Variation in completeness of coding external cause of injuries under ICD-10-CM.

INTRODUCTION: Information about causes of injury is key for injury prevention efforts. Historically, cause-of-injury coding in clinical practice has been incomplete due to the need for extra diagnosis codes in the International Classification of Diseases-Ninth Revision-Clinical Modification (ICD-9-CM) coding. The transition to ICD-10-CM and increased use of clinical support software for diagnosis coding is expected to improve completeness of cause-of-injury coding. This paper assesses the recording of external cause-of-injury codes specifically for those diagnoses where an additional code is still required. METHODS: We used electronic health record and claims data from 10 health systems from October 2015 to December 2021 to identify all inpatient and emergency encounters with a primary diagnosis of injury. The proportion of encounters that also included a valid external cause-of-injury code is presented. RESULTS: Most health systems had high rates of cause-of-injury coding: over 85% in emergency departments and over 75% in inpatient encounters with primary injury diagnoses. However, several sites had lower rates in both settings. State mandates were associated with consistently high external cause recording. CONCLUSIONS: Completeness of cause-of-injury coding improved since the adoption of ICD-10-CM coding and increased slightly over the study period at most sites. However, significant variation remained, and completeness of cause-of-injury coding in any diagnosis data used for injury prevention planning should be empirically determined.

Depression Treatment Initiation Among Patients With Versus Without Chronic Pain.

OBJECTIVE: The purpose of this study was to examine the extent to which the presence of chronic noncancer pain (CNCP) impacts the likelihood that patients with diagnoses of depression will initiate depression treatment compared with those without CNCP. METHODS: We performed a retrospective cohort study of Kaiser Permanente of Georgia members older than 18 years who received a diagnosis of depression. Demographics and medical history were extracted from the electronic health record database. Members were further classified by the presence or absence of a CNCP diagnosis. Outcomes of interest were treated as time dependent and included ( 1 ) time to fulfillment of a new antidepressant medication and ( 2 ) time to a follow-up mental health encounter. Outcomes were compared between members with and without a CNCP diagnosis using Kaplan-Meier survival curves and Cox proportional hazard regression models. RESULTS: During the study period, 22,996 members met the inclusion criteria and 27.4% had a diagnosis of CNCP. In the matched sample, there was no difference in the time to a new antidepressant fill among members with and without CNCP (hazard ratio = 0.96; 95% confidence interval = 0.90-1.02; p = .18). In contrast, members with CNCP were significantly less likely to have a new mental health encounter after diagnosis (hazard ratio = 0.87; 95% confidence interval = 0.81-0.94; p < .001). CONCLUSIONS: Patients with CNCP were significantly less likely to have a new mental health encounter after a depression diagnosis compared with patients without CNCP. Additional outreach and consideration may be needed to improve initiation of depression treatment for newly diagnosed patients with comorbid depression and CNCP.

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.

Suicide Deaths Before and During the Coronavirus Disease 2019 Pandemic: An Interrupted Time-series Study.

INTRODUCTION: With stressors that are often associated with suicide increasing during the coronavirus disease 2019 (COVID-19) pandemic, there has been concern that suicide mortality rates may also be increasing. Our objective was to determine whether suicide mortality rates increased during the COVID-19 pandemic. METHODS: We conducted an interrupted time-series study using data from January 2019 through December 2020 from 2 large integrated health care systems. The population at risk included all patients or individuals enrolled in a health plan at HealthPartners in Minnesota or Henry Ford Health System in Michigan. The primary outcome was change in suicide mortality rates, expressed as annualized crude rates of suicide death per 100,000 people in 10 months following the start of the pandemic in March 2020 compared with the 14 months prior. RESULTS: There were 6,434,675 people at risk in the sample, with 55% women and a diverse sample across ages, race/ethnicity, and insurance type. From January 2019 through February 2020, there was a slow increase in the suicide mortality rate, with rates then decreasing by 0.45 per 100,000 people per month from March 2020 through December 2020 (SE=0.19, P=0.03). CONCLUSIONS: Overall suicide mortality rates did not increase with the pandemic, and in fact slightly declined from March to December 2020. Our findings should be confirmed across other settings and, when available, using final adjudicated state mortality data.

Comparisons Between Patients Diagnosed with PTSD in Primary Care Versus Mental Health Care in Five Large Civilian Health Care Systems.

Posttraumatic stress disorder (PTSD) is a serious mental health disorder that may not be adequately detected or treated in primary care (PC). The purpose of this study was to compare the clinical characteristics and health care utilization of PTSD patients diagnosed in PC versus in specialty mental health care (MHC) across five large, civilian, not-for-profit healthcare systems. Electronic claims and medical record data on patients treated during 2014 were analyzed. Treatment was considered in terms of initiation and dose (i.e., psychotherapy sessions; pharmacotherapy-prescription psychotropics). Of 5256 patients aged 15-88 with a diagnosis of PTSD, 84.4% were diagnosed by a MHC provider. Patients diagnosed by MHC providers had 4 times the rate of and more enduring psychotherapy than those diagnosed by PC providers. Receipt of psychotropics varied by provider type, with generally higher prescription fill levels for patients in MHC. Strategies to better align patient needs with access and treatment modality in PC settings are needed.

Visual Conformity With Affirmed Gender or "Passing": Its Distribution and Association With Depression and Anxiety in a Cohort of Transgender People.

BACKGROUND: Visual conformity with affirmed gender (VCAG) or "passing" is thought to be an important, but poorly understood, determinant of well-being in transgender people. VCAG is a subjective measure that is different from having an inner sense of being congruent with one's gender identity. AIM: We examined the frequency and determinants of VCAG and explored its association with mental health outcomes in a cohort of transgender adults. METHODS: The "Study of Transition, Outcomes & Gender (STRONG)" is a cohort of transgender individuals recruited from 3 Kaiser Permanente health plans located in Georgia, Northern California and Southern California. A subset of cohort members completed a survey between 2015 and 2017. VCAG was assessed as the difference between 2 scales: scale 1 reflecting the person's sense of how they are perceived by others, and scale 2 reflecting the person's desire to be perceived. Participants were considered to have achieved VCAG when their scale 1 scores were equal to or exceeded their scale 2 scores. The frequency of VCAG and their independent associations with anxiety and depression symptoms were explored using data from 620 survey respondents including 309 transwomen and 311 transmen. Based on self-described gender identity, none of the participants identified as nonbinary or gender fluid. OUTCOMES: VCAG, depression, and anxiety. RESULTS: VCAG was achieved in 28% of transwomen and 62% of transmen and was more common in persons who reported greater sense of acceptance and pride in their gender identity as measured on the Transgender Congruence Scale. Another factor associated with greater likelihood of VCAG was receipt of gender-affirming surgery, but the association was only evident among transmen. Participants who achieved VCAG had a lower likelihood of depression and anxiety with prevalence ratios (95% confidence intervals) of 0.79 (0.65, 0.96) and 0.67 (0.46, 0.98), respectively. CLINICAL IMPLICATIONS: VCAG may serve as an important outcome measure after gender-affirming therapy. STRENGTHS AND LIMITATIONS: Strengths of this study include a well-defined sampling frame and use of a novel patient-centered outcome of interest. Cross-sectional design and uncertain generalizability of results are the limitations. CONCLUSION: These results, once confirmed by prospective studies, may help better characterize the determinants of well-being in the transgender community, facilitating the design of interventions to improve the well-being and quality of life of this vulnerable population. To M, Zhang Q, Bradlyn A, et al. Visual Conformity With Affirmed Gender or "Passing": Its Distribution and Association With Depression and Anxiety in a Cohort of Transgender People. J Sex Med 2020;17:2084-2092.

Variation in patterns of health care before suicide: A population case-control study.

BACKGROUND: The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention. OBJECTIVE: To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population. DESIGN: Case-Control Study. SETTING: Eight healthcare systems across the United States. PARTICIPANTS: 2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation. MEASUREMENTS: Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls. RESULTS: Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide. LIMITATIONS: Participant race/ethnicity was not available. The sample did not include uninsured individuals. CONCLUSIONS: This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.

The Mediating Effect of Sleep Disturbance on the Relationship Between Nonmalignant Chronic Pain and Suicide Death.

IMPORTANCE: Few studies have examined the relationship between nonmalignant chronic pain (NMCP) and suicide death, and even fewer have specifically explored what role sleep disturbance might play in the association between NMCP and suicide death. OBJECTIVE: To assess whether sleep disturbance mediates the relationship between NMCP and suicide death. DESIGN: This case-control study included 2,674 individuals who died by suicide between 2000 and 2013 (cases) and 267,400 matched individuals (controls). SETTING: Eight Mental Health Research Network (MHRN)-affiliated healthcare systems. PARTICIPANTS: All cases and matched controls were health plan members for at least 10 months during the year prior to the index date. MAIN OUTCOMES AND MEASURES: Sociodemographic data and diagnosis codes for NMCP and sleep disorders were extracted from the MHRN's Virtual Data Warehouse. Suicide mortality was identified using International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes from official government mortality records matched to health system records. RESULTS: After accounting for covariates, there was a significant relationship between NMCP and sleep disturbance; those who were diagnosed with NMCP were more likely to develop subsequent sleep disturbance. Similarly, sleep disturbance was significantly associated with suicide death. Finally, a significant indirect effect of NMCP on suicide death, through sleep disturbance, and a nonsignificant direct effect of NMCP on suicide death provide support for a fully mediated model. CONCLUSIONS AND RELEVANCE: There is a need for clinicians to screen for both sleep disturbance and suicidal ideation in NMCP patients and for health systems to implement more widespread behavioral treatments that address comorbid sleep problems and NMCP.

Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals.

BACKGROUND: Transgender individuals sometimes seek gender confirmation treatments (GCT), including hormone therapy (HT) and/or surgical change of the chest and genitalia ("top" and "bottom" gender confirmation surgeries). These treatments may ameliorate distress resulting from the incongruence between one's physical appearance and gender identity. AIM: The aim was to examine the degree to which individuals' body-gender congruence, body image satisfaction, depression, and anxiety differed by GCT groups in cohorts of transmasculine (TM) and transfeminine (TF) individuals. METHODS: The Study of Transition, Outcomes, and Gender is a cohort study of transgender individuals recruited from 3 health plans located in Georgia, Northern California, and Southern California; cohort members were recruited to complete a survey between 2015-2017. Participants were asked about: history of GCT; body-gender congruence; body image satisfaction; depression; and anxiety. Participants were categorized as having received: (1) no GCT to date; (2) HT only; (3) top surgery; (4) partial bottom surgery; and (5) definitive bottom surgery. OUTCOMES: Outcomes of interest included body-gender congruence, body image satisfaction, depression, and anxiety. RESULTS: Of the 2,136 individuals invited to participate, 697 subjects (33%) completed the survey, including 347 TM and 350 TF individuals. The proportion of participants with low body-gender congruence scores was significantly higher in the "no treatment" group (prevalence ratio [PR] = 3.96, 95% CI 2.72-5.75) compared to the definitive bottom surgery group. The PR for depression comparing participants who reported no treatment relative to those who had definitive surgery was 1.94 (95% CI 1.42-2.66); the corresponding PR for anxiety was 4.33 (95% CI 1.83-10.54). CLINICAL TRANSLATION: Withholding or delaying GCT until depression or anxiety have been treated may not be the optimal treatment course given the benefits of reduced levels of distress after undergoing these interventions. CONCLUSIONS: Strengths include the well-defined sampling frame, which allowed correcting for non-response, a sample with approximately equal numbers of TF and TM participants, and the ability to combine data on HT and gender confirmation surgeries. Limitations include the cross-sectional design and the fact that participants may not be representative of the transgender population in the United States. Body-gender congruence and body image satisfaction were higher, and depression and anxiety were lower among individuals who had more extensive GCT compared to those who received less treatment or no treatment at all. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction and Mental Health in a Cohort Of Transgender Individuals. J Sex Med 2018;15:591-600.

Dermatologic Conditions and Risk of Suicide: A Case-Control Study.

BACKGROUND: Patients diagnosed with skin conditions have a higher risk of comorbid psychiatric conditions and suicide-related outcomes such as suicidal ideations and behaviors. There is paucity of evidence in the US general population about the risk of suicide death in patients with dermatologic conditions. METHODS: We conducted a retrospective case-control study to investigate the risk of suicide death in patients receiving care for dermatologic conditions. This study involved 8 US health systems. A total of 2674 individuals who died by suicide (cases) were matched with 267,400 general population control individuals. RESULTS: After adjusting for age, sex, and any mental health or substance use condition, we did not find an association between death by suicide and any skin condition including conditions where clinicians are generally concerned about the risk such as acne (adjusted odds ratio [aOR] = 1.04, p = 0.814), atopic dermatitis (aOR = 0.77, p = 0.28), and psoriasis (aOR = 0.91, p = 0.64). CONCLUSION: This case-control study provides no evidence of increased risk of death by suicide in individuals with major skin disorders in the US general population.

Improving Adherence to Cardiovascular Therapies: An Economic Evaluation of a Randomized Pragmatic Trial.

OBJECTIVE: Preplanned economic analysis of a pragmatic trial using electronic-medical-record-linked interactive voice recognition (IVR) reminders for enhancing adherence to cardiovascular medications (i.e., statins, angiotensin-converting enzyme inhibitors [ACEIs], and angiotensin receptor blockers [ARBs]). METHODS: Three groups, usual care (UC), IVR, and IVR plus educational materials (IVR+), with 21,752 suboptimally adherent patients underwent follow-up for 9.6 months on average. Costs to implement and deliver the intervention (from a payer perspective) were tracked during the trial. Medical care costs and outcomes were ascertained using electronic medical records. RESULTS: Per-patient intervention costs ranged from $9 to $17 for IVR and from $36 to $47 for IVR+. For ACEI/ARB, the incremental cost-effectiveness ratio for each percent adherence increase was about 3 times higher with IVR+ than with IVR ($6 and $16 for IVR and IVR+, respectively). For statins, the incremental cost-effectiveness ratio for each percent adherence increase was about 7 times higher with IVR+ than with IVR ($6 and $43 for IVR and IVR+, respectively). Considering potential cost offsets from reduced cardiovascular events, the probability of breakeven was the highest for UC, but the IVR-based interventions had a higher probability of breakeven for subgroups with a baseline low-density lipoprotein (LDL) level of more than 100 mg/dl and those with two or more calls. CONCLUSIONS: We found that the use of an automated voice messaging system to promote adherence to ACEIs/ARBs and statins may be cost-effective, depending on a decision maker's willingness to pay for unit increase in adherence. When considering changes in LDL level and downstream medical care offsets, UC is the optimal strategy for the general population. However, IVR-based interventions may be the optimal choice for those with elevated LDL values at baseline.

Antimicrobial Stewardship Knowledge, Attitudes, and Practices among Health Care Professionals at Small Community Hospitals.

Background: Very little is known about antimicrobial stewardship knowledge, attitudes, and practices (KAP) among health care practitioners in small, community hospitals (SCHs) compared to large community hospitals (LCHs). Objective: To compare infectious diseases (ID) clinical resources and describe KAP pertaining to antimicrobial stewardship among prescribers, pharmacists, and administrators from a large hospital network including a comparison between SCHs and LCHs. Methods: An anonymous 48-item antimicrobial stewardship KAP survey was administered to pharmacists, prescribers, and administrators at 15 SCH (<200 beds) and 5 LCHs (>200 beds) within an integrated health care network. Results: In total, 588 (14%) completed the survey: 198 from SCHs and 390 from LCHs. Most respondents were familiar or very familiar with the term antimicrobial stewardship and felt that antimicrobial stewardship was necessary. Most pharmacists and prescribers agreed that antimicrobials were overused at their hospital. However, SCH pharmacists and prescribers were more likely to disagree that antibiotic resistance is a significant problem locally. Pharmacists saw restrictions as a reasonable method of controlling antibiotic use more than prescribers. SCH practitioners were less familiar with IDSA guidelines and less likely to rely on ID specialists to a greater extent than LCH practitioners. Most respondents strongly agreed they would like more antimicrobial education. Conclusion: SCH and LCH pharmacists, prescribers, and administrators are aware of antimicrobial resistance and overuse and agree that antimicrobial stewardship programs are necessary. SCHs are less likely to contact ID for information. These results support the development of antimicrobial stewardship programs at SCHs, while recognizing the significant differences in availability and utilization of resources.

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.

The rapid shift to virtual mental health care: Examining psychotherapy disruption by rurality status.

BACKGROUND: Given the low usage of virtual health care prior to the COVID-19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID-19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations. METHODS: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID-19 pandemic onset. RESULTS: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre- to post-COVID-19 onset (32.5-16.0% and 44.7-24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in-person visits compared with the rural cohort (96.6-45.0 vs. 98.0-66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre- to post-COVID-19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption. CONCLUSIONS: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits).

Racial-Ethnic Differences in Receipt of Past-Year Health Care Services Among Suicide Decedents: A Case-Control Study.

OBJECTIVE: Suicide remains an urgent public health crisis. Although some sociodemographic characteristics are associated with greater suicide risk in the general population, it is unclear whether individuals utilizing health care in the United States have similar suicide incidence patterns. The authors examined whether race-ethnicity is associated with suicide death among patients seeking health care and investigated health care utilization patterns. METHODS: Data were collected from electronic health records and government mortality records for patients seeking health care across nine health care systems in the United States. Patients who died by suicide (N=1,935) were matched with patients in a control group (N=19,350) within each health care system. RESULTS: Patients who died by suicide were significantly more likely to be White, older, male, living in low-education areas, living in rural areas, or diagnosed as having mental health conditions or were significantly less likely to have commercial insurance (p<0.05). Among most racial-ethnic groups, those who died by suicide had a higher number of past-year mental health, primary care, and total health care visits; for American Indian/Alaska Native patients, the number of health care visits tended to be lower among suicide decedents. CONCLUSIONS: These findings suggest that higher past-year health care utilization was associated with increased likelihood of suicide death across several racial-ethnic groups. This observation underscores the need for identifying and managing suicide risk in health care settings, including outside of mental health visits, among most racial-ethnic groups.

Clozapine Use Among People With Psychotic Disorders Who Experience Specific Indications for Clozapine.

Objective: To examine rates of clozapine use among people with psychotic disorders who experience specific indications for clozapine.Methods: Records data from 11 integrated health systems identified patients aged 18 years or older with recorded International Classification of Diseases, Tenth Revision, Clinical Modification, diagnoses of schizophrenia, schizoaffective disorder, or other psychotic disorder who experienced any of the 3 events between January 1, 2019, and December 31, 2019, suggesting indications for clozapine: a diagnosis of self-harm injury or poisoning, suicidal ideation diagnosed or in response to standardized assessments, and hospitalization or emergency department (ED) care for psychotic disorder despite treatment with 2 or more antipsychotic medications. Prescription dispensing data identified all clozapine use prior to or in the 12 months following each indication event. Analyses were conducted with aggregate data from each health system; no individual data were shared.Results: A total of 7,648 patients with psychotic disorder diagnoses experienced at least 1 indication event. Among 1,097 experiencing a self-harm event, 32 (2.9%) had any prior clozapine use, and 10 (0.9%) initiated clozapine during the following 12 months. Among 6,396 with significant suicidal ideation, 238 (3.7%) had any prior clozapine use, and 70 (1.1%) initiated clozapine over 12 months. Among 881 with hospitalization or ED visit despite pharmacotherapy, 77 (8.7%) had any prior clozapine treatment, and 41 (4.7%) initiated clozapine over 12 months. Among those with significant suicidal ideation, rates of both prior clozapine treatment and subsequent initiation varied significantly by race and ethnicity, with rates among Hispanic and non-Hispanic Black patients lower than among non Hispanic White patients.Conclusions: Initiating clozapine treatment is uncommon among people with psychotic disorders who experience events suggesting clozapine is indicated, with even lower rates among Black and Hispanic patients.

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.

Are People Who Die by Intentional Medication Poisoning Dispensed Those Medications in the Year Prior to Death?

OBJECTIVE: The rate of suicidal poisoning in the United States has increased substantially over the past 20 years. Understanding whether prescription medications used for self-poisoning were recently dispensed would help inform suicide prevention efforts. Alternatively, medications for self-poisoning could have been formerly dispensed or collected from friends, family, or illicit sources. METHODS: Among those who died by intentional opioid and psychotropic poisonings, we conducted a descriptive study to determine what proportion had a recently filled prescription that could have been the means of suicide. Subjects were all people who died by intentional poisoning across nine health-care systems within the NIH-funded Mental Health Research Network. RESULTS: Among the 3,300 people who died by suicide, 700 died by any poisoning and 194 died by intentional opioid or psychotropic/hypnotic medication poisoning. Among those who died by intentional opioid poisoning 73% were dispensed an opioid in the year prior. Among those who died by intentional psychotropic/hypnotic poisoning, 83% were dispensed any psychotropic and 61% were dispensed a hypnotic in prior year. Most people were continuously dispensed the same medications used in their intentional poisonings in the year prior to death. CONCLUSIONS: Our results indicate that most medications used in suicidal overdose were likely recently dispensed. Therefore, future suicide prevention studies and prevention resources should focus on medication safety interventions such as lethal-means counseling for medication access, limiting quantities dispensed, opioid antagonists, and blister packs. HIGHLIGHTSUnderstanding whether medications used for self-poisoning were recently dispensed or formerly/never dispensed would help inform future studies and suicide prevention efforts.We found that most people who died by intentional poisoning with opioids or psychotropic/hypnotic medications received frequent dispensings of the medication used for self-poisoning in the year prior to death.Future suicide prevention studies and efforts should focus on medication safety interventions such as lethal-means counseling for medication access, limiting quantities dispensed, opioid antagonists, and blister packs.

Understanding TBI as a Risk Factor Versus a Means of Suicide Death Using Electronic Health Record Data.

OBJECTIVE: The aim of this research was to examine predictors and characterize causes of suicide death in people with traumatic brain injury (TBI) and conduct sensitivity analyses with and without people whose first diagnosis of TBI occurred within 3 days of their suicide death. METHODS: This case-control study examined suicide risk for people with TBI in eight Mental Health Research Network-affiliated healthcare systems. Sample 1 included 61 persons with TBI who died by suicide and their 75 matched controls with TBI who did not die by suicide between January 1, 2000, and December 31, 2013. Sample 2 excluded the 34 persons with TBI whose first TBI diagnosis occurred within 3 days of their suicide death and their 46 matched controls. Descriptive statistics characterized the sample stratified by cases and controls, while conditional logistic regression models estimated the adjusted odds of suicide. RESULTS: Over half of suicide deaths occurred within 3 days of a person's first diagnosis of TBI in the larger sample. After excluding these persons, people with TBI were 2.84 (95% confidence interval [CI]: 2.15-2.73) times more likely to die by suicide than were people without TBI. Among those with TBI, men were 16.39 times (95% CI: 1.89-142.15) more likely to die by suicide than were women. CONCLUSIONS: Accounting for TBI as a potential consequence of suicide attenuates the association between TBI and suicide, but a robust association persists-especially among men. Ultimately, all people with TBI should be carefully screened and monitored for suicide risk.HIGHLIGHTSPeople with traumatic brain injury (TBI) were at considerably elevated risk for suicide deathMen with TBI had significantly increased risk of suicide death compared to women with TBITBI timing suggests confusion of risk factors for and consequences of suicide.

Cancer and psychiatric diagnoses in the year preceding suicide.

BACKGROUND: Patients with cancer are known to be at increased risk for suicide but little is known about the interaction between cancer and psychiatric diagnoses, another well-documented risk factor. METHODS: Electronic medical records from nine healthcare systems participating in the Mental Health Research Network were aggregated to form a retrospective case-control study, with ICD-9 codes used to identify diagnoses in the 1 year prior to death by suicide for cases (N = 3330) or matching index date for controls (N = 297,034). Conditional logistic regression was used to assess differences in cancer and psychiatric diagnoses between cases and controls, controlling for sex and age. RESULTS: Among patients without concurrent psychiatric diagnoses, cancer at disease sites with lower average 5-year survival rates were associated with significantly greater relative risk, while cancer disease sites with survival rates of >70% conferred no increased risk. Patients with most psychiatric diagnoses were at higher risk, however, there was no additional risk conferred to these patients by a concurrent cancer diagnosis. CONCLUSION: We found no evidence of a synergistic effect between cancer and psychiatric diagnoses. However, cancer patients with a concurrent psychiatric illness remain at the highest relative risk for suicide, regardless of cancer disease site, due to strong independent associations between psychiatric diagnoses and suicide. For patients without a concurrent psychiatric illness, cancer disease sites associated with worse prognoses appeared to confer greater suicide risk.