Temporal Patterns of Suicidality Among Adolescents Receiving Behavioral and Mental Health Services in the Community: A Survival Analysis.

Adolescent suicide is a major public health concern, particularly among adolescents who have endured Adverse Childhood Experiences (ACEs). Adolescents who have been exposed to multiple ACEs are as much as three times more likely to present with suicidality compared to the general adolescent population. Adolescents who have been exposed to multiple ACEs are also more likely to receive behavioral and mental health services in the community. It is therefore important to understand patterns of suicidality among this sub-population of adolescents in order to provide the best clinical care. The present study examined the temporal patterns of suicidality among adolescents who have been exposed to multiple ACEs and are receiving behavioral and mental health services in the community. Using Electronic Health Record (EHR) data from a community-based behavioral and mental health care organization, an exploratory survival analysis was conducted on time to suicidal thoughts and behaviors (STBs) after suicidality risk screen at intake. Average time from suicidality risk screen at intake to STB was 185 days (6.2 months). Youth who screened negative for suicidality risk at intake had a longer survival time than youth who screened positive for suicidality risk, and the survival distributions between the two groups was significant. Predictors of STBs were also examined, with gender being a significant predictor of an STB occurring during the follow-up period. These findings may be used to guide suicidality screening and clinical practice at community-based behavioral and mental health care organizations serving adolescents who have been exposed to multiple ACEs.

Correlates for Suicidality Among At-risk Youth Receiving Community-Based Mental Health Services.

"At-risk" adolescents are at high risk of unsuccessfully transitioning into adulthood and are also at elevated risk for suicidal behavior. Though much research has been conducted on risk factors for suicidality among the general adolescent population, research on suicidality among "at-risk" adolescents is lacking. This is a notable gap in the literature given that "at-risk" adolescents may be three times more likely to exhibit suicidality. The present study addressed this research gap by examining correlates for suicidality among "at-risk" adolescents receiving mental health services in the community. Using Electronic Health Record (EHR) data, risk factors for suicidality were analyzed at the bivariate and multivariate levels. Sexual abuse was a significant predictor of suicidality, as well as impulsivity for suicide attempt only. These findings may serve as useful adjuncts in the design of suicidality-screening tools and follow-up practices within the context of community-based mental health organizations which target at-risk adolescents.

Using Patient Flow Analysis to Streamline Intakes at a Community Mental Health Clinic.

This case study reports on a quality improvement strategy used by a community mental health clinic (CMHC) to improve the intake process at the clinic. Patient Flow Analysis (PFA) was used to assess outpatient intakes, identify possible areas of improvement, and test an intervention to improve the intake process. At baseline, the mean time to complete intakes for 22 clients was 106.9 min. Using these data, an intervention was designed to reduce the mean intake time, with a target time of 90 min. Post-intervention data revealed that the mean time to complete intakes decreased to 94.5 min for 28 clients. Patient Flow Analysis is a cost-effective way to assess current processes and identify areas of improvement in the intake flow at CMHCs. The present study used PFA in a CMHC to improve the intake process and saw favorable results from this quality improvement initiative.

Suicide attempts and behavioral correlates among a nationally representative sample of school-attending adolescents in the Republic of Malawi.

BACKGROUND: Suicide is among the top causes of adolescent mortality worldwide. While correlates of suicidal behavior are better understood and delineated in upper-income countries, epidemiologic knowledge of suicidal behavior in low-income countries remains scant, particularly in the African continent. The present study sought to add to the epidemiologic literature on suicidal behavior in Africa by examining the behavioral correlates of suicide attempts among Malawi adolescents. METHODS: A cross-sectional study using a nationally-representative sample extracted from publically-available data was conducted. Bivariate and multivariate analyses were performed to discern associations between suicide attempts and a host of behavioral variables. 2225 records were included in the study. RESULTS: At the multivariate level, suicide attempters had significantly higher odds of being anxious, being physically bullied, having sustained a serious injury and having a greater number of lifetime sexual partners. Alcohol use (at an early age and within the past 30 days) was also associated with suicide attempts. CONCLUSIONS: These findings have the potential to guide public health interventions geared toward suicide prevention in Africa and other, similar regions, as well as provide the impetus for future epidemiologic studies on suicidal behavior in low-income countries.

Mental health services for children of substance abusing parents: voices from the community.

This qualitative study explores how to improve services for children of parents with Substance Use Disorders (SUD) with unmet mental health needs. Focus groups were conducted with parents and caregivers to identify perceived barriers to services, including: (1) attitudes and beliefs about mental health care, (2) inadequacies in mental health services, (3) children's ambivalence about treatment, and (4) parental disagreement and lack of involvement. Peer support, afterschool activities, and family counseling were identified as potential improvements. This information can serve as a foundation and guide to develop services for the underserved population of children and adolescents of substance abusing parents.

Legal, ethical, and wider implications of suicide risk detection systems in social media platforms.

Suicide remains a problem of public health importance worldwide. Cognizant of the emerging links between social media use and suicide, social media platforms, such as Facebook, have developed automated algorithms to detect suicidal behavior. While seemingly a well-intentioned adjunct to public health, there are several ethical and legal concerns to this approach. For example, the role of consent to use individual data in this manner has only been given cursory attention. Social media users may not even be aware that their social media posts, movements, and Internet searches are being analyzed by non-health professionals, who have the decision-making ability to involve law enforcement upon suspicion of potential self-harm. Failure to obtain such consent presents privacy risks and can lead to exposure and wider potential harms. We argue that Facebook's practices in this area should be subject to well-established protocols. These should resemble those utilized in the field of human subjects research, which upholds standardized, agreed-upon, and well-recognized ethical practices based on generations of precedent. Prior to collecting sensitive data from social media users, an ethical review process should be carried out. The fiduciary framework seems to resonate with the emergent roles and obligations of social media platforms to accept more responsibility for the content being shared.

Tobacco Use and Parental Monitoring-Observations from Three Diverse Island Nations-Cook Islands, Curaçao, and East Timor.

Tobacco use among adolescents is a global problem of public health importance. This study examined the profile of differences and similarities in adolescent tobacco use, and the role of parental monitoring activities among adolescents in three island nations of varying economic status: Cook Islands, Curaçao, and East Timor. Using nationally representative data we conducted regression modeling to determine the effect of four types of parental monitoring activities on tobacco use. Within a recall period of 30 days prior to being surveyed, 29.7% of students in East Timor, 21.6% in Cook Islands, and 13.1% in Curaçao reported having smoked cigarettes and/or used tobacco in other forms during 1 or more days during the preceding 30 days. Lower rates of parental monitoring as measured by four variables (parental understanding of problems and worries; knowing about how free time was being spent; going over things without approval; and checking to see if homework was done) were associated with higher percentages of adolescent tobacco use. Taken together the results underscore the need for increased parental involvement in programs which are designed to reduce tobacco use among adolescents.

Physical Fighting among School-Attending Adolescents in Pakistan: Associated Factors and Contextual Influences.

BACKGROUND: Adolescent physical fighting is a problem of public health importance, with varied consequences in the form of school absenteeism, injury, and, in some cases, death. Although research on risk and protective factors exists, most has been conducted in high-income countries. METHODS: The 2009 Pakistan Global School-based Health Survey (GSHS) data were used. Logistic regression models were used to determine the associations. Five independent variables were investigated at the individual level (anxiety, suicide planning, truancy, physical activity, and bullying victimization) and four independent variables at the social level (presence of supportive parental figures, presence of helpful peers, extent of social network, and food insecurity). RESULTS: Among adolescents in this study (N = 5177), 20% reported being involved in two or more physical fights, most of whom were males (79.9%). The factors associated with physical fighting were: being male (OR = 2.78); bullying victimization (OR = 3.14); truancy (OR = 1.63), loneliness (OR = 1.44); and suicidality, as evidenced by having a suicide plan (OR = 1.75). Having few close friends (0-2) as opposed to more (>3) was found to be protective against engaging in physical fighting. CONCLUSION: Risk factors for physical fighting among adolescents in South Asia seem to corroborate with previously-identified risk factors using samples in high-income countries, while protective factors seemed to differ. More research needs to be conducted to understand why certain factors do not have the same protective effect among South Asian adolescents. AIM: The aim of this study was to examine demographic and contextual factors associated with physical fighting among a nationally representative sample in a rapidly developing South Asian context.

Psychotherapy Alone and Combined With Medication as Treatments for Bipolar II Depression: A Randomized Controlled Trial.

OBJECTIVE: Bipolar II disorder (BP-II) is associated with marked morbidity and mortality. Quetiapine, the treatment with greatest evidence for efficacy in BP-II depression, is associated with metabolic burden. Psychotherapy, a treatment with few side effects, has not been systematically evaluated in BP-II. This study compared psychotherapy plus placebo to psychotherapy plus pharmacotherapy as treatments for BP-II depression. METHODS: From 2010 to 2015, unmedicated adults (n = 92) with DSM-IV-TR BP-II depression were randomly assigned to weekly sessions of Interpersonal and Social Rhythm Therapy (IPSRT) plus placebo or IPSRT plus quetiapine and followed for 20 weeks. RESULTS: For primary outcomes, IPSRT + quetiapine yielded significantly faster improvement on 17-item Hamilton Depression Rating Scale (F1,115.4 = 3.924, P = .048) and greater improvement on Young Mania Rating Scale (F58.5 = 4.242, P = .044) scores. Both groups, however, improved significantly over time with comparable response rates (≥ 50% reduction in depression scores): 67.4% (62/92) in the entire sample, with no between-group differences. Those randomly assigned to their preferred treatment were 4.5 times more likely to respond (OR = 4.48, 95% CI = 1.20-16.77, P = .026). IPSRT + quetiapine assignment was associated with significantly higher body mass index over time (F67.96 = 6.671, P = .012) and rates of dry mouth (79% v. 58%; χ² = 4.0, P = .046) and a trend toward more complaints of oversedation (100% vs 92%; χ² = 3.4, P = .063). CONCLUSIONS: IPSRT plus quetiapine resulted in greater symptomatic improvement but also more side effects than IPSRT alone. A subset of participants improved with IPSRT alone, although absence of an inactive comparator limits interpretation of this finding. Receipt of preferred treatment was associated with better outcomes. Harms, benefits, and preferences should be considered when recommending treatments for BP-II depression. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01133821.

Pediatric TBI in Finland: An examination of hospital discharges (1998-2012).

BACKGROUND: Traumatic brain injury constitutes a persistent health problem among pediatric populations worldwide and is often referred to as a silent epidemic. There remains a paucity of scientific exploration with regard to understanding the ecological risk profiles of well-defined populations. In Finland, the healthcare system covers all hospitals, provides uniform access to care and has a universal surveillance system that allows for epidemiological examination of a wide variety of health issues. The present study aims to clarify the incidence, type and geographical presentation of pediatric TBI in Finland. METHODS: We utilized the National Hospital Discharge Register (NHDR) to prospectively identify all new cases of TBI among persons aged 18 years or younger between 1998 and 2012. Incidence rates were computed as average annual rates per 100,000 person years (py). RESULTS: During the study period 1998-2012, 21,457 children and adolescents were hospitalized for TBI. The cumulative incidence rate for the entire period was 99/100,000. Males were approximatively 1.5 times more likely to have sustained a TBI and had consistently higher rates during each year under study. Concussions were the most common form of TBI (92.9/100,000 person years), with diffuse brain injuries being the second most common (8.7/100,000 py). Diagnostic trends differed markedly with southern Finland experiencing the lowest rates of TBI when adjusted for population size. CONCLUSIONS: TBI are serious and potentially disabling conditions. The elevated levels of pediatric TBI in Finland warrant increased attention.

Psychosocial Treatment of Bipolar Disorder: Clinician Knowledge, Common Approaches, and Barriers to Effective Treatment.

OBJECTIVE: Nonphysician mental health clinicians were surveyed to understand their knowledge about bipolar disorder, treatment approaches, and perceived barriers to optimal treatment. METHODS: Nonphysician mental health clinicians (N=55) from five community mental health clinics reported on their therapeutic approach, knowledge, and skill related to treatment of bipolar disorder. Chi square and t tests were used to detect differences in responses by clinician characteristics. RESULTS: Most clinicians wished to improve their treatment for bipolar disorder. They felt best prepared to provide counseling and least prepared to identify medication side effects. Among psychotherapies, CBT was the most familiar to clinicians. Although knowledgeable overall about bipolar disorder, the clinicians were less knowledgeable about pharmacotherapy. The most commonly reported treatment barrier was comorbid substance use disorders. CONCLUSIONS: Clinicians would benefit from additional training in effective therapeutic approaches for bipolar disorder as well as information about pharmacotherapy and supporting individuals with comorbid substance use problems.

Implementing a Web-Based Intervention to Train Community Clinicians in an Evidence-Based Psychotherapy: A Pilot Study.

OBJECTIVE: The authors conducted a feasibility assessment of online training plus an online learning collaborative to support implementation of an evidence-based psychosocial treatment in a community mental health system. METHODS: Two mental health centers were randomly allocated to in-person training with local supervision, and three were assigned to online training plus an online learning collaborative supported by expert clinicians. Participants (N=36) were clinicians interested in interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. After training, 136 patients reported monthly on the extent to which clinicians used 19 IPSRT techniques. RESULTS: Clinicians from both training groups increased use of IPSRT techniques. Patients of clinicians receiving Internet-supported e-learning and of those receiving in-person training reported comparable clinician use of IPSRT techniques. CONCLUSIONS: Internet-supported e-learning by community clinicians was found to be feasible and led to uptake of an evidence-based psychotherapy comparable to that by clinicians who received face-to-face training.

Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators.

OBJECTIVE: Using evidence-based psychotherapies in community mental health clinics could significantly improve patient functioning. This study explored perceived facilitators and barriers related to implementing interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. METHODS: The authors conducted 30-minute semistructured interviews with clinic administrators, supervisors, and clinicians from five community mental health clinics focusing on anticipated barriers and facilitators related to implementing IPSRT. RESULTS: Seventeen participants (four administrators, three supervisors, and ten clinicians) completed the interviews. Important barriers to effective implementation included frequent client no-shows, difficulties transitioning from training to practice, and time constraints. Facilitators included support from supervisors and other clinicians, decreased productivity requirements or compensation for time spent while learning IPSRT, and reference materials. CONCLUSIONS: Administrators and clinicians expressed similar beliefs about facilitators and barriers related to implementing IPSRT. The challenge of high no-show rates was not identified as a barrier in previous research.

Evaluation of an implementation initiative for embedding Dialectical Behavior Therapy in community settings.

We examined the effectiveness of Dialectical Behavior Therapy (DBT) training in community-based agencies. Data were gathered at four time points over a 2-year period from front-line mental health therapists (N=64) from 10 community-based agencies that participated in a DBT implementation initiative. We examined change on therapist attitudes toward consumers with Borderline Personality Disorder (BPD), confidence in the effectiveness of DBT, and use of DBT model components. All measures were self-report. Participating in DBT training was associated with positive changes over time, including improved therapist attitudes toward consumers with BPD, improved confidence in the effectiveness of DBT, and increased use of DBT components. Therapists who had the lowest baseline scores on the study outcomes had the greatest self-reported positive change in outcomes over time. Moreover, there were notable positive correlations in therapist characteristics; therapists who had the lowest baseline attitudes toward individuals with BPD, confidence in the effectiveness of DBT, or who were least likely to use DBT modes and components were the therapists who had the greatest reported increase over time in each respective area. DBT training with ongoing support resulted in changes not commonly observed in standard training approaches typically used in community settings. It is encouraging to observe positive outcomes in therapist self-reported skill, perceived self-efficacy and DBT component use, all of which are important to evidence-based treatment (EBT) implementation. Our results underscore the importance to recognize and target therapist diversity of learning levels, experience, and expertise in EBT implementation.

Physical fighting among Egyptian adolescents: social and demographic correlates among a nationally representative sample.

Introduction. Adolescent interpersonal violence is a global public health problem, yet gaps remain in the epidemiologic literature on adolescent violence in low- and middle-income countries (LMIC). Prevalence rates and risk and protective factors reported in high-income countries may be different from those reported in LMICs. Culturally-relevant epidemiologic data is important in efforts aimed at addressing adolescent interpersonal violence in these countries. Methods. A cross-sectional study of Egyptian adolescent involvement in violent behavior was conducted. Data collected from a 2006 school-based survey initiative were used; participants were adolescents aged 11-17 (N = 5, 249). Some participants were excluded from the dataset due to incomplete data (N = 111) resulting in a final sample of 5,138. Bivariate and logistic regression analyses were run to determine demographic and social variables associated with participation in physical fighting. Results. Thirty-one percent of adolescents reported being involved in a physical fight. Previously reported risk factors for violent behavior among adolescents such as depressive symptoms (OR = 1.29; CI = 1.11-1.50) and bullying victimization (OR = 2.44; CI = 2.12-2.83) were positively associated with violent behavior in the present study, while the more novel factor of sedentary behavior was also observed as having a positive association with violent behavior (OR = 1.43; CI = 1.21-1.69). Known protective factors such as helpful peers (OR = 0.75; CI = 0.62-0.90) and understanding parents (OR = 0.67; CI = 0.56-0.81) were found to have negative associations with violent behavior in the present study, in addition to the counterintuitive protective effect of having fewer friends (OR = 0.75; CI = 0.60-0.92). Conclusions. Prevalence rates of adolescent interpersonal violence in Egypt are similar to rates in other LMICs. The high reported rates of depressive symptomatology and bully victimization along with their positive association with physical fighting suggest that interventions aimed at treating and preventing these problems may help mitigate the likelihood of adolescents engaging in violent behavior; involvement in appropriate physical activity in a safe environment may be beneficial as well. More research is needed to understand the observed protective factor of having fewer friends.

Facilitators and barriers associated with implementation of evidence-based psychotherapy in community settings.

OBJECTIVE Despite widespread use of individual outpatient psychotherapies among community mental health centers (CMHCs), few studies have examined implementation of these psychotherapies. This exploratory qualitative study identified key themes associated with the implementation of an empirically supported psychotherapy in CMHCs. METHODS The authors conducted semistructured interviews with 12 key informants from four CMHCs that had implemented interpersonal and social rhythm therapy (IPSRT). Their responses were categorized into key themes. RESULTS Five major themes were identified: pretraining familiarity with IPSRT, administrative support for implementation, IPSRT fit with usual practice and clinic culture, implementation team and plan, and supervision and consultation. Discussion of these themes varied among participants from clinics considered successful or unsuccessful implementers. CONCLUSIONS Participants identified both key themes and several strategies for facilitating implementation. The findings suggest that when these key factors are present, outcome-enhancing treatments can be implemented and sustained, even in clinics with limited resources.

Understanding community mental health administrators' perspectives on dialectical behavior therapy implementation.

In this study, key informant interviews were conducted with 13 administrators from nine community-based mental health agencies implementing dialectical behavior therapy in order to assess their perspectives on implementation. Four major themes were identified. They include opinions about dialectical behavior therapy and its fit with existing practices, resource concerns (for example, reimbursement issues, time commitment, and staff training), staff selection for training and staff turnover, and ongoing client referrals. Understanding agency administrators' unique perspectives and addressing their concerns is critical to treatment implementation given administrators' role in determining whether and how a treatment will be implemented. Better understanding of the fit between dialectical behavior therapy and existing service structures, the impact of staff turnover on implementation, and the resources required for implementation are all needed to ensure successful implementation and sustainability.