Improving Our Understanding of Suicidal Ideation in Cancer Survivors

The Brief Pain Inventory (BPI; Cleeland \& Ryan, 1994) Pain Severity Scale consists of four 0-10 numerical rating scales evaluating (1) current pain as well as (2) worst (3) least and (4) average pain during the past 7 days. For this rating scale zero indicates, "no pain" while 10 indicates, "pain as bad as you can imagine". Averaging these four scores creates a composite score for pain severity. The measures has shown good internal consistency with Cronbach's alphas ranging from .78-.97 (Jensen, 2003).

The BPI's Pain Interference Scale (Cleeland \& Ryan, 1994) consists of seven items reflecting daily activities, including general activity, mood, walking ability, work, relationships, sleep, and enjoyment of life. A 0-10 numerical rating scale indicates the level of interference pain has had on each activity, with zero indicating, "does not interfere" and 10 indicating, "completely interferes". Averaging these seven scores creates a composite score for pain interference. The measure has shown good internal consistency with Cronbach's alphas ranging from .78-.91 (Jensen, 2003).

The MD Anderson Symptom Inventory (MDASI; Cleeland et al, 2000) is a self-report measure of cancer treatment-related symptoms. The measure includes 19 items, 13 of which comprise the symptom severity subscale and 6 of which comprise the symptom interference subscale. The symptom severity subscale asks patients to rate how severe various cancer-related symptoms (e.g., lack of appetite, dry mouth, fatigue) have been for them in the past 24 hours. Items on the symptom severity subscale are rated on a 0-10 numeric rating scale where 0 indicates "not present" and 10 indicates "as bad as you can imagine". The symptom interference subscale asks patients to rate the extent to which their symptoms have interfered with various domains of functioning (e.g. walking, enjoyment of life) in the past 24 hours. Items on the symptom interference subscale are rated on a 0-10 numeric rating scale where 0 indicates "did not interfere" and 10 indicates "interfered completely".

The PROMIS physical function short-form 6b (PF 6b) is a six item measure evaluating physical function using items from the National Institute of Health's Patient-Reported Outcomes Measurement Information System. Items on the PF 6b include questions such as "Does your health now limit you in doing two hours of physical labor?" and "Are you able to go up and down stairs at a normal pace?. Item responses are made on a 5-point Likert scale with one indicating "unable to do" and five indicating "without any difficulty". The measure has good internal reliability with a Cronbach's alpha of 0.94 (Jensen et al, 2015)

The Functional Assessment of Cancer Therapy Scale-General (FACT-G; Cella et al, 1993) is a 27-item self-report measure of general cancer quality of life which includes physical, functional, social, and emotional well-being subscales. Items evaluate the endorsement of various cancer related symptoms, treatment related difficulties, or facets of psychosocial functioning within the past week. Item responses are rated on a 5-point Likert scale with zero indicating "not at all" and four indicating "very much". The measure has good internal reliability with a Cronbach's alpha of .89 (Cella et al, 1993).

The Suicidal Behaviors Questionnaire-Revised (SBQ-R; Osman et al, 2001) consists of four items which each tap into a different dimension of suicidality. Item 1 taps into lifetime suicidal ideation and/or suicide attempt. Item 2 assesses the frequency of suicidal ideation over the past twelve months. Item 3 assesses the threat of suicide attempt. Item 4 evaluates self-reported likelihood of suicidal behavior in the future. In adult general populations, this measure demonstrated 93% sensitivity and 95% specificity (Osman et al, 2001).

The Acceptance and Action Questionnaire-II (Bond et al, 2011) is a 7 item self-report measure assessing experiential avoidance. Item responses are rated on a seven-point Likert scale indicating the degree to which each statement is true for them ranging from (1) never true to (7) always true. The scale is scored by summing the seven items, with higher scores indicating lower levels of experiential acceptance. The measure has shown good internal reliability with a Cronbach's alpha of .84 (Bond et al, 2011).

The Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, \& Williams, 2001) is a nine item self-report measure assessing the presence of DSM-IV criteria for major depressive episodes in the past two-week period. Item responses are rated on a four-point Likert scale with zero indicating "not at all" and three indicating "nearly every day". It has good internal reliability, with a Cronbach's alpha of 0.89 in primary care populations (Kroenke et al, 2001), and is endorsed by the American Society of Clinical Oncology (ASCO; Andersen et al, 2014) as a recommended screening tool for depression in cancer patients.

The Hopelessness Assessment in Illness Questionnaire (Rosenfeld et al, 2011) is an eight item measure designed specifically to assess the construct of hopelessness as it pertains to terminally ill patients as it assesses hopelessness rather than awareness of prognosis. It is also shorter than other commonly used measures of hopelessness resulting in reduced patient burden. Each item has a three-choice anchored response format. The HAI has good internal reliability, with a Cronbach's alpha of 0.87. It demonstrated utility in predicting important psychosocial outcomes in terminally ill patients including suicidal ideation and desire for hastened death. It is recommended for use in other medically ill populations as well as terminally ill populations.

The GAD-7 (Spitzer, Kroenke, Williams \& Lowe, 2006) is a seven-item self- report measure evaluating symptoms of anxiety associated with Generalized Anxiety Disorder experienced over the past two weeks. Items are rated on a 4-point Likert scale with zero indicating "not at all" and three indicating "nearly every day". It has good internal reliability, with a Cronbach's alpha of 0.92 (Spitzer et al. 2006), and is endorsed by ASCO as a recommended screening tool for anxiety in cancer patients (Andersen et al, 2014).

The Demoralization Scale-II (DS-II; Robinson et al., 2016a) is a sixteen-item scale that consists of two eight item subscales, meaning and purpose and distress and coping ability. A subtest analysis supported the use of a total score to estimate the construct of demoralization. Each item contains three response options (never, sometimes, and often). The DS-II has good internal consistence, as Cronbach's alpha for the total scale is .89. The scale demonstrated convergent validity with measures of quality of life and psychological distress in patients receiving palliative care (Robinson et al., 2016b).

The Schedule of Attitudes Toward Hastened Death-Abbreviated (SAHD-A; Kolva, Rosenfeld, Liu, Pessin, Breitbart, 2016) is a six item measure self-report measure evaluating the desire for hastened death. The SAHD-A is short form of the Schedule of Attitudes toward Hastened Death (SAHD; Rosenfeld et al., 1999) the most commonly used self-report measure of desire for hastened death. The SAHD-A uses a True/False format and is comparable to the SAHD-A in its relationship to measures of psychological distress (i.e., depression, hopelessness, suicidal ideation), has good internal consistency (Cronbach's alpha = .83), and its short form reduces patient burden.