Development and validation of the Durham Risk Score for estimating suicide attempt risk: A prospective cohort analysis

Abstract

Background Worldwide, nearly 800,000 individuals die by suicide each year; however, longitudinal prediction of suicide attempts remains a major challenge within the field of psychiatry. The objective of the present research was to develop and evaluate an evidence-based suicide attempt risk checklist [i.e., the Durham Risk Score (DRS)] to aid clinicians in the identification of individuals at risk for attempting suicide in the future. Methods and findings Three prospective cohort studies, including a population-based study from the United States [i.e., the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study] as well as 2 smaller US veteran cohorts [i.e., the Assessing and Reducing Post-Deployment Violence Risk (REHAB) and the Veterans After-Discharge Longitudinal Registry (VALOR) studies], were used to develop and validate the DRS. From a total sample size of 35,654 participants, 17,630 participants were selected to develop the checklist, whereas the remaining participants (N = 18,024) were used to validate it. The main outcome measure was future suicide attempts (i.e., actual suicide attempts that occurred after the baseline assessment during the 1- to 3-year follow-up period). Measure development began with a review of the extant literature to identify potential variables that had substantial empirical support as longitudinal predictors of suicide attempts and deaths. Next, receiver operating characteristic (ROC) curve analysis was utilized to identify variables from the literature review that uniquely contributed to the longitudinal prediction of suicide attempts in the development cohorts. We observed that the DRS was a robust prospective predictor of future suicide attempts in both the combined development (area under the curve [AUC] = 0.91) and validation (AUC = 0.92) cohorts. A concentration of risk analysis found that across all 35,654 participants, 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. The DRS also performed well among important subgroups, including women (AUC = 0.91), men (AUC = 0.93), Black (AUC = 0.92), White (AUC = 0.93), Hispanic (AUC = 0.89), veterans (AUC = 0.91), lower-income individuals (AUC = 0.90), younger adults (AUC = 0.88), and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals (AUC = 0.88). The primary limitation of the present study was its its reliance on secondary data analyses to develop and validate the risk score. Conclusions In this study, we observed that the DRS was a strong predictor of future suicide attempts in both the combined development (AUC = 0.91) and validation (AUC = 0.92) cohorts. It also demonstrated good utility in many important subgroups, including women, men, Black, White, Hispanic, veterans, lower-income individuals, younger adults, and LGBTQ individuals. We further observed that 82% of prospective suicide attempts occurred among individuals in the top 15% of DRS scores, whereas 27% occurred in the top 1%. Taken together, these findings suggest that the DRS represents a significant advancement in suicide risk prediction over traditional clinical assessment approaches. While more work is needed to independently validate the DRS in prospective studies and to identify the optimal methods to assess the constructs used to calculate the score, our findings suggest that the DRS is a promising new tool that has the potential to significantly enhance clinicians’ ability to identify individuals at risk for attempting suicide in the future. Using data from three prospective cohorts in the US, Nathan Kimbrel and colleagues report on the development and validation of an evidence-based checklist to identify those at risk of future suicide attempts. Author summary Why was this study done? Nearly 800,000 individuals die by suicide each year worldwide; however, longitudinal prediction of suicide attempts remains a major challenge within the field of psychiatry. Current clinical risk instruments and assessments to detect risk for future suicide attempts lack sufficient diagnostic accuracy to guide treatment decisions. What did the researchers do and find? The goal of this study was to develop and evaluate a risk score (the Durham Risk Score or DRS) to aid clinicians in identifying individuals at risk for attempting suicide. Secondary analyses were conducted on 3 prospective cohort studies from the US (total sample size = 35,654 participants), including a large general population study and 2 smaller veteran cohorts. The risk score was a strong predictor of future suicide attempts in both the combined development (area under the curve [AUC] = 0.91) and validation (AUC = 0.92) cohorts. Moreover, 82% of prospective suicide attempts occurred among individuals in the top 15% of risk scores, whereas 27% occurred among individuals scoring in the top 1% of risk scores. The risk score also performed well among important subgroups, including women, men, Black, White, Hispanic, veterans, lower-income individuals, younger adults, and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) individuals. What do these findings mean? Our findings suggest that the DRS is a promising new tool that has the potential to enhance clinicians’ ability to identify individuals at risk for attempting suicide. The primary limitation of this work is its reliance on secondary data analyses to develop and validate the score. More work is needed to independently validate the DRS in prospective studies and to identify the optimal methods to assess each of the constructs used to calculate the score.