Linguistic adaptation
In order to ensure the linguistic validity, C-SSRS was provided in Persian by two independent groups. One the Lighthouse Project in Columbia University and the other one of our research team. By Merging these two versions by a third person, preliminary version prepared. This version was back translated to confirm accuracy of translation. So, after correcting mismatched items, the second version was prepared. This version was given to expert panel (23 professionals in mental health) and feedbacks were obtained to provide the final version.
In order to evaluate the content validity and face validity quantitatively, the final version was assessed by expert panel. Based on feedbacks from a group of soldiers in the pilot study, including 36 persons, this version was revised. one of the main goals in this study was to evaluate risk level of C-SSRS. Risk level had been determined according to Table1.
Table 1: role of each item in suicide risk level if the response was positive
|
item
|
recent
|
lifetime
|
Severity of suicidal ideation
|
Wish to be dead
|
|
|
Non-specific Active Suicidal Thoughts
|
|
|
Active Suicidal Ideation with any methods (not plan) without intent to act
|
|
|
Active Suicidal Ideation with some intent to act, without specific plan
|
|
|
Active Suicidal Ideation with specific plan and intent
|
|
|
Intensity of suicidal ideation
|
frequency
|
|
|
Duration
|
|
|
controllability
|
|
|
deterrents
|
|
|
Reasons
|
|
|
Suicidal behavior
|
Actual Attempt
|
|
|
Interrupted Attempt
|
|
|
Aborted Attempt
|
|
|
Preparatory Acts or Behavior
|
|
|
lethality
|
Actual Lethality/Medical Damage
|
|
|
Potential Lethality
|
|
|
* for items in suicidal ideation recent period refers to last month and in suicidal behavior to last three months
Participants
In the next step, to evaluate the tool, we administered the translated version to a group of 686 soldiers. Minimum sample size was determined as 384 based on Cochran formula, which N was the sample size, Z was 1.96, d (margin of error) was 0.05 and p assumed as 0.5. We recruited two groups of participants. First group, the normal population, were soldiers from an army barracks (n=338) and the other group included soldiers referred to a psychiatry hospital, belongs to Iran army as clinical population (N=348). Sampling was done by consecutive sampling method. Persons that didn’t consent to participate in this study, were excluded. the average age of participants was 23.26 (±3.95), all of them were soldiers of Iran army so they all were male.
Measures
Columbia suicide severity rating scale (CSSRS): CSSRS is a well-known instrument to assess suicidal ideation and behavior. CSSRS was evaluated in several studies and its reliability and validity has been proved [10, 11]. its ability to predict suicidal behavior is shown in a variety of studies [7, 10, 18]. The scale has four sections, includes: severity of suicide ideation (1-wish to be dead, 2-nonspecific active suicidal thoughts, 3-suicidal thoughts with methods, 4-suicidal intent without plan, 5-suicidal intent with specific plan), intensity of suicide ideation (frequency, duration, controllability, deterrents and reasons for ideation), suicidal behavior and lethality. Also, C-SSRS classifies suicidal behaviors according to Columbia Classification Algorithm of Suicide Assessment (C-CASA) so it can reduce ambiguity in terminology of suicide [14]. Data from the primary study showed that the convergent and divergent validity, predictive validity, sensitivity, specificity, sensitivity to change, and internal consistency of the C-SSRS are at desirable level [11, 19, 20]. Also, C-SSRS can be used as an electronic assessment tool [21-23].
General health questionnaire 28 (GHQ28): this tool is a self-report tool for screening the psychological disorder. It consists of 28 questions that includes four items: somatic symptom (1-7), anxiety-insomnia (8-14), social dysfunction (15-21), severe depression (22-28). Four of questions are allocated to suicide issue [24].
Beck helplessness scale (BHS): BHS is composed of 20 true/false questions that aims to assess the three subscales including negative attitude toward future, loss of motivation, negative expectation. BHS evaluates hopelessness that is associated with suicide risk [25].
Beck Scale for Suicidal Ideation (BSSI): this self-report instrument has 19 items that evaluates the presence and intensity of suicidal thoughts in the last week. The first 5 items are screening questions and each item has ordinal scoring from 0 to 2 [26].
Procedure
CSSRS was taken from participants by trained psychologist. Beside CSSRS, participants were evaluated by Beck scale for suicidal ideation and Beck hopelessness inventory were used for evaluation. Also, we gathered GHQ28 data from normal group but we did not have these data from clinical sample. These demographic variables were collected from participants: age, marital status and education level. in this study, all of participants were male.
Statistical analysis
Data analysis was done by Statistical Package for the Social Sciences software (SPSS) version 23. Content validity was assessed quantitatively by content validity ratio, content validity index and impact score. Pearson correlation coefficient was performed to estimate correlation of CSSRS with other instruments, Cronbach’s alpha coefficient and split-half method for internal consistency and Spearman-Brown for test-retest correlation. Factor analysis was performed to verify the construct of CSSRS and in this regard, Kaiser-Meyer-Olkin and Bartlett’s sphericity tests were used to determine data adequacy. demographic characteristic is presented by descriptive table and graph.