Beyond clinical outcomes: Case control study of the role of race in disruptive life events for people with serious mental illness.

OBJECTIVE: To understand how race and serious mental illness (SMI) interact for disruptive life events defined as financial (bankruptcy and judgement filings), and non-financial (arrests). METHODS: Patients were adults with schizophrenia (SCZ; N = 16,159) or bipolar I disorder (BPI; N = 30,008) matched 1:1 to patients without SMI (non-SMI) from health systems in Michigan and Southern California during 1/1/2007 through 12/31/2018. The main exposure was self-reported race, and the outcome was disruptive life events aggregated by Transunion. We hypothesized that Black patients with SCZ or BPI would be the most likely to experience a disruptive life event when compared to Black patients without SMI, and all White or Asian patients regardless of mental illness. RESULTS: Black patients with SCZ had the least likelihood (37% lower) and Asian patients with BPI had the greatest likelihood (2.25 times higher) of experiencing a financial disruptive life event among all patients in the study. There was no interaction of race with either SCZ or BPI for experiencing an arrest. The findings did not support our hypotheses for patients with SCZ and partially supported them for patients with BPI. CONCLUSIONS: Clinical initiatives to assess social determinants of health should consider a focus on Asian patients with BPI.

Association Between Adverse Social Determinants of Health and Suicide Death.

OBJECTIVE: The aim of this study was to identify adverse social determinants of health (SDoH) International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code prevalence among individuals who died by suicide and to examine associations between documented adverse SDoH and suicide. RESEARCH DESIGN: A case-control study using linked medical record, insurance claim, and mortality data from 2000 to 2015 obtained from 9 Mental Health Research Network-affiliated health systems. We included 3330 individuals who died by suicide and 333,000 randomly selected controls matched on index year and health system location. All individuals in the study (cases and controls) had at least 10 months of enrollment before the study index date. The index date for the study for each case and their matched controls was the suicide date for that given case. RESULTS: Adverse SDoH documentation was low; only 6.6% of cases had ≥1 documented adverse SDoH in the year before suicide. Any documented SDoH and several specific adverse SDoH categories were more frequent among cases than controls. Any documented adverse SDoH was associated with higher suicide odds [adjusted odds ratio (aOR)=2.76; 95% CI: 2.38-3.20], as was family alcoholism/drug addiction (aOR=18.23; 95% CI: 8.54-38.92), being an abuse victim/perpetrator (aOR=2.53; 95% CI: 1.99-3.21), other primary support group problems (aOR=1.91; 95% CI: 1.32-2.75), employment/occupational maladjustment problems (aOR=8.83; 95% CI: 5.62-13.87), housing/economic problems (aOR: 6.41; 95% CI: 4.47-9.19), legal problems (aOR=27.30; 95% CI: 12.35-60.33), and other psychosocial problems (aOR=2.58; 95% CI: 1.98-3.36). CONCLUSIONS: Although documented SDoH prevalence was low, several adverse SDoH were associated with increased suicide odds, supporting calls to increase SDoH documentation in medical records. This will improve understanding of SDoH prevalence and assist in identification and intervention among individuals at high suicide risk.

Assessment of Disruptive Life Events for Individuals Diagnosed With Schizophrenia or Bipolar I Disorder Using Data From a Consumer Credit Reporting Agency.

Importance: There is a dearth of population-level data on major disruptive life events (defined here as arrests by a legal authority, address changes, bankruptcy, lien, and judgment filings) for patients with bipolar I disorder (BPI) or schizophrenia, which has limited studies on mental health and treatment outcomes. Objective: To conduct a population-level study on disruptive life events by using publicly available data on disruptive life events, aggregated by a consumer credit reporting agency in conjunction with electronic health record (EHR) data. Design, Setting, and Participants: This study used EHR data from 2 large, integrated health care systems, Kaiser Permanente Southern California and Henry Ford Health. Cohorts of patients diagnosed from 2007 to 2019 with BPI or schizophrenia were matched 1:1 by age at analysis, age at diagnosis (if applicable), sex, race and ethnicity, and Medicaid status to (1) an active comparison group with diagnoses of major depressive disorder (MDD) and (2) a general health (GH) cohort without diagnoses of BPI, schizophrenia, or MDD. Patients with diagnoses of BPI or schizophrenia and their respective comparison cohorts were matched to public records data aggregated by a consumer credit reporting agency (98% match rate). Analysis took place between November 2020 and December 2022. Main Outcomes and Measures: The differences in the occurrence of disruptive life events among patients with BPI or schizophrenia and their comparison groups. Results: Of 46 167 patients, 30 008 (65%) had BPI (mean [SD] age, 42.6 [14.2] years) and 16 159 (35%) had schizophrenia (mean [SD], 41.4 [15.1] years). The majoriy of patients were White (30 167 [65%]). In addition, 18 500 patients with BPI (62%) and 6552 patients with schizophrenia (41%) were female. Patients with BPI were more likely to change addresses than patients in either comparison cohort (with the incidence ratio being as high as 1.25 [95% CI, 1.23-1.28]) when compared with GH cohort. Patients with BPI were also more likely to experience any of the financial disruptive life events with odds ratio ranging from 1.15 [95% CI, 1.07-1.24] to 1.50 [95% CI, 1.42-1.58]). The largest differences in disruptive life events were seen in arrests of patients with either BPI or schizophrenia compared with GH peers (3.27 [95% CI, 2.84-3.78] and 3.04 [95% CI, 2.57-3.59], respectively). Patients with schizophrenia had fewer address changes and were less likely to experience a financial event than their matched comparison cohorts. Conclusions and Relevance: This study demonstrated that data aggregated by a consumer credit reporting agency can support population-level studies on disruptive life events among patients with BPI or schizophrenia.

Assessing the differential item functioning of PHQ-9 items for diverse racial and ethnic adults with mental health and/or substance use disorder diagnoses: A retrospective cohort study.

BACKGROUND: Improving health equity in depression care and suicide screening requires that measures like the Patient Health Questionnaire 9 (PHQ-9) function similarly for diverse racial and ethnic groups. We evaluated PHQ-9 differential item functioning (DIF) between racial/ethnic groups in a retrospective cohort study of secondary electronic health record (EHR) data from eight healthcare systems. METHODS: The population (n = 755,156) included patients aged 18-64 with mental health and/or substance use disorder (SUD) diagnoses who had a PHQ-9 with no missing item data in the EHR for primary care or mental health visits between 1/1/2009-9/30/2017. We drew two random samples of 1000 from the following racial/ethnic groups originally recorded in EHRs (n = 14,000): Hispanic, and non-Hispanic White, Black, Asian, American Indian/Alaska Native, Native Hawaiian/Other Pacific Islander, multiracial. We assessed DIF using iterative hybrid ordinal logistic regression and item response theory with p < 0.01 and 1000 Monte Carlo simulations, where change in model R2 > 0.01 represented non-negligible (e.g., clinically meaningful) DIF. RESULTS: All PHQ-9 items displayed statistically significant, but negligible (e.g., clinically unmeaningful) DIF between compared groups. The negligible DIF varied between random samples, although six items showed negligible DIF between the same comparison groups in both random samples. LIMITATIONS: Our findings may not generalize to disaggregated racial/ethnic groups or persons without mental health and/or SUD diagnoses. CONCLUSIONS: We found the PHQ-9 had clinically unmeaningful cross-cultural DIF for adult patients with mental health and/or SUD diagnoses. Future research could disaggregate race/ethnicity to discern if within-group identification impacts PHQ-9 DIF.

Detecting and distinguishing indicators of risk for suicide using clinical records.

Health systems are essential for suicide risk detection. Most efforts target people with mental health (MH) diagnoses, but this only represents half of the people who die by suicide. This study seeks to discover and validate health indicators of suicide death among those with, and without, MH diagnoses. This case-control study used statistical modeling with health record data on diagnoses, procedures, and encounters. The study included 3,195 individuals who died by suicide from 2000 to 2015 and 249,092 randomly selected matched controls, who were age 18+ and affiliated with nine Mental Health Research Network affiliated health systems. Of the 202 indicators studied, 170 (84%) were associated with suicide in the discovery cohort, with 148 (86%) of those in the validation cohort. Malignant cancer diagnoses were risk factors for suicide in those without MH diagnoses, and multiple individual psychiatric-related indicators were unique to the MH subgroup. Protective effects across MH-stratified models included diagnoses of benign neoplasms, respiratory infections, and utilization of reproductive services. MH-stratified latent class models validated five subgroups with distinct patterns of indicators in both those with and without MH. The highest risk groups were characterized via high utilization with multiple healthcare concerns in both groups. The lowest risk groups were characterized as predominantly young, female, and high utilizers of preventive services. Healthcare data include many indicators of suicide risk for those with and without MH diagnoses, which may be used to support the identification and understanding of risk as well as targeting of prevention in health systems.

Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation: A Randomized Clinical Trial.

Importance: People at risk of self-harm or suicidal behavior can be accurately identified, but effective prevention will require effective scalable interventions. Objective: To compare 2 low-intensity outreach programs with usual care for prevention of suicidal behavior among outpatients who report recent frequent suicidal thoughts. Design, Setting, and Participants: Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020. Interventions: Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care. Main Outcomes and Measures: The primary outcome was time to first nonfatal or fatal self-harm. Nonfatal self-harm was ascertained from health system records, and fatal self-harm was ascertained from state mortality data. Secondary outcomes included more severe self-harm (leading to death or hospitalization) and a broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm). Results: A total of 18 644 patients (9009 [48%] aged 45 years or older; 12 543 [67%] female; 9222 [50%] from mental health specialty clinics and the remainder from primary care) contributed at least 1 day of follow-up data and were included in analyses. Thirty-one percent of participants offered care management and 39% offered skills training actively engaged in intervention programs. A total of 540 participants had a self-harm event (including 45 deaths attributed to self-harm and 495 nonfatal self-harm events) over 18 months following randomization: 172 (3.27%) in care management, 206 (3.92%) in skills training, and 162 (3.27%) in usual care. Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07; 97.5% CI, 0.84-1.37) but was significantly higher in the skills training group than in usual care (HR, 1.29; 97.5% CI, 1.02-1.64). For severe self-harm, care management vs usual care had an HR of 1.03 (97.5% CI, 0.71-1.51); skills training vs usual care had an HR of 1.34 (97.5% CI, 0.94-1.91). For the broader self-harm definition, care management vs usual care had an HR of 1.10 (97.5% CI, 0.92-1.33); skills training vs usual care had an HR of 1.17 (97.5% CI, 0.97-1.41). Conclusions and Relevance: Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce risk of self-harm, and offering brief dialectical behavior therapy skills training significantly increased risk of self-harm, compared with usual care. These findings do not support implementation of the programs tested in this study. Trial Registration: ClinicalTrials.gov Identifier: NCT02326883.

Predicting Suicide Attempts for Racial and Ethnic Groups of Patients During Routine Clinical Care.

The aim of this study was to examine variation in suicide ideation and its relationship to risk of suicide attempt in the subsequent 90 days by race and ethnicity. Participants were adults who completed the Patient Health Questionnaire depression module (PHQ9) during an outpatient encounter between January 10, 2010, and December 12, 2012 (N = 509,945 patients; N = 1,228,308 completed PHQ9). Data came from the Virtual Data Warehouse from four health care systems in the Mental Health Research Network. The sample was majority female (73.7%), primarily 30-64 years old (60.1%), healthy (64.5% comorbidity index = 0), and over half were non-Hispanic White (52.9%). Only Asian patients (OR: 1.31; 95% CI: 1.24, 1.39) had higher odds of reporting suicide ideation when compared to non-Hispanic White people. All racial and ethnic groups had increased risk for suicide attempt with increased frequency of suicide ideation. The PHQ9 item 9 can be used as an indicator of suicide ideation and risk for suicide attempt up to 90 days after the reported ideation in racial and ethnic minority patients during routine clinical care.

Does Patient Adherence to Antidepressant Medication Actually Vary Between Physicians?

OBJECTIVE: Previous research and improvement efforts have presumed that patients' nonadherence to antidepressant medication reflects physicians' quality of care. We used population-based health records to examine whether adherence to antidepressant medication actually varies between prescribing physicians. METHODS: Electronic health records and insurance claims data from 5 integrated health systems in Washington, Idaho, Minnesota, Colorado, Hawaii, and California were used to identify 150,318 adults starting new episodes of antidepressant treatment for depression between January 1, 2010, and December 31, 2012. Early adherence was defined as any refill or dispensing of antidepressant medication in the 180 days following an initial antidepressant prescription. Patient-level demographic and clinical characteristics potentially associated with adherence were identified from health system records. RESULTS: Average probability of early adherence was 82% for psychiatrists and 74% for primary care physicians. Among individual physicians, the range of raw or unadjusted early adherence rates (5th to 95th percentiles) was from 33% to 100% for psychiatrists and from 0% to 100% for primary care physicians. After accounting for sampling variation and case mix differences, the range of adjusted early adherence rates (5th to 95th percentiles) was from 72% to 78% for psychiatrists and from 64% to 69% for primary care physicians. CONCLUSIONS: After accounting for sampling variation and case mix differences, early adherence to antidepressant medication varies minimally among prescribing physicians. Early discontinuation of antidepressant treatment is not an appropriate measure of individual physician performance, and efforts to improve adherence should emphasize system-level interventions rather than the performance of individual physicians.

Major Physical Health Conditions and Risk of Suicide.

INTRODUCTION: Most individuals make healthcare visits before suicide, but many do not have a diagnosed mental health condition. This study seeks to investigate suicide risk among patients with a range of physical health conditions in a U.S. general population sample and whether risk persists after adjustment for mental health and substance use diagnoses. METHODS: This study included 2,674 individuals who died by suicide between 2000 and 2013 along with 267,400 controls matched on year and location in a case-control study conducted in 2016 across eight Mental Health Research Network healthcare systems. A total of 19 physical health conditions were identified using diagnostic codes within the healthcare systems' Virtual Data Warehouse, including electronic health record and insurance claims data, during the year before index date. RESULTS: Seventeen physical health conditions were associated with increased suicide risk after adjustment for age and sex (p<0.001); nine associations persisted after additional adjustment for mental health and substance use diagnoses. Three conditions had a more than twofold increased suicide risk: traumatic brain injury (AOR=8.80, p<0.001); sleep disorders; and HIV/AIDS. Multimorbidity was present in 38% of cases versus 15.5% of controls, and represented nearly a twofold increased risk for suicide. CONCLUSIONS: Although several individual conditions, for example, traumatic brain injury, were associated with high risk of suicide, nearly all physical health conditions increased suicide risk, even after adjustment for potential confounders. In addition, having multiple physical health conditions increased suicide risk substantially. These data support suicide prevention based on the overall burden of physical health.

Racial/Ethnic differences in health care visits made before suicide attempt across the United States.

BACKGROUND: Suicide is a public health concern, but little is known about the patterns of health care visits made before a suicide attempt, and whether those patterns differ by race/ethnicity. OBJECTIVES: To examine racial/ethnic variation in the types of health care visits made before a suicide attempt, when those visits occur, and whether mental health or substance use diagnoses were documented. RESEARCH DESIGN: Retrospective, longitudinal study, 2009-2011. PARTICIPANTS: 22,387 individuals who attempted suicide and were enrolled in the health plan across 10 health systems in the Mental Health Research Network. MEASURES: Cumulative percentage of different types of health care visits made in the 52 weeks before a suicide attempt, by self-reported racial/ethnicity and diagnosis. Data were from the Virtual Data Warehouse at each site. RESULTS: Over 38% of the individuals made any health care visit within the week before their suicide attempt and ∼95% within the preceding year; these percentages varied across racial/ethnic groups (P<0.001). White individuals had the highest percentage of visits (>41%) within 1 week of suicide attempt. Asian Americans were the least likely to make visits within 52 weeks. Hawaiian/Pacific Islanders had proportionally the most inpatient and emergency visits before an attempt, but were least likely to have a recorded mental health or substance use diagnosis. Overall, visits were most common in primary care and outpatient general medical settings. CONCLUSIONS: This study provides temporal evidence of racial/ethnic differences in health care visits made before suicide attempt. Health care systems can use this information to help focus the design and implementation of their suicide prevention initiatives.

Use of antipsychotic medications in pediatric populations: what do the data say?

Recent reports of antipsychotic medication use in pediatric populations describe large increases in rates of use. Much interest in the increasing use has focused on potentially inappropriate prescribing for non-Food and Drug Administration-approved uses and use amongst youth with no mental health diagnosis. Different studies of antipsychotic use have used different time periods, geographic and insurance populations of youth, and aggregations of diagnoses. We review recent estimates of use and comment on the similarities and dissimilarities in rates of use. We also report new data obtained on 11 health maintenance organizations that are members of the Mental Health Research Network in order to update and extend the knowledge base on use by diagnostic indication. Results indicate that most use in pediatric populations is for disruptive behaviors and not psychotic disorders. Differences in estimates are likely a function of differences in methodology; however, there is remarkable consistency in estimates of use by diagnosis.

The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics.

BACKGROUND: The many randomized trials of the collaborative care model for improving depression in primary care have not described the implementation and maintenance of this model. This paper reports how and the degree to which collaborative care process changes were implemented and maintained for the 75 primary care clinics participating in the DIAMOND Initiative (Depression Improvement Across Minnesota-Offering a New Direction). METHODS: Each clinic was trained to implement seven components of the model and participated in ongoing evaluation and facilitation activities. For this study, assessment of clinical process implementation was accomplished via completion of surveys by the physician leader and clinic manager of each clinic site at three points in time. The physician leader of each clinic completed a survey measure of the presence of various practice systems prior to and one and two years after implementation. Clinic managers also completed a survey of organizational readiness and the strategies used for implementation. RESULTS: Survey response rates were 96% to 100%. The systems survey confirmed a very high degree of implementation (with large variation) of DIAMOND depression practice systems (mean of 24.4 ± 14.6%) present at baseline, 57.0 ± 21.0% at one year (P = <0.0001), and 55.9 ± 21.3% at two years. There was a similarly large increase (and variation) in the use of various quality improvement strategies for depression (mean of 29.6 ± 28.1% at baseline, 75.1 ± 22.3% at one year (P = <0.0001), and 74.6 ± 23.0% at two years. CONCLUSIONS: This study demonstrates that under the right circumstances, primary care clinics that are prepared to implement evidence-based care can do so if financial barriers are reduced, effective training and facilitation are provided, and the new design introduces the specific mental models, new care processes, and workers and expertise that are needed. Implementation was associated with a marked increase in the number of improvement strategies used, but actual care and outcomes data are needed to associate these changes with patient outcomes and patient-reported care.