Addressing the Spectrum of Opioid Misuse Prevention, Treatment, and Recovery in Rural Washington State Communities: Provider Identified Barriers and Needs.

The opioid overdose epidemic has significantly impacted rural communities. Rural settings present unique challenges to addressing opioid misuse. The purpose of the current study was to understand the similarities and differences between rural and urban-based providers serving rural communities. Washington state-based opioid-related service providers who serve rural communities (N = 75) completed an online survey between July and September 2020. Chi-square tests of association were used to examine significant differences in proportions between rural providers and rural-serving urban providers across opioid prevention, treatment, and recovery training topics. Rural providers reported receiving significantly less opioid treatment and recovery training on the criminal legal system, workplace-based education on treatment and recovery, and co-occurring disorder treatment; and significantly higher prior opioid prevention training on the prevention programs for youth and accessing prevention funding. Differences between rural and rural-serving urban providers demonstrate ways in which rural-urban partnerships can be strengthened to enhance public health.

Introduction to the Special Issue: Toward a Lifespan Prevention Science - A Focus on Middle and Late Adulthood.

The interdisciplinary field of prevention science was founded on the premise of a lifespan developmental model. Prevention scientists have developed a strong set of tools and intervention technologies for understanding and potentially modifying risk and protective factors through early adulthood. However, there is a demographic imperative to apply prevention science principles to health issues in middle and late adulthood. The articles in this special issue utilize a variety of methods to investigate important scientific questions about how theories, methodologies, and interventions applied in the science of prevention can be usefully integrated into the study of health and wellness in middle and late adulthood. More specifically, contributions (1) highlight current empirical research that draws on lifespan developmental science to address the unique prevention and intervention needs in middle and late adulthood, (2) illustrate the opportunities and challenges of a lifespan approach to prevention science with special attention to middle and late adulthood, and (3) identify additional areas that prevention science can contribute to advancements in middle and late adulthood. These articles provide a glimpse into the challenges and opportunities at the intersection of prevention science and gerontology. As a field, we have much room to grow in leveraging innovative tools, approaches, and efforts to best support older adults' physical, mental, and social health, particularly for diverse and under-served populations.

Symptoms of Depression, Anxiety, and Post-Traumatic Stress Disorder, and Suicidal Ideation Among School Nurses in Prekindergarten through Grade 12 Schools - United States, March 2022.

School nurses are integral to creating safe environments in U.S. schools. Many experienced increased work burden and stress during the COVID-19 pandemic. CDC collaborated with the National Association of School Nurses and the National Association of State School Nurse Consultants to distribute a 121-item online, anonymous survey to school nurses nationwide during March 7-30, 2022. Among the 7,971 respondents, symptoms of depression, anxiety and PTSD, and suicidal ideation were measured, and prevalence ratios were used to identify associations with demographics, workplace characteristics, and support. Results found high levels of work-related stressors and indicated that employment characteristics, COVID-19-related job duties, and other workplace stressors and supports affected school nurse mental health. The survey findings underscore the mental health challenges many school nurses experienced during the 2021/2022 school year. The findings can inform supportive policies and practices to reduce workplace stressors and increase workplace supports for school nurses.

Pedophile, Child Lover, or Minor-Attracted Person? Attitudes Toward Labels Among People Who are Sexually Attracted to Children.

The primary label for people who are sexually attracted to children ("pedophile") is conflated with sexual offending behavior and tainted with stigma. In the present pre-registered mixed-method study, we therefore investigated attitudes and preferences regarding "pedophile/hebephile" and other labels among 286 people who report a stronger or equally strong sexual attraction to prepubescent and pubescent children than to adults. Overall, quantitative data showed acceptance of "pedophile/hebephile" as well as a range of alternative labels in a personal (Labeling Oneself) and a professional context (Being Labeled by Others). "Minor-attracted person" and "pedophile/hebephile" received generally higher support than other terms and appeared to be least divisive across three major online fora. Qualitative data revealed four themes: "Contested self-labels," "Person-first language and pathologizing sexuality/identity," "Stigma and shame," and "Reclaiming the pedophile label." Our results allow deeper insight into reasons for adopting certain labels over others, as well as difficulties of finding a non-stigmatizing label. We discuss limitations of the study and practical implications for clinical and research contexts.

Youth risk profiles and their prediction of distal cannabis and tobacco co-use in the Population Assessment of Tobacco Health (PATH).

Background: Co-use of cannabis and tobacco is common and increases negative behavioral, physical and mental health consequences. This study aimed to describe latent profiles of youth internalizing and externalizing problems, sensation seeking, and family environment in the US and their relationships with substance co-use. Methods: Data come from the Population Assessment of Tobacco Health (PATH). Using latent profile analysis with a distal outcome, we conducted a secondary data analysis examining relationships between latent profiles and the distal outcome of cannabis/tobacco use and co-use one year later. Participants were a nationally representative sample of youth ages 12-17 (N = 13,651). Results: We identified five youth subgroups: (1;11%) Family Risk, (2;32%) Family Protection with Very Low Internalizing, (3;21%) Family Protection with High Youth Risk, (4;24%) Family Protection with Moderate Youth Risk, (5;12%) Family Risk with High Youth Risk. Relationships between group membership and tobacco/cannabis outcomes, one year later, indicated that the least likely tobacco/cannabis users were the Family Protection with Very Low Internalizing class (no lifetime use probability (PR)=0.86, standard error (SE)=0.007; no 30-day use PR = 0.96, SE = 0.004). In contrast, the Family Risk with High Youth Risk class had the highest probability of both co-use (lifetime co-use PR = 0.33; SE = 0.014; 30-day co-use PR = 0.10; SE = 0.010) and single substance use (probability of lifetime single substance use PR = 0.30; SE = 0.013; 30-day single substance use PR = 0.24; SE = 0.014). Conclusions: A "protective but reactive" risk buffering pattern effect of family factors on youth factors was observed in that the lowest rates of co-use were observed in the three classes with family protection. These findings highlight the need for interventions addressing multiple domains and focusing on youth and family risk factors.

Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic - United States, March-April 2021.

Increases in mental health conditions have been documented among the general population and health care workers since the start of the COVID-19 pandemic (1-3). Public health workers might be at similar risk for negative mental health consequences because of the prolonged demand for responding to the pandemic and for implementing an unprecedented vaccination campaign. The extent of mental health conditions among public health workers during the COVID-19 pandemic, however, is uncertain. A 2014 survey estimated that there were nearly 250,000 state and local public health workers in the United States (4). To evaluate mental health conditions among these workers, a nonprobability-based online survey was conducted during March 29-April 16, 2021, to assess symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation among public health workers in state, tribal, local, and territorial public health departments. Among 26,174 respondents, 52.8% reported symptoms of at least one mental health condition in the preceding 2 weeks, including depression (30.8%), anxiety (30.3%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms of a mental health condition was among respondents aged ≤29 years (range = 13.6%-47.4%) and transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages (range = 30.4%-65.5%). Public health workers who reported being unable to take time off from work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. Implementing prevention and control practices that eliminate, reduce, and manage factors that cause or contribute to public health workers' poor mental health might improve mental health outcomes during emergencies.

Symptoms of Depression, Anxiety, Post-Traumatic Stress Disorder, and Suicidal Ideation Among State, Tribal, Local, and Territorial Public Health Workers During the COVID-19 Pandemic - United States, March-April 2021.

Increases in mental health conditions have been documented among the general population and health care workers since the start of the COVID-19 pandemic (1-3). Public health workers might be at similar risk for negative mental health consequences because of the prolonged demand for responding to the pandemic and for implementing an unprecedented vaccination campaign. The extent of mental health conditions among public health workers during the COVID-19 pandemic, however, is uncertain. A 2014 survey estimated that there were nearly 250,000 state and local public health workers in the United States (4). To evaluate mental health conditions among these workers, a nonprobability-based online survey was conducted during March 29-April 16, 2021, to assess symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal ideation among public health workers in state, tribal, local, and territorial public health departments. Among 26,174 respondents, 53.0% reported symptoms of at least one mental health condition in the preceding 2 weeks, including depression (32.0%), anxiety (30.3%), PTSD (36.8%), or suicidal ideation (8.4%). The highest prevalence of symptoms of a mental health condition was among respondents aged ≤29 years (range = 13.6%-47.4%) and transgender or nonbinary persons (i.e., those who identified as neither male nor female) of all ages (range = 30.4%-65.5%). Public health workers who reported being unable to take time off from work were more likely to report adverse mental health symptoms. Severity of symptoms increased with increasing weekly work hours and percentage of work time dedicated to COVID-19 response activities. Implementing prevention and control practices that eliminate, reduce, and manage factors that cause or contribute to public health workers' poor mental health might improve mental health outcomes during emergencies.

Identification of Y chromosome markers in the eastern three-lined skink (Bassiana duperreyi) using in silico whole genome subtraction.

BACKGROUND: Homologous sex chromosomes can differentiate over time because recombination is suppressed in the region of the sex determining locus, leading to the accumulation of repeats, progressive loss of genes that lack differential influence on the sexes and sequence divergence on the hemizygous homolog. Divergence in the non-recombining regions leads to the accumulation of Y or W specific sequence useful for developing sex-linked markers. Here we use in silico whole-genome subtraction to identify putative sex-linked sequences in the scincid lizard Bassiana duperreyi which has heteromorphic XY sex chromosomes. RESULTS: We generated 96.7 × 109 150 bp paired-end genomic sequence reads from a XY male and 81.4 × 109 paired-end reads from an XX female for in silico whole genome subtraction to yield Y enriched contigs. We identified 7 reliable markers which were validated as Y chromosome specific by polymerase chain reaction (PCR) against a panel of 20 males and 20 females. CONCLUSIONS: The sex of B. duperreyi can be reversed by low temperatures (XX genotype reversed to a male phenotype). We have developed sex-specific markers to identify the underlying genotypic sex and its concordance or discordance with phenotypic sex in wild populations of B. duperreyi. Our pipeline can be applied to isolate Y or W chromosome-specific sequences of any organism and is not restricted to sequence residing within single-copy genes. This study greatly improves our knowledge of the Y chromosome in B. duperreyi and will enhance future studies of reptile sex determination and sex chromosome evolution.

The Society for Prevention Research 20 Years Later: a Summary of Training Needs.

The Society for Prevention Research (SPR) aims to continually provide relevant professional development training opportunities to advance scientific investigation of ways to improve the health, well-being, and social and educational outcomes of individuals and communities. Our study, led by the Training Needs Assessment Task Force, designed a quantitative questionnaire informed by semistructured, qualitative interviews of 13 key prevention science informants. The questionnaire was deployed to all SPR members, of which 347 completed it. Questions about training topics were asked along 8 categories: (1) theory; (2) preventive interventions; (3) research methods, design, and evaluation; (4) teaching and mentoring; (5) practical and interpersonal skills; (6) communication; (7) project management; and (8) data analysis. Across all categories, respondents reported a high level of interest in receiving training: more than 80% were interested in training in data analytic methods; about 70% indicated interest in theory, preventive interventions, and research methods, design, and evaluation; about 65% were interested in at least 1 communication and project management topic; and 60% showed interest in at least 1 practical and interpersonal skills topic. Training-related interests varied across career level and race/ethnicity, with early-career individuals and people of color typically indicating the most interest. Participants were most likely to endorse self-initiated learning and webinars. SPR preconference training workshops were strongly endorsed for data analysis and preventive intervention topics. Recommendations from our study include a need for SPR to more strongly support self-initiated learning opportunities and continue preconference training programs, with special focuses in statistical methods and preventive interventions and regular assessment of members' training preferences.

Interleukin-1 mediates ischaemic brain injury via distinct actions on endothelial cells and cholinergic neurons.

The cytokine interleukin-1 (IL-1) is a key contributor to neuroinflammation and brain injury, yet mechanisms by which IL-1 triggers neuronal injury remain unknown. Here we induced conditional deletion of IL-1R1 in brain endothelial cells, neurons and blood cells to assess site-specific IL-1 actions in a model of cerebral ischaemia in mice. Tamoxifen treatment of IL-1R1 floxed (fl/fl) mice crossed with mice expressing tamoxifen-inducible Cre-recombinase under the Slco1c1 promoter resulted in brain endothelium-specific deletion of IL-1R1 and a significant decrease in infarct size (29%), blood-brain barrier (BBB) breakdown (53%) and neurological deficit (40%) compared to vehicle-treated or control (IL-1R1fl/fl) mice. Absence of brain endothelial IL-1 signalling improved cerebral blood flow, followed by reduced neutrophil infiltration and vascular activation 24 h after brain injury. Conditional IL-1R1 deletion in neurons using tamoxifen inducible nestin-Cre mice resulted in reduced neuronal injury (25%) and altered microglia-neuron interactions, without affecting cerebral perfusion or vascular activation. Deletion of IL-1R1 specifically in cholinergic neurons reduced infarct size, brain oedema and improved functional outcome. Ubiquitous deletion of IL-1R1 had no effect on brain injury, suggesting beneficial compensatory mechanisms on other cells against the detrimental effects of IL-1 on endothelial cells and neurons. We also show that IL-1R1 signalling deletion in platelets or myeloid cells does not contribute to brain injury after experimental stroke. Thus, brain endothelial and neuronal (cholinergic) IL-1R1 mediate detrimental actions of IL-1 in the brain in ischaemic stroke. Cell-specific targeting of IL-1R1 in the brain could therefore have therapeutic benefits in stroke and other cerebrovascular diseases.

Expanding Our Horizons: Risk, Protection, and Intervention in Emerging Adulthood.

Prevention science research has focused on early childhood and early school years, on the logic that addressing individual and contextual risk factors as early as possible would prevent the compounding of risk downstream. Methodological and technological advances have opened the door to an expanded exploration of risk, health promotion, and intervention in emerging adulthood and throughout the lifespan, but prevention science remains dominated by research on early childhood and adolescence. Articles in this special issue of Prevention Science showcase the use of new technologies to access young adult populations and to develop and deliver interventions as well as strategies to help account for developmental and cultural contexts in designing interventions. The issue represents an important step forward in applying the preventive research cycle to emerging adulthood, and it provides an opportunity to expand our horizons by building theories of development that are not tied solely to age progression.

Local Overdose Fatality Review Team Recommendations for Overdose Death Prevention.

This study compiled and detailed recommendations from Maryland Local Overdose Fatality Review Teams (LOFRTs) to provide state and local health departments with innovative strategies to address the worsening opioid epidemic and overdose-related deaths. LOFRTs consist of jurisdictional multiagency, multidisciplinary teams that share data to critically examine drug overdose cases. Goals include identification of risk factors and intervention opportunities to inform overdose prevention programs and policy. The authors qualitatively analyzed reports from Maryland LOFRTs case reviews to categorize outcomes and assess using frequency analyses. A total of 9 macro-level categories emerged from the review of approximately 361 recommendations from LOFRTs. Most recommendations related to Prevention Education, Integrated Care, and Harm Reduction strategies. Overdose fatality review is an effective means of understanding the opioid epidemic, strengthening coordinated interventions, and informing local and state health department overdose prevention strategic planning. Teams have a unique vantage point from which to view systems-level gaps and policy issues because of their collaborative nature and the quality of data provided by agencies that directly served decedents.

Qualitative Comparative Analysis: A Mixed-Method Tool for Complex Implementation Questions.

The translation and scale-up of evidence-based programs require new methods to guide implementation decisions across varying contexts. As programs are translated to real-world settings, variability is introduced. Some program components may have minor roles to play in producing positive outcomes, and some may have major roles, but only if adapted to meet different contextual demands. While some sources of variability are likely to improve program outcomes, we currently lack methods that allow us to determine the critical components or combinations of components that serve as causal pathways to a desired outcome and then to advise practitioners accordingly. In this paper, we introduce a promising tool for this purpose and illustrate its use in a translational research context. Qualitative Comparative Analysis (QCA) is often used to examine causality in situations that have complex, multiply-determined outcomes. The basic premise of QCA is that different sets of causal conditions, or causal pathways, may lead to a single outcome (the principle of equifinality). We applied QCA to a selection of the highest- and lowest-performing programs from a multi-year two-state dissemination of The Strengthening Families Program for Parents and Adolescents 10-14 to determine which components or combinations of components at the implementation, program delivery, and participant levels produced desired participant outcomes. In particular, we examined which components were necessary (i.e., in the absence of these factors, the outcome didnot occur), and which were sufficient (i.e., in the presence of these factors, the outcome always occurred). Results demonstrated that certain conditions were necessary for program success. In addition, given those necessary conditions, there were two sets of conditions sufficient to produce success, regardless of the presence or absence of any of the others. QCA, not previously used in prevention science research, helps to illuminate causal pathways, leading to concrete, evidence-based implementation decisions that facilitate generalization and scale-up.

The acceptability, feasibility, and possible benefits of a neurobiologically-informed 5-day multifamily treatment for adults with anorexia nervosa.

OBJECTIVE: Novel treatments for adults with anorexia nervosa (AN) are lacking. Recent scientific advances have identified neurobiologically-driven temperament contributors to AN symptoms that may guide development of more effective treatments. This preliminary study evaluates the acceptability, feasibility and possible benefits of a multicenter open trial of an intensive 5-day neurobiologically-informed multifamily treatment for adults with AN and their supports (SU). The temperament-focused treatment combines psychoeducation of AN neurobiology and SU involvement to develop skills to manage traits contributing to disease chronicity. METHOD: Fifty-four adults with AN and at least one SU (n = 73) received the 5-day treatment. Acceptability, feasibility, and attrition were measured post-treatment. Clinical outcome (BMI, eating disorder psychopathology, family function) was assessed post-treatment and at >3-month follow-up. RESULTS: The treatment had low attrition, with only one drop-out. Patients and SU rated the intervention as highly acceptable, and clinicians reported good feasibility. At post-treatment, patients demonstrated significantly increased BMI, reduced eating disorder psychopathology, and improved family function. Benefits were maintained in the 39 patients who completed follow-up assessment, with 62% reporting full or partial remission. DISCUSSION: Preliminary results are promising and suggest this novel treatment is feasible and acceptable. To establish treatment efficacy, fully-powered randomized controlled trials are necessary.

Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science.

Over a decade ago, the Society for Prevention Research endorsed the first standards of evidence for research in preventive interventions. The growing recognition of the need to use limited resources to make sound investments in prevention led the Board of Directors to charge a new task force to set standards for research in analysis of the economic impact of preventive interventions. This article reports the findings of this group's deliberations, proposes standards for economic analyses, and identifies opportunities for future prevention science. Through examples, policymakers' need and use of economic analysis are described. Standards are proposed for framing economic analysis, estimating costs of prevention programs, estimating benefits of prevention programs, implementing summary metrics, handling uncertainty in estimates, and reporting findings. Topics for research in economic analysis are identified. The SPR Board of Directors endorses the "Standards of Evidence for Conducting and Reporting Economic Evaluations in Prevention Science."

Ammonia Inhalation Does Not Increase Deadlift 1-Repetition Maximum in College-Aged Male and Female Weight Lifters.

Vigil, JN, Sabatini, PL, Hill, LC, Swain, DP, and Branch, JD. Ammonia inhalation does not increase deadlift 1-repetition maximum in college-aged male and female weight lifters. J Strength Cond Res 32(12): 3392-3397, 2018-Ammonia inhalant use by powerlifters and weight lifters is a prevalent practice with little research support for improved performance. The purpose of this study was to investigate the effects of ammonia as a stimulant on athletic performance during a deadlift 1-repetition maximum (1RM) absolute strength test. Subjects (men: n = 10, mean ± SD age = 21 ± 1 year, mass = 72.5 ± 6.8 kg; and women: n = 10, age = 22 ± 5 years, mass = 66.2 ± 8.1 kg) were required to have at least 2 years of resistance training experience while lacking a history of asthma, lightheadedness, fainting, anaphylaxis, sickle cell traits, and other respiratory disorders. After a baseline 1RM test, subjects were paired by 1RM performance and gender, then randomly assigned in a counterbalanced treatment order to control (water) or ammonia trials after a minimum 72-hour recovery period for another 1RM test involving attempts at 100.0, 102.5, 105.0, and 107.5% of the established 1RM value. Testing was then repeated after the minimum rest period for the remaining trial. Results revealed the expected gender main effect for absolute deadlift 1RM (93.0 ± 29.5 [women]; 152.0 ± 29.5 kg [men]; p < 0.001), but no trial main effect (p = 0.874) or gender by trial interaction effect (baseline = 93.0 ± 15.3, 151.8 ± 42.3 kg; water = 92.0 ± 12.5, 150.9 ± 37.8 kg; ammonia = 92.5 ± 16.4, 153.4 ± 37.9 kg) for women and men, respectively (p = 0.559). Within the limitations of this study, there is no support for the practice of ammonia inhalation to improve deadlift 1RM in training or competition.

A Strategy for Changing Adherence to National Guidelines for Decreasing Laboratory Testing for Early Breast Cancer Patients.

INTRODUCTION: Past studies indicate delays in adoption of consensus-based guideline updates. In June 2016, the National Comprehensive Cancer Network changed its guidelines from routine testing to omission of ordering complete blood cell count (CBC) and liver function tests (LFT) in patients with early breast cancer. In response, we developed an implementation strategy to discontinue our historical practice of routine ordering of these tests in asymptomatic patients. METHODS: The ordering of CBC and LFT for clinical stage I-IIIA breast cancer patients was audited in 2016. In June 2016, we utilized the levers of the National Quality Strategy implementation methodology to enact a system-wide change to omit routine ordering. To measure the plan's effectiveness, guideline compliance for ordering was tracked continually. RESULTS: Of 92 patients with early stage cancer in 2016, the overall rate of compliance with guidelines for ordering a CBC and LFT was 82% (88/107) and 87% (93/107), respectively. Segregated by the pre- and post-guideline change time period, the compliance rates for ordering a CBC and LFT were 78% and 87% (P = 0.076). CONCLUSION: In contrast to historical reports of delays in adoption of new evidence-based guideline changes, we were able to quickly change provider practice during the transition from routine ordering to omission of ordering screening blood tests in newly diagnosed patients with early breast cancer.

Is laxative misuse associated with binge eating? Examination of laxative misuse among individuals seeking treatment for eating disorders.

OBJECTIVE: Our research focuses on laxative misuse, which has been understudied in previous eating disorders (ED) research, to understand its prevalence and correlates among individuals seeking ED treatment. We also test the association between laxative misuse and binge eating to examine the assumption that laxative misuse is intended to compensate for binge eating. METHOD: Participants were 2,295 ED treatment-seeking adults (29.5 ± 10.5) who self-reported their disordered eating behaviors on the Eating Disorder Questionnaire. Participants met DSM-5 diagnostic criteria for anorexia nervosa (AN: 11.5%, n = 264), bulimia nervosa (BN: 39.0%, n = 896), binge-eating disorder (14.9%, n = 343), or other specified feeding or eating disorder (34.5%, n = 792). RESULTS: Nearly 25% of participants (n = 571) reported misusing laxatives during the last month. Laxative misusers with AN reported significantly higher frequency of laxative misuse relative to misusers with BN (F(1,440) = 5.226, p = .023, ηp2= .012). Among laxative misusers, there was no association between frequency of binge eating and frequency of laxative misuse. DISCUSSION: Laxative misusers with AN tend to misuse laxatives more frequently than those with BN. Binge eating was not related to laxative misuse in our sample. Future research may use real-time data collection to understand the function of laxative misuse and to validate our cross-sectional findings.

A comparison of the frequency of familial suicide attempts across eating disorder diagnoses.

This study examined the prevalence of reported suicide attempts among family members of individuals with an eating disorder (ED). 1870 individuals presenting for ED treatment reported whether their family members ever made a suicide attempt using the Eating Disorders Questionnaire. A lifetime suicide attempt by any family member was reported by 10.8% (n = 202) of the sample and ranged from 7.0% of those with eating disorder not otherwise specified to 16.1% of those with purging disorder. Controlling for age and gender, individuals with bulimia nervosa had a higher prevalence of any familial suicide attempt and mother suicide attempt than individuals with EDNOS; no other differences were observed across ED diagnoses. There were no differences in prevalence of reported suicide attempts made by fathers, brothers, sisters, uncles, or aunts by ED diagnosis. Findings support a growing literature indicating a familial association between EDs and suicide risk.