A Mixed-Methods Evaluation to Inform the Hawai'i Suicide Prevention Strategic Plan.

The Prevent Suicide Hawai'i Taskforce is a state, public, and private partnership of individuals, organizations, and community groups that leads statewide suicide prevention efforts in Hawai'i. The purpose of this evaluation was to identify the progress and barriers of the Taskforce to inform the upcoming 2025 Hawai'i Suicide Prevention Strategic Plan in the following areas: Hope, Help, Heal, Research and Evaluation, and Policy and Advocacy. Utilizing a sequential exploratory mixed-methods approach, 18 key informants were interviewed, followed by a 13-question survey sent to the Taskforce member listserv. Results were analyzed using qualitative coding techniques and descriptive statistics. Interview findings contained six themes: importance of community relationships, interconnection of suicide prevention efforts, progress in diversifying training, organizational challenges, adaptations to the COVID-19 pandemic, and funding challenges. Of the 34 survey respondents, most were involved in the area of Hope (91%). The respondents reported the area with most progress was Hope (87%), and the most important area to address was Help (41%). The majority (82%) of the respondents characterized the level of Taskforce communication as Excellent or Good. Interview and survey data corroborated each other and revealed new insights about the successes and barriers of the Taskforce and their progress in implementing the Strategic Plan. Recommendations included advocating for long-term funding for suicide prevention and building community relationships.

Prioritizing Connection and Centering on Community: Take Your Shoes Off and Don't Put Your Feet on the Furniture.

This column describes what it means to be "in" a community and how to create a leading role for community partners in shaping research. It highlights essential components for conducting clinical and translational research in the community, including: (1) invitation to share history and purpose; (2) community-initiated collaboration and engagement; (3) focus on social and cultural determinants of health; (4) community-driven measures and frameworks; (5) application of Indigenous methods and approaches; and (6) implementation of Indigenous and adaptable interventions. Partnering with a community entails building relationships and positioning research around community interests, using methodologies and interventions right for the community.

Utilization of Nurse-Administered Screening, Brief Intervention, and Referral to Treatment in a Brief Psychiatric Inpatient Unit.

BACKGROUND: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been established as an effective screening tool for providing interventions for patients with risky substance use. OBJECTIVES: The objectives of this project were to train and coach staff nurses in the use of SBIRT, offer SBIRT to all admissions of a brief psychiatric inpatient unit, and decrease readmission rates. DESIGN: Using the Iowa Model for Implementing Evidence-Based Practices, SBIRT was implemented on the unit. Data were collected on the frequency of patients offered SBIRT and readmission rates. RESULTS: Fifty-nine percent of all admissions were offered SBIRT. The average readmission rates decreased by 18.3% for the first 2 months of implementation and by 67.5% for Days 16-31 postdischarge. CONCLUSIONS: SBIRT is an effective tool for nurses on psychiatric units to address substance use and to decrease readmission rates.

Suicide Risk Assessment, Management, and Mitigation in the Emergency Setting.

Suicide is a serious public health issue and is a leading cause of death worldwide. Suicidal ideation is a common presentation in emergency department (ED) settings, with many nuanced complications. Therefore, understanding screening, assessment, and mitigation is paramount to successful encounters with individuals presenting to emergency settings in psychiatric crises. Screening helps to identify the few people at risk within a large group. Assessment seeks to decide whether a specific individual is at significant risk. Mitigation aims to reduce the risk of suicide or of a serious attempt for a person at risk. These aims cannot be achieved with perfect reliability, but some approaches are more effective than others. Suicide screening specifics are important, even to individual practitioners, because a positive screen triggers assessment. Most practitioners understand assessment well: beginning with early psychiatric training, they are taught signs and symptoms suggesting that a patient might be at risk of suicide. Mitigating suicide risk is increasingly important to reduce the misery of ED boarding for patients awaiting psychiatric admission. For many patients, hospital admission is unnecessary if support, monitoring, and contingency plans are workable. For any individual patient, there may be a complicated mix of findings, risks, and interventions. Evidence-based screening and assessment tools are inadequate for the possible complexities, making care of individual patients dependent on good clinical assessment. The authors review the available evidence and offer experienced recommendations for challenges not yet thoroughly researched.

A Historical and Contemporary Review of the Contextualization and Social Determinants of Health of Micronesian Migrants in the United States.

Hawai'i's Pacific Islander (PI) population has suffered a higher burden of coronavirus disease 2019 (COVID-19) infections, hospitalizations, and deaths compared to other groups in the state. The Hawai'i Emergency Management Agency Community Care Outreach Unit conducted an assessment across the state to gain an understanding of the impact of the COVID-19 pandemic on the health and social welfare of households. Survey data was collected from individuals across the state during a period of 3 weeks (August 12-September 5, 2020). The following are resulting recommendations from the Pacific Island community to mitigate the impact and disparities of the pandemic as immediate and medium-term structural requests: (1) ensure that Pacific Island communities are proactively represented in state and county committees that develop health interventions to ensure that relevant language and culturally tailored communications and strategies are included, (2) provide consistent funding and community centered support to ensure consistent COVID-19 impact services for the Pacific Island families, (3) enhance the capacity of PI health care navigators and interpreters through increased funding and program support, and (4) engage state policy makers immediately to understand and address the systemic structural barriers to health care and social services for Pacific Islanders in Hawai'i. These recommendations were developed to address the generational inequities and disparities that exist for Pacific islanders in Hawai'i which were exacerbated by the COVID-19 pandemic.

Applying ideation-to-action theories to predict suicidal behavior among adolescents.

BACKGROUND: Although many risk factors for adolescent suicidal behavior have been identified, less is known about distinct risk factors associated with the progression from suicide ideation to attempts. Based on theories grounded in the ideation-to-action framework, we used structural equation modeling to examine risk and protective factors associated with the escalation from suicide ideation to attempts in adolescents. METHODS: In this cross-sectional study, data from the 2013 and 2015 Hawaii High School Youth Risk Behavior Surveys (N = 8,113) were analyzed. The sample was 54.0% female and racially/ethnically diverse. Risk factors included depression, victimization, self-harm, violent behavior, disinhibition, and hard substance use, and protective factors included adult support, sports participation, academic achievement and school safety. RESULTS: One in 6 adolescents (16.4%) reported suicide ideation, and nearly 1 in 10 (9.8%) adolescents had made a suicide attempt. Overall, disinhibition predicted the escalation to attempts among adolescents with suicide ideation, and higher academic performance was associated with lower suicide attempt risk. Depression and victimization were associated with suicide ideation. LIMITATIONS: This study examined data from the Youth Risk Behavior Survey, and other known risk factors such as anxiety and family history of suicide were not available in these data. CONCLUSIONS: Findings provide guidance for targets for clinical interventions focused on suicide prevention. Programs that incorporate behavioral disinhibition may have the greatest potential for reducing suicide attempt risk in adolescents with suicidal thoughts.

Inspiring hope through sources of strength among predominantly Pacific Islander communities.

Suicide death rates for Indigenous Hawaiians and other Pacific Islanders are amongst the highest in the world for youth, taking a tremendous toll on local communities (Else et al., 2007; Goebert, 2014). Comprehension of community perspectives of suicide and well-being can enhance suicide prevention interventions. This community-initiated project aimed to culturally adapt the components of an evidence-based youth suicide prevention intervention and refine the intervention methodology to align with these adaptations. Formative qualitative work was conducted with community members to obtain information on community strengths and program fit. Narrative analyses were emergent and emphasized components for suicide prevention, incorporating cultural auditing to ensure information reflected group views. Participants highlighted cultural aspects pertaining to the program philosophy, the importance of cultural protocol, local innovation in suicide prevention, and culturally grounded advancements that give back to their community. This insight was applied to two adjacent but distinct communities to integrate suicide prevention in a sustainable way by culturally adapting the program. Effective suicide prevention for rural and Indigenous youth requires a broad-based community commitment, connection, and network.

A Multidisciplinary Consultation-Liaison Team Approach to Reduce Enhanced Observer Usage.

BACKGROUND: There are few evidence-informed guidelines and findings to show that the use of sitters improves patient safety; overall, it is a costly intervention to address patients with disruptive behaviors. OBJECTIVE: The purpose of this article is to demonstrate that the creation of a multidisciplinary consultation-liaison (C-L) team, integrated with a psychiatric C-L team, together can decrease sitter use and improve outcomes using nonpharmacologic interventions. METHODS: This retrospective study describes the planning, implementation, and data collection using in creating an multidisciplinary C-L team to collaborate with the psychiatric C-L team and outcomes to support the approach. The multidisciplinary C-L team was composed of advanced practice registered nurses and creative art therapists. The teams worked closely with the medical units to develop and monitor criteria for sitter use. The key outcomes of the intervention improved patient safety and reduced overall cost. RESULTS: In the first year of implementation of a multidisciplinary C-L approach, sitter use decreased by 72%. Nonpharmacologic interventions improved patient outcomes by providing education to medical staff that enhanced the assessment and implementation of enhanced observer use across all the medical units. Subsequent data also reflect a sustained reduction in cost over the next 2-year period, saving the institution nearly $70K a month. CONCLUSION: An multidisciplinary C-L and psychiatric C-L team collaborated on the need for psychiatric medications, or nonpharmacologic interventions to address behaviors and decrease the need for an enhanced observer. The teams worked together to make policy revisions and algorithms and provide education, the result of which was significant financial savings and improved patient safety.

Youth Voice in Suicide Prevention in Hawai'i.

Increasing evidence indicates that youth leadership programs that hold youth as key stakeholders are successful for suicide prevention. This project served to evaluate a train-the-trainer program for youth and their supportive adults. Hawaii's Caring Communities Initiative for Youth Suicide Prevention developed and practiced a youth leadership model to promote individual and community well-being and to decrease suicide risks. In collaboration with multiple community partners and the Hawai'i State Department of Health, Hawaii's Caring Communities Initiative brought together 57 youth and 17 supportive adults from around the state for the 2019 Prevent Suicide Hawai'i Conference: Hope, Help, and Healing, a 2-day, train-the-trainer workshop, consisting of games and activities centered towards education of suicide prevention methods, in early April 2019. Of the participants attending the workshop, 44 youth and 12 supportive adults completed surveys measuring knowledge about suicide prevention and local resources, and comfort level in delivering the programs. Open-ended questions were also used to assess whether key messages were conveyed. Quantitative analyses indicated the lessons helped the participants retain the information better and increased their comfort with the material. The power of youth voice was a common theme in the qualitative data, exemplified by the statement: "We can actually make a difference in our school and community." Findings suggest that youth engagement is an important factor in preventing suicide. Interventions centered on strength-based models of youth leadership may promote healing and enhance prevention strategies to address persistent suicide disparities in minority communities by promoting their voices in the community.

The Hawai'i Child and Adolescent Psychiatry Resources for Primary Care: An Evidence-Informed Tool to Improve Quality of Care.

Mental health continues to be a significant concern both globally and locally in Hawai'i, with nearly half of all mental illness beginning in childhood or adolescence. A shortage of mental health providers has led to less than a third of patients receiving appropriate and timely care. Primary care providers are often the first-line responders to untreated mental health conditions, but they are often underprepared to address these conditions. To help provide guidance to primary care providers and other first-line responders, a child and adolescent mental health resource manual was developed, that is tailored to Hawai'i. This manual was presented at several pediatric didactic sessions and general conferences to describe its evolution, utility, to elicit feedback, as well as for an initial distribution. While feedback was overall positive, future manual development and strategic updates will be made to insure its suitability and timeliness, while continuing circulation efforts to primary care providers will ultimately benefit a greater proportion of children in need.

Protecting Youth in the Mental Health Service Settings.

The authors present the development of the field of psychiatry with the evolution of patient safeguards. They address the recent publicized events involving sexual harassment and abuse perpetrated by mental health service providers who have harmed youth who were under their direct psychiatric care. Recommendations are provided for primary care physicians and parents and legal guardians to further ensure patient safety.

A Qualitative Evaluation of the Impacts of a Strength-based and Youth-driven Approach to Suicide Prevention in Rural and Minority Communities in Hawai'i.

Suicide is a serious public health issue, particularly for Native Hawaiians and Other Pacific Islander youth living in rural communities in Hawai'i. The Hawai'i's Caring Communities Initiative (HCCI) for Youth Suicide Prevention was implemented to address these concerns and used a strength-based, youthleadership approach to suicide prevention. A qualitative study was completed with youth leaders and adult community coordinators to evaluate the impacts of participating in HCCI. Participants included 9 adult community coordinators and 17 youth leaders ages 13-18 years. Coordinator interviews took place at a location of the interviewee's convenience, and youth leader focus groups were conducted at 1 of 6 rurally-based community organizations. A team of university staff members coded transcripts using a narrative approach and grouped codes into themes. Five themes emerged that fit with an adapted socio-ecological model framework, which included increased knowledge in suicide risk, pride in leadership identity, sense of positive relationships, positive affirmation from community members, and sustainability. Future efforts that focus on youth-related issues are encouraged to integrate a youth leadership model and preventive approach while considering implications such as long-term funding and capitalizing on community strengths and resources.

Improving Patient Care through Collaborative Consultation Integration: a Quality Improvement Initiative.

Evidence suggests that interdisciplinary care leads to improvements in patient care and efficiency. To determine whether integrating inpatient hospital behavioral health services would result in improved perceptions of patient care and efficiency, team members (N = 23) were surveyed 1 year after integration on measures of patient care, efficiency, and personal satisfaction. A majority of respondents believed integration improved patient care and efficiency. Overall satisfaction was high. The results suggest integration of behavioral health services improves individual perceptions of patient care, efficiency, and satisfaction.

Rapid and sustained improvement in treatment-refractory depression through use of acute intravenous ketamine and concurrent transdermal selegiline: A case series.

BACKGROUND: Treatment resistant depression is a significant source of morbidity and mortality. For patients having failed or unable to undergo the electroconvulsive therapy procedure few effective alternative treatments exist. METHODS: A case series is presented where six patients with treatment resistant depression failing both electroconvulsive therapy and oral antidepressants are concomitantly treated with short course intravenous ketamine and longer term selegiline transdermal system. RESULTS: All six patients experienced clinical improvement with intravenous ketamine, with resolution of suicidality, increased food intake, and commitment to treatment adherence. Five patients showed sustained improvement with the selegiline transdermal system. One patient discontinued selegiline after developing peripheral edema and palpitations. LIMITATIONS: This case series included only patients experiencing moderate to severe treatment resistant depression. Availability of long-term follow-up data not available in some cases. CONCLUSION: Intravenous ketamine with simultaneous administration of the selegiline transdermal system is one strategy for treating treatment resistant depression in patients having failed or unable to undergo the electroconvulsive therapy procedure.

Change Pathways in Indigenous and Nonindigenous Youth Suicide.

Multivariate dynamic relationships among suicide attempts, anxiety and/or depressive symptoms, hope, and help-seeking were examined across time in Native Hawaiian and non-Hawaiian adolescents, using data from a 5-year longitudinal cohort study (N = 7,317). The rate of suicide attempts decreased over time, but this reduction was significantly less among Native Hawaiian youth than their non-Hawaiian peers. There were also significant differences between groups in hope and help-seeking, with Native Hawaiian youth increasing help-seeking and decreasing hope to a greater degree. Youth-centered, cultural approaches to suicide prevention are essential in enhancing well-being in indigenous communities.

Hope, help, and healing: Culturally embedded approaches to suicide prevention, intervention and postvention services with native Hawaiian youth.

Suicide rates have reached their highest documented levels in the United States with the greatest increases among indigenous youth, including Native Hawaiians. Culturally informed, effective prevention and treatment services are needed now more than ever for Native communities to heal and flourish. Multicomponent prevention and service strategies rooted in indigenous values and approaches show the most promise. Native Hawaiian communities are united around a common goal of suicide prevention, intervention and postvention, linking cultural meanings to improve understanding and guide local efforts. This paper highlights important cultural values to consider when developing and implementing suicide prevention, intervention and postvention. Strategies build upon the strengths of Native Hawaiian youth and their respective communities. Native Hawaiian sayings anchor each level and serve to organize a set of culturally informed and culturally embedded programs and approaches along the continuum of prevention, intervention and postvention. Application of indigenization to suicide prevention enhances connections to people and place, inspiring hope among Native Hawaiian youth, their families and their communities. (PsycINFO Database Record