Bridging the Gap Between Individualized Inpatient Safety Planning and Postdischarge Efficacy.

INTRODUCTION: Implementation of programs that increase both psychiatric patient education and their involvement in treatment programming can lead to positive outcomes postdischarge. Patients involved in programs focusing on skills, recovery, and that are individualized show a reduction in symptoms as well as an increase in engagement, treatment, and recovery posthospitalization. AIMS: This quality improvement project examines (1) the effectiveness of a safety planning group on an inpatient psychiatric unit for developing individualized safety plans, (2) the usefulness of the safety plans upon discharge, and (3) how helpful the patient found them. METHODS: A standardized safety plan was presented during 1-hour groups on an adult inpatient unit. Completed safety plans scored using a rubric to determine how patients individualized the content. One week postdischarge, patients were contacted to determine location and use of the safety plan since discharge. RESULTS: Patient's (n = 124) safety plans were relatively individualized when compared to the standardized safety plan (mean [SD] = 32.85 [8.27] on a 44-point rating). Of those patients who were contacted postdischarge (n = 76), 73 (96.1%) had a copy of their safety plan 1-week postdischarge while 28 (36.8%) reported using their safety plan since discharge. Many of the patients who used their safety plan reported that it was helpful (n = 19; 67.9%). CONCLUSIONS: Developing a safety plan can be a helpful tool for individuals admitted to a psychiatric inpatient unit.

Effects of forehead cooling and supportive care on menopause-related sleep difficulties, hot flashes and menopausal symptoms: a pilot study.

OBJECTIVE/BACKGROUND: This pilot study explored the efficacy of a novel forehead cooling device for perceived sleep difficulties and hot flashes in menopausal-age women. PARTICIPANTS: 20 women (55.1 ± 4.2 years; 19 post-menopausal) with insomnia symptoms and self-reported two or more hot flashes per day. METHODS: Participants completed daily assessments of sleep and hot flashes (via diaries) across 1 baseline week and 4 weeks of open-label, in-home, nightly treatment with a forehead cooling device (15-18°C) along with sleep hygiene instructions. They also completed ratings of insomnia and menopausal symptoms using standardized questionnaires. RESULTS: Women reported reductions in sleep onset latency (SOL), wakefulness after sleep onset (WASO), and nocturnal hot flash severity during the first week of treatment (SOL: 25.7 ± 18.4 min; WASO: 36.3 ± 27.3 min; hot flash severity: 3.0 ± 2.8) compared with baseline (SOL: 38 ± 26.3 min; WASO: 52.2 ± 35.6 min; hot flash severity: 6.8 ± 3.7), with further improvements after 2-4 weeks of use (p < .001). There were also clinically meaningful reductions in insomnia severity and hot flash-related daily interference and lower psychological and physical symptom scores on the Greene climacteric scale after treatment (all p's<0.001). CONCLUSIONS: This exploratory, naturalistic, pilot study shows that nightly use of a forehead cooling device produces improvements in self-reported sleep and reductions in insomnia, hot flash, and other menopausal, symptoms. Controlled studies are warranted to determine the role of this therapy in the management of sleep difficulties and menopausal symptoms in women. Further mechanistic studies are needed to understand the physiological impact of forehead cooling on sleep and menopausal symptoms.

Effects of a forehead cooling device in veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions: a pilot study.

PURPOSE: While forehead cooling has been studied in patients with insomnia in the absence of comorbid medical/psychiatric disorders, it has never been evaluated in patients with insomnia in the presence of co-morbid medical/psychiatric disorders. METHODS: Veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions received 4-week open-label, in-home, nightly treatment with a forehead cooling device (14-16 °C) along with personalized sleep hygiene following baseline assessments. Pre- and post-treatment, participants completed the Insomnia Severity Index (ISI), the Generalized Anxiety Disorder 7-item scale (GAD-7), and the Patient Health Questionnaire 9-item scale (PHQ-9). Participants recorded daily sleep and anxiety/arousal symptoms. RESULTS: Of 24 veterans (20 men, 42.2 ± 9.5 years), 17 (71%) had marked insomnia severity improvement (a decrease of > 8 on the ISI) and 10 (42%) participants scored 7 or below on the ISI at post-treatment reflecting remission. Participants reported reductions in sleep onset latency (SOL) (F = 12.9, p < 0.001), and wakefulness after sleep onset (WASO) (F = 8.4, p < 0.001) across treatment. They also had significant reductions in insomnia severity (t = 10.04, p < 0.001), anxiety (t = 3.59, p = 0.002), and depression (t = 7.75, p < 0.001) from pre- to post-treatment. CONCLUSION: This pilot study shows that 4-week nightly use of a forehead cooling device produces improvements in insomnia, anxiety, and depressive symptoms in veterans with chronic insomnia disorder and co-morbid medical and psychiatric conditions. Controlled studies are warranted to determine the role of this therapy in the management of insomnia in veterans. TRIAL REGISTRATION: Not required as a small sample size feasibility study.

Time, Age, and Predictors of Psychosocial Outcome in Borderline Personality Disorder.

In longitudinal studies, BPD symptoms diminish over time, though psychosocial functioning lags far behind. The effects of time and advancing age on BPD are poorly understood. We sought prospective predictors of psychosocial outcome and recovery in 150 BPD subjects followed 2 to 31 years (mean 9.94 years) using a multidimensional assessment method and biannual follow-ups. Time-in-study had no significant effect on achieving diagnostic remission in BPD, good psychosocial outcomes, meaningful interpersonal relationships, full employment, or total recovery; however, younger age was associated with social and vocational achievement independent of BPD remission. Significant contributions to psychosocial outcome were found for age, employment status, MDD, SUD, Any Anxiety Disorder, and Alcohol abuse/dependence (ALC). Remission from BPD was neither necessary or sufficient for good interpersonal relationships or full-time employment. Full-time employment and social and vocational adjustment (SAS-sr) predicted good psychosocial outcome. Axis I comorbidity with Any Anxiety Disorder, MDD, or SUD predicted poor outcome.

10-Year Outcome of Suicidal Behavior in Borderline Personality Disorder.

Prospective predictors of suicide attempts were assessed in 118 subjects with borderline personality disorder (BPD) after 10 or more years of follow-up. Mean (SD) time to follow-up was 14.4 (4.7) years. Subjects were predominately female (78.8%), Caucasian (81.4%), and of lower socioeconomic status. Initial recruitment was evenly balanced between inpatient, outpatient, and non-patient (community) sources. In the 10-year interval, 55 subjects (46.6%) attempted suicide. Compared to baseline, suicidal ideation, number of attempts, and non-suicidal self-injury diminished markedly. Core symptoms of BPD, substance abuse, and alcohol use disorders decreased significantly; however, major depressive disorder (MDD) remained constant at 50%. Forty-four percent of subjects had poor psychosocial, vocational, and economic outcomes. Psychosocial outcome was independent of suicide history and any treatment. Increased risk was associated with interval hospitalization prior to any attempt (illness severity), as well as poor social, vocational, and psychosocial functioning at baseline.

Motivational Interviewing to Increase Outpatient Attendance for Adolescent Psychiatric Patients.

Motivational interviewing (MI) is a therapeutic technique that has been demonstrated to increase adherence to various treatment regimens. Nonattendance at outpatient appointments is associated with read-mission to psychiatric hospitals. The purpose of the current study was to examine the effectiveness of MI in promoting treatment adherence and increasing pediatric attendance rates at patients' first follow-up appointment after inpatient admission. A sample of 111 patients discharged from one of two child and adolescent units at an urban, inpatient psychiatric hospital in Southwestern Pennsylvania participated in the MI discharge process. Compared to hospital population data from 1 month prior to the current study, the MI discharge process demonstrated an increase of approximately 10% in attendance at the scheduled follow-up appointments and a decrease of approximately 4% in cancellations and no-show appointments. It was concluded that particularly for adolescents, MI may be a valuable treatment approach grounded in partnerships with health care providers, patients, and families to enhance outpatient appointment attendance. [Journal of Psychosocial Nursing and Mental Health Services, 56(6), 31-35.].

Suicidal Behavior and Psychosocial Outcome in Borderline Personality Disorder at 8-Year Follow-Up.

We sought predictors of both suicidal behavior and psychosocial outcome in subjects with BPD followed for 8 years and asked if there was a relationship between these outcomes. One hundred twenty-three BPD subjects, recruited from inpatient (35.8%), outpatient (30.9%) and community (33.3%) sources, were assessed annually for known risk factors for suicidal behavior. Interval attempts were reported by 25 subjects (20.2%). Increased risk of suicide attempt was associated with negative affectivity, aggression, inpatient recruitment, hospitalizations, minority race, and frequent changes in employment. Decreased risk was associated with increased education. Poor psychosocial outcome was predicted by impulsivity, negative affectivity, and antisocial traits at baseline, and by comorbid MDD at 8-year follow-up. There was no significant relationship between poor psychosocial outcome at 8-year follow-up and risk of suicidal behavior. Predictors of suicidality include modifiable risk factors. Rehabilitation models are needed to address educational and vocational deficits associated with suicidality, especially among minorities.

Cognitive testing in older primary care patients: A cluster-randomized trial.

INTRODUCTION: This study investigated whether neuropsychological testing in primary care (PC) offices altered physician-initiated interventions related to cognitive impairment (CI) or slowed the rate of CI progression. METHODS: This 24-month, cluster-randomized study included 11 community-based PC practices randomized to either treatment as usual (5 practices) or cognitive report (CR; 6 practices) arms. From 2005 to 2008, 533 patients aged ≥65 years and without a diagnosis of CI were recruited; 423 were retested 24 months after baseline. RESULTS: CR physicians were significantly more likely to order cognitive-related interventions (P = .02), document discussions about cognition (P = .003), and order blood tests to rule out reversible CI (P = .002). At follow-up, significantly more CR patients had a medication for cognition listed in their chart (P = .02). There was no difference in the rate of cognitive decline between the groups. DISCUSSION: Providing cognitive information to physicians resulted in higher rates of physician-initiated interventions for patients with CI.

Nonpharmacological therapeutic techniques to decrease agitation in geriatric psychiatric patients with dementia.

Agitation is not only a frequent and disturbing behavior for many patients with dementia, but it also troubles their caregivers and families. Many serious problems and side effects are associated with the use of medications to treat agitation; therefore, alternative approaches to treating agitation must be assessed. The current article presents results from a quality improvement pilot project that examined the usefulness of a specially designed, multisensory room intervention for geriatric psychiatric inpatients with mild to moderate agitation. Thirty-two visits to the sensory room were made by 13 inpatients with dementia. A significant decrease occurred in the Pittsburgh Agitation Scale (PAS) total scores over time from pre-room to post-room intervention, as well as 1-hour post-room intervention (F = 95.3, p < 0.001). Significant effects were found for all PAS subscales (i.e., aberrant vocalizations, motor agitation, and resistance to care), with the exception of the aggression subscale. The multisensory room intervention was effective in decreasing some symptoms of agitation in the geriatric psychiatric patient, thus contributing to positive patient, family, and nursing outcomes.

Effects of serotonin-2A receptor binding and gender on personality traits and suicidal behavior in borderline personality disorder.

Impulsivity and aggressiveness are personality traits associated with a vulnerability to suicidal behavior. Behavioral expression of these traits differs by gender and has been related to central serotonergic function. We assessed the relationships between serotonin-2A receptor function, gender, and personality traits in borderline personality disorder (BPD), a disorder characterized by impulsive-aggression and recurrent suicidal behavior. Participants, who included 33 BPD patients and 27 healthy controls (HC), were assessed for Axis I and II disorders with the Structured Clinical Interview for DSM-IV and the International Personality Disorders Examination, and with the Diagnostic Interview for Borderline Patients-Revised for BPD. Depressed mood, impulsivity, aggression, and temperament were assessed with standardized measures. Positron emission tomography with [(18)F]altanserin as ligand and arterial blood sampling was used to determine the binding potentials (BPND) of serotonin-2A receptors in 11 regions of interest. Data were analyzed using Logan graphical analysis, controlling for age and non-specific binding. Among BPD subjects, aggression, Cluster B co-morbidity, antisocial PD, and childhood abuse were each related to altanserin binding. BPND values predicted impulsivity and aggression in BPD females (but not BPD males), and in HC males (but not HC females.) Altanserin binding was greater in BPD females than males in every contrast, but it did not discriminate suicide attempters from non-attempters. Region-specific differences in serotonin-2A receptor binding related to diagnosis and gender predicted clinical expression of aggression and impulsivity. Vulnerability to suicidal behavior in BPD may be related to serotonin-2A binding through expression of personality risk factors.

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

OBJECTIVES: Adverse drug events (ADEs) are common in ambulatory care and may result from poor patient-physician communication about medication-related symptoms. A module was developed within an electronic patient portal that was designed to enhance communication about medication symptoms and, in turn, reduce ADEs and health-care utilization. METHODS: The researchers conducted a randomized, controlled clinical trial of MedCheck, an automated electronic message generated in a patient Internet portal. MedCheck asked intervention patients if they had filled a recent prescription and if they had experienced any problems with the medication. Patients' responses were forwarded automatically to primary care physicians. The study enrolled 375 intervention patients and 363 controls. After 3 months, the investigators reviewed patients' medical records and conducted telephone interviews to identify ADEs and to assess health-care utilization. RESULTS: Among the 375 intervention patients, 184 (49%) responded to at least 1 MedCheck message. Patients reported 52 unfilled prescriptions and 56 medication problems. Patients responded to 72% of messages within 1 day. There was no statistically significant difference between intervention and control groups in the rate of ADEs, preventable or ameliorable ADEs, serious ADEs, or in subjects' health-care utilization. CONCLUSIONS: Internet portals have the potential to enhance patient-physician communication. However, additional development is required to demonstrate that such interventions can improve medication safety or health-care utilization.

Subtyping borderline personality disorder by suicidal behavior.

Course and outcome of Borderline Personality Disorder (BPD) are favorable for the vast majority of patients; however, up to 10% die by suicide. This discrepancy begs the question of whether there is a high lethality subtype in BPD, defined by recurrent suicidal behavior and increasing attempt lethality over time. In a prospective, longitudinal study, we sought predictors of high lethality among repeat attempters, and defined clinical subtypes by applying trajectory analysis to consecutive lethality scores. Criteria-defined subjects with BPD were assessed using standardized instruments and followed longitudinally. Suicidal behavior was assessed on the Columbia Suicide History, Lethality Rating Scale, and Suicide Intent Scale. Variables discriminating single and repeat attempters were entered into logistic regression models to define predictors of high and low lethality attempts. Trajectory analysis using three attempt and five attempt models identified discrete patterns of Lethality Rating Scale scores. A high lethality trajectory was associated with inpatient recruitment, and poor psychosocial function, a low lethality trajectory with greater Negativism, Substance Use Disorders, Histrionic and/or Narcissistic PD co-morbidity. Illness severity, older age, and poor psychosocial function are characteristics of a poor prognosis subtype related to suicidal behavior.

Prospective predictors of suicidal behavior in borderline personality disorder at 6-year follow-up.

OBJECTIVE: Recurrent suicidal behavior is a defining characteristic of borderline personality disorder. Although most patients achieve remission of suicidal behavior over time, as many as 10% die by suicide, raising the question of whether there is a high-risk suicidal subtype. The authors conducted a longitudinal study of suicidal behavior in borderline personality disorder patients to identify prospective predictors of suicide attempts and to characterize those patients at highest risk for suicide completion. METHOD: Demographic and diagnostic characteristics and clinical and psychosocial risk factors assessed at baseline were examined for predictive association with medically significant suicide attempts using Cox proportional hazards models. The authors defined prospective predictors for participants who completed 6 or more years in the study and compared the data to those of earlier intervals. RESULTS: Among 90 participants, 25 (27.8%) made at least one suicide attempt in the interval, and most attempts occurred in the first 2 years. The risk of suicide attempt was increased by low socioeconomic status, poor psychosocial adjustment, family history of suicide, previous psychiatric hospitalization, and absence of any outpatient treatment before the attempt. Higher global functioning scores at baseline decreased this risk. CONCLUSIONS: Risk factors predictive of suicide attempt change over time. Acute stressors such as major depressive disorder were predictive only in the short term (12 months), while poor psychosocial functioning had persistent and long-term effects on suicide risk. Half of borderline patients have poor psychosocial outcomes despite symptomatic improvement. A social and vocational rehabilitation model of treatment is needed to decrease suicide risk and optimize long-term outcomes.

Educating for wellness: a wellness education group intervention for adults with chronic severe mental illness living in the community.

Chronic severe mental illness (CSMI) is a common disorder in the United States associated with numerous adverse health effects. Health promotion educational interventions can be beneficial. The purpose of this project was to implement and evaluate a community-based educational program for adults with CSMI. Analyses of quantitative and qualitative data showed overall satisfaction with the program and achievement of some specific consumer health modifications. Three primary areas of interest and benefit included socialization and support, education and information, and motivation to change. The Wellness Education Group Intervention (WEGI) can serve as a model for wellness education with adults in similar communities.

Hospitalized patients' participation and its impact on quality of care and patient safety.

OBJECTIVE: To understand the extent to which hospitalized patients participate in their care, and the association of patient participation with quality of care and patient safety. DESIGN: Random sample telephone survey and medical record review. SETTING: US acute care hospitals in 2003. PARTICIPANTS: A total of 2025 recently hospitalized adults. MAIN OUTCOME MEASURES: Hospitalized patients reported participation in their own care, assessments of overall quality of care and the presence of adverse events (AEs) in telephone interviews. Physician reviewers rated the severity and preventability of AEs identified by interview and chart review among 788 surveyed patients who also consented to medical record review. RESULTS: Of the 2025 patients surveyed, 99.9% of patients reported positive responses to at least one of seven measures of participation. High participation (use of >4 activities) was strongly associated with patients' favorable ratings of the hospital quality of care (adjusted OR: 5.46, 95% CI: 4.15-7.19). Among the 788 patients with both patient survey and chart review data, there was an inverse relationship between participation and adverse events. In multivariable logistic regression analyses, patients with high participation were half as likely to have at least one adverse event during the admission (adjusted OR = 0.49, 0.31-0.78). CONCLUSIONS: Most hospitalized patients participated in some aspects of their care. Participation was strongly associated with favorable judgments about hospital quality and reduced the risk of experiencing an adverse event.

Associations between religiosity and sexual and contraceptive behaviors.

STUDY OBJECTIVE: To determine associations between religiosity and female adolescents' sexual and contraceptive behaviors. DESIGN: We conducted a secondary analysis on data from a randomized controlled trial comparing interventions designed to prevent pregnancy and sexually transmitted diseases (STDs). Multivariable modeling assessed the association between a religiosity index consisting of items related to religious behaviors and impact of religious beliefs on decisions and sexual outcomes. PARTICIPANTS: 572 female adolescents aged 13 to 21, recruited via a hospital-based adolescent clinic and community-wide advertisements. MAIN OUTCOME MEASURES: Sexual experience, pregnancy, STDs, number of lifetime partners, frequency of sexual activity, previous contraceptive use, and planned contraceptive use. RESULTS: Mean participant age was 17.4 +/- 2.2 years and 68% had been sexually active. Most (74.1%) had a religious affiliation and over half (52.8%) reported that their religious beliefs impact their decision to have sex at least "somewhat." Multivariate analyses showed that, compared with those with low religiosity, those with high religiosity were less likely to have had sexual intercourse (OR = 0.23, 95% CI = 0.14, 0.39). Among sexually active participants, those with high religiosity were less likely to have been pregnant (OR = 0.46, 95% CI = 0.22, 0.97), to have had an STD (OR = 0.42, 95% CI = 0.22, 0.81), or to have had multiple (>or=4) lifetime partners (OR = 0.38, 95% CI = 0.21, 0.68) compared to those with low religiosity. Levels of religiosity were not significantly associated with frequency of intercourse, contraception use at last intercourse, or planned contraceptive use. CONCLUSION: In this cohort, religiosity appeared to be a protective factor rather than a risk factor with regard to sexual behavior and was not associated with contraception use.

Improving residents' end-of-life communication skills with a short retreat: a randomized controlled trial.

BACKGROUND: Internal medicine residents are largely unprepared to carry out end-of-life (EOL) conversations. There is evidence that these skills can be taught, but data from randomized controlled trials are lacking. PURPOSE: We studied whether a day-long communication skills training retreat would lead to enhanced performance of and confidence with specific EOL conversations. We also studied the effect of the retreat on residents' ability to respond to patient emotions. METHODS: PGY-2 resident volunteers were randomly assigned to a retreat group or a control group. The retreat involved a combination of teaching styles and skills practice with standardized patients. All participants completed questionnaires and were evaluated carrying out two types of conversations (breaking bad news or discussing direction of care) with a standardized patient before (T1) and after (T2) the intervention phase. Conversations were audio-taped and later rated by a researcher blinded to group assignment and time of assessment. RESULTS: Forty-nine residents agreed to randomization (88%) with 23 residents randomized to the retreat group and 26 to the control group. Compared to controls, retreat participants demonstrated higher T2 scores for breaking bad news, discussing direction of care, and responding to emotion. Comparing T2 to T1, the retreat group's improvement in responding to emotion was statistically significant. The retreat group's confidence improved significantly only for the breaking bad news construct. CONCLUSIONS: A short course for residents can significantly improve specific elements of resident EOL conversation performance, including the ability to respond to emotional cues.

Depression, anxiety and quality of life in suicide survivors: a comparison of close and distant relationships.

The study's purpose was to describe and compare depression, anxiety, and quality of life, by degree of relationship, between closely related and distantly related survivors (persons close to the suicide victim, or "suicide survivors"; N = 60) during the acute phase of bereavement (within 1 month of the death). The close relationship category included spouses, parents, children, and siblings, whereas the distant relationship category included in-laws, aunts/uncles, and nieces/nephews. Analysis of covariance examined differences between the two groups on the symptom measures. Results indicate that, after controlling for age and gender effects, closely related survivors had significantly higher mean levels of depression and anxiety and had lower levels of mental health quality of life. There were no statistically significant differences on the physical health quality of life subscale.

Adolescent and young adult women's knowledge of and attitudes toward the intrauterine device.

BACKGROUND: This study aimed to assess adolescent (aged 14-18 years) and young adult (aged 19-24 years) women's knowledge of and attitudes toward intrauterine devices (IUDs) before and after a brief educational intervention. STUDY DESIGN: We administered a 43-item survey to 144 women aged 14-24 years, with half in each age category. The survey assessed knowledge of and attitudes toward IUDs, and incorporated a 3-min educational intervention about IUDs. Predictors for knowledge of and attitudes toward the IUD were examined using logistic regression. RESULTS: Forty percent of participants had heard of the IUD. Having ever heard of the IUD was associated with age >18 years [adjusted odds ratio (OR)=5.7; 95% confidence interval (95% CI)=2.1-15.7], a higher level of maternal education (adjusted OR=4.5; 95% CI=1.5-13.3) and a history of voluntary sexual intercourse (adjusted OR=4.9; 95% CI=1.0-23.5). Of those who had heard of the IUD previously, 37.5% reported a positive attitude toward the IUD before the intervention. After the educational intervention, 53.5% of all participants reported a positive attitude toward the IUD, with both adolescent and young adult women having similarly positive attitudes (51.4% vs. 55.6%, p=.62). This positive attitude was associated only with a history of voluntary sexual intercourse (adjusted OR=5.2; 95% CI=1.3-21.1). The characteristics of the IUD that the participants strongly liked and disliked were rated similarly by the two age groups. However, more adolescent women considered the privacy of the IUD and the ability to use the copper IUD for 10 years as positive characteristics. CONCLUSION: Most young women were unaware of IUDs but were likely to think positively about IUDs after being educated about them. Demographic and reproductive health history did not predict attitude; thus, all young women should be offered education about IUDs.

Factors associated with mental health service utilization among bipolar youth.

OBJECTIVES: This study aims to characterize patterns of mental health service utilization within a sample of bipolar youth. Demographic variables, youth bipolar characteristics, youth comorbid conditions, and parental psychopathology were examined as predictors of treatment utilization across different levels of care. METHODS: A total of 293 bipolar youth (aged 7-17 years) and their parents completed a diagnostic interview, family psychiatric history measures, and an assessment of mental health service utilization. Demographic and clinical variables were measured at baseline and mental health service use was measured at the six-month follow-up. RESULTS: Approximately 80% of bipolar youth attended psychosocial treatment services over the span of 6 months. Of those who attended treatment, 67% attended only outpatient services, 22% received inpatient/partial hospitalization, and 12% received residential/therapeutic school-based services. Using multinomial logistic regression, older age, female gender, and bipolar characteristics, including greater symptom severity and rapid cycling, were found to predict higher levels of care. Youth suicidal and non-suicidal self-injurious behavior, comorbid conduct disorder, and parental substance use disorders also predicted use of more restrictive treatment settings. CONCLUSIONS: Results underscore the importance of assessing for and addressing suicidality, comorbid conduct disorder, and parental substance use disorders early in the treatment of bipolar youth to potentially reduce the need for more restrictive levels of care.