The Concise Health Risk Tracking Self-Report (CHRT-SR) assessment of suicidality in depressed outpatients: A psychometric evaluation

Trajectories of suicidal ideation during rTMS for treatment-resistant depression

BACKGROUND

rTMS is a safe and effective intervention for treatment-resistant depression (TRD). However, there is limited data on its specific impact on suicidal ideation (SI), and the trajectory of SI over the treatment course.

OBJECTIVE

This open-label clinical trial investigated SI outcomes and trajectories in patients with TRD receiving low-frequency rTMS (LFR) to the right dorsolateral prefrontal cortex (DLPFC; N = 55).

METHODS

A latent class mixed-effect model was used to identify response trajectories for SI as well as core mood symptoms. Logistic regression analyses investigated risk factors associated with identified trajectories.

RESULTS

For each symptom domain, we identified two distinct trajectories during LFR, one tracking improvement (SI: n = 35, 60 %; mood: n = 29, 53 %) and the other tracking no improvement (SI: n = 20, 40 %; mood: n = 26, 47 %). Male sex, higher baseline anxiety, and higher baseline SI were risk factors for no improvement of SI; while higher baseline anxiety and benzodiazepine use were risk factors for no improvement of mood. Mediation analyses showed that anxiety was a risk factor for no improvement of SI and mood independent of benzodiazepine treatment.

CONCLUSIONS

This is the first study to investigate trajectories of response to LFR to the right DLPFC. SI and mood improved with LFR in most patients but the severity of anxiety symptoms was a factor of poor prognosis for both. Nuanced characterization of SI response to rTMS may lead to critical insights for individualized targeting strategies.

Psychometrics of the Concise Health Risk Tracking Self-Report (CHRT-SR16) Assessment of Suicidality in a Sample of Adults with Moderate to Severe Methamphetamine Use Disorder: Findings from the ADAPT-2 Randomized Trial

Background

The co-occurrence of suicidality and substance use disorders has been well established, but rating scales to examine suicidal behavior and risk are sparse among participants with substance use disorders. We examined the psychometric properties of the 16-item Concise Health Risk Tracking Scale - Self Report (CHRT-SR₁₆) to measure suicidality among adults with moderate-to-severe methamphetamine use disorder.

Methods

Participants (n = 403) with moderate-to-severe methamphetamine use disorder completed the CHRT-SR₁₆ as part of a randomized, double-blind, placebo-controlled pharmacotherapy trial. The CHRT-SR₁₆ factor structure was assessed using confirmatory factor analysis (CFA). Internal consistency was estimated with coefficients alpha (α) and omega (ω), test-retest reliability with intraclass correlation coefficient (ICC) and standard error of measurement, and convergent validity using Spearman's ρ rank order correlation coefficient test between CHRT-SR₁₆ factors and the Patient Health Questionnaire (PHQ-9). The analyses utilized baseline and week 1 data (for test-retest reliability only).

Results

CFA revealed a seven-factor model of Pessimism, Helplessness, Social Support, Despair, Impulsivity, Irritability, and Suicidal Thoughts as the best-fitting model. The CHRT-SR₁₆ also exhibited strong internal consistency (α = 0.89; ω = 0.89), test-retest reliability (ICC = 0.78) and convergent validity with the PHQ-9 total score (ρ = 0.62).

Conclusion

The CHRT-SR₁₆ showed strong psychometric properties in a sample of participants with primary methamphetamine use disorder.

Clinicaltrialsgov Identifier

NCT03078075.

Predictive value of suicidal risk assessment using data from China's largest suicide prevention hotline

BACKGROUND

Suicide hotlines are widely used, with potential for identification of callers at especially high risk.

METHODS

This prospective study was conducted at the largest psychological support hotline in China. From 2015 to 2017, all distressed callers were consecutively included and assessed, using a standardized scale consisting of 12 elements, yielding scores of high risk (8-16), moderate risk (4-7), and low risk (0-3) for suicidal act. All high-risk and half of moderate- and low-risk callers were scheduled for a 12-month follow-up. Main outcomes were suicidal acts (nonlethal attempt, death) over follow-up.

RESULTS

Of 21,346 fully assessed callers, 5822, 11,791, and 3733 were classified as high-, moderate-, or low-risk for suicidal acts, with 8869 callers (4076 high-, 3258 moderate-, and 1535 low-risk) followed up over 12 months. Over follow-up, 802 (9.0 %) callers attempted suicide or died by suicide. The high-risk callers (15.1 %) had 3-fold higher risk for subsequent suicidal acts than moderate- (5.1 %) and 12-fold higher risk than low-risk callers (1.3 %). The weighted sensitivity, specificity, and positive predictive value of high risk scores were 56.4 %, 74.9 %, and 14.4 %.

LIMITATIONS

Assessed callers with different risk levels were followed disproportionally.

CONCLUSIONS

Suicidal risk assessment during a hotline call is both feasible and predictive of risk, guiding resource allocation to higher risk callers.

Assessing suicidality during the SARS-CoV-2 pandemic: Lessons learned from adaptation and implementation of a telephone-based suicide risk assessment and response protocol in Malawi

The SARS-CoV-2 pandemic led to the rapid transition of many research studies from in-person to telephone follow-up globally. For mental health research in low-income settings, tele-follow-up raises unique safety concerns due to the potential of identifying suicide risk in participants who cannot be immediately referred to in-person care. We developed and iteratively adapted a telephone-delivered protocol designed to follow a positive suicide risk assessment (SRA) screening. We describe the development and implementation of this SRA protocol during follow-up of a cohort of adults with depression in Malawi enrolled in the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP) randomized control trial during the COVID-19 era. We assess protocol feasibility and performance, describe challenges and lessons learned during protocol development, and discuss how this protocol may function as a model for use in other settings. Transition from in-person to telephone SRAs was feasible and identified participants with suicidal ideation (SI). Follow-up protocol monitoring indicated a 100% resolution rate of SI in cases following the SRA during this period, indicating that this was an effective strategy for monitoring SI virtually. Over 2% of participants monitored by phone screened positive for SI in the first six months of protocol implementation. Most were passive risk (73%). There were no suicides or suicide attempts during the study period. Barriers to implementation included use of a contact person for participants without personal phones, intermittent network problems, and pre-paid phone plans delaying follow-up. Delays in follow-up due to challenges with reaching contact persons, intermittent network problems, and pre-paid phone plans should be considered in future adaptations. Future directions include validation studies for use of this protocol in its existing context. This protocol was successful at identifying suicide risk levels and providing research assistants and participants with structured follow-up and referral plans. The protocol can serve as a model for virtual SRA development and is currently being adapted for use in other contexts.

The 9-item Concise Health Risk Tracking - Self-Report (CHRT-SR9) measure of suicidal risk: Performance in adult primary care patients

PURPOSE

To evaluate the psychometric properties of a 9-item Concise Health Risk Tracking Self-Report (or CHRT-SR₉) to assess suicidal risk in adult primary care outpatients.

METHODS

Overall, 369 adults completed the original 14-item version of CHRT-SR at baseline and within 4 months thereafter, from which the CHRT-SR₉ was extracted using multigroup confirmatory factor analysis. Measurement invariance (across age and sex) and classical test theory characteristics of the CHRT-SR₉ were evaluated. Concurrent validity was assessed by comparing CHRT-SR₉ responses to those of the suicide item in the Patient Health Questionnaire (PHQ-9), both cross-sectionally and as a change measure over time.

RESULTS

Confirmatory factor analysis identified the CHRT-SR₉ as the optimal solution. Factors included pessimism, helplessness, despair (2 items each) and suicidal thoughts (3 items). Measurement invariance held across sex and age groups, indicating that mean differences among sub-groups were real and not attributable to measurement bias. Classical test theory revealed acceptable item-total correlations overall (0.57-0.79) and internal consistency (Spearman-Brown from 0.76 to 0.90). Concurrent validity analyses revealed that the CHRT-SR₉ can measure both improvement and worsening of suicidality over time. A PHQ-9 response of 0, 1, 2, and 3 on the suicide item corresponded to 7.82 (5.53), 16.80 (4.99), 20.71 (5.36), and 25.95 (7.30) (mean and SD) on CHRT-SR₉ total score, respectively.

CONCLUSION

The CHRT-SR₉ is a brief self-report evaluating suicidality with excellent psychometric properties that is sensitive to change over time.

Suicidality as a Predictor of Overdose among Patients with Substance Use Disorders

Increasing rates of overdose and overdose deaths are a significant public health problem. Research has examined co-occurring mental health conditions, including suicidality, as a risk factor for intentional and unintentional overdose among individuals with substance use disorder (SUD). However, this research has been limited to single site studies of self-reported outcomes. The current research evaluated suicidality as a predictor of overdose events in 2541 participants who use substances enrolled across eight multi-site clinical trials completed within the National Drug Abuse Treatment Clinical Trials Network between 2012 to 2021. The trials assessed baseline suicidality with the Concise Health Risk Tracking Self-Report (CHRT-SR). Overdose events were determined by reports of adverse events, cause of death, or hospitalization due to substance overdose, and verified through a rigorous adjudication process. Multivariate logistic regression was performed to assess continuous CHRT-SR score as a predictor of overdose, controlling for covariates. CHRT-SR score was associated with overdose events (p = 0.03) during the trial; the likelihood of overdose increased as continuous CHRT score increased (OR 1.02). Participants with lifetime heroin use were more likely to overdose (OR 3.08). Response to the marked rise in overdose deaths should integrate suicide risk reduction as part of prevention strategies.

The Concise Health Risk Tracking - Self-Report (CHRT-SR)-A measure of suicidal risk: Performance in adolescent outpatients

OBJECTIVES

The Concise Health Risk Tracking Self-Report (CHRT-SR) assesses the risk of suicidal behavior. We report its psychometric properties in a representative sample of adolescent outpatients.

METHODS

A sample (n = 657) of adolescents (<18 years of age) in primary or psychiatric care completed the 14-item version of CHRT-SR at both baseline and within 3 months. To identify an optimal brief solution for the scale, we evaluated the factor structure of CHRT-SR using multigroup confirmatory factor analysis, and testing measurement invariance across age and gender. The item response theory and classical test theory characteristics of the optimal solution were evaluated. Concurrent validity (both cross-sectional and as a change measure over time) of the optimal solution was assessed by comparing it to another suicide measure.

RESULTS

Confirmatory factor analysis identified the 9-item CHRT-SR (CHRT-SR₉ ) as the optimal solution. Classical test theory and item response theory indicated excellent fit. Concurrent validity analyses revealed that it can measure both improvement/worsening of suicidality over time.

CONCLUSION

The CHRT-SR₉ is a brief self-report with excellent psychometric properties in a sample of adolescents that is sensitive to changes in suicidality over time. Its performance in other populations and ability to predict future suicidal events deserves study.

The Concise Health Risk Tracking-Self Report: Psychometrics within a placebo-controlled antidepressant trial among depressed outpatients

BACKGROUND/AIMS

While substantial prior research has evaluated the psychometric properties of the 12-item Concise Health Risk Tracking-Self Report (CHRT-SR₁₂), a measure of suicide propensity and suicidal thoughts, no prior research has investigated its factor structure, sensitivity to change over time, and other psychometric properties in a placebo-controlled trial of antidepressant medication, nor determined whether symptoms change throughout treatment.

METHODS

Participants in the multi-site Establishing Moderators and Biosignatures of Antidepressant Response in Clinical Care (EMBARC) study ( n=278) provided data to evaluate the factor structure and sensitivity to change over time of the CHRT-SR₁₂ through eight weeks of a clinical trial in which participants received either placebo or antidepressant medication (sertraline).

RESULTS/OUTCOMES

Factor analysis confirmed two factors: propensity (comprised of first-order factors including pessimism, helplessness, social support, and despair) and suicidal thoughts. Internal consistency (α's ranged from 0.69-0.92) and external validity were both acceptable, with the total score and propensity factor scores significantly correlated with total scores and single-item suicidal-thoughts scores on the self-report Quick Inventory of Depressive Symptoms and the clinician-rated 17-item Hamilton Rating Scale for Depression. Through analyzing CHRT-SR₁₂ changes over eight treatment weeks, the total score and both the factors decreased regardless of baseline suicidal thoughts. Change in clinician-rated suicidal thoughts was reflected by change in both the total score and propensity factor score.

CONCLUSIONS/INTERPRETATION

These results confirm the reliability, validity, and applicability of the CHRT-SR₁₂ to a placebo-controlled clinical trial of depressed outpatients receiving antidepressant medication.