Review ArticlePsychometric properties of the concise health risk tracking (CHRT) in adolescents with suicidality
Introduction
Adolescent suicidal behavior is common. Almost 5000 adolescents die by suicide each year, and 1-million attempt suicide annually in the US (Curtin et al., 2016, Nock et al., 2013), making suicide the second leading cause of death among 15-24-year-olds (American Foundation of Suicide Prevention, 2014). The most salient risk factors associated with suicidal behaviors include mood disorders, prior suicide attempts, and non-suicidal self-injury. Hopelessness or helplessness, limited social support, and impulsivity have also been associated with suicide attempts (Bridge et al., 2006, Bridge, 2006).
While many rating scales have been developed that assess the severity of suicidal ideation and behaviors, there is presently no accepted standard measure for use in clinical or research settings (Ghasemi et al., 2015). Several scales are clinician-rated measures, which can be an obstacle to use in high volume settings. Of the available self-report measures of suicidality, only a few validate in both adults and adolescents. Additionally, most suicidal behavior rating scales focus specifically on suicidal thoughts and past behaviors while neglecting other factors associated with suicidal behaviors, such as mental illness, hopelessness/helplessness, limited social support, impulsivity, etc. (Bridge et al., 2006, Bridge, 2006). A brief rating scale that collects parameters which inform clinicians about the severity of suicidal thoughts and behaviors, assesses other potential risk factors for suicide (within a single measure), is sensitive to change, and is reliable across all ages is an important contribution.
A recently developed self-report measure, the Concise Health Risk Tracking (CHRT), appears to be a promising measure for assessing suicidal severity and risk in adults, and includes assessment of characteristics beyond merely current ideation and behaviors (Ostacher et al., 2015, Reilly-Harrington et al., 2016, Trivedi et al., 2011). The CHRT was designed as a tool to monitor suicidal ideation and related symptoms that could be used repeatedly to detect changes in these “symptoms” over time. To select related symptoms, the developers modeled items based on suicide risk research to date. The items included questions regarding pessimism about the future, helplessness, perception of social support, despair, and actual suicidal thoughts and plans. The original scale included 12 items. It showed strong reliability with Cronbach's coefficient alpha (a) of 0.90, and three factors were identified (current suicidal thoughts and plans, perceived lack of social support, and hopelessness) (Ostacher et al., 2015, Trivedi et al., 2011). An additional two items on impulsivity were added, making the scale 14 items; the 14 items also showed strong reliability with Cronbach's coefficient alpha of 0.88, and significant correlations with depression severity and suicidality based on the Bipolar Inventory of Symptoms Scale suicidality item (Reilly-Harrington et al., 2016). Furthermore, the 14-item CHRT predicted the risk of subsequent suicide-related serious adverse events in adults with bipolar disorder (Reilly-Harrington et al., 2016). Prior reports have also validated a shorter version of the CHRT (7 items) (Ostacher et al., 2015, Reilly-Harrington et al., 2016, Trivedi et al., 2011).
This study evaluated the 14-item CHRT-SR in a sample of adolescents treated in a suicide-prevention intensive outpatient program to determine whether the psychometric features found in adults are comparable in adolescents. Specifically, we examined the following questions: 1) Does the factor structure found in adults replicate in adolescents? 2) Does the scale demonstrate similar internal consistency reliability in adolescents as found in adults? 3) Is the scale sensitive to change following an intervention? 4) Is there evidence of construct validity for the overall total score and factors?
Section snippets
Method
Data are from a retrospective chart review of youth treated in a clinical intensive outpatient program (IOP) for adolescents with severe suicidality between January 1, 2014, and December 31, 2015, in a large not-for-profit children's hospital. The study protocol was approved by the Institutional Review Board at the University of Texas Southwestern Medical Center at Dallas. All identifying data were removed from the clinical database prior to conducting analyses. Because this study is a
Results
Altogether, 304 youth were assessed for IOP, 271 of whom fully completed the CHRT-SR. Most youth (n = 231, 85.2%) also completed the CHRT-SR at discharge. The majority were female (82.3%, n = 223), non-Hispanic (87.1%, n = 236), and Caucasian (82.7%, n = 224). The mean age was 14.93 ± 1.38 years. Over half of the sample (55.0%) was referred to IOP following a suicide attempt, although almost 3-out-of-4 patients had made a suicide attempt at some point in their lifetime. Length of treatment in
Discussion
This study evaluated the psychometric properties of the CHRT-SR in suicidal adolescents. We found three factors: Propensity (comprised of domains of Pessimism, Helplessness, Limited Social Support, and Despair), Impulsivity, and Suicidal Thoughts, all of which had good-to-excellent Cronbach a internal consistency reliability coefficients at both baseline and exit. Construct validity of the CHRT-SR was demonstrated for the total and factor scores when compared to depression severity both by
Conflicts of interest
Dr. Rush has received consulting fees from Brain Resource Ltd, Duke-NUS, Eli Lilly, Emmes Corp, Lundbeck A/S, Medavante Inc. Montana State University, National Institute of Drug Abuse, Santium, Inc., Stanford University, Takeda USA, the University of Colorado, University of Texas Southwestern Med Center; speaking fees from the University of California at San Diego, Hershey Penn State Medical Center, New York State Psychiatric Institute, the American Society for Clinical Psychopharmacology;
Author contributions
Study design: TLM, MHT
Data acquisition, analysis, and/or interpretation: TLM, BDK, MK, TC, BG, AJR, MJ, GJE, MHT
Manuscript drafting: TLM, TC, BG, AJR, MHT
All authors edited and approved the final manuscript prior to submission.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors are grateful to the following contributors:
The treatment team at Children's Health Systems of Texas, Children's Medical Center, for the exceptional care provided to youth with emotional and behavioral illness. We also are thankful to all of the children and families who participated in the SPARC program. We thank Jennifer Furman, PhD for her administrative and editorial support, and Jeremy A. Kee, M.A. for his administrative support.
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