Identifying opportunities for informatics-supported suicide prevention: the case of Caring Contacts.

Suicide is the tenth leading cause of death in the United States. Caring Contacts (CC) is a suicide prevention intervention involving care teams sending brief messages expressing unconditional care to patients at risk of suicide. Despite solid evidence for its effectiveness, CC has not been broadly adopted by healthcare organizations. Technology has the potential to facilitate CC if barriers to adoption were better understood. This qualitative study assessed the needs of organizational stakeholders for a CC informatics tool through interviews that investigated barriers to adoption, workflow challenges, and participant-suggested design opportunities. We identified contextual barriers related to environment, intervention parameters, and technology use. Workflow challenges included time-consuming simple tasks, risk assessment and management, the cognitive demands of authoring follow-up messages, accessing and aggregating information across systems, and team communication. To address these needs, we propose design considerations that focus on automation, cognitive support, and data and workflow integration. Future work will incorporate these findings to design informatics tools supporting broader adoption of Caring Contacts.

Mental Health and the Perceived Usability of Digital Mental Health Tools Among Essential Workers and People Unemployed Due to COVID-19: Cross-sectional Survey Study.

BACKGROUND: COVID-19 has created serious mental health consequences for essential workers or people who have become unemployed as a result of the pandemic. Digital mental health tools have the potential to address this problem in a timely and efficient manner. OBJECTIVE: The purpose of this study was to document the extent of digital mental health tool (DMHT) use by essential workers and those unemployed due to COVID-19, including asking participants to rate the usability and user burden of the DMHT they used most to cope. We also explored which aspects and features of DMHTs were seen as necessary for managing stress during a pandemic by having participants design their own ideal DMHT. METHODS: A total of 2000 people were recruited from an online research community (Prolific) to complete a one-time survey about mental health symptoms, DMHT use, and preferred digital mental health features. RESULTS: The final sample included 1987 US residents that identified as either an essential worker or someone who was unemployed due to COVID-19. Almost three-quarters of the sample (1479/1987, 74.8%) reported clinically significant emotional distress. Only 14.2% (277/1957) of the sample used a DMHT to cope with stress associated with COVID-19. Of those who used DMHTs to cope with COVID-19, meditation apps were the most common (119/261, 45.6%). Usability was broadly in the acceptable range, although participants unemployed due to COVID-19 were less likely to report user burden with DMHTs than essential workers (t198.1=-3.89, P<.001). Individuals with emotional distress reported higher financial burden for their DMHT than nondistressed individuals (t69.0=-3.21, P=.01). When the sample was provided the option to build their own DMHT, the most desired features were a combination of mindfulness/meditation (1271/1987, 64.0%), information or education (1254/1987, 63.1%), distraction tools (1170/1987, 58.9%), symptom tracking for mood and sleep (1160/1987, 58.4%), link to mental health resources (1140/1987, 57.4%), and positive psychology (1131/1986, 56.9%). Subgroups by employment, distress, and previous DMHT use status had varied preferences. Of those who did not use a DMHT to cope with COVID-19, most indicated that they did not consider looking for such a tool to help with coping (1179/1710, 68.9%). CONCLUSIONS: Despite the potential need for DMHTs, this study found that the use of such tools remains similar to prepandemic levels. This study also found that regardless of the level of distress or even past experience using an app to cope with COVID-19, it is possible to develop a COVID-19 coping app that would appeal to a majority of essential workers and unemployed persons.

Correction to: The Society for Implementation Research Collaboration Instrument Review Project: a methodology to promote rigorous evaluation.

Following publication of the original article [1] the authors reported an important acknowledgement was mistakenly omitted from the 'Acknowledgements' section. The full acknowledgement is included in this Correction article.

Perceived burdensomeness, bullying, and suicidal ideation in suicidal military personnel.

OBJECTIVE: Suicide is a major public health concern among military servicemembers and previous research has demonstrated an association between bullying and suicide. This study evaluated the association between workplace bullying and suicidal ideation via perceived burdensomeness and thwarted belongingness which were hypothesized to mediate this association. METHOD: Four hundred and seventy-one suicidal Army Soldiers and U.S. Marines completed self-report measures of suicidal ideation, thwarted belongingness, perceived burdensomeness, and bullying. A series of regressions were used to test the hypothesized mediation model using the baseline data from a larger clinical trial. RESULTS: Perceived burdensomeness was a significant mediator of the association between bullying and the level of suicidal ideation, but thwarted belongingness was not a significant mediator. CONCLUSIONS: Perceived burdensomeness may represent a malleable target for intervention to prevent suicide among military service members, and should be evaluated further as an intervening variable with regard to suicidality in the setting of bullying victimization.

Suicidal ideation in American Indian/Alaska Native and White adolescents: The role of social isolation, exposure to suicide, and overweight.

Social isolation, exposure to suicide, and overweight increase suicidal ideation in adolescents, but no study to date has examined their relative significance in American Indian and Alaska Native (AI/AN) youth. Generalized estimating equations and path analyses were used to measure the significance and mediation of these variables in the suicidal ideation of 721 AI/ANs and 12,107 White adolescents. Social isolation, exposure to suicide, and overweight were risk factors for suicidal ideation in both races, and the associations among the variables of interest and suicidal ideation varied by race. Interventionists need to consider race in the prevention of suicidal ideation in AI/AN and White youth.

A methodology for enhancing implementation science proposals: comparison of face-to-face versus virtual workshops.

BACKGROUND: With the current funding climate and need for advancements in implementation science, there is a growing demand for grantsmanship workshops to increase the quality and rigor of proposals. A group-based implementation science-focused grantsmanship workshop, the Implementation Development Workshop (IDW), is one methodology to address this need. This manuscript provides an overview of the IDW structure, format, and findings regarding its utility. RESULTS: The IDW methodology allows researchers to vet projects in the proposal stage in a structured format with a facilitator and two types of expert participants: presenters and attendees. The presenter uses a one-page handout and verbal presentation to present their proposal and questions. The facilitator elicits feedback from attendees using a format designed to maximize the number of unique points made. After each IDW, participants completed an anonymous survey assessing perceptions of the IDW. Presenters completed a funding survey measuring grant submission and funding success. Qualitative interviews were conducted with a subset of participants who participated in both delivery formats. Mixed method analyses were performed to evaluate the effectiveness and acceptability of the IDW and compare the delivery formats. Of those who participated in an IDW (N = 72), 40 participated in face-to-face only, 16 in virtual only, and 16 in both formats. Thirty-eight (face-to-face n = 12, 35 % response rate; virtual n = 26, 66.7 % response rate) responded to the surveys and seven (15.3 % response rate), who had attended both formats, completed an interview. Of 36 total presenters, 17 (face-to-face n = 12, 42.9 % response rate; virtual n = 5, 62.9 % response rate) responded to the funding survey. Mixed method analyses indicated that the IDW was effective for collaboration and growth, effective for enhancing success in obtaining grants, and acceptable. A third (35.3 %) of presenters ultimately received funding for their proposal, and more than 80 % of those who presented indicated they would present again in the future. The IDW structure and facilitation process were found to be acceptable, with both formats rated as equally strong. CONCLUSIONS: The IDW presents an acceptable and successful methodology for increasing competitiveness of implementation science grant proposals.

The Society for Implementation Research Collaboration Instrument Review Project: a methodology to promote rigorous evaluation.

BACKGROUND: Identification of psychometrically strong instruments for the field of implementation science is a high priority underscored in a recent National Institutes of Health working meeting (October 2013). Existing instrument reviews are limited in scope, methods, and findings. The Society for Implementation Research Collaboration Instrument Review Project's objectives address these limitations by identifying and applying a unique methodology to conduct a systematic and comprehensive review of quantitative instruments assessing constructs delineated in two of the field's most widely used frameworks, adopt a systematic search process (using standard search strings), and engage an international team of experts to assess the full range of psychometric criteria (reliability, construct and criterion validity). Although this work focuses on implementation of psychosocial interventions in mental health and health-care settings, the methodology and results will likely be useful across a broad spectrum of settings. This effort has culminated in a centralized online open-access repository of instruments depicting graphical head-to-head comparisons of their psychometric properties. This article describes the methodology and preliminary outcomes. METHODS: The seven stages of the review, synthesis, and evaluation methodology include (1) setting the scope for the review, (2) identifying frameworks to organize and complete the review, (3) generating a search protocol for the literature review of constructs, (4) literature review of specific instruments, (5) development of an evidence-based assessment rating criteria, (6) data extraction and rating instrument quality by a task force of implementation experts to inform knowledge synthesis, and (7) the creation of a website repository. RESULTS: To date, this multi-faceted and collaborative search and synthesis methodology has identified over 420 instruments related to 34 constructs (total 48 including subconstructs) that are relevant to implementation science. Despite numerous constructs having greater than 20 available instruments, which implies saturation, preliminary results suggest that few instruments stem from gold standard development procedures. We anticipate identifying few high-quality, psychometrically sound instruments once our evidence-based assessment rating criteria have been applied. CONCLUSIONS: The results of this methodology may enhance the rigor of implementation science evaluations by systematically facilitating access to psychometrically validated instruments and identifying where further instrument development is needed.

Treatment differences in the therapeutic relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus nonbehavioral psychotherapy experts for borderline personality disorder.

OBJECTIVE: The present study explored the role of the therapeutic relationship and introject during the course of dialectical behavior therapy (DBT; Linehan, 1993) for the treatment of borderline personality disorder. METHOD: Women meeting DSM-IV criteria for borderline personality disorder (N = 101) were randomized to receive DBT or community treatment by experts. The Structural Analysis of Social Behavior (Benjamin, 1974) was used to measure both the therapeutic relationship and introject. RESULTS: Relative to community treatment by experts, DBT participants reported the development of a more positive introject, including significantly greater self-affirmation, self-love, self-protection, and less self-attack, during the course of treatment and 1-year follow-up. The therapeutic relationship did not have an independent effect on intrapsychic or symptomatic outcome but did interact with treatment. DBT participants who perceived their therapist as affirming and protecting reported less frequent occurrences of nonsuicidal self-injury. CONCLUSIONS: The study showed positive intrapsychic change during DBT and emphasized the importance of affirmation and control in the therapeutic relationship. Results are discussed in the context of understanding the mechanisms of change in DBT.

Dialectical behavior therapy as a precursor to PTSD treatment for suicidal and/or self-injuring women with borderline personality disorder.

This study examined the efficacy of dialectical behavior therapy (DBT) in reducing behaviors commonly used as exclusion criteria for posttraumatic stress disorder (PTSD) treatment. The sample included 51 suicidal and/or self-injuring women with borderline personality disorder (BPD), 26 (51%) of whom met criteria for PTSD. BPD clients with and without PTSD were equally likely to eliminate the exclusionary behaviors during 1 year of DBT. By posttreatment, 50-68% of the BPD clients with PTSD would have been suitable candidates for PTSD treatment. Borderline personality disorder clients with PTSD who began treatment with a greater number of recent suicide attempts and more severe PTSD were significantly less likely to become eligible for PTSD treatment.

Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: a 2-year randomized trial of dialectical behavior therapy versus community treatment by experts.

This study evaluated whether dialectical behavior therapy (DBT) was more efficacious than treatment by nonbehavioral psychotherapy experts in reducing co-occurring Axis I disorders among suicidal individuals with borderline personality disorder (BPD). Women with BPD and recent and repeated suicidal and/or self-injurious behavior (n = 101) were randomly assigned to 1 year of DBT or community treatment by experts (CTBE), plus 1 year of follow-up assessment. For substance dependence disorders (SDD), DBT patients were more likely to achieve full remission, spent more time in partial remission, spent less time meeting full criteria, and reported more drug- and alcohol-abstinent days than did CTBE patients. These findings suggest that improvements in co-occurring SDD among suicidal BPD patients are specific to DBT and cannot be attributed to general factors associated with nonbehavioral expert psychotherapy. Further, group differences in SDD remission were not explained by either psychotropic medication usage or changes in BPD criterion behaviors. DBT and CTBE did not significantly differ in the reduction of anxiety disorders, eating disorders, or major depressive disorder.

Psychiatric risk factors associated with postpartum suicide attempt in Washington State, 1992-2001.

OBJECTIVE: The purpose of this study was to evaluate preexisting psychiatric risk factors for postpartum suicide attempts resulting in hospitalization. STUDY DESIGN: We performed a population-based case-control study using Washington State birth certificates linked to hospital discharge data to evaluate the association between hospitalization with a psychiatric diagnosis, substance use diagnosis, or dual diagnosis in the 5 years before delivery with risk of postpartum suicide attempt. We compared cases (n = 355) hospitalized postpartum for a suicide attempt with controls (n = 1420) by using multivariable logistic regression. RESULTS: Women with a psychiatric disorder were at a 27.4-fold (95% confidence interval 10.6-70.8) increased risk, and those with a substance use disorder were at a 6.2-fold (95% confidence interval 2.8-13.9) increased risk, and those with a dual diagnosis were at an 11.1-fold (95% confidence interval 5.1-24.2) increased risk of postpartum suicide attempt compared with controls. CONCLUSION: Prenatal screening for preexisting psychiatric or substance abuse diagnoses may help identify women at risk of postpartum suicide attempt.

Outcomes of managing disability benefits among patients with substance dependence and severe mental illness.

To evaluate the feasibility and efficacy of a program to manage Social Security disability benefits in a clinical sample of patients with severe mental illness and co-occurring substance dependence, 41 patients were randomly assigned to have their benefits either contingently or noncontingently managed through their mental health center. Contingent management involved adjustments to the type or frequency (not amount) of disability benefits and payments for study participation based on ratings of substance use, money management, and treatment follow-through. The patients with contingent management used significantly less alcohol and drugs and showed much better money management than those with noncontingent management. Patients and case managers who participated in the study reported that they found the management strategy to be acceptable and useful.

Psychometric properties and utility of the problem severity summary for adults with serious mental illness.

OBJECTIVE: The authors studied the psychometric properties and utility of the Problem Severity Summary (PSS), a 13-item instrument that assesses symptom severity and functioning among adults with severe and persistent mental illness. METHODS: Case managers rated the PSS among more than 1,000 adults with severe and persistent mental illness who were receiving services at either mainstream community mental health centers or specialty community mental health centers (serving various minority groups) in one county in Washington State. A subsample of clients was used to assess the concurrent validity of the PSS with the Psychiatric Symptom Assessment Scale. RESULTS: Interrater reliability was adequate for ten of the 13 PSS items. Four meaningful factors were derived, each with adequate internal consistency: community functioning, negative social behavior, affective distress, and psychotic disturbance. The PSS demonstrated adequate concurrent and predictive validity. Sensitivity of the PSS factors to change showed that scores on three of the four scales changed significantly over one year. Discriminant validity indicated that the PSS is generally unbiased in terms of demographic characteristics. CONCLUSIONS: The PSS is a brief, easily administered instrument that shows psychometric promise for use in clinical contexts, such as treatment planning, concurrent review of care, and guidance for level-of-care decisions, as well as for quality management purposes.