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Suicide Intent Scale in the prediction of suicide

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 Journal of Affective Disorders 136 (2012) 167–171

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Brief report

Suicide Intent Scale in the prediction of suicide

J. Stefansson, P. Nordström, J. Jokinen ⁎
Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institutet, Karolinska University Hospital, Solna, SE-171 76 Stockholm, Sweden

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To assess the predictive value of the Suicide Intent Scale in patients with high suicide
Received 13 October 2010 risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale may
Received in revised form 15 November 2010 offer a better predictive value in suicide risk detection. Finally a shorter version of the scale was
Accepted 15 November 2010 created after an item analysis.
Available online 8 December 2010
Method: Eighty-one suicide attempters were assessed with the Beck's Suicide Intent Scale (SIS).
All patients were followed up for cause of death. Receiver-operating characteristic (ROC)
Keywords: curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to
Suicide intent predict suicide.
Prediction Results: Seven patients committed suicide during a mean follow up of 9.5 years. The major finding
Suicide attempt
was that mean SIS scores distinguished between suicides and survivors. The positive predictive
Suicide
value was 16.7% and the Area Under Curve (AUC) was 0.74. Only the planning subscale reached
Scales
ROC statistical significance. Four items were used to test a shorter version of the SIS in the suicide
Karolinska Institutet prediction. The positive predictive value was 19% and the AUC was 0.82.
Conclusions: The Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a shorter
version of the scale may offer a better predictive value.
© 2010 Elsevier B.V. All rights reserved.

1. Introduction
Over the past 30 years, Beck's Suicide Intent Scale (SIS) has
been the prevailing psychometric scale for assessing suicide
intent in suicide attempters (Freedenthal, 2008). In a recent
review article, five out of 13 studies showed a positive
relationship between SIS scores and suicide over a follow-up
period ranging from 10 months to 20 years (Freedenthal,
2008). Only two earlier clinical studies have used receiver
operating characteristics (ROC) to assess the optimal threshold
of the SIS in suicide prediction (Niméus et al., 2002; Harriss and
Hawton, 2005).
Earlier studies of the factorial structure of the SIS have
identified between two and four factors (Antretter et al., 2008).
Mieczkowski found two factors: planning subscale and lethal
⁎ Corresponding author. Department of Clinical Neuroscience/Psychiatry,
Karolinska Institutet, R5, Karolinska University Hospital, Solna, SE-171 76
Stockholm, Sweden. Tel.: + 46 8 51776759; fax: + 46 8 303706.
E-mail address: jussi.jokinen@ki.se (J. Jokinen).
intent, and recently Misson et al. presented a four factor solution
of the SIS in suicide attempters. In a recent study by Antretter et
al. only one factor: “subjective part” of the SIS consisting of items
9 to 14 (the same items as in factor lethal intent by Mieczkowski)
was strongly supported, whereas an acceptable model fit for the
‘objective part’ was not found in eleven clinical samples
(Antretter et al., 2008). They concluded that possible future
revisions of ‘objective’ SIS items may be worth consideration.
There is a need for validated clinical tools for suicide risk
assessment that can be easily administered. To the best of our
knowledge, only two studies have compared underlying factors
of the SIS in suicide prediction (Niméus et al., 2002; Harriss and
Hawton, 2005) and only one study has assessed the suicide
predictive validity of individual items of the scale (Niméus et al.,
2002). We hypothesized that high scores with Suicide Intent
Scale may predict future suicide after attempted suicide.
The aim of the present study was to assess the predictive
value of the Suicide Intent Scale in patients with high suicide
risk, i.e. patients admitted to a psychiatric clinic after a suicide
attempt. The secondary aim was to assess the predictive value

0165-0327/$ – see front matter © 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2010.11.016
168 J. Stefansson et al. / Journal of Affective Disorders 136 (2012) 167–171
of the factors of the Suicide Intent Scale to detect future suicide
in suicide attempters. Finally a shorter version of the scale was
created after an item analysis.
2. Methods
2.1. Study setting
Patients having their clinical follow-up after a suicide attempt
at the Karolinska University Hospital were asked to participate in
a study of biological and psychological risk factors for suicidal
behaviour. The Regional Ethical Review Board in Stockholm
approved the study protocols (Dnr 93-211) and the participants
gave their written informed consent to the study.
2.2. Subjects
This is a cohort study involving 81 suicide attempters
(35 men, mean age 39 years, S.D.=11.8, range 20–69 and 46
women, mean age 35 years, S.D.=12.1, range 18–68). Patients
were included to the study between 1993 and 1998. Inclusion
criteria were a recent suicide attempt (a time limit of one month),
fair capacity to communicate verbally and in writing in the
Swedish language and an age of 18 years or older. Exclusion
criteria were schizophrenia spectrum psychosis, dementia,
mental retardation and intravenous drug abuse. Suicide attempt
was defined as any nonfatal, self-injurious behaviour with some
intent to cause death. The participants were interviewed by a
trained psychiatrist using the SCID I research version interview to
establish diagnosis according to DSM-III (American Psychiatric
Association). Axis II diagnoses were established with SCID II
interview.
Ninety-four percent of participants had at least one current
Axis I psychiatric diagnosis; 80% of patients fulfilled criteria for
mood disorder, 5% for adjustment disorder and 4% for anxiety
disorders, one patient had substance related disorder, one
patient had anorexia nervosa and one an unspecified psychiatric
disorder (not psychotic). Twenty-one percent of the patients
had a co morbid substance related disorder (mostly alcohol
dependence). Among Axis II diagnoses, 39% of the patients
fulfilled criteria for a personality disorder. Fourteen patients
(17%) had used a violent suicide attempt method.
2.3. Assessments
Beck's Suicide Intent Scale (SIS), is an instrument using
15-items designed to examine the factual aspects of the suicide
attempt; such as the patients thoughts and feelings and the
circumstances at the time of the suicide attempt (Beck et al.,
1974a). One patients SIS rating was incomplete survivor and was
not used in the statistical analysis. The mean value of SIS was 16,
(median 16, S.D. 5.7, range 2–27, n =80). One two-factor model
of the SIS (Factor 1: Lethal intent and Factor 2: Planning)
(Mieczkowski et al., 1993) and one four-factor model of the SIS
(Conception, Preparation, Precautions and Communication)
(Misson et al., 2010) were composed and tested separately.
The factor Lethal Intent is identical to the factor Conception
according to Misson consisting of items 9–14 of the SIS also
named as the “subjective part” according to Antretter as well as.
To evaluate severity of depression, the Montgomery–Åsberg
Depression Rating Scale (MADRS) was used (Montgomery and
Åsberg, 1979). The mean score of MADRS was 16 (median 17,
S.D. 9, range 0–37).
The Beck Hopelessness Scale is a 20-item true/false
instrument with statements of pessimistic beliefs about oneself
and the future (Beck et al., 1974b). Mean level of hopelessness
was 10.4, (median 11, S.D. 6.2, range 0–20).
2.4. Outcomes
By use of the unique personal identification number patients
were linked to the Cause of Death register, maintained by the
National Board of Health and Welfare in Sweden (http://
www.socialstyrelsen.se). Seven patients had committed suicide
before January 2009; suicides were ascertained from the death
certificates. Five patients committed suicide within 6 years, two
patients died of suicide after 11 years from entering to the study
(time to suicide: median 4 years, mean 6 years, range between
1.7 and 12.8 years). The follow up time ranged between 10 and
15 years. There was no age difference between suicides and
survivors.
2.5. Data analysis
Characteristics of the population were described by
using the mean, the median and the range for quantitative
variables. Shapiro–Wilk test was used to test if data was
normally distributed. Parametric statistics, t-test one tailed
was applied for between-group comparisons, suicide victims
vs. survivors if data was normally distributed. If skewed,
nonparametric statistics (Kruskal–Wallis' test) in continuous
variables was applied for between-group comparisons.
An ad hoc ROC analysis was used to find optimal thresholds
for SIS and SIS factors to predict suicide. Receiver-operating
characteristic (ROC) curves and tables were created for scales to
establish the optimal cut-off values. ROC areas under the curves
(AUCs) were calculated as a measure of the diagnostic
performance, and differences were calculated and tested
according to the methods of Hanley and McNeil. The cut-off
point that optimized sensitivity (proportion of suicides correctly
identified) and specificity (proportion of survivors correctly
identified) was used. Pearson Chi-square and Fisher's exact test
were used for cross tabulations of categorical variables.
Statistical analyses were performed using JMP VI software,
SAS Institute inc., Cary, NC, USA. The p value was set at b0.05.
25
20
15
SIS ratings
10
5
0
Suicide victims Survivors
Fig. 1. Suicide Intent scores in suicide victims (mean + SE) (20.1 ± 1.2) and
in survivors (15.7 ± 0.7) (n = 80, p = 0.026).
 J. Stefansson et al. / Journal of Affective Disorders 136 (2012) 167–171 169

1,00

0,90

0,80
0,70

0,60

0,50
Sensitivity
0,40

0,30
0,20

0,10

0,00
0,00 0,10 0,20 0,30 0,40 0,50 0,60 0,70 0,80 0,90 1,00
1-Specificity

Fig. 2. ROC curve for Suicide Intent Scale in suicide prediction, AUC = 0.74.

3. Results shows positive predictive values of SIS, SIS planning subscale

The SIS scores were normally distributed but not the scores
of the factors. Seven suicides (8.6%) occurred during the follow-
up time: 3 women (6.5%) and 4 men (11.4%). The major finding
was that mean SIS scores distinguished between suicides
(mean+SD) (20.1±3.2) and survivors (15.7±5.8) (n=80,
t ratio=1.98, p=0.026, t-test, one-tailed), Fig. 1.
To estimate which cut-off level of SIS scores optimally
predicts suicide, we analyzed the ROC curves and the ROC
tables. The cut-off 16 gave a specificity of 52% and a sensitivity of
100%. The positive predictive value was 16.7% and the AUC was
0.74, Fig. 2.
The ratings of SIS factors in suicide victims and survivors
are presented in Table 1. Only the planning subscale reached
statistical significance.
From an analysis of the separate scores of each item in the
SIS we found that four items of the scale were different in
suicide victims compared with survivors under the significance
level p b 0.1. We constructed a new scale with these items. Items
4, 7, 12 and 13 were used to test a shorter version of the SIS in
suicide prediction. ROC analysis revealed an optimal cut-off of 6
which gave specificity of 59% and sensitivity of 100%. The
positive predictive value was 19% and the AUC was 0.82. Table 2
and SIS shorter version in suicide prediction.
The Beck Hopelessness Scale did not distinguish between
suicides and survivors (p b 0.69). The correlations between
SIS and BHS as well as SIS and MADRS were non significant.
There were no differences of SIS ratings in suicide attempters
with or without co morbid substance abuse or personality
disorder. There were no differences of SIS ratings between suicide
attempters who had used a violent suicide attempt method vs.
non violent method.
4. Discussion
In this follow up study of 81 suicide attempters, 8.6%
committed suicide during a mean follow-up time of almost ten
years. This can be compared with clinical studies reporting
suicide mortality between 4 and 12% in suicide attempters
(Beck and Steer, 1989; Lindqvist et al., 2007; Niméus et al., 2002;
Nordström et al., 1995; Skogman et al., 2004; Suominen et al.,
2004; Runeson et al., 2010). We found that suicide intent
assessed shortly after a suicide attempt predicted subsequent
suicide. This is in line with five earlier studies in different clinical
populations showing the Suicide Intent Scale as a significant
predictor of suicide (Harriss et al., 2005; Hawton and Harriss,

Table 1

Suicide victims (N = 7) Survivors (N = 74)

Rating Items Mean Median SD Range Mean Median SD Range Statistic

SIS planning 1–7, 15 10.1 10 2.5 7–15 7.3 7 3.8 0–15 Z = 2.0
p b 0.045
SIS lethal intent/Conception/“subjective part” 9–14 9.7 10 1.1 8–11 8.3 8.5 2.9 1–12 Z = 1.2
p b 0.22
Preparation 5, 6, 7, 15 3.9 3 2.1 2–8 0.98 2.6 2.4 0–8 Z = 1.3
p b 0.19
Precautions 1–3 4.4 5 1.5 2–6 3.5 4 1.9 0–6 Z = 1.3
p b 0.21
Communication 4, 8 2.1 2 0.4 2–3 1.5 2 0.9 0–4 Z = 1.9
p b 0.058
SIS shorter version 4, 7, 12, 13 7 7 1 6–8 5 5 1.9 0–8 Z = 2.8
p b 0.0046
170 J. Stefansson et al. / Journal of Affective Disorders 136 (2012) 167–171
Table 2
Positive predictive values of SIS, SIS planning subscale and SIS shorter version in suicide prediction.
Test Cut off Suicide+ Suicide− Sensitivity
SIS N16 7 35 100%
(7/7)
b16 0 38
SIS planning N7 7 39 100%
(7/7)
b7 0 33
SIS shorter version N6 7 30 100%
(7/7)
b6 0 43
⁎ Fisher exact (2-sided).
2006; Niméus et al., 2002; Pierce, 1987; Suominen et al., 2004).
One study found a positive relationship for women only
(Skogman et al., 2004). Two of the earlier positive reports
studied elderly patients (Pierce, 1987; Hawton and Harriss,
2006).
However there are several large negative studies. So far
seven studies, with follow-up periods from 113 days to 10 years,
did not find a statistically significant association between the SIS
scores and later suicide (see review by Freedenthal, 2008). One
of the negative studies showed that the total SIS score did not
predict suicide whereas items 1, 2 and 3 measuring precaution
did so (Beck and Steer, 1989).
Only two studies have compared the underlying factors of the
Beck's Suicide Intent Scale in suicide prediction (Niméus et al.,
2002; Harriss and Hawton, 2005). In the study of Niméus and his
coworkers all the subscales/factors were predictive for future
suicide. We found that only higher scores in the Planning
subscale were a significant predictor of future suicide. The
Planning subscale showed a very similar predictive value and the
AUC compared with the SIS total score, whereas Lethal intent
factor scores did not predict suicide. The seven attempters who
later killed themselves had reported more planning at the time of
their index attempt than the 74 patients who did not commit
suicide. This is partly in line with the results of Harris and Hawton
who found a stronger association between the circumstances
section of the SIS (items 1–8) and suicide especially in female
deliberate self harm patients. Interestingly the planning subscale
was associated with lower levels of CSF 5-HIAA, a replicated
biomarker of suicide risk (Mann et al., 1996). We have earlier
reported that CSF 5-HIAA was a short term predictor of suicide
compared to suicide intent and hopelessness assessed after a
suicide attempt in male mood disorder inpatients (Samuelsson
et al., 2006).
In this study, we found that the cut-off point of 16 was
optimal and the positive predictive value was 16.7%, which is
higher than the PPV in the study of Niméus et al. who reported a
PPV of 9.7% in the whole sample. They also found that Suicide
Intent Scale may offer a better prediction if targeted in elderly
suicide attempters with PPV of 22.5% for those 55 years or older.
Harris and Hawton reported a low PPV of 4.0% in a large group of
deliberate self harm patients. They concluded that the SIS cannot
predict which individual patients will ultimately die by suicide
due to a large number of false positives. Our optimal cut-off of 16
was somewhat lower than in the study of Niméus et al. but
higher than in deliberate self harm patients (Niméus et al., 2002;
Harriss and Hawton, 2005). This could partly be explained by
suicidal intent being lower in deliberate self harm patients.
Specificity Positive predictive value AUC Test ⁎
52% 16.7% 0.74 p = 0.012
(38/73) (7/42)
46% 15.2% 0.73 p = 0.012
(39/72) (7/46)
59% 19% 0.82 p = 0.003
(43/73) (7/37)
We constructed a shorter version of the SIS with items 4, 7,
12 and 13. When we used this shorter version of the SIS in
suicide prediction we found that an optimal cut-off of 6 gave
specificity of 59% and sensitivity of 100%. The positive predictive
value was 19% and the AUC was 0.82 which gave a better
prediction by reducing the number of false positives.
In the study of Niméus et al., shorter versions of the SIS or
the factors were not superior to the original SIS scale in
predicting suicide. Having a shorter test may increase the
clinical utility of the scale. The utility and predictive value of
the shorter version should be replicated in a larger cohort of
suicide attempters.
Limitation of this study is a small number of patients;
furthermore suicidal intentions are very difficult to measure per
se (Freedenthal, 2007). A patient who tried to die may deny
suicidal intent to avoid hospitalization. Shame, ambivalence,
confusion or intoxication can contribute to recall bias.
In summary, our findings support the use of information
about suicidal intent as part of a clinical suicide risk assessment.
Further work needs to be done to test the utility of a shorter
version of the SIS combined with other clinical rating scales
measuring other types of suicide risk factors such as violence.
Role of funding source
Funding for this study was provided by the Swedish Research Council
(Project number K2009-61P-21304-04-4) by Söderström-Königska Foundation
and by the Thurings Foundation.
The Swedish Research Council, Söderström-Königska Foundation and the
Thurings Foundation had no further role in study design; in the collection,
analysis and interpretation of data; in the writing of the report; and in the
decision to submit the paper for publication.
Conflict of interest
No conflicts of interests to declare for any of the co authors.
Acknowledgements
We want to acknowledge Professor Marie Åsberg for inspiring
us with studies in suicidology Dr Kaj Forslund for careful clinical
assessments and Dr. Large who made helpful comments on the
electronic version of the paper resulting in an improved final
paper version.
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