<0.01; lifetime r=0.83, p<0.01), SPS-suicide subscale score (last month: r=0.83, p<0.01; lifetime r=0.82, p<0.01), SPS-total score (last month: r=0.77, p<0.01; lifetime r=0.78, p<0.01) and the MINI-suicide score (last month: r=0.88, p<0.01; lifetime r=0.82, p<0.01. The correlation coefficients were lower with the suicide items of the parent reported CBCL (item 18 “Deliberately harms self or attempts suicide, last month r=0.60, p<0.01; lifetime r=0.61, p<0.01 and for item 92 “talks about killing self”, last month r=0.57, p<0.01; lifetime r=0.60, p<0.01). Intensity of suicide ideation scores of the C-SSRS (last month and lifetime) scores were also strongly correlated with most of the above parameters. Pearson correlation values (p values and correlation coefficients) are summarized in Table 2.
One-way between-groups ANOVA was applied to determine if the severity of suicidal ideation differentiates the four adolescent groups. The groups differed according to severity (last month and lifetime) and intensity (last month and lifetime) of suicidal ideation. Post-hoc Tukey HSD test revealed that the mean scores of the C-SSRS most severe suicide ideation scores in the last month was statistically higher in Group 1 (M= 2.87, SD= 1.81) compared to Group 2 (p<0.01, M=1.9, SD=1.48), Group 3 (p<0.01, M=.24, SD=0.62) and Group 4 (p<0.01, M=0.22, SD=0.64). Lifetime most severe suicide ideation scores of Group 1 (M=2.90, SD=1.78) was higher than Group 3 (p<0.01, M=0.48, SD=0.91) and Group 4 (p<0.01, M=0.34, SD=0.79) but similar to Group 2 (p=0.527, M=2.54, SD=1.55). Suicide attempt group showed significant difference in the scores of current and lifetime intensity of suicidal ideation (M=10, SD=6.9; M=10.43, SD=6.78) with group 3 (M=0.90, SD=2.54 current; M=1.68, SD=3.35 lifetime) and group 4 (M=0.84, SD=2.48 current; M=1.32, SD=3.01 lifetime), but not with group 2 (M=8.08, SD=5.21 current; M=10.46, SD=5.03 lifetime).
METHOD
Translation
After obtaining necessary approvals from the local ethics committee and governmental authorities, the study was initiated. The Turkish translation of the C-SSRS was provided by Kelly Posner, the developer of the scale. Linguistic validation was conducted by several clinicians proficient in both Turkish and English and included four steps: revision of the scale by two of the researchers for clinical and cultural issues, independent comparison of the original and translated forms and revision by two psychiatrists experienced on adolescent suicide, establishment of the final version by the consultant who is experienced as a clinician and researcher in adolescent suicide and suicide scales, and the final revision of the draft after a pilot study with 20 participants for language intelligibility. Two clinicians completed the C-SSRS online education module and evaluated 25 cases for inter-rater reliability.
Instruments & Procedure
The participants were recruited from Child and Adolescent Psychiatric Outpatient Clinic and Pediatric Emergency Service of the Istanbul Faculty of Medicine, and a General Practitioner (GP)’s office. Four different patient groups between the ages 12 and 18 were included in the study: suicide attempters in the last month (Group 1: n=41), major depression group (Group 2: n=50), non-depressive psychiatric outpatient group (Group 3: n=50), and non-psychiatric GP outpatient group (Group 4: n=70). The psychiatric diagnoses were given according to DSM-IV and patients with active psychosis, mental retardation and autistic spectrum disorder were excluded. Patients in the non-psychiatric outpatient group were excluded if they got any psychiatric diagnosis. All participants underwent psychiatric interview and filled in the C-SSRS, Suicide Probability Scale (SPS), MINI Suicidal Scale – Kid, Child Depression Inventory (CDI), Beck Hopelessness Scale (BHS) and the parents filled in the Child Behavior Checklist (CBCL).
REFERENCES
RESULT
1.Turkish State Statistics Institute, Suicide Statistics, 2013 (
2.Devrimci-Ozguven H, Sayıl I. Suicide attempts in Turkey: results of the WHO-EURO Multicentre Study on Suicidal behaviour. Can J Psychiatry 2003; 48:
3.Borges G, Benjet C. Suicide Ideation, Plan, and Attempt in the Mexican Adolescent Mental Health Survey. J . Am. Acad. Chıld Adolesc. Psychıatry. 2008; 47:1.
4.Eaton DK, Kann L, Kinchen S, Shanklin S, Flint KH. Hawkins J, Wechsler H. Youth risk behavior surveillance - United States, MMWR Surveill Summ, 2012; 61(4), 1–162.
5.Bongiovi-Garcia ME, Merville J, Almeida MG, Burke A, Ellis S, Stanley BH, Posner K, Mann JJ, Oquendo MA. Comparison of clinical and research assessments of diagnosis, suicide attempt history, and suicidal ideation in major depression. J Affect Disord 2009; 115:183–188
Table 2. Correlation between C-SSRS scores with other measures.
C-SSRS
(N=211)
CDI suicide item
CDI
total score
SPS
suicide subscale
SPS total score
BHS
CBCL
item 18
item 92
int. score
ext.
score
tot.
MINI suicide
KID total score
MSI Last Month
.905**
.727**
.831**
.772**
.697**
.575**
.545**
.401**
.338**
.441**
.857**
MSI Lifetime
.843**
.720**
.832**
.769**
700**
.596**
.501**
.396**
383**
.454**
.877**
ISI Last Month
.899**
745**
.837**
.780**
.713**
562**
.558**
.412**
.335**
.446*
.796**
ISI Lifetime
.734**
.775**
.696**
.569**
.605**
.403**
.363**
.448**
Suicide Last
Month
.421**
.250**
.379**
.297**
.247**
.496**
.440**
.179**
.256**
.255**
.710**
Suicide Lifetime
.548**
.283**
.529**
.432**
.360**
.647**
.555**
.245**
.322**
.329**
.806**
Risk Level
.691**
.539**
.673**
.589**
.504**
.554**
.364**
.394**
.437**
.937**
Pearson correlation *p < **p < .01
C-SSRS: Columbia Suicide Severity Rating Scale, MSI: Most Severe Ideation, ISI: Intensity of Suicide Ideation, CDI: Child Depression Inventory, SPS: Suicide Probability Scale, BHS: Beck Hopelessness Scale, CBCL: Child Behavior Checklist, MINI: Mini International Neuropsychiatric Interview for Children and Adolescents