Suicidal Ideation and Behavioral in Persons with Dementia Spectrum Conditions: Alzheimer's Association Task Force Survey (ve 0)

Suicidal Ideation and Behavioral in Persons with Dementia Spectrum Conditions: Alzheimer's Association Task Force Survey (ver6.0)

Page One

Please note:

1) Using the "Save and continue survey later" button at the top of each page (pages 2 - 5) only saves the previous page and not the page you are currently completing. To save the page you are currently working on, you must proceed to the next page.

2) A red asterisk "*" indicates you must complete the question before being able to move to the next page. However, questions #5 and #6 will allow you to go to the next page to save your answers before completing the table. This will allow you to save an incomplete table and come back to the survey at another time.  

1) What is your training and background?*

[ ] Geriatric Psychiatrist

[ ] Geriatric Internist

[ ] Gerontologist

[ ] Internist

[ ] Neurologist

[ ] Nurse

[ ] Primary Care/Family Medicine Physician

[ ] Psychiatrist

[ ] Psychologist

[ ] Social Worker

[ ] Other (requires answer in text box)

2) What is your geographical location?*

( ) United States

( ) Afghanistan

( ) Albania

( ) Algeria

( ) Andorra

( ) Angola

( ) Antigua and Barbuda

( ) Argentina

( ) Armenia

( ) Australia

( ) Austria

( ) Azerbaijan

( ) Bahamas, The

( ) Bahrain

( ) Bangladesh

( ) Barbados

( ) Belarus

( ) Belgium

( ) Belize

( ) Benin

( ) Bhutan

( ) Bolivia

( ) Bosnia and Herzegovina

( ) Botswana

( ) Brazil

( ) Brunei

( ) Bulgaria

( ) Burkina Faso

( ) Burma

( ) Burundi

( ) Cambodia

( ) Cameroon

( ) Canada

( ) Cape Verde

( ) Central African Republic

( ) Chad

( ) Chile

( ) China

( ) Colombia

( ) Comoros

( ) Congo, Democratic Republic of the

( ) Congo, Republic of the

( ) Costa Rica

( ) Cote d'Ivoire

( ) Croatia

( ) Cuba

( ) Curacao

( ) Cyprus

( ) Czech Republic

( ) Denmark

( ) Djibouti

( ) Dominica

( ) Dominican Republic

( ) East Timor (see Timor-Leste)

( ) Ecuador

( ) Egypt

( ) El Salvador

( ) Equatorial Guinea

( ) Eritrea

( ) Estonia

( ) Ethiopia

( ) Fiji

( ) Finland

( ) France

( ) Gabon

( ) Gambia, The

( ) Georgia

( ) Germany

( ) Ghana

( ) Greece

( ) Grenada

( ) Guatemala

( ) Guinea

( ) Guinea-Bissau

( ) Guyana

( ) Haiti

( ) Holy See

( ) Honduras

( ) Hong Kong

( ) Hungary

( ) Iceland

( ) India

( ) Indonesia

( ) Iran

( ) Iraq

( ) Ireland

( ) Israel

( ) Italy

( ) Jamaica

( ) Japan

( ) Jordan

( ) Kazakhstan

( ) Kenya

( ) Kiribati

( ) Kosovo

( ) Kuwait

( ) Kyrgyzstan

( ) Laos

( ) Latvia

( ) Lebanon

( ) Lesotho

( ) Liberia

( ) Libya

( ) Liechtenstein

( ) Lithuania

( ) Luxembourg

( ) Macau

( ) Macedonia

( ) Madagascar

( ) Malawi

( ) Malaysia

( ) Maldives

( ) Mali

( ) Malta

( ) Marshall Islands

( ) Mauritania

( ) Mauritius

( ) Mexico

( ) Micronesia

( ) Moldova

( ) Monaco

( ) Mongolia

( ) Montenegro

( ) Morocco

( ) Mozambique

( ) Namibia

( ) Nauru

( ) Nepal

( ) Netherlands

( ) Netherlands Antilles

( ) New Zealand

( ) Nicaragua

( ) Niger

( ) Nigeria

( ) North Korea

( ) Norway

( ) Oman

( ) Pakistan

( ) Palau

( ) Palestinian Territories

( ) Panama

( ) Papua New Guinea

( ) Paraguay

( ) Peru

( ) Philippines

( ) Poland

( ) Portugal

( ) Qatar

( ) Romania

( ) Russia

( ) Rwanda

( ) Saint Kitts and Nevis

( ) Saint Lucia

( ) Saint Vincent and the Grenadines

( ) Samoa

( ) San Marino

( ) Sao Tome and Principe

( ) Saudi Arabia

( ) Senegal

( ) Serbia

( ) Seychelles

( ) Sierra Leone

( ) Singapore

( ) Slovakia

( ) Slovenia

( ) Solomon Islands

( ) Somalia

( ) South Africa

( ) South Korea

( ) South Sudan

( ) Spain

( ) Sri Lanka

( ) Sudan

( ) Suriname

( ) Swaziland

( ) Sweden

( ) Switzerland

( ) Syria

( ) Taiwan

( ) Tajikistan

( ) Tanzania

( ) Thailand

( ) Timor-Leste

( ) Togo

( ) Tonga

( ) Trinidad and Tobago

( ) Tunisia

( ) Turkey

( ) Turkmenistan

( ) Tuvalu

( ) Uganda

( ) Ukraine

( ) United Arab Emirates

( ) United Kingdom

( ) Uruguay

( ) Uzbekistan

( ) Vanuatu

( ) Venezuela

( ) Vietnam

( ) Yemen

( ) Zambia

( ) Zimbabwe

Since you live in the US, what state do you live in?*

( ) Alabama

( ) Alaska

( ) American Samoa

( ) Arizona

( ) Arkansas

( ) California

( ) Colorado

( ) Connecticut

( ) Delaware

( ) District of Columbia

( ) Federated States of Micronesia

( ) Florida

( ) Georgia

( ) Guam

( ) Hawaii

( ) Idaho

( ) Illinois

( ) Indiana

( ) Iowa

( ) Kansas

( ) Kentucky

( ) Louisiana

( ) Maine

( ) Marshall Islands

( ) Maryland

( ) Massachusetts

( ) Michigan

( ) Minnesota

( ) Mississippi

( ) Missouri

( ) Montana

( ) Nebraska

( ) Nevada

( ) New Hampshire

( ) New Jersey

( ) New Mexico

( ) New York

( ) North Carolina

( ) North Dakota

( ) Northern Mariana Islands

( ) Ohio

( ) Oklahoma

( ) Oregon

( ) Palau

( ) Pennsylvania

( ) Puerto Rico

( ) Rhode Island

( ) South Carolina

( ) South Dakota

( ) Tennessee

( ) Texas

( ) Utah

( ) Vermont

( ) Virgin Islands

( ) Virginia

( ) Washington

( ) West Virginia

( ) Wisconsin

( ) Wyoming

3) What is your role at your clinical trial site?*

( ) Principal Investigator

( ) Rater

( ) Sub-Principal Investigator

( ) Site Coordinator

( ) Other (e.g. nurse) (requires answer in text box): _________________*

4) Have you personally conducted interviews to assess suicidal ideation and behavior at your site?*

( ) Yes

( ) No

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Suicidal Ideation and Behavior Survey:

5) Please indicate your site's clinical trial experience in the past 2 years for the following patient groups. Dementia groups include both Alzheimer's disease and other types of dementia.

Please provide best estimate, exact numbers are not required. All boxes require a number no longer than 3 digits. Also, if no trials have been done please enter "0" in the boxes.

	Number of Trials in Past 2 Years	Total Number of Patients Studied
MCI	___	___
Mild to Moderate Dementia	___	___
Severe Dementia	___	___
All Other Diagnoses	___	___

Save and Return to the Survey: If you want to save your current answers, but still have boxes to complete, leave any remaining boxes empty, fix any current errors (a whole row needs to be empty in order to not get an error), and press next at the bottom of the page. This will take you to the next page. At the top of the page click "Save and continue survey later" button.

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Suicidal Ideation and Behavior Survey:

6) Please enter the approximate number of subjects in a clinical trial setting that you personally assessed in the past 2 years in each of these subject groups and how many of those reported suicidal ideation or behavior** or died by suicide. (**Includes actual attempts, aborted or interrupted attempts, and preparatory acts towards making an attempt (such as acquiring the means of committing suicide); does not include non-suicidal self-injurious behaviors.)

Please provide best estimate, exact numbers are not required. All boxes require a number with no more than 3 digits. Also, if no trials have been done please enter "0" in the boxes.

	Total Number of Subjects Assessed in the Past 2 Years	Number of Subjects that had Suicidal Ideation	Number of Subjects that had Suicidal Behavior**	Number of Subjects that Completed Suicide
MCI	___	___	___	___
Mild to Moderate Dementia	___	___	___	___
Severe Dementia	___	___	___	___

Save and Return to the Survey: If you want to save your current answers, but still have boxes to complete, leave any remaining boxes empty, fix any current errors (a whole row needs to be empty in order to not get an error), and press next at the bottom of the page. This will take you to the next page. At the top of the page click "Save and continue survey later" button.

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Suicidal Ideation and Behavior Survey:

7) When you conduct interviews as part of prospective assessments of suicidal ideation and behavior, which of the following sources of information do you typically use for each of the subject groups below?*

	Interview Subject Only	Interview Caregiver Only	Interview both Subjects and Caregiver
MCI	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )
Severe Dementia	( )	( )	( )

8) How long does it usually take to conduct a prospective assessment of suicidal ideation and behavior of a subject with dementia or Mild Cognitive Impairment in a clinical trial at your site (including obtaining input from the caregiver)?*

	≤ 15 min	> 15 to ≤ 30 min	> 30 to ≤ 60 min	> 60 min
MCI	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )

9) Based on your experience, how often do the subjects and caregiver reports on suicidal ideation and behavior of the patient differ or contradict each other?*

	Never	Occasionally	Often	Always	Unable to assess**
MCI	( )	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )	( )

** Select 'Unable to Assess' if you have not had any cases of suicidal ideation or behavior in the Patient Group at your site.

10) Based on your clinical experience, what level of confidence (low, medium or high) would you have that a subject (not the caregiver) can accurately report presence or absence of suicidal ideation that occurred over the following time periods?


Three answers are needed for each of the time periods. Refers to subject's and not the caregiver's report. *

	≤ 24 hr			> 24 hr to ≤ 1 wk			> 1 wk to ≤ 1 month
	L*	M*	H*	L*	M*	H*	L*	M*	H*
MCI	( )	( )	( )	( )	( )	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )	( )	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )	( )	( )	( )	( )	( )

11) Based on your clinical experience, what level of confidence (low, medium or high) would you have that a subject (not the caregiver) can accurately report presence or absence of suicidal behavior** that occurred over the following time periods? 

Three answers are needed for each of the time periods. Referes to subject's and not the caregiver's report.*

	≤ 24 hr			> 24 hr to ≤ 1 wk			> 1 wk to ≤ 1 month
	L*	M*	H*	L*	M*	H*	L*	M*	H*
MCI	( )	( )	( )	( )	( )	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )	( )	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )	( )	( )	( )	( )	( )

**Includes actual attempts, aborted or interrupted attempts, and preparatory acts towards making an attempt (such as acquiring the means of committing suicide); does not include non-suicidal self-injurious behaviors.

12) In your experience, how well can subjects with dementia or Mild Cognitive Impairment understand what is meant by the statement: "Have you had some intention of acting on your thoughts to kill yourself?"*

	Not at All	To Some Degree	Very Much	Not Sure
MCI	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )

13) In general, how reliable is the information on suicidal ideation that you obtain from all sources of prospective assessments in each of the groups below:*

	Low	Medium	High	Not Sure
MCI	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )

14) In general, how reliable is the information on suicidal behavior that you obtain from all sources of prospective assessments in each of the groups below:*

	Low	Medium	High	Not Sure
MCI	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )

15) Based on your experience, please rate the level of subject/caregiver acceptance of prospective assessments of suicidal ideation and behavior in clinical trials?*

	Low	Medium	High
MCI	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )
Severe Dementia	( )	( )	( )

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Suicidal Ideation and Behavior Survey:

16) How helpful is the prospective assessment of suicidal ideation and behavior to identify subjects at risk in the following patient groups?*

	Not at All Helpful	A Little Bit Helpful	Moderately Helpful	Very Helpful	No opinion
MCI	( )	( )	( )	( )	( )
Mild to Moderate Dementia	( )	( )	( )	( )	( )
Severe Dementia	( )	( )	( )	( )	( )

17) Have subject self-report questionnaires on suicidal ideation and/or behavior been used in any clinical trials of subjects with dementia or MCI at your site? (Self-report questionnaires are completed by the subject either on paper, over the phone, or on a computer.)*

( ) Yes. If yes, please provide the name of the self-report questionnaire(s) and subject group(s) (Clicking "Yes" will open textbox.)

( ) No

Name of the self-report questionnaire and subject group (Please add only one questionnaire and subject group per text box. Upon hitting the return key with each entry a new text box will appear.)

*: ____________________________________________

18) Aside from interviews of the subject and the caregiver, what other sources of data are used in assessing the suicidal risk of subjects with dementia or Mild Cognitive Impairment in clinical trials at your site? (Check all that apply)

[ ] Medical/psychiatric records

[ ] Information provided by the referring physician or medical provider

[ ] Information from assisted living or nursing home staff

[ ] Other sources of data (Please specify, clicking "Other" will open textbox.)

[ ] None

Other source of data

*: ____________________________________________

19) Please add any additional comments you may have on the issue of prospective assessment of suicidal thinking and behavior in patients with Mild Cognitive Impairment or Dementia: [Text Box – 250 characters or less]

Thank You!

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