Is the SAD PERSONS Scale dangerous?

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:

• Sex – Men die by suicide 3x as often as women (see my article Understanding and Preventing Male Suicide)
• 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.

Research Evidence

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.

Alternative Risk Assessment Tools

• Columbia Suicide Severity Rating Scale (C-SRSS)
• DCIB Suicide Risk Assessment

Bibliography

Patterson, W.M., Dohn, H.H., Patterson, J. & Patterson, G.A. (1983). “Evaluation of suicidal patients: the SAD PERSONS scale.” Psychosomatics 24(4): 343–5, 348–9. doi:10.1016/S0033-3182(83)73213-5. PMID 6867245

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