SAD PERSONS Scale

Assesses suicide risk in adults based on ten criteria considered as risk factors.

Refer to the text below the scale for more information on the clinical opinions about its risk screening specificity and sensibility.

The SAD PERSONS scale was designed as an assessment tool for screening adult patients suicide risk, based on an acronym model of the most common risk factors.

SAD PERSONS scores range from 0 to 10, where the higher the score, the higher the suicide risk:

0-4: Low risk;
5-6: Medium risk;
7-10: High risk.

Several studies have found that the scales sensitivity is low so its clinical value may be put under serious question. Another found disadvantage of the scale was that the risk factors may not be applicable to all individuals.

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The SAD PERSONS Scale – Applicability and criticism

The scale was designed by Patterson et al. in 1983 to help medical professional with screening suicide risk in adults. It consists in 10 risk factors, organized under the mnemonic: “SAD PERSONS”. A further adaptation for use of the scale in children was published by Juhnke in 1996.

The 10 risk factors from the scale are:

S: Male sex
A: Age (<19 or >45 years)
D: Depression
P: Previous attempt
E: Excess alcohol or substance use
R: Rational thinking loss
S: Social supports lacking
O: Organized plan
N: No spouse
S: Sickness

SAD PERSONS score range from 0 to 10, where the higher the score, the higher the suicide risk:

0-4: Low risk;
5-6: Medium risk;
7-10: High risk.

Since then, several studies have found that the scales sensitivity is low so its clinical value may be put under serious question. Another found disadvantage of the scale was that the risk factors may not be applicable to all individuals, hence why personalized risk screening would be safer than the application of the scale in assessing an individual’s suicide risk.

A study by Bolton et al. compared the SAD PERSONS and Modified SAD PERSONS (MSPS) scale scores following subsequent assessments. The 2 main outcome measures in the study were current suicide attempts (at first presentation) and future suicide attempts (within the next 6 months).

The ability of the scales to predict suicide attempts was evaluated with logistic regression, sensitivity and specificity analyses, and receiver operating characteristic curves.

Both the SAD PERSONS and MSPS scale showed poor predictive ability for future suicide attempts whilst SAD PERSONS did not predict suicide attempts better than chance (area under the curve =0.572; 95% confidence interval [CI], 0.51-0.64; P value nonsignificant).

A study by Saunders et al. set out to explore the utility of the SAD PERSONS Scale as a screening tool for suicide risk in those presenting to emergency department following self-harm.

Clinical management outcomes following assessment were recorded, from psychiatric hospital admission, community psychiatric aftercare and repetition of self-harm in the next 6 months.

While the specificity of the SAD PERSONS scores was greater than 90% for all outcomes, sensitivity was:

Only 2.0% for admission;
Only 5.8% for community aftercare;
Only 6.6% for repetition of self-harm in the following 6 months.

In the context of the Saunders study, SAD PERSONS failed to identify the majority of those either requiring psychiatric admission or community psychiatric aftercare, or to predict repetition of self-harm.

And so, the authors advised against using the scale to screen self-harm patients presenting to general hospitals. Instead, clinical assessment was advised to be centred on the individual risk factors of the subject.