Clinician Perspectives on Suicide Safety Planning and Its Implementation.

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

Demographic predictors of emergency service utilization patterns in youth at risk of suicide.

OBJECTIVE: To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors). METHODS: Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period. RESULTS: Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission. CONCLUSIONS: Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.

Insulin Dosing and Glycemic Outcomes Among Steroid-treated Hospitalized Patients.

OBJECTIVE: To determine the optimal insulin-to-steroid dose ratio for the attainment of glycemic control in hospitalized patients. METHODS: We retrospectively studied data collected from the electronic health records within an academic medical center from 18 599 patient-days where patients were treated concurrently with insulin and steroids. Multivariate logistic regression analyses, which included demographic and clinical variables, were performed to assess the relationships between the exposures of total and basal insulin-to-steroid ratios and the outcomes of glycemic control (all blood glucose readings on the following patient-day were >70 and ≤180 mg/dL) and hypoglycemia within 3 subgroups of steroid dosing: low (≤10-mg prednisone equivalent dose [PED]), medium (from >10-mg to ≤40-mg PED), and high (>40-mg PED). RESULTS: Increased insulin-to-steroid ratio was associated with increased odds of both glycemic control and hypoglycemia. The optimal total insulin-to-steroid ratio for attaining glycemic control was 0.294 U/kg/10-mg PED in the low-dose subgroup, 0.257 U/kg/10-mg PED in the medium-dose subgroup, and 0.085 U/kg/10-mg PED in the high-dose subgroup. The optimal basal insulin-to-steroid ratio was 0.215 U/kg/10-mg PED in the low-dose subgroup, 0.126 U/kg/10-mg PED in the medium-dose subgroup, and 0.036 U/kg/10-mg PED in the high-dose subgroup. CONCLUSION: Increasing insulin-to-steroid ratios are positively associated with glycemic control and hypoglycemia. Our study suggests that approximately 0.3 U/kg/10-mg PED is an optimal dose for low- and medium-dose steroids, whereas approximately 0.1 U/kg/10-mg PED is an optimal dose for high-dose steroids. Further prospective studies are needed to identify insulin regimens that will optimize glycemic control in steroid-treated patients while minimizing the risk of hypoglycemia.

Rates of self-reported postpartum depressive symptoms in the United States before and after the start of the COVID-19 pandemic.

BACKGROUND: This study aimed to determine the relationship between the start of the COVID-19 pandemic and changes in postpartum depressive symptoms (PDS) in individuals in the United States. Further analyses explored how these changes related to state-level measures of pandemic severity, economic hardship, and social isolation. METHODS: Data were collected from users of the Flo mobile health application who completed a survey about their mood within 90 days of giving birth. Analyses assessed changes in national and state-level self-reported PDS from a pre-pandemic period (N = 159,478) to a pandemic period (N = 118,622). Linear regression determined which state-level pandemic severity or economic factors were associated with changes in PDS. RESULTS: National rates of PDS increased from 6.5% (pre-pandemic) to 6.9% (pandemic). There was a significant increase in PDS over the course of the pandemic timeframe. Linear regressions revealed a negative association between percent change in PDS across states and COVID-19 deaths per 100 K residents as well as 2020 women's unemployment rate. There was no association between change in PDS and COVID-19 cases per 100 K residents, percent job loss, percent change in women's unemployment rate, or percentage of population staying at home. CONCLUSIONS: There was a national increase in PDS that worsened over the course of a year following the start of the COVID-19 pandemic. States with a greater increase in PDS tended to show overall fewer deaths from COVID-19 and lower women's unemployment rates. Further work is needed to identify what individual-level factors may be driving these differences.

Threat imminence reveals links among unfolding of anticipatory physiological response, cortical-subcortical intrinsic functional connectivity, and anxiety.

Excessive expression of fear responses in anticipation of threat occurs in anxiety, but understanding of underlying pathophysiological mechanisms is limited. Animal research indicates that threat-anticipatory defensive responses are dynamically organized by threat imminence and rely on conserved circuitry. Insight from basic neuroscience research in animals on threat imminence could guide mechanistic research in humans mapping abnormal function in this circuitry to aberrant defensive responses in pathological anxiety. 50 pediatric anxiety patients and healthy-comparisons (33 females) completed an instructed threat-anticipation task whereby cues signaled delivery of painful (threat) or non-painful (safety) thermal stimulation. Temporal changes in skin-conductance indexed anxiety effects on anticipatory responding as function of threat imminence. Multivariate network analyses of resting-state functional connectivity data from a subsample were used to identify intrinsic-function correlates of anticipatory-response dynamics, within a specific, distributed network derived from translational research on defensive responding. By considering threat imminence, analyses revealed specific anxiety effects. Importantly, pathological anxiety was associated with excessive deployment of anticipatory physiological response as threat, but not safety, outcomes became more imminent. Magnitude of increase in threat-anticipatory physiological responses corresponded with magnitude of intrinsic connectivity within a cortical-subcortical circuit. Moreover, more severe anxiety was associated with stronger associations between anticipatory physiological responding and connectivity that ventromedial prefrontal cortex showed with hippocampus and basolateral amygdala, regions implicated in animal models of anxiety. These findings link basic and clinical research, highlighting variations in intrinsic function in conserved defensive circuitry as a potential pathophysiological mechanism in anxiety.

Attention bias to negative versus non-negative faces is related to negative affectivity in a transdiagnostic youth sample.

This study identified a shared pathophysiological mechanism of pediatric anxiety and irritability. Clinically, anxiety and irritability are common, co-occurring problems, both characterized by high-arousal negative affective states. Behaviorally, anxiety and irritability are associated with aberrant threat processing. To build on these findings, we examined eye-tracking measures of attention bias in relation to the unique and shared features of anxiety and irritability in a transdiagnostic sample of youth (n = 97, 58% female, Mage = 13.03, SDage = 2.82). We measured attention bias to negative versus non-negative emotional faces during a passive viewing task. We employed bifactor analysis to parse the unique and shared variance of anxiety and irritability symptoms from self- and parent-report questionnaires. Negative affectivity is the derived latent factor reflecting shared variance of anxiety and irritability. We found that higher negative affectivity was associated with looking longer at negative versus non-negative faces, reflecting a shared mechanism of anxiety and irritability. This finding suggests that modification of elevated attention to negative emotional faces may represent a common potential treatment target of anxiety and irritability.

Threat-anticipatory psychophysiological response is enhanced in youth with anxiety disorders and correlates with prefrontal cortex neuroanatomy.

Background: Threat anticipation engages neural circuitry that has evolved to promote defensive behaviours; perturbations in this circuitry could generate excessive threat-anticipation response, a key characteristic of pathological anxiety. Research into such mechanisms in youth faces ethical and practical limitations. Here, we use thermal stimulation to elicit pain-anticipatory psychophysiological response and map its correlates to brain structure among youth with anxiety and healthy youth. Methods: Youth with anxiety (n = 25) and healthy youth (n = 25) completed an instructed threat-anticipation task in which cues predicted nonpainful or painful thermal stimulation; we indexed psychophysiological response during the anticipation and experience of pain using skin conductance response. High-resolution brain-structure imaging data collected in another visit were available for 41 participants. Analyses tested whether the 2 groups differed in their psychophysiological cue-based pain-anticipatory and pain-experience responses. Analyses then mapped psychophysiological response magnitude to brain structure. Results: Youth with anxiety showed enhanced psychophysiological response specifically during anticipation of painful stimulation (b = 0.52, p = 0.003). Across the sample, the magnitude of psychophysiological anticipatory response correlated negatively with the thickness of the dorsolateral prefrontal cortex (pFWE < 0.05); psychophysiological response to the thermal stimulation correlated positively with the thickness of the posterior insula (pFWE < 0.05). Limitations: Limitations included the modest sample size and the cross-sectional design. Conclusion: These findings show that threat-anticipatory psychophysiological response differentiates youth with anxiety from healthy youth, and they link brain structure to psychophysiological response during pain anticipation and experience. A focus on threat anticipation in research on anxiety could delineate relevant neural circuitry.

A computational network perspective on pediatric anxiety symptoms.

BACKGROUND: While taxonomy segregates anxiety symptoms into diagnoses, patients typically present with multiple diagnoses; this poses major challenges, particularly for youth, where mixed presentation is particularly common. Anxiety comorbidity could reflect multivariate, cross-domain interactions insufficiently emphasized in current taxonomy. We utilize network analytic approaches that model these interactions by characterizing pediatric anxiety as involving distinct, inter-connected, symptom domains. Quantifying this network structure could inform views of pediatric anxiety that shape clinical practice and research. METHODS: Participants were 4964 youths (ages 5-17 years) from seven international sites. Participants completed standard symptom inventory assessing severity along distinct domains that follow pediatric anxiety diagnostic categories. We first applied network analytic tools to quantify the anxiety domain network structure. We then examined whether variation in the network structure related to age (3-year longitudinal assessments) and sex, key moderators of pediatric anxiety expression. RESULTS: The anxiety network featured a highly inter-connected structure; all domains correlated positively but to varying degrees. Anxiety patients and healthy youth differed in severity but demonstrated a comparable network structure. We noted specific sex differences in the network structure; longitudinal data indicated additional structural changes during childhood. Generalized-anxiety and panic symptoms consistently emerged as central domains. CONCLUSIONS: Pediatric anxiety manifests along multiple, inter-connected symptom domains. By quantifying cross-domain associations and related moderation effects, the current study might shape views on the diagnosis, treatment, and study of pediatric anxiety.

Converging Multi-modal Evidence for Implicit Threat-Related Bias in Pediatric Anxiety Disorders.

This report examines the relationship between pediatric anxiety disorders and implicit bias evoked by threats. To do so, the report uses two tasks that assess implicit bias to negative-valence faces, the first by eye-gaze and the second by measuring body-movement parameters. The report contrasts task performance in 51 treatment-seeking, medication-free pediatric patients with anxiety disorders and 36 healthy peers. Among these youth, 53 completed an eye-gaze task, 74 completed a body-movement task, and 40 completed both tasks. On the eye-gaze task, patients displayed longer gaze duration on negative relative to non-negative valence faces than healthy peers, F(1, 174) = 8.27, p = .005. In contrast, on the body-movement task, patients displayed a greater tendency to behaviorally avoid negative-valence faces than healthy peers, F(1, 72) = 4.68, p = .033. Finally, implicit bias measures on the two tasks were correlated, r(38) = .31, p = .049. In sum, we found an association between pediatric anxiety disorders and implicit threat bias on two tasks, one measuring eye-gaze and the other measuring whole-body movements. Converging evidence for implicit threat bias encourages future research using multiple tasks in anxiety.