A Comparison of Suicides in Public Safety Personnel With Suicides in the General Population in Ontario, 2014 to 2018.

Background: There is conflicting evidence on the suicide rates of different public safety personnel (PSP). There have been few studies that compare suicides in PSP with the general population and none that have used a detailed comparison of coroner records. Aims: The current study estimates suicide rates among different PSP and compares PSP suicides with the general population. Method: We identified coroner records of PSP suicides from January 2014 to December 2018 and compared each one to two matched general population controls. Results: We identified 36 PSP suicides and 72 general population controls. Police had a higher suicide rate than other PSP groups. PSP were more likely to die by firearm, be separated/divorced or married, die in a motor vehicle, have problems at work, and have a PTSD diagnosis. PSP were less likely to die by jumping. Limitations: The study may have not identified all PSP suicides. Apart from the cause of death, data in coroner records are not systematically collected, so information may be incomplete. Conclusion: PSP suicides appear different than the general population. Death records need to have an occupation identifier to enable monitoring of trends in occupational groups, such as PSP.

Applying the Theoretical Domains Framework to identify police, fire, and paramedic preferences for accessing mental health care in a First Responder Operational Stress Injury Clinic: a qualitative study. / Application du cadre Theoretical Domains Framework pour cerner les préférences des policiers, des pompiers et des ambulanciers en matière d'accès aux soins de santé mentale dans une clinique de traitement des blessures de stress opérationnel pour les premiers répondants : une étude qualitative.

INTRODUCTION: First responders and other public safety personnel (PSP; e.g. correctional workers, firefighters, paramedics, police, public safety communicators) are often exposed to events that have the potential to be psychologically traumatizing. Such exposures may contribute to poor mental health outcomes and a greater need to seek mental health care. However, a theoretically driven, structured qualitative study of barriers and facilitators of help-seeking behaviours has not yet been undertaken in this population. This study used the Theoretical Domains Framework (TDF) to identify and better understand critical barriers and facilitators of help-seeking and accessing mental health care for a planned First Responder Operational Stress Injury (OSI) clinic. METHODS: We conducted face-to-face, one-on-one semistructured interviews with 24 first responders (11 firefighters, five paramedics, and eight police officers), recruited using purposive and snowball sampling. Interviews were analyzed using deductive content analysis. The TDF guided study design, interview content, data collection, and analysis. RESULTS: The most reported barriers included concerns regarding confidentiality, lack of trust, cultural competency of clinicians, lack of clarity about the availability and accessibility of services, and stigma within first responder organizations. Key themes influencing help-seeking were classified into six of the TDF's 14 theoretical domains: environmental context and resources; knowledge; social influences; social/professional role and identity; emotion; and beliefs about consequences. CONCLUSION: The results identified key actions that can be utilized to tailor interventions to encourage attendance at a First Responder OSI Clinic. Such approaches include providing transparency around confidentiality, policies to ensure greater cultural competency in all clinic staff, and clear descriptions of how to access care; routinely involving families; and addressing stigma.

Workplace Assessment Scale: Pilot Validation Study.

First responders, such as police officers, paramedics, and firefighters are at an increased risk of experiencing negative mental health outcomes compared to the general population. This predisposition can partially be attributed to common occupational stressors, which may provoke strong feelings of betrayal and humiliation. The Workplace Assessment Scale (WAS) was developed as there is currently no appropriate measure to assess such feelings in the first responder population. Initial development of the WAS included a Betrayal Subscale and the Humiliation Subscale, each comprised of 5 Likert scale questions which ask participants to report the frequency at which they experience specific feelings associated with their workplace. This pilot validation study was conducted to determine if there is preliminary evidence to support a large-scale validation study. To determine this, we assessed the internal structure and the convergent, concurrent, and predictive validity of the WAS. Based on 21/22 (95%) participant responses, a factor analysis did not support the two-factor model we anticipated, with only one factor and seven items retained from the original version of the scale. However, the internal consistency of the remaining items was strong. The validity analysis found moderate convergent validity and weak predictive validity based on correlations between the WAS and other psychometric scales. Minimal concurrent validity was noted. Additional research is needed for further analysis and validation of the WAS.

The BEACON study: an update to the protocol for a cohort study as part of an evaluation of the effectiveness of smartphone-assisted problem-solving therapy in men who present with intentional self-harm to emergency departments in Ontario.

BACKGROUND: Men who present to the emergency department (ED) with self-harm are at high risk of dying by suicide, with 2.7% of men dying in the year following their presentation, more than double the rate for women (1.2%). Despite this, care received after an ED visit is highly variable and many are not assessed for psychological needs. Furthermore, the limited psychological care that is available is often not covered by provincial health insurance. Even when referrals for follow-up care are made, engagement rates are low. Previous recommendations to improve engagement include written discharge plans, caring contacts, and focused interventions targeting middle-aged men at elevated risk of dying by suicide. Blended care, the incorporation of technology into traditional care, has also been proposed as a method to increase engagement in and clinical benefits from psychotherapy. This project aims to determine whether the delivery of an evidence based treatment (problem-solving therapy (PST)) is enhanced by the addition of a custom smartphone application (BEACON) compared to usual care. Due to the impact of the COVID-19 pandemic on site participation and the planned implementation, we have made several changes to the study design, primary outcome, and implementation. METHOD: We originally proposed a cohort study nested within a larger cluster randomized trial wherein intervention sites would deliver the blended care, and control sites, whose personnel were not aware of their participation, would continue delivering usual care. The cohort study evaluated participant level outcomes as previously described by Hatcher et al. (2020). Due to pandemic-related constraints, our number of participating sites dropped to five potential sites which left the cohort study underpowered. As such, we changed the study design to a multi-site, individual randomized controlled trial (RCT) among the five remaining sites. Participants will be randomized to six sessions of therapy (PST) alone, or to the therapy plus BEACON, and followed up for 6 months. Our primary outcome was changed to evaluate feasibility and acceptability with the aim of designing a definitive RCT. Study implementation was reimagined to allow for completely virtual/online conduct to comply with local COVID-19 and institutional restrictions on in-person activities. CONCLUSION: This updated protocol will provide strong results for the planning of a definitive RCT of the blended care intervention in the future, addressing areas of difficulty and concern prior to its implementation. We will evaluate the feasibility of the study intervention, assess recruitment and retention of participants, and address challenges with implementing the protocol. Lastly, we will evaluate the appropriateness of our primary outcome measure and accurately determine a sample size for a definitive RCT. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03473535 . Registered on March 22, 2018.

Enhancing COVID Rehabilitation with Technology (ECORT): protocol for an open-label, single-site randomized controlled trial evaluating the effectiveness of electronic case management for individuals with persistent COVID-19 symptoms.

BACKGROUND: As of May 2022, Ontario has seen more than 1.3 million cases of COVID-19. While the majority of individuals will recover from infection within 4 weeks, a significant subset experience persistent and often debilitating symptoms, known as "post-COVID syndrome" or "Long COVID." Those with Long COVID experience a wide array of symptoms, with variable severity, including fatigue, cognitive impairment, and shortness of breath. Further, the prevalence and duration of Long COVID is not clear, nor is there evidence on the best course of rehabilitation for individuals to return to their desired level of function. Previous work with chronic conditions has suggested that the addition of electronic case management (ECM) may help to improve outcomes. These platforms provide enhanced connection with care providers, detailed symptom tracking and goal setting, and access to relevant resources. In this study, our primary aim is to determine if the addition of ECM with health coaching improves Long COVID outcomes at 3 months compared to health coaching alone. METHODS: The trial is an open-label, single-site, randomized controlled trial of ECM with health coaching (ECM+) compared to health coaching alone (HC). Both groups will continue to receive usual care. Participants will be randomized equally to receive health coaching (± ECM) for a period of 8 weeks and a 12-week follow-up. Our primary outcome is the WHO Disability Assessment Scale (WHODAS), 36-item self-report total score. Participants will also complete measures of cognition, fatigue, breathlessness, and mental health. Participants and care providers will be asked to complete a brief qualitative interview at the end of the study to evaluate acceptability and implementation of the intervention. DISCUSSION: There is currently little evidence about the optimal treatment of Long COVID patients or the use of digital health platforms in this population. The results of this trial could result in rapid, scalable, and personalized care for people with Long COVID which will decrease morbidity after an acute infection. Results from this study will also inform decision making in Long COVID and treatment guidelines at provincial and national levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT05019963. Registered on 25 August 2021.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials.

BACKGROUND: Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population. METHODS: Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted. RESULTS: Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant. CONCLUSION: While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Feasibility and acceptability of Narrative Exposure Therapy to treat individuals with PTSD who are homeless or vulnerably housed: a pilot randomized controlled trial.

BACKGROUND: Diagnosed PTSD rates in people who are homeless are more than double that of the general population, ranging between 21 and 53%. Complex PTSD (cPTSD) also appears to be more common than PTSD. One treatment option is Narrative Exposure Therapy (NET), a brief trauma-focused psychotherapy which attempts to place trauma within a narrative of the person's life. Our primary aim was to assess the feasibility and acceptability of recruiting people to a randomized controlled trial (RCT) of NET alone compared to NET augmented by a genealogical assessment. We hypothesized that incorporating a genealogical assessment may be more effective than NET alone in a population with predominately complex PTSD. METHODS: This pilot RCT enrolled participants who were 18 years of age or older, currently homeless or vulnerably housed, and with active symptoms of PTSD. Participants were randomized to NET alone or NET plus a genealogical assessment. Rates of referral, consent, and retention were examined as part of feasibility. Demographic and clinical data were collected at baseline. Symptoms of PTSD, drug use, and housing status were re-assessed at follow-up visits. We conducted a thematic analysis of qualitative interviews of service providers involved in the study which explored barriers and facilitators of study participation. RESULTS: Twenty-two potential participants were referred to the study, with 15 consenting to participate. Of these, one was a screen failure and 14 were randomized equally to the treatment arms. One randomized participant was withdrawn for safety. Attrition occurred primarily prior to starting therapy. Once therapy began, retention was high with 80% of participants completing all six sessions. Seven participants completed all follow-up sessions. Service providers identified a clear need for the treatment and emphasized the importance of trauma-informed care, a desire to know more about NET, and more communication about the process of referral. CONCLUSION: Recruiting participants who were vulnerably housed to an RCT of a trauma-based therapy was possible. Once therapy had started, participants were likely to stay engaged. We will incorporate the results of this trial into a conceptual model which we will test in a factorial study as part of the optimization phase of MOST. TRIAL REGISTRATION: ClinicalTrials.gov NCT03781297 . Registered: December 19, 2018.

Interventions to treat post-traumatic stress disorder (PTSD) in vulnerably housed populations and trauma-informed care: a scoping review.

OBJECTIVES: The goals of this study are to identify and analyse interventions that aim to treat post-traumatic stress disorder (PTSD) and complex PTSD in people who are vulnerably housed and to describe how these treatments have been delivered using trauma-informed care. DESIGN: Scoping review. SEARCH STRATEGY: We searched electronic databases including MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, Web of Science and PTSDpubs for published literature up to November 2021 for any studies that examined the treatment of PTSD in adults who were vulnerably housed. Websites of relevant organisations and other grey literature sources were searched to supplement the electronic database search. The characteristics and effect of the interventions were analysed. We also explored how the interventions were delivered and the elements of trauma-informed care that were described. RESULTS: 28 studies were included. We identified four types of interventions: (1) trauma focused psychotherapies; (2) non-trauma psychotherapies; (3) housing interventions and (4) pharmacotherapies. The trauma-informed interventions were small case series and the non-trauma focused therapies included four randomised controlled trials, were generally ineffective. Of the 10 studies which described trauma-informed care the most commonly named elements were physical and emotional safety, the experience of feeling heard and understood, and flexibility of choice. The literature also commented on the difficulty of providing care to this population including lack of private space to deliver therapy; the co-occurrence of substance use; and barriers to follow-up including limited length of stay in different shelters and high staff turnover. CONCLUSIONS: This scoping review identified a lack of high-quality trials to address PTSD in people who are vulnerably housed. There is a need to conduct well designed trials that take into account the unique setting of this population and which describe those elements of trauma-informed care that are most important and necessary.

Innovations in suicide assessment and prevention during pandemics.

Emerging evidence, based on the synthesis of reports from past infectious disease-related public health emergencies, supports an association between previous pandemics and a heightened risk of suicide or suicide-related behaviours and outcomes. Anxiety associated with pandemic media reporting appears to be one critical contributing factor. Social isolation, loneliness, and the disconnect that can result from public health strategies during global pandemics also appear to increase suicide risk in vulnerable individuals. Innovative suicide risk assessment and prevention strategies are needed to recognise and adapt to the negative impacts of pandemics on population mental health.

Needs, gaps and opportunities for standard and e-mental health care among at-risk populations in the Asia Pacific in the context of COVID-19: a rapid scoping review.

BACKGROUND: The COVID-19 pandemic is expected to have profound mental health impact, including in the Asia Pacific Economic Cooperation (APEC) region. Some populations might be at higher risk of experiencing negative mental health impacts and may encounter increased barriers to accessing mental health care. The pandemic and related restrictions have led to changes in care delivery, including a rapid shift to the use of e-mental health and digital technologies. It is therefore essential to consider needs and opportunities for equitable mental health care delivery to the most at-risk populations. This rapid scoping review: 1) identifies populations in the APEC region that are at higher risk of the negative mental health impacts of COVID-19, 2) identifies needs and gaps in access to standard and e-mental health care among these populations, and 3) explores the potential of e-mental health to address these needs. METHODS: We conducted a rapid scoping review following the PRISMA Extension for Scoping Reviews (PRISMA-ScR). We searched Medline, Embase and PsychInfo databases and Google Scholar using a search strategy developed in consultation with a biomedical librarian. We included records related to mental health or psychosocial risk factors and COVID-19 among at-risk groups; that referred to one or more APEC member economies or had a global, thus generalizable, scope; English language papers, and papers with full text available. RESULTS: A total of 132 records published between December 2019 and August 2020 were included in the final analysis. Several priority at-risk populations, risk factors, challenges and recommendations for standard and e-mental health care were identified. Results demonstrate that e-mental health care can be a viable option for care delivery but that specific accessibility and acceptability considerations must be considered. Options for in-person, hybrid or "low-tech" care must also remain available. CONCLUSIONS: The COVID-19 pandemic has highlighted the urgent need for equitable standard and e-mental health care. It has also highlighted the persistent social and structural inequities that contribute to poor mental health. The APEC region is vast and diverse; findings from the region can guide policy and practice in the delivery of equitable mental health care in the region and beyond.

Strategies for facilitating the delivery of cluster randomized trials in hospitals: A study informed by the CFIR-ERIC matching tool.

BACKGROUND: Recruitment and engagement of clusters in a cluster randomized controlled trial can sometimes prove challenging. Identification of successful or unsuccessful strategies may be beneficial in guiding future researchers in conducting their cluster randomized controlled trial. This study aimed to identify strategies that could be used to facilitate the delivery of cluster randomized controlled trials in hospitals. METHODS: The study employed the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool. The barriers and enablers to cluster randomized controlled trial conduct identified in our previously conducted studies served as a means of determinant identification for the conduct of cluster randomized controlled trials. These determinants were mapped to Consolidated Framework for Implementation Research constructs and then matched to Expert Recommendations for Implementing Change compilation strategies using the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool. RESULTS: The Expert Recommendations for Implementing Change strategies matched to at least one determinant Consolidated Framework for Implementation Research construct were as follows: (1) 'Identify and prepare champions', (2) 'Conduct local needs assessment', (3) 'Conduct educational meetings', (4) 'Inform local opinion leaders', (5) 'Build a coalition', (6) 'Promote adaptability', (7) 'Develop a formal implementation blueprint', (8) 'Involve patients/consumers and family members', (9) 'Obtain and use patients/consumers and family feedback', (10) 'Develop educational materials', (11) 'Promote network weaving', (12) 'Distribute educational materials', (13) 'Access new funding' and (14) 'Develop academic partnerships'. CONCLUSION: This study was intended as a step in the research agenda aimed at facilitating cluster randomized controlled trial delivery in hospitals and can act as a resource for future researchers when planning their cluster randomized controlled trial, with the expectation that the strategies identified here will be tailored to each context.

The Impact of Infectious Disease-Related Public Health Emergencies on Suicide, Suicidal Behavior, and Suicidal Thoughts.

Background: Infectious disease-related public health emergencies (epidemics) may increase suicide risk, and high-quality evidence is needed to guide an international response. Aims: We investigated the potential impacts of epidemics on suicide-related outcomes. Method: We searched MEDLINE, EMBASE, PsycInfo, CINAHL, Scopus, Web of Science, PsyArXiv, medRxiv, and bioRxiv from inception to May 13-16, 2020. Inclusion criteria: primary studies, reviews, and meta-analyses; reporting the impact of epidemics; with a primary outcome of suicide, suicidal behavior, suicidal ideation, and/or self-harm. Exclusion criteria: not concerned with suicide-related outcomes; not suitable for data extraction. PROSPERO registration: #CRD42020187013. Results: Eight primary papers were included, examining the effects of five epidemics on suicide-related outcomes. There was evidence of increased suicide rates among older adults during SARS and in the year following the epidemic (possibly motivated by social disconnectedness, fears of virus infection, and concern about burdening others) and associations between SARS/Ebola exposure and increased suicide attempts. A preprint study reported associations between COVID-19 distress and past-month suicidal ideation. Limitations: Few studies have investigated the topic; these are of relatively low methodological quality. Conclusion: Findings support an association between previous epidemics and increased risk of suicide-related outcomes. Research is needed to investigate the impact of COVID-19 on suicide outcomes.

The BEACON study: protocol for a cohort study as part of an evaluation of the effectiveness of smartphone-assisted problem-solving therapy in men who present with intentional self-harm to emergency departments in Ontario.

BACKGROUND: Patients who present to emergency departments after intentional self-harm are at an increased risk of dying by suicide. This applies particularly to men, who represent nearly two-thirds of those who die by suicide in Ontario. One way of potentially addressing this gap is to offer a course of blended problem-solving therapy, comprised of a brief course of evidence-based psychotherapy for individuals at risk for suicide, facilitated by the use of a patient-facing smartphone application and a clinician-facing "dashboard." This approach has the potential to combine the benefits of face-to-face therapy and technology to create a novel intervention. METHODS: This is a cohort study nested within a larger pragmatic multicentre pre- and post-design cluster randomised trial. Suicidal ideation assessed by the Beck Scale for Suicide Ideation is the primary outcome variable. Secondary outcome measures include depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder 7-item scale), post-traumatic stress disorder (Primary Care PTSD Screen), health-related quality of life (EuroQol 5-dimension 5-level questionnaire), meaning in life (Experienced Meaning in Life Scale), perceived social supports (Multidimensional Scale of Perceived Social Support), alcohol use (Alcohol Use Disorders Identification Test), drug use (Drug Abuse Screening Test Short Form 10), problem-solving skills (Social Problem-Solving Inventory-Revised Short Form), and self-reported healthcare costs, as well as health service use measured using Ontario administrative health data. A process evaluation will also be conducted following study completion. DISCUSSION: The cohort study will test whether better adherence to the intervention results in better outcomes. The value of the cohort study design is that we can examine in more detail certain subgroups or other variables that are not available in the larger cluster randomised trial. This trial will aim to improve standards by informing best practice in management of men who self-harm and present to hospitals in Ontario. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03473535 . Registered on March 22, 2018.

Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial).

BACKGROUND: Non-fatal self-harm is one of the commonest reasons for adults' emergency hospital attendance. Although strongly associated with fatal and non-fatal repetition, there is weak evidence about effective interventions-and no clear NICE guidance or clinical consensus concerning aftercare. We examined the practicability of a definitive trial to evaluate problem-solving therapy (PST) to reduce repetition of self-harm; MIDSHIPS is a single-centre, parallel-group, individually randomised controlled feasibility trial comparing treatment-as-usual (TAU) alone to TAU plus up to six sessions of brief problem-solving therapy (PST) with adults who had recently attended hospital because of self-harm. Objectives were to adapt the intervention for a UK setting, train therapists, recruit and randomise patients, deliver PST under supervision, and establish comparative outcomes, assessed blindly. METHODS: We adapted the problem-solving intervention from an earlier trial and trained a mental-health nurse to deliver it. Adult patients attending the general hospital for self-harm were recruited while undergoing psychosocial assessment by the mental health team, and 62 were randomly allocated (32 TAU, 30 PST). The primary outcome assessed repeat hospital attendance due to further self-harm 6 months post-randomisation. Secondary outcomes included participant-reported outcomes and service use at 3 and 6 months post-randomisation. RESULTS: The recruitment period had to be extended and 710 patients screened in order to establish a trial sample of the planned size (N = 62). A quarter of participants allocated to PST did not undertake the therapy offered; those who received PST attended a median of three sessions. Secondary outcomes were established for 49 (79%) participants at 6 months; all participants' hospital records were retrieved. Repetition of self-harm leading to hospital presentation occurred in 19 of the 62 participants (30.6%, 95% CI 19.2%, 42.1%) within 6 months of randomisation. Promising differential rates of self-harm were observed with an event rate of 23.3% (95% CI 8.2%, 38.5%) in the PST arm; and 37.5% (95% CI 20.7%, 54.3%) in TAU. Economic findings were also encouraging, with a small QALY gain (0.0203) in the PST arm together with less reported use of the NHS in the PST arm (average £2120) than with TAU-only (£2878). CONCLUSIONS: The feasibility trial achieved its objectives despite considerable difficulties with recruitment-adapting the PST, training a therapist, recruiting patients who had recently self-harmed, delivering the therapy, and establishing primary and secondary outcomes. These data provide a robust platform for a definitive multicentre randomised controlled trial of brief problem-solving therapy after hospital attendance due to self-harm. TRIAL REGISTRATION: Identification number and URL: ISRCTN54036115 http://www.isrctn.com/search?q=midships. Registered: 13 January 2012.

Coach-Facilitated Web-Based Therapy Compared With Information About Web-Based Resources in Patients Referred to Secondary Mental Health Care for Depression: Randomized Controlled Trial.

BACKGROUND: Depression is a common mental disorder with a high social burden and significant impact on suicidality and quality of life. Treatment is often limited to drug therapies because of long waiting times to see psychological therapists face to face, despite several guidelines recommending that psychological treatments should be first-line interventions for mild to moderate depression. OBJECTIVE: We aimed to evaluate, among patients on a waitlist to receive secondary mental health care services for depression, how effective coach-guided web-based therapy (The Journal) is, compared with an information-only waitlist control group, in reducing depression symptoms after 12 weeks. METHODS: We conducted a randomized controlled trial with 2 parallel arms and a process evaluation, which included interviews with study participants. Participants assigned to the intervention group received 12 weeks of web-based therapy guided by a coach who had a background in social work. Patients in the control group receive a leaflet of mental health resources they could access. The primary outcome measure was a change in depression scores, as measured by the Patient-Health Questionnaire (PHQ-9). RESULTS: A total of 95 participants were enrolled (intervention, n=47; control, n=48). The mean change in PHQ-9 scores from baseline to week 12 was -3.6 (SD 6.6) in the intervention group and -3.1 (SD 6.2) in the control group, which was not a statistically significant difference with a two-sided alpha of .05 (t91=-0.37; P=.72, 95% CI -3.1 to 2.2). At 12 weeks, participants in the intervention group reported higher health-related quality of life (mean EuroQol 5 dimensions visual analogue scale [EQ-5D-VAS] score 66.8, SD 18.0) compared with the control group (mean EQ-5D VAS score 55.9, SD 19.2; t84=-2.73; P=.01). There were no statistically significant differences between the two groups in health service use following their initial consultation with a psychiatrist. The process evaluation showed that participants in the intervention group completed a mean of 5.0 (SD 2.3) lessons in The Journal and 8.8 (SD 3.1) sessions with the coach. Most participants (29/47, 62%) in the intervention group who completed the full dose of the intervention, by finishing 6 or more lessons in The Journal, were more likely to have a clinically important reduction in depressive symptoms at 12 weeks compared with the control group (Χ21=6.3; P=.01, Φ=0.37). Participants who completed the interviews reported that the role played by the coach was a major factor in adherence to the study intervention. CONCLUSIONS: The results demonstrate that the use of guided web-based therapy for the treatment of depression is not more effective than information-only waitlist control. However, it showed that the coach has the potential to increase adherence and engagement with web-based depression treatment protocols. Further research is needed on what makes the coach effective. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02423733; https://clinicaltrials.gov/ct2/show/NCT02423733.

Barriers and enablers to conducting cluster randomized control trials in hospitals: A theory-informed scoping review.

BACKGROUND: Cluster randomized control trials (cRCTs) have unique challenges compared to single site trials with regards to conduct of the trial, and it is important to understand these barriers. The aim of this scoping review was to describe the current literature surrounding the implementation of the cRCTs in hospitals. METHODS: The search strategy was designed to identify literature relevant to conduct of cRCTs, with hospitals as the unit of randomization. Data was extracted and was mapped using the Consolidated Framework for Implementation Research (CFIR) as a codebook, which contains 39 constructs organized into five domains. RESULTS: Twenty-two articles met inclusion criteria and were included. 18 of 39 constructs of the CFIR were identified in coding, spanning four of the five domains. Barriers to the conduct of the trial were rarely reported as the main outcome of the study, and few details were included in the identified literature. CONCLUSIONS: The review can provide guidance to future researchers planning cRCTs in hospitals. It also identified a large gap in reporting of conduct of these trials, demonstrating the need for a research agenda that further explores the barriers and facilitators, with the aim of garnering knowledge for improved guidance in the implementation.

Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study.

BACKGROUND: Self-harm is increasing among adolescents, and because of changing behaviours, current data are needed on the consequences of self-harm. We sought to investigate the trends related to hospital presentation, readmission, patient outcome and medical costs in adolescents who presented with self-harm to the emergency department. METHODS: We used administrative data on 403 805 adolescents aged 13-17 years presenting to Ontario emergency departments in 2011-2013. Adolescents with self-harm visits were 1:2 propensity matched to controls with visits without self-harm, using demographic, mental health and other clinical variables. Five years after the index presentation, hospital or emergency department admission rates for self-harm, overall mortality, suicides and conservative cost estimates were compared between the 2 groups. RESULTS: Of 5832 adolescents who visited Ontario emergency departments in 2011-2013 after self-harm (1.4% of visits), 5661 were matched to 10 731 adolescents who presented for reasons other than self-harm. Adolescents who presented with self-harm had a shorter time to a repeat emergency department or hospital admission for self-harm (hazard ratio [HR] 4.84, 95% confidence interval [CI] 4.44-5.27), more suicides (HR 7.96, 95% CI 4.00-15.86), and higher overall mortality (HR 3.23, 95% CI 2.12-4.93; p < 0.001). The positive predictive value of self-harm-related emergency department visits for suicide was 0.7%. Adolescents with self-harm visits had mean 5-year estimates of health care costs of $30 388 compared with $19 055 for controls (p < 0.001). INTERPRETATION: Adolescents with emergency department visits for self-harm have higher rates of mortality, suicide and recurrent self-harm, as well as higher health care costs, than matched controls. Development of algorithms and interventions that can identify and help adolescents at highest risk of recurrent self-harm is warranted.

Changing Rates of Self-Harm and Mental Disorders by Sex in Youths Presenting to Ontario Emergency Departments: Repeated Cross-Sectional Study.

OBJECTIVE: To document the rates of intentional self-harm and mental disorders among youths aged 13 to 17 years visiting Ontario emergency departments (EDs) from 2003-2017. METHODS: This was a repeated cross-sectional observational design. Outcomes were rates of adolescents with (1) at least 1 self-harm ED visit and (2) a visit with a mental disorder code. RESULTS: Rates of youths with self-harm visits fell 32% from 2.6/1000 in 2003 to 1.8 in 2009 but rose 135% to 4.2 by 2017. The slope of the trend in self-harm visits changed from -0.18 youths/1000/year (confidence interval [CI], -0.24 to -0.13) during 2003 to 2009 to 0.31 youths/1000/year (CI, 0.27 to 0.35) during 2009 to 2017 (P < 0.001). Rates of youths with mental health visits rose from 11.7/1000 in 2003 to 13.5 in 2009 (15%) and to 24.1 (78%) by 2017. The slope of mental health visits changed from 0.22 youths/1000/year (CI, 0.02 to 0.42) during 2003 to 2009 to 1.84 youths/1000/year (CI, 1.38 to 2.30) in 2009 to 2017 (P < 0.001). Females were more likely to have self-harm (P < 0.001) and mental health visits (P < 0.001). Rates of increase after 2009 were greater for females for both self-harm (P < 0.001) and mental health (P < 0.001). CONCLUSIONS: Rates of adolescents with self-harm and mental health ED visits have increased since 2009, with greater increases among females. Research is required on the determinants of adolescents' self-harm and mental health ED visits and how they can be addressed in that setting. Sufficient treatment resources must be supplied to address increased demands for services.

RecoverNow: A patient perspective on the delivery of mobile tablet-based stroke rehabilitation in the acute care setting.

BACKGROUND/AIM: We previously reported the feasibility of RecoverNow (a mobile tablet-based post-stroke communication therapy in acute care). RecoverNow has since expanded to include fine motor and cognitive therapies. Our objectives were to gain a better understanding of patient experiences and recovery goals using mobile tablets. METHODS: Speech-language pathologists or occupational therapists identified patients with stroke and communication, fine motor, or cognitive/perceptual deficits. Patients were provided with iPads individually programmed with applications based on assessment results, and instructed to use it at least 1 h/day. At discharge, patients completed a 19-question quantitative and open-ended engagement survey addressing intervention timing, mobile device/apps, recovery goals, and therapy duration. RESULTS: Over a six-month period, we enrolled 33 participants (three did not complete the survey). Median time from stroke to initiation of tablet-based therapy was six days. Patients engaged in therapy on average 59.6 min/day and preferred communication and hand function therapies. Most patients (63.3%) agreed that therapy was commenced at a reasonable time, although half expressed an interest in starting sooner, 66.7% reported that using the device 1 h/day was enough, 64.3% would use it after discharge, and 60.7% would use it for eight weeks. Sixty-seven percent of patients expressed a need for family/friend/caregiver to help them use it. CONCLUSION: Our results suggest that stroke patients are interested in mobile tablet-based therapy in acute care. Patients in the acute setting prefer to focus on communication and hand therapies, are willing to begin within days of their stroke and may require assistance with the tablets.