Assessing Suicidal Risk in Practice: A Validation Study Initiated by Medical Social Workers

Assessing Suicidal Risk in Practice: A Validation Study Initiated by Medical Social Workers Abstract Medical social workers may often assess the suicide risk of patients. In addition to their professional assessment via clinical interviews, a valid scale may help provide a quick assessment of the risk of suicide. In Hong Kong, medical social workers wanted to initiate practice-based research with a social work scholar in the university. This research aimed to validate the Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI) and explore its factor structure among patients. Patients who revealed suicidal thoughts to medical social workers or were referred by other health-care professionals for assessing suicidal risks were invited to join this study. They were asked to complete a set of questionnaires which included the HKC-SSI and other scales validating it. The reliability, validity and factor structure of the HKC-SSI were examined. A total of 157 patients completed the questionnaires. The HKC-SSI showed good reliability and demonstrated construct validity by indicating significant correlations with other scales that measure depression, anxiety, presence of meaning and search for meaning in the expected directions. A two-factor structure, ‘motivation’ and ‘preparation’, was found. Suicide, validation, medical social work Introduction Medical social workers often work with patients who may experience different levels of suicide risk, such as those who indicate suicidal ideation when they attend the specialty out-patient clinics or patients who were hospitalised due to attempted suicide. Assessing the suicide risk of patients, including the risk of attempting and reattempting, is one of the important tasks of medical social workers (Miller et al., 1998). Medical social workers often assess the suicide risk of patients through clinical interviews, in which various aspects are explored. For example, these social workers may assess whether patients have previously attempted suicide, whether they were suffering from mental health problems like clinical depression, whether they had adequate social support, whether they showed suicidal ideation and whether they had concrete plans for attempting suicide (Granello, 2010). The success of this kind of professional assessment via clinical interviews may often depend on the experience of medical social workers. However, the use of a brief scale in suicide risk assessment can be a useful adjunct to the professional assessment of medical social workers (Cochrane-Brink et al., 2000). It may help enhance the communication and understanding of other health-care professionals in medical social workers’ practice (Chan et al., 2013). For example, the contents of the scale may help other health-care professionals to understand what medical social workers may assess, and the scores of the scale may provide an easy reference to the conditions of the patients. All these factors are important for indicating the value of medical social workers’ practice in hospitals (Auerbach et al., 2007), increasing other health-care professionals’ understanding of the roles of medical social workers (Craig and Muskat, 2013) and enhancing inter-professional collaboration in health care (Ambrose-Miller and Ashcroft, 2016). The Hong Kong context: medical social workers working with suicidal patients Medical social work has been developing in Hong Kong since 1939 (under the name almoner) (Wong et al., 2000). At present, medical social workers in Hong Kong can be categorised into two main groups: those employed by the Social Welfare Department (SWD) of the government and those employed by the Hospital Authority (HA), which receives funding from the government. The HA was developed to manage all public hospitals in Hong Kong. For historical reasons, in some public hospitals, medical social workers were assigned by the SWD and, in some public hospitals, they were directly employed by the HA. Medical social workers of the SWD may be deployed to other welfare units of the SWD every few years, and therefore they may not be able to specialise in medical social work. Medical social workers of the HA may often develop new initiatives for the professional advancement of medical social work in Hong Kong. The suicide rate in Hong Kong was 12.6 per 100,000 persons in 2015. Adults aged sixty-five or above had the highest suicide rate of all age groups (28.6 per 100,000 persons) (Hong Kong Jockey Club Centre for Suicide Research and Prevention, 2017). When patients indicate suicidal ideation or when they are admitted to hospital due to suicide attempt in Hong Kong, they are often referred to medical social workers for psycho-social assessment and support. Medical social workers in Hong Kong developed a specific protocol in working with suicidal patients, which highlights the proper handling procedures and areas to be assessed. They also look for a validated scale which could be used in their practice, to help assess the suicidal risk of patients. Scales for assessing suicide risk in the Chinese context In the Chinese context, several scales that aim to assess suicide risks have been validated, such as the Positive and Negative Suicide Ideation Inventory (PANSI) (Osman et al., 1998; Chang et al., 2009), the Scale for Suicide Ideation (SSI) (Beck et al., 1979; Zhang and Brown, 2007) and the Suicide Intent Scale (SIS) (Beck et al., 1974; Zhang and Jia, 2007; Gau et al., 2009). The PANSI is a relatively new scale which was mainly validated in the student and youth samples (Osman et al., 2003; Chang et al., 2009). The SIS aims to assess the severity of suicidal intention associated with an episode of self-harm or suicide attempt (Beck et al., 1974), whereas the SSI aims to assess the severity of indicating suicidal ideation. According to Beck et al. (1979), suicide ideation logically precedes a suicide attempt. That means some patients may only indicate suicidal ideation but not consider attempting suicide. In contrast, patients who indicate strong intent to attempt suicide should have also indicated strong suicidal ideation. It seems that the SSI, a scale that may apply to a more diverse patient population (from showing suicidal ideation to indicating intent to attempt suicide), is more appropriate for use in medical social workers’ practice. Moreover, the predictive power of the SSI for suicide attempts has been proved in a twenty-year prospective study (Brown et al., 2000). The psychometric properties of the Chinese version of the SSI were examined in a study conducted in mainland China (Zhang and Brown, 2007), but the scale was only validated in student samples. The validity of the Chinese version of the SSI among clinical samples, such as adult patients, remains unclear. Also, the validity for using it in Hong Kong requires further verification, because there may be great differences in the Chinese wording in the scale developed in mainland China and the Cantonese version used in Hong Kong (Wong et al., 2015). As proposed by Beck et al. (1979), there are three factors under the SSI: ‘Active Suicide Desire’, ‘Preparation’ and ‘Passive Suicide Desire’. However, in a study done by Beck et al. (1997), a two-factor structure (‘motivation’ and ‘preparation’) was found instead. The same two-factor structure was also confirmed in a later study (Holden and DeLisle, 2005). The factor structure of the Chinese version of the SSI was not reported by Zhang and Brown (2007). Therefore, in view of the need for including validated scales for assessment in practice, medical social workers of the HA initiated a research project and invited a social work scholar in Hong Kong to collaborate. With reference to the review mentioned above, they aim to develop a Hong Kong Chinese version of the SSI, explore its factor structure and validate it with the use of other validated scales among patient samples. Methods Participants and procedures Participants were recruited by medical social workers from in-patients and out-patients. Inclusion criteria included: (i) patients aged eighteen or above, (ii) patients who gave either verbal or written consent to join this study and (iii) patients who self-reported suicidal thoughts to medical social workers, or patients who were referred to medical social workers by other health-care professionals (e.g. doctors or nurses) for assessing suicidal risk. Exclusion criteria included: (i) being too emotionally unstable to participate in this study, (ii) being cognitively unfit (e.g. having difficulty comprehending the content of the scale) or (iii) being physically unstable (e.g. not having recovered physically from the suicide attempt). Patients were excluded from the above criteria based on the assessment and information obtained by medical social workers. According to Ferketich (1991), the sample sizes for item analysis should be at least five times the number of items of that scale, or at least 200–300. After considering the feasibility of data collection, we took the first recommendation, aiming to recruit at least 95 (N = 19 × 5) patients. Because this is a practice-based research collaboration between the researcher and medical social workers (Epstein, 2010; Lalayants et al., 2013), meetings were conducted to ensure the implementation of research but at the same time ensure the research would not overwhelm medical social workers and have negative effects on their practice. Medical social work departments from seven public hospitals in Hong Kong were involved in this research. To meet the targeted sample size, a quota sampling method was used to assign a different sampling quota to each of these departments, after considering their capacity for data collection. The same sampling method was used and found to be feasible in a previous study which involved medical social work departments in Hong Kong (Chan et al., 2013). Ethical approval was obtained from the ethics committee of each participating hospital. Patients were given a set of questionnaires to complete. Medical social workers helped complete the questionnaires if participants had any difficulty (e.g. elderly patients who were illiterate). Measures Background information of patients Information concerning the profile of patients was collected, such as age, gender, education level, religion and marital status. The number of suicide attempts of each patient was also explored via interviews. The Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI) The SSI was developed and validated by Beck et al. (1979) to assess suicidal intent by examining the severity of suicidal ideations. It includes nineteen items, and patients were asked to respond to each item with a rating of 0–2. The total score indicates the suicidal intent of patients, in which a greater score represents a greater suicide risk. The SSI was translated into Chinese and validated among 292 rural high school students in mainland China (Zhang and Brown, 2007). The author of this paper communicated with the author who validated the Chinese version (Mandarin version) in mainland China (Zhang), and consent was obtained to modify it to develop the Hong Kong Chinese version. The modification aims to serve two purposes. One is to identify contents which are difficult to understand in the original Mandarin Chinese version. The other is to ensure the wording of the scale is relevant to the local Hong Kong context. The original Mandarin version was sent for feedback to the medical social workers of all involved hospitals. Modifications were made to the wording. One significant modification was in Item 5, which explores passive suicidal desire. The term ‘passive suicidal desire’ was identified as difficult to understand and is not used in the Hong Kong Chinese context, and thus a direct translation only is not feasible. The item was rewritten to include an example of passive suicidal desire (e.g. a person who puts him or herself in a dangerous situation, such as crossing the road without paying attention to the traffic light). Ten patients were invited to complete this modified Hong Kong Chinese version for a pilot test, and all could understand and complete it without queries. The Chinese version of the Hospital Anxiety and Depression Scale (C-HADS) HADS includes fourteen items, of which seven belong to the anxiety subscale and seven to the depression subscale (Zigmond and Snaith, 1983). This Chinese version was developed and validated in Hong Kong (Leung et al., 1993). A four-point Likert scale was used to rate how often a person experienced the situation described in each item. The Chinese version of Meaning in life Questionnaire (C-MLQ) The MLQ was originally developed and validated by Steger, Frazier, Oishi and Kaler (2006). It includes ten items. There are two are subscales: Presence (MLQ-P; five items) and Search (MLQ-S; five items). Each item was rated by a Likert scale of 1 (Absolutely untrue) to 7 (Absolutely true). MLQ-P measures the presence of meaning in life, in which a higher score indicates a higher level of meaning in life. MLQ-S measures the search for meaning in life, in which a higher score indicates a greater tendency to search for meaning in life. This Chinese version was developed and validated in both student and clinical samples in Hong Kong (Chan, 2017) and its two-factor structure (C-MLQ-P and C-MLQ-S) was confirmed (Chan, 2014). Data analysis Data were entered and analysed using the SPSS 21 for Windows software package. Descriptive statistics was conducted to examine the profiles of the participants. Bivariate correlations were conducted to examine the construct validity of the HKC-SSI. Cronbach’s alpha was computed to examine the reliability of the HKC-SSI. Exploratory Factor Analysis (EFA) was conducted with Oblimin rotation. Items with factor loading ≥0.3 were retained. Results Data were collected from October 2013 to October 2014. A total of 397 patients who satisfied the inclusion criteria were met by medical social workers. Only 157 patients finally completed the questionnaires, but the sample size exceeded the proposed quota. Patient refusal to take part is one of the reasons for the 240 excluded patients not joining the study (52.9 per cent). Another is that these patients were too emotionally unstable to complete the questionnaires (20.8 per cent). Patients who were excluded were significantly older than those who joined the study (age = 46.22 versus 41.1, p < 0.01). About two-thirds of participants were female (66.9 per cent). The mean age was 41.1. Most did not have religious beliefs (61.1 per cent). Some participants had not attempted suicide (22.9 per cent) but most had: 43.9 per cent attempted suicide once and 33.1 per cent attempted twice or more. Details are shown in Table 1. The mean score of the HKC-SSI is 12.74. The mean score of the HKC-SSI and subscales of C-HADS and C-MLQ are shown in Table 2. Table 1 Background information of participants (N = 157) Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Table 1 Background information of participants (N = 157) Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Table 2 Descriptive statistics of HKC-SSI and subscales of C-HADS and C-MLQ (N = 157) Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Table 2 Descriptive statistics of HKC-SSI and subscales of C-HADS and C-MLQ (N = 157) Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Reliability and validity The Cronbach’s alpha of the HKC-SSI was 0.87. Construct validity of the HKC-SSI was demonstrated by its correlations with C-HADS, C-MLQ and number of suicide attempts. The HKC-SSI indicated significant and positive relationships with the anxiety subscale (r = 0.54, p < 0.001) and the depression subscale (r = 0.61, p < 0.001) of C-HADS. The HKC-SSI indicated significant and negative relationships with MLQ-P (r = –0.52, p < 0.001) and MLQ-S (r = –0.38, p < 0.001). Also, the HKC-SSI showed a significant and positive relationship with a patient’s number of suicide attempts (r = 0.24, p < 0.01). Factor structure A two-factor structure was found. Items 7 and 8 were removed due to double loading, and Items 10, 11, 18 and 19 were not retained because the factor loading of these items was below 0.3. Factor one—Items 1 to 6 and Item 9—was termed ‘motivation’. This factor reflects participants’ motivation to live. Factor 2, Items 12 to 17, was termed ‘preparation’. This factor indicates participants’ preparation for the suicidal act. Details are shown in Table 3. Table 3 Exploratory Factor Analysis of the Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI)   Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39    Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39  Extraction method: Principal Axis Factoring. Rotation method: Oblimin with Kaiser Normalization. Table 3 Exploratory Factor Analysis of the Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI)   Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39    Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39  Extraction method: Principal Axis Factoring. Rotation method: Oblimin with Kaiser Normalization. Discussion Findings show that the Hong Kong Chinese version of the SSI is valid and reliable for measuring suicide risk. The construct validity of the HKC-SSI was supported by the correlations with scales that measure anxiety, depression, presence of meaning and search for meaning in the expected directions. Consistently with the literature, participants who were more at risk of suicide may be more depressive and anxious and may experience a lower level of meaning in life (Bomyea et al., 2013; Hawton et al., 2013; Kleiman and Beaver, 2013). Our findings also indicate that participants who were more at risk of suicide also experienced a lower tendency to search for meaning in life. This echoes the view of Vitkor Frankl, founder of logotherapy, that ‘will to meaning’ is essential for motivating people to pass through sufferings (Frankl, 2006). Also, consistently with previous studies (Hesdorffer et al., 2006), our study shows that participants who were more at risk of suicide may be more likely to have previously attempted suicide. Consistently with the two-factor structure as found by Beck et al. (1997), we also replicated this two-factor structure in our study. In fact, all items loaded to a particular factor in this study were grouped together in the same factor in the study of Beck et al. (1997) and the same cut-off of factor loading (0.3) was used for scale inclusion. We suggest that the conceptualisation of these two factors as found in this study is very similar to that in the previous study of Beck et al. (1997). Therefore, we used the same terms as proposed by Beck et al. (1997) to call these factors ‘motivation’ and ‘preparation’. Unlike in an earlier study of Beck et al. (1979), the original proposed factor, ‘passive suicide desire’, was omitted in our current study. As mentioned, ‘passive suicide’ is not a term used in the Chinese language. Similarly, Chinese verbs, unlike English ones, do not have a passive voice. Concepts in the form of the passive voice may be more difficult for Chinese people to understand. Thus, items in the original proposed factor, ‘passive suicide desire’, were either grouped into the other two factors or removed due to factor loading. This may further explain why a two-factor structure was found in the current study. Limitations Sampling of participants was not random, and the representativeness was limited by different factors, such as a high refusal rate and emotional instability. The high refusal rate of participating in the research study is understandable, as patients with suicidal risk may often lose interest in being involved in different activities, and this reflects that medical social workers followed the ethical guidelines in respecting patients’ autonomy of not participating in the study. This is, however, a breakthrough for medical social workers coming from different hospitals in Hong Kong to conduct practice-based research on patients with suicide risks. Surprisingly, to our knowledge, previous hospital-based studies in Hong Kong only focused on the suicidal risk of psychiatric patients after discharge from hospital (Ho, 2003; Yim et al., 2004). No study has been conducted in Hong Kong to examine the profile of patients who indicate suicide risks and have received services from medical social workers. The sample size of this study is not adequate for performing the Confirmatory Factor Analysis, and future studies may include a larger sample size for confirming the factor structure of the HKC-SSI. The cut-off score of the SSI was reported to be 16 for persons who considered their worst situation in completing the SSI (nineteen items) (Beck et al., 1999). This cut-off score refers to a score above which patients may be classified as having high suicide risk. Beck et al. (1999) showed very good predictive power of the SSI in predicting actual death by suicide when using this cut-off score among patients in the USA: patients who scored 16 or above were 13.84 times more likely to die by suicide than those who scored below 16. Yet, to establish a cut-off score of the HKC-SSI among our participants, we may need to conduct a prospective study to follow up with these patients and see whether they attempt suicide in future. Limited by the time and resource constraints in this study, we are not able to do so. Therefore, this study was not able to establish a cut-off score of the HKC-SSI locally in Hong Kong. It is hoped that future studies could be conducted to develop a local cut-off score of the HKC-SSI, which is important for social work practice. Such a cut-off score could be used to alert medical social workers and other health-care professionals to conduct suicidal precaution for these patients and provide timely intervention, such as referral for psychiatric follow-up. Implications for research and practice Findings were disseminated to medical social workers in Hong Kong through a research briefing. Medical social workers were recommended to use the HKC-SSI to assess the suicide risks of patients in Hong Kong. It is also suggested that medical social workers consider the use of the HKC-SSI as a supplementary method for assessing the suicide risks of patients, in addition to their professional assessment which is based on the clinical interviews with patients. The score of the HKC-SSI could be used as a way of communicating the suicide risks of patients to other health-care professionals. The use of the HKC-SSI is particularly valuable for medical social workers who are relatively inexperienced, and the rating of each individual item may provide invaluable content for their further exploration in conducting interviews with patients. Medical social workers may also observe patients’ changes in the suicide risk level by using this scale for assessment over a period of time, such as between two follow-ups at the specialist out-patient clinic. This study has not only validated the Hong Kong Chinese version of the SSI, but also established its validity among the clinical samples of patients who indicated suicidal thoughts or were prone to suicide risk. Using this groundwork, future cross-cultural studies using the SSI can be conducted, such as studies which examine the psycho-social factors that may predict suicide risk among patients in the USA and Hong Kong. Our findings on the factor structure also suggest that the terminology of passive suicide may not be well understood by Chinese people. Therefore, it may be important for medical social workers or other helping professionals of other ethnicities (e.g. medical social workers in the USA) to be more culturally sensitive and pay attention to this point when exploring the suicide risk among Chinese immigrants or Chinese Americans whose mother language is not English. Conclusion The idea of validating a scale that assesses the suicide risks of patients was initiated by medical social workers in Hong Kong. Through collaboration with a social work researcher in the university, a practice-based research study was conducted. The Hong Kong Chinese version of the SSI was developed and validated in this study. This scale was recommended for medical social workers’ application in their practice. It is hoped that this scale may supplement their professional assessment to assess the suicide risks of patients. Further research may be conducted to examine the correlates of patients with a higher level of suicide risk by using the HKC-SSI. Acknowledgements Special thanks to all medical social workers of the Hospital Authority in Hong Kong for initiating this research collaboration, especially for the hard work of all members in the Suicide Working Group. Also, thanks to Ms Wong Lok Yi Karen for her help in the early part of this research project. References Ambrose-Miller W., Ashcroft R. ( 2016) ‘Challenges faced by social workers as members of interprofessional collaborative health care teams’, Health & Social Work , 41( 2), pp. 101– 9. Google Scholar CrossRef Search ADS PubMed  Auerbach C., Mason S. E., Laporte H. H. ( 2007) ‘ Evidence that supports the value of social work in hospitals’, Social Work in Health Care , 44( 4), pp. 17– 32. 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Assessing Suicidal Risk in Practice: A Validation Study Initiated by Medical Social Workers

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of The British Association of Social Workers. All rights reserved.
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0045-3102
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1468-263X
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10.1093/bjsw/bcx156
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Abstract

Abstract Medical social workers may often assess the suicide risk of patients. In addition to their professional assessment via clinical interviews, a valid scale may help provide a quick assessment of the risk of suicide. In Hong Kong, medical social workers wanted to initiate practice-based research with a social work scholar in the university. This research aimed to validate the Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI) and explore its factor structure among patients. Patients who revealed suicidal thoughts to medical social workers or were referred by other health-care professionals for assessing suicidal risks were invited to join this study. They were asked to complete a set of questionnaires which included the HKC-SSI and other scales validating it. The reliability, validity and factor structure of the HKC-SSI were examined. A total of 157 patients completed the questionnaires. The HKC-SSI showed good reliability and demonstrated construct validity by indicating significant correlations with other scales that measure depression, anxiety, presence of meaning and search for meaning in the expected directions. A two-factor structure, ‘motivation’ and ‘preparation’, was found. Suicide, validation, medical social work Introduction Medical social workers often work with patients who may experience different levels of suicide risk, such as those who indicate suicidal ideation when they attend the specialty out-patient clinics or patients who were hospitalised due to attempted suicide. Assessing the suicide risk of patients, including the risk of attempting and reattempting, is one of the important tasks of medical social workers (Miller et al., 1998). Medical social workers often assess the suicide risk of patients through clinical interviews, in which various aspects are explored. For example, these social workers may assess whether patients have previously attempted suicide, whether they were suffering from mental health problems like clinical depression, whether they had adequate social support, whether they showed suicidal ideation and whether they had concrete plans for attempting suicide (Granello, 2010). The success of this kind of professional assessment via clinical interviews may often depend on the experience of medical social workers. However, the use of a brief scale in suicide risk assessment can be a useful adjunct to the professional assessment of medical social workers (Cochrane-Brink et al., 2000). It may help enhance the communication and understanding of other health-care professionals in medical social workers’ practice (Chan et al., 2013). For example, the contents of the scale may help other health-care professionals to understand what medical social workers may assess, and the scores of the scale may provide an easy reference to the conditions of the patients. All these factors are important for indicating the value of medical social workers’ practice in hospitals (Auerbach et al., 2007), increasing other health-care professionals’ understanding of the roles of medical social workers (Craig and Muskat, 2013) and enhancing inter-professional collaboration in health care (Ambrose-Miller and Ashcroft, 2016). The Hong Kong context: medical social workers working with suicidal patients Medical social work has been developing in Hong Kong since 1939 (under the name almoner) (Wong et al., 2000). At present, medical social workers in Hong Kong can be categorised into two main groups: those employed by the Social Welfare Department (SWD) of the government and those employed by the Hospital Authority (HA), which receives funding from the government. The HA was developed to manage all public hospitals in Hong Kong. For historical reasons, in some public hospitals, medical social workers were assigned by the SWD and, in some public hospitals, they were directly employed by the HA. Medical social workers of the SWD may be deployed to other welfare units of the SWD every few years, and therefore they may not be able to specialise in medical social work. Medical social workers of the HA may often develop new initiatives for the professional advancement of medical social work in Hong Kong. The suicide rate in Hong Kong was 12.6 per 100,000 persons in 2015. Adults aged sixty-five or above had the highest suicide rate of all age groups (28.6 per 100,000 persons) (Hong Kong Jockey Club Centre for Suicide Research and Prevention, 2017). When patients indicate suicidal ideation or when they are admitted to hospital due to suicide attempt in Hong Kong, they are often referred to medical social workers for psycho-social assessment and support. Medical social workers in Hong Kong developed a specific protocol in working with suicidal patients, which highlights the proper handling procedures and areas to be assessed. They also look for a validated scale which could be used in their practice, to help assess the suicidal risk of patients. Scales for assessing suicide risk in the Chinese context In the Chinese context, several scales that aim to assess suicide risks have been validated, such as the Positive and Negative Suicide Ideation Inventory (PANSI) (Osman et al., 1998; Chang et al., 2009), the Scale for Suicide Ideation (SSI) (Beck et al., 1979; Zhang and Brown, 2007) and the Suicide Intent Scale (SIS) (Beck et al., 1974; Zhang and Jia, 2007; Gau et al., 2009). The PANSI is a relatively new scale which was mainly validated in the student and youth samples (Osman et al., 2003; Chang et al., 2009). The SIS aims to assess the severity of suicidal intention associated with an episode of self-harm or suicide attempt (Beck et al., 1974), whereas the SSI aims to assess the severity of indicating suicidal ideation. According to Beck et al. (1979), suicide ideation logically precedes a suicide attempt. That means some patients may only indicate suicidal ideation but not consider attempting suicide. In contrast, patients who indicate strong intent to attempt suicide should have also indicated strong suicidal ideation. It seems that the SSI, a scale that may apply to a more diverse patient population (from showing suicidal ideation to indicating intent to attempt suicide), is more appropriate for use in medical social workers’ practice. Moreover, the predictive power of the SSI for suicide attempts has been proved in a twenty-year prospective study (Brown et al., 2000). The psychometric properties of the Chinese version of the SSI were examined in a study conducted in mainland China (Zhang and Brown, 2007), but the scale was only validated in student samples. The validity of the Chinese version of the SSI among clinical samples, such as adult patients, remains unclear. Also, the validity for using it in Hong Kong requires further verification, because there may be great differences in the Chinese wording in the scale developed in mainland China and the Cantonese version used in Hong Kong (Wong et al., 2015). As proposed by Beck et al. (1979), there are three factors under the SSI: ‘Active Suicide Desire’, ‘Preparation’ and ‘Passive Suicide Desire’. However, in a study done by Beck et al. (1997), a two-factor structure (‘motivation’ and ‘preparation’) was found instead. The same two-factor structure was also confirmed in a later study (Holden and DeLisle, 2005). The factor structure of the Chinese version of the SSI was not reported by Zhang and Brown (2007). Therefore, in view of the need for including validated scales for assessment in practice, medical social workers of the HA initiated a research project and invited a social work scholar in Hong Kong to collaborate. With reference to the review mentioned above, they aim to develop a Hong Kong Chinese version of the SSI, explore its factor structure and validate it with the use of other validated scales among patient samples. Methods Participants and procedures Participants were recruited by medical social workers from in-patients and out-patients. Inclusion criteria included: (i) patients aged eighteen or above, (ii) patients who gave either verbal or written consent to join this study and (iii) patients who self-reported suicidal thoughts to medical social workers, or patients who were referred to medical social workers by other health-care professionals (e.g. doctors or nurses) for assessing suicidal risk. Exclusion criteria included: (i) being too emotionally unstable to participate in this study, (ii) being cognitively unfit (e.g. having difficulty comprehending the content of the scale) or (iii) being physically unstable (e.g. not having recovered physically from the suicide attempt). Patients were excluded from the above criteria based on the assessment and information obtained by medical social workers. According to Ferketich (1991), the sample sizes for item analysis should be at least five times the number of items of that scale, or at least 200–300. After considering the feasibility of data collection, we took the first recommendation, aiming to recruit at least 95 (N = 19 × 5) patients. Because this is a practice-based research collaboration between the researcher and medical social workers (Epstein, 2010; Lalayants et al., 2013), meetings were conducted to ensure the implementation of research but at the same time ensure the research would not overwhelm medical social workers and have negative effects on their practice. Medical social work departments from seven public hospitals in Hong Kong were involved in this research. To meet the targeted sample size, a quota sampling method was used to assign a different sampling quota to each of these departments, after considering their capacity for data collection. The same sampling method was used and found to be feasible in a previous study which involved medical social work departments in Hong Kong (Chan et al., 2013). Ethical approval was obtained from the ethics committee of each participating hospital. Patients were given a set of questionnaires to complete. Medical social workers helped complete the questionnaires if participants had any difficulty (e.g. elderly patients who were illiterate). Measures Background information of patients Information concerning the profile of patients was collected, such as age, gender, education level, religion and marital status. The number of suicide attempts of each patient was also explored via interviews. The Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI) The SSI was developed and validated by Beck et al. (1979) to assess suicidal intent by examining the severity of suicidal ideations. It includes nineteen items, and patients were asked to respond to each item with a rating of 0–2. The total score indicates the suicidal intent of patients, in which a greater score represents a greater suicide risk. The SSI was translated into Chinese and validated among 292 rural high school students in mainland China (Zhang and Brown, 2007). The author of this paper communicated with the author who validated the Chinese version (Mandarin version) in mainland China (Zhang), and consent was obtained to modify it to develop the Hong Kong Chinese version. The modification aims to serve two purposes. One is to identify contents which are difficult to understand in the original Mandarin Chinese version. The other is to ensure the wording of the scale is relevant to the local Hong Kong context. The original Mandarin version was sent for feedback to the medical social workers of all involved hospitals. Modifications were made to the wording. One significant modification was in Item 5, which explores passive suicidal desire. The term ‘passive suicidal desire’ was identified as difficult to understand and is not used in the Hong Kong Chinese context, and thus a direct translation only is not feasible. The item was rewritten to include an example of passive suicidal desire (e.g. a person who puts him or herself in a dangerous situation, such as crossing the road without paying attention to the traffic light). Ten patients were invited to complete this modified Hong Kong Chinese version for a pilot test, and all could understand and complete it without queries. The Chinese version of the Hospital Anxiety and Depression Scale (C-HADS) HADS includes fourteen items, of which seven belong to the anxiety subscale and seven to the depression subscale (Zigmond and Snaith, 1983). This Chinese version was developed and validated in Hong Kong (Leung et al., 1993). A four-point Likert scale was used to rate how often a person experienced the situation described in each item. The Chinese version of Meaning in life Questionnaire (C-MLQ) The MLQ was originally developed and validated by Steger, Frazier, Oishi and Kaler (2006). It includes ten items. There are two are subscales: Presence (MLQ-P; five items) and Search (MLQ-S; five items). Each item was rated by a Likert scale of 1 (Absolutely untrue) to 7 (Absolutely true). MLQ-P measures the presence of meaning in life, in which a higher score indicates a higher level of meaning in life. MLQ-S measures the search for meaning in life, in which a higher score indicates a greater tendency to search for meaning in life. This Chinese version was developed and validated in both student and clinical samples in Hong Kong (Chan, 2017) and its two-factor structure (C-MLQ-P and C-MLQ-S) was confirmed (Chan, 2014). Data analysis Data were entered and analysed using the SPSS 21 for Windows software package. Descriptive statistics was conducted to examine the profiles of the participants. Bivariate correlations were conducted to examine the construct validity of the HKC-SSI. Cronbach’s alpha was computed to examine the reliability of the HKC-SSI. Exploratory Factor Analysis (EFA) was conducted with Oblimin rotation. Items with factor loading ≥0.3 were retained. Results Data were collected from October 2013 to October 2014. A total of 397 patients who satisfied the inclusion criteria were met by medical social workers. Only 157 patients finally completed the questionnaires, but the sample size exceeded the proposed quota. Patient refusal to take part is one of the reasons for the 240 excluded patients not joining the study (52.9 per cent). Another is that these patients were too emotionally unstable to complete the questionnaires (20.8 per cent). Patients who were excluded were significantly older than those who joined the study (age = 46.22 versus 41.1, p < 0.01). About two-thirds of participants were female (66.9 per cent). The mean age was 41.1. Most did not have religious beliefs (61.1 per cent). Some participants had not attempted suicide (22.9 per cent) but most had: 43.9 per cent attempted suicide once and 33.1 per cent attempted twice or more. Details are shown in Table 1. The mean score of the HKC-SSI is 12.74. The mean score of the HKC-SSI and subscales of C-HADS and C-MLQ are shown in Table 2. Table 1 Background information of participants (N = 157) Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Table 1 Background information of participants (N = 157) Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Item  n  %  Gender       Male  52  33.1   Female  105  66.9  Age  M = 41.1 (SD = 16.8, range = 18–92)  Education       Never received formal education  7  4.5   Primary school or below  24  15.3   Secondary school  101  64.3   Tertiary education  24  15.3   Other  1  0.6  Religion       No religion  96  61.1   Buddhism  15  9.6   Daoism  2  1.3   Catholicism  3  1.9   Protestantism  26  16.6   Ancestor worship  11  7.0   Other  3  1.9   Missing data  1  0.6  Occupation       Unemployed  16  10.2   Self-employed  13  8.3   Employer  1  0.6   Full-time employee  48  30.6   Part-time employee  17  10.8   Homemaker  34  21.7   In school  8  5.1   Retired  12  7.6   Other  6  3.8   Missing data  2  1.3  Main source of income       Work  92  58.6   Savings  16  10.2   CSSA (public assistance from government)  17  10.8   Supported by others  20  12.7   Other  3  1.9   Missing data  9  5.7  Monthly household income       $10,000 or below  69  43.9   $10,001–$20,000  41  26.1   $20,001–$30,000  21  13.4   30,001–$40,000  11  7.0   $40,001–$50,000  4  2.5   $50,001 or above  11  7.0  Marital status       Single  52  33.1   Married  69  43.9   Divorced/separated  25  15.9   Widowed  11  7.0  Number of children       0  64  40.8   1  37  23.6   2  37  23.6   3  11  7.0  Table 2 Descriptive statistics of HKC-SSI and subscales of C-HADS and C-MLQ (N = 157) Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Table 2 Descriptive statistics of HKC-SSI and subscales of C-HADS and C-MLQ (N = 157) Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Variables  Theoretical range  M  SD  Internal consistency (α)  HKC-SSI  0–38  12.74  7.13  0.87  C-HADS           Anxiety  0–21  10.43  5.00  0.86   Depression  0–21  8.57  4.80  0.82  C-MLQ           Search  5–35  22.66  7.91  0.90   Presence  5–35  21.88  7.57  0.83  Reliability and validity The Cronbach’s alpha of the HKC-SSI was 0.87. Construct validity of the HKC-SSI was demonstrated by its correlations with C-HADS, C-MLQ and number of suicide attempts. The HKC-SSI indicated significant and positive relationships with the anxiety subscale (r = 0.54, p < 0.001) and the depression subscale (r = 0.61, p < 0.001) of C-HADS. The HKC-SSI indicated significant and negative relationships with MLQ-P (r = –0.52, p < 0.001) and MLQ-S (r = –0.38, p < 0.001). Also, the HKC-SSI showed a significant and positive relationship with a patient’s number of suicide attempts (r = 0.24, p < 0.01). Factor structure A two-factor structure was found. Items 7 and 8 were removed due to double loading, and Items 10, 11, 18 and 19 were not retained because the factor loading of these items was below 0.3. Factor one—Items 1 to 6 and Item 9—was termed ‘motivation’. This factor reflects participants’ motivation to live. Factor 2, Items 12 to 17, was termed ‘preparation’. This factor indicates participants’ preparation for the suicidal act. Details are shown in Table 3. Table 3 Exploratory Factor Analysis of the Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI)   Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39    Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39  Extraction method: Principal Axis Factoring. Rotation method: Oblimin with Kaiser Normalization. Table 3 Exploratory Factor Analysis of the Hong Kong Chinese version of the Scale for Suicide Ideation (HKC-SSI)   Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39    Factor   1  2  1. Wish to live  0.74    2. Wish to die  0.63    3. Reasons for living/dying  0.76    4. Desire to make active suicide attempt  0.65    5. Passive suicidal desire  0.64    6. Time dimension: Duration  0.54    9. Control over suicidal action  0.52    12. Method: Specificity/planning    0.73  13. Method: Availability/opportunity    0.60  14. Sense of ‘capability’ to carry out attempt    0.62  15. Expectancy/anticipation of actual attempt    0.65  16. Actual preparation    0.71  17. Suicide note    0.39  Extraction method: Principal Axis Factoring. Rotation method: Oblimin with Kaiser Normalization. Discussion Findings show that the Hong Kong Chinese version of the SSI is valid and reliable for measuring suicide risk. The construct validity of the HKC-SSI was supported by the correlations with scales that measure anxiety, depression, presence of meaning and search for meaning in the expected directions. Consistently with the literature, participants who were more at risk of suicide may be more depressive and anxious and may experience a lower level of meaning in life (Bomyea et al., 2013; Hawton et al., 2013; Kleiman and Beaver, 2013). Our findings also indicate that participants who were more at risk of suicide also experienced a lower tendency to search for meaning in life. This echoes the view of Vitkor Frankl, founder of logotherapy, that ‘will to meaning’ is essential for motivating people to pass through sufferings (Frankl, 2006). Also, consistently with previous studies (Hesdorffer et al., 2006), our study shows that participants who were more at risk of suicide may be more likely to have previously attempted suicide. Consistently with the two-factor structure as found by Beck et al. (1997), we also replicated this two-factor structure in our study. In fact, all items loaded to a particular factor in this study were grouped together in the same factor in the study of Beck et al. (1997) and the same cut-off of factor loading (0.3) was used for scale inclusion. We suggest that the conceptualisation of these two factors as found in this study is very similar to that in the previous study of Beck et al. (1997). Therefore, we used the same terms as proposed by Beck et al. (1997) to call these factors ‘motivation’ and ‘preparation’. Unlike in an earlier study of Beck et al. (1979), the original proposed factor, ‘passive suicide desire’, was omitted in our current study. As mentioned, ‘passive suicide’ is not a term used in the Chinese language. Similarly, Chinese verbs, unlike English ones, do not have a passive voice. Concepts in the form of the passive voice may be more difficult for Chinese people to understand. Thus, items in the original proposed factor, ‘passive suicide desire’, were either grouped into the other two factors or removed due to factor loading. This may further explain why a two-factor structure was found in the current study. Limitations Sampling of participants was not random, and the representativeness was limited by different factors, such as a high refusal rate and emotional instability. The high refusal rate of participating in the research study is understandable, as patients with suicidal risk may often lose interest in being involved in different activities, and this reflects that medical social workers followed the ethical guidelines in respecting patients’ autonomy of not participating in the study. This is, however, a breakthrough for medical social workers coming from different hospitals in Hong Kong to conduct practice-based research on patients with suicide risks. Surprisingly, to our knowledge, previous hospital-based studies in Hong Kong only focused on the suicidal risk of psychiatric patients after discharge from hospital (Ho, 2003; Yim et al., 2004). No study has been conducted in Hong Kong to examine the profile of patients who indicate suicide risks and have received services from medical social workers. The sample size of this study is not adequate for performing the Confirmatory Factor Analysis, and future studies may include a larger sample size for confirming the factor structure of the HKC-SSI. The cut-off score of the SSI was reported to be 16 for persons who considered their worst situation in completing the SSI (nineteen items) (Beck et al., 1999). This cut-off score refers to a score above which patients may be classified as having high suicide risk. Beck et al. (1999) showed very good predictive power of the SSI in predicting actual death by suicide when using this cut-off score among patients in the USA: patients who scored 16 or above were 13.84 times more likely to die by suicide than those who scored below 16. Yet, to establish a cut-off score of the HKC-SSI among our participants, we may need to conduct a prospective study to follow up with these patients and see whether they attempt suicide in future. Limited by the time and resource constraints in this study, we are not able to do so. Therefore, this study was not able to establish a cut-off score of the HKC-SSI locally in Hong Kong. It is hoped that future studies could be conducted to develop a local cut-off score of the HKC-SSI, which is important for social work practice. Such a cut-off score could be used to alert medical social workers and other health-care professionals to conduct suicidal precaution for these patients and provide timely intervention, such as referral for psychiatric follow-up. Implications for research and practice Findings were disseminated to medical social workers in Hong Kong through a research briefing. Medical social workers were recommended to use the HKC-SSI to assess the suicide risks of patients in Hong Kong. It is also suggested that medical social workers consider the use of the HKC-SSI as a supplementary method for assessing the suicide risks of patients, in addition to their professional assessment which is based on the clinical interviews with patients. The score of the HKC-SSI could be used as a way of communicating the suicide risks of patients to other health-care professionals. The use of the HKC-SSI is particularly valuable for medical social workers who are relatively inexperienced, and the rating of each individual item may provide invaluable content for their further exploration in conducting interviews with patients. Medical social workers may also observe patients’ changes in the suicide risk level by using this scale for assessment over a period of time, such as between two follow-ups at the specialist out-patient clinic. This study has not only validated the Hong Kong Chinese version of the SSI, but also established its validity among the clinical samples of patients who indicated suicidal thoughts or were prone to suicide risk. Using this groundwork, future cross-cultural studies using the SSI can be conducted, such as studies which examine the psycho-social factors that may predict suicide risk among patients in the USA and Hong Kong. Our findings on the factor structure also suggest that the terminology of passive suicide may not be well understood by Chinese people. Therefore, it may be important for medical social workers or other helping professionals of other ethnicities (e.g. medical social workers in the USA) to be more culturally sensitive and pay attention to this point when exploring the suicide risk among Chinese immigrants or Chinese Americans whose mother language is not English. Conclusion The idea of validating a scale that assesses the suicide risks of patients was initiated by medical social workers in Hong Kong. Through collaboration with a social work researcher in the university, a practice-based research study was conducted. The Hong Kong Chinese version of the SSI was developed and validated in this study. This scale was recommended for medical social workers’ application in their practice. 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The British Journal of Social WorkOxford University Press

Published: Jan 29, 2018

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