Daily prediction of inpatient suicide attempts using routinely collected theory-driven data.

We lack knowledge about the short-term predictors of suicide attempts (SAs) among treatment-seeking individuals. The current study evaluated whether (a) interpersonal difficulties, hopelessness, and affective states are associated with an increased risk of SAs on the same and the next day; (b) these daily states are interconnected differently over time among inpatients who attempt suicide compared to those who do not. In total, 110 psychiatric inpatients who attempted suicide during their stay at a psychiatric hospital self-reported their suicidal ideation, negative affect, positive affect, wish to live, interpersonal needs, and hopelessness each day (3,018 daily reports). Multilevel structural equation modeling was used to examine same-day and next-day predictors of SAs. Multilevel temporal network models assessed interconnectedness between daily predictors and were compared to network models from a matched sample of 110 psychiatric inpatients who did not attempt suicide. In multivariate models, increases in perceived burdensomeness were significantly associated with same-day SAs, whereas increased hopelessness was associated with next-day SAs. Network models for patients who attempted suicide indicated that hopelessness and suicidal ideation were central to change, leading to next-day deteriorations in mental health. In subsequent models, feeling calm and relaxed, and feeling fresh and rested were centrally connected to other variables. The centrality of these metrics tended to be higher than in the network models for patients who did not attempt suicide, suggesting differences in the interplay between risk and protective factors. This study suggests routinely monitoring interpersonal factors and hopelessness may help identify increased short-term risk of SAs among psychiatric inpatients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Connections Matter: Bi-Directional Learning in Program Evaluation and Practice-Oriented Research.

Intended for researchers and clinical leaders, this article suggests that embedded program evaluation is a good fit with the desired features of practice-oriented research. The systematic nature of evaluation that is built into the operational workflow of a practice setting may increase the diversity of methods available to explore processes and outcomes of interest. We propose a novel conceptual framework that uses a human-centered systems lens to foster such embedded evaluation in clinical routine. This approach emphasizes the evaluator-practitioner partnership to build confidence in the bi-directional learning of practice-based evidence with evidence-based practice. The iterative cycles inherent to design thinking are aimed at developing better evaluation questions. The attention to structure and context inherent to systems thinking is intended to support meaningful perspectives in the naturally complex world of health care. Importantly, the combined human-centered systems lens can create greater awareness of the influence of individual and systemic biases that exist in any endeavor or institution that involves people. Recommended tools and strategies include systems mapping, program theory development, and visual facilitation using a logic model to represent the complexity of mental health treatment for communication, shared understanding, and connection to the broader evidence base. To illustrate elements of the proposed conceptual framework, two case examples are drawn from routine outcome monitoring (ROM) and progress feedback. We conclude with questions for future collaboration and research that may strengthen the partnership of evaluators and practitioners as a community of learners in service of local and system-level improvement.

Daily prediction of nonsuicidal self-injury among inpatients: The roles of suicidal thoughts, interpersonal difficulties, hopelessness, and affect.

OBJECTIVE: Nonsuicidal self-injury (NSSI) is a major public health issue. Despite increased research efforts in clinical samples, we still have little understanding of the short-term correlates, predictors, and targets of NSSI among treatment-seeking individuals. The present study was designed to (a) evaluate how suicidal thoughts, interpersonal difficulties, hopelessness, and affective states are associated with same-day and next-day NSSI; (b) identify which factors may be effective targets in treatment through network modeling. METHOD: Data from 1,265 psychiatric inpatients who self-injured throughout their visit to a psychiatric hospital self-reported their suicidal ideation, negative affect, and positive affect on a daily basis (in total 36,345 prospective reports). An additional 632 patients were also surveyed regarding feelings of hopelessness, wish to live, and interpersonal difficulties. Using multilevel structural equation modeling, we examined contemporaneous and time-lagged associations with NSSI. Multilevel network analyses assessed interconnectedness of daily predictors and were compared with a matched sample of 1,265 patients who did not self-injure during their stay. RESULTS: Increases in suicidal ideation were associated with increased probability of same-day and next-day self-injury, and an inverse relationship was observed for wish to live. Increases in positive affect were also significantly associated with decreased probability of next-day self-injury. Perceived burdensomeness had high centrality in network models, particularly among patients who self-injured, indicating it is susceptible to activation and directly associated with all predictors. CONCLUSIONS: Routine monitoring may improve prediction of when a patient is at short-term risk to self-injure and provides person-specific data that can assist in targeting risk and protective factors during treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Repetitive transcranial magnetic stimulation: Course and early prediction of response in depression.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) is an effective treatment for depression, yet few studies have mapped the trajectories of symptom change over treatment. Tracking clinical response during early treatment may be helpful to predict outcome, particularly non-response. METHODS: We used naturalistic data (N = 117) to examine changes in the Daily Symptom Index (DI-5) scores of adult patients with unipolar or bipolar depression who underwent ≥16 treatment sessions of left dorsolateral prefrontal cortex rTMS at a private psychiatric facility in Western Australia, between 2016 and 2019. RESULTS: Two response trajectories were charted: non-response (N = 71, 61%) and response (N = 46, 39%). Both trajectories diverged at 99% confidence interval at session 10, which was used as the point to predict treatment response at session 20. The response group showed a reduction of 4.21 in the mean DI-5 score from baseline at session 10. On this basis, a 4-point reduction in the DI-5 score at session 10 was defined as predictor of responder status at session 20. If the improvement is < 4 points at session 10, the probability of non-response at session 20 is 75%. If the improvement is ≥ 4 points, the probability of response at session 20 is 66%. LIMITATIONS: The DI-5 scores were not examined beyond 20 treatment sessions, which may have shown delayed responders in the non-response group. CONCLUSIONS: In this study of depression response trajectories with rTMS treatment, prediction of response at session 20 can be made at session 10 of treatment. Further research is required to generalise the current findings.

A Short-Form Measure of Loneliness to Predict Depression Symptoms Among Adolescents.

The purpose of this study was to produce a short-form measure of loneliness and assesses its prediction of depressive symptoms relative to a comprehensive measure. Western Australian adolescents completed the Friendship Related Loneliness and Isolation subscales of the Perth Aloneness Scale (PALs) three times over 18 months (T 1 n = 1538; T 2, n = 1683; T 3, n = 1406). Items were reduced while preserving predictability. Follow-up confirmatory factor analyses and predictive models with the reduced and full PALs were then tested. A reduced six-item scale (PALs-6) preserved the two-factor structure of the PALs and showed strong prediction of very elevated depressive symptoms (Sensitivity = 0.70, Specificity = 0.78, AUC = 0.81); it was less successful in predicting future symptoms (Sensitivity = 0.67, Specificity = 0.64, AUC = 0.74). The PALs-6 provides a brief measure of adolescent loneliness for clinicians and researchers that also predicts very elevated levels of depression.

Illustrating routine outcomes monitoring at different points in a patient's journey: Inpatient then daypatient treatment of a patient with depressive and borderline symptoms.

Routine outcomes monitoring (ROM), combined with a psychotherapeutic intervention, can improve outcomes by assisting therapists in supporting patients who are off track to achieve a better treatment endpoint. While many ROM systems are suitable for particular clinical contexts, psychotherapy delivered in a hospital setting presents unique challenges. People can be treated as inpatients and daypatients, and psychotherapy may be delivered in multiple formats (e.g., closed and open groups; group and individual). The present case study will illustrate the adaptation of ROM to this environment with an 18-year-old woman with Borderline Personality Disorder. The patient was successfully treated with Dialectical Behavior Therapy as both an inpatient and daypatient. The case demonstrates the use of ROM systems and illustrate they are sufficiently flexible to accommodate these complexities of routine care.

Screening for depressive symptoms in adolescence: A Rasch analysis of the short-form childhood depression inventory-2 (CDI 2:SR[S]).

BACKGROUND: Screening for depressive symptoms during adolescence is of high clinical significance. The shorter 12-item version of the Children's Depression Inventory (CDI 2:SR[S]) was specifically developed for this purpose. Evaluations of the CDI 2:SR[S] psychometrics are limited, however. The purpose of this study was to validate the CDI 2: SR[S] for use as a screening measure using Rasch analysis. METHODS: The CDI 2: SR[S] was administered online to 1513 10-17 year old Western Australian adolescents (635 males, 878 females) from 11 schools. Overall fit, individual item fit, local response dependence, dimensionality, operation of response categories, and differential item functioning (DIF) were examined. RESULTS: The Rasch analysis demonstrated the CDI 2: SR[S] has good reliability. Thresholds for all items were ordered, showing its three response categories functioned as intended. One item (I have to push myself to do schoolwork) showed misfit. No items were locally dependent. Two items (I am sad) and (I have to push myself to do schoolwork) showed DIF for gender. At the same level of depression, females reported being sad more than males, while males pushed themselves more to do schoolwork than did females. Adolescents (14-17 years) reported significantly higher mean depressive symptom scores than early adolescents (10-13 years). LIMITATIONS: Sole reliance on adolescent's self-report and limited data about cultural backgrounds are limitations. CONCLUSIONS: The results support the interval scale measurement properties of the CDI 2: SR[S] and provides educators, clinicians and researchers with a screening measure to assess depressive symptoms in adolescents.

An experimental investigation of the influence of loneliness on changes in belongingness and desire to escape.

OBJECTIVE: Loneliness is a well-established risk factor for suicide in young adults, but the mechanisms involved are still unclear. Drawing on the Interpersonal Theory of Suicide, the Evolutionary Model of Loneliness, and Prospect Theory, we examined if high and low levels of loneliness are associated with different patterns of response to losses or gains of belongingness. METHODS: A sample of 188 students completed the UCLA-Loneliness scale (version 3) and measures of suicide risk. Participants in the top and bottom tertiles of loneliness scores completed a computerized task designed to induce changes (gains, losses) or consistency in risk factors for suicide (belongingness, burdensomeness) over time, and examined the effect on desire to quit the task. RESULTS: The results showed that the high loneliness group exhibited a larger magnitude of effect on desire to quit from gaining belongingness than for losing belongingness. In contrast, the low loneliness group showed a larger change in desire to quit from losing belongingness than gaining belongingness. CONCLUSION: The findings provide preliminary experimental support for distinct profiles of suicide risk based on prevailing levels of loneliness. The findings are discussed in relation to a need for increased precision in theoretical models of suicide and loneliness.

Distress tolerance as a moderator of the dynamic associations between interpersonal needs and suicidal thoughts.

BACKGROUND: Identifying the interaction between dispositional and dynamic risk factors is necessary in understanding, predicting, and managing suicide risk. Interpersonal factors have consistently been linked to suicidal ideation over short-term periods. Additionally, distress tolerance may be a relevant dispositional protective factor against stressful events. METHODS: Seven hundred and seventeen psychiatric inpatients (Male = 30.31%, Average Age = 40.71 years, Min = 14, Max = 82) self-reported their distress tolerance at hospital admission, and interpersonal needs and suicidal ideation on a daily basis. Dynamic structural equation modelling was used to examine whether within-level dynamics were moderated by distress tolerance. RESULTS: Both perceived burdensomeness and thwarted belongingness were significantly associated with same-day suicidal ideation. Higher distress tolerance was associated with weaker daily associations between suicidal ideation and both perceived burdensomeness and thwarted belongingness. Distress tolerance was also associated with lower variability in suicidal ideation. Moderating effects were also evident when lifetime suicide attempts were added as a covariate, which was associated with stronger associations between interpersonal dysfunction and suicidal ideation, and higher variability in ideation. CONCLUSIONS: Distress tolerance may be important to consider when examining the dynamic relationships between suicidal ideation and proximal factors. Psychotherapy that specifically targets distress tolerance may be effective in reducing reactivity to interpersonal stressors.

Development of the Perth Adolescent Worry Scale (PAWS).

Tools to assess worry among adolescents exist but do not capture the content of worries. This study reports on the development of a brief, psychometrically sound measure of worry for use with adolescents. Phase 1 involved identification of 27 potential items from existing instruments as well as item generation identified in interviews with students, teachers, school psychologists, and parents. In Phase 2, the candidate items were completed by 835 Australian adolescents (317 males, 508 females, 10 unspecified; Mean age = 13.55, SD = 1.31) from Grades 5 to 10. These data were randomly split in half, and an exploratory factor analysis on the first half identified a two-factor solution with 12 items: Peer Relationships (6 items) and Academic Success and the Future (6 items). On the second half of the data, confirmatory factor analyses supported the factor structure and supported strong invariance across age, socioeconomic status, and presence/absence of a diagnosed neurodevelopmental disorder. Weak invariance was evident across sex. Differences across groups are reported as are correlations with indicators of psychological wellbeing. In conclusion, the Perth Adolescent Worry Scale provides both applied professionals and researchers with a short, easy-to-administer, and psychometrically strong instrument to evaluate adolescents' everyday worries.

Outcomes of brief versions of Dialectical Behaviour Therapy for diagnostically heterogeneous groups in a routine care setting.

INTRODUCTION: Brief versions of Dialectical Behaviour Therapy (DBT) may enhance patient outcomes in diverse service settings. This study examined the effectiveness of two DBT-informed treatments for diagnostically heterogeneous groups in routine practice: 5-day group training in DBT skills (DBT-5) and a 12-week DBT program (DBT-12). METHODS: : Depression, anxiety, stress, borderline symptoms, self-esteem, and general mental wellbeing were measured at pre-and post-treatment in a sample of inpatients and outpatients (N=395). Rates of clinically significant change on these measures were calculated and effect sizes benchmarked against prior DBT outcome studies. Readmission rates were used to measure treatment response maintenance. RESULTS: : Scores on all measures improved significantly from pre- to post-treatment. DBT-5 and DBT-12 yielded similar effect sizes compared to prior DBT outcome studies. At least 43.5% of patients were classified as recovered or improved regarding borderline symptoms at the end of both DBT-5 and DBT-12. Readmission rates were also low (5%-6.8%). CONCLUSIONS: Brief DBT-informed treatments may offer a fast reduction in symptoms and quicker return to functioning.

A comprehensive group-based cognitive behavioural treatment for blood-injection-injury phobia.

OBJECTIVES: A key feature of blood-injection-injury (BII) phobia is activation of disgust responses, in addition to fear. Yet, standard treatments have largely neglected addressing disgust responses. The disorder is further complicated by fainting in 75% of sufferers. Moreover, treatments have been traditionally delivered in an individual format, which may not be as efficient as group treatment. The aim of this study was to develop a group-based programme for BII phobia, with components targeting fear, disgust, and fainting, to determine feasibility and effectiveness of such an intervention. METHODS: Participants took part in an 8-session, group-based Cognitive Behavioural Therapy (CBT) programme for BII phobia (N = 40). The key outcome measure was the Multidimensional Blood/Injury Phobia Inventory, which assesses a range of phobic stimuli and responses (including fear, disgust, and fainting). RESULTS: There were significant improvements, with large effect sizes, across symptoms over the course of treatment. Participants with higher disgust sensitivity reported higher pre-treatment symptom severity and greater life interference than those with lower disgust scores. Despite this, neither pre-treatment disgust sensitivity nor fainting history impacted on treatment response. For the first time, however, we showed that greater reductions in disgust to BII stimuli were associated with greater overall symptom reductions, highlighting the importance of disgust in the treatment of this disorder, and potentially others. CONCLUSION: Despite the heterogeneous nature of BII phobia, this group-based, modified CBT intervention was effective in reducing a variety of phobic responses, including fear, disgust, and fainting. PRACTITIONER POINTS: Disgust is a key maintaining factor in blood-injection-injury phobia, which clinicians should consider in their assessment and treatment of this disorder. There is little in the existing literature to guide clinicians in this regard. This study examined a novel group treatment for blood-injection-injury phobia which included strategies to target disgust, in addition to traditional CBT strategies to address fear and fainting. The treatment was feasible and acceptable. Symptoms of fear, disgust, and fainting reduced significantly over treatment. Changes in disgust symptoms were associated with overall symptom changes, however a control group is needed to determine the effects of individual treatment components and to make more robust conclusions about the benefits of this enhanced approach.

Prevalence and predictors of suicidal thoughts and behaviours among Australian police and emergency services employees.

OBJECTIVE: This study presents rates of suicide thoughts and behaviours of police and emergency services personnel around Australia. In addition, it examines personal (i.e. mental health, substance use) and working environment risk and protective factors. METHOD: A stratified random sample of personnel from 33 Australian emergency services organisations were invited to participate in a mental health and wellbeing survey. In total, 14,868 Australian ambulance, fire and rescue, police and state emergency services employees participated and self-reported any suicidal thoughts, plans and/or attempts in the 12 months prior to the survey or at any stage in their life. Logistic regressions assessed factors associated with suicidal thoughts and behaviours. RESULTS: Employees reported notably higher rates of suicidal thoughts and plans than the general Australian adult population, but not attempts. Male, single/divorced, non-heterosexual or longer-serving employees reported higher rates of suicidal thoughts and behaviours across each sector. Perceptions of stigma regarding mental health conditions from others in the workplace, negative impact of work on one's private life and low meaning of work were associated with suicidal thoughts, while bullying significantly differentiated who planned and attempted suicide from those who reported suicidal thoughts only. Higher resilience and social support were associated with lower suicidal thoughts, while intermittent explosive anger and illegal drug use were associated with higher rates of suicidal thoughts. Post-traumatic stress disorder symptoms significantly differentiated who planned suicide, while misuse of prescription drugs and psychological distress differentiated who attempted suicide from those who only reported suicidal thoughts. CONCLUSION: Amid inherently stressful occupations, it is important that workplaces function in a way that supports their personnel. Access to mental health services should be promoted and readily available to personnel.

Prediction and network modelling of self-harm through daily self-report and history of self-injury.

BACKGROUND: Self-harm is a significant public health issue, and both our understanding and ability to predict adverse outcomes are currently inadequate. The current study explores how preventative efforts could be aided through short-term prediction and modelling of risk factors for self-harm. METHODS: Patients (72% female, Mage = 40.3 years) within an inpatient psychiatric facility self-reported their psychological distress, interpersonal circumstances, and wish to live and die on a daily basis during 3690 unique admissions. Hierarchical logistic regressions assessed whether daily changes in self-report and history of self-harm could predict self-harm, with machine learning used to train and test the model. To assess interrelationships between predictors, network and cross-lagged panel models were performed. RESULTS: Increases in a wish to die (ß = 1.34) and psychological distress (ß = 1.07) on a daily basis were associated with increased rates of self-harm, while a wish to die on the day prior [odds ratio (OR) 3.02] and a history of self-harm (OR 3.02) was also associated with self-harm. The model detected 77.7% of self-harm incidents (positive predictive value = 26.6%, specificity = 79.1%). Psychological distress, wish to live and die, and interpersonal factors were reciprocally related over the prior day. CONCLUSIONS: Short-term fluctuations in self-reported mental health may provide an indication of when an individual is at-risk of self-harm. Routine monitoring may provide useful feedback to clinical staff to reduce risk of self-harm. Modifiable risk factors identified in the current study may be targeted during interventions to minimise risk of self-harm.

An exploration of the relationships between patient application of CBT skills and therapeutic outcomes during a two-week CBT treatment.

The application of Cognitive Behavioural Therapy (CBT) skills are believed to be a mechanism of therapeutic change in treatment. Research has shown that the application of CBT skills affects outcomes, however, the way these relationships may change during treatment has not been explored. In this study, a naturalistic observational approach is used to examine the relationships between patients' wellbeing, symptoms, and the application of CBT skills throughout treatment. It is hypothesized that the application of CBT skills would lead to an increase in patients reported wellbeing, and a decrease in symptoms. Additionally, it was hypothesized that the application of CBT skills affects wellbeing and symptoms at different points in therapy. A sample of 584 patients in a two-week CBT treatment completed session-to-session measures of wellbeing, symptoms, and their application of CBT skills. Results of an autoregressive cross-lagged path analysis indicated that in the early stages of treatment the application of CBT skills predicted patient wellbeing but not symptoms. At the later stages of therapy, the application of CBT skills predicted both patient wellbeing and symptoms. At no point in treatment did patient wellbeing or symptoms predict the later application of CBT skills. Implications and future directions for research are discussed.

Allowing nondisclosure in surveys with suicide content: Characteristics of nondisclosure in a national survey of emergency services personnel.

Suicide is a leading cause of morbidity, yet a significant challenge to receiving adequate support is an unwillingness to disclose mental health issues. The current study explores reasons for nondisclosure among emergency personnel, a population at risk of developing mental health problems. Twenty-nine police, ambulance, and fire and rescue agencies from around Australia participated in a mental health and wellbeing survey (N = 14,536, male = 60.5%, 52.0% over 45 years of age, heterosexual = 92.5%). Rates of mental health issues and perceptions of stigma were compared between participants who answered suicide-related questions and those who preferred not to say. Participants who preferred not to answer suicide-related questions (n = 1,098) reported higher rates of psychological distress (symptoms of depression and anxiety), and lower wellbeing and social support, than those who reported suicidal thoughts (n = 1,966) or no suicidal thoughts (n = 11,472). Perceptions of mental health stigma within the workplace, and regarding one's own mental health, also tended to be higher among nonresponders. Imputing their responses based on this survey information resulted in notably higher rates of estimated suicidal thoughts, plans, and attempts. Allowing for nondisclosure in self-report measures of suicide may provide more accurate prevalence estimates and facilitate identification of individuals most at risk of suicide. Addressing stigma in the workplace and also regarding one's own mental health issues may act to improve disclosure of suicidal thoughts and adaptive help-seeking behaviors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Severity of borderline personality disorder symptoms as a moderator of the association between the use of dialectical behaviour therapy skills and treatment outcomes.

A core aspect of Dialectical Behaviour Therapy (DBT) is the acquisition and use of DBT skills to replace maladaptive behaviours. However, it is unclear whether DBT skill use is associated with differential reductions in psychological distress across individuals with varying severities of borderline personality disorder (BPD) symptoms. In the current study, moderated mediation analyses were conducted to examine the relationships among DBT skill use and attitudes towards skill use, pre-treatment BPD symptom severity and changes in psychological distress over the course of a 12-week DBT-informed program in a sample of outpatients with mixed psychopathology (N = 102), including a minority with BPD (N = 16). It was predicted that (i) self-reported use of the four types of DBT skills (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) and (ii) patient attitudes towards these skills (confidence and perceived effectiveness) would be associated with greater improvements in psychological distress in individuals with higher levels of BPD symptoms compared to individuals with lower levels of BPD symptoms. Results supported this hypothesis, indicating that self-reported DBT skill use and attitudes towards DBT skills are associated with differential patterns of reductions in psychological distress.

Progress monitoring and feedback delivered in routine psychiatric care: Beneficial but not reaching those thought to need it most.

Objective: The study evaluated the use and effectiveness of a progress monitoring system routinely operational in a private mental health care setting. Method: In a nonrandomized trial in which 778 consecutively admitted patients underwent a 2-week cognitive behavioral therapy intervention, the effectiveness of therapists choosing to use progress monitoring feedback to frame therapist-patient discussions about individuals' progress was evaluated. Results: Patients engaged in discussions involving progress monitoring feedback during the intervention achieved a more consistent recovery rate. Furthermore, individuals that were not-on-track to achieve a positive outcome experienced a boost to recovery immediately after receiving feedback. However, evidence suggested that therapists were not using progress monitoring to primarily focus additional resources on not-on-track patients. Conclusion: Progress monitoring feedback benefited patient recovery. However, guidelines could improve the system by directing therapists to use feedback primarily with patients not on course for a positive therapeutic outcome.

Delivering cognitive behaviour therapy informed by a contemporary framework of psychotherapy treatment selection and adaptation.

Research into cognitive behaviour therapy can be viewed through a contemporary framework of psychotherapy delivery. This model divides psychotherapy decision-making into two phases: selection and adaptation. In the first, selection phase, clinicians consider the evidence-base of therapies for a clinical presentation and choose which to implement first. The second element of the contemporary framework of psychotherapy delivery is adaptation. Thus, psychotherapy research needs to go beyond a demonstration of the effectiveness of CBT to understanding the processes of psychotherapy.