Risk and Protective Factors Associated with Suicidal Thoughts and Behaviors Among Maryland Middle School Students.

The aim of this study was to identify independent risk and protective factors associated with self-reported suicidal thoughts and behaviors (STB) among young adolescents by examining self-report data on mental health, substance abuse, violence involvement, social and economic challenges and supports, physical health and demographics in relation to STB. Data from nearly 27,000 students who completed the 2018-19 Maryland Middle School Youth Risk Behavior Survey/Youth Tobacco Survey (YRBS/YTS) were used to identify independent risk and protective factors associated with STB among middle school students (grades 6-8; ages 11-14). Twenty-three percent of students reported lifetime suicidal ideation and nine percent reported lifetime attempt(s). Independent risk factors associated with STB include depression, substance abuse or misuse, violence involvement, bullying victimization at school or electronically, sexual activity, and sleep deprivation. Protective factors include having an adult outside of school to confide in and feeling that teachers care and provide encouragement. Interactive effects by gender and/or race/ethnicity were observed for some factors in relation to STB. These results suggest that evidence-based programs and policies at the universal and selective/indicated levels in school settings are needed and should be introduced earlier on to address the widespread prevalence of STB in young adolescents. Program planners should take into consideration social, cultural and language needs when implementing and developing intervention strategies. Supplementary Information: The online version contains supplementary material available at 10.1007/s12310-022-09521-6.

Psychological First Aid Well-Being Support Rounds for Frontline Healthcare Workers During COVID-19.

Background and Objective: Frontline healthcare workers face unprecedented stress from the current SARS COV-2 (COVID-19) pandemic. Hospital systems need to develop support programs to help frontline staff deal with this stress. The purpose of this article is to describe a support program for front line healthcare workers. Methods: In this community case report, we describe a well-being support rounding program that was developed to deliver Psychological First Aid (PFA) to frontline healthcare workers in a large urban medical center to maintain their sense of psychological well-being and self-efficacy. A team of clinicians from the department of psychiatry, who were trained on the Johns Hopkins RAPID model (Reflective Listening, Assessment, Prioritization, Intervention, and Disposition) to provide PFA, were deployed throughout the hospital. These clinicians carried out daily well-being rounds from April to June during the peak of the pandemic. Results: Approximately 20% of the frontline staff members were going through an acute crisis and benefited from PFA. Anxiety, anger, exhaustion, economic worry, job insecurity, dehumanized interactions with patients due to Personal Protective Equipment (PPE), and stress of taking care of sick and dying patients without their families present, were the main themes identified by the staff. The deployed team used active listening, mindfulness, validation, reframing and other cognitive interventions to support staff. Conclusions: Our experience suggests that frontline staff are willing to engage with in-person, on-site support programs. Fostering resilience and self-efficacy through PFA is a useful model to provide emotional support to frontline healthcare workers during health crises.

Preteen Behaviors and Sexual Orientation of High School Students Who Report Depressive Symptoms, United States, 2015-2017.

Unhealthy preteen behaviors are associated with adolescent depression. However, little is known about preteen factors among sexual minority young people, a group at increased risk for teen depression and suicide. We completed weighted multivariate logistic regression analyses on data from the national 2015 and 2017 Youth Risk Behavior Survey of 30 389 high school students in the United States. Preteen sex, cigarette smoking, and alcohol and marijuana use were significantly more prevalent among lesbian, gay, or bisexual (LGB) and questioning students who reported depressive symptoms than among their heterosexual peers (adjusted prevalence ratio [APR] range, 1.33-2.34; all significant at P < .05). The only exception was that marijuana use among questioning students was not significantly different from use among heterosexual peers (APR = 1.34; P = .11). Assessment of preteen sex and substance use-especially among LGB and questioning young people, who are more prone to depressive symptoms and more likely to initiate risky preteen behaviors than their heterosexual counterparts-will facilitate a life course approach to sexual minority mental health that should begin by early adolescence.

Thirteen Reasons Why Revisited: A Monograph for Teens, Parents, and Mental Health Professionals.

Jay Asher's novel Thirteen Reasons Why and its Netflix adaptation have enjoyed widespread popularity. While they draw needed attention to issues like bullying and teen estrangement, they may have an unintended effect: they mislead about the etiology of suicide and even glamorize it to a degree. The medical literature has shown that suicide is almost always the result of psychiatric disorder, not provocative stress, in much the same way an asthmatic crisis is primarily the result of an underlying medical condition, not an allergic stimulus. Both the novel and Netflix series ignore this premise and even belittle the idea. Thus, while the story has artistic merits, it also has the potential to be destructive if accessed by young readers and viewers seeking guidance. Approximately ten percent of teens suffer from depression, and suicide recently surpassed homicide as the second-leading cause of death among persons ages ten to twenty-four in the United States. A more balanced view addressing these misconceptions is provided for teens, parents, and mental health professionals.

Lessons for psychiatrists from the COVID pandemic: the need for expanded roles and additional competencies.

The disaster of the COVID-19 pandemic has fundamentally changed the norms of psychiatric practice: from its methods of care delivery to its methods of practice. Traditional methods of care delivery using in-person visits became impractical or unsafe. Meanwhile, the pandemic has resulted in an increased demand for services. The resulting pivot to telepsychiatry required a skillset that was not a part of traditional psychiatry training. To meet the demand for services, many providers needed to join collaborative models of care to help scale their expertise. Although many innovative collaborative models of care exist, providers remain in their traditional consultative roles within many of those models. In a disaster, when there is an expanding mental health care need in the population, psychiatrists need to adapt their practice to meet expanded roles that naturally build on their usual ones. We explore the expanded roles that psychiatrists will need to fill based on what is known about the field of disaster mental health and principles from Psychological First Aid (PFA). In preparation for a new normal, in what George Everly describes as a 'disaster of uncertainty,' we propose evolutions in the way psychiatrists are trained. Specific training on telepsychiatry best practices will prepare psychiatrists to use this method most effectively and appropriately. Additional training should focus on the core competencies of disaster psychiatry: effective crisis leadership and strategic planning, disaster surveillance, knowledge of benign vs. concerning symptoms, psychological triage, implementation of crisis interventions, resource facilitation, crisis communication, and self and peer care. Developing and integrating these competencies into psychiatry training programs will best prepare psychiatrists for the expanding mental health care needs of the community in this ongoing disaster and future ones.

Co-occurring risk factors among U.S. high school students at risk for suicidal thoughts and behaviors.

BACKGROUND: Suicidal thoughts and behaviors (STBs) are increasing among adolescents in the United States and are challenging to predict and prevent.  The current study identifies subtypes of youth at risk for suicidal thoughts and behaviors (STBs) in school-based settings. METHOD: Data are from the CDC's 2015 and 2017 National Youth Risk Behavior Survey of US high school students. Among students reporting depression symptoms, latent class analysis is used to identify subtypes at risk for STBs based on personal characteristics, risk behaviors and environments. RESULTS: Two distinct subtypes of youth were found to be at high risk for STBs: The first, larger subtype (22%) is predominately females in early high school, many of whom identify as bisexual, experienced past-year bullying, and are likely to have experienced sexual victimization.  These students have low levels of externalizing risk behaviors making them difficult to detect.  The second high-risk subtype (7%) is characterized by students with significant social integration challenges, with extremely high levels of substance abuse, fighting, physical and sexual victimization and poor academic performance.  Many of these students have low English fluency, and identify as sexual minority. LIMITATIONS: Due to attrition or language barriers, experiences of some students at high-risk for STBs may not have been captured by this survey. CONCLUSION: Universal screening in clinical settings, and universally focused suicide prevention programs in school-based settings are needed and should be introduced early on. Interventions should be tailored to reach high-risk students with language, cultural and social integration challenges.

Teacher Mental Health Literacy is Associated with Student Literacy in the Adolescent Depression Awareness Program.

The Adolescent Depression Awareness Program, developed by psychiatrists and psychiatric nurses at the Johns Hopkins University School of Medicine, is a depression literacy program delivered to high school students by teachers. This mode of delivery represents an effective and sustainable way to increase awareness of mental health, reduce stigma, improve early detection, and facilitate help-seeking behavior among adolescents. The present study explores the depression literacy and stigma of teachers and their students. Survey responses of 66 teachers and 6679 high school students about depression literacy and stigma pre- and post-education intervention were analyzed using a multilevel model fit in Mplus. Teacher depression literacy was significantly associated with student depression literacy [ß = 0.199, SE = 0.095, p = 0.035, 95% CI (0.044, 0.355)] at the post-assessment, but was not associated with student stigma. Teacher stigma was not significantly related to student depression literacy or stigma in the post-assessment. These findings highlight the importance of optimizing teacher depression literacy in order to maximize student depression literacy while also diminishing concerns about the transmission of stigmatized beliefs from teachers to students.

Effectiveness of the Adolescent Depression Awareness Program (ADAP) on Depression Literacy and Mental Health Treatment.

BACKGROUND: Analysis of data from a NIMH-supported study was conducted to evaluate the effectiveness of the Adolescent Depression Awareness Program (ADAP) in promoting depression literacy and help-seeking behavior. METHODS: Eighteen Pennsylvania schools were matched on size, sex, race, test scores, median income, and free/reduced lunch status. Schools randomized to the intervention implemented ADAP as a compulsory part of the schools health curriculum, while control schools collected study measures. RESULTS: Post-randomization analysis revealed no significant differences by sex on the pre-assessments between intervention and control schools. In the intervention schools, a total of 1427 students received ADAP. Written parental consent and adolescent assent was obtained from 33.7% students. The online REDCap survey was completed by 41.78% of the consenting students. The Adolescent Depression Knowledge Questionnaire (ADKQ) findings suggest that ADAP significantly improved depression knowledge (Est. =1.07, SE =.25, p < .001), compared to those in the control group. ADAP was found to facilitate help-seeking behavior by student report in those participating in the REDCap survey 4 months following the ADAP curriculum. CONCLUSIONS: Results of the survey suggests that ADAP facilitates help-seeking behaviors in teens. This study supports the efficacy of a teacher delivered school-based universal prevention program, ADAP, on depression literacy.

Gender Differences in Depression Literacy and Stigma After a Randomized Controlled Evaluation of a Universal Depression Education Program.

PURPOSE: Depression is a debilitating illness with frequent onset during adolescence. Depression affects women more often than men; men are more likely to complete suicide and less likely to seek treatment. The Adolescent Depression Awareness Program (ADAP) is a school-based depression intervention that educates adolescents about depression symptoms and addresses accompanying stigma. The study aims examined gender differences in the ADAP's impact on depression literacy and stigma. METHODS: Data came from a randomized trial (2012-2015). Six thousand six hundred seventy-nine students from 54 schools in several states were matched into pairs and randomized to the intervention or wait-list control. Teachers delivered the ADAP as part of the health curriculum. Depression literacy and stigma outcomes were measured before intervention, 6 weeks later, and at 4 months. Multilevel models evaluated whether gender moderated the effect of ADAP on depression literacy and stigma. RESULTS: At 4 months, there was a main effect of the ADAP on depression literacy (odds ratio [OR] = 3.3, p = .001) with intervention students achieving depression literacy at higher rates than controls. Gender exhibited a main effect, with women showing greater rates of depression literacy than men (OR = 1.51, p = .001). There was no significant intervention × gender interaction. The ADAP did not exhibit a significant main effect on stigma. There was a main effect for gender, with women demonstrating less stigma than men (OR = .65, p = .001). There was no significant interaction between the intervention and gender on stigma. CONCLUSIONS: The ADAP demonstrates effectiveness for increasing rates of depression literacy among high school students. In this study, gender was not associated with ADAP's effectiveness.

School-Based Curriculum to Improve Depression Literacy Among US Secondary School Students: A Randomized Effectiveness Trial.

OBJECTIVES: To determine the effectiveness of a universal school-based depression education program. METHODS: In 2012-2015, we matched 6679 students from 66 secondary schools into pairs by state (Maryland, Delaware, Pennsylvania, Michigan, and Oklahoma) and randomized to the Adolescent Depression Awareness Program (ADAP; n = 3681) or to a waitlist control condition (n = 2998). Trained teachers delivered ADAP as part of the health education curriculum to students aged 14 to 15 years. The primary outcome was depression literacy. Secondary outcomes included mental health stigma and, in a subset of the sample, the receipt of mental health services. Follow-up was at 4 months. RESULTS: ADAP resulted in significantly higher levels of depression literacy among participating students than did waitlist controls, after adjusting for pretest assessment depression literacy (P < .001). Overall, ADAP did not significantly affect stigma (P = .1). After ADAP, students approached 46% of teachers with concerns about themselves or others. Of students who reported the need for depression treatment, 44% received treatment within 4 months of ADAP implementation. CONCLUSIONS: ADAP is an effective public health intervention for improving depression literacy among students. TRIAL REGISTRATION: Clinicaltrials.gov NCT02099305.

The Association of School Climate, Depression Literacy, and Mental Health Stigma Among High School Students.

BACKGROUND: Although school climate is linked with youth educational, socioemotional, behavioral, and health outcomes, there has been limited research on the association between school climate and mental health education efforts. We explored whether school climate was associated with students' depression literacy and mental health stigma beliefs. METHODS: Data were combined from 2 studies: the Maryland Safe Supportive Schools Project and a randomized controlled trial of the Adolescent Depression Awareness Program. Five high schools participated in both studies, allowing examination of depression literacy and stigma measures from 500 9th and 10th graders. Multilevel models examined the relationship between school-level school climate characteristics and student-level depression literacy and mental health stigma scores. RESULTS: Overall school climate was positively associated with depression literacy (odds ratio [OR] = 2.78, p < .001) and negatively associated with stigma (Est. = -3.822, p = .001). Subscales of engagement (OR = 5.30, p < .001) and environment were positively associated with depression literacy (OR = 2.01, p < .001) and negatively associated with stigma (Est. = -6.610, p < .001), (Est. = -2.742, p < .001). CONCLUSIONS: Positive school climate was associated with greater odds of depression literacy and endorsement of fewer stigmatizing beliefs among students. Our findings raise awareness regarding aspects of the school environment that may facilitate or inhibit students' recognition of depression and subsequent treatment-seeking.

The importance of social support for women with elevated anxiety undergoing care for gynecologic malignancies.

OBJECTIVES: The aim of this study was to screen for depression and anxiety and to assess well-being among women diagnosed with gynecologic malignancies, identify factors associated with elevated depressive or anxiety symptoms, and further characterize the needs of those with elevated anxiety or depressive symptoms. METHODS/MATERIALS: Women presenting for gynecologic cancer at an academic center during the course of 10 months were offered screening for depressive and anxiety symptoms. Patients were screened with the Primary Care Evaluation of Mental Disorders' Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7. The Functional Assessment of Cancer Therapy-General assessed well-being. Demographics, psychiatric history, and components about the cancer and treatment were collected. Those who screened positive with scores of 10 or higher on the Patient Health Questionnaire-9 or the Generalized Anxiety Disorder-7 were offered a meeting with the study psychiatrist for further evaluation both with the Structured Clinical Interview for Diagnosis as well as with an interview to discuss their experiences and to assess their desired needs. RESULTS: When family and social well-being was added to the logistic regression model, higher family and social well-being was the strongest factor associated with lower amounts of anxiety (odds ratio, 0.10; P = 0.001 for a cutoff of 10; odds ratio, 0.21; P = 0.012 for a cutoff of 8). Less than 30% who screened positive met with the study psychiatrist and were not receiving optimal treatment. CONCLUSIONS: Given that low family and social well-being and elevated anxiety symptoms were so highly correlated, those with anxiety symptoms would most benefit from social interventions. However, this study also found that patients with elevated depressive or anxiety symptoms were difficult to engage with a psychiatric provider. We need partnership between psychiatry and gynecology oncology to identify those with elevated depressive and anxiety symptoms and develop better ways to provide psychosocial supports.

Achieving Depression Literacy: The Adolescent Depression Knowledge Questionnaire (ADKQ).

Mental health literacy appears to be an important target for prevention and intervention efforts. However, limitations exist in this literature base, including the lack of a validated measure to assess this construct. The Adolescent Depression Knowledge Questionnaire (ADKQ) was created to assess knowledge of depression and attitudes about seeking help (i.e., depression literacy) for mental health issues before and after introduction of a universal, school-based intervention, the Adolescent Depression Awareness Program (ADAP). The ADKQ measured depression knowledge and attitudes in 8,216 high school students immediately before ADAP was implemented and 6 weeks after. The latent structure of the Knowledge section was examined with attention to measurement invariance between males and females and type of instructor, as well as pre- to post-test. Categories were developed for the open-ended questions of the Attitudes section. A one-factor (General Knowledge) latent structure was the best fit to the data. The latent structure of the ADKQ did not differ by student's gender or type of instructor, nor did it differ based on pre- or post-test. Categories for the Attitudes portion of the ADKQ were developed. Psychometric evidence supports the ADKQ as a measure to evaluate adolescent depression literacy pre- to post-test and within several groups of interest (e.g., gender, facilitator). Categories for the Attitudes section of the ADKQ will allow for easier evaluation of this measure with quantitative data.

Depression knowledge in high school students: effectiveness of the adolescent depression awareness program.

BACKGROUND: Major depression is a common disorder among teenagers and is associated with significant morbidity and mortality. Suicide is the third leading cause of death among 15-24 year olds. Early identification and treatment is essential to prevent suicide. Depression education is a potential intervention for improving knowledge about depression and help-seeking behavior. METHODS: The Adolescent Depression Awareness Program (ADAP) is a school-based depression education intervention with a core message that depression is a treatable medical illness. 710 high school students from six schools in Tulsa, OK participated in the study comparing changes in knowledge about depression and attitudes toward treatment-seeking between students receiving the intervention and those who did not. Changes in depression knowledge and attitude toward help-seeking were measured using the ADAP Depression Knowledge Questionnaire (ADKQ). RESULTS: There was a significant positive change in ADKQ score for students receiving the intervention but not in the control group. The intervention group also demonstrated a significant difference in willingness to "tell someone" if concerned about depression in a peer, which was not present in the control group. LIMITATIONS: The students were not randomized to the intervention and control groups. The ADKQ evaluates attitudes about help-seeking but not behavior. CONCLUSIONS: A school-based educational intervention improved knowledge about depression and attitudes toward help-seeking in adolescents. Future studies should investigate if such change in knowledge results in help-seeking behaviors.

Special report: suicidal ideation among American surgeons.

BACKGROUND: Suicide is a disproportionate cause of death for US physicians. The prevalence of suicidal ideation (SI) among surgeons and their use of mental health resources are unknown. STUDY DESIGN: Members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life. RESULTS: Of 7905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported SI during the previous 12 months. Among individuals 45 years and older, SI was 1.5 to 3.0 times more common among surgeons than the general population (P < .02). Only 130 surgeons (26.0%) with recent SI had sought psychiatric or psychologic help, while 301 (60.1%) were reluctant to seek help due to concern that it could affect their medical license. Recent SI had a large, statistically significant adverse relationship with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment) and symptoms of depression. Burnout (odds ratio, 1.910; P < .001) and depression (odds ratio, 7.012; P < .001) were independently associated with SI after controlling for personal and professional characteristics. Other personal and professional characteristics also related to the prevalence of SI. CONCLUSIONS: Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeon's degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.

The effectiveness of a school-based adolescent depression education program.

In an effort to decrease the suicide rate in adolescents, many interventions have focused on school-based suicide prevention programs. Alternatively, depression education in schools might be effective in decreasing the morbidity, mortality, and stigma associated with adolescent depression. The Adolescent Depression Awareness Program (ADAP) developed a 3-hour curriculum to teach high school students about the illness of depression. The purpose of this study was to assess the effectiveness of the ADAP curriculum in improving high school students' knowledge about depression. From 2001 to 2005, 3,538 students were surveyed on their knowledge about depression before and after exposure to the ADAP curriculum. The number of students scoring 80% or higher on the assessment tool more than tripled from pretest to posttest (701 to 2,180), suggesting the effectiveness of the ADAP curriculum. Further study and replication are required to determine if improved knowledge translates into increased treatment-seeking behavior.

Premenstrual mood symptoms: study of familiality and personality correlates in mood disorder pedigrees.

We sought to determine whether premenstrual mood symptoms exhibit familial aggregation in bipolar disorder or major depression pedigrees. Two thousand eight hundred seventy-six women were interviewed with the Diagnostic Interview for Genetic Studies as part of either the NIMH Genetics Initiative Bipolar Disorder Collaborative study or the Genetics of Early Onset Major Depression (GenRED) study and asked whether they had experienced severe mood symptoms premenstrually. In families with two or more female siblings with bipolar disorder (BP) or major depressive disorder (MDD), we examined the odds of having premenstrual mood symptoms given one or more siblings with these symptoms. For the GenRED MDD sample we also assessed the impact of personality as measured by the NEO-FFI. Premenstrual mood symptoms did not exhibit familial aggregation in families with BP or MDD. We unexpectedly found an association between high NEO openness scores and premenstrual mood symptoms, but neither this factor, nor NEO neuroticism influenced evidence for familial aggregation of symptoms. Limitations include the retrospective interview, the lack of data on premenstrual dysphoric disorder, and the inability to control for factors such as medication use.

Factors influencing the choice of a psychiatric residency program: a survey of applicants to the johns hopkins residency program in psychiatry.

OBJECTIVE: The authors set out to determine what general factors are important in the selection of a psychiatric residency program, the views applicants have of several aspects of the Johns Hopkins Hospital Psychiatric Residency Program, and what relationships exist among these elements. METHODS: A survey mailed to Johns Hopkins Hospital psychiatric residency-interviewed applicants asked applicants to rate six factors in relation to choosing a psychiatric residency program. A second section asked applicants to rate five factors more specific to the Johns Hopkins Hospital residency. RESULTS: The most important general factors in choosing a residency program included the perceived philosophical orientation of a psychiatric department, exposure to different psychotherapy modalities, and the perceived prestige of the department. Several statistically significant correlations were evident among factors. CONCLUSION: Knowledge of applicants' views could assist residency program directors in their assessment of factors influencing program choices.

Reproductive cycle-associated mood symptoms in women with major depression and bipolar disorder.

BACKGROUND: We sought to determine the prevalence of, and association between, reproductive cycle-associated mood symptoms in women with affective disorders. We hypothesized that symptoms would correlate with each other across a woman's reproductive life span in both major depression (MDD) and bipolar I disorder (BP). METHODS: 2412 women with, MDD or BP were asked standardized questions about mood symptoms prior to menstruation, within a month of childbirth and during perimenopause. Lifetime rates for each of these symptom types were determined and an odds ratio was calculated correlating each of the types with the others. RESULTS: Of 2524 women with mood disorders, 67.7% reported premenstrual symptoms. Of those at risk, 20.9% reported postpartum symptoms and 26.4% reported perimenopausal symptoms. The rates did not differ between women with MDD and BP but were significantly different from women who were never ill. The symptoms were significantly correlated in women with MDD with odds ratios from 1.66 to 1.82, but were not in women with BP. LIMITATIONS: This is a secondary analysis of a sample that was collected for other purposes and is based upon retrospective reporting. CONCLUSIONS: Reproductive cycle-associated mood symptoms were commonly reported in women with mood disorders and did not differ based on diagnosis. In MDD, but not BP, the occurrence of these symptoms was trait-like as the presence of one predicted the occurrence of the others. Further prospective study is required to clarify the determinants of this trait.