Zero Suicide Quality Improvement: Developmental and Pandemic-Related Patterns in Youth at Risk for Suicide Attempts.

The Zero Suicide (ZS) approach to health system quality improvement (QI) aspires to reduce/eliminate suicides through enhancing risk detection and suicide-prevention services. This first report from our randomized trial evaluating a stepped care for suicide prevention intervention within a health system conducting ZS-QI describes 1) our screening and case identification process, 2) variation among adolescents versus young adults; and 3) pandemic-related patterns during the first COVID-19 pandemic year. Between April 2017 and January 2021, youths aged 12-24 with elevated suicide risk were identified through an electronic health record (EHR) case-finding algorithm followed by direct assessment screening to confirm risk. Eligible/enrolled youth were evaluated for suicidality, self-harm, and risk/protective factors. Case finding, screening, and enrollment yielded 301 participants showing suicide risk-indicators: 97% past-year suicidal ideation, 83% past suicidal behavior; 90% past non-suicidal self-injury (NSSI). Compared to young adults, adolescents reported: more past-year suicide attempts (47% vs 21%, p<.001) and NSSI (past 6-months, 64% vs 39%, p<.001); less depression, anxiety, posttraumatic stress, and substance use; and greater social connectedness. Pandemic-onset was associated with lower participation of racial-ethnic minority youths (18% vs 33%, p<.015) and lower past-month suicidal ideation and behavior. Results support the value of EHR case-finding algorithms for identifying youths with potentially elevated risk who could benefit from suicide-prevention services, which merit adaptation for adolescents versus young adults. Lower racial-ethnic minority participation after the COVID-19 pandemic-onset underscores challenges for services to enhance health equity during a period with restricted in-person health care, social distancing, school closures, and diverse stresses.

Recruitment and Feasibility of Hair Cortisol Collection in a Sample of Ethnically and Sexually Diverse, Low-Income Adults: A Qualitative Community-Partnered Participatory Research Study.

The current study describes how a community-partnered participatory research (CPPR) model was used to enhance hair cortisol research engagement among low-income adults of diverse ethnicities and sexual and gender identities. Participants' reported motivations and concerns surrounding providing a hair sample are also described. Participants from a larger longitudinal study were invited to provide a hair sample and/or complete acceptability interviews. Results indicated that 71% of all persons (N=133) contacted participated in the current study, of whom 82% provided hair samples. Several themes emerged from the interviews indicating that participants were motivated to provide a hair sample due to internal and external factors; however, concerns about mistrust of research remained. Thus, collecting biospecimens in research with underserved groups requires careful consideration of benefits and risks to the individual and their communities. Our results provide guidelines for engaging low-income racially/ethnically and sexually diverse community members in biospecimen research to understand stress-health relationships.

Understanding the characteristics of Latino individuals with first-time DUI offenses to facilitate effective interventions.

Literature shows that Latinos who drink are more likely to experience alcohol-related consequences and less likely to seek care for alcohol misuse than Whites. We aim to understand characteristics, consumption patterns, and openness to treatment among Latino first-time offenders driving under the influence. Latino participants were significantly younger (29.0 years) than non-Latinos (37.7 years). In adjusted models, Latino participants were significantly more likely than non-Latinos to binge drink, but there were no significant group differences in amount of alcohol consumed in a typical week. There was no significant difference in incidence of alcohol-related consequences, readiness to change drinking, and driving behaviors in this sample.

Stepped care for suicide prevention in teens and young adults: Design and methods of a randomized controlled trial.

BACKGROUND: Suicide is the second­leading cause of death among adolescents and young adults in the United States, with rates rising over much of the last decade. The design, testing, and implementation of interventions to prevent suicide in this population is a public health priority. This manuscript outlines the design and methods for a research study that compares two interventions aimed at reducing suicide and suicide attempts in youth. METHODS: We will enroll 300 youth aged 12-24 at high risk for suicide in this randomized controlled parallel group superiority trial. Participants will be randomly assigned to one of two study arms: (1) Zero Suicide Quality Improvement (ZSQI) implemented within the Kaiser Permanente Northwest (KPNW) health system, or (2) ZSQI plus a stepped care intervention for suicide prevention (SC-SP), where the services offered (including care management and dialectical behavior therapy [DBT]) increase based on risk level. Outcomes will be assessed at baseline, as well as 3-, 6-, and 12-months post randomization. The study was conceptualized and designed collaboratively by investigators at UCLA and KPNW. RESULTS: To be reported in future manuscripts. CONCLUSION: The main objective of the study is to determine whether the SC-SP intervention is superior to ZSQI with regard to lowering rates of fatal and nonfatal suicide attempts. Interventions that incorporate the latest research need to be designed and tested under controlled conditions to make progress toward the goal of achieving zero suicide. The results from this trial will directly inform those efforts. CLINICALTRIALS: gov, NCT03092271, https://clinicaltrials.gov/ct2/show/NCT03092271https://clinicaltrials.gov/ct2/show/NCT01379027.

Age-Associated Differences in Mental Distress Among Sexual and Gender Minority Adults.

OBJECTIVE: This study aimed to use a large population-based sample to investigate age-associated differences in mental distress among sexual and gender minority (SGM) adults compared with their heterosexual, cisgender counterparts. METHODS: Data were pooled from five cycles (2014-2018) of the Behavioral Risk Factor Surveillance System (BRFSS) survey (N=762,541) and included states that administered the optional SGM module during that interval. Mean days of self-reported mental distress and the rate of frequent mental distress (≥14 days of mental distress per month) were calculated for each age and SGM identity stratum by using linear and logistic regression, respectively. Models controlled for socioeconomic factors and medical comorbid conditions. All analyses accounted for the complex survey design of the BRFSS. RESULTS: Among those ages 18-24 years, mean days of mental distress and the rate of frequent mental distress were significantly higher for SGM subgroups compared with cisgender, heterosexual adults. Among those ages 45-54, 55-64, or ≥65, no differences were noted between SGM groups and their cisgender, heterosexual peers. CONCLUSIONS: Younger SGM respondents reported the highest levels of mental distress. Differences in general mental distress were less detectable with increasing age. The findings suggest that SGM young adults have an increased need for mental health services.

Life Events, Barriers to Care, and Outcomes Among Minority Women Experiencing Depression: A Longitudinal, Mixed-Method Examination.

ABSTRACT: The long-term course of depression is not well-understood among minority women. We assessed depression trajectory, barriers to depression care, and life difficulties among minority women accessing health and social service programs as part of the Community Partners in Care study. Data include surveys ( N = 339) and interviews ( n = 58) administered at 3-year follow-up with African American and Latina women with improved versus persistent depression. The majority of the sample reported persistent depression (224/339, 66.1%), ≥1 barrier to mental health care (226/339, 72.4%), and multiple life difficulties (mean, 2.7; SD, 2.3). Many barriers to care ( i.e. , related to stigma and care experience, finances, and logistics) and life difficulties ( i.e. , related to finances, trauma, and relationships) were more common among individuals reporting persistent depression. Results suggest the importance of past experiences with depression treatment, ongoing barriers to care, and negative life events as contributors to inequities in depression outcomes experienced by minority women.

Depression, Anxiety, and Suicide Risk among Ugandan Youth in Vocational Training.

The current study examines the prevalence of depression, anxiety, suicide risk, and PTSD in Ugandan youth (13-25 years) attending vocational training programs. Youth from five urban (n=224 females, 81 males) and four rural (n=153 females only) vocational training centers operated by a non-governmental organization completed demographic and mental health questionnaires. Nearly half of the youth reported moderate or severe depression and/or anxiety. More than half reported anxiety and depression-related impairment. Nearly a quarter of youth had considered or attempted suicide. More than half screened positive on the PC-PTSD screen. Rural female youth reported the most food insecurity (56.9%), trafficking (37.9%), severe depression (35.9%), depression-related impairment (56.9%), severe anxiety (26.1%), and anxiety-related impairment (55.6%). Results from this study suggest that Ugandan youth have exceedingly high rates of depression, anxiety, suicide risk, and probable PTSD. Rural female youth may be especially at risk. Relevant treatment interventions are needed that can be adapted to youth in vocational training centers.

Impact of the 2016 Election on the Quality of Life of Sexual and Gender Minority Adults: A Difference-in-Differences Analysis.

Purpose: The 2016 U.S. election significantly changed the political landscape for sexual and gender minority (SGM) individuals. The current study assessed the consequences of the election and transition to a new overtly discriminatory administration on the health-related quality of life of SGM adults compared with their cisgender and heterosexual counterparts. Methods: The study used repeated cross-sectional data from the 17 states that administered the sexual orientation and gender identity module in the 2015 and 2018 Behavioral Risk Factor Surveillance System surveys. The sample included 268,851 adult respondents: 12,006 SGM adults (5.35%) and 256,845 cisgender and heterosexual adults (94.65%). Outcomes were frequent (≥14 days in the last month) physical distress, mental distress, limited activity, and/or fair/poor general health. Difference-in-differences estimates were calculated from logistic regression models, controlling for sociodemographic, health care coverage, and chronic medical condition confounders. Results: Compared with the cisgender and heterosexual population, frequent mental distress among SGM adults increased by 5% points, corresponding to a relative increase of 32.5% (p < 0.001) from 2015. Rates of frequent physical distress, limited activity, and fair/poor general health were not significantly altered between the two populations. Gender minority adults were most negatively affected with a relative increase in frequent mental distress of 117.5% (p < 0.001). Conclusions: The 2016 U.S. election and administration changeover were associated with a substantial increase in the proportion of SGM adults reporting frequent mental distress. These data provide empirical evidence as to the psychological effects of an abrupt political realignment on SGM mental health.

Engaging LGBTQ Communities in Community-Partnered Participatory Research: Lessons from the Resilience Against Depression Disparities Study.

BACKGROUND: The Resilience Against Depression Disparities (RADD), a community partnered, randomized comparative effectiveness study, aimed to address mental health in Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) racial/ethnic populations in New Orleans and Los Angeles. OBJECTIVES: To describe engagement methods, lessons learned, and recommendations in engaging LGBTQ individuals and agencies throughout the RADD study. METHODS: RADD used a community partnered participatory research framework to engage LGBTQ community members and agencies. Observational and quantitative data were collected to describe engagement activities and study adaptations from October 2016 to May 2019. RESULTS: Our partnered approach resulted in multiple study adaptations. The principles of cultural humility, coleadership, and addressing health determinants were important to successful engagement with LGBTQ community members and study participants. We recommend maintaining cultural humility as the tenant of all research activities. CONCLUSIONS: This project's engagement plan demonstrates that community-academic partnerships can be forged to create and modify existing study models for LGBTQ communities.

Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care.

OBJECTIVE: Suicidality is common among participants in clinical trials and health services research, but approaches to suicide risk assessment and mitigation vary widely. Studies involving vulnerable populations with limited access to care raise additional ethical concerns. The authors applied a community-partnered approach to develop and implement a suicide-risk management protocol (SRMP) in a depression study in an underresourced setting in Los Angeles. METHODS: Using a community-partnered participatory research framework, the authors designed and adapted the SRMP. Qualitative data regarding SRMP implementation included notes from SRMP development meetings and from study clinicians conducting outreach calls to study participants. Analyses included baseline and 6- and 12-month telephone survey data from 1,018 enrolled adults with moderate to severe depressive symptoms (8-item Patient Health Questionnaire score ≥10), of whom 48% were Black and 40% Latino. RESULTS: Community stakeholders prioritized a robust SRMP to ensure participant safety. Features included rapid telephone outreach by study clinicians in all cases of reported recent suicidality and expedited treatment access. Using a suicidality timeframe prompt of "in the past 2 weeks," endorsement of suicidality was common (15% at baseline, 32% cumulative). Midway through the study, the SRMP was modified to assess for present suicidality, which reduced the frequency of clinician involvement. Overall, 318 outreach calls were placed, with none requiring an emergency response. Treatment referrals were provided in 157 calls, and outreach was well received. CONCLUSIONS: SRMP implementation in research involving underresourced and vulnerable communities merits additional considerations. Partnering with community stakeholders can facilitate the development of acceptable and feasible SRMP procedures.

An Anti-Racist Approach to Achieving Mental Health Equity in Clinical Care.

Racism is an important determinant of health and health disparities, but few strategies have been successful in eliminating racial discrimination from medical practice. This article proposes a novel antiracist approach to clinical care that acknowledges the racism shaping the clinical encounter and historical arc of racial oppression embedded in health care. Although preliminary, this approach can be easily implemented into clinical care and may reduce the harm done by racism. It could also serve as a template for antiracist service provision in other sectors, such as education and law enforcement.

Community Interventions to Promote Mental Health and Social Equity.

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

A critical review of current evidence on multiple types of discrimination and mental health.

Little is known about people who experience multiple types of discrimination (e.g., racism and heterosexism). While some work suggests that multiply discriminated groups are at higher risk for poor mental health, other studies propose that they may develop resilience against additional kinds of discrimination. We conducted a review of published studies on the relationship between multiple types of discrimination and mental health to critically examine evidence in support of broad risk and resilience models. Using PRISMA guidelines, we identified 40 studies that met our inclusion criteria. Typically, studies examined either whether experiencing multiple discrimination was related to poorer mental health, or whether one kind of discrimination was more predictive of poor mental health. Studies generally showed support for the risk model, with multiple forms of discrimination associated with higher risk for depression symptoms. Furthermore, both racism and heterosexism uniquely predicted symptoms of depression, although initial evidence suggested that only heterosexism predicted suicidality among lesbian, gay, bisexual, transgender, and queer (LGBTQ) racial/ethnic minorities. Findings on multiple discrimination and other mental health problems (e.g., anxiety, posttraumatic stress disorder [PTSD], distress, and substance use) were mixed. The current evidence suggests that multiply discriminated groups exhibit higher risk for some mental health problems, particularly depression symptoms. However, methodological problems abound in this literature (e.g., correspondence between study sample and types of discrimination assessed), which limits our ability to draw clear conclusions about multiple discrimination. We propose that to further our understanding of how multiple kinds of discrimination may affect mental health, studies must remedy these and other issues. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Resilience Against Depression Disparities (RADD): a protocol for a randomised comparative effectiveness trial for depression among predominantly low-income, racial/ethnic, sexual and gender minorities.

INTRODUCTION: Depression is the leading cause of adult disability and common among sexual and gender minority (SGM) adults. The current study builds on findings showing the effectiveness of depression quality improvement (QI) and delivery of cognitive behavioural therapy (CBT) skills provided by community health workers in reducing depression. Depression QI approaches across healthcare and social/community services in safety-net settings have shown improvements in mental wellness, mental health quality of life and depression over 12 months. Further, a randomised study showed improved depression among low-income racial/ethnic minorities enrolled in a CBT-informed resiliency class (Building Resilience and Increasing Community Hope (B-RICH)). The current protocol describes a comparativeness effectiveness study to evaluate whether predominantly low-income, SGM racial/ethnic minority adults randomised to a CBT-informed resiliency class have improvements in depressive symptoms over and above community-engaged QI resources and training only. METHODS AND ANALYSIS: The study approached three clusters of four to five programs serving predominantly SGM and racial/ethnic minority communities in the USA: two clusters in Los Angeles, California, and one in New Orleans, Louisiana. Clusters are comprised of one primary care, one mental health and two to three community agencies (eg, faith-based, social services/support, advocacy). All programs received depression QI training. The current study employed a community-partnered participatory research model to adapt the CBT-informed resiliency class, B-RICH+, to SGM communities. Study participants were screened and recruited in person from participating programs, and will complete baseline, 6- and 12-month survey follow-ups. Participants were depressed adults (8-item Patient Health Questionnaire ≥10; ≥18 years of age) who provided contact information. Enrolled participants were individually randomised to B-RICH+ or depression QI alone. Primary outcomes are depressive symptoms; secondary outcomes are mental health quality of life, mental wellness and physical health quality of life. Data collection for this study is ongoing. ETHICS AND DISSEMINATION: The current study was approved by the UCLA Institutional Review Board. Study findings will be disseminated through scientific publications and community conferences. TRIAL REGISTRATION NUMBER: https://clinicaltrials.gov/ct2/show/NCT02986126.

The Juntos Pilot Study: A Diabetes Management Intervention for Latino Caregiving Dyads.

PURPOSE: The purpose of this study was to design a culturally sensitive dyad-level diabetes intervention to improve glycemic control for older Latino adults with type 2 diabetes. METHODS: This study used a pretest-posttest noncontrol group design. The intervention was developed from formative research with Mexican-origin caregiving dyads. The curriculum was adapted from 2 randomized trials of community interventions specifically designed for Latino older adults with type 2 diabetes. The curriculum consisted of communication skill-building exercises and dyad decision making on lifestyle changes to improve the older adult's blood glucose levels. Thirty-two community-dwelling dyads completed a 6-week program of one-on-one sessions with a trained program facilitator. Main outcomes were feasibility and acceptability of the Juntos program. The authors assessed feasibility by examining participant burden and retention and acceptability by participant exit interviews. Although underpowered for outcomes, A1C, health status, and dyadic communication were also assessed to evaluate whether trends suggested the effectiveness of the intervention. RESULTS: Most participants viewed Juntos as an acceptable program and wanted the program expanded in terms of length and scope. All outcomes showed improvement from baseline through 6 months postintervention. CONCLUSIONS: Results show that Juntos is acceptable to Mexican-origin caregiving dyads and is a promising approach for effectively controlling type 2 diabetes among older Latino adults who have a family caregiver.

Developing and evaluating a lay health worker delivered implementation intervention to decrease engagement disparities in behavioural parent training: a mixed methods study protocol.

INTRODUCTION: Behavioural parent training (BPT) programmes are effective in preventing and treating early-onset conduct problems and child maltreatment. Unfortunately, pervasive mental health service disparities continue to limit access to and engagement in these interventions. Furthermore, challenges with parental engagement can impede the successful implementation of evidence-based practices (EBPs) in community settings that serve low-income, ethnic minority families. Lay health workers (LHWs)-individuals without formal mental health training-represent an important workforce to increase engagement, as they are members of the communities they serve. However, the mobilisation of LHWs has not been well studied as an implementation strategy to extend the reach or effectiveness of EBPs in the USA. LHW-delivered implementation interventions that specifically support the engagement of Latinx parents in evidence-based BPT programmes have the potential to improve clinical and implementation outcomes. METHODS AND ANALYSIS: A community-partnered approach will use the Quality Implementation Framework (QIF) to tailor and implement an LHW-delivered implementation intervention that aims to promote Latinx parent engagement in BPT programmes. Steps from the QIF will guide study activities to (1) conduct a mixed methods needs assessment to fit the implementation intervention to the local context, (2) adapt LHW-delivered implementation strategies to promote parent access to and engagement in Parent-Child Interaction Therapy and (3) conduct a hybrid effectiveness-implementation pilot trial to examine the feasibility, acceptability and preliminary effectiveness of the LHW implementation intervention at increasing engagement. ETHICS AND DISSEMINATION: Study procedures have been approved by the Institutional Review Board at the University of California, Santa Barbara. Results will be shared with the community-advisory group, at community-based meetings for other stakeholders involved in the pilot project, and submitted for publication in peer-reviewed journals.

Depression Remission From Community Coalitions Versus Individual Program Support for Services: Findings From Community Partners in Care, Los Angeles, California, 2010-2016.

Objectives. To explore effects of coalitions (Community Engagement and Planning [CEP]) versus technical assistance (Resources for Services [RS]) for depression collaborative care and the effects of social determinants on long-term remission outcomes. Methods. We randomized 95 health care and community programs in Los Angeles County, California, to CEP or RS. In 2010, 1246 depressed (Patient Health Questionnaire [PHQ-8] ≥ 10) adults enrolled and were invited for baseline and 6-, 12-, and 36-month surveys. Of 598 3-year completers, 283 participated at 4 years (2016). We examined effects of CEP versus RS, social factors (e.g., family income, food insecurity) on time to and periods in clinical (PHQ-8 < 10) and community-defined (PHQ-8 < 10 or PHQ-2 < 3; mental health composite score [MCS-12] > 40, or mental wellness) remission during the course of 3 years, and at 4 years. Results. We found that CEP versus RS increased 4-year depression remission and, for women, community-defined remission outcomes during the course of 3 years. Social factors and clinical factors predicted remission. Conclusions. At 4 years, CEP was more effective than RS at increasing depression remission. Public Health Implications. Coalitions may improve 4-year depression remission, while addressing social and clinical factors associated with depression may hold potential to enhance remission.

The symptom-specific efficacy of antidepressant medication vs. cognitive behavioral therapy in the treatment of depression: results from an individual patient data meta-analysis.

A recent individual patient data meta-analysis showed that antidepressant medication is slightly more efficacious than cognitive behavioral therapy (CBT) in reducing overall depression severity in patients with a DSM-defined depressive disorder. We used an update of that dataset, based on seventeen randomized clinical trials, to examine the comparative efficacy of antidepressant medication vs. CBT in more detail by focusing on individual depressive symptoms as assessed with the 17-item Hamilton Rating Scale for Depression. Five symptoms (i.e., "depressed mood" , "feelings of guilt" , "suicidal thoughts" , "psychic anxiety" and "general somatic symptoms") showed larger improvements in the medication compared to the CBT condition (effect sizes ranging from .13 to .16), whereas no differences were found for the twelve other symptoms. In addition, network estimation techniques revealed that all effects, except that on "depressed mood" , were direct and could not be explained by any of the other direct or indirect treatment effects. Exploratory analyses showed that information about the symptom-specific efficacy could help in identifying those patients who, based on their pre-treatment symptomatology, are likely to benefit more from antidepressant medication than from CBT (effect size of .30) versus those for whom both treatments are likely to be equally efficacious. Overall, our symptom-oriented approach results in a more thorough evaluation of the efficacy of antidepressant medication over CBT and shows potential in "precision psychiatry" .

Community Engagement and Planning versus Resources for Services for Implementing Depression Quality Improvement: Exploratory Analysis for Black and Latino Adults.

Objective: Racial/ethnic minorities experience disparities in depression1 and there is a paucity of evidence-based interventions to improve depression care access and outcomes. Community Partners in Care (CPIC) is a community-partnered study of depression care quality improvement (QI) in under-resourced, urban communities: Community Engagement and Planning (CEP) for multi-sector coalitions, and Resources for Services (RS) for program technical assistance.2 CEP demonstrated benefits for the overall CPIC study population; effects for Black and Latino sub-populations are unknown. Methods: This sub-analysis examines outcomes for 409 Latino and 488 Black (non-Latino) adults recruited from 90 programs who completed baseline or 6-month follow-up. Regression analyses were used to estimate CEP vs RS intervention effects on primary (Mental Health Related Quality of Life [MHRQL], Patient Health Questionnaire-9 [PHQ-9]) and community-prioritized (mental wellness, physical activity, risk for homelessness) outcomes at 6-months. Results: Baseline characteristics did not differ significantly by intervention in either group. In the adjusted analysis for Black adults, CEP resulted in decreased odds of poor MHRQL (OR: .62, 95% CI=.41-.94, P=.028) with a trend for reducing homelessness risk (OR: .60, .35-1.05, P=.69). For Latino adults, CEP resulted in greater probability of mental wellness (OR: 1.81, 1.05-3.13, P=.034) and a trend for increased physical activity (OR: 1.52, .93-2.49, P=.091). Conclusions: Exploratory analyses of CEP for depression quality improvement suggests significant 6-month benefits in mental health outcomes for Black and Latino participants and trends for improvement in community-prioritized outcomes for both groups. Findings may inform research in multi-sector coalitions to promote equity in depression care.