Predictive validity of the Suicide Trigger Scale (STS-3) for post-discharge suicide attempt in high-risk psychiatric inpatients

PLoS One. 2014 Jan 21;9(1):e86768. doi: 10.1371/journal.pone.0086768. eCollection 2014.


Background: The greatly increased risk of suicide after psychiatric hospitalization is a critical problem, yet we are unable to identify individuals who would attempt suicide upon discharge. The Suicide Trigger Scale v.3 (STS-3), was designed to measure the construct of an affective 'suicide trigger state' hypothesized to precede a suicide attempt (SA). This study aims to test the predictive validity of the STS-3 for post-discharge SA on a high-risk psychiatric-inpatient sample.

Methods: The STS-3, and a psychological test battery measuring suicidality, mood, impulsivity, trauma history, and attachment style were administered to 161 adult psychiatric patients hospitalized following suicidal ideation (SI) or SA. Receiver Operator Characteristic and logistic regression analyses were used to assess prediction of SA in the 6-month period following discharge from hospitalization.

Results: STS-3 scores for the patients who made post-discharge SA followed a bimodal distribution skewed to high and low scores, thus a distance from median transform was applied to the scores. The transformed score was a significant predictor of post-discharge SA (AUC 0.731), and a subset of six STS-3 scale items was identified that produced improved prediction of post-discharge SA (AUC 0.814). Scores on C-SSRS and BSS were not predictive. Patients with ultra-high (90(th) percentile) STS-3 scores differed significantly from ultra-low (10(th) percentile) scorers on measures of affective intensity, depression, impulsiveness, abuse history, and attachment security.

Conclusion: STS-3 transformed scores at admission to the psychiatric hospital predict suicide attempts following discharge among the high-risk group of suicidal inpatients. Patients with high transformed scores appear to comprise two clinically distinct groups; an impulsive, affectively intense, fearfully attached group with high raw STS-3 scores and a low-impulsivity, low affect and low trauma-reporting group with low raw STS-3 scores. These groups may correspond to low-plan and planned suicide attempts, respectively, but this remains to be established by future research.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Depressive Disorder / psychology*
  • Female
  • Hospitalization
  • Hospitals, Psychiatric
  • Humans
  • Inpatients / psychology*
  • Male
  • Patient Discharge
  • Risk
  • Risk Factors
  • Suicidal Ideation
  • Suicide / psychology*
  • Suicide, Attempted / psychology*

Grant support

This project was supported by grant 1-SRG-xxxx-00139-1208-0609 awarded to Dr. Igor Galynker from the American Foundation for Suicide Prevention ( <>). The Family Center for Bipolar Disorder and Zirinsky Mood Disorders Center provided additional funding. These are privately funded clinical treatment entities affiliated with Beth Israel Medical Center, which are directed by IIG, and employ ZSY and IK. The funding entities have no special interest in the study beyond the authors' own. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Foundation for Suicide Prevention, The Family Center for Bipolar Disorder, or the Zirinsky Mood Disorders Center. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.