Relations between discrimination, rejection sensitivity, negative affect, and decrements in problem-solving ability following social rejection: An experimental investigation.

INTRODUCTION: While negative affect and problem-solving deficits have been consistently linked to suicidal thoughts and behaviors, the latter are often conceptualized and studied as time- and/or context-invariant. Though requiring additional empirical support, theory suggests that discrimination may strengthen the relation between rejection sensitivity and increases in negative affect as well as declines in problem-solving abilities following rejection. The aim of the current study was to test this claim using a social rejection paradigm (i.e., Cyberball) with young adults experiencing past-month suicidal ideation. METHODS: The sample consisted of 50 participants. Lifetime discrimination and rejection sensitivity were assessed prior to Cyberball. Negative affect and problem-solving abilities were assessed pre- and post-Cyberball. SPSS and the PROCESS macro were used to test relations among variables of interest. RESULTS: Rejection sensitivity predicted greater problem-solving decrements, but not negative affect, following rejection among individuals who had experienced higher (vs. lower) levels of lifetime discrimination. CONCLUSION: Addressing rejection sensitivity and sources of discrimination within the context of treatment may reduce the impact of social rejection on problem-solving abilities among young adults at risk for suicide.

Impact of a Virtual Suicide Safety Planning Training on Clinician Knowledge, Self-Efficacy, and Use of Safety Plans in Community Mental Health Clinics.

OBJECTIVE: Safety planning is a critical evidence-based intervention used to prevent suicide among individuals who report suicidal ideation or behavior. There is a dearth of research on optimal ways to disseminate and implement safety plans in community settings. The present study examined one implementation strategy, a 1-hour virtual pre-implementation training, designed to teach clinicians to effectively use an electronic safety plan template (ESPT), integrated with suicide risk assessment tools, in the context of a measurement feedback system. We examined the effect of this training on clinician knowledge and self-efficacy in use of safety planning as well as ESPT completion rates. METHOD: Thirty-six clinicians across two community-based clinical psychology training clinics completed the virtual pre-implementation training as well as pre- and post-training knowledge and self-efficacy assessments. Twenty-six clinicians completed a 6-month follow-up term. RESULTS: Clinicians reported significant improvements in self-efficacy and knowledge from pre- to post-training. They retained significant improvements in self-efficacy and a trend toward greater knowledge at the 6-month follow-up. Of the clinicians who worked with suicidal youth, 81% attempted to use an ESPT and 63% successfully completed all sections of the ESPT. Reasons for partial completion included technological difficulties and time constraints. CONCLUSION: A brief virtual pre-implementation training can improve clinician knowledge and self-efficacy in use of an ESPT with youth at risk for suicide. This strategy also holds the potential to improve the adoption of this novel evidence-based intervention in community-based settings.

Interpersonal stress and proinflammatory activity in emerging adults with a history of suicide risk: A pilot study.

Interpersonal stress during adolescence and young adulthood can threaten healthy developmental trajectories. A "primed" proinflammatory response to acute stress may serve as an underlying process that results in negative outcomes for youth. The present pilot study examined the relation between interpersonal stress and two proinflammatory cytokines in a sample of 42 university-recruited emerging adults with recent suicidal thoughts and behaviors. Participants completed self-report measures of mood, suicidal thoughts and behaviors, recent peer-related stressors, and interpersonal sensitivity. They also participated in an acute laboratory social stress task and provided three saliva samples to measure their proinflammatory responses (IL-6 and TNF-α) to the stressor. Participants reported significant increases in sadness and exclusion, and significant decreases in inclusion, following task participation. Importantly, no participants reported an increase in or onset of suicidal thoughts. No significant associations between interpersonal stress and proinflammatory cytokines were found. Changes in affect during the task coupled with lack of increased suicidal thoughts indicate it is acceptable to use this exclusion and rejection paradigm with this population, with proper debriefing and positive mood induction procedures. Given all other nonsignificant associations, future research considerations are discussed, including impact of COVID-19 on task potency and incorporation of multiple stress response systems.

Facets of social problem-solving as moderators of the real-time relation between social rejection and negative affect in an at-risk sample.

Social rejection predicts negative affect, and theoretical work suggests that problem-solving deficits strengthen this relation in real-time. Nevertheless, few studies have explicitly tested this relation, particularly in samples at risk for suicide. This may be particularly important as social rejection and negative affect are significant predictors of suicide. The aim of the current study was to examine whether cognitive (i.e., perceiving problems as threats) and behavioral (i.e., avoidance) facets of problem-solving deficits moderated the real-time relation between social rejection and negative affect. The sample consisted of 49 young adults with past-month suicidal ideation. Demographic information, social problem-solving deficits, as well as depressive/anxiety symptoms and stress levels were assessed at baseline. Social rejection and negative affect were assessed using ecological momentary assessment over the following 28 days. Dynamic structural equation modeling was used to assess relations among study variables. After accounting for depressive/anxiety symptoms, stress levels, sex, and age, only avoidance of problems bolstered the real-time positive relation between social rejection severity and negative affect (b = 0.04, 95% credibility interval [0.003, 0.072]). Individuals with suicidal ideation who possess an avoidant problem-solving style may be particularly likely to experience heightened negative affect following social rejection and may benefit from instruction in problem-solving skills.

Examination of proinflammatory activity as a moderator of the relation between momentary interpersonal stress and suicidal ideation.

INTRODUCTION: Peer-related interpersonal stress can increase risk for suicidal thoughts among adolescents and young adults. However, not all individuals who undergo peer-related interpersonal stressors experience suicidal thoughts. Heightened proinflammatory activity is one factor that may amplify the relation between interpersonal stress and suicidal thinking. METHODS: This pilot study examined the relation between interpersonal stress and suicidal ideation in real time, as well as whether proinflammatory cytokine (IL-6 and TNF-α) activity across a laboratory social stressor moderated this association in a sample of 42 emerging adults with recent suicidal ideation. Participants completed 28 days of 6×/daily ecological momentary assessment that assessed for suicidal ideation (presence vs. absence, ideation intensity), occurrence of negative peer events, and feelings of exclusion. RESULTS: There was a trend for within-person increases in feelings of exclusion to be associated with increases in concurrent suicidal ideation intensity. Additionally, within-person increases in negative peer events were associated with increased odds of subsequent suicidal ideation among individuals with very low IL-6 activity. However, this finding is considered preliminary. CONCLUSION: Interventions targeting perceptions of exclusion and increasing social support may be of benefit. However, findings require replication in larger samples, and thus must be interpreted with caution.

A prospective investigation of the relation between dysfunctional family communication and suicidal ideation severity in a clinical adolescent sample: A serial mediation model.

BACKGROUND: Extant research has documented a relation between the quality of family communication and adolescent suicidal ideation. However, few studies have examined this relation longitudinally or explored potential mechanisms of this effect. In the present study, unhealthy family communication was hypothesized to be associated with suicidal ideation severity over 18 months via a serial mediation pathway through emotion regulation difficulties and depressive symptom severity. METHODS: The sample consisted of 147 adolescents (Mage = 14.91, SD = 1.51, range = 12-18 years; 76.2% female, 85.5% White) enrolled in a randomized clinical trial. Family communication quality was assessed at baseline using the Family Assessment Device. Emotion regulation difficulties and depressive symptoms were assessed using the Difficulties in Emotion Regulation Scale and Children's Depression Inventory-2, respectively, at baseline, 6-, and 12-months. Suicidal ideation was assessed using the Suicidal Ideation Questionnaire-JR at baseline and 18-months. Path analysis was used to analyze temporal relations between constructs. RESULTS: After accounting for participant's age, sex, treatment condition, and baseline levels of variables of interest, analyses supported the indirect relation between baseline family communication and 18-month suicidal ideation severity through 6-month emotion regulation difficulties and 12-month depressive symptom severity. LIMITATIONS: Data were exclusively collected via self-report, and the sample was racially homogenous. CONCLUSIONS: Treatment aimed at improving family communication may help bolster emotion regulation abilities, lower depressive symptoms, and subsequently, suicide risk.

Posttraumatic stress disorder symptom clusters, suicidal ideation, and social support in a clinical adolescent sample.

Posttraumatic stress disorder (PTSD) is a risk factor for adolescent suicidal ideation (SI). This study explored the relation between PTSD symptom clusters and SI, and whether social support moderates this association, in a cross-sectional, adolescent, clinical sample (N = 125). We hypothesized that each cluster would be positively associated with SI severity and that social support would buffer these associations. Only the persistent avoidance cluster was significantly associated with SI severity. Further, social support moderated this association. Results highlight the positive association between persistent avoidance symptoms of PTSD and SI and suggest that bolstering social support serves a protective function.

Depression-related emotional problems mediate the relation between hopelessness and suicidal ideation severity.

OBJECTIVE: Cross-sectional research with adult samples suggests that hopelessness may indirectly affect suicidal ideation (SI) through overall depressive symptom severity. However, particular depressive symptom constellations, rather than overall symptoms, may underlie the association between hopelessness and SI. Yet, the cross-sectional nature of these studies precludes examination of the temporal associations among these constructs. METHODS: Using path analysis, the present study examined whether depression-related emotional problems mediate the relation between hopelessness and SI in a clinical sample of 110 adolescents over a 6-month period. The specificity of depression-related emotional problems as a mediator was also evaluated. RESULTS: After accounting for covariates, results supported the specificity of 3-month depression-related emotional problems as a mediator of the association between baseline levels of hopelessness and 6-month SI. CONCLUSION: Results suggest that treatment targeted specifically at hopelessness may help reduce depression-related emotional problems and lower SI, and ultimately, adolescent suicide risk.

Adolescent depressed mood and difficulties with emotion regulation: Concurrent trajectories of change.

INTRODUCTION: Adolescent depression is a significant mental health concern. Emotion regulation difficulties have been associated with subsequent depressive symptoms, though different facets of emotion regulation are rarely compared. This study examined the degree to which trajectories of change in different facets of emotion regulation (goal-directed behavior, impulse control, and regulation strategies) and depressive symptoms were associated across twelve months in a clinical adolescent sample. METHODS: Participants included 110 adolescents from the US who were enrolled in a randomized trial that tested a cognitive-behavioral treatment for youth with co-occurring mental health and substance use concerns (Mage = 15.71 years; 57.3% male). Assessments were conducted at baseline, 3-, 6-, and 12-month follow-ups. Three separate bivariate latent basis growth curve analyses were conducted. Correlations between latent intercepts and latent slopes, as well as overall model fit, were examined. RESULTS: Impulse control and goal-directed behavior were each associated with depressive symptoms at baseline. Additionally, change in impulse control over time was significantly associated with change in depressive symptoms. However, the same was not true for goal-directed behavior. Overall fit indices for models of emotion regulation strategies were below acceptable levels and thus could not be interpreted. CONCLUSIONS: Findings from the present study indicate that adolescents' depressive symptoms appear to improve as their perceived ability to control impulses improves. These results suggest that addressing impulse control difficulties may be an important step in treating adolescent depression and co-occurring disorders.

Depressive symptom severity mediates the association between avoidant problem-solving style and suicidal ideation.

BACKGROUND: The contemporaneous association between avoidant style, a maladaptive social problem-solving strategy, and adolescent suicidal ideation has been well established. However, the mechanisms underlying this association are not well understood. Using cross-lagged panel modeling, the present study examined whether depressive symptom severity mediates the relation between avoidant style and severity of suicidal ideation. The specificity of depressive symptom severity as a mediator was also evaluated by simultaneously testing whether avoidant style mediates the association between depressive symptom and suicidal ideation severity. METHODS: The sample included 110 adolescents enrolled in a randomized controlled clinical effectiveness trial. Avoidant style as well as depressive symptom and suicidal ideation severity were assessed via self-report with the Social Problem-Solving Inventory-Revised, Children's Depression Scale-2, and Suicidal Ideation Questionnaire-Junior, respectively, at baseline, 3-and 6-months. RESULTS: After accounting for participant age, sex, and treatment condition, path analyses supported the specificity of 3-month depressive symptom severity as a mediator of the association between baseline levels of avoidant style and 6-month suicidal ideation severity. LIMITATIONS: Results may not be generalizable to non-clinical samples. Causality cannot be inferred from study results. Data were exclusively collected via self-report. CONCLUSIONS: Findings suggest that avoidant style is indirectly related to suicidal ideation through depressive symptom severity. Thus, treatment targeted at improving social problem-solving skills, particularly avoidant style, may help reduce depressive symptoms and lower suicide risk.

Characteristics of a First Suicide Attempt that Distinguish Between Adolescents Who Make Single Versus Multiple Attempts.

Although a history of a suicide attempt is the strongest predictor of future suicide attempts, not all adolescents who make an attempt engage in repetitive suicidal behavior. The present study sought to determine whether certain characteristics of a first suicide attempt (e.g., age of first attempt, method of attempt used, intent seriousness, medical lethality, and receipt of treatment after attempt) can distinguish between adolescents who make single versus multiple suicide attempts. Adolescents (N = 95) who were psychiatrically hospitalized and their guardian completed a diagnostic interview to gather information on all lifetime suicide attempts. A multivariate hierarchical logistic regression was conducted, predicting single attempt versus multiple attempt status. Of the first-attempt characteristics examined, only age of first attempt, OR = 0.33, 95% CI [0.17-0.63], p = .001, and receipt of treatment following attempt, OR = 0.28, 95% CI [0.09-0.88], p = .028, significantly distinguished SA vs. MA status, even after controlling for current age and depression at the time of first attempt. Female and White participants were overrepresented in this sample, which limits generalization to more heterogenous and diverse samples. The cross-sectional nature of data introduces the potential for retrospective recall bias. Younger age of first attempt and lack of receipt of mental health treatment following a first attempt were associated with multiple attempt status. These findings highlight the importance of early mental health screening, parental psychoeducation, and linkage to mental health care after a suicide attempt.

Is the focus of community-based mental health treatment consistent with adolescent psychiatric diagnoses?

Most adolescents do not receive effective mental health services. This may stem in part from infrequent use of evidence-based and multi-informant diagnostic assessments to guide clinical care. The primary purpose of the present study was to examine whether adolescent mental health diagnoses and suicidality, derived via evidence-based diagnostic interviews and assessments, correspond with reported "reason for treatment" received by adolescents. Secondarily, we examined the potential association between socio-economic status and the match between youth diagnoses and reasons for treatment. The influence of parent-adolescent agreement on diagnoses and reasons for treatment on findings was also explored. Using chi-square analyses, a significant association was found between youth diagnoses of mood disorders, disruptive behavior disorders, and suicidality, respectively, and a focus of treatment on these conditions per combined parent-adolescent report. The same was not true for youth anxiety, attention-deficit hyperactivity, or substance abuse disorders. Results of exploratory analyses suggest that these results are driven by adolescent, but not parent report. With regard to socio-economic status, there was a trend for those with higher incomes to report a treatment focus consistent with youth diagnoses, per combined parent-adolescent report. Results suggest that focus of mental health treatment received by adolescents in standard community-based care may not uniformly address all current disorders. Efforts are needed to disseminate multi-informant evidence-based assessments to enhance the quality and effectiveness of care.

Developing a sustainable child and family service system after a community tragedy: Lessons from Sandy Hook.

This paper describes a systematic approach to assessing community services post-Sandy Hook shooting. An evaluation team was invited to develop a sustainability plan for community services in Newtown. Service organizations, providers and families were interviewed. Descriptive statistics were used to characterize the range of services; respondent perspectives were coded using content analysis. We found that Newtown has a broad array of community services, but respondent groups varied in their perceptions of service adequacy. Consensus existed about core components of an ideal service system, including centralizing access; coordinating care; personalizing and tailoring services for families; and providing evidence-based care. The strategic community assessment approach developed here may inform how communities examine their service capacity and develop sustainability plans post-disaster.

Parent Burden in Accessing Outpatient Psychiatric Services for Adolescent Depression in a Large State System.

OBJECTIVE: This study examined barriers facing parents who seek outpatient psychiatric care in a large state system for adolescents with depression. METHODS: A total of 264 outpatient facilities licensed to treat youths in New York were contacted by using a mystery shopper methodology. Callers tracked the number of call attempts, in-person appointments, and other steps required prior to seeing a psychiatrist. RESULTS: Fewer than two-thirds of parents made a psychiatry, therapy, or intake appointment. Of those who did not make an appointment, 19% received no referrals. Most callers made at least two calls and spoke with at least two people before initiating scheduling. Virtually all clinics required at least one intake or therapy appointment before receipt of a psychiatry appointment. Parental burden did not differ by region, urbanicity, clinic type, seasonality (spring or summer), or insurance status. CONCLUSIONS: Families of youths with mental health needs face considerable burden in accessing timely treatment.

Access to Care for Youth in a State Mental Health System: A Simulated Patient Approach.

OBJECTIVE: To examine access to psychiatric care for adolescents with depression in outpatient specialty clinics within a state mental health system, using a simulated patient approach. METHOD: Trained callers posed as the mother of a 14-year-old girl with depression, following a script. A stratified random sample (n = 264) of 340 state-licensed outpatient mental health clinics that serve youth was selected. Clinics were randomly assigned to season and insurance condition. We examined whether access varied by season, clinic characteristics, and caller insurance type. Weighted logistic and linear mixed effects regression models were fitted to examine associations with appointment availability and wait times. RESULTS: Among clinics at which a treatment appointment could be scheduled, appointment availability differed by season. Clinics that had participated in state-sponsored trainings targeting access were more available. Wait times for treatment appointments varied by season and region. Wait times in New York City were shorter than in some other regions. Although callers were 4.1 times more likely to be able to schedule a psychiatry appointment in the spring, wait times for psychiatry appointments were significantly longer in the spring than in the summer (49.9 vs. 36.7 days). Wait times for therapy appointments were significantly shorter in community than in hospital clinics (19.1 days vs. 35.3 days). CONCLUSION: Access to psychiatric care for youth with depression was found to be variable in a state system. State-sponsored trainings on strategies to reduce wait times appear to improve care access. The simulated patient approach has promise for monitoring the impact of health care policy reforms on care quality measures.

Can Postpartum Depression Be Managed in Pediatric Primary Care?

BACKGROUND: Postpartum depression is prevalent among women who have had a baby within the last 12 months. Depression can compromise parenting practices, child development, and family stability. Effective treatments are available, but access to mental healthcare is challenging. Routine infant healthcare visits represent the most regular contact mothers have with the healthcare system, making pediatric primary care (PPC) an ideal venue for managing postpartum depression. METHODS: We conducted a review of the published literature on postpartum depression programs. This was augmented with a Google search of major organizations' websites to identify relevant programs. Programs were included if they focused on clinical care practices, for at-risk or depressed women during the first year postpartum, which were delivered within the primary care setting. RESULTS: We found that 18 programs focused on depression care for mothers of infants; 12 were developed for PPC. All programs used a screening tool. Psychosocial risk assessments were commonly used to guide care strategies, which included brief counseling, motivating help seeking, engaging social supports, and facilitating referrals. Available outcome data suggest the importance of addressing postpartum depression within primary care and providing staff training and support. The evidence is strongest in family practices and community-based health settings. More outcome data are needed in pediatric practices. CONCLUSION: Postpartum depression can be managed within PPC. Psychosocial strategies can be integrated as part of anticipatory guidance. Critical supports for primary care clinicians, especially in pediatric practices, are needed to improve access to timely nonstigmatizing care.