Exploring the evocative qualities of masks' visual imagery and their associations with adversity and trauma.

Introduction: Studies suggest a relationship between the emotional evocativeness of visual imagery and viewer responses, however, there is limited understanding of these associations, especially as they relate to viewers' personal experiences of adversities. Methods: In this exploratory study, we examined the relationship between the visual content of mask images and viewers' responses. In an online survey 699 participants (of n = 1,010 total initial participants) rated 98 masks based on valence, arousal, and personal relevance and completed the Life Events Checklist. The masks included those created by service members (SMs) with traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD), depicting physical, psychological, and moral injuries and matched neutral masks created by creative arts therapists and arts in health scholars. Findings: The findings indicated that responses to mask image content (traumatic versus neutral) were associated with viewers' personal history of adversity and trauma. Specifically, images representing injury/trauma provoked stronger reactions on valence and arousal than neutral images. Moreover, participants with personal histories of trauma had heightened emotional responses to distressing imagery. Discussion: These findings have implications for art therapists as well as for clinical and general populations in that these results highlight the potential impact of distressing imagery particularly for individuals with personal histories of experiencing or witnessing traumatic events.

Factors associated with perceived stress and depressive symptoms among college students during the COVID-19 pandemic.

The COVID-19 pandemic had detrimental effects on college students' psychosocial well-being due to campus closures starting in Spring 2020. This study examined changes in perceived stress and depressive symptoms before and during the pandemic using longitudinal data collected from students over the 2019-2020 academic year. We also compared data from this sample in Fall 2019 (N = 282) to data collected from another sample in Fall 2020 (N = 240). Latent change modeling showed increases in stress during Spring 2020. Additionally, the Fall 2020 sample had higher levels of stress than the Fall 2019 sample. Differences in stress and depressive symptoms did not depend on underrepresented minority (URM) status, income, gender, or membership in Greek life or other organizations. However, third- and fourth-year students and student-athletes experienced more stress during the pandemic. Findings suggest an adverse and differential impact of the pandemic on students' psychosocial well-being.

Combining attachment-based family therapy and cognitive behavioral therapy to improve outcomes for adolescents with anxiety.

Increases in adolescent anxiety over the past several years suggest a need for trauma-informed, culturally responsive interventions that help teens cope with environmental stressors like those associated with the COVID-19 pandemic. Although abundant evidence supports the efficacy of cognitive behavioral therapy (CBT) in treating adolescent anxiety, not all teens respond positively to CBT. CBT does not typically include strategies that address important family factors that may be impacting the teen's functioning, such as the attachment relationship. Attachment-based family therapy (ABFT) addresses the attachment relationship and other factors that contribute to the adolescent's anxiety and related distress. By enhancing positive parenting behaviors, such as acceptance and validation of the adolescent's distress and promotion of their autonomy, ABFT sessions may repair the attachment relationship and increase the family's ability and willingness to engage in CBT tasks aimed at reducing anxiety. This theoretical paper describes the ABFT model and proposes that implementing ABFT sessions prior to CBT could result in better clinical outcomes for adolescents with anxiety disorders by improving the context within which the anxiety symptoms and treatment are experienced. Given that ABFT is sensitive and responsive to family and other contextual factors, adolescents from marginalized communities and those from less individualistic cultures may find the model to be more acceptable and appropriate for addressing factors related to their anxiety. Thus, a combined ABFT+CBT model might result in better outcomes for adolescents who have not historically responded well to CBT alone.

Anxiety-related difficulties in goal-directed behavior predict worse treatment outcome among adolescents treated for suicidal ideation and depressive symptoms.

Although treatments for youth at risk for suicide have been successful, they are not similarly effective for everyone. Anxiety may interfere with adolescents' ability to engage with therapy and explain why some adolescents do not respond as well as others to treatment. The current study tested whether an anxiety diagnosis predicted treatment outcome among a sample of adolescents with suicidal ideation and depressive symptoms participating in either attachment-based family therapy or family-enhanced nondirective supportive therapy (N = 129; M age = 14.87, SD = 1.68; 81.9% female). The data set that the current study used had a high representation of Black/African American adolescents (48.8% of sample), which is valuable, as few studies have included adequate representation of this population. A significant indirect effect (.88; 95% confidence interval [.01, 2.64]) showed that across both treatment conditions, participants who met criteria for an anxiety disorder had greater difficulties engaging in goal-directed behavior midtreatment, and these difficulties, in turn, predicted more posttreatment suicidal ideation. The effect of anxiety on treatment outcome via difficulties with goal-directed behavior was nonspecific to the treatment condition. However, attachment-based family therapy was superior to family-enhanced nondirective supportive therapy in improving this aspect of emotion regulation among adolescents who did not have anxiety. In addition, difficulties with goal-directed behavior on treatment outcome were worse for adolescents' who reported greater attachment avoidance to their parents. Future research should test whether targeting goal-directed behavior and attachment avoidance would result in better treatment outcome for adolescents with suicidal ideation and anxiety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Exploring the relations between interpersonal risk and adolescent suicidality during treatment.

OBJECTIVE: Despite considerable evidence that supports perceived burdensomeness (PB) and thwarted belongingness (TB) as risk factors for suicidal ideation (SI), far less is known about the direction of effects between these constructs in treatments for suicidal adolescents. The present study examined bidirectional relations between PB, TB, and adolescents' suicidal ideation (SI) during a 16-week randomized clinical trial. METHOD: 129 depressed and suicidal adolescents completed PB, TB, and SI measures at three time points: baseline (T1), mid-treatment (T2), and treatment completion (T3). Random-intercept cross-lagged panel models (RI-CLPM) examined within-subject direction of effects between interpersonal variables (PB & TB) and suicidal ideation (SI) in the first and second halves of treatment. RESULTS: Within-subjects, autoregressive paths indicated significant carryover in PB and SI. In the first half of treatment, a significant cross-lagged path indicated that T1 PB predicted change in T2 SI, and in the last half of treatment change in T2 SI predicted change in T3 PB. There were no significant auto-regressive or cross-lagged effects for TB. CONCLUSIONS: In the first half of treatment, baseline PB predicted fewer reductions in SI suggesting that PB initially moderated adolescents' response to treatment. However, in the last half of treatment, initial reductions in SI predicted subsequent reductions in PB suggesting that adolescents' initial response to treatment decreased their perceptions of burdening others. The clinical and treatment implications of these bidirectional findings are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Unique Interactions of Interpersonal Trauma and Positive Peer and Family Experiences on Traumatic Distress Among Pediatric Primary Care Patients.

Individuals with histories of interpersonal trauma are at increased risk for posttraumatic stress disorder (PTSD). Risk of PTSD is particularly salient during critical periods of development, such as adolescence and emerging adulthood. However, little is known about the unique effects and interactions of protective factors and interpersonal trauma on PTSD symptoms in adolescents and young adults. The current study tested whether positive peer and family experiences decrease the associations between interpersonal trauma and PTSD symptoms and whether these associations differed by victim-perpetrator relationships. Participants included 3,618 adolescents and young adults (aged 14-24 years) who completed the Behavioral Health Screen-a web-based screening tool that assesses psychiatric symptoms and associated risk factors-during a routine visit across 10 primary care sites in Pennsylvania. In support of the stress buffering hypothesis, results revealed that positive peer and family experiences buffered the effects of interpersonal trauma by a romantic partner and an adult in the home. Future research should examine whether programs aimed at improving peer or family relationships improve outcomes for traumatized youth.

A Socioecological Model of Risk Associated With Campus Sexual Assault in a Representative Sample of Liberal Arts College Students.

Campus sexual assault (CSA) is a growing area of research and public health concern, yet little research has considered the sociocultural context in which CSA occurs or the effect of sociocultural factors on the posttraumatic stress disorder (PTSD) symptoms of CSA survivors. This study describes the results of a web-based census survey administered to students at a liberal arts college. Of the 1,611 students who completed the survey (74% female; 71.4% White, 4.3% African American, 12% Hispanic), 13.5% reported experiencing at least one type of completed or attempted CSA. Female students, participants in Greek life, and students who reported victimization prior to college were more likely to report having experienced CSA. CSA was positively correlated with PTSD symptoms, and this relationship was stronger for racial/ethnic minorities, those who reported less sense of community, and those who were more aware of campus services to address CSA. This study demonstrates multiple levels of sociocultural influence on the mental health of college students who have experienced CSA and may suggest ways for improving prevention and intervention strategies to address CSA and its consequences.

Prior Day Negative Affect Influences Current Day Procrastination: A Lagged Daily Diary Analysis.

Background and objectives: Procrastination is a common problem among college students. Negative affect associated with stress and anxiety is linked to higher levels of procrastination. Although there is a relationship between procrastination and affect, little is known about the direction of this relationship. The current study explored whether changes in daily negative affect (NA) or positive affect (PA) preceded procrastination or whether procrastination preceded changes in affect. Method and design: The current study is a secondary data analysis of a larger study. After completing an initial survey assessing students' emotional well-being, students were asked to participate in a follow-up daily diary survey. Participants in the daily diary (N = 53) completed a brief survey each weekday evening for two weeks that assessed daily affect and events. Multilevel regression tested whether NA and PA predicted next-day procrastination and vice versa. Results: Cross-lag panel analysis demonstrated that students reported more procrastination following days they experienced higher levels of NA. However, procrastination did not predict changes in NA. PA was not associated with prior day or next day procrastination experiences when controlling for NA. Conclusions: These findings demonstrate that negative emotions motivate procrastination behavior. Implications for helping students cope with and regulate NA are discussed.

Outcomes of Visual Self-Expression in Virtual Reality on Psychosocial Well-Being With the Inclusion of a Fragrance Stimulus: A Pilot Mixed-Methods Study.

AIMS: In this pilot mixed-methods study, we examined the participants experiences of engaging in virtual drawing tasks and the impact of an olfactory stimulus (calming fragrance blend) on outcomes of affect, stress, self-efficacy, anxiety, creative agency, and well-being (satisfaction with life). METHODS: This study used a parallel mixed-methods, simple block randomization design. The study participants included 24 healthy adults aged 18 to 54 years, including 18 women and six men. The participants completed two 1-h immersive virtual art making sessions and were randomly assigned to receive either a fragrance or a non-fragrance condition for the first session. Quantitative (standardized self-report measures) and qualitative (open-ended survey responses and virtual artwork) datasets were collected concurrently and integrated during data analysis. RESULTS: The quantitative results indicated that the fragrance condition demonstrated a significant reduction in negative affect (e.g., feeling hostile, jittery, upset, distressed, etc.), namely, reduced feelings of negativity when compared to the non-fragrance condition. A trend toward improvement in self-efficacy was also seen in the fragrance condition. No significant changes were found for fragrance or non-fragrance conditions for positive affect, anxiety, and creative agency. The qualitative findings included five themes related to art making experiences in virtual reality in both conditions: fun and joy; novelty of virtual media, experimentation, and play; relaxation and calm; learning curve; and physical discomfort and disorientation. Four themes were identified for virtual art content and visual qualities: nature imagery, references to memories and personal symbols, fantasy and play within imagery, and depiction of everyday objects. CONCLUSIONS: Overall, the participants reported positive responses to the novel virtual art making experiences which were further heightened by the inclusion of the fragrance stimulus for negative affect. These preliminary findings need to be replicated with larger sample sizes to confirm the outcomes and the trends that were seen in this pilot study. Further research is recommended to examine the differences between experiences of virtual and traditional art media and to examine different olfactory stimuli promoting focus and concentration.

Characteristics and behavioral risk factors of firearm-exposed youth in an urban emergency department.

Assessing firearm access among adolescents with behavioral health risk factors is important for the primary prevention of suicide and interpersonal violence. We describe self-reported firearm access and the associated behavioral risk factors and demographic characteristics in a cross-sectional study conducted in the emergency department of an urban pediatric hospital from June 2013 to June 2014. A total of 2258 adolescents received a behavioral health survey to assess access to firearms inside and outside the home, mental health symptoms, and risk behaviors. One of 6 patients in our sample (15%) endorsed access to a firearm. Male gender, lifetime alcohol use, lifetime marijuana use, and lifetime other drug use were associated with access. Participants reporting access were more likely to report clinical levels of lifetime suicidality and depression. The odds of current suicidality were highest in those with 24-h access (OR 2.77 CI 1.73-4.46), compared to those who did not endorse access.

Identifying Risk Factors for Disordered Eating among Female Youth in Primary Care.

Eating disorders are a serious, life-threating condition impacting adolescents and young adults. Providers in primary care settings have an important role in identifying disordered eating (DE) symptoms. Unfortunately, symptoms go undetected in 50% of patients in medical settings. Using the behavioral health screen, this study identified DE risk profiles in a sample of 3620 female adolescents and young adults (ages 14-24), presenting in primary care. A latent class analysis with twenty psychosocial factors identified three DE risk groups. The group at highest risk for DE was characterized by endorsement of internalizing symptoms and a history of trauma. The next risk group consisted of those with externalizing symptoms, particularly substance use. The group at lowest risk for DE reported more time spent with friends compared to their peers. Primary care providers and psychiatric teams can benefit from knowing the psychosocial risk patterns affiliated with DE, and using brief, comprehensive screening tools to identify these symptoms.

Differences in Suicide Risk Severity Among Suicidal Youth With Anxiety Disorders.

Background: Adolescent suicidality is a growing public health concern. Although evidence supports a link between anxiety and suicidality, little is known about risk associated with specific anxiety disorders. Aims: This study examined the prevalence of anxiety disorders in a sample of adolescents with depression and suicidal ideation and the associations between specific anxiety disorders and suicide ideation severity and attempt history. Method: The sample consisted of 115 adolescents (Mage = 14.96 years; 55.8% African American) entering a clinical trial for suicidal ideation and depressive symptoms. Prior to treatment, adolescents completed self-report and interview measures. Results: In all, 48% of the sample met criteria for an anxiety disorder, 22% met criteria for social anxiety disorder (SAD), and 40% met criteria for major depressive disorder (MDD). SAD was uniquely associated with more severe suicidal ideation. Limitations: Findings may not generalize to all suicidal adolescents, and non-measured variables may account for the observed relationships. Conclusion: Future research should examine whether targeting social anxiety would improve treatment response for suicidal adolescents.

A Randomized Controlled Trial: Attachment-Based Family and Nondirective Supportive Treatments for Youth Who Are Suicidal.

OBJECTIVE: To evaluate the efficacy of attachment-based family therapy (ABFT) compared with a family-enhanced nondirective supportive therapy (FE-NST) for decreasing adolescents' suicide ideation and depressive symptoms. METHOD: A randomized controlled trial of 129 adolescents who are suicidal ages 12- to 18-years-old (49% were African American) were randomized to ABFT (n = 66) or FE-NST (n = 63) for 16 weeks of treatment. Assessments occurred at baseline and 4, 8, 12, and 16 weeks. Trajectory of change and clinical recovery were calculated for suicidal ideation and depressive symptoms. RESULTS: There was no significant between-group difference in the rate of change in self-reported ideation (Suicidal Ideation Questionnaire-Jr; F1,127 = 181, p = .18). Similar results were found for depressive symptoms. However, adolescents receiving ABFT showed a significant decrease in suicide ideation (t127 = 12.61, p < .0001; effect size, d = 2.24). Adolescents receiving FE-NST showed a similar significant decrease (t127 = 10.88, p < .0001; effect size, d = 1.93). Response rates (ie, ≥50% decrease in suicide ideation symptoms from baseline) at post-treatment were 69.1% for ABFT versus 62.3% for FE-NST. CONCLUSION: Contrary to expectations, ABFT did not perform better than FE-NST. The 2 treatments produced substantial decreases in suicidal ideation and depressive symptoms that were comparable to or better than those reported in other more intensive, multicomponent treatments. The equivalent outcomes could be attributed to common treatment elements, different active mechanisms, or regression to the mean. Future studies will explore long-term follow up, secondary outcomes, and potential moderators and mediators. CLINICAL TRIAL REGISTRATION INFORMATION: Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.

Emotion regulation and spillover of interpersonal stressors to postsession insight among depressed and suicidal adolescents.

OBJECTIVE: Little is known about the extent to which previous weeks' stressful events spill over and influence adolescents' abilities to derive insight from treatment sessions. Even less is known about factors that moderate clients' vulnerabilities to these spillover effects. The current study examined the spillover of negative interpersonal events to postsession insight and the role of difficulties in emotion regulation in this spillover effect. METHOD: Participants were 129 adolescents with moderate to severe depressive symptoms and suicidal ideation (Mage = 14.96, 83% female, 56% African American/Black) participating in a comparative efficacy trial of Attachment-Based Family Therapy (ABFT) and Family-Enhanced Nondirective Supportive Therapy (FE-NST). A within-subject mediation model tested presession negative affect as a mediator of spillover of past week's events on postsession insight. We then examined baseline difficulties in emotion regulation (DERS) as a between-subjects moderator of the mediation model. RESULTS: Negative affect partially mediated (44%) the spillover of the past week's negative events on adolescents' ratings of postsession insight (p = .03, 95% confidence interval, CI [-.09., -.002]). Baseline DERS increased adolescents' vulnerabilities to spillover effects (p = .01, 95% CI [-.28, -.03]). Negative interpersonal events from the past week influence presession negative affect and spill over to adolescents' abilities to gain insight from their treatment sessions. Adolescents who began treatment with greater DERS were particularly vulnerable to these spillover effects. Findings indicate the need for therapists to adapt sessions to individual differences in depressed and suicidal adolescents' exposure to negative interpersonal events preceding treatment and in their vulnerabilities to spillover and emotion dysregulation. (PsycINFO Database Record

Observational study of associations between visual imagery and measures of depression, anxiety and post-traumatic stress among active-duty military service members with traumatic brain injury at the Walter Reed National Military Medical Center.

OBJECTIVES: The study aimed tocompare recurring themes in the artistic expression of military service members (SMs) with post-traumatic stress disorder (PTSD), traumatic brain injury and psychological health (PH) conditions with measurable psychiatric diagnoses. Affective symptoms and struggles related to verbally expressing information can limit communication in individuals with symptoms of PTSD and deployment-related health conditions. Visual self-expression through art therapy is an alternative way for SMs with PTSD and other PH conditions to communicate their lived experiences. This study offers the first systematic examination of the associations between visual self-expression and standardised clinical self-report measures. DESIGN: Observational study of correlations between clinical symptoms of post-traumatic stress, depression and anxiety and visual themes in mask imagery. SETTING: The National Intrepid Center of Excellence at the Walter Reed National Military Medical Center, Bethesda, Maryland, USA. PARTICIPANTS: Active-duty military SMs (n=370) with a history of traumatic brain injury, post-traumatic stress symptoms and related PH conditions. INTERVENTION: The masks used for analysis were created by the SMs during art therapy sessions in week 1 of a 4-week integrative treatment programme. PRIMARY OUTCOMES: Associations between scores on the PTSD Checklist-Military, Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale on visual themes in depictions of aspects of individual identity (psychological injury, military symbols, military identity and visual metaphors). RESULTS: Visual and clinical data comparisons indicate that SMs who depicted psychological injury had higher scores for post-traumatic stress and depression. The depiction of military unit identity, nature metaphors, sociocultural metaphors, and cultural and historical characters was associated with lower post-traumatic stress, depression and anxiety scores. Colour-related symbolism and fragmented military symbols were associated with higher anxiety, depression and post-traumatic stress scores. CONCLUSIONS: Emergent patterns of resilience and risk embedded in the use of images created by the participants could provide valuable information for patients, clinicians and caregivers.

Emotional reactivity to daily events in youth with anxiety disorders.

BACKGROUND: Although research supports associations between anxiety and emotional reactivity in adults (Cisler, J. M., Olatunji, B. O., Feldner, M. T., & Forsyth, J. P. (2010). Emotion regulation and the anxiety disorders: an integrative review. Journal of Psychopathology and Behavioral Assessment, 32(1), 68-82.), few studies have examined emotional reactivity in anxious youth (e.g., Carthy et al., 2010; Tan, P. Z., Forbes, E. E., Dahl, R. E., Ryan, N. D., Siegle, G. J., Ladouceur, C. D., & Silk, J. S. (2012). Emotional reactivity and regulation in anxious and nonanxious youth: a cell-phone ecological momentary assessment study. Journal of Child Psychology and Psychiatry, 53(2), 197-206.). METHODS: Using daily diary methodology, this study examined both negative affect (NA) and positive affect (PA) reactivity to daily events in youth diagnosed with anxiety (N = 68; 60% female; 78% non-Hispanic White; M age = 11.18 years, SD = 3.17). We also examined whether parent-reported emotion regulation would predict emotional reactivity. RESULTS: Participants reported more NA on days they experienced more negative parent and teacher events and less PA on days that they experienced more negative peer events. Additionally, better emotion regulation was associated with less NA reactivity to negative teacher events and to both negative and positive academic events. CONCLUSIONS: Interpersonal events have a salient effect on daily affect for anxious youth. Youth anxiety therapists should target emotion regulation associated with negative events involving adults and address barriers to developing and maintaining positive peer relationships.

Evaluating referral, screening, and assessment procedures for middle school trauma/grief-focused treatment groups.

There is a need to delineate best practices for referring, assessing, and retaining students suspected of posttraumatic stress (PTS) and maladaptive grief (MG) in school-based treatment. Evidence-based risk-screening procedures should accurately include students who are appropriate for group treatment and exclude students who do not require treatment or who are better served by other forms of intervention and support. We described and evaluated the sequence of steps used to screen 7th- and 8th-grade students (N = 89) referred by school staff as candidates for an open trial of group-based Trauma and Grief Component Therapy for Adolescents (TGCTA; Saltzman et al., in press). We used t tests to compare included versus excluded students on PTS symptom and MG reaction scores (University of California at Los Angeles Posttraumatic Stress Disorder Reaction Index; Grief Screening Scale) during the group screen, individual interview, and treatment-implementation phases. Logistic regressions tested the incremental utility of including measures of both trauma exposure and related emotional and conduct problems (Strengths and Difficulties Questionnaire) in the screening battery. Results suggest that the group screen helped to detect mental health needs and that the individual interview further identified students with PTS and emotional problems. Conduct problems and trauma exposure predicted attrition among students who qualified for treatment. MG incrementally predicted students who advanced from the group screening to the individual interview, and trauma exposure incrementally predicted attrition from treatment. Findings yield implications for improving research and practice, including procedures for enhancing school-based referral, screening, assessment, and selection procedures. (PsycINFO Database Record

Screening to Identify Groups of Pediatric Emergency Department Patients Using Latent Class Analysis of Reported Suicidal Ideation and Behavior and Non-Suicidal Self-Injury.

Latent class analysis of medical records data from 3,523 emergency department (ED) patients (ages 14-24; 31% Caucasian; 67% female) distinguished 6 groups with varying histories of suicidal ideation and behavior based on items endorsed on the Behavioral Health Screen, a web based, nurse-initiated screening tool. As expected, the more severe suicidality groups reported higher levels of depressive symptoms, traumatic distress, and substance abuse symptoms. Findings support the validity of the BHS and its utility as a medical decision tool to help ED staff evaluate the severity of patients' suicidality.

Religion, Sexual Orientation, and Suicide Attempts Among a Sample of Suicidal Adolescents.

Despite condemnation of same-sex attraction by certain religious groups, few studies have explored the relationship between religion, same-sex attraction, and suicidality. This study examined the moderating effect of same-sex attraction on the relationship between parent/adolescent religiosity and suicide ideation/attempts in a suicidal adolescent sample (N = 129). Linear and negative binomial regressions tested the effects of a two-way dichotomous (same-sex attraction, yes/no) by continuous (religiosity) interaction on ideation and attempts, respectively. The interaction was not significant for ideation. However, high religiosity was associated with more attempts in youth reporting same-sex attraction but fewer attempts in those reporting opposite-sex attraction only.

Comprehensive Screening for Suicide Risk in Primary Care.

INTRODUCTION: Suicide is a major public health problem and a complex clinical challenge. Assessment and early identification could be enhanced with screening tools that look beyond depression. The purpose of this study was to identify profiles of risk behaviors and social stress associated with suicidal ideation and behavior using the Behavioral Health Screen. METHODS: The study used screening data from 2,513 primary care patients (aged 14-24 years). Data were collected between 2008 and 2012, and were analyzed in 2016. RESULTS: Latent class analysis identified a high and low risk profile. Domains of primary influence included substance use, sexual assault, same-sex behavior, and unsafe sex. The high-risk group was 11 times more likely to have made a suicide attempt, five times more likely to report a history of suicidal ideation and behavior, and three times more likely to report recent suicidal ideation and behavior. CONCLUSIONS: Risk behaviors and social stress contribute to the risk for suicide above and beyond depression and should be assessed during routine primary care visits with adolescents. The Behavioral Health Screen can screen all these domains and thus assist primary care providers in assessing for both psychiatric and social stress factors associated with youth suicide.