A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder.

OBJECTIVE: Mortality from opioid use disorder (OUD) can be reduced for patients who receive opioid agonist treatment (OAT). In the United States (US), OATs have different requirements including nearly daily visits to a dispensing facility for methadone but weekly to monthly prescriptions for buprenorphine. Our objective was to compare mortality rates for buprenorphine and methadone treatments among a large sample of US patients with OUD. METHODS: We measured all-cause mortality, overdose mortality, and suicide mortality among US Department of Veterans Affairs patients with a diagnosis of OUD who received OAT from 2010 through 2019. We leveraged substantial and sustained regional variation in prescribing buprenorphine versus methadone as an instrumental variable (IV) and used inverse propensity of treatment weighting to balance relevant covariates across treatment groups. We compared mortality with true two-stage IV using both probit and linear probability models, as well as a reduced form IV model, adjusting for demographics and health status. RESULTS: Our cohort consisted of 61,997 patients with OUD who received OAT, of whom 92.7% were male with a mean age of 47.9 (SD = 14.1) years. Patients were followed for a median of 2 (IQR = 1,4) calendar years. Across regional terciles, mean methadone prescribing was 4.8%, 19.5%, and 75.1% of OAT patients. All models identified significant reductions in all-cause and suicide mortality for buprenorphine relative to methadone. For example, predicted all-cause mortality from the probit model was 169.7 per 10,000 person years (95% CI, 157.8, 179.6) in the lowest tercile of methadone prescribing compared with 206.1 (95% CI, 196.0, 216.3) in the highest tercile. No difference was identified for overdose mortality. CONCLUSION: We found significantly lower all-cause mortality and suicide mortality rates for buprenorphine compared with methadone. Our results support the less restrictive prescribing practices for buprenorphine as OAT in the US.

Is It Time for the Mental Health Field to Consider Unplanned Discharge a Key Metric of Patient Safety?

ABSTRACT: Mental health lacks robust measures to assess patient safety. Unplanned discharge is common in mental health populations and associated with poor outcomes. Clarifying whether unplanned discharge varies across settings may highlight the need to develop measures to reduce harms associated with this event. Unplanned discharge rates were compared across the Department of Veterans Affairs' acute inpatient and residential mental health treatment settings from 2009 to 2019. Logistic regression was used to create facility-level, adjusted unplanned discharge rates stratified by setting. Results were described using central tendency. Among 847,661 acute inpatient discharges, the mean unplanned discharge rate was 3.3% (range, 0%-18%). Among 358,117 residential discharges, the mean unplanned discharge rate was 17.9% (range, 1%-48.3%). Unplanned discharge is a marked problem in mental health, with large variation across treatment settings. Unplanned discharge should be measured as part of patient safety efforts.

A systematic review and meta-analysis of long-term reintervention after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: Patients who undergo endovascular aneurysm repair (EVAR) often require reintervention after the index repair. The long-term rate of reintervention and how this has changed with newer device technology are poorly understood. Therefore, we performed a systematic review and meta-analysis of the available literature to determine long-term freedom from reintervention after EVAR and the change in reintervention rates over time. METHODS: We performed a systematic review of MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included randomized controlled trials and observational studies that documented the rate of reintervention after EVAR. We performed a meta-analysis of Kaplan-Meier freedom from reintervention at each year after EVAR. We used linear regression to evaluate change in reintervention rate over time with newer device technology. RESULTS: We included a total of 30 studies (randomized trials, n = 3; observational studies, n = 27) comprising 32,126 patients in this review and meta-analysis. Studies ranged in the implantation date of the EVAR device from 1996 to 2014. The probability of freedom from reintervention was 81% (95% confidence interval [CI], 77%-85%) at 5 years, 70% (95% CI, 65%-76%) at 10 years, and 64% (95% CI, 46%-79%) at 14 years. Linear regression demonstrated an improvement in freedom from reintervention when results were stratified by the year of device implantation. At 1 year, estimated freedom from reintervention improved from 90% in 1998 to 94% in 2008 (n = 26 studies; R2 = 0.11; P = .10). At three years, estimated freedom from reintervention improved from 77% in 1998 to 90% in 2008 (n = 26 studies; R2 = 0.27; P = .006). At 5 years, estimated freedom from reintervention improved from 68% in 1998 to 81% in 2008 (n = 22 studies; R2 =0.12; P = .12). At 7 years, estimated freedom from reintervention improved from 51% in 1998 to 86% in 2011 (n = 22 studies; R2 = 0.40; P = .015). CONCLUSIONS: EVAR patients remain at risk for reintervention indefinitely, and therefore lifelong surveillance is imperative. Encouragingly, reintervention rates have improved over time, with newer devices exhibiting lower rates. Reintervention rate remains an important metric for new devices and registries.

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder.

Objective: Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. Methods: We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. Results: A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years (SD = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). Conclusions: In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.

A Pilot Study of an Intervention to Prevent Suicide After Psychiatric Hospitalization.

A prior meta-analysis found that the World Health Organization Brief Intervention and Contact Program (WHO BIC) significantly reduces suicide risk. WHO BIC has not been studied in high-income countries. We piloted an adapted version of WHO BIC on an inpatient mental health unit in the United States. We assessed the feasibility and acceptability. We also evaluated changes in suicidal ideation, hopelessness, and connectedness using a repeated measures analysis of variance. Of 13 eligible patients, 9 patients enrolled. Patients experienced significant improvements in suicidal ideation, hopelessness, and connectedness at 1 and 3 months (Beck Scale for Suicidal Ideation, F(2,16) = 14.96, p < 0.01; Beck Hopelessness Scale, F(2,16) = 5.88, p < 0.05; perceived burdensomeness subscale, F(2,16) = 10.97, p < 0.013; and thwarted belongingness subscale, F(2,16) = 4.77, p < 0.03). Patients were highly satisfied. An adapted version of WHO BIC may be feasible to implement in a high-resource setting, but trials need to confirm efficacy.

Health Care Processes Contributing to Suicide Risk in Veterans During and After Residential Substance Abuse Treatment.

Objective: Substance use disorders are an important risk factor for suicide. While residential drug treatment programs improve clinical outcomes for substance use disorders, less is known about the role of related health care processes in contributing to suicide risk. These data may help to inform strategies to prevent suicide during and after residential treatment.Methods: A retrospective analysis was conducted on root-cause analysis (RCA) reports of suicide in veterans occurring within 3 months of discharge from a residential drug treatment program that were reported to a Veterans Affairs facility between 2001 and 2017. Demographic information such as age, gender, and psychiatric comorbidity were abstracted from each report. In addition, an established codebook was used to code root causes from each report. Root causes were grouped into categories in order to characterize the key system and organizational-level processes that may have contributed to the suicide.Results: A total of 39 RCA reports of suicide occurring within 3 months after discharge from a residential drug treatment program were identified. The majority of decedents were men and the average age was 42.9 years (SD = 11.2). The most common method of suicide was overdose (33%) followed by hanging (28%). Most suicides occurred in close proximity to discharge, with 56% (n = 22) occurring within seven days of discharge and 36% (n = 14) occurring within 48 hours of discharge. The most common substances used by decedents prior to admission were alcohol or opiates. RCA teams identified a total of 140 root causes and the majority were due to problems with suicide risk assessment (n = 32, 22.9%). Non-engagement with treatment during (n = 20, 14.3%) and after the residential stay (n = 18, 12.9%) was also highlighted as an important concern. Finally, several reports raised concerns that a discharge prior to treatment completion or a precipitous discharge due to program violation negatively impacted treatment outcomes.Conclusions: Efforts to prevent suicide in the period following discharge from a residential drug treatment program should focus on addressing suicide risk factors during admission and helping patients engage more fully in substance use disorder treatment.

A Meta-analysis of the Impact of Aspirin, Clopidogrel, and Dual Antiplatelet Therapy on Bleeding Complications in Noncardiac Surgery.

OBJECTIVE: The aim of this study was to determine the bleeding risks associated with single (aspirin) and dual (aspirin + clopidogrel) antiplatelet therapy (DAPT) versus placebo or no treatment in adults undergoing noncardiac surgery. SUMMARY OF BACKGROUND DATA: The impact of antiplatelet therapy on bleeding during noncardiac surgery remains controversial. A meta-analysis was performed to examine the risk associated with single and DAPT. METHODS: A systematic review of antiplatelet therapy, noncardiac surgery, and perioperative bleeding was performed. Peer-reviewed sources and meeting abstracts from relevant societies were queried. Studies without a control group, or those that only examined patients with coronary stents, were excluded. Primary endpoints were transfusion and reintervention for bleeding. RESULTS: Of 11,592 references, 46 studies met inclusion criteria. In a meta-analysis of >30,000 patients, the relative risk (RR) of transfusion versus control was 1.14 [95% confidence interval (CI) 1.03-1.26, P = 0.009] for aspirin, and 1.33 (1.15-1.55, P = 0.001) for DAPT. Clopidogrel had an elevated risk, but data were too heterogeneous to analyze. The RR of bleeding requiring reintervention was not significantly higher for any agent compared to control [RR 0.96 (0.76-1.22, P = 0.76) for aspirin, 1.84 (0.87-3.87, P = 0.11) for clopidogrel, and 1.51 (0.92-2.49, P = 0.1) for DAPT]. Subanalysis of thoracic and abdominal procedures was similar. There was no difference in RR for myocardial infarction [1.06 (0.79-1.43)], stroke [0.97 (0.71-1.33)], or mortality [0.97 (0.87-1.1)]. CONCLUSIONS: Antiplatelet therapy at the time of noncardiac surgery confers minimal bleeding risk with no difference in thrombotic complications. In many cases, it is safe to continue antiplatelet therapy in patients with important indications for their use.

Electronic Medical Record Reporting Enhances Proactive Psychiatric Consultation.

BACKGROUND: Numerous studies have demonstrated that psychiatric and substance use issues in general hospital inpatients result in increased length of stay and associated costs. Additional studies have demonstrated that proactive consultation models in psychiatry can effectively address these problems. Selecting patients for proactive interventions is less well studied. OBJECTIVE: We sought to develop an automated, electronic medical record-based screening tool to select patients who might benefit from proactive psychiatric consultation. METHODS: An automated daily report was developed using information stored in electronic medical record and billing systems. Discrete data fields populating the report included diagnoses, orders, and nursing care plans. RESULTS: Over a 9-month period, the report identified 2177 patients (19% of the total nonpsychiatric adult admissions) as potentially benefitting from proactive psychiatric interventions. Of these, 367 were confirmed as likely to benefit from intervention; 139 (38%) were randomized to the proactive psychiatric consultation group. Of those patients randomized to "treatment as usual," a subset later required psychiatric consultation, which was requested an average of 4 days after the time they were flagged by the report. CONCLUSIONS: The use of an electronic medical record-based automated report is feasible to select patients for proactive psychiatric interventions on admission and throughout the hospital stay. Early identification of patients may decrease length of stay and improve patient outcomes.

The effect of preoperative penicillin allergy testing on perioperative non-beta-lactam antibiotic use: A systematic review and meta-analysis.

Background: The majority of patients for elective surgery and with a history of penicillin allergy are placed on alternative prophylactic antibiotic therapies, which have been associated with the emergence of multidrug-resistant pathogens and increased morbidity and mortality rates. However, self-reporting of penicillin allergy alone may overestimate the prevalence of penicillin allergy in the population. Objective: To assess the effects of preoperative antibiotic allergy testing protocols in reducing the use of non-beta-lactam antibiotics. Methods: We searched medical literature data bases through July of 2018. Two reviewers independently extracted data from published studies and assessed the risk of bias in cohort studies by using the Newcastle-Ottawa Scale. We collected information related to study design, methodology, demographics, interventions, and outcomes. We pooled odds ratios for the rate of prescribing non-beta-lactam antibiotics by using a fixed-effects model. Results: Of 905 citations screened for eligibility, nine studies met inclusion criteria for qualitative analysis. Studies reported that the rates of non-beta-lactam use after preoperative skin testing ranged from 6 to 30%. In addition, four of the nine studies had sufficient control data to be included in a meta-analysis. These four studies found that preoperative testing protocols significantly decreased the rates of prescribing non-beta-lactam antibiotics compared with usual care (odds ratio 3.64 [95% confidence interval, 2.67-4.98]; p < 0.0001). Seven studies reported on adverse drug reactions after preoperative skin testing and found that the rate of such reactions was rare. Conclusion: Preoperative antibiotic allergy testing protocols seemed to be a safe and effective tool in reducing the use of non-beta-lactam antibiotics during surgery.

Strategies to prevent death by suicide: meta-analysis of randomised controlled trials.

BackgroundFew randomised controlled trials (RCTs) have shown decreases in suicide.AimsTo identify interventions for preventing suicide.MethodWe searched EMBASE and Medline from inception until 31 December 2015. We included RCTs comparing prevention strategies with control. We pooled odds ratios (ORs) for suicide using the Peto method.ResultsAmong 8647 citations, 72 RCTs and 6 pooled analyses met inclusion criteria. Three RCTs (n = 2028) found that the World Health Organization (WHO) brief intervention and contact (BIC) was associated with significantly lower odds of suicide (OR = 0.20, 95% CI 0.09-0.42). Six RCTs (n = 1040) of cognitive-behavioural therapy (CBT) for suicide prevention and six RCTs of lithium (n = 619) yielded non-significant findings (OR = 0.34, 95% CI 0.12-1.03 and OR = 0.23, 95% CI 0.05-1.02, respectively).ConclusionsThe WHO BIC is a promising suicide prevention strategy. No other intervention showed a statistically significant effect in reducing suicide.

Analysis of Reported Suicide Safety Events Among Veterans Who Received Treatment Through Department of Veterans Affairs-Contracted Community Care.

INTRODUCTION: Veteran patients have access to a broad range of health care services in the Veterans' Health Administration (VHA). There are concerns, however, that all Veteran patients may not have access to timely care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act was passed in 2018 to ensure that eligible Veterans can receive timely, high-quality care. The Maintaining Internal Systems and Strengthening Integrated Outside Networks Act makes use of Department of Veterans Affairs (VA)-contracted care to achieve its goal. There are concerns, however, that these transitions of care may, in fact, place Veterans at a higher risk of poor health outcomes. This is a particular concern with regard to suicide prevention. No study has investigated suicide-related safety events in Veteran patients who receive care in VA-contracted community care settings. MATERIALS AND METHODS: A retrospective analysis of root-cause analysis (RCA) reports and patient safety reports of suicide-related safety events that involved VA-contracted community care was conducted. Events that were reported to the VHA National Center for Patient Safety between January 1, 2018, and June 30, 2022, were included. A coding book was developed to abstract relevant variables from each report, for example, report type and facility and patient characteristics. Root causes reported in RCAs were also coded, and the factors that contributed to the events were described in the patient safety reports. Two reviewers independently coded 10 cases, and we then calculated a kappa. Because the kappa was greater than 80% (i.e. 89.2%), one reviewer coded the remaining cases. RESULTS: Among 139 potentially eligible reports, 88 reports were identified that met the study inclusion criteria. Of these 88 reports, 62.5% were patient safety reports and 37.5% were RCA reports. There were 129 root causes of suicide-related safety events involving VA-contracted community care. Most root causes were because of health care-related processes. Reports cited concerns around challenges with communication and deficiencies in mental health treatment. A few reports also described concerns that community care providers were not available to engage in patient safety activities. Patient safety reports voiced similar concerns but also pointed to specific issues with the safety of the environment, for example, access to methods of strangulation in community care treatment settings in an emergency room or a rehabilitation unit. CONCLUSIONS: It is important to strengthen the systems of care across VHA- and VA-contracted community care settings to reduce the risk of suicide in Veteran patients. This includes developing standardized methods to improve the safety of the clinical environment as well as implementing robust methods to facilitate communication between VHA and community care providers. In addition, Veteran patients may benefit from quality and safety activities that capitalize on the collective knowledge of VHA- and VA-contracted community care organizations.

Are suicide risk scales sensitive to change? A scoping review.

INTRODUCTION: Clinician- or self-administered scales are frequently used to assist in detecting risk of death by suicide and to determine the effectiveness of interventions. No recent review studies have examined whether these scales are sensitive to change. We conducted a scoping review to identify suicide risk scales that are sensitive to change. MATERIAL AND METHODS: We searched Medline and Excerpta Medica Database from inception through March 17, 2022, to identify randomized trials, pooled analysis, quasi-experimental studies, and cohort studies reporting on sensitivity to change of suicide risk scales. We assessed sensitivity to change by examining internal and external responsiveness. Internal responsiveness evaluates whether the scale measures changes in suicide-related symptoms in response to an intervention while external responsiveness assess whether changes in the scale correspond to changes in risk of suicide. We summarized findings across studies using descriptive analysis. RESULTS: Among 38 eligible scales, we identified 27 scales that included items that were modifiable to change. However, only 7 scales had been studied to determine their sensitivity to change based on internal or external responsiveness. While the results of studies suggested that 6 scales have internal responsiveness, none of the included studies confirmed that scales have external responsiveness. DISCUSSION: A few suicide risk scales are internally responsive and may be useful in a clinical or research setting. It is unclear, however, whether changes in scores correspond to an actual change in suicide risk. Future research should confirm the external responsiveness of scales using robust metrics including suicide mortality.

The efficacy and safety of buprenorphine for the treatment of depression: A systematic review and meta-analysis.

BACKGROUND: Depressive disorders are common. Many patients with major depression do not achieve remission with available treatments. Buprenorphine has been raised as a potential treatment for depression as well as suicidal behavior but may pose certain risks. METHODS: A meta-analysis comparing the efficacy, tolerability, and safety of buprenorphine (or combinations such as buprenorphine/samidorphan) versus control in improving symptoms in patients with depression. Medline, Cochrane Database, PsycINFO, Excerpta Medica Database and The Cumulative Index to Nursing and Allied Health Literature were searched from inception through January 2, 2022. Depressive symptoms were pooled using Hedge's g with 95% Confidence Intervals (CI). Tolerability, safety, suicide outcomes were summarized qualitatively. RESULTS: 11 studies (N = 1699) met inclusion criteria. Buprenorphine had a small effect on depressive symptoms (Hedges' g 0.17, 95%CI: 0.05-0.29). Results were driven by six trials of buprenorphine/samidorphan (N = 1,343, Hedges's g 0.17, 95%CI: 0.04-0.29). One study reported significant improvement in suicidal thoughts (Least Squares Mean Change: -7.1, 95%CI: -12.0 - 2.3). Most studies found buprenorphine was well-tolerated with no evidence of abuse behavior or dependency. CONCLUSIONS: Buprenorphine may have a small benefit for depressive symptoms. Future research should clarify the dose response relationship between buprenorphine and depression.

Safety of Single High-Dose Liposomal Amphotericin B for Induction Treatment of Cryptococcal Meningitis and Histoplasmosis in People With HIV: A Systematic Review and Meta-analysis.

Background: Evidence for efficacy of single, high-dose liposomal amphotericin B (LAmB) in HIV-associated cryptococcal meningitis and histoplasmosis is growing. No systematic review has examined the safety of this regimen across multiple studies. Methods: We systematically searched Medline, Scopus, and the Cochrane Library from inception to April 2023 for studies reporting grade 3 and 4 adverse events (AEs) with single high-dose LAmB vs traditional amphotericin regimens for HIV-associated fungal infections. Results: Three trials (n = 946) were included. Compared with traditional regimens, single high-dose LAmB was associated with equivalent risk of grade 3 and 4 AEs (risk ratio [RR], 0.75; 95% CI, 0.53-1.06) and lower overall risk of grade 4 AEs (RR, 0.68; 95% CI, 0.55-0.86), grade 4 renal (RR, 0.43; 95% CI, 0.20-0.94) and grade 4 hematological AEs (RR, 0.46; 95% CI, 0.32-0.65). Conclusions: Single, high-dose LAmB is associated with a lower risk of life-threatening AEs compared with other World Health Organization-endorsed amphotericin B-based regimens in invasive HIV-related fungal infection.

An Analysis of Irregular Discharges From Residential Treatment Programs in the Department of Veterans Affairs Health Care System.

INTRODUCTION: Veteran populations are frequently diagnosed with mental health conditions such as substance use disorder and PTSD. These conditions are associated with adverse outcomes including a higher risk of suicide. The Veterans Health Administration (VHA) has designed a robust mental health system to address these concerns. Veterans can access mental health treatment in acute inpatient, residential, and outpatient settings. Residential programs play an important role in meeting the needs of veterans who need more structure and support. Residential specialty types in the VHA include general mental health, substance use disorder, PTSD, and homeless/work programs. These programs are affiliated with a DVA facility (i.e., medical center). Although residential care can improve outcomes, there is evidence that some patients are discharged from these settings before achieving the program endpoint. These unplanned discharges are referred to using language such as against medical advice, self-discharge, or irregular discharge. Concerningly, unplanned discharges are associated with patient harm including death by suicide. Although there is some initial evidence to locate factors that predict irregular discharge in VHA residential programs, no work has been done to examine features associated with irregular discharge in each residential specialty. METHODS: We conducted a retrospective cohort study of patients who were discharged from VHA residential treatment programs between January 2018 and September 2022. We included the following covariates: Principal diagnosis, gender, age, race/ethnicity, number of physical health conditions, number of mental health diagnostic categories, marital status, risk of homelessness, urbanicity, and service connection. We considered two discharge types: Regular and irregular. We used logistic regression to determine the odds of irregular discharge using models stratified by bed specialty as well as combined odds ratios and 95% CIs across program specialties. The primary purposes are to identify factors that predict irregular discharge and to determine if the factors are consistent across bed specialties. In a secondary analysis, we calculated facility-level adjusted rates of irregular discharge, limiting to facilities with at least 50 discharges. We identified the amount of residual variation that exists between facilities after adjusting for patient factors. RESULTS: A total of 279 residential programs (78,588 patients representing 124,632 discharges) were included in the analysis. Substance use disorder and homeless/work programs were the most common specialty types. Both in the overall and stratified analyses, the number of mental health diagnostic categories and younger age were predictors of irregular discharge. In the facility analysis, there was substantial variation in irregular discharge rates across residential specialties even after adjusting for all patient factors. For example, PTSD programs had a mean adjusted irregular discharge rate of 15.3% (SD: 7.4; range: 2.1-31.2; coefficient of variation: 48.4%). CONCLUSIONS: Irregular discharge is a key concern in VHA residential care. Patient characteristics do not account for all of the observed variation in rates across residential specialty types. There is a need to develop specialty-specific measures of irregular discharge to learn about system-level factors that contribute to irregular discharge. These data can inform strategies to avoid harms associated with irregular discharge.

Lithium in the prevention of suicide in adults: systematic review and meta-analysis of clinical trials.

Controversy exists regarding the efficacy of lithium for suicide prevention. Except for a recent trial that enrolled over 500 patients, available trials of lithium for suicide prevention have involved small samples. It is challenging to measure suicide in a single randomised controlled trial (RCT). Adding a single large study to existing meta-analyses may provide insights into lithium's anti-suicidal effects. We performed a meta-analysis of RCTs comparing lithium with a control condition for suicide prevention. MEDLINE and other databases were searched up to 30 November 2021. Efficacy was assessed by calculating the summary Peto odds ratio (OR) and incidence rate ratio (IRR) with 95% confidence intervals. Among seven RCTs, the odds of suicide were lower among patients receiving lithium versus control (OR = 0.30, 95% CI 0.09-1.02; IRR = 0.22, 95% CI 0.05-1.05), although the findings were still not statistically significant. The role of lithium in suicide prevention remains uncertain.

Association of Medication Treatment for Opioid Use Disorder With Suicide Mortality.

OBJECTIVE: Understanding the effectiveness of medication treatment for opioid use disorder to decrease the risk of suicide mortality may inform clinical and policy decisions. The authors sought to describe the effect of medications for opioid use disorder (MOUD) on risk of suicide mortality. METHODS: This was a retrospective cohort study in Department of Veterans Affairs (VA) patients from 2003 to 2017. The authors linked three data sources: the VA Corporate Data Warehouse, Centers for Medicare and Medicaid Services Claims Data, and the VA-Department of Defense Mortality Data Repository. The exposure of interest was MOUD, including starting periods (first 14 days on treatment), stopping periods (first 14 days off treatment), stable time on treatment, and stable time off treatment (reference category). The main outcome measures included suicide mortality, external-cause mortality, and all-cause mortality in the 5 years following initiation of MOUD. RESULTS: Over 60,000 VA patients received MOUD. Patients were typically male (92.8%) and their mean age was 46.5 years (SD=13.1). After adjusting for demographic characteristics, mental health and physical health conditions, and health care utilization, the adjusted hazard ratio during stable MOUD was 0.45 (95% CI=0.32, 0.63) for suicide mortality, 0.35 (95% CI=0.31, 0.40) for external-cause mortality, and 0.34 (95% CI=0.31, 0.37) for all-cause mortality. MOUD starting periods were associated with an adjusted hazard ratio for suicide mortality of 0.55 (95% CI=0.25, 1.21), and MOUD stopping periods were associated with an adjusted hazard ratio for suicide mortality of 1.38 (95% CI=0.82, 2.34). CONCLUSIONS: Treatment with MOUD was associated with a substantial reduction in suicide mortality as well external causes of mortality and all-cause mortality.

Tools to Detect Risk of Death by Suicide: A Systematic Review and Meta-Analysis.

Objective: There is limited knowledge about the ability of instruments to detect risk of suicide in a range of settings. Prior reviews have not considered whether the utility of instruments depends on prior probability of risk. We performed a systematic review to determine the diagnostic accuracy of instruments to detect risk of suicide in adults using likelihood ratio analysis. This method aids evaluation of prior probabilities of risk.Data Sources: We searched MEDLINE, Cochrane Database of Systematic Reviews, PsycINFO, EMBASE, and Scopus from inception through January 19, 2021.Study Selection: We included clinical trials, observational studies, and quasi-experimental studies assessing the diagnostic accuracy of instruments to detect risk of suicide in adults. There were no language restrictions.Data Extraction: Three reviewers in duplicate assessed full texts to determine eligibility and extracted data from included studies. Positive (LR+) and negative likelihood ratio (LR-) and 95% CIs were calculated for each instrument.Results: Thirty studies met inclusion criteria. Most instruments showed minimal utility to detect or rule out risk of suicide, with LR+ ≤ 2.0 and LR- ≥ 0.5. A few instruments had a high utility for improving risk detection in emergency department, inpatient mental health, and prison settings when patients scored above the cutoff (LR+ > 10). For example, among patients discharged from an emergency department, the Columbia Suicide Severity Rating Scale-Clinical Practice Screener had a LR+ of 10.3 (95% CI, 6.3-16.8) at 3-month follow-up. The clinical utility of the instruments depends on the pretest probability of suicide in the setting. Because studies spanned over 6 decades, the findings are at risk for secular trends.Discussion: We identified several instruments that may hold promise for detecting risk of suicide in emergency department, inpatient mental health, or prison settings. The utility of the instrument hinges, in part, on baseline suicide risk.Registration: PROSPERO: CRD42021285528.