Changes in Serum Concentration of Antidepressants After Bariatric Surgery and Recommendations for Postbariatric Surgery Antidepressant Therapy.

BACKGROUND: Bariatric surgery affects the absorption of medications including antidepressants, but data regarding these effects are limited. OBJECTIVES: Our objectives were to review publicly available data regarding changes in antidepressant serum concentration following bariatric surgery in order to develop medication dosing recommendations in this patient population. METHODS: A comprehensive literature review was performed utilizing key search terms in Pubmed. Additional data were retrieved from the Food and Drug Administration and DrugBank Online resources. RESULTS: A total of twelve published articles were included in addition to the publicly available data from the Food and Drug Administration and DrugBank. The serum concentration of antidepressants following bariatric surgery demonstrated considerable variability between and within drug classes due to unique pharmacokinetic features, drug preparation, and formulation. Recommendations were developed from published data regarding changes in serum concentration and drug-specific pharmacokinetic data. CONCLUSIONS: To our knowledge, this is the first study to propose medication dose-adjustment recommendations for patients on antidepressants undergoing bariatric surgery. We were limited by the relatively small amount of data available and recommend monitoring patients and use of clinical judgment along with this guidance.

Voicing their choices: Advance care planning with adolescents and young adults with cancer and other serious conditions.

OBJECTIVES: To determine whether engaging in advance care planning (ACP) using a formal tool, Voicing My CHOiCES (VMC), would alleviate adolescent and young adults (AYAs) anxiety surrounding ACP and increase social support and communication about end-of-life care preferences with family members and health care providers (HCPs). METHODS: A total of 149 AYAs aged 18-39 years receiving cancer-directed therapy or treatment for another chronic medical illness were enrolled at seven US sites. Baseline data included prior ACP communication with family members and HCPs and measures of generalized anxiety, ACP anxiety, and social support. Participants critically reviewed each page of VMC and then completed three pages of the document. ACP anxiety was measured again immediately after the completion of VMC pages. One month later, participants repeated anxiety and social support measures and were asked if they shared what they had completed in VMC with a family member or HCP. RESULTS: At baseline, 50.3% of participants reported that they previously had a conversation about EoL preferences with a family member; 19.5% with an HCP. One month later, 65.1% had subsequently shared what they wrote in VMC with a family member; 8.9% shared with an HCP. Most (88.6%) reported they would not have had this conversation if not participating in the study. No significant changes occurred in social support. There was an immediate drop in anxiety about EoL planning after reviewing VMC which persisted at 1 month. Generalized anxiety was also significantly lower 1 month after reviewing VMC. SIGNIFICANCE OF RESULTS: Having a document specifically created for AYAs to guide ACP planning can decrease anxiety and increase communication with family members but not necessarily with HCPs. Future research should examine ways ACP can be introduced more consistently to this young population to allow their preferences for care to be heard, respected, and honored, particularly by their healthcare providers.

Implementing Suicide Risk Screening in a Pediatric Primary Care Setting: From Research to Practice.

OBJECTIVE: To describe the methodological development and feasibility of real-world implementation of suicide risk screening into a pediatric primary care setting. METHODS: A suicide risk screening quality improvement project (QIP) was implemented by medical leadership from a suburban-based pediatric (ages 12-25 years) primary care practice in collaboration with a National Institute of Mental Health (NIMH) suicide prevention research team. A pilot phase to acclimate office staff to screening procedures preceded data collection. A convenience sample of 271 pediatric medical outpatients was screened for suicide risk. Patients, their parents, and medical staff reported their experiences and opinions of the screening procedures. RESULTS: Thirty-one (11.4%) patients screened positive for suicide risk, with 1 patient endorsing imminent suicide risk (3% of positive screens; 0.4% of total sample). Over half of the patients who screened positive reported a past suicide attempt. Most patients, parents, and medical staff supported the implementation of suicide risk screening procedures into standard care. A mental health clinical pathway for suicide risk screening in outpatient settings was developed to provide outpatient medical settings with guidance for screening. CONCLUSIONS: Screening for suicide risk in pediatric primary care is feasible and acceptable to patients, their families, and medical staff. A clinical pathway used as guidance for pediatric health care providers to implement screening programs can aid with efficiently detecting and managing patients who are at risk for suicide.

A Comparison of Suicide Attempt Histories of Pediatric and Adult Medical Inpatients and Implications for Screening.

OBJECTIVE: A suicide attempt is the most potent predictor of future suicidal behavior, yet little is known about how to manage and respond to reports of attempt histories in hospitalized medical patients. This study aims to describe the prevalence and characteristics of pediatric and adult medical inpatients who report a past suicide attempt. METHOD: Participants were medical inpatients, aged 10-93 years, enrolled in two suicide risk screening instrument validation studies. Participants completed the Ask Suicide-Screening Questions (ASQ) and the Patient Health Questionnaire (PHQ). RESULTS: A total of 1324 medical inpatients (624 pediatric, 700 adult) completed the ASQ, with 114 participants (8.6%) reporting a past suicide attempt (51 pediatric; 63 adults). Comparing youth to adults, there was no significant difference between attempt rates (χ2=0.29, p = 0.59). Youth with a past attempt were significantly more likely to report past week suicidal ideation (OR = 28.22; 95% CI = 5.90, 135.06) and have a history of mental health care (OR = 9.11; 95% CI = 2.59-32.10), compared to those without a past attempt. Adults with a past attempt were significantly more likely to screen positive for depression, compared to those without attempt histories (OR = 5.00; 95% CI = 2.31-10.83). CONCLUSIONS: Nearly 9% of hospitalized medical patients endorsed a past suicide attempt when screened. Since adolescence is a critical time for detecting suicide risk, screening that includes past suicidal behavior may be an important means to identify youth with recent suicidal thoughts. By assessing recency of suicide attempts in adults, medical settings may optimize the effectiveness of how positive suicide risk screens are managed.HIGHLIGHTSRoughly 9% of medical patients reported a past suicide attempt when screened.Adolescence is a critical time for detecting suicide risk and intervening.Assessing past suicide attempts in adults can help with managing positive screens.

Self-reported Symptoms of Anxiety Predict Positive Suicide Risk Screening in Adolescents Presenting to the Emergency Department.

OBJECTIVE: The objective of this study was to assess whether patient-reported anxiety symptoms are associated with suicide risk in pediatric emergency department (ED) patients. An additional objective was to examine differences between patients presenting for medical/surgical or psychiatric complaints. METHODS: Pediatric patients aged 10 to 21 years were recruited from 3 pediatric EDs. Participants completed self-report questionnaires assessing for suicidal ideation and behavior, in addition to questions of interest about recent feelings of unbearable anxiety and depression. Adjusted odds ratios were calculated to assess the relationship between endorsement of recent anxiety and screening positive for suicide risk. RESULTS: Data were analyzed from 522 participants, including 344 presenting with medical/surgical chief complaints and 178 presenting with psychiatric complaints. Overall, 28.9% of participants screened positive for suicide risk, 29.9% endorsed recent feelings of anxiety, and 24.3% endorsed recent feelings of depression. Patients who self-reported recent anxiety symptoms were 5 times more likely to screen positive for suicide risk (adjusted odds ratios = 5.18, 95% confidence interval = 3.06-8.76). Analysis of the 344 medical/surgical patients revealed that this subsample was also 5 times more likely to screen positive for suicide risk if they endorsed recent anxiety (adjusted odds ratios = 4.87, 95% confidence interval = 2.09-11.36). CONCLUSIONS: Self-reported suicidal ideation and feelings of unbearable anxiety are prevalent among patients presenting to pediatric EDs. Patients who self-report recent feelings of unbearable anxiety are significantly more likely to screen positive for suicide risk, regardless of whether their presenting complaint is medical/surgical or psychiatric in nature.

Limitations of Screening for Depression as a Proxy for Suicide Risk in Adult Medical Inpatients.

BACKGROUND: Medically ill hospitalized patients are at elevated risk for suicide. Hospitals that already screen for depression often use depression screening as a proxy for suicide risk screening. Extant research has indicated that screening for depression may not be sufficient to identify all patients at risk for suicide. OBJECTIVE: The present study aims to determine the effectiveness of a depression screening tool, the Patient Health Questionnaire-9, in detecting suicide risk among adult medical inpatients. METHODS: Participants were recruited from inpatient medical/surgical units in 4 hospitals as part of a larger validation study. Participants completed the Patient Health Questionnaire-9 and 2 suicide risk measures: the Ask Suicide-Screening Questions and the Adult Suicidal Ideation Questionnaire. RESULTS: The sample consisted of 727 adult medical inpatients (53.4% men; 61.8% white; mean age 50.1 ± 16.3 years). A total of 116 participants (116 of 727 [16.0%]) screened positive for suicide risk and 175 (175 of 727 [24.1%]) screened positive for depression. Of the 116 patients who screened positive for suicide risk, 36 (31.0%) screened negative for depression on the Patient Health Questionnaire-9. Of 116, 73 (62.9%) individuals who were at risk for suicide did not endorse item 9 (thoughts of harming oneself or of being better off dead) on the Patient Health Questionnaire-9. CONCLUSION: Using depression screening tools as a proxy for suicide risk may be insufficient to detect adult medical inpatients at risk for suicide. Asking directly about suicide risk and using validated tools is necessary to effectively and efficiently screen for suicide risk in this population.

Screening Pediatric Medical Patients for Suicide Risk: Is Depression Screening Enough?

PURPOSE: Medically ill youth are at increased risk for suicide. For convenience, hospitals may screen for suicide risk using depression screening instruments, though this practice might not be adequate to detect those at risk for suicide. This study aims to determine whether depression screening can detect suicide risk in pediatric medical inpatients who screen positive on suicide-specific measures. METHODS: A convenience sample of medical inpatients ages 10-21 years were recruited as part of a larger instrument validation study. Participants completed the Ask Suicide-Screening Questions, the Suicidal Ideation Questionnaire/Suicidal Ideation Questionnaire-Junior, and the Patient Health Questionnaire-Adolescent Version (PHQ-A). Univariate and multivariate statistics were calculated to examine the relationship between screening positive for depression and suicide risk. RESULTS: The sample consisted of 600 medical inpatients (59.2% female; 55.2% white; mean age 15.2 ± 2.84 years). Of participants who screened positive for suicide risk (13.5%; 81/600), 39.5% (32/81) did not screen positive for depression, and more than half (45/81) did not endorse PHQ-A item 9, which queries for thoughts of harming oneself or being better off dead. Twenty-six participants (32%) who screened negative for depression and on PHQ-A item nine were at risk for suicide. CONCLUSIONS: In this sample, depression screening alone failed to detect nearly a third of youth at risk for suicide. Although depression and suicide risk are strongly related, a significant portion of pediatric medical inpatients at risk for suicide may pass through the healthcare system unrecognized if depression screening is used as a proxy for identifying suicide risk.

Integrated care to address child and adolescent health in the 21st century: A clinical review.

Background: Increasing specialisation and technical sophistication of medical tools across the 21st century have contributed to dramatic improvements in the life-expectancy of children and adolescents with complex physical health problems. Concurrently, there is growing appreciation within the community of the extent that children and adolescents experience mental disorders, which are more prevalent in those with complex chronic, serious or life-limiting health conditions. In this context, there are compelling reasons for paediatric services to move to a model of care that promotes greater integration of child psychiatry within the medical, somatic teams that care for children and adolescents in children's hospitals. Aims: In this article, we discuss the range of medical disorders managed by contemporary paediatrics. Materials and Methods: We conducted a broad review of the literature and existing services, and use individual accounts to illustrate adolescents' healthcare preferences in the context of the challenges they experience around their mental health. Results: Relevant disorders include life-limiting disorders, such as cancer; disorders involving the brain, such as epilepsy; common chronic disorders, such as asthma and diabetes; psychiatric emergencies, such as deliberate self-harm; and conditions that most commonly present to paediatric services, but where psychiatric input is required, such as severe eating disorders, somatic symptom disorders and gender dysphoria. The persisting legacy of the historical separation of physical and mental health services is described. Yet there are many models of service integration that can promote more collaborative care between psychiatrists and medical specialists, including some which have been taken to scale. Discussion: In essence, clinical teams in children's hospitals require more collaborative approaches that facilitate early recognition and treatment of the psychological aspects of illness as an integral part of patient-centred, family-focussed paediatric care, rather than as something that is bolted on when things go wrong. Conclusion: Whilst trust and goodwill between services and providers will be required for novel models of care to be implemented, evaluation of these new models and incorporation of young people's healthcare preferences is needed.

The acceptability of screening for suicide risk among youth in outpatient medical settings: Child and parent perspectives.

OBJECTIVE: Psychosocial providers in medical settings are increasingly being asked to identify suicide risk in youth with medical illnesses. This pilot study aimed to determine the acceptability of suicide risk screening among youth with cancer and other serious illnesses and their parents. METHODS: Youth ages 8-21 years presenting to an outpatient medical setting were screened for suicide risk using a modified version of the Ask Suicide-Screening Questions (ASQ) screening tool. Patient and parent perceptions of acceptability were collected. FINDINGS: The sample included 32 patient/parent dyads. The overall positive screen rate was 9.4% (n = 3/32). Most patients (75%; n = 24/32) and parents (84.4%; n = 27/32) reported that medical settings should screen young patients for suicide risk. CONCLUSIONS: Suicide risk screening was acceptable to most patients and parents in a pediatric clinic. IMPLICATIONS FOR PSYCHOSOCIAL PROVIDERS: Medically ill patients are at risk for suicide. Universal suicide risk screening using a validated measure can provide meaningful clinical information to patients' families and providers and has the potential to save young lives.

Validation and Feasibility of the ASQ Among Pediatric Medical and Surgical Inpatients.

OBJECTIVES: To validate the use of a brief suicide risk screening tool, the Ask Suicide-Screening Questions (ASQ) instrument, in pediatric inpatient medical and surgical settings. METHODS: Pediatric patients (10-21 years) hospitalized on inpatient medical and surgical units were recruited through convenience sampling for participation in a cross-sectional instrument validation study. The Suicidal Ideation Questionnaire was used as a standard criterion to validate the ASQ. Patient opinions about screening and parent consent to enroll in a suicide risk screening study were assessed to determine the feasibility of administering the ASQ in this venue. RESULTS: A total of 600 pediatric medical inpatients were screened. Compared with the gold standard, the ASQ had strong psychometric properties, with a sensitivity of 96.67% (95% confidence interval [CI]: 82.78 to 99.92), a specificity of 91.05% (95% CI: 88.40 to 93.27), a negative predictive value of 99.81% (95% CI: 98.93 to 99.99), and an area under curve of 0.94 (95% CI: 0.90 to 0.97). Only 3 participants (0.5%) had acute positive screen results on the ASQ, endorsing current suicidal ideation, whereas 77 participants (12.8%) screened nonacute positive, and 48 participants (8.0%) reported a past suicide attempt. CONCLUSIONS: The brief 4-item ASQ is a valid tool to detect elevated suicide risk in pediatric medical and surgical inpatients. Our findings also reveal that screening is feasible in terms of detection of suicidal thoughts and behaviors and is acceptable to parents and patients.

Validation of the Ask Suicide-Screening Questions for Adult Medical Inpatients: A Brief Tool for All Ages.

BACKGROUND: Few brief suicide risk screening instruments are validated for use in both adult and pediatric medical populations. Using the pediatric Ask Suicide-Screening Questions (ASQ) development study as a model, this study aimed to determine whether the ASQ is a valid suicide risk-screening instrument for use among adults medical patients, as well as to evaluate a set of other potential screening questions for use in adults. METHODS: Adult patients hospitalized on inpatient medical/surgical units from 4 hospitals were recruited to participate in a cross-sectional instrument-validation study. The 4-item ASQ and other candidate items were compared against the 25-item, previously validated Adult Suicidal Ideation Questionnaire as the criterion standard. RESULTS: A total of 727 adult medical inpatients completed the screening process. Compared with the Adult Suicidal Ideation Questionnaire, the ASQ performed best among the full set of candidate items, demonstrating strong psychometric properties, with a sensitivity of 100% (95% confidence interval = 90%-100%), a specificity of 89% (95% confidence interval = 86%-91%), and a negative predictive value of 100% (95% confidence interval = 99%-100%). A total of 4.8% (35/727) of the participants screened positive for suicide risk based on the standard criterion Adult Suicidal Ideation Questionnaire. CONCLUSIONS: The ASQ is a valid and brief suicide risk-screening tool for use among adults. Screening medical/surgical inpatients for suicide risk can be performed effectively for both adult and pediatric patients using this brief, primary screener.

From Pilot to Practice: Implementation of a Suicide Risk Screening Program in Hospitalized Medical Patients.

INTRODUCTION: Hospitals have become an important venue for identifying medical patients with occult suicidality. This article describes the implementation of a quality improvement project at the National Institutes of Health Clinical Center (NIHCC) to systematically screen medical/surgical inpatients for suicide risk. METHODS: Using the Plan-Do-Study-Act method, questions from the Ask Suicide-Screening Questions (ASQ) tool were deployed with medical inpatients aged 10 years and older between April 2018 and April 2019. Goals included the development of a training program, policy and procedure review, electronic medical record integration and data collection, and ongoing management and troubleshooting. RESULTS: A total of 4,284 patients were screened for suicide risk with a nurse screening compliance rate of 94.3%. Prevalence data on patients aged 10 years and older revealed an overall screen positive rate of 2.3% (97/4,284), with 3.1% of youth aged 10 to 24 years and 2.2% of adults screening positive. Of the 97 patients who screened positive, 96 were non-acute positive screens. Of the full sample, only 1 patient (0.02%) was deemed acute positive, requiring a 1:1 observer and full safety precautions. CONCLUSION: Universal suicide risk screening was successfully implemented in the NIHCC without incurring a need for additional resources. The intermediate step of a brief suicide safety assessment is a critical part of the workflow, providing guidance for determining appropriate follow-up in a safe and efficient manner that spares limited mental health and hospital resources. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral.

Primary and Secondary Prevention of Youth Suicide.

Youth suicide is a national and global public health crisis. Pediatricians can use primary and secondary prevention strategies to intervene with youth before or after the onset of suicidal behaviors. Universal suicide risk screening programs can be used to identify youth in medical settings who may otherwise pass through the health care setting with undetected suicide risk. Pediatricians are uniquely positioned to help foster resilience in their young patients and equip families of at-risk youth with safety plans and lethal means safety counseling. Pediatricians on the frontlines of this critical public health crisis require education and training in detecting suicide risk, managing those who screen positive, and connecting their patients to much needed mental health interventions and treatments. Evidence-based suicide risk screening and assessment tools, paired with interventions, are feasible and potentially life-saving in the medical setting.

The Importance of Screening Preteens for Suicide Risk in the Emergency Department.

OBJECTIVES: To describe the prevalence of screening positive for suicide risk in a sample of 10- to 12-year-olds presenting to the emergency department (ED). METHODS: Patients presenting to the ED were administered a battery of measures, including the Ask Suicide-Screening Questions and the criterion-standard Suicidal Ideation Questionnaire. Answering affirmatively to any of the 4 Ask Suicide-Screening Questions and/or scoring above the Suicidal Ideation Questionnaire cutoff score was considered a positive screen result for suicide risk. RESULTS: The sample included 79 preteen patients. The overall positive screen result rate was 29.1% (23 of 79). More than half (54.1%) of patients presenting with psychiatric chief complaints screened positive for suicide risk, and 7.1% of preteens presenting with chief medical complaints screened positive. Of preteens, 17.7% (14 of 79) reported previous suicidal behavior. CONCLUSIONS: Preteens think about suicide and engage in suicidal behavior at rates that warrant further study. Notably, 7% of preteens presenting with chief medical complaints screened positive, highlighting the importance of screening all preteen patients as young as 10 years old for suicide risk in the ED.

Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis.

BACKGROUND: Youth suicide is on the rise worldwide. Most suicide decedents received healthcare services in the year before killing themselves. Standardized workflows for suicide risk screening in pediatric hospitals using validated tools can help with timely and appropriate intervention, while attending to The Joint Commission Sentinel Event Alert 56. OBJECTIVE: Here we describe the first attempt to generate clinical pathways for patients presenting to pediatric emergency departments (EDs) and inpatient medical settings. METHODS: The workgroup reviewed available evidence and generated a series of steps to be taken to feasibly screen medical patients presenting to hospitals. When evidence was limited, expert consensus was used. A standardized, iterative approach was utilized to create clinical pathways. Stakeholders reviewed initial drafts. Feedback was incorporated into the final pathway. RESULTS: Clinical pathways were created for suicide risk screening in pediatric EDs and inpatient medical/surgical units. The pathway outlines a 3-tiered screening process utilizing the Ask Suicide-Screening Questions for initial screening, followed by a brief suicide safety assessment to determine if a full suicide risk assessment is warranted. This essential step helps conserve resources and decide upon appropriate interventions for each patient who screens positive. Detailed implementation guidelines along with scripts for provider training are included. CONCLUSION: Youth suicide is a significant public health problem. Clinical pathways can empower hospital systems by providing a guide for feasible and effective suicide risk-screening implementation by using validated tools to identify patients at risk and apply appropriate interventions for those who screen positive. Outcomes assessment is essential to inform future iterations.

"Will You Remember Me?": Talking with Adolescents About Death and Dying.

This article describes the preparation, rationale, and benefits of talking with adolescents who have life-threatening or life-limiting illness about advance care planning (ACP) and end-of-life concerns in a developmentally sensitive manner. The first step is to ensure that a health care provider is ready to work with adolescents in ACP discussions by taking a self-inventory, learning communication skills, and understanding individual barriers. The authors then outline how to assess patient and family readiness, including developmental, cultural, personal, and psychosocial considerations. Evidence-based techniques for respectfully and productively engaging adolescents in ACP conversations are discussed.

Complex phenotype of dyskeratosis congenita and mood dysregulation with novel homozygous RTEL1 and TPH1 variants.

Dyskeratosis congenita (DC) is an inherited bone marrow failure syndrome caused by germline mutations in telomere biology genes. Patients have extremely short telomeres for their age and a complex phenotype including oral leukoplakia, abnormal skin pigmentation, and dysplastic nails in addition to bone marrow failure, pulmonary fibrosis, stenosis of the esophagus, lacrimal ducts and urethra, developmental anomalies, and high risk of cancer. We evaluated a patient with features of DC, mood dysregulation, diabetes, and lack of pubertal development. Family history was not available but genome-wide genotyping was consistent with consanguinity. Whole exome sequencing identified 82 variants of interest in 80 genes based on the following criteria: homozygous, <0.1% minor allele frequency in public and in-house databases, nonsynonymous, and predicted deleterious by multiple in silico prediction programs. Six genes were identified likely contributory to the clinical presentation. The cause of DC is likely due to homozygous splice site variants in regulator of telomere elongation helicase 1, a known DC and telomere biology gene. A homozygous, missense variant in tryptophan hydroxylase 1 may be clinically important as this gene encodes the rate limiting step in serotonin biosynthesis, a biologic pathway connected with mood disorders. Four additional genes (SCN4A, LRP4, GDAP1L1, and SPTBN5) had rare, missense homozygous variants that we speculate may contribute to portions of the clinical phenotype. This case illustrates the value of conducting detailed clinical and genomic evaluations on rare patients in order to identify new areas of research into the functional consequences of rare variants and their contribution to human disease.