Case fatality of repeated suicidal acts among suicide attempters in rural China: a retrospective cohort study.

Background: Individuals presenting to hospital due to suicide attempt are at high risk for repeated suicidal act, yet there are meager data on the extent to which repeated suicidal acts result in death. Methods: This retrospective cohort study was based on a general hospital self-harm register system in a rural county in China. Identified individuals who attempted suicide were contacted and followed up for up to 8 years. Main outcomes over follow-up were: 1) suicide death, 2) nonlethal suicide attempt, and 3) suicidal acts including suicide death and nonlethal attempt. Incidence densities, correlates, and case fatality of repeated suicidal acts were estimated. Findings: A total of 1086 individuals (two-thirds females, mean age 40.6 years) with a suicide attempt presenting to hospital (index attempt) were identified and followed up, with most of the index attempts by pesticide ingestion (79%). Over follow-up, there were 116 suicidal acts carried out by 108 individuals (69 females, 39 males), including 34 suicide deaths (21 females, 13 males), yielding a high case-fatality of 29.3%. During follow-up, suicide death rates were also high overall and in the first year of follow-up (846.7 and 1787.2 per 100,000 person years). Over follow-up, pesticide was the most common method (47/116) of repeated suicidal act and yielded a higher case-fatality than other methods (46.8% vs 17.4%, χ2 = 11.68, P < 0.001). The incidence densities of repeated suicidal acts and nonlethal attempts were low compared to rates reported in previous literature. Interpretation: Incidence densities of repeated suicidal acts in a rural China cohort were low compared to previous studies. However, rates of suicide deaths over follow-up were high, a result driven by the high case-fatality of suicidal acts and attributable to the common use of pesticides. Reducing suicidal acts with pesticides is a key target for suicide prevention in rural China. Funding: Beijing Municipal High Rank Public Health Researcher Training Program, Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support, and Beijing Hospitals Authority's Ascent Plan.

Deaf perceptions about treatment for alcohol use and mental health.

INTRODUCTION: Recent research suggests that alcohol use disorder may be more prevalent in the Deaf community, a diverse sociolinguistic minority group. However, rates of treatment-seeking among Deaf individuals are even lower than in the general society. This study used the Theory of Planned Behavior to identify Deaf adults' beliefs about treatment that may prevent their treatment-seeking behaviors. METHODS: This study conducted elicitation interviews with 16 Deaf adults. The study team recruited participants from across the U.S. and conducted interviews on Zoom. Participant ages ranged from 27 to 67 years (M = 40, SD =10.8). Seventy-five percent of the sample was male, 75 % were White, and 12.5 % were Hispanic/Latine. The study conducted interviews in American Sign Language, subsequently interpreted into English by a nationally certified interpreter, and transcribed for data analyses. The study analyzed transcripts using the Framework Method. The study team coded the interviews in groups and assessed for saturation (≤ 5 % new themes) of themes throughout the analysis. This study reached saturation in the third group (six total groups). RESULTS: Identified themes followed the Theory of Planned Behavior constructs. The study identified nine Behavioral Beliefs with four advantages and five disadvantages of seeking treatment, four Normative Beliefs with one support and three oppositions to seeking treatment, and thirteen Control Beliefs with five facilitators and eight barriers to seeking treatment. Overall, the Deaf participants reported several unique beliefs based on their cultural and linguistic perspectives, including a concern about unqualified providers, experiencing stress in treatment with hearing providers, stigma within the Deaf community, less access to cultural information about alcohol and mental health, less encouragement of traditional treatment in marginalized communities, and additional barriers (e.g., communication, limited Deaf treatment options, discrimination, etc.). CONCLUSIONS: A thorough understanding of individual beliefs about treatment is necessary to develop interventions that may increase treatment-seeking behaviors. Previous research has demonstrated that individual beliefs may be modified using Cognitive Behavioral Therapy techniques to increase treatment-seeking behaviors among hearing individuals. Similar interventions may be useful with Deaf individuals; however, they must consider the unique cultural and linguistic perspectives of the community.

Adolescent Predictors of Firearm Suicide Over Four Decades of Life in U.S. Men.

INTRODUCTION: There are meager individual-level data on long-term predictors of firearm suicide. METHODS: This was an analysis of males (N=189,558) in the Project Talent cohort, a national probability sample of high school schools in 1960 when students completed a baseline Project Talent self-report inventory. Mortality follow-up was contingent on survival until 1979, the onset of the National Death Index when the cohort had a mean age of 35.7 years. Mortality follow-up continued until death or age 75 years, reached by all surviving members by 2018. Analyses were conducted in 2022, with the main outcome being firearm suicide deaths (n=479). Factor analyses of Project Talent items yielded three key factors: (1) interests in firearm-related professions (i.e., military service, police force), (2) interests in hunting or fishing and knowledge of long guns, and (3) stereotypic masculinity. RESULTS: Survival analyses showed that long-term risk for firearm suicide was associated with 1-SD increases in firearm-related vocational interests in adolescence (adjusted hazard ratio [95% CI]=1.23 [1.09, 1.40]) and masculinity (adjusted hazard ratio [95% CI]=1.15 [1.04, 1.28]). Decreased long-term firearm suicide risk was associated with increased hunting interests and knowledge of long guns in adolescence (adjusted hazard ratio [95% CI]=0.86 [0.77, 0.96]) and competitive sports participation, an exploratory variable (adjusted hazard ratio [95% CI]=0.89 [0.80, 0.99]). CONCLUSIONS: Prevention efforts are needed to lower long-term firearm suicide risk among adolescent males with high stereotypic masculinity and those interested in military or police service. Potential protective effects of competitive sports participation and socialization to long guns through hunting require further study.

Use of Routine Emergency Department Care Practices with Deaf American Sign Language Users.

BACKGROUND: Deaf individuals who communicate using American Sign Language (ASL) seem to experience a range of disparities in health care, but there are few empirical data. OBJECTIVE: To examine the provision of common care practices in the emergency department (ED) to this population. METHODS: ED visits in 2018 at a U.S. academic medical center were assessed retrospectively in Deaf adults who primarily use ASL (n = 257) and hearing individuals who primarily use English, selected at random (n = 429). Logistic regression analyses adjusted for confounders compared the groups on the provision or nonprovision of four routine ED care practices (i.e., laboratories ordered, medications ordered, images ordered, placement of peripheral intravenous line [PIV]) and on ED disposition (admitted to hospital or not admitted). RESULTS: The ED encounters with Deaf ASL users were less likely to include laboratory tests being ordered: adjusted odds ratio 0.68 and 95% confidence interval 0.47-0.97. ED encounters with Deaf individuals were also less likely to include PIV placement, less likely to result in images being ordered in the ED care of ASL users of high acuity compared with English users of high acuity (but not low acuity), and less likely to result in hospital admission. CONCLUSION: Results suggest disparate provision of several types of routine ED care for adult Deaf ASL users. Limitations include the observational study design at a single site and reliance on the medical record, underscoring the need for further research and potential reasons for disparate ED care with Deaf individuals.

Brief, cognitive-behavioral intervention to promote treatment seeking in adults with severe alcohol use disorder: A randomized controlled trial.

BACKGROUND AND AIMS: There is little RCT evidence that brief interventions improve treatment seeking in individuals with severe alcohol use disorder (AUD) or treatment seeking reduces alcohol use. The aim was to test the efficacy of a brief intervention to increase treatment seeking in treatment naïve adults with severe AUD and measure its effects on alcohol use. DESIGN: Parallel group, non-pharmacologic RCT with intervention (n = 197) and active control (n = 203) conditions, with blinded assessors conducting follow-ups at 1, 3 and 6 months. SETTING: Online recruitment in a 17-county region of upstate New York, USA. PARTICIPANTS: Inclusion criteria consisted of ages ≥18 years, Alcohol Use Disorders Identification Test score ≥16, exceeds recommended limits for alcohol use and no history of AUD treatment. n = 400; 50% female; 79% white; mean age, 40.7; mean education, 14.6 years. INTERVENTION AND COMPARATOR: One-session telephone-delivered interventions: Cognitive-Behavioral Therapy for Treatment Seeking (CBT-TS; intervention), review of a National Institute on Alcohol Abuse and Alcoholism pamphlet on AUD treatment (control). MEASUREMENTS: Self-report of any AUD treatment use over 3 months (primary outcome) and two standard measures of alcohol use over 6 months (secondary outcomes). FINDINGS: Intent-to-treat analyses were used. Assessment follow-up rates were ≥93%. Any alcohol-related treatment use over 3-month follow-up was obtained by 38 (19%) intervention participants and 36 (18%) control participants, a non-significant difference, χ2 [1] = 0.16, P = 0.689. Secondary analysis showed a significant interaction term between sex and intervention assignment (ß = -1.197, P = 0.027). The interaction suggested CBT-TS was effective in men (22% vs 13%), although the evidence was somewhat weak (P = 0.071), and it was not effective in women (17% vs 24%). CONCLUSIONS: A one-session cognitive-behavioral therapy intervention to increase treatment seeking in treatment naïve adults with severe alcohol use disorder did not increase treatment seeking.

Youth Mobile Response and Stabilization Services: Factors Associated with Multiple Episodes of Care.

Mobile response and stabilization services (MRSS) provide short-term, community-based, care to individuals in crisis. Minimal studies have explored which factors are associated with multiple episodes of MRSS care. We used a retrospective cohort design of MRSS electronic health records to explore demographic and clinical characteristics associated with multiple episodes of care among 2,641 youth ages 5-21 years old in New York, USA. Youth with multiple episodes of care (n = 585; 22.2%) were more likely to be non-Hispanic, have treatment histories including presenting problems related to adjustment, conduct, mood, or suicidal thoughts and behaviors, have high-level mental health visits, and more follow-up visits. Future research should examine the unmet needs of non-Hispanic populations and whether characteristics associated with multiple MRSS episodes are consistent across populations to inform procedures targeting unmet needs that prevent or minimize repeated use during crises.

Efficacy of CBT for Treatment Seeking (CBT-TS) in Untreated Veterans and Service Members at Risk for Suicidal Behavior.

OBJECTIVE: Military members and Veterans at-risk for suicide are often unlikely to seek behavioral health treatment. The primary aim of this study was to test the efficacy of brief CBT for Treatment Seeking (CBT-TS) to improve behavioral health treatment utilization among U.S. military service members and Veterans at-risk for suicide. METHODS: A total of 841 participants who served in the U.S. military since 9/11 and who reported suicidality but were not in behavioral health treatment were recruited to participate in this trial. Participants were randomly assigned to either brief CBT-TS delivered by phone or an assessment-only control condition. Follow-up assessments were conducted at baseline and months 1, 3, 6, and 12 to track treatment utilization and symptoms. RESULTS: CBT-TS resulted in significantly greater behavioral health treatment initiation within 1 month compared to the control condition (B = .93, p < .001); and the higher treatment initiation persisted for 12 months post intervention. CONCLUSIONS: This study employed a low-cost, easily implementable one-session intervention administered by phone. The study provides evidence that CBT-TS is efficacious in promoting behavioral health treatment initiation in an adult population at risk for suicidal behavior and showed enduring benefits for 6-12 months. CBT-TS provides a unique strategy for treatment engagement for at-risk adults unlikely to seek treatment. TRIAL REGISTRATION: Clinicaltrials.gov NCT05077514.

Predictive value of suicidal risk assessment using data from China's largest suicide prevention hotline.

BACKGROUND: Suicide hotlines are widely used, with potential for identification of callers at especially high risk. METHODS: This prospective study was conducted at the largest psychological support hotline in China. From 2015 to 2017, all distressed callers were consecutively included and assessed, using a standardized scale consisting of 12 elements, yielding scores of high risk (8-16), moderate risk (4-7), and low risk (0-3) for suicidal act. All high-risk and half of moderate- and low-risk callers were scheduled for a 12-month follow-up. Main outcomes were suicidal acts (nonlethal attempt, death) over follow-up. RESULTS: Of 21,346 fully assessed callers, 5822, 11,791, and 3733 were classified as high-, moderate-, or low-risk for suicidal acts, with 8869 callers (4076 high-, 3258 moderate-, and 1535 low-risk) followed up over 12 months. Over follow-up, 802 (9.0 %) callers attempted suicide or died by suicide. The high-risk callers (15.1 %) had 3-fold higher risk for subsequent suicidal acts than moderate- (5.1 %) and 12-fold higher risk than low-risk callers (1.3 %). The weighted sensitivity, specificity, and positive predictive value of high risk scores were 56.4 %, 74.9 %, and 14.4 %. LIMITATIONS: Assessed callers with different risk levels were followed disproportionally. CONCLUSIONS: Suicidal risk assessment during a hotline call is both feasible and predictive of risk, guiding resource allocation to higher risk callers.

A controlled examination of acute warning signs for suicide attempts among hospitalized patients.

BACKGROUND: Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt. METHODS: Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period). RESULTS: Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses. CONCLUSIONS: The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

Impact of mandatory COVID-19 shelter-in-place order on controlled substance use among rural versus urban communities in the United States.

PURPOSE: Mandatory COVID-19 shelter-in-place (SIP) orders have been imposed to fight the pandemic. They may also have led to unintended consequences of increased use of controlled substances especially among rural communities due to increased social isolation. Using the data from the American Association of Poison Control Centers, this study tests the hypothesis that the poison control centers received higher rates of calls related to exposures to controlled substances from rural counties than they did from urban counties during the SIP period. METHODS: Call counts received by the poison control centers between October 19, 2019 and July 6, 2020 due to exposure to controlled substance (methamphetamine, opioids, cocaine, benzodiazepines, and other narcotics) were aggregated to per-county-per-month-per-10,000 population exposure rates. A falsification test was conducted to reduce the possibility of spurious correlations. FINDINGS: During the study period, 2,649 counties in the United States had mandatory SIP orders. The rate of calls reporting exposure to any of the aforementioned controlled substances among the rural counties was higher (14%; P = .047) relative to the urban counties. This overall increase was due to increases in the rates of calls reporting exposure to opioids (26%; P = .017) and methamphetamine (39%; P = .077). Moreover, the rate of calls reporting exposures at home was also higher among the rural counties (14%; P = .069). CONCLUSION: The mandatory SIP orders may have had an unintended consequence of exacerbating the use of controlled substances at home in rural communities relative to urban communities.

Qualitative analysis of hospital patient narratives of warning signs on the day of their suicide attempt.

OBJECTIVE: Research on warning signs, defined as acute risk factors for suicide or suicide attempt, has been slow due to the difficulty of examining the hours and minutes preceding suicidal behavior. This study sought to identify new warning signs and to re-examine warning signs that have been proposed. METHOD: Narrative stories of adult patients with substance use problems hospitalized following a suicide attempt were transcribed. The narrative segments describing the 24-h period prior to suicide attempt were examined with directed qualitative content analysis using codes based on prior literature and new codes developed inductively. RESULTS: The sample (N = 35) was mean age = 40, 51% female, and 49% White non-Hispanic. Analysis of the transcripts of the 24-h periods (M word count = 637) yielded a broad range of cognitive (e.g., cognitive disturbance such as rumination), behavioral (e.g., alcohol use), emotional (e.g., dramatic mood changes), and social (e.g., social withdrawal) warning signs, along with a small number of cognitions and behaviors that appeared to mark a dangerous shift to acute preparation and intent for attempt, for example 'self-persuasion to attempt suicide.' CONCLUSION: We posit that a broad range of cognitive, behavioral, emotional, and social warning signs increase acute risk for suicidal behavior by creating the conditions for a shift to acute preparation and intent, a highly potent category of warning signs.

Intergenerational social mobility and suicide risk by firearm and other means in US males.

Firearms are the leading method of suicide in US men, and socioeconomic status (SES) is associated with suicide risk. In this 40-year mortality follow-up of a national cohort of US men, we examined if improved SES relative to one's family of origin, upward intergenerational social mobility (ISM), is associated with lowered risk for firearm suicide and suicide by other means in US men. Family of origin SES was assessed as part of Project Talent, a broad survey of US high school students in 1960. 42,766 men in the cohort completed follow-up surveys at age 29, assessing attained SES via education, occupation, and income. ISM was measured by change between harmonized SES composites. Mortality follow-up was conducted through age 70. Adjusting for baseline SES and race/ethnicity, a 1 standard deviation increase in SES was associated with a 31% reduction in firearm suicide risk later in the life course (HR [95% CI] = 0·69 [0·54, 0·88], P = 0·003), and a smaller, non-significant reduction in suicide by other means (HR [95% CI] = 0·80 [0·60, 1·07], P = 0·136). Traits associated with both suicide and SES attainment (cognitive ability, calm, impulsivity) only modestly attenuated this association. Upward ISM was more strongly associated with reduced firearm suicide risk in males with parents of low SES. The association between upward ISM and reduced firearm suicide mortality risk prevailed over ensuing decades. Policies improving social mobility in US males, particularly those of lower SES, may function as de-facto firearm suicide prevention strategies.

Alcohol use during COVID-19 in adults with severe untreated AUD.

Evidence demonstrating increased alcohol use during COVID-19 comes from low- to moderate-alcohol use samples and has yet to use adults with severe but untreated AUD. Using a community sample of adults with severe AUD, this exploratory, cross-sectional study examined associations of COVID-19 alcohol use. Participants were recruited for a phase-II RCT. Only baseline measures, completed prior to randomization, were analyzed in the present study. Key variables were alcohol consumption, COVID-19-related worries and experiences, and qualitative responses of 1) alcohol use and 2) positive changes during COVID-19. 176 pariticpants recruited since COVID-19 were on average 41.4 years old, 49.1% female, and 79% White. Participants drank alcohol nearly 23 of the past 30 days, consumed 7 standard drinks per drinking day, and nearly 90% reported increased alcohol use. More heavy episodic drinking was reported in the first six-months of COVID-19 and more COVID-related concerns in the most recent six-months. Participants reported drinking increased due to "more time on their hands", but the pandemic also "strengthened relationships". Results affirm an increase in alcohol use during COVID-19 in adults with severe, untreated AUD. Findings underscore the need to understand how alcohol use and pandemic-related circumstances may influence one another for adults with severe AUD.

Alcohol-related consequences and the intention to seek care in treatment naïve women and men with severe alcohol use disorder.

INTRODUCTION: Research on treatment utilization for alcohol use disorder (AUD) is based primarily on clinical samples and community samples of low AUD severity that may not need formal care. Using a community sample of adults with untreated but severe AUD symptoms, we tested the hypothesis that alcohol-related consequences, but not alcohol consumption levels, are associated with the intention to seek AUD treatment, examined associations of specific types of alcohol-related consequences with intention, and explored sex differences in these associations. METHODS: The sample was recruited using social media ads for a randomized controlled trial to test a brief intervention to promote AUD treatment seeking. This report is based on analysis of baseline data collected prior to treatment intervention. Multiple linear regressions examined associations of measures of alcohol consumption, alcohol-related consequences broadly, and specific alcohol-related consequences with the intention to seek treatment. Moderating effects of sex on associations were explored. RESULTS: Subjects (n = 349) averaged 41 years of age, 48% were female, 6% were Latinx, 80% were white, 15% were Black, and 92% met criteria for severe AUD. Alcohol consumption measures were not associated with intention to seek treatment whereas interpersonal- and intrapersonal- consequences were associated with intention. Sex served as a moderator, with intrapersonal consequences (e.g., sad mood) showing a stronger association with intention in women and social responsibility consequences (particularly financial) associated with intention in men. CONCLUSION: Select alcohol-related consequences may be keys to understanding increased intention to seek AUD treatment including intrapersonal consequences in women and financial consequences in men.

BRIEF MOTIVATIONAL INTERVENTION FOR SUBSTANCE USE MAY DECREASE VIOLENCE AMONG HEAVY ALCOHOL USERS IN A JAIL DIVERSION PROGRAM.

Rates of harmful alcohol use are high among justice-involved individuals and may contribute to violent recidivism. Robust treatments for alcohol-related violence in criminal justice systems are thus a public health priority. In this analysis of existing randomized controlled trial data (N = 105), we examined the impact of a brief motivational intervention (BMI) for harmful substance use on violent recidivism among individuals in a pretrial jail diversion program. Results indicated that, after controlling for violence history, the intervention's impact on violent recidivism was moderated by baseline harmful alcohol use. Specifically, among people with severe alcohol problems at baseline, the BMI + standard care group had less violent recidivism at a 1-year follow-up than participants randomized to standard care alone. This finding was unchanged when we accounted for psychopathic traits. Our study provides preliminary evidence that a BMI may be useful for decreasing violent recidivism among heavy drinkers in criminal justice systems.

Suicide attempt risks among hotline callers with and without the coronavirus disease 2019 related psychological distress: a case-control study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic profoundly impacts on mental health, yet it is still unclear whether COVID-19 distress makes people more vulnerable to suicidal behavior. The present study aims to examine the association between COVID-19 related psychological distress and risk for suicide attempt, and moderators of this association, among hotline callers. METHODS: This case-control study was conducted at the largest psychological support hotline in China. Hotline callers who sought help for psychological distress and reported whether or not they attempted suicide in the last 2 weeks (recent suicide attempt) were analyzed. The primary predictor of recent suicide attempt was the presence or absence of COVID-19 related psychological distress. Demographic variables and common risk and protective factors for suicidal behavior were also studied. Callers with COVID-19 related distress (COVID-19 callers) and those without such distress (non-COVID-19 callers) were compared on these variables. Recent suicide attempt was regressed on COVID-19 related distress and the other variables, and significant interaction terms of aforementioned predictors by COVID-19 related distress, to identify variables that moderate the association of COVID-19 related distress and recent suicide attempt. RESULTS: Among 7337 included callers, there were 1252 COVID-19 callers (17.1%) and 6085 non-COVID-19 callers (82.9%). The COVID-19 callers were less likely to report recent suicide attempt (n = 73, 5.8%) than the non-COVID-19 callers (n = 498, 8.2%, P = 0.005). The COVID-19 callers were also less likely to have high scores on depressive symptoms (22.6% vs 26.3%, P < 0.001) and psychological distress (19.5% vs 27.3%, P < 0.001), and were more likely to have high hopefulness scores (46.5% vs 38.0%, P < 0.001). Tests of moderating effects showed that acute life events were associated with one-half lower risk (P = 0.021), and a trend that suicide attempt history was associated with two-thirds greater risk (P = 0.063) for recent suicide attempt, among COVID-19 callers than non-COVID-19 callers. CONCLUSIONS: The COVID-19 calls are from individuals with lower suicide-related risk compared to more typical callers. Acute stressful life events provided a key context for suicide attempt in non-COVID-19 callers, i.e., more typical calls.

Pilot RCT of the Attempted Suicide Short Intervention Program (ASSIP) adapted for rapid delivery during hospitalization to adult suicide attempt patients with substance use problems.

OBJECTIVE: The Attempted Suicide Short Intervention Program (ASSIP) was adapted for hospital delivery and to address substance use problems as well as evaluated for feasibility, acceptability, and therapist fidelity in a series of preparatory steps (n = 28) and in a pilot randomized controlled trial, RCT (n = 34). METHOD: In the RCT, patients with suicide attempts and substance use problem(s) with sufficient lengths of stay to deliver three ASSIP therapy sessions in hospital were randomized to adapted ASSIP or treatment as usual control. A blinded assessor identified suicide reattempts over 6-month follow-up with the Columbia-Suicide Severity Rating Scale (C-SSRS) and a comprehensive multi-source method. Treatment process measures and the Scale for Suicidal Ideation (SSI) were also administered. RESULTS: Median hospital stay was 13 days. ASSIP subjects reported high satisfaction with the treatment and high therapeutic alliance. Study therapists showed high fidelity to the modified ASSIP intervention. Repetition of suicide attempt was common in both study groups including a combined 9 (26%) subjects with reattempt based on C-SSRS and 13 (38%) subjects with reattempt based on multiple sources. CONCLUSIONS: Adult suicide attempt patients with substance use problems who require lengthy hospitalizations are at exceptionally high risk and may require additional strategies to lower risk.

Substance use, current criminal justice involvement, and lifetime suicidal thoughts and behaviors history: The moderating role of thwarted belonging.

OBJECTIVE: Criminal justice involvement, substance use, and suicide pose significant public health concerns; however, the unique and synergistic effects of these experiences among high-risk individuals remain understudied. We hypothesized positive main effects for alcohol-related severity, drug-related severity, current criminal justice involvement, and thwarted belonging (TB) on suicide ideation history (SIH) and suicide attempt history (SAH) and that TB would moderate these associations. METHOD: We report on cross-sectional analyses of self-report assessments completed by 824 adult residential substance use patients. RESULTS: Multinomial logistic regression analyses indicated that as alcohol- and drug-related severity increases, the probability of SIH and SAH increases; however, TB was only associated with a higher SIH probability. Significant two-way interactions (current criminal justice involvement*TB; alcohol-related severity*TB) indicated that (1) those high in TB with current criminal justice involvement were more likely to report a SIH than those without current criminal justice involvement; and (2) those low in TB and alcohol-related severity had the lowest SAH probability, whereas those low in TB and high in alcohol-related severity had the highest SAH probability. CONCLUSION: The unique and combined effects of interpersonal and contextual risk factors may improve suicide risk conceptualization and assessment, and allow for tailored treatments for this high-risk population.

Introducing the Psychological Autopsy Methodology Checklist.

OBJECTIVE: Case-control psychological autopsy studies are the research standard for the postmortem, quantitative study of ongoing or recent risk factors for suicide. We aimed to develop a reliable checklist of methodological quality of these studies. METHOD: We adapted items from a validated checklist to address general methodological elements and created novel items to address the unique aspects of psychological autopsy research to generate a 16-item checklist assessing reporting, external validity, internal validity, and power. We used percent agreement and kappa to evaluate inter-rater reliability of the items and overall checklist based on independent ratings of 26 case-control psychological autopsy studies conducted internationally. We also summed the items to generate overall quality ratings, assessing internal consistency with coefficient alpha (α). RESULTS: Inter-rater reliability for the overall checklist was high (percent agreement, 86.5%) and that based conservatively on kappa was substantial (κ .71) whereas internal consistency was low (α = 0.56). The inter-rater reliability of the individual items showed acceptable to high agreement. CONCLUSION: A novel checklist provides a reliable means to assess the methodological quality of specific elements of quantitative case-control psychological autopsy studies, providing detailed guidance in planning such studies. Lower internal consistency may limit its utility as a summary measure of study quality.

URMC Universal Depression Screening Initiative: Patient Reported Outcome Assessments to Promote a Person-Centered Biopsychosocial Population Health Management Strategy.

Background: Patient-reported outcomes (PROs) can promote person-centered biopsychosocial health care by measuring outcomes that matter to patients, including functioning and well-being. Data support feasibility and acceptability of PRO administration as part of routine clinical care, but less is known about its effects on population health, including detection of unmet healthcare needs. Our objectives were to examine differences in rates of clinically significant depression across sociodemographic groups and clinical settings from universal depression screens in a large health system, estimate the number of patients with untreated depression detected by screenings, and examine associations between biopsychosocial PROs-physical, psychological, and social health. Methods: We analyzed data from over 200,000 adult patients who completed depression screens-either PROMIS (Patient Reported Outcomes Measurement Information System) or PHQ-2/9-as part of routine outpatient care. Results: Depression screens were positive in 14.2% of the sample, with more positive screens among younger vs. older adults, women vs. men, non-White vs. White, and Hispanics vs. non-Hispanics. These same sociodemographic indicators, as well as completing screening in primary care (vs. specialty care) were also associated with greater likelihood of detected depression in the medical record. Discussion: Universal screening for depression symptoms throughout a large health system appears acceptable and has the potential to detect depression in diverse patient populations outside of behavioral health. Expanded delivery of PROs to include physical and social health as well as depression should be explored to develop a clinically-relevant model for addressing patients' biopsychosocial needs in an integrated fashion across the health system.