A 4-week morning light treatment reduces amygdala reactivity and clinical symptoms in adults with traumatic stress.

Trauma leads to mental health problems including posttraumatic stress disorder (PTSD), depression, and anxiety. New treatments are needed for traumatic stress that can overcome barriers to care while targeting underlying biological mechanisms of the pathology. Morning light treatment has potential as a novel intervention for traumatic stress. We conducted a randomized clinical trial testing 3 doses of a 4-week morning light treatment in people with traumatic stress to evaluate brain mechanisms underlying the treatment. Forty-six participants completed a baseline week followed by a 4-week morning light treatment (15, 30 or 60 mins each morning). Functional magnetic resonance imaging was conducted at pre- and post-treatment using an emotional faces task to probe the amygdala, based on prior work showing direct effects of light on the amygdala and the role of amygdala in traumatic stress. Clinician-rated symptoms and self-reported symptoms were also assessed at pre- and post-treatment. No group differences were observed in left amygdala reactivity, but right amygdala reactivity reduced only in the 30 and 60 min groups with medium effect sizes. Clinical symptoms reduced in all groups with medium to large effect sizes. Self-reported depression and anxiety scores reduced more in the 60 min than in the 15 min group (p = .02). The results suggest that 4 weeks of morning light treatment of at least 30 min per day can reduce amygdala reactivity and symptoms of traumatic stress. Morning light treatment should be further explored as a potential treatment for traumatic stress, given it is relatively safe, acceptable, accessible and scalable.

Comparative Effectiveness of Three Digital Interventions for Adults Seeking Psychiatric Services: A Randomized Clinical Trial.

Importance: There is a substantial gap between demand for and availability of mental health services. Digital mental health interventions (DMHIs) are promising tools for bridging this gap, yet little is known about their comparative effectiveness. Objective: To assess whether patients randomized to a cognitive behavioral therapy (CBT)-based or mindfulness-based DMHI had greater improvements in mental health symptoms than patients randomized to the enhanced personalized feedback (EPF)-only DMHI. DESIGN,: SETTING, AND PARTICIPANTS This randomized clinical trial was conducted between May 13, 2020, and December 12, 2022, with follow-up at 6 weeks. Adult patients of outpatient psychiatry services across various clinics within the University of Michigan Health System with a scheduled or recent outpatient psychiatry appointment were recruited. Eligible patients were randomized to an intervention arm. All analyses followed the intent-to-treat principle. Interventions: Participants were randomized to 1 of 5 intervention arms: (1) EPF only; (2) Silvercloud only, a mobile application designed to deliver CBT strategies; (3) Silvercloud plus EPF; (4) Headspace only, a mobile application designed to train users in mindfulness practices; and (5) Headspace plus EPF. Main Outcomes and Measures: The primary outcome was change in depressive symptoms as measured by the Patient Health Questionnaire-9 (PHQ-9; score range: 0-27, with higher scores indicating greater depression symptoms). Secondary outcomes included changes in anxiety, suicidality, and substance use symptoms. Results: A total of 2079 participants (mean [SD] age, 36.8 [14.3] years; 1423 self-identified as women [68.4%]) completed the baseline survey. The baseline mean (SD) PHQ-9 score was 12.7 (6.4) and significantly decreased for all 5 intervention arms at 6 weeks (from -2.1 [95% CI, -2.6 to -1.7] to -2.9 [95% CI, -3.4 to -2.4]; n = 1885). The magnitude of change was not significantly different across the 5 arms (F4,1879 = 1.19; P = .31). Additionally, the groups did not differ in decrease in anxiety or substance use symptoms. However, the Headspace arms reported significantly greater improvements on a suicidality measure subscale compared with the Silvercloud arms (mean difference in mean change = 0.63; 95% CI, 0.20-1.06; P = .004). Conclusions and Relevance: This randomized clinical trial found decreases in depression and anxiety symptoms across all DMHIs and minimal evidence that specific applications were better than others. The findings suggest that DMHIs may provide support for patients during waiting list-related delays in care. Trial Registration: ClinicalTrials.gov Identifier: NCT04342494.

A review of the peak-end rule in mental health contexts.

The peak-end rule, a memory heuristic in which the most emotionally salient part of an experience (i.e., peak) and conclusion of an experience (i.e., end) are weighted more heavily in summary evaluations, has been understudied in mental health contexts. The recent growth of intensive longitudinal methods has provided new opportunities for examining the peak-end rule in the retrospective recall of mental health symptoms, including measures often used in measurement-based care initiatives. Additionally, principles of the peak-end rule have significant potential to be applied to exposure-based therapy procedures. Additional research is needed to better understand the contexts in which, and persons for whom, the peak-end rule presents a greater risk of bias, to ultimately improve assessment strategies and clinical care.

Intensive longitudinal assessment following index trauma to predict development of PTSD using machine learning.

There are significant challenges to identifying which individuals require intervention following exposure to trauma, and a need for strategies to identify and provide individuals at risk for developing PTSD with timely interventions. The present study seeks to identify a minimal set of trauma-related symptoms, assessed during the weeks following traumatic exposure, that can accurately predict PTSD. Participants were 2185 adults (Mean age=36.4 years; 64% women; 50% Black) presenting for emergency care following traumatic exposure. Participants received a 'flash survey' with 6-8 varying symptoms (from a pool of 26 trauma symptoms) several times per week for eight weeks following the trauma exposure (each symptom assessed ∼6 times). Features (mean, sd, last, worst, peak-end scores) from the repeatedly assessed symptoms were included as candidate variables in a CART machine learning analysis to develop a pragmatic predictive algorithm. PTSD (PCL-5 ≥38) was present for 669 (31%) participants at the 8-week follow-up. A classification tree with three splits, based on mean scores of nervousness, rehashing, and fatigue, predicted PTSD with an Area Under the Curve of 0.836. Findings suggest feasibility for a 3-item assessment protocol, delivered once per week, following traumatic exposure to assess and potentially facilitate follow-up care for those at risk.

Management of suicidal risk in the emergency department: A clinical pathway using the computerized adaptive screen for suicidal youth.

Objective: Given the critical need for efficient and tailored suicide screening for youth presenting in the emergency department (ED), this study establishes validated screening score thresholds for the Computerized Adaptive Screen for Suicidal Youth (CASSY) and presents an example of a suicide risk classification pathway. Methods: Participants were primarily from the Study One derivation cohort of the Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) enrolled in collaboration with Pediatric Emergency Care Applied Research Networks (PECARN). CASSY scores corresponded to the predicted probabilities of a suicide attempt in the next 3 months and risk thresholds were classified as minimal (<1%), low (1%-5%), moderate (5%-10%), and high (>10%). CASSY scores were compared to risk thresholds derived from clinical consensus and ED complaints and dispositions. CASSY risk thresholds were also examined as predictors of future suicide attempts in the Study Two validation cohort of ED-STARS. Results: A total of 1452 teens were enrolled with a median age of 15.2 years, 59.5% were female, 55.6% were White, 22% were Black, 22.3% were Latinx, and 42.8% received public assistance. The clinical consensus suicide risk groups were strongly associated with the CASSY-predicted risk thresholds. Suicide attempts in the Study Two cohort occurred at a frequency consistent with the CASSY-predicted thresholds. Conclusions: The CASSY can be a valuable tool in providing patient-specific risk probabilities for a suicide attempt at 3 months and tailor the threshold cutoffs based on the availability of local mental health resources. We give an example of a clinical risk pathway, which should include segmentation of the ED population by medical versus psychiatric chief complaint.

The Cost of Universal Suicide Risk Screening for Adolescents in Emergency Departments.

Suicide is the second leading cause of death among adolescents. As nearly 20% of adolescents visit emergency departments (EDs) each year, EDs have an opportunity to identify previously unrecognized suicide risk. A novel Computerized Adaptive Screen for Suicidal Youth (CASSY) was shown in a multisite study to be predictive for suicide attempts within 3 months. This study uses site-specific data to estimate the cost of CASSY implementation with adolescents in general EDs. When used universally with all adolescents who are present and able to participate in the screening, the average cost was USD 5.77 per adolescent. For adolescents presenting with non-behavioral complaints, the average cost was USD 2.60 per adolescent. Costs were driven primarily by time and personnel required for the further evaluation of suicide risk for those screening positive. Thus, universal screening using the CASSY, at very low costs relative to the cost of an ED visit, can facilitate services needed for at-risk adolescents.

Potential Neuroprotective Effects of Dietary Omega-3 Fatty Acids on Stress in Alzheimer's Disease.

BACKGROUND: A large number of individual potentially modifiable factors are associated with risk for Alzheimer's disease (AD). However, less is known about the interactions between the individual factors. METHODS: In order to begin to examine the relationship between a pair of factors, we performed a pilot study, surveying patients with AD and controls for stress exposure and dietary omega-3 fatty acid intake to explore their relationship for risk of AD. RESULTS: For individuals with the greatest stress exposure, omega-3 fatty acid intake was significantly greater in healthy controls than in AD patients. There was no difference among those with low stress exposure. CONCLUSIONS: These initial results begin to suggest that omega-3 fatty acids may mitigate AD risk in the setting of greater stress exposure. This will need to be examined with larger populations and other pairs of risk factors to better understand these important relationships. Examining how individual risk factors interact will ultimately be important for learning how to optimally decrease the risk of AD.

Peak-end bias in retrospective recall of depressive symptoms on the PHQ-9.

Mental health care is built around patient recall and report of clinical symptoms. However, memories of events and experiences rely on cognitive heuristics that influence our recall. The peak-end bias, which refers to the tendency for the most intense and proximate aspects of an experience to disproportionately influence our memory, has been understudied in the context of mental health symptoms and may unduly influence self-reported symptoms, even in the context of standardized assessments. To determine whether the peak-end bias applies to the report of depressive symptoms on the standardized Patient Health Questionnaire-9 (PHQ-9) assessment, we compared two scores from daily mood assessments collected over a 2-week period from 4,322 medical interns (56% women; 60% non-Hispanic White). The peak-end-mood score, which averaged the single lowest and most recent mood scores over 2 weeks had a significantly stronger correlation with the PHQ-9 than the mean-mood score, which averaged all mood scores during the 2 weeks. Likelihood ratio tests and fit statistics provided further support that the peak-end-mood score was a significantly better predictor of depression than the mean-mood score. Results were consistent when limiting the sample to those with mild-to-severe depressive symptoms, and when only examining the two primary mood items as the dependent variable. These findings provide evidence for a modest peak-end recall bias for mood and depressive symptoms. There may be benefits to implementing intermittent assessment strategies to support clinical decision-making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Alcohol intake in relation to suicidal ideation and behavior among university students.

ObjectiveHeavy alcohol use has been clearly linked to risk for suicidal behaviors and is also prevalent on many American college campuses. This report uses a large sample of college students to explore relationships between alcohol use, depressive symptoms, and suicidality. Methods: A brief suicide screen was completed by 40,335 university students at four pariticipating sites. Assessments quantified recent depressive symptoms, alcohol use, suicidal ideation, and suicide attempts. Results: Problems from alcohol use were consistently associated with suicidal thoughts and attempts in the previous month, and in the previous year, but the quantity of alcohol used was not. Alcohol related problems exerted effects on the likelihood of both suicide ideation and attempts beyond those explained by their relationship with depressive symptoms. Conclusions: Screens for individuals at increased risk for suicidal ideation and behavior should emphasize alcohol-related problems over quantification of alcohol intake.

Using machine learning with intensive longitudinal data to predict depression and suicidal ideation among medical interns over time.

BACKGROUND: Use of intensive longitudinal methods (e.g. ecological momentary assessment, passive sensing) and machine learning (ML) models to predict risk for depression and suicide has increased in recent years. However, these studies often vary considerably in length, ML methods used, and sources of data. The present study examined predictive accuracy for depression and suicidal ideation (SI) as a function of time, comparing different combinations of ML methods and data sources. METHODS: Participants were 2459 first-year training physicians (55.1% female; 52.5% White) who were provided with Fitbit wearable devices and assessed daily for mood. Linear [elastic net regression (ENR)] and non-linear (random forest) ML algorithms were used to predict depression and SI at the first-quarter follow-up assessment, using two sets of variables (daily mood features only, daily mood features + passive-sensing features). To assess accuracy over time, models were estimated iteratively for each of the first 92 days of internship, using data available up to that point in time. RESULTS: ENRs using only the daily mood features generally had the best accuracy for predicting mental health outcomes, and predictive accuracy within 1 standard error of the full 92 day models was attained by weeks 7-8. Depression at 92 days could be predicted accurately (area under the curve >0.70) after only 14 days of data collection. CONCLUSIONS: Simpler ML methods may outperform more complex methods until passive-sensing features become better specified. For intensive longitudinal studies, there may be limited predictive value in collecting data for more than 2 months.

Suicidality and Alcohol Use as Predictors of Future Suicidal Behavior in College Students.

AIMS: There has been a marked increase in suicide fatalities among college-age students in recent years. Moreover, heavy alcohol use, a well-known risk factor for suicide, is present on most campuses. Yet, no prospective studies have examined alcohol use patterns among college students as predictors of suicidal behaviors. METHODS: Online of 40,335 students at four universities took place at the beginning of four academic years, 2015-2018. Of these, 2296 met criteria for an increased risk of suicidal behavior and completed 1- and/or 6-month follow-up evaluation(s). Baseline assessments included the Alcohol Use Disorders Identification Test to quantify alcohol consumption and resulting problems, and measures of depression, suicidal ideation and suicidal behavior. RESULTS: Suicide attempts during follow-up were reported by 35 (1.5%) of high-risk students. Regression analyses indicated that baseline severity of alcohol use consequences, but not amount of alcohol consumption, was associated with greater odds of a follow-up suicide attempt after controlling for baseline suicidal ideation, functional impairment and history of suicide attempts. CONCLUSIONS: Among college students at elevated risk for suicide, the severity of alcohol-related consequences was a significant predictor of future suicide attempts. Alcohol consumption was not a significant predictor, suggesting that the amount students drink is less of a concern for suicidal behavior than are the problems (e.g. failing to meet expectations, experiencing blackouts) associated with drinking.

Utilizing daily mood diaries and wearable sensor data to predict depression and suicidal ideation among medical interns.

BACKGROUND: Intensive longitudinal methods (ILMs) for collecting self-report (e.g., daily diaries, ecological momentary assessment) and passive data from smartphones and wearable sensors provide promising avenues for improved prediction of depression and suicidal ideation (SI). However, few studies have utilized ILMs to predict outcomes for at-risk, non-clinical populations in real-world settings. METHODS: Medical interns (N = 2881; 57 % female; 58 % White) were recruited from over 300 US residency programs. Interns completed a pre-internship assessment of depression, were given Fitbit wearable devices, and provided daily mood ratings (scale: 1-10) via mobile application during the study period. Three-step hierarchical logistic regressions were used to predict depression and SI at the end of the first quarter utilizing pre-internship predictors in step 1, Fitbit sleep/step features in step 2, and daily diary mood features in step 3. RESULTS: Passively collected Fitbit features related to sleep and steps had negligible predictive validity for depression, and no incremental predictive validity for SI. However, mean-level and variability in mood scores derived from daily diaries were significant independent predictors of depression and SI, and significantly improved model accuracy. LIMITATIONS: Work schedules for interns may result in sleep and activity patterns that differ from typical associations with depression or SI. The SI measure did not capture intent or severity. CONCLUSIONS: Mobile self-reporting of daily mood improved the prediction of depression and SI during a meaningful at-risk period under naturalistic conditions. Additional research is needed to guide the development of adaptive interventions among vulnerable populations.

Morning light treatment for traumatic stress: The role of amygdala reactivity study protocol.

BACKGROUND: Exposure to trauma can result in various mental health disorders including anxiety, depression, and posttraumatic stress disorder (PTSD). Although psychotherapies and pharmacotherapies exist for the treatment of these disorders, many individuals fail to receive treatment and among those who do, many remain symptomatic. Therefore, it is critical to continue developing new interventions for traumatic stress that target underlying mechanisms of pathology and offer a safe and acceptable alternative to current treatments. Morning light treatment has good potential as a novel non-invasive, low risk treatment for traumatic stress. Evidence suggests that morning light may improve traumatic stress by reducing reactivity in the amygdala, a brain region implicated in the pathophysiology of PTSD and anatomically linked to circadian photoreceptors in the eye. METHODS: In this study, we aim to establish a significant dose-response relationship between duration of morning light treatment and reduction in amygdala reactivity among individuals with traumatic stress symptoms (NCT# 04117347). Using a transdiagnostic approach, sixty-six individuals with a history of a DSM-5 criterion A trauma and traumatic stress symptoms will be recruited to participate in a 5-week study. Participants will be randomized across three treatment arms based on morning light treatment duration: 15-minutes, 30-minutes, or 60-minutes of light treatment per day for four weeks. To evaluate amygdala activity, participants will undergo fMRI at pre-treatment, mid-treatment, and post-treatment. Participants will also complete clinical assessments and self-report measures of PTSD, depression, and anxiety at pre-treatment, mid-treatment, and post-treatment. DISCUSSION: Morning light therapy may be an acceptable, feasible, and effective treatment for individuals suffering from traumatic stress. Identifying mechanistically relevant targets, and the doses needed to impact them, are critical steps in developing this new treatment approach for the sequelae of traumatic stress.

Does coping reduce suicidal urges in everyday life? Evidence from a daily diary study of adolescent inpatients.

BACKGROUND: Youth suicide has been increasing at an alarming rate. Identifying how youth at risk for suicide cope with daily distress and suicidal thoughts could inform prevention and intervention efforts. We investigated the relationship between previous-day coping and next-day suicidal urge intensity in a high-risk adolescent sample for a 4-week period. We also investigated the influence of adolescents' average coping levels, over 4 weeks, on daily severity of suicidal urges. METHODS: A total of 78 adolescents completed daily diaries after psychiatric hospitalization (n = 1621 observations). Each day, adolescents reported their use of specific coping strategies, overall coping helpfulness, and intensity of suicidal urges. RESULTS: Greater professional support seeking from providers/crisis lines and perceptions of coping helpfulness on the previous day were associated with lower next-day suicidal urges. Adolescents who reported greater average use of cognitive strategies, personal support seeking from family/friends, and higher average perceptions of coping helpfulness, relative to others, had lower daily suicidal urges. Noncognitive strategy use was not related to daily suicidal urge intensity. CONCLUSION: Findings point to the benefit of intervention efforts focusing on strengthening personal and professional supportive relationships, assisting youth with developing a broader coping repertoire, and working with adolescents to identify strategies they perceive to be helpful.

Engagement With Personalized Feedback for Emotional Distress Among College Students at Elevated Suicide Risk.

Depression and suicidal ideation have substantially increased among college students, yet many students with clinically significant symptoms do not perceive their distress as warranting mental health services. Personalized feedback (PF) interventions deliver objective data, often electronically, comparing an individual's reported symptoms or behaviors to a group norm. Several studies have shown promise for PF interventions in the context of mood and depression, yet little is known regarding how, and for whom, mood-focused PF interventions might be best deployed. The primary aim of this study was to examine the sociodemographic, clinical, and treatment-seeking factors associated with reviewing PF reports on emotional distress among college students (N = 1,673) screening positive for elevated suicide risk and not receiving mental health treatment. Results indicated that PF engagement was greatest among those with higher depression scores, and those reporting privacy/stigma concerns as barriers to treatment. Sexual minority students were more likely to review their PF than heterosexual students. Taken together, PF interventions may be a useful tool for engaging those with greater clinical acuity, and those hesitant to seek in-person care. Further research is warranted to examine the circumstances in which PF interventions might be used in isolation, or as part of a multitiered intervention strategy.

Electronic bridge to mental health for college students: A randomized controlled intervention trial.

OBJECTIVE: Suicide is the second leading cause of death among college students in the United States, and the percentage of students reporting suicidal thoughts is increasing. Nevertheless, many students at risk do not seek mental health (MH) services. This randomized controlled trial (RCT) examined the efficacy of Electronic Bridge to Mental Health for College Students (eBridge) for increasing at-risk students' linkage to MH services. METHOD: Students from four universities were recruited via email; 40,347 (22.6%) completed the online suicide risk screen; and 3,363 (8.3%) met criteria for randomization based on suicide risk factors and lack of current treatment (62.2% female, 35.0% male, 2.8% transgender/nonbinary; 73.2% White, 7.0% Black, 19.9% Asian, 11.7% other; 12.4% Hispanic, 76.2% undergraduate). These students were randomized to eBridge [personalized feedback (PF) with option of online counseling] or Control (PF). The primary outcome was linkage to MH services within 6 months. RESULTS: Among students assigned to eBridge, 355 students (21.0%) posted ≥1 message, and 168 (10.0%) posted ≥2 messages to the counselor. In intent-to-treat analyses, there was no eBridge effect on obtaining MH services. However, within the eBridge group, students who posted ≥1 message were significantly more likely to link to MH services. CONCLUSIONS: eBridge shows promise for reaching a relatively small subset of college students at risk for suicide; however, engagement in eBridge was low. This study underscores the urgent need for more effective strategies to engage young adults in online mental health interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Risk and protective factors for suicide among sexual minority youth seeking emergency medical services.

BACKGROUND: Differences in risk and protective factors (e.g., victimization, abuse, social support) have been used to explain elevated rates of suicidal ideation and suicide attempts in sexual minority youth (SMY) relative to heterosexual peers. However, little is known regarding how risk and protective factors may explain suicide risk differences among subgroups of SMY. The aims of this study were to 1) examine differences in prevalence and severity for suicide risk and protective factors among SMY, and 2) explore whether risk and protective factors are differentially associated with suicidal ideation and suicide attempts for SMY subgroups. METHODS: Participants were 6,423 adolescents (ages 12-17) recruited from 14 Emergency Departments across the United States who completed an assessment of suicide risk and protective factors. SMY were 20% of the sample (n = 1,275) and categorized as bisexual (8%), gay/lesbian (2%), mostly straight (5%), or other sexual minority (5%). RESULTS: Bisexual youth had elevated rates of suicidal ideation and attempts, more risk factors (e.g., bullying victimization, depression), and fewer protective factors (e.g., parent-family connectedness, positive affect) relative to mostly straight and other sexual minority youth. Bisexual and gay/lesbian youth only differed in parent-family connectedness (lower among bisexual youth). Depression and parent-family connectedness had weaker associations with suicidal ideation for bisexual youth. LIMITATIONS: Emergency departments were not nationally representative. Study design was cross-sectional, preventing causal inferences. CONCLUSIONS: Interventions seeking to mitigate risk factors and promote protective factors are greatly needed for SMY and may benefit from tailoring to address unique stressors for sexual minority subgroups.

Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk.

BACKGROUND: College student mental health (MH) problems and suicide risk have steadily increased over the past decade and a significant number of students with MH problems do not seek treatment. While some barriers to mental health care service utilization (MHSU) have been identified, very little is known regarding how these barriers differ among sociodemographic subgroups of students. METHOD: Participants were 3,358 college students from four US universities who screened positive for elevated suicide risk (defined as 2 or more of: depression, alcohol misuse, suicidal ideation, suicide attempt) and were not actively receiving MH services. Reported barriers to MHSU were categorized into: Low perceived need, privacy/stigma concerns, questioning helpfulness of treatment, logistics, time constraints, finances, and cultural issues. RESULTS: Adjusted odds ratios indicated that finances were a greater barrier for women, sexual and gender minority students, and Black and Hispanic students. Privacy/stigma concerns were more prominent for men and young undergraduate students. White students and older undergraduate and graduate students were more likely to report a lack of time, and cultural sensitivity issues were significant barriers for sexual and gender minority, and racial/ethnic minority, students. LIMITATIONS: Participating sites were not nationally representative. The barriers assessment did not examine the degree to which a specific barrier contributed to lack of MHSU relative to others. CONCLUSIONS: In light of the significant variation in barriers based on age, gender identity, race/ethnicity, and sexual orientation, efforts to increase MHSU should be tailored to meet the unique needs of specific sociodemographic student subgroups.

Variation in Suicide Risk among Subgroups of Sexual and Gender Minority College Students.

OBJECTIVE: Sexual and gender minorities are at elevated risk for suicide, yet few studies have examined differences in risk within many sexual and gender minority subgroups. The purpose of this study was to examine differences in prevalence for suicide risk factors among a wide range of sexual orientations and gender identities. METHOD: Forty-one thousand four hundred and twelve college students (62% cis-female, 37% cis-male, 1% transgender/genderqueer) completed a wellness screen that included four suicide risk factors (depression, heavy alcohol use, suicide ideation, suicide attempt). RESULTS: Gender minority students (i.e., transgender, genderqueer/non-binary) had significantly higher rates of depression, suicide ideation, and suicide attempts relative to cisgender peers, although there were no within-group differences among gender minority students. Adjusted odds ratios for endorsing two or more (2+) suicide risk factors were substantially higher for all sexual minority subgroups relative to heterosexuals. Among sexual minorities, those identifying as pansexual, bisexual, queer, or mostly gay/lesbian had greater odds of endorsing 2+ suicide risk factors relative to students identifying as mostly heterosexual, gay/lesbian, asexual, or 'other sexual minority'. Pansexual students had 33% greater odds of endorsing 2+ suicide risk factors relative to bisexual students. CONCLUSIONS: These findings highlight significant variation in suicide risk among sexual minority subgroups and the need for targeted interventions for subgroups at highest risk.