How can social workers facilitate suicide prevention in primary care? Findings from a national survey of primary care physicians.

There are currently no national data regarding U.S. Primary Care Physicians' (PCPs') suicide screening practices. This study surveyed 302 U.S. PCPs about their current suicide screening practices to identify service gaps and intervention points for social workers. Although one-third of PCPs reported providing screening and safety planning, few were using evidence-based tools. Factors that increased the likelihood of routine screening were belief in the importance of screening (p < .01), time (p < .01), and access to co-located behavioral health (p < .01). Findings support the role of social workers in primary care and suggest areas for training and collaboration.

The Feasibility and Impact of a Suicide Risk Screening Program in Rural Adult Primary Care: A Pilot Test of the Ask Suicide-Screening Questions Toolkit.

OBJECTIVE: The purpose of this study was to evaluate the feasibility and impact of a suicide risk screening program in a rural West Virginia primary care practice. METHODS: Patients presenting for routine and sick visits were asked to participate in electronic suicide risk screening using the Ask Suicide-Screening Questions tool; screen positive individuals were assessed with the Ask Suicide-Screening Questions Brief Suicide Safety Assessment. Screening program feasibility was evaluated by the proportion of patients consenting to participate, participant Ask Suicide-Screening Questions and Brief Suicide Safety Assessment completion rates, and response to a question asking whether primary care providers should ask about suicide. Screening impact was evaluated quasi-experimentally by comparing electronic medical record documentation of suicide risk screening, assessment, and risk determination in practice patients before and after implementing the screening program. RESULTS: Over half of the patients approached agreed to participate in a research study about suicide (N = 196; 57.7%). Feasibility of the screening program was demonstrated by the high completion rates for the Ask Suicide-Screening Questions (99.0%) and the Brief Suicide Safety Assessment (100.0%) among study participants. Additionally, 95.4% (N = 187) of participants agreed primary care providers should screen patients for suicide. Suicide screening rates rose significantly between the baseline and intervention phases (5.8% to 61.0%; X2 = 200.61, P < 0.001), as did suicide risk detection rates (0.7% to 6.2%; X2 = 12.58, P < 0.001). CONCLUSION: Suicide risk screening was feasible and well accepted by adult patients in rural primary care and has potential to improve suicide risk detection in this setting.

Mapping suicide mortality in Ohio: A spatial epidemiological analysis of suicide clusters and area level correlates.

Previous studies have investigated spatial patterning and associations of area characteristics with suicide rates in Western and Asian countries, but few have been conducted in the United States. This ecological study aims to identify high-risk clusters of suicide in Ohio and assess area level correlates of these clusters. We estimated spatially smoothed standardized mortality ratios (SMR) using Bayesian conditional autoregressive models (CAR) for the period 2004 to 2013. Spatial and spatio-temporal scan statistics were used to detect high-risk clusters of suicide at the census tract level (N=2952). Logistic regression models were used to examine the association between area level correlates and suicide clusters. Nine statistically significant (p<0.05) high-risk spatial clusters and two space-time clusters were identified. We also identified several significant spatial clusters by method of suicide. The risk of suicide was up to 2.1 times higher in high-risk clusters than in areas outside of the clusters (relative risks ranged from 1.22 to 2.14 (p<0.01)). In the multivariate model, factors strongly associated with area suicide rates were socio-economic deprivation and lower provider densities. Efforts to reduce poverty and improve access to health and mental health medical services on the community level represent potentially important suicide prevention strategies.

Integration of Pediatric Behavioral Health Services in Primary Care: Improving Access and Outcomes with Collaborative Care.

OBJECTIVE: To examine collaborative care interventions to integrate pediatric mental health services into primary care as a means of addressing barriers to mental health service delivery, improving access to care, and improving health outcomes. METHOD: Selective review of published literature addressing structural and attitudinal barriers to behavioural health service delivery and the integration of behavioural health services for pediatric mental problems and disorders into primary care settings, with a special focus on Canadian and U.S. RESULTS: Integration of pediatric behavioural health services in primary care has potential to address structural and attitudinal barriers to care delivery, including shortages and the geographical misdistribution of behavioural health specialists. Integration challenges stigma by communicating that health cannot be compartmentalized into physical and mental components. Stepped collaborative care interventions have been demonstrated to be feasible and effective in improving access to behavioural health services, outcomes, and patient and family satisfaction relative to existing care models. CONCLUSION: Collaborative integration of behavioural health services into primary care is a promising means of improving access to care and outcomes for children and adolescents struggling with mental problems and disorders. Dissemination to real-world practice settings will likely require changes to existing models of reimbursement and the culture of health service delivery.

Quality of care for Medicaid-enrolled youth with bipolar disorders.

This study examined conformance to clinical practice guidelines for children and adolescents with bipolar disorders and identified patient and provider factors associated with guideline concordant care. Administrative records were examined for 4,047 Medicaid covered youth aged 5-18 years with new episodes of bipolar disorder during 2006-2010. Main outcome measures included 5 claims-based quality of care measures reflecting national treatment guidelines. Measures addressed appropriate pharmacotherapy, therapeutic drug monitoring, and psychosocial treatment. The results indicated that current treatment practices for youth diagnosed with bipolar disorder typically fall short of recommended practice guidelines. Although the majority of affected youth are treated with recommended first-line pharmacotherapy, only a minority receive therapeutic drug monitoring and/or psychotherapy of recommended duration, underscoring the need for quality improvement initiatives.

Clinician Perspectives on Suicide Safety Planning and Its Implementation.

OBJECTIVE: The safety planning intervention is an evidence-based practice shown to reduce suicide risk, but implementation of high-quality safety planning has proven challenging. We aimed to understand clinician perspectives on the safety planning intervention to inform future implementation efforts. METHOD: This cross-sectional survey of clinicians who care for patients at risk of suicide in an academic medical center asked about comfort levels and fidelity to components of the safety planning intervention and assessed implementation barriers and facilitators. We used exploratory data analysis and regression analysis to explore clinician perspectives and assess the relationship between formal training and implementation. RESULTS: Ninety-two clinicians responded to the survey. Two-thirds of participants (64.9%) endorsed using all six core elements of the safety planning intervention. Participants who reported receiving formal training in safety planning were significantly more likely to report being comfortable completing a safety plan (p < .001); those with higher levels of comfort were significantly more likely to endorse using all of the core elements of the safety planning intervention (p < .001). CONCLUSIONS: Training in the evidence-based safety planning intervention is associated with clinician comfort and awareness of the core elements of the intervention. Our results suggest that there are gaps in clinician training and that formal safety planning intervention training could have a positive effect on clinician comfort and treatment fidelity.

Identifying Subgroups of Youth Suicide Decedents Based on Clinical Profiles of Psychiatric and Medical Diagnoses: A Latent Class Analysis.

PURPOSE: To identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic profiles to inform tailored youth suicide prevention efforts. METHODS: This study linked Ohio Medicaid and death certificate data for Medicaid enrolled youth aged 8-25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. RESULTS: Three latent classes were identified. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was confined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. DISCUSSION: Internalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized.

Prevalence of pain-predominant functional gastrointestinal disorders and somatic symptoms in patients with anxiety or depressive disorders.

OBJECTIVE: To determine whether children with symptoms of internalizing psychiatric disorders have a greater prevalence of pain-predominant functional gastrointestinal disorders (FGIDs) and migraine-like headaches. STUDY DESIGN: Children and adolescents aged 6-18 years were recruited from a behavioral health center (n = 31) and a primary care center (n = 36). Subjects completed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-based symptom inventory questionnaires to screen for internalizing psychiatric disorders, the Questionnaire on Pediatric Gastrointestinal Symptoms, and a somatic distress assessment interview. RESULTS: Thirty-three subjects (19 of 31 from the behavioral health center and 14 of 36 from the primary care center) screened positive for symptoms of anxiety or depressive disorders. The remainder screened negative and served as controls. Pain-predominant FGIDs were more common in the group with symptoms of anxiety or depression compared with controls (prevalence, 51.5% vs 8.8%; P = .0002). Migraine headaches occurred in 57.6% of the subjects with internalizing psychiatric disorders vs 23.5% of the control group (P = .006). The prevalence of functional constipation did not differ significantly between the 2 groups. The data remained essentially unchanged when analyzed within each center of recruitment. CONCLUSION: Youths with anxiety or depressive symptoms are more likely to suffer from pain-predominant FGIDs and migraine-like headaches, but not from functional constipation. The lack of an association between functional constipation and internalizing psychiatric symptoms suggests that FGIDs associated with pain may bear a specific relationship to emotional disorders.

Impact of Treatment Initiation and Engagement on Deliberate Self-Harm Among Individuals With First-Episode Psychosis.

OBJECTIVE: Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP). METHODS: A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates. RESULTS: Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH. CONCLUSIONS: These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

Racial Differences in Emergency Department Visit Characteristics and Management of Preadolescents at Risk of Suicide.

OBJECTIVE: Suicide rates and frequency of pediatric emergency department (ED) visits for suicidal thoughts and behaviors have increased among Black preadolescents in the United States in recent years. This study examined whether characteristics of ED visits and treatment management of preadolescents with suicidal thoughts and behaviors differed by race. METHODS: An electronic medical record query identified patients ages 8-12 (N=504) who visited a pediatric ED with a psychiatric-related chief complaint in 2019. The authors examined suicidal thoughts and behaviors that were reported with the Ask Suicide-Screening Questions tool, ED clinical impression, and ED disposition overall and by race. RESULTS: Compared with other racial groups, Black preadolescents were less likely to report suicidal thoughts, despite equivalent lifetime histories of suicide attempts, and were more likely to be brought to the ED by police and discharged (instead of being admitted to inpatient psychiatric care). CONCLUSIONS: Research to better understand racial disparities in suicide risk among preadolescents can inform prevention efforts.

Spatiotemporal Patterns of Deaths of Despair Across the U.S., 2000-2019.

INTRODUCTION: Deaths of despair (i.e., suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis) have been increasing over the past 2 decades. However, no large-scale studies have examined geographic patterns of deaths of despair in the U.S. This ecologic study identifies geographic and temporal patterns of individual and co-occurring clusters of deaths of despair. METHODS: All individuals aged ≥10 years who died in the U.S. between 2000 and 2019 and resided within the 48 contiguous states and Washington, District of Columbia were included (N=2,171,105). Causes of death were limited to deaths of despair, namely suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis. Univariate and multivariate space-time scan statistics were used to identify individual and co-occurring clusters with excess risk of deaths of despair. County-level RRs account for heterogeneity within each cluster. Analyses were conducted from late 2021 to early 2022. RESULTS: Six suicide clusters, four overdose clusters, nine liver disease clusters, and three co-occurring clusters of all three types of deaths were identified. A large portion of the western U.S., southeastern U.S., and Appalachia/rust belt were contained within the co-occurring clusters. The co-occurring clusters had average county RRs ranging from 1.17 (p<0.001) in the southeastern U.S. to 4.90 (p<0.001) in the western U.S. CONCLUSIONS: Findings support identifying and targeting risk factors common to all types of deaths of despair when planning public health interventions. Resources and policies that address all deaths of despair simultaneously may be beneficial for the areas contained within the co-occurring high-risk clusters.

Suicide in young people: screening, risk assessment, and intervention.

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Youth Suicide During the First Year of the COVID-19 Pandemic.

OBJECTIVE: To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies. METHODS: This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020). RESULTS: Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected. CONCLUSIONS: Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Annual research review: functional somatic symptoms and associated anxiety and depression--developmental psychopathology in pediatric practice.

BACKGROUND: Medically unexplained physical symptoms, commonly referred to as functional somatic symptoms (FSS), are common in pediatric medical settings and associated with suffering, impairment, and medical help seeking. The association of pediatric FSS with anxiety and depressive symptoms and disorders across the life span is reviewed. METHOD: Review and critique of controlled studies examining cross-sectional and longitudinal associations of FSS with anxiety and depressive symptoms and disorders in community-based and clinical samples of children and adolescents. RESULTS: FSS are consistently associated cross-sectionally with anxiety and depressive symptoms and disorders in childhood and adolescence, and the likelihood of associated anxiety and depression increases with the number of reported FSS. The presence of one or more FSS early in life is associated with an increased likelihood of multiple FSS and anxiety and depressive symptoms and disorders later in life, and anxiety and depressive symptoms and disorders in childhood are associated with subsequent multiple FSS. CONCLUSION: Strong associations between FSS, anxiety, and depression across the life span suggest the need to reconsider existing nosology and reconceptualize symptomatic relationships. Large, population-based longitudinal studies of FSS, anxiety, and depressive symptoms and disorders are needed to establish temporal relationships between the various symptoms and conditions.

Anxiety, Depression, and Somatic Distress: Developing a Transdiagnostic Internalizing Toolbox for Pediatric Practice.

Anxiety, depression, and somatic complaints are a common set of comorbid problems in children and adolescents. This "internalizing cluster" is highly prevalent, impairing during youth and into adulthood, and has substantial impacts on health-care systems. Fortunately, these problem areas may share several etiological factors and, thus, respond to similar interventions. In this paper, we present (a) the rationale for focusing on this cluster, (b) clinical theory on transdiagnostic processes uniting these problems, (c) description of core treatment techniques for this group, with a description of clinical outcomes for two sample cases, and (d) implications of this approach for new transdiagnostic treatment development and everyday clinical practice.

Editorial: The Enigma of Suicide Risk in Childhood and Its Evolution Across Development.

The problem of suicide can appear incomprehensible at any stage of the life cycle, but little is more puzzling than suicidal thinking and behavior in young children. Despite preadolescent suicide being rare in comparison to suicide later in life, it is the fifth leading cause of death for children ages 5 to 12 in the United States1 and a serious public health problem deserving of study. The study of preadolescent suicide risk also has potential to inform our understanding of suicide across the lifespan. In an important effort to expand our limited understanding of the developmental aspects of suicidal thoughts and behaviors (STBs), Whalen and colleagues2 report on the longitudinal trajectories of STBs for a sample of more than 300 preschool children recruited between the ages of 3 and 6 years and followed prospectively through age 17 years. Longitudinal studies allow researchers to collect more detailed information than could be obtained from a single cross-sectional survey and can offer insights into how psychopathology and associated risks evolve over time. This study is relatively unique in prospectively assessing STBs and associated risk and protective factors from the preschool period through adolescence.

Factors associated with antidepressant adherence for Medicaid-enrolled children and adolescents.

BACKGROUND: Antidepressants have been shown to be efficacious for the treatment of pediatric depression. However, many youths do not receive an adequate duration of treatment, and factors associated with nonadherence in this population remain poorly understood. OBJECTIVE: To examine rates of antidepressant adherence for depressed youth and identify factors associated with adherence during the acute and continuation phases of treatment. METHODS: A retrospective cohort analysis was conducted using claims data from a state Medicaid-enrolled population of 1650 youths (aged 5-17 years) with new episodes of depression between January 1, 2005, and December 30, 2007. These patients were treated with selective serotonin reuptake inhibitors or newer antidepressants and followed for 6 months from the first prescription fill date. Adherence measures were derived from the Health Plan Employer Data and Information Set (HEDIS) quality indicators on antidepressant management (3 months of continuous treatment for the acute phase and 6 months for the continuation phase) and assessed using the medication possession ratio. Multivariate logistic regression analyses evaluated the association between demographic, clinical, medication, and treatment factors, and adherence. RESULTS: About half (49.5%) of the youths were adherent to antidepressant medication during the acute phase, and 42% of these were adherent during the continuation phase; 21% were adherent across both treatment phases. Optimal follow-up visits and adequate antidepressant dosing was associated with better adherence during both treatment phases, as was use of other psychotropic medications. Youths prescribed trazodone for sleep had higher adherence rates during the acute phase. Minority youths and adolescents had lower adherence rates during the acute phase. Youths in foster care had higher adherence rates during both treatment phases. CONCLUSIONS: Nonadherence with antidepressant medications is common among Medicaid-covered children and adolescents. Study findings underscore the need for clinicians to deliver guideline-concordant care, assess adherence, and develop interventions that improve adherence, particularly for vulnerable subgroups.

Moderators and predictors of clinical outcome in a randomized trial for behavior problems in pediatric primary care.

OBJECTIVES: To evaluate putative moderator, predictor, and treatment parameter variables in relation to three outcomes in a clinical trial that compared a modular protocol for on-site, nurse-administered intervention (PONI) and enhanced usual care (EUC) for pediatric behavioral problems in primary care. METHODS: Patients were 163 clinically referred children for behavior problems in six primary care offices. PONI consisted of seven treatment modules adapted from prior treatment trials with this population, whereas EUC involved a facilitated referral to a community provider. Outcome measures were based on standardized scales reflecting one parent-rated aggregate (child dysfunction) and one child-rated aggregate (child health), and diagnostic interviews with both informants (remission in oppositional defiant disorder). RESULTS: Moderator analyses revealed that PONI was more effective than EUC in reducing child dysfunction by 12-month follow-up among Caucasian children, whereas EUC was more effective than PONI among non-Caucasian children. In the full sample, child health improvement was predicted by the severity of the child's depression and anxiety, and level of family conflict. Duration of child exposure to cognitive-behavioral treatment in PONI was related to greater improvement in overall child health, but other treatment parameters were unrelated to outcome. CONCLUSIONS: These few significant relationships notwithstanding the findings indicate that the two treatments had robust effects on several outcomes and across selected child, parent, family, and treatment variables. The findings extend efforts to incorporate mental health services in pediatric practice.

Universal suicide risk screening: Views of rural adults on acceptability and implementation in primary care.

OBJECTIVE: This study gathered data from rural adult primary care patients regarding the acceptability of universal suicide risk screening and preferred methods of implementation. METHOD: Patients from a rural primary care clinic in southern West Virginia participating in a pilot test of a suicide risk screening program were administered a Screening Opinions Survey and resulting data were evaluated using descriptive and content analyses. RESULTS: The majority of participants (96%) believed that primary care providers (PCPs) should screen patients for suicide and noted multiple benefits to screening. Most participants described the experience of screening in primary care as positive or neutral and preferred a personalized screening process where the provider asked questions directly. Demographic analyses indicated that males and older adults were less likely to report being previously screened for suicide and that older adults were less likely to support the practice of screening. CONCLUSIONS: Results provide support for the acceptability of universal suicide risk screening programs to patients in rural primary care and suggest that PCP involvement in the screening process may encourage patient participation. Additional training for PCPs and psychoeducational interventions for older adults may help to address demographic influences on screening practices and engagement.