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Multicenter Study
. 2021 May 1;78(5):540-549.
doi: 10.1001/jamapsychiatry.2020.4576.

Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth

Cheryl A King  1 , David Brent  2 , Jacqueline Grupp-Phelan  3 , T Charles Casper  4 , J Michael Dean  4 , Lauren S Chernick  5 , Joel A Fein  6 , E Melinda Mahabee-Gittens  7 , Shilpa J Patel  8 , Rakesh D Mistry  9 , Susan Duffy  10   11 , Marlene Melzer-Lange  12 , Alexander Rogers  13   14 , Daniel M Cohen  15 , Allison Keller  16 , Rohit Shenoi  17 , Robert W Hickey  18 , Margaret Rea  19 , Mary Cwik  20 , Kent Page  4 , Taylor C McGuire  1 , Jiebiao Wang  21 , Robert Gibbons  22   23   24   25 ; Pediatric Emergency Care Applied Research Network
Collaborators, Affiliations
Multicenter Study

Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth

Cheryl A King et al. JAMA Psychiatry. .

Abstract

Importance: The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services.

Objective: To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs).

Design, setting, and participants: Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts.

Exposures: Presentation at an ED.

Main outcome and measure: A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report.

Results: The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1.

Conclusions and relevance: In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Gibbons is a founder of Adaptive Testing Technologies, which distributes the Computerized Adaptive Test—Mental Health suite of computerized adaptive tests (CAT-MH™ is a trademark of Adaptive Testing Technologies); the terms of this arrangement have been reviewed and approved by the University of Chicago in accordance with its conflict of interest policies. Dr King reported grants from the National Institute of Mental Health and is a member of the National Advisory Mental Health Council during the conduct of the study. Dr King also reported being a member of the scientific council of the American Foundation for Suicide Prevention outside the submitted work; in addition, Dr King has copyright work and associated materials are being directly licensed to end users via University of Michigan Office of Technology Transfer and received royalties from Guilford Press. Dr Brent reported royalties from eRT, UpToDate, and Guilford Press; personal fees from Healthwise for consultation and Klingenstein Third Generation Foundation; and grants from the National Institute of Mental Health, American Foundation for Suicide Prevention, Once Upon A Time Foundation, and Beckwith Institute outside the submitted work. Dr Casper reported grants from the National Institute of Mental Health and Health Resources and Services Administration during the conduct of the study. Drs Dean, Patel, Cohen, and Page reported grants from the National Institutes of Health during the conduct of the study. Dr Fein reported grants from the National Institute of Mental Health during the conduct of the study. Dr Mahabee-Gittens reported grants from National Institutes of Health, Maternal and Child Health Bureau, Emergency Medical Services for Children Network Development Demonstration Program, and Health Resources and Services Administration during the conduct of the study, as well as grants from the National Institutes of Health and American Academy of Pediatrics, Ohio Chapter, outside the submitted work. Dr Duffy reported grants from the National Institute of Mental Health during the conduct of the study. Dr Rogers reported grants from the National Institute of Mental Health and Health Resources and Services Administration during the conduct of the study. Dr Shenoi reported grants from the National Institute of Mental Health during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study 1 Participant Flow for Adolescents in Cells at Low, Moderate, and High Suicide Risk
aCriteria for adolescent assignment to cells with moderate suicide risk involved suicidal ideation (without a method, plan, or intent), homicidal ideation without a plan or intent, more than 2 other suicide risk factors (eg, hopelessness, alcohol misuse, physical fighting, sexual or gender minority status). bCriteria for adolescent assignment to cells with high suicide risk involved a lifetime history of suicide attempt (including interrupted and aborted attempts); a lifetime suicidal ideation with intent, method, or plan; homicidal ideation with an intent or plan; and 5 or more incidents of nonsuicidal self-injury in past 12 months.
Figure 2.
Figure 2.. Receiver Operating Characteristic Curves for the Computerized Adaptive Screen for Suicidal Youth (CASSY) in Study 1 and Study 2
The vertical lines indicate the 80% and 90% specificity cut points.
See this image and copyright information in PMC

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