Val/Met BDNF as a genetic risk for a false sense of security in post-discharge suicide risk

BACKGROUND

The time after discharge from psychiatric inpatient care is one of the most dangerous periods in terms of suicide risk. Predicting who is at higher risk could help with resource allocation to assure patients at high risk of suicide attempts are most closely followed. We previously showed that inpatients who improve their suicide ideation levels faster while in inpatient treatment are the ones with highest rates of post-discharge suicide. Here, we studied the possible genetic underpinnings associated with such risk.

METHOD

We recorded the slope of suicide ideation recovery of 710 psychiatric inpatients from which we studied two genetic variants likely associated with suicide risk: The serotonin transporter variant 5-HTTLPR, and the BDNF gene variant Val66Met.

RESULTS

We found that inpatients carrying the BDNF Met variant (hypothesized as conferring higher suicide risk) improved their suicide ideation scores faster than Val/Val carrying inpatients. No significant association was found for 5-HTTLPR.

LIMITATIONS

The present sample was genetically homogenous, and future research should replicate these findings on a more diverse sample.

CONCLUSIONS

In conclusion, we found a paradoxical result: Carrying the BDNF Met variant allows inpatients to improve faster, which was shown to confer higher risk at the post-discharge period. This may explain some inconsistencies in the literature in terms of the role of BDNF in suicide ideation and attempts.

Gender Identity and Mental Health Symptom Severity Among Adolescents Admitted to an Inpatient Psychiatric Hospital

Transgender youth are at an increased risk of suicide, substance use, experiencing violent assaults, and reporting major depressive episodes and greater psychological distress compared to their cisgender counterparts. This study examined mental health symptom severity in adolescents admitted to an inpatient psychiatric hospital who wished they were of a different gender compared to those who did not. A group of 180 adolescents admitted to an inpatient psychiatric hospital completed assessments to measure mental health symptom severity at admission. Gender diverse (n = 90) and cisgender (n = 90) groups were established. Analyses of variance (ANOVA) were used to examine between group (gender diverse vs. cisgender) difference on depression, anxiety, suicide risk, nighttime sleep quality, and emotion regulation problems. Results revealed significant differences in emotion regulation difficulties at admission, specifically in nonacceptance and awareness. There were no significant differences on measures of depression, anxiety, suicide risk, and nighttime sleep quality at admission. This study is one of the first to measure mental health symptom severity in gender diverse adolescents while admitted to an inpatient psychiatric setting. Adolescents in the gender diverse group had significantly higher level of difficulty with emotion regulation, which may indicate an increased risk of developing psychiatric symptoms such as depression and anxiety. This paper demonstrates the importance of using targeted interventions to address difficulties with emotion regulation in at-risk adolescents.

Factor Analysis and Validation of the Disturbing Dream and Nightmare Severity Index in an Inpatient Sample

STUDY OBJECTIVES

The Disturbing Dream and Nightmare Severity Index (DDNSI) has been used widely in research and clinical practice without psychometric evidence supporting its use in clinical samples. The present study aimed to explore and confirm the factor structure of the DDNSI in an inpatient sample. We also sought to test the measure's construct validity.

METHODS

Two samples of U.S. inpatients including adult (N = 937) and adolescent (N = 274) participants provided data on nightmares (i.e. DDNSI), sleep quality (i.e. the Pittsburgh Sleep Quality Index) and related psychopathology symptoms (e.g. depression, posttraumatic stress disorder, anxiety).

RESULTS

Exploratory and confirmatory factor analyses found the six original items of the DDNSI to load onto a single latent factor.

CONCLUSIONS

The DDNSI was found to be a valid measure of nightmare frequency and distress, as it was significantly correlated with the items related to disturbing dreams, and the DDNSI was able to differentiate between nightmares and psychopathology symptoms. Though this research comes nearly two decades after the initial creation and use of the DDNSI, it provides a foundation for the scientific rigor of previous and future studies on nightmares using the DDNSI.

Perceived worsening of obsessive-compulsive disorder symptoms after childbirth in women and men: An understudied phenomenon

The aim of this study was to examine worsening of OCD symptoms after childbirth in individuals seeking assessment or treatment of OCD. The postpartum period may make parents biologically and psychologically vulnerable to OCD symptoms. Participants included 222 parents with OCD who completed surveys through a self-help website. Most women and almost half of men with self-reported OCD reported an increase in OCD symptoms following childbirth. Retrospective report of perceived worsening of OCD symptoms after childbirth was associated with more aggressive obsessions for both men and women, in comparison to individuals whose OCD symptoms did not worsen around childbirth. Women whose OCD symptoms worsened after childbirth reported more impairment in social functioning than individuals whose symptoms did not worsen. These results highlight the need to develop a better understanding of aggressive obsessions in parents, and improve education about prevalence, content, assessment, and intervention for aggression-focused intrusive thoughts.

Relationship between parental attachment styles and suicide in adolescents and adults admitted to an inpatient psychiatric hospital

BACKGROUND

Suicide is among one of the leading causes of death in the United States affecting individuals of all ages.

METHODS

We examined the relationship between suicide risk and parental attachment among an inpatient psychiatric sample of 690 adolescents and 1000 adults. Participants completed self-report measures of suicide risk and attachment.

RESULTS

We found that both adolescents and adults with insecure (i.e., preoccupied, dismissive, fearful) maternal and paternal attachment are at a significantly higher risk of suicide compared to those with secure maternal and paternal attachment. Adolescents who endorsed a previous suicide attempt (27.2 %) were less likely to have a secure maternal attachment, while adults who endorsed a previous suicide attempt (28.9 %) were less likely to have secure paternal attachment.

LIMITATIONS

Our sample had limited racial and ethnic diversity which may limit the generalizability of the results to a broader population.

CONCLUSIONS

The present study provides evidence of the importance of parental attachment styles as a predictor of suicide-related behaviors across both adolescents and adults who are admitted inpatient. This suggests the importance of utilizing family-based interventions in order to reduce the risk of suicide.

Nighttime sleep quality & daytime sleepiness across inpatient psychiatric treatment is associated with clinical outcomes

Prior research has demonstrated the strong link between sleep disturbance and mental health outcomes, including the importance of examining nighttime sleep quality and daytime sleepiness as separate constructs in relation to mental health outcomes. As such, the current study examined patients' self-reported nighttime sleep quality and daytime sleepiness trajectories over the course of inpatient treatment and how these trajectories related to treatment outcomes. Participants were 1,500 adults who voluntarily admitted to an inpatient psychiatric hospital. Mental health outcomes measured were emotion regulation problems, anxiety severity, depression severity, nightmare severity, and suicide risk. Group-based trajectory modeling was used to determine nighttime sleep quality and daytime sleepiness trajectory groups. Multivariate analyses of covariance (MANCOVA) were used to determine between group differences on mental health outcomes. Patients fit into distinct groups based on their trajectories of nighttime sleep quality and daytime sleepiness across inpatient psychiatric treatment: Low, Moderate, and High. Individuals with greater nighttime sleep disturbance and greater daytime sleepiness throughout treatment (High group) demonstrated significantly increased suicide risk, higher nightmare severity, more anxiety, more depression, and more emotion regulation difficulties at discharge. Results suggest an important connection exists between nighttime sleep quality and excessive daytime sleepiness and mental health outcomes for inpatient psychiatry.

An Examination of the Treatment Utility of the MMPI-2-RF: Prediction of Post-Treatment Depressive Symptoms and Increased Understanding of the Therapeutic Alliance in an Inpatient Mood Disorder Treatment

The study examined the ability of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) substantive scales to predict depressive symptoms in a psychiatric inpatient setting. The indirect effect of patient-rated alliance with their treatment team on these relationships was also investigated. Participants included 678 (52.5% female, 97.1% White) inpatients diagnosed with a mood disorder. MMPI-2-RF scales, Patient Health Questionnaire (PHQ-9) at intake and discharge, and Working Alliance Inventory-Short at discharge were used to test study hypotheses regarding MMPI-2-RF predictive utility and the influence of alliance. Jacobson and Truax's (1991) reliable change index (RCI) was calculated to identify those who did (74% of the sample) and did not (24%) make reliable and clinically significant depressive symptom change, and the predictive utility of MMPI-2-RF scores in distinguishing these groups was examined. MMPI-2-RF scales assessing internalizing and somatic dysfunction accounted for an additional 2% to 8% of the variance in depressive symptoms reported at discharge, above and beyond depressive symptoms reported at intake. Somatic scales were also able to differentiate groups based on clinically significant change on the PHQ-9 (small-sized effect). The relationship between MMPI-2-RF scales and depressive symptoms at discharge was indirect through alliance in 64% of models. Clinical implications are discussed.

Impact of personality dysfunction on interdisciplinary treatment team working alliance in an inpatient psychiatric population

Cluster B personality disorders (PDs) share specific traits that can result in interpersonal conflict. As therapeutic working alliance has a strong relationship with improved outcomes, there is interest in understanding the relationship between PDs, working alliance, and clinical outcomes. This is especially compelling in inpatient populations, where symptoms are severe, and patients are working with a treatment team. The aims of this study were to (a) assess whether higher team working alliance is associated with lower depressive symptoms, (b) assess whether patients with Cluster B PD traits have worse working alliance with their team than patients without those Cluster B PD traits, and (c) assess whether higher team working alliance is associated with lower depressive symptoms when Cluster B PD traits are present. Team working alliance was measured at baseline and at discharge for 3,406 inpatients at a psychiatric hospital. Improved team working alliance was associated with lower depression scores at discharge. Patients with borderline personality disorder traits had worse team working alliance, whereas patients with narcissistic personality disorder and antisocial personality disorder traits had similar working alliance scores as other patients. Borderline personality disorder and antisocial personality disorder traits moderated the association between team working alliance and depressive symptoms differently. Findings suggest that team working alliance works similarly to therapist working alliance. Of clinical importance is the finding that team working alliance and its relationship with depression symptoms differ based on Cluster B PD traits, and the importance of strong working alliance regardless of interpersonal challenges due to personality pathology. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Nighttime Sleep Quality and Daytime Sleepiness Predicts Suicide Risk in Adults Admitted to an Inpatient Psychiatric Hospital

As sleep problems have been identified as an important, yet understudied, predictor of suicide risk, the present study analyzed the relationship between daytime sleepiness and nighttime sleep disturbance in a high-risk population of adults admitted to an inpatient psychiatric hospital. Objectives were to (1) examine the time course of subjective daytime sleepiness, nighttime sleep disturbance, and suicide risk throughout inpatient psychiatric treatment, (2) examine pre- to post-treatment changes in sleep disturbance with treatment as usual in an inpatient psychiatric setting, and (3) investigate whether daytime sleepiness and nighttime sleep disturbance predicted suicide risk above and beyond anxiety and depression. Participants were 500 consecutively admitted adults admitted to an intermediate length of stay (4-6 weeks) inpatient psychiatric hospital (47% female; 18-87 years of age). Measures of sleep, suicide risk, depression, and anxiety were completed at admission, weeks 1 through 4, and at discharge. Latent growth curve modeling (LGM) and hierarchal linear modeling (HLM) were conducted. The LGM analysis demonstrated that daytime sleepiness, nighttime sleep disturbance, and suicide risk all improved throughout inpatient treatment. Further, HLM showed that daytime sleepiness predicted suicide risk above and beyond symptoms of anxiety, depression, major sleep medications, and prior suicidal ideation and attempts, while nighttime sleep disturbance predicted suicide risk above and beyond symptoms of anxiety, major sleep medications, and prior suicidal ideation and attempts. Findings indicate the need to reevaluate safety protocols that may impact sleep, particularly that may increase daytime sleepiness, and to develop evidence-based sleep interventions for individuals admitted to inpatient psychiatric hospitals.

A next-generation approach to mental health outcomes: Treatment, time, and trajectories

Over the last several decades, inpatient psychiatric length of stay (LOS) has been greatly reduced to the detriment of patients. Latent variable mixture modeling, can be used to improve the quality of care for patients by identifying unobserved subgroups and optimize treatment variables, including LOS. This study had three objectives (1) to replicate the findings made by Oh et al. in a distinct sample, (2) to examine demographic differences related to inpatient treatment trajectories, and (3) to relate additional variables to each trajectory. We collected data on six key mental illness factors and information on felonies, misdemeanors, history of stopping psychiatric medication and psychotherapy, length of time in psychotherapy, and the number of therapists and psychiatrists from 489 patients at an inpatient psychiatric hospital. We derived latent mental illness scores after applying growth mixture modeling to these data. We identified three distinct trajectories of mental illness change: High-Risk, Rapid Improvement (HR-RI), Low-Risk, Partial Response (LR-PR), and High-Risk, Gradual Improvement (HR-GI). The HR-GI group was more likely to have patients who were female, Asian, younger, Yearly Income (YI) <$20,000, that spent more time in psychotherapy throughout their life, and had the longest LOS while inpatient. The LR-PR group had was more likely to be male, Hispanic/Latino and multiracial, older, YI >$500,000, have a history of misdemeanors, and this group had the shortest LOS (p < .05). These findings replicate and extend our previous findings in Oh et al. (2020a) and highlight the clinical utility of agnostically determining the treatment trajectories.

Increased symptom severity in adults and adolescents admitting to an inpatient psychiatric hospital during the COVID-19 pandemic

While the negative effects of Coronavirus Disease-2019 (COVID-19) on general mental health are well-established, less is known about the impact on those with severe mental illness. Thus, this study examined symptom severity among psychiatric inpatients admitted prior to versus during the COVID pandemic. Self-reported anxiety (GAD-7), depression (PHQ-9), emotional dysregulation (DERS-SF), sleep quality (PSQI), nightmares (DDNSI), and suicidal ideation (SBQ-R) were examined in 470 adults (n = 235 admitted pre-pandemic) and 142 children and adolescents (n = 65 admitted pre-pandemic) at admission. Adults also completed measures of disability (WHODAS) and substance use (WHOASSIST). Adults admitted during the COVID pandemic reported significantly higher levels of anxiety [p < .001, partial η²=0.18], depression [p < .001, partial η²=0.06], emotion dysregulation [p < .001, partial η²=0.05], nightmares [p = .013, partial η²=0.01], and disability [p < .001, partial η²=0.04] compared to adults admitted pre-COVID. Levels of anxiety [p = .005, partial η²=0.05], depression [p = .005, partial η²=0.06], and sleep quality [p = .011, partial η²=0.05] were significantly higher among adolescents admitted during COVID compared to pre-COVID. The findings help identify areas of prioritization for future mental health prevention/intervention efforts for future disease outbreaks.

Assessing the clinical utility of MMPI-2-RF interpersonal theory of suicide proxy indices in psychiatric hospitalization setting

INTRODUCTION

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF Ben-Porath & Tellegen, 2008/2011) has been applied to suicide risk assessment through derived proxy indices of perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide (Anestis et al., 2018, Joiner, 2005). However, limited research has examined the clinical utility of these proxy indices outside the outpatient setting. This study examined the performance of these proxy indices in identifying past-month suicide ideation intensity and attempts upon admission to a psychiatric inpatient program and changes in suicidal ideation intensity at discharge. We expected these indices and their interaction would be associated with suicide ideation intensity and attempts at baseline and with a lack of significant improvement in suicide ideation intensity at discharge, including when controlling for MMPI-2-RF Suicide/Death Ideation (SUI) scale scores.

METHOD

Participants were 1007 patients in a private inpatient psychiatric hospital in the southwestern United States, 968 of whom completed study measures at admission and discharge. Participants were administered the C-SSRS and MMPI-2-RF upon admission, while the C-SSRS was administered again prior to discharge. A series of moderation analyses were conducted to examine the main and interaction effects of the MMPI-2-RF derived proxy indices on suicidal ideation intensity and suicide attempts at admission. Logistic regression analyses were conducted to examine whether MMPI-2-RF proxy index scores at admission were associated with changes in suicidal ideation intensity at discharge.

RESULTS

Neither the proxy indices nor their interaction was associated with all study outcomes. The acquired capability for suicide proxy index and its interaction with other indices were not associated with suicide attempt status at admission. However, high thwarted belongingness proxy index scores were associated with greater suicidal ideation intensity at admission; high perceived burdensomeness proxy index scores were indicative of a lack of significant change in suicide ideation intensity at discharge.

CONCLUSION

These results indicate a need to further examine these proxy indices in high acuity samples.

Emotion Regulation Mediates the Relationship Between Therapeutic Alliance and Anxiety in Emerging Adults During Inpatient Psychiatric Treatment

Emerging adulthood is a critical developmental period characterized by emotional growth and unstructured living. To date, there is little research on emerging adults-defined as those 18 to 25 years old-with serious mental illnesses and even less on emerging adults in psychiatric hospitals. This study analyzed therapeutic alliance with the clinical team and change in anxiety symptoms in emerging adult psychiatric inpatients with the goal of establishing whether emotion regulation could serve as a mediator between these 2 constructs. Participants were 913 emerging adults (46.7% female; 18 to 25 y of age) who were voluntarily admitted to an intermediate length-of-stay (6 to 8 wk) inpatient psychiatric hospital. Each patient completed measures assessing anxiety symptoms, emotion regulation strategies, and working alliance as an assessment of therapeutic alliance. The results indicated that working alliance had significant indirect effects on change in anxiety symptoms through emotion dysregulation and lack of awareness, limited access to emotion regulation strategies, and lack of emotional clarity. This study emphasizes the need to understand emerging adults and the difficulties characteristic of this developmental period, and that clinicians should be aware that cognitive factors involved in emotion regulation may impact anxiety symptoms in emerging adult populations.

Assessing the Effects of the COVID-19 Pandemic on Nontraditional Students' Mental Health and Well-Being

The current study sought to measure how the COVID-19 pandemic affected the mental health and well-being of college students, particularly nontraditional students. Participants (n = 321) completed a series of surveys assessing their level of depression, anxiety, sleep disturbances, insomnia, and well-being. Participants also indicated their nontraditional student characteristics, level of resilience, and additional life stressors due to the pandemic. Statistical analyses found that participants reported higher levels of depression, anxiety, sleep disturbances, and insomnia, with corresponding lower levels of well-being across all students, compared with prepandemic levels. Results showed that while nontraditional students indicated an increased number of life stressors during the pandemic compared with their traditional peers, nontraditional students also demonstrated higher levels of resilience. Nontraditional students appear to be more successful at managing stressful life events due to the increased resilience that comes with age and experience, which can better prepare them to persevere and overcome challenges.

A false sense of security: Rapid improvement as a red flag for death by suicide

OBJECTIVE

Postdischarge from inpatient psychiatry is the highest risk period for suicide, thus better understanding the predictors of death by suicide during this time is critical for improving mortality rates after inpatient psychiatric treatment. As such, we sought to determine whether there were predictable patterns in suicide ideation in hospitalized psychiatric patients.

METHOD

We examined a sample of 2,970 adult's ages 18-87 admitted to an extended length of stay (LOS) inpatient psychiatric hospital. We used group-based trajectory modeling via the SAS macro PROC TRAJ to quantitatively determine four suicide ideation groups: nonresponders (i.e., high suicide ideation throughout treatment), responders (i.e., steady improvement in suicide ideation across treatment), resolvers (i.e., rapid improvement in suicide ideation across treatment), and no-suicide ideation (i.e., never significant suicide ideation in treatment). Next, we compared groups to clinical and suicide-specific outcomes, including death by suicide.

RESULTS

Resolvers were the most likely to die by suicide postdischarge relative to all other suicide ideation groups. Resolvers also demonstrated significant improvement in all clinical outcomes from admission to discharge.

CONCLUSION

There are essential inpatient psychiatry clinical implications from this work, including that clinical providers should not be lulled into a false sense of security when hospitalized adults rapidly improve in terms of suicide ideation. Instead, inpatient psychiatric treatment teams should increase caution regarding the patient's risk level and postdischarge treatment planning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Suicide Screening in a Large Pediatric Emergency Department: Results, Feasibility, and Lessons Learned

OBJECTIVE

This study examined the feasibility of screening all patients entering the ED using the Columbia-Suicide Severity Rating Scale as well as examining the rates of suicide ideation and attempts endorsed by adolescents who present at the ED.

METHODS

This study used a sample of 12,113 patients between the ages of 11 and 19 years.

RESULTS

Results revealed that 13.5% of the participants endorsed passive suicide ideation in the month leading up to their ED visit and 11.3% of the participants reported active ideation in the prior month. Results also revealed that patients whose chief complaints were coded as psychiatric or medical trauma were more likely to endorse either active or passive suicidal ideation than other presenting problems. Patients with a psychiatric or medical trauma chief complaint were also more likely to report lifetime suicidal behavior and suicidal behavior 3 months before the ED visit.

CONCLUSIONS

In addition to findings, implications, feasibility, and lessons learned are discussed for other institutions or departments considering implementation of a widespread screening.Highlights:• Suicide screenings were implemented in a large pediatric emergency department.• One in 5 endorsed suicidal ideation or behavior regardless of presenting problem.• Feasibility and lessons learned are discussed for others hoping to implement a widespread screening.

The Association of Sleep Disturbance and Suicide Risk Among Firefighters: Exploring Emotion Regulation Dimensions

AIM

This study explored the extent to which emotion regulation dimensions statistically mediate the association between sleep disturbance and suicide risk among firefighters.

METHOD

Participants were 865 firefighters working for a fire department in an urban area in the southern U.S. Bootstrapping was used to test the indirect effects of sleep disturbance on suicide risk through emotion regulation dimensions, after controlling for depression and trauma exposure.

RESULTS

The effect of sleep disturbance on suicide risk was significantly statistically mediated by emotion regulation difficulties (β= .09, SE = .02, 95% CI: .05, .14). Moreover, each of the five dimensions of emotion regulation difficulties significantly statistically mediated this association, with difficulties in engaging in goal-direct behavior (β = .09, SE = .02, 95% CI: .05, .14) and lack of strategies to reduce distress demonstrating the strongest indirect effects (β = .07, SE = .02, 95% CI: .04, .11), after accounting for depression and trauma exposure.

CONCLUSION

Results suggest that suicide interventions for firefighters who suffer from sleep disturbance should focus on the development of emotion regulation strategies.

Predicting suicide attempt history in a psychiatric inpatient sample: A replication and extension

Stanley et al. (Psychological Assessment, 2018, 20, 1249) examined Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, Minnesota Multiphasic Personality Inventory-2 Restructured Form: Manual for administration, scoring, and interpretation, 2008/2011, University of Minnesota Press) profile configurations to predict which individuals engage in suicidal behavior using an outpatient psychiatric sample. Their results revealed that an interaction of overarousal [Hypomanic Activation (RC9) or Activation (ACT)] and shutdown [Demoralization (RCd)] indicators predicted increased history of suicide attempts. The purpose of the present study was to replicate and extend these results to a psychiatric inpatient sample in order to determine their generalizability to a clinically severe, at-risk population. The present study examined 581 valid MMPI-2-RF protocols of adult psychiatric inpatients who endorsed any level of suicide ideation on the Columbia-Suicide Severity Rating Scale (C-SSRS; Posner et al., The American Journal of Psychiatry, 2011, 168, 1266) in the 2 weeks prior to admission. Results revealed that in four of the six models tested, shutdown (Low Positive Emotions [RC2], Helplessness/Hopelessness [HLP]) but not overactivation (RC9, ACT) indicators provided an additional prediction of suicide attempt history beyond Suicidal/Death Ideation (SUI) and the covariates. The two models containing RCd did not provide additional predictive value above Suicidal/Death Ideation (SUI) with main effects or interaction terms. Overall, our results do not replicate those of Stanley et al. (Psychological Assessment, 2018, 20, 1249). Furthermore, while SUI was the best predictor of a history of suicide attempts, results indicate the main effects of RC2 and HLP were negative predictors of prior suicide attempts. Limitations of the study and clinical implications of the results are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Underreporting on the MMPI-2-RF extends to extra-test measures of suicide risk

Detection of underreporting in suicide risk assessment remains a significant concern in clinical practice. The aim of this research is to examine whether underreporting based on elevated Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) K-r and L-r scale scores may aid in identifying patients with suppressed scores on the Suicide/Death Ideation scale (SUI) and extra-test measures of suicide risk. We anticipated that, in voluntarily admitted psychiatric inpatients (N = 1,011) and individuals receiving outpatient services in a university-affiliated psychology clinic (N = 521), those indicated as underreporting would produce lower mean scores across SUI and extra-test measures of suicide risk, and that the magnitudes of the associations between SUI and extra-test scores would be strongest for those underreporting. A series of t tests and correlational analyses were conducted in both samples. Although those classified as underreporting consistently produced lower mean scores for SUI and extra-test measures of suicide risk, the magnitudes of the associations were consistently significant and stronger only in outpatients without K-r or L-r scale elevations. Clinical implications for this research include examining K-r elevations when assessing suicide risk and incorporating a therapeutic assessment approach to suicide risk assessment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Examining the temporal stability of suicide capability among undergraduates: A latent growth analysis

BACKGROUND

Relatively few studies test the interpersonal psychological theory's monotonicity hypothesis. The monotonicity hypothesis proposes that suicide capability (i.e., fearlessness about death and pain tolerance) is stable or increases linearly with exposure to painful and provocative events. Research is conflicted, suggesting that suicide capability is static, decreases, or increases and returns to baseline. The current study thus tested this hypothesis in a sample of college students with histories of suicidal ideation. We hypothesized a stable and an increasing trajectory.

METHODS

Participants were 206 undergraduates; primarily women (73%), on average 19.05 years old, heterosexual (85%), and first-years (69%). Participants completed a baseline battery of questionnaires on suicide risk factors and daily diaries on suicide capability and suicidal ideation for 90 days (n = 7,342 surveys, 40% compliance rate). Group-based trajectory analyses were conducted with the SAS macro PROC TRAJ.

RESULTS

Modeling revealed a three group quadratic model.  Low (27.7%), Moderate (41.3%), and High (31.1%) suicide capability groups remained static over time. Baseline suicidal ideation, but not history of suicide attempts or family history of suicidal behavior, distinguished groups; participants with suicidal ideation at baseline were less likely to be in the low suicide capability group.

LIMITATIONS

Brief, dichotomized assessments, and a high attrition rate.

CONCLUSIONS

These data showed temporal stability of suicide capability and suggest that the "acquired" component of capability may be overemphasized. Clarifying the stability and modifiability of suicide capability will enable empirically-based applications of the theory to suicide prevention.

Family accommodation in Chinese individuals with obsessive-compulsive disorder

Family accommodation is a common, treatment-relevant construct related to obsessive-compulsive disorder (OCD) severity and treatment outcome. This initial study examined the nature, incidence, and clinical correlates of family accommodation in Chinese adults with OCD and their relative or person in a close relationship. One hundred four outpatients diagnosed with OCD completed self-report measures of obsessive-compulsive, anxiety, and depression symptoms. Additionally, the individuals with OCD and a relative completed a measure of family accommodation and impairment. Patient-reports of family accommodation were significantly correlated with OCD symptomology and severity. A multiple linear regression indicated that OCD symptomology was a significant predictor of family accommodation, but anxiety, stress, and depression were not. In addition, the current Chinese sample demonstrated greater levels of family accommodation than previous English-speaking samples. Potential explanations and implications of the high levels of reported family accommodation are discussed. Family accommodation could play a significant role in OCD development and/or maintenance in China. Future research considerations are discussed.

Sleep disturbance in patients in an inpatient hospital mediates relationship between PTSD and suicidal ideation

A common reason for admission to inpatient psychiatric units is suicidal ideation. Growing evidence of the link between sleep disturbance and suicidal ideation brings an interest in greater clarity of the pathways; this paper focused on post-traumatic stress disorder (PTSD), which carries increased risk for both sleep disturbance and suicidal ideation, as well as sex differences in those pathways. Patients were 2822 inpatients studied at admission to an inpatient psychiatric hospital and mediation analyses were used to examine pathways of interest. There was an indirect effect of PTSD on suicidal ideation through sleep disturbances for the entire sample and for men and women separately. The effect for men was larger than that for women, suggesting a stronger effect for sleep disturbance in the relationship for men. For women only, the direct effect between PTSD and suicidal ideation remained significant after mediation. Sleep disturbance plays an important role in the relationship between PTSD and suicidal ideation. Early identification of sleep disturbance in inpatients and targeted focus of sleep in conjunction with resolving trauma-related symptoms may help reduce suicidal ideation. This may be especially true of men; the indirect effect was smaller for women, suggesting that sleep disturbance should be addressed in conjunction with other PTSD symptoms likely leading to suicidal ideation.

Time in treatment: Examining mental illness trajectories across inpatient psychiatric treatment

Early discharge or reduced length of stay for inpatient psychiatric patients is related to increased readmission rates and worse clinical outcomes including increased risk for suicide. Trajectories of mental illness outcomes have been identified as an important method for predicting the optimal length of stay but the distinguishing factors that separate trajectories remain unclear. We sought to identify the distinct classes of patients who demonstrated similar trajectories of mental illness over the course of inpatient treatment, and we explore the patient characteristics associated with these mental illness trajectories. We used data (N = 3406) from an inpatient psychiatric hospital with intermediate lengths of stay. Using growth mixture modeling, latent mental illness scores were derived from six mental illness indicators: psychological flexibility, emotion regulation problems, anxiety, depression, suicidal ideation, and disability. The patients were grouped into three distinct trajectory classes: (1) High-Risk, Rapid Improvement (HR-RI); (2) Low-Risk, Gradual Improvement (LR-GI); and (3) High-Risk, Gradual Improvement (HR-GI). The HR-GI was significantly younger than the other two classes. The HR-GI had significantly more female patients than males, while the LR-GI had more male patients than females. Our findings indicated that younger females had more severe mental illness at admission and only gradual improvement during the inpatient treatment period, and they remained in treatment for longer lengths of stay, than older males.

Emotion regulation difficulties are associated with nightmares and suicide attempts in an adult psychiatric inpatient sample

Although many studies have examined potential moderators of the relation between nightmares and suicide, few have examined emotion regulation, particularly utilizing severe populations such as psychiatric inpatients. The present study sought to investigate whether emotion regulation difficulties are associated with nightmares and suicide attempts in an inpatient sample. We included 2,683 psychiatric inpatients ranging from 18 to 81 years (M = 34.35, SD = 14.70). Nightmare frequency, emotion regulation difficulties, and their interaction predicted previous suicide attempts. Limitations include the homogeneity and cross-sectional nature of the sample. Suggestions for future study are discussed.

Objective measurement of sleep, heart rate, heart rate variability, and physical activity in suicidality: A systematic review

BACKGROUND

Emerging literature suggests that the arousal and regulatory systems as measured by sleep-wakefulness, heart rate (HR) and heart rate variability (HRV) may be powerful objective warning signs of suicidality. However, there is no systematic literature review examining the association between objective measurements of these variables with suicide and suicidal behavior.

METHODS

A web-based, systematic literature search using PubMed and EMBASE was conducted for articles that measured sleep-wakefulness and HR/HRV quantitatively in association with suicide. Search results were limited to human subjects and articles published in peer-reviewed journals in English. There were no restrictions for age, sex, settings and durations of measurements, types of mental illnesses, or comorbidity.

RESULTS

Twenty-three studies were included in the current systematic review. Across the studies, consistent patterns of disturbed sleep-wakefulness such as greater sleep onset latency and lower sleep efficiency were related to suicide. In addition, higher HR and lower variance of R-R intervals was an indicator of risk of suicide.

LIMITATIONS

Studies that used different equipment for sleep studies (i.e., polysomnography, electroencephalogram, actigraphy) were combined, and potential differences in their findings due to the different equipment were not considered.

CONCLUSIONS

Findings provide initial evidence for consistent patterns of sleep-wakefulness and HR/HRV possibly associated with suicidality; however, more studies are needed in order to identify the precise objective variables (e.g., sleep onset latency, high-frequency HRV), as well as time-varying patterns in these variables, that are related to acute suicide risk.

Trajectories of self-reported sleep disturbance across inpatient psychiatric treatment predict clinical outcome in comorbid major depressive disorder and generalized anxiety disorder

BACKGROUND

As there has been a demonstrated link between sleep disturbance and suicide, the present study investigated the relationship between self-reported sleep disturbance during inpatient psychiatric treatment and clinical outcomes at discharge and six months post-discharge.

METHODS

Participants were 2,970 adults receiving care in a long-term inpatient psychiatric hospital. Greater than 90% of inpatients reported at least mild sleep disturbance throughout treatment. Group-based trajectory modeling was used to determine patterns of sleep disturbance changes over time.

RESULTS

Participants fit into distinct categories based on their trajectories of sleep problems across treatment: No Sleep Problems (10.3% of participants, no sleep problems endorsed over the course of inpatient psychiatric treatment), Resolvers (sleep problems completely resolved over the course of inpatient psychiatric treatment; 10.6%), Non-Responders (did not respond to inpatient psychiatric treatment; 35.7%) and Responders (sleep problems decreased but did not fully resolve over the course of inpatient psychiatric treatment; 43.4%). Individuals with comorbid major depressive disorder and generalized anxiety disorder were significantly more likely to demonstrate higher rates of sleep disturbance throughout inpatient psychiatric treatment and their sleep problems did not respond to treatment as usual (Non-Responders). Further, patients in the Non-Responder group had significantly more suicidal ideation and worse clinical outcomes (higher anxiety, more disability, and lower well-being) at discharge and six months post-discharge, as well as were on more medication including hypnotics throughout treatment.

CONCLUSIONS

Findings indicate the urgent need to design and implement inpatient psychiatry sleep protocols to not only improve sleep and clinical outcomes, but also reduce the risk for suicide post-discharge.

Development and Psychometric Evaluation of the Children's Yale-Brown Obsessive-Compulsive Scale Second Edition

OBJECTIVE

To develop and examine the psychometric properties of the Children's Yale-Brown Obsessive-Compulsive Scale Second Edition (CY-BOCS-II) in children and adolescents with obsessive-compulsive disorder (OCD).

METHOD

Youth with OCD (N = 102; age range 7-17 years), who were seeking treatment from 1 of 2 specialty OCD treatment centers, participated in the study. The CY-BOCS-II was administered at an initial assessment, and measures of OCD symptom severity, anxiety and depressive symptoms, behavioral and emotional problems, and global functioning were administered. Inter-rater and test-retest reliabilities were assessed on a subsample of participants (n = 50 and n = 31, respectively) approximately 1 week after intial assessment.

RESULTS

The CY-BOCS-II demonstrated moderate-to-strong internal consistency (α = 0.75-0.88) and excellent inter-rater (intraclass correlation coefficient = 0.86-0.92) and test-retest (intraclass correlation coefficient = 0.95-0.98) reliabilities across all scales. Construct validity was supported by strong correlations with clinician-rated measures of OCD symptom severity and moderate correlations with measures of anxiety symptoms. Exploratory factor analysis showed a 2-factor structure, which was generally inconsistent with its adult counterpart, the Yale-Brown Obsessive-Compulsive Scale Second Edition.

CONCLUSION

Initial findings support the CY-BOCS-II as a reliable and valid measure of obsessive-compulsive symptoms in youth.

The impact of victimization and mental health symptoms on recidivism for early system-involved juvenile offenders

Although research has linked mental health symptoms and prior victimization to recidivism for youth on probation or in detention, little attention has been given to these risk factors for early system-involved youth. We conducted a survival/hazard model to estimate the impact of official records of abuse/neglect, crime victimization, and mental health issues (mood, anxiety, disruptive, and substance use disorders) on recidivism in a sample of 2,792 youth in a large Midwestern diversion program. Results indicated that youth with official records of abuse/neglect, person crime victimization, and property crime victimization were more likely to recidivate sooner than those without these victimization experiences (hazard ratio: 1.37, 1.42, and 1.52, respectively). Findings from the present study also demonstrated that substance use disorder was the only mental health cluster that predicted quicker time to recidivism. As one of the earliest points of entry into the juvenile justice system, diversion programs are in a unique position to address trauma from multiple types of victimization and adapt diversion programming to be responsive to each juvenile's mental health needs. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Contributions of Cognitions, Psychological Flexibility, and Therapeutic Alliance to Suicidal Ideation in Psychiatric Inpatients

Although suicide treatment is an expanding area of research, there is relatively less in the literature with respect to how specific vulnerabilities to suicide are addressed by treatment. Utilizing measures of suicide cognitions, therapeutic alliance, and psychological flexibility, we compared their relative contributions to suicidal ideation during and posttreatment among a group of adult psychiatric inpatients (N = 434). Results revealed that cognitions contributed considerably more unique variance to suicidal ideation than alliance and flexibility at discharge and at 2 weeks postdischarge, and to change in suicidal ideation over the course of treatment. Psychological flexibility explained a small amount of variance at the 6-month time point. Factor level analyses also were conducted, with the unsolvability factor within suicide cognitions accounting for the largest portion of variance at both discharge and 2 weeks postdischarge. Study limitations, implications, and future directions are discussed.

A controlled comparison trial of the Collaborative Assessment and Management of Suicidality (CAMS) in an inpatient setting: Outcomes at discharge and six-month follow-up

This controlled comparison trial evaluated a suicide-specific intervention, the Collaborative Assessment and Management of Suicidality (CAMS), in an extended-stay psychiatric inpatient setting. Multiple outcomes were examined for 104 patients, half of whom received individual therapy from therapists trained in CAMS. The comparison group was selected from a larger pool through Propensity Score Matching to ensure comparability on age, sex, treatment program, number of prior suicide attempts, and severity of suicidal ideation. Results showed that a) all patients improved significantly across a wide range of measures, including depression, suicidal ideation, functional disability, and well-being; b) these gains were durable over a 6-month post-discharge period; and c) patients treated by a CAMS-trained individual therapist improved significantly more from admission to discharge across all measures. Differences between CAMS and non-CAMS patients were no longer statistically significant at 6-month follow-up, although statistical power was compromised due to attrition. Although replication studies are needed, these findings suggest that interventions specifically tailored for suicidal patients may have advantages compared to usual, intensive inpatient treatment, perhaps by addressing psychological vulnerabilities specific to the population. The lack of significant differences at follow-up suggest that post-treatment contact may be needed to maintain advantages associated with this and similar interventions.

Acute Suicidal Affective Disturbance (ASAD): A confirmatory factor analysis with 1442 psychiatric inpatients

Acute Suicidal Affective Disturbance (ASAD) is a newly proposed diagnostic entity that characterizes rapid onset suicidal intent. This study aims to confirm the factor structure of ASAD among psychiatric inpatients, and to determine the clinical utility of ASAD in predicting suicide attempt status. Overall, 1442 psychiatric inpatients completed a battery of self-report questionnaires assessing symptoms theorized to comprise the ASAD construct. Utilizing these data, a confirmatory factor analysis with a one-factor solution was performed. Regression analyses were employed to determine if the ASAD construct predicted past suicide attempts, and analyses of variance (ANOVAs) were employed to determine if ASAD symptoms differed by the presence and number of past suicide attempts. The one-factor solution indicated good fit: χ(2)(77) = 309.1, p < 0.001, Tucker-Lewis Index (TLI) = 0.96, comparative fit index (CFI) = 0.97, root-mean-square error of approximation (RMSEA) = 0.05. Controlling for depressive disorders and current symptoms, the ASAD construct significantly predicted the presence of a past suicide attempt. Moreover, ASAD differentiated in the expected directions between individuals with a history of multiple suicide attempts, individuals with a single suicide attempt, and individuals with no history of a suicide attempt. Acute Suicidal Affective Disturbance (ASAD) appears to be a unified construct that predicts suicidal behavior and is distinct from an already-defined mood disorder.

Understanding the Relationship Between Suicidality and Psychopathy: An Examination of the Interpersonal-Psychological Theory of Suicidal Behavior

A number of studies have reported a bifurcated relationship between psychopathy and suicidality, such that suicidality is positively related to Factor 2 (impulsive-antisocial lifestyle) of psychopathy but negatively related or unrelated to Factor 1 (affective-interpersonal deficits). The present study aims to expand these findings by investigating this relationship through the lens of the interpersonal-psychological theory of suicidal behavior across both undergraduate and forensic samples. We hypothesized that, although both Factors 1 and 2 would be associated with the acquired capability for suicide, Factor 2 would exhibit a unique relationship with suicidal desire (perceived burdensomeness and thwarted belongingness). Results were largely supportive of these hypotheses, although differences were noted across samples and measures. Findings highlight the importance of precision in the assessment of antisociality and suggest potential differences in the construct of psychopathy between non-criminal and criminal samples.

Change in Experiential Avoidance is Associated with Reduced Suicidal Ideation over the Course of Psychiatric Hospitalization

Growing empirical literature in recent years indicates that experiential avoidance plays a role in a wide variety of psychological disorders and psychotherapeutic interventions. This study explored the view of suicidal ideation as a form of experiential avoidance by examining the association between suicidal ideation and therapeutic change in a sample of 189 adult psychiatric inpatients. Results were consistent with predictions, showing a statistically significant association between scores on the Beck Scale for Suicidal Ideation and the Acceptance and Action Questionnaire-II (AAQ-II). It was further shown that change in AAQ-II scores over the course of hospitalization was associated with change in suicidality, independent of changes in depression severity and hopelessness. Moreover, treatment responders (patients whose suicidal ideation scores dropped significantly over the course of treatment) showed greater drops in experiential avoidance relative to nonresponders. These results are consistent with a view of suicidal ideation (and, by extension, suicide) as a form of experiential avoidance and potentially a therapeutic approach that specifically seeks to reduce experiential avoidance.

Psychometric Reevaluation of the Columbia-Suicide Severity Rating Scale: Findings From a Prospective, Inpatient Cohort of Severely Mentally Ill Adults

OBJECTIVE

Accurate prediction of suicide remains elusive due to lack of predictive measures. Given the Columbia-Suicide Severity Rating Scale's (C-SSRS) emerging "gold-standard" status for risk assessment, studies are needed to assess its psychometric properties, particularly predictive validity. The current study adds to the limited literature by assessing the C-SSRS's internal consistency, factor structure, concurrent validity, and predictive validity.

METHODS

In this longitudinal study of 1,055 adults with DSM-IV diagnoses consecutively admitted to a specialized psychiatric hospital between July 1, 2012, and June 30, 2014, patients completed standardized assessments, including the C-SSRS, at admission and 2, 12, and 24 weeks postdischarge.

RESULTS

The C-SSRS evidenced excellent internal consistency (ordinal α = .95). Principal components analysis (PCA) revealed a 2-factor solution, accounting for 65.3% of the variance across items. The severity of ideation and behavioral items loaded onto the first factor, and the intensity of ideation items loaded onto the second factor. The total score, factors, and the most severe ideation single item were moderately correlated with other measures of suicidality (0.27 ≤ r ≤ 0.58; P < .0001). The summary score from the ideation/behavior factor was found to be modestly correlated with any suicide-related behavior within the 6 months following hospitalization. Receiver operator characteristics indicated that the C-SSRS performed adequately in correctly classifying any suicide-related behavior within 6 months of discharge from the hospital (AUC = 0.757, P < .001) with the total score and summary score from the ideation/behavior factor providing the best balance between sensitivity (0.694) and specificity (0.652-0.674).

CONCLUSIONS

This study is the first to assess the factor structure of the C-SSRS in a large, high-risk sample. The measure has solid psychometric properties and merits use as a suicide risk assessment measure.

Correspondence between correctional staff and offender ratings of adaptive behavior

Although several experts have raised concerns about using correctional officers as informants for adaptive behavior assessments, no studies have compared ratings from correctional officers to those from other informants. We compared Adaptive Behavior Assessment System-Second Edition (ABAS-II; Harrison & Oakland, 2003) scores assigned by correctional staff to those assigned by probationers (N = 56) residing in a community corrections facility. Correctional staff assigned markedly lower scores than did probationers on many ABAS-II scales (d = .59 to 1.41 for ABAS-II composite scores). Although none of the probationers qualified for a diagnosis of intellectual disability, 29% received a staff-report ABAS-II composite score that was more than 2 SDs below the normative sample mean, suggesting significant impairment. Correlations between ABAS-II and intelligence measure scores were lower than expected for both types of informants, although they were somewhat stronger for self-report. Lower staff-report scores were associated with higher levels of probationer-reported psychopathology and need for treatment. Overall, these findings highlight limitations of using correctional staff as informants for adaptive behavior assessments. (PsycINFO Database Record

Implicit Measure of Life/Death Orientation Predicts Response of Suicidal Ideation to Treatment in Psychiatric Inpatients

In this study, we set out to extend empirical research on the Life-Death Implicit Association Test (IAT) by administering the measure to an adult psychiatric inpatient population with suicidal ideation. We sought to examine its association with other suicide-relevant measures and to determine whether it adds predictive utility beyond that offered by other measures of suicide risk. The IAT was administered (N = 124) at biweekly intervals as part of an assessment battery at an inpatient facility for complex, treatment resistant psychiatric disorders (average length of stay: approximately 6 weeks). Multiple regression procedures were utilized to examine relationships among the measures and their predictive utility with respect to suicidal ideation at discharge. Consistent with prior research with other populations, significant associations were found between IAT performance and explicit (self-report and interview) measures of suicide risk. Moreover, the IAT was found to predict suicidal ideation at discharge above and beyond number of prior suicide attempts and admission scores on measures of depression, suicidal ideation, and hopelessness. Change in IAT performance over the course of treatment was observed. The IAT shows promise as an addition to explicit measures conventionally used to estimate suicide risk in psychiatric patients. These findings are consistent with a cognitive vulnerability model of suicide risk.

Impact of a Suicide-Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide-specific interventions may offer benefits beyond conventional care. This naturalistic controlled-comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide-specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.

Evaluator differences in Psychopathy Checklist-Revised factor and facet scores

Recent research suggests that the reliability of some measures used in forensic assessments--such as Hare's (2003) Psychopathy Checklist-Revised (PCL-R)--tends to be weaker when applied in the field, as compared with formal research studies. Specifically, some of the score variability in the field is attributable to evaluators themselves, rather than the offenders they evaluate. We studied evaluator differences in PCL-R scoring among 558 offenders (14 evaluators) and found evidence of large evaluator differences in scoring for each PCL-R factor and facet, even after controlling for offenders' self-reported antisocial traits. There was less evidence of evaluator differences when we limited analyses to the 11 evaluators who reported having completed a PCL-R training workshop. Findings provide indirect but positive support for the benefits of PCL-R training, but also suggest that evaluator differences may be evident to some extent in many field settings, even among trained evaluators.

Are Forensic Experts Biased by the Side That Retained Them?

How objective are forensic experts when they are retained by one of the opposing sides in an adversarial legal proceeding? Despite long-standing concerns from within the legal system, little is known about whether experts can provide opinions unbiased by the side that retained them. In this experiment, we paid 108 forensic psychologists and psychiatrists to review the same offender case files, but deceived some to believe that they were consulting for the defense and some to believe that they were consulting for the prosecution. Participants scored each offender on two commonly used, well-researched risk-assessment instruments. Those who believed they were working for the prosecution tended to assign higher risk scores to offenders, whereas those who believed they were working for the defense tended to assign lower risk scores to the same offenders; the effect sizes ( d) ranged up to 0.85. The results provide strong evidence of an allegiance effect among some forensic experts in adversarial legal proceedings.

Borderline personality symptomatology as a mediator of the link between child maltreatment and adult suicide potential

The present study tests borderline personality symptoms as meditational pathways between child maltreatment and suicide potential among college students. A sample of 268 participants completed a questionnaire battery including demographic data, the Comprehensive Child Maltreatment Scale, Inventory of Altered Self-Capacities, and Personality Assessment Inventory.

RESULTS

Three multiple mediation models (1 for each type of child maltreatment) were conducted. Results demonstrated that the same set of borderline personality characteristics mediated the relations between each type of child maltreatment (i.e., physical abuse, emotional abuse, and neglect) and suicide potential. The mediating borderline symptoms were affective dysregulation, identity problems, and paranoia. The meditation model is discussed with regard to attachment, trauma, and suicide theories, as well as suicide risk assessment.

When experts disagreed, who was correct? A comparison of PCL-R scores from independent raters and opposing forensic experts

Researchers recently found that Psychopathy Checklist-Revised (PCL-R; Hare, 2003) scores reported by state experts were much higher than those reported by defense experts in sexually violent predator cases pursued for civil commitment (Murrie, Boccaccini, Johnson, & Janke, 2008), which raised the question of which scores were more accurate. In this study, two independent raters rescored the PCL-R from file review for 44 offenders from that sample who had opposing evaluator scores (allegiance cases) and 44 who had state expert, but not defense expert, scores (comparison cases). The independent raters agreed with one another in their scoring of the allegiance and comparison cases (Intraclass Correlation Coefficient [ICC] ICCA,1 = .95), but they disagreed with both state (ICCA,1 = .29) and defense (ICCA,1 = .14) experts in the allegiance cases. Agreement was stronger between state experts and independent raters for the comparison cases (ICCA,1 = .63), but the independent raters assigned significantly higher PCL-R scores than experts for both the allegiance and comparison cases. These findings suggest that offenders who were selected for rescoring by the defense may have been more difficult to score. Findings also raise questions about the extent to which PCL-R scores based on correctional file review only are comparable to those based on file and interview.

Do PCL-R scores from state or defense experts best predict future misconduct among civilly committed sex offenders?

In a recent study of sex offender civil commitment proceedings, Murrie et al. (Psychol Public Policy Law 15:19-53, 2009) found that state-retained experts consistently assigned higher PCL-R total scores than defense-retained experts for the same offenders (Cohen's d > .83). This finding raises an important question about the validity of these discrepant scores: Which type of score, state or defense evaluator, provides the most useful information about risk? We examined the ability of PCL-R total scores from state and defense evaluators to predict future misconduct among civilly committed sex offenders (N = 38). For comparison, we also examined predictive validity when two state experts evaluated the same offender (N = 32). Agreement between evaluators was low for cases with opposing experts (ICCA,1 = .43 to .52) and for cases with two state experts (ICCA,1 = .40). Nevertheless, scores from state and defense experts demonstrated similar levels of predictive validity (AUC values in the .70 range), although scores from different types of state evaluators (corrections-contracted vs. prosecution-retained) did not. The finding of mean differences between opposing evaluator scores, but similar levels of predictive validity, suggests that scores from opposing experts in SVP cases may need to be interpreted differently depending on who assigned them. Findings have important implications for understanding how rater disagreement may relate to predictive validity.

On Individual Differences in Person Perception: Raters’ Personality Traits Relate to Their Psychopathy Checklist-Revised Scoring Tendencies

This study investigated raters’ personality traits in relation to scores they assigned to offenders using the Psychopathy Checklist—Revised (PCL-R). A total of 22 participants, including graduate students and faculty members in clinical psychology programs, completed a PCL-R training session, independently scored four criminal offenders using the PCL-R, and completed a comprehensive measure of their own personality traits. A priori hypotheses specified that raters’ personality traits, and their similarity to psychopathy characteristics, would relate to raters’ PCL-R scoring tendencies. As hypothesized, some raters assigned consistently higher scores on the PCL-R than others, especially on PCL-R Facets 1 and 2. Also as hypothesized, raters’ scoring tendencies related to their own personality traits (e.g., higher rater Agreeableness was associated with lower PCL-R Interpersonal facet scoring). Overall, findings underscore the need for future research to examine the role of evaluator characteristics on evaluation results and the need for clinical training to address evaluators’ personality influences on their ostensibly objective evaluations.

Scoring Subjectivity and Item Performance on Measures Used to Assess Violence Risk

Although reliability is essential to validity, most research on violence risk assessment tools has paid little attention to strategies for improving rater agreement. The authors evaluated the degree to which perceived subjectivity in scoring guidelines for items from two measures—the Psychopathy Checklist–Revised (PCL-R) and the Historical, Clinical, Risk Management-20 (HCR-20)—were related to indices of interrater agreement reported in the research literature. Nine doctoral students with experience scoring the PCL-R and HCR-20 showed a high level of agreement with respect to the amount of subjectivity required to score items. Decreased subjectivity was associated with increased rater agreement for both tools. For the PCL-R, items on aggregate measures that have the strongest effects in predictive validity research (i.e., Factor 2, Facet 4) were rated as the least subjective. For the HCR-20, items on the Historical scale were rated as the least subjective. Implications for measure development and refinement are discussed.