The SIMPLE STEPS Model (McGlothlin, 2008) for suicide risk assessment provides a simple mnemonic similar to others like SADPERSONS (Patterson, et. al., 1983) or IS PATH WARM (from the American Association of Suicidology). Each of these is correlated with increasing suicide lethality and so this can be a useful short-hand to remember these items.
Suicide risk assessment on the crisis line is mostly concerned with imminent risk, and many suicide screeners designed for lay people may miss important variables in a goal to be simplistic; the SIMPLE STEPS model appears to avoid both of these traps, by providing an assessment tool simple enough to be used in the crisis line environment but comprehensive enough to be used by counsellors or therapists for ongoing monitoring of suicide risk.
Items in the SIMPLE STEPS Model
Suicidal – Is the individual expressing suicidal ideation?
Ideation – What is their suicidal intent?
Method – How detailed and accessible is their suicidal method?
Perturbation – How strong is their emotional pain
Loss – Have they experienced actual or perceived losses? (Relationships, material objects)
Earlier Attempts – What previous attempts has the individual experienced, what happened after those attempts?
Substance Use – Is the individual abusing drugs, alcohol, or other substances?
(Lack of) Troubleshooting Skills – Are they able to see alternatives or options other than suicide?
Emotions / Diagnosis – “Assessment of emotional attributes (hopelessness, helplessness, worthlessness, loneliness, agitation, depression, and impulsivity) and diagnoses commonly associated with completed suicide (e.g., substance abuse, mood disorders, personality disorders, etc.)” (McGlothlin, et. al., 2016)
(Lack of) Protective Factors – What is keeping this person safe from suicide? Who are their supports (internal such as personal values and external like people), resources and agencies
Stressors and Life Events – What has happened in their life to lead them to suicide?
Sharp readers will identify that these elements map very neatly onto the DCIB Model of Suicide Risk Assessment, but perhaps provide a better mnemonic in order to make sure that clinicians who do not have the DCIB in front of them are able to perform that assessment.
Validation of the SIMPLE STEPS Model
McGlothlin, et. al. (2016) used 13,000 calls over six years to a crisis line and correlated the SIMPLE STEPS items with the lethality risk present in that call. One limitation of this study is that it used self-reported (by the helpline worker taking the call) lethality rather than using another evidence-based risk assessment in order to compare with. I am satisfied that McGlothlin addressed this in his limitations section, where he noted the difficulty with using data collected in this manner.
McGlothlin, J. (2008). Developing clinical skills in suicide assessment, prevention and treatment.
Alexandria, VA: American Counseling Association
McGlothlin, J., Page, B., & Jager, K. (2016). Validation of the SIMPLE STEPS Model of Suicide Assessment. Journal Of Mental Health Counseling, 38(4), 298-307. doi:10.17744/mehc.38.4.02
Studies on the connection between religion and suicide have led to mixed results. Some studies indicated higher levels of suicidality, no relation or reduced risk. Many of the studies that indicated a relationship (either positive or negative), had mediators attached – such as that individuals who were more religious were less likely to attempt suicide as long as they lacked other social supports.
Religiosity and Suicide
Meta-reviews, large scale analyses of suicide risk have helped shed some evidence on the connection between religion and suicide.
Lawrence, Oquendo & Stanley (2016) noted that suicide and religion are both complex dimensions (e.g. suicide ideation versus attempts versus death, religious affiliation versus attendance.) Being part of a majority religious community was found to be a greater protective factor against suicide than a minority community, but that attending religious services was not as important as having social supports (whether religious or not.)
Norko et. al. (2017) noted that all major faith communities (including Islam, Hinduism, Judaism, Buddhism, and Christianity) have strong objections to suicide.
In Lawrence et. al. (2016) a sample of clinically depressed patients in a hospital setting were found to have a higher rate of suicidality if they identified a religious affiliation, the more they attended religious services, and the more they indicated religion was important.
Finally, Wu, Wang & Jia (2015), analyzing over 5000 participants across several large studies identified the three elements that are responsible for the protective factor of suicide: being of a western culture, being older, and living in a area with religious homogeneity.
Spirituality and Suicide
Spirituality can be examined through a lens different from organized religion. While religion may entail specific doctrine, spirituality instead examines one’s relationship with “self, others and ‘God’” (Mandhoui, et. al., 2016), in whatever form that takes.
Mandhoui et. al. (2016) surveyed individuals who were in hospital for suicide attempts. Those individuals lower in spirituality were more likely to attempt suicide at 18 months, with “value of life” tending to reduce the chance that someone re-attempts.
Amato, et. al. (2016) noted that spirituality can be integrated into suicide prevention programs such as case management, therapy and suicide assessment to determine the impact for that individual. They summarize the impact of spirituality by noting that “some individuals at high risk of suicide may find fellowship in an affirming community of faith; others may be helped by rituals that confer atonement or a state of exaltation; still others may learn, through mindfulness meditation, to suspend their inclination to judge themselves harshly.”
Specific Religions / Denominations and Suicide
Buddhism and Suicide
Buddhism has received some exploration in the scientific literature, especially in light of Buddhist monks who have self-immolated for political reasons, the most famous of whom was Thích Quảng Đức in 1963, but research on the exact suicide rate, especially when considered with other religions is lacking.
Lizardi & Gearing (2010) noted several elements that may decrease suicide in Buddhist individuals, including that the largest communities of Buddhists (Asian Americans and Pacific Islanders) have lower suicide rates than whites (who tend to belong to different religious communities) and a strong aversion to killing. In contrast, a belief in reincarnation and life-after-death may contribute to an increase in the suicide rate among specific individuals who adhere strongly to Buddhist traditions.
Catholicism / Protestantism and Suicide
Emile Durkheim in his 1897 work Suicide examined the suicide rates among Catholics and Protestants. He found that Catholics had much lower rates of suicide than Protestants and theorized that it was the result of social support provided in the Catholic community. Additional support was confirmed by Torgler & Schaltegger (2014) and Siegrist (1996) in a modern sample, who also found that church attendance reduced suicide.
Hinduism / Islam and Suicide
Ineichen (1998) examined a number of studies on Hinduism and Islam and consistently found that Muslims had much lower suicide rates than Hindus, focused on a variety of South Asian diaspora (such as individuals in the United Kingdom from other countries.)
Following up on this research, Thimmaiah et. al. (2016) explored a population of Muslims and Hindus in India and found that , while Muslims indicated more negative attitudes towards suicide which may help explain why they are less likely to attempt suicide.
Judaism and Suicide
Examining Jewish Israelis, Eliezer & Daniel (2012) found a rate of suicide lower in Jewish individuals than those who are Catholic or Protestant. Significantly, those with other risk factors for suicide (like veterans, immigrants or those who have experienced trauma) are at elevated at risk of suicide despite their religiosity.
After a review of the literature, it emerges that religious denominations and other factors can have an influence on suicide. Some religions have higher rates of suicide, and some have lower rates, which may be explained by the value system of those religions or the social support of those religions.
The suicide risk by religion, from highest to lowest is below:
Other religions with less well established data sets can be compared to each other, but not necessarily to other religions: Islam has a lower level of suicide than Hinduism, while Buddhism has a lower level of suicide than Native American spirituality.
Amato, J. J., Kayman, D. J., Lombardo, M., & Goldstein, M. F. (2016). Spirituality and religion: Neglected factors in preventing veteran suicide?. Pastoral Psychology, doi:10.1007/s11089-016-0747-8
Dyson, J., Cobb, M., Forman, D. (1997) The meaning of spirituality: a literature review. Journal of Advanced Nursing. 26(6). Retrieved on March 3, 2017 from http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2648.1997.00446.x/abstract doi: 10.1046/j.1365-2648.1997.00446.x
Durkheim, E. (1897). Le suicide: étude de sociologie. F. Alcan: Chicago, IL.
Eliezer, W., & Daniel, S. (2012). Suicide in Judaism with a Special Emphasis on Modern Israel. Religions, Vol 3, Iss 3, Pp 725-738 (2012), (3), 725. doi:10.3390/rel3030725
Ineichen, B. (1998). The influence of religion on the suicide rate: Islam and Hinduism compared. Mental Health, Religion & Culture, 1(1), 31.
Lawrence, R. E., Brent, D., Mann, J. J., Burke, A. K., Grunebaum, M. F., Galfalvy, H. C., & Oquendo, M. A. (2016). Religion as a risk factor for suicide attempt and suicide ideation among depressed patients. Journal Of Nervous And Mental Disease, 204(11), 845-850. doi:10.1097/NMD.0000000000000484
Lawrence, R. E., Oquendo, M. A., & Stanley, B. (2016). Religion and suicide risk: A systematic review. Archives Of Suicide Research, 20(1), 1-21. doi:10.1080/13811118.2015.1004494
Mandhouj, O., Perroud, N., Hasler, R., Younes, N., & Huguelet, P. (2016). Characteristics of spirituality and religion among suicide attempters. Journal Of Nervous And Mental Disease, 204(11), 861-867. doi:10.1097/NMD.0000000000000497
Norko, M. A., Freeman, D., Phillips, J., Hunter, W., Lewis, R., & Viswanathan, R. (2017). Can Religion Protect Against Suicide?. Journal Of Nervous & Mental Disease, 205(1), 9-14. doi:10.1097/NMD.0000000000000615
Siegrist, M. (1996). Church Attendance, Denomination, and Suicide Ideology. Journal Of Social Psychology, 136(5), 559-566.
Thimmaiah, R., Poreddi, V., Ramu, R., Selvi, S., & Math, S. (2016). Influence of Religion on Attitude Towards Suicide: An Indian Perspective. Journal Of Religion & Health, 55(6), 2039-2052. doi:10.1007/s10943-016-0213-z
Torgler, B., & Schaltegger, C. (2014). Suicide and Religion: New Evidence on the Differences Between Protestantism and Catholicism. Journal For The Scientific Study Of Religion, 53(2), 316-340. doi:10.1111/jssr.12117
Wu, A., Wang, J., & Jia, C. (2015). Religion and Completed Suicide: a Meta-Analysis. Plos ONE, 10(6), 1-14. doi:10.1371/journal.pone.0131715
The Crisis Triage Rating Scale (CTRS; Bengelsdorf, et. al. 1984) is a telephone triage tool that can be used for determining whether an individual in crisis requires psychiatric assessment. Turner & Turner (1991) determined that a cut-off score of 9 or lower necessitated admission. This was confirmed in a follow up study by Adeosun et. al. (2013)
The CTRS has three subscales:
Ability to Cooperate
Each category is rated from 1-3, so the entire scale is scored from 3-15 (with a lower score representing less functioning.) This copy of the CTRS from the Human Services and Justice Coordinating Committee lists the response guidelines:
Urgency of Response
Immediate response recommended
A. Dangerousness _____
See within 2 hours
B. Support System _____
See within 12 hours
C. Ability to Cooperate _____
See within 48 hours
Total Score: _______
See within 2 weeks
Community Use and Validation of the CTRS
The CTRS has been used in community organizations that have mobile crisis teams, for the purpose of assessing whether callers require inpatient admission to a hospital. This can help guide the often murky process of crisis assessment.
Bonynge & Thurber (2008) determined that the CTRS was accurate in determining the difference between inpatient and outpatient treatment but that with all the tools tested (the Crisis Triage Rating Scale, the Triage Assessment Form and the Suicide Assessment Checklist), the determination of exactly what inpatient treatment (Hospitalization in a psychiatric or substance abuse settings, partial hospitalization or crisis beds) is most effective.
Limitations of the Crisis Triage Rating Scale
Molina-Lopz et. al. (2016) note that the CTRS “requires knowledge of each patient’s social and family support system at the time of assessment, which can be especially difficult to gauge in aggressive, agitated, suspicious, isolated or non-cooperative patients” which is a reasonable criticism of the Support System subscale of the tool.
The criteria used for the Dangerousness subscale is also interesting, for each rating there are 3-4 criteria given. Because of the difficulty in evaluating these (e.g. “Expresses suicidal/homicidal ideas with ambivalence, or made only ineffectual gestures. Questionable impulse control”) the reliability of the CTRS may be suspect.
The CTRS can be downloaded from the Human Services and Justice Coordinating Committee here.
Adeosun, I., Adegbohun, A., Jeje, O., & Omoniyi, O. (2013). 1364 – Predictive validity of the crisis triage rating scale in the disposition of patients attending a nigerian psychiatric emergency unit. European Psychiatry, 281. doi:10.1016/S0924-9338(13)76409-5
Bengelsdorf, H., Levy, L., Emerson, R., & Barile, F. (1984). A crisis triage rating scale: Brief dispositional assessment of patients at risk for hospitalization. Journal Of Nervous And Mental Disease, 172(7), 424-430.
Bonynge & Thurber (2008). Development of Clinical Ratings for Crisis Assessment In Community Mental Health. Brief Treatment and Crisis Intervention. 8(4):304-312; doi:10.1093/brief-treatment/mhn017
Molina-López, A., Cruz-Islas, J. B., Palma-Cortés, M., Guizar-Sánchez, D. P., Garfias-Rau, C. Y., Ontiveros-Uribe, M. P., & Fresán-Orellana, A. (2016). Validity and reliability of a novel Color-Risk Psychiatric Triage in a psychiatric emergency department.BMC Psychiatry, 161-11. doi:10.1186/s12888-016-0727-7
Turner, P.M., Turner, T.J. (1991). Validation of the crisis triage rating scale for psychiatric emergencies. Canadian Journal of Psychiatry. 36(9):651-4
Suicides in prisons and jails are several times higher than the general population (Thigpen, Beauclair, Hutchinson & Zandi, 2010) for a variety of reasons: incarceration is stressful, mental health issues can be exacerbated in the corrections environment, and overcrowding and understaffing mean that suicidality can be hard to detect. This led to the development of the JSAT.
The JSAT, or Jail Suicide Assessment Tool (Carlson, 2002) is a semi-structured tool featuring 24 domains associated with suicidality, These categories explore supports in your life, physical health, mental health, suicidal thoughts and attempts, and more. This tool is NOT to be confused with the similarly named Jail Screening Assessment Tool, also abbreviated as JSAT.
Each domain or category in the JSAT features some sample words to help guide the answering of that question. For example, the category “Psychiatric treatment” includes the sample words “counseling, medication, compliance, hospitalization, diagnoses.
Components of the JSAT:
The 24 components of the JSAT can be clustered under five broad categories, Mental Health, Physical Issues, Personality and Emotional State, Social Supports and Other / Situational.
Depression (current signs)
Reality testing (current signs)
Self-harm history (could also be classified under Physical Health Issues)
Recent suicide signs
Physical Health Issues
Personality and Emotional State
View of death
View of suicide
Other / Situational
Scoring the JSAT
Each category is scored + (positive, lack of suicide risk), – (negative or risk of suicidality) or n (neutral). Additionally, the tool provides some ways of operationalizing these categories.
Looking at the category “Suicidal intention”, the category is described as “Resolution to act, lethal plan with available means.” To mark + (absence of risk) the prisoner must convincingly deny any intent to harm themselves, while to mark – (presence of risk) they must express a desire to die by suicide in the near future and/or have a lethal suicide plan with available means.
Time for Administration is between 30 and 120 minutes
Research Supporting the JSAT
There have been no research studies that I am aware of evaluating the JSAT in a corrections population. It was prepared for the Federal Bureau of Prisons based on a previous tool called the Prison Suicide Risk Assessment Checklist (PSRAC), which itself has not been evaluated either.
Evaluation of the JSAT
Although there is no published research review of the JSAT, the general principles of suicide risk assessment can be applied to confirm whether the JSAT is an effective tool for evaluating risk. The principles include:
Does the tool appear to measure what it claims to? (face validity)
Will the tool cover the important risk factors and warning signs of suicide? (content validity)
If two professionals complete the tool on the same prisoner in the same circumstances, will they reach the same conclusion? (reliability)
Can the completed tool be defensible in court if a suicide occurs? (documentation)
Let’s review each of these below.
Face Validity of the JSAT
The JSAT includes elements covering history of suicide attempts, current suicide warning signs, presence of depression, self-injury and substance abuse issues, social supports, view of suicide and many other risk factors.
On this basis the JSAT appears to be face valid for suicide – though I would question if all the elements are necessary in a comprehensive assessment. For example, “Cooperation” is identified as whether there is a good rapport between the interviewer and the client, as evidenced by a no-suicide contract. This is clearly not evidence-based (no suicide-contracts do not work), and rapport is not a suicide risk factor.
A minor criticism as well, some of the categories in the JSAT are oddly named. For instance, the criteria for the category Character is listed below:
“+” No indication of prominem character disorder traits.
“-“A diagnosed personality disorder; prominent, innexible. maladaptive character traits which cause significant functional impairment or distress.
Given the Character item explores the presence of a personality disorder (which is also not a major risk factor for suicide on its own outside of Borderline Personality Disorder) it makes much more sense to simply name it “Personality Disorder.”
Content Validity of the JSAT
Content validity explores whether the elements of an effective suicide risk assessment is covered. The acronym IS PATH WARM (Lester, Mcswain & Gunn, 2011), developed by the American Association of Suicidology (AAS) can be used to verify suicide warning signs.
Mapping the IS PATH WARM mnemonic onto the JSAT criteria we see the following matchup:
The presence of suicidal thoughts. This is covered by the JSAT category Suicidal Intention, which has as a risk factor “Expresses desire to commit suicide in the ncar future; has a lethal suicide plan with available means.”
Current or former substance abuse issues. This category is found in the JSAT as Chemical Abuse/Use where the risk factor is “Presently intoxicated or going through symptoms of withdrawal; recent history of drug or alcohol abuse”
Purposelessness is adequately covered by the JSAT category Hope. The risk factor is described as “no future orientation or life goals; cannot identify reasons to live.”
The JSAT category Mental Status is defined as “Significantly impaired orientation; disturbed mood/affect; thought content or form showing signs of psychosis; severe anxiety; severe agitation.”
Trapped does not appear to be represented in any of the JSAT categories.
See purposelessness above.
See Substance Abuse above.
See anxiety above.
Recklessness or impulsiveness is explored in the JSAT category Measured Reasoning, defined as “sudden destructive action toward self/others, impulsive. a hot-head.”
See Anxiety above.
Summary of JSAT Content Validity
Given the above, it appears the JSAT has adequate content validity for the risk factors of suicide, though some of them appear to be lumped together in multiple categories. A more effective tool would separate these categories to make sure the nuances are not overlooked.
Reliability of the JSAT
Reliability describes the ability for a tool’s consistency. This makes no claim to the correctness of the evaluation (known as validity), but rather that two people using the same tool with the same person will come to similar results.
Given the detailed operationalization, the reliability of the JSAT should be good. For instance, looking at “View of Death”, the risk and non-risk options are below:
“+” Convincingly expresses a desire to survive.
“-” Would welcome a natural death; can name good things that would occur as a result of dying
This is specific enough that two assessors should be able to come to the same conclusion.
Documenting a Jail Suicide Assessment
Would the JSAT stand up in court? This is often one of the most important elements of a risk assessment. Even if it is valid, if you can’t “show your work” and demonstrate that you have adequately considered all elements, you may be legally exposed in the event of a client suicide.
Obegi, Rankin, Williams, & Ninivaggio, (2015) explore the elements of a risk assessment required to stand up in court. They use the acronym CAIPS, which stands for:
Chronic and Acute Factors
Imminent Warning Signs
Chronic and Acute Factors / Imminent Warning Signs
The chronic and acute factors, and imminent warning signs of the JSAT have been adequately explored above.
One major problem with the JSAT is that a simple + or – sign will not provide the detail required to defend the presence or absence of a risk factor. For example, reviewing “View of Death” above, how does the clinician prove the client welcomes a natural death? What good things do they believe would occur upon their death?
Protective factors are explored fairly extensively in the JSAT, with Social Supports, Important Relationships, View of Death (which explores the idea of a perceived burden), Hope (future plans, reasons for living, hope for the future), Help Self (problem-solving ability and sense of control), Cognitive Themes (presence of optimism), and View of Suicide (beliefs or values that resist suicide).
The final element of the CAIPS element is the Summary Statement. This is the major element missing from the JSAT, as noted above. A detailed risk assessment requires both a discussion of the individual risk factors and warning signs, as well as an overall summary noting their risk and prescribing the appropriate interventions (e.g. removal of suicide means or surveillance.)
Case Study Using the JSAT
Brandy et. al. (2008) provide a number of suicide case studies, one of which is adapted here to demonstrate use of the JSAT. For more information see the original source.
49-year-old, single male who is in the county jail for attempted robbery
Noose discovered in his personal effects
Client is awaiting a 10 year prison sentence
Notes if he is sentenced to 10 years he would hang himself, making another noose if the first one was taken away
Cares deeply for his girlfriend and her children but feels they don’t care for him
Refused mental health support and had nothing to live for
An evaluation using the JSAT would result in negative (risk present) selections in at least the following categories:
Recent Suicide Signs
The most important elements here are the lack of supports, hopelessness and expressed intent to die. This client would be considered high risk for suicide given the lack of protective factors and should be restricted from accessing means for hanging.
Applying the DCIB Risk Assessment as an alternative risk assessment for confirmation, we note that this client is showing suicide desire, capability, intent and has a lack of protective factors.
Brandy L. Blasko , Elizabeth L. Jeglic & Stanley Malkin (2008) Suicide Risk Assessment in Jails, Journal of Forensic Psychology Practice, 8:1, 67-76, DOI: 10.1080/15228930801947310
Lester, D., Mcswain, S., & Gunn Iii, J. F. (2011). A TEST OF THE VALIDITY OF THE IS PATH WARM WARNING SIGNS FOR SUICIDE. Psychological Reports,108(2), 402-404. doi:10.2466/09.12.13.PR0.108.2.402-404
Thigpen, M.L., Beauclair, T.J., Hutchinson, V.A., Zandi, F. (2010) National Study of Jail Suicide: 20 Years Later. National Institute of Corrections. Accessed electronically on Mar 12 2016 from http://static.nicic.gov/Library/024308.pdf
Obegi, J. H., Rankin, J. M., Williams, J. J., & Ninivaggio, G. (2015). How to write a suicide risk assessment that’s clinically sound and legally defensible. Current Psychiatry, (3), 50.
The SAD PERSONS scale was first developed in 1983 by Patterson, Dohn, Patterson & Patterson to teach medical students clinical suicide risk assessment skills. In that first publication, students taught the tool – which features 10 risk factors for suicide that are added up, “demonstrated a significantly greater ability to accurately evaluate and make recommendations for disposition of a low-risk and a high-risk patient” compared to controls who rated both patients as high risk for suicide.
SAD PERSONS Risk Factors
The risk factors of the SAD PERSONS scale are below:
Age – Suicide rates rise with age in the US; in Canada they tend to peak in middle age
Depression – Depression is the most common diagnosed mental illness in those who die by suicide (Isometsä, 2014)
Prior History – The greatest predictor of future suicidal behaviour is past suicidal behaviour (May, Klonsky & Kline, 2012)
Ethanol Abuse – Substance abuse disorders are the second most common disorder (behind mood disorders) in suicide deaths, and those who are acutely intoxicated are at 5-10x greater risk (Conner, 2014)
Rational Thinking Loss – The inability to think clearly can raise a person’s acute suicide risk
Support System Loss – Along with No Significant Other, lacking a support system can be a risk factor
Organized Plan – The more detailed someone’s suicide plan is, the more likely they may be to attempt
No Significant Other
Sickness – Physical health issues can increase suicidality
Scoring and Types of Risk Factors
Each factor that is present increases the score by 1, with higher scores indicating increased risk to die by suicide.
Some of these factors (sex, age, prior history of suicide, no significant other) are historical or static risk factors while some (depression, ethanol abuse, rational thinking loss, support system loss, organized plan) are dynamic risk factors and at least one, sickness could fit into either one.
Since 1983, we’ve learned a lot about suicide. It’s important that suicide risk assessment tools be validated and show an ability to predict suicide. Juhnke (1994) reviewed some of the early history of the tool and found that although it was used regularly in clinical settings, the research evidence supporting it was limited.
More recently, Warden, et. al. (2014) reviewed a number of studies on the SAD PERSONS scale and found that none of the studies that explored its ability to predict suicide showed that it was able to do so.
Finally, Saunders, et. al. (2013) noted that the SADPERSONS scale misses so many suicidal individuals that it may be harmful. Given the lack of research support for the scale, it would be wise to explore alternate tools.
Conner, K. R., Bagge, C. L., Goldston, D. B., & Ilgen, M. A. (2014). Alcohol and Suicidal Behavior. What Is Known and What Can Be Done. American Journal Of Preventive Medicine, 47(Supplement 2), S204-S208. doi:10.1016/j.amepre.2014.06.007
Isometsä, E. (2014). Suicidal Behaviour in Mood Disorders–Who, When, and Why?. Canadian Journal Of Psychiatry, 59(3), 120-130.
Juhnke, G. A. (1994). SAD PERSONS Scale review. Measurement & Evaluation In Counseling & Development (American Counseling Association), 27(1), 325.
May, A. M., Klonsky, E. D., & Klein, D. N. (2012). Predicting future suicide attempts among depressed suicide ideators: A 10-year longitudinal study. Journal Of Psychiatric Research, 46946-952. doi:10.1016/j.jpsychires.2012.04.009
Saunders K et al. The sad truth about the SADPERSONS Scale: An evaluation of its clinical utility in self-harm patients. Emerg Med J 2013 Jul 29 [e-pub ahead of print]. (http://dx.doi.org/10.1136/emermed-2013-202781) – See more at: http://www.jwatch.org/na31829/2013/08/02/sad-performance-sadpersons-scale#sthash.YsRHmKja.dpuf
Warden, S., Spiwak, R., Sareen, J., & Bolton, J. M. (2014). The SAD PERSONS Scale for Suicide Risk Assessment: A Systematic Review. Archives Of Suicide Research, 18(4), 313-326 14p. doi:10.1080/13811118.2013.824829