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

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

Attention-Deficit/Hyperactivity Disorder and Sports: A Lifespan Perspective.

Attention-deficit/hyperactivity disorder (ADHD), characterized by inattention, impulsivity and hyperactivity is a major health problem. This paper discusses ADHD across the life span and looks at the impact of debilitating symptoms, diagnosis, and treatment in athletes. Psychosocial interventions, with or without psychopharmacology including stimulants and nonstimulants, are discussed to help athletes achieve their highest level of symptom abatement and functioning. The age of the patient, the sport played, the athlete's overall health, and the regulations of the sport-governing body play a role in determining the most appropriate treatment.

Serious Suicide Attempts and Risk of Suicide Death.

Background: In the US, more than one million people attempt suicide each year. History of suicide attempt is a significant risk factor for death by suicide; however, there is a paucity of data from the US general population on this relationship. Aim: The objective of this study was to examine suicide attempts needing medical attention as a risk for suicide death. Method: We conducted a case-control study involving eight US healthcare systems. A total of 2,674 individuals who died by suicide from 2000 to 2013 were matched to 267,400 individuals by year and location. Results: Prior suicide attempt associated with a medical visit increases risk for suicide death by 39.1 times, particularly for women (OR = 79.2). However, only 11.3% of suicide deaths were associated with an attempt that required medical attention. The association was the strongest for children 10-14 years old (OR = 98.0). Most suicide attempts were recorded during the 20-week period prior to death. Limitations: Our study is limited to suicide attempts for which individuals sought medical care. Conclusion: In the US, prior suicide attempt is associated with an increased risk of suicide death; the risk is high especially during the period immediately following a nonlethal attempt.

Substance use disorders and risk of suicide in a general US population: a case control study.

BACKGROUND: Prior research suggests that substance use disorders (SUDs) are associated with risk of suicide mortality, but most previous work has been conducted among Veterans Health Administration patients. Few studies have examined the relationship between SUDs and suicide mortality in general populations. Our study estimates the association of SUDs with suicide mortality in a general US population of men and women who receive care across eight integrated health systems. METHODS: We conducted a case-control study using electronic health records and claims data from eight integrated health systems of the Mental Health Research Network. Participants were 2674 men and women who died by suicide between 2000-2013 and 267,400 matched controls. The main outcome was suicide mortality, assessed using data from the health systems and confirmed by state death data systems. Demographic and diagnostic data on substance use disorders and other health conditions were obtained from each health system. First, we compared descriptive statistics for cases and controls, including age, gender, income, and education. Next, we compared the rate of each substance use disorder category for cases and controls. Finally, we used conditional logistic regression models to estimate unadjusted and adjusted odds of suicide associated with each substance use disorder category. RESULTS: All categories of substance use disorders were associated with increased risk of suicide mortality. Adjusted odds ratios ranged from 2.0 (CI 1.7, 2.3) for patients with tobacco use disorder only to 11.2 (CI 8.0, 15.6) for patients with multiple alcohol, drug, and tobacco use disorders. Substance use disorders were associated with increased relative risk of suicide for both women and men across all categories, but the relative risk was more pronounced in women. CONCLUSIONS: Substance use disorders are associated with significant risk of suicide mortality, especially for women, even after controlling for other important risk factors. Experiencing multiple substance use disorders is particularly risky. These findings suggest increased suicide risk screening and prevention efforts for individuals with substance use disorders are needed.

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

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

Diagnosed Mental Health Conditions and Risk of Suicide Mortality.

OBJECTIVE: Although mental health conditions are risk factors for suicide, limited data are available on suicide mortality associated with specific mental health conditions in the U.S. population. This study aimed to fill this gap. METHODS: This study used a case-control design. Patients in the case group were those who died by suicide between 2000 and 2013 and who were patients in eight health care systems in the Mental Health Research Network (N=2,674). Each was matched with 100 general population patients from the same system (N=267,400). Diagnostic codes for five mental health conditions in the year before death were obtained from medical records: anxiety disorders, attention deficit-hyperactivity disorder (ADHD), bipolar disorder, depressive disorders, and schizophrenia spectrum disorder. RESULTS: Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men. CONCLUSIONS: Half of those who died by suicide had at least one diagnosed mental health condition in the year before death, and most mental health conditions were associated with an increased risk of suicide. Findings suggest the importance of suicide screening and providing an approach to improve awareness of mental health conditions.

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

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

Screening and follow-up for depression among Arab Americans.

BACKGROUND: The authors compared proportions and associations of depression screening, major depression, and follow-up care of Arab Americans compared to non-Hispanic whites, non-Hispanic blacks, Asians, and Hispanics. METHODS: Administrative data was electronically abstracted from a large health system in metropolitan Detroit among 97,918 adult patients in 2014 and 2015. A valid and reliable surname list was used to identify Arab Americans. Using chi-squares, we examined the relationship between race/ethnicity and depression screening, major depression, and follow-up care. We calculated odds ratios (OR) and 95% confidence intervals (CI) to examine the relationship between the main independent variable of race/ethnicity and the dependent variables of depression screening and major depression while controlling for confounders. RESULTS: Arab American women were 23% less likely to be screened for depression compared to non-Hispanic white women (OR = 0.77; 95% CI = 0.70, 0.86). The age- and sex-adjusted proportions of major depression were 5.5% for Arab Americans compared to 7.0% for Hispanics, 6.0% for non-Hispanic blacks, 5.9% for non-Hispanic whites, and 1.5% for Asians. Arab Americans with major depression were less likely to follow up with a behavioral specialist and more likely to follow up with a primary care physician compared to other racial and ethnic groups. CONCLUSIONS: Our study adds to the discourse on depression care among Arab Americans by highlighting the existing disparities related to adequate screening and appropriate management of depression. Future studies should include information about the influences of acculturation, culture, stigma, family, and religion on depression care.

General Medical, Mental Health, and Demographic Risk Factors Associated With Suicide by Firearm Compared With Other Means.

OBJECTIVE: Mitigation of suicide risk by reducing access to lethal means, such as firearms and potentially lethal medications, is a highly recommended practice. To better understand groups of patients at risk of suicide in medical settings, the authors compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group). METHODS: In a case-control study in 2016 from eight health care systems within the Mental Health Research Network, 2,674 suicide cases from 2010-2013 were matched to a control group (N=267,400). The association between suicide by firearm or other means and medical record information on demographic characteristics, general medical disorders, and mental disorders was assessed. RESULTS: The odds of having a mental disorder were higher among cases of suicide involving a method other than a firearm. Fourteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by firearm, including traumatic brain injury (TBI) (odds ratio [OR]=23.53), epilepsy (OR=3.17), psychogenic pain (OR=2.82), migraine (OR=2.35), and stroke (OR=2.20). Fifteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by other means, with particularly high odds for TBI (OR=7.74), epilepsy (OR=3.28), HIV/AIDS (OR=6.03), and migraine (OR=3.17). CONCLUSIONS: Medical providers should consider targeting suicide risk screening for patients with any mental disorder, TBI, epilepsy, HIV, psychogenic pain, stroke, and migraine. When suicide risk is detected, counseling on reducing access to lethal means should include both firearms and other means for at-risk groups.

Stimulant Formulations for the Treatment of Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: Clinicians have access to a variety of formulations of methylphenidate and amphetamine to treat attention-deficit/hyperactivity disorder (ADHD). However, due to new emerging formulations, clinicians may lack up-to-date knowledge about all available stimulant formulations. Presented here is a comprehensive guide to13 formulations of methylphenidate and 10 formulations of amphetamine that have US Food and Drug Administration approval to treat ADHD. DATA SOURCES: PubMed was searched using the following MeSH terms: attention-deficit/hyperactivity disorder, ADHD, stimulant, amphetamine, and methylphenidate. Inclusion criteria were randomized controlled trials and systematic reviews published through 2017. STUDY SELECTION AND EXTRACTION: Forty-eight articles were identified; however, these included analyses using product labels and anecdotal or uncontrolled reports of apparent clinical inequivalence. Thus, 34 articles were included in the final review to provide a thorough evidence-based guide. RESULTS: Each formulation has a unique pharmacokinetic profile. Clinically, one formulation may not be suitable for all patients. To select the most appropriate formulation, clinicians should consider the individual patient's preferences such as dosing schedule, time required to reach peak plasma concentration and duration of action, and tolerability. CONCLUSION: This review provides clinical guidance to help clinicians prescribe the most suitable treatment for an individual.​​​.

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

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

Major Physical Health Conditions and Risk of Suicide.

INTRODUCTION: Most individuals make healthcare visits before suicide, but many do not have a diagnosed mental health condition. This study seeks to investigate suicide risk among patients with a range of physical health conditions in a U.S. general population sample and whether risk persists after adjustment for mental health and substance use diagnoses. METHODS: This study included 2,674 individuals who died by suicide between 2000 and 2013 along with 267,400 controls matched on year and location in a case-control study conducted in 2016 across eight Mental Health Research Network healthcare systems. A total of 19 physical health conditions were identified using diagnostic codes within the healthcare systems' Virtual Data Warehouse, including electronic health record and insurance claims data, during the year before index date. RESULTS: Seventeen physical health conditions were associated with increased suicide risk after adjustment for age and sex (p<0.001); nine associations persisted after additional adjustment for mental health and substance use diagnoses. Three conditions had a more than twofold increased suicide risk: traumatic brain injury (AOR=8.80, p<0.001); sleep disorders; and HIV/AIDS. Multimorbidity was present in 38% of cases versus 15.5% of controls, and represented nearly a twofold increased risk for suicide. CONCLUSIONS: Although several individual conditions, for example, traumatic brain injury, were associated with high risk of suicide, nearly all physical health conditions increased suicide risk, even after adjustment for potential confounders. In addition, having multiple physical health conditions increased suicide risk substantially. These data support suicide prevention based on the overall burden of physical health.

Mapping Direct Observations From Objective Structured Clinical Examinations to the Milestones Across Specialties.

BACKGROUND: Little is known about residents' performance on the milestones at the institutional level. Our institution formed a work group to explore this using an institutional-level curriculum and residents' evaluation of the milestones. OBJECTIVE: We assessed whether beginner-level milestones for interpersonal and communication skills (ICS) related to observable behaviors in ICS-focused objective structured clinical examinations (OSCEs) for postgraduate year (PGY) 1 residents across specialties. METHODS: The work group compared ICS subcompetencies across 12 programs to identify common beginner-level physician-patient communication milestones. The selected ICS milestone sets were compared for common language with the ICS-OSCE assessment tool-the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). To assess whether OSCE scores related to ICS milestone scores, all PGY-1 residents from programs that were part of Next Accreditation System Phase 1 were identified; their OSCE scores from July 2013 to June 2014 and ICS subcompetency scores from December 2014 were compared. RESULTS: The milestones for 10 specialties and the transitional year had at least 1 ICS subcompetency that related to physician-patient communication. The language of the ICS beginner-level milestones appears similar to behaviors outlined in the KEECC-A. All 60 residents with complete data received at least a beginner-level ICS subcompetency score and at least a satisfactory score on all 3 OSCEs. CONCLUSIONS: The ICS-OSCE scores for PGY-1 residents appear to relate to beginner-level milestones for physician-patient communication across multiple specialties.