The Veterans Health Administration REACH VET Program: Suicide Predictive Modeling in Practice.

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model.

Effectiveness of interpersonal psychotherapy-trauma for depressed women with childhood abuse histories.

BACKGROUND: Women with depression and childhood sexual abuse histories constitute more than 20% of the female patient population in publicly funded community mental health centers (CMHCs). Interventions are needed that address depression and posttraumatic stress disorder (PTSD) symptoms and social health. METHOD: We compared Interpersonal Psychotherapy-Trauma (IPT-T), an IPT adaptation for this population and setting, to Clinic Psychotherapy (CP). CP clinicians were free to implement the psychotherapy of choice. Women (n = 162; 54% White, 10.5% Hispanic; 52.2% Medicaid-insured) with a major depressive episode (MDE) and history of sexual abuse before 18 were randomly assigned to IPT-T or CP. Participants were offered 16 free sessions of IPT-T or CP. Outcomes were MDE remission, improved depression (Beck Depression Inventory, Hamilton Depression Rating Scale) and PTSD symptoms (Modified PTSD Symptom Scale), and improved social health (e.g., UCLA Loneliness Scale). Weighted generalized estimating equations were used to examine outcomes at 8 (primary) and 20 (secondary) months postrandomization. RESULTS: IPT-T led to greater improvements in PTSD symptoms and many social health indicators, including loneliness and social support, at both 8- and 20-month follow-up. Effect sizes ranged from .18 to .39 at the primary endpoint (8 months). IPT-T and CP yielded comparable improvements in depression symptoms and MDE remission. CONCLUSION: Evidence-based psychotherapies like IPT-T are needed in CMHCs, where some of the most vulnerable patients receive treatment. With comparable findings for depression, IPT's superior improvements in social health and PTSD symptoms are cause for optimism. IPT-T should be evaluated in dissemination trials. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Depressive symptoms mediate the relationship between changes in emotion regulation during treatment and abstinence among women with alcohol use disorders.

Women with alcohol use disorders (AUD) experience high rates of co-occurring conditions, such as depression and posttraumatic stress disorder (PTSD), which can complicate treatment engagement and response. Therefore, identifying factors that underlie alcohol use, depression, and PTSD symptoms in women with AUD has important treatment implications. The current study investigated emotion regulation as one such underlying factor. We tested a model that examined the extent to which changes in emotion regulation during treatment predicted women's depression and PTSD symptom severity at treatment completion and subsequent alcohol use following treatment. The study included 48 participants enrolled in a randomized controlled trial of interpersonal psychotherapy versus usual care for women with co-occurring alcohol dependence and major depression. Assessments were conducted at baseline, posttreatment (16 weeks), and follow-up (24 weeks). Descriptive statistics of baseline data revealed heightened levels of emotion dysregulation in this sample, which were related to fewer days abstinent from alcohol, more negative consequences from alcohol, and greater PTSD symptom severity. Women's lower depressive symptoms at the end of treatment were found to mediate the relationship between improved emotion regulation during the treatment period and greater abstinence following treatment. Posttreatment PTSD symptoms, however, were not found to mediate that relationship. These results suggest that improvements in depressive symptoms during treatment are associated with emotion regulation at the end of treatment, which may contribute to greater abstinence from alcohol following treatment. (PsycINFO Database Record

Randomized controlled trial of interpersonal psychotherapy versus enhanced treatment as usual for women with co-occurring depression and pelvic pain.

OBJECTIVE: Our study assessed the effectiveness of Interpersonal Psychotherapy (IPT) tailored for biomedical patients with depression and pain. IPT was compared to enhanced treatment as usual (E-TAU) among women with co-occurring depression and chronic pain presenting for care at a women's health or family medicine practice. We hypothesized that women presenting to urban medical practices with depression and chronic pain would benefit from IPT tailored to address their needs to a greater degree than from E-TAU. METHODS: We conducted a randomized controlled psychotherapy trial of 61 women from 2 urban medical practices who met criteria for major depressive disorder and chronic pelvic pain. Participants were assigned to receive either 8 sessions of IPT or a facilitated psychotherapy referral to a community mental health center, and assessed for depression, social interactions, and pain at 0-, 12-, 24-, and 36-weeks, with score on the Hamilton Rating Scale for Depression as the primary outcome. Both intent-to-treat (ITT) and causal modeling analyses correcting for treatment attendance were conducted. RESULTS: ITT analyses were not significant. In causal modeling analyses, participants assigned to IPT showed significantly more improvement for depression and social interactions, but not for pain. CONCLUSION: IPT may be a viable option as part of a comprehensive treatment program for women in medical practices with depression and chronic pain. CLINICAL TRIALS REGISTRATION: ClinicalTrials.gov, NCT00895999.

Substance-induced depression and independent depression in proximal risk for suicidal behavior.

OBJECTIVE: Major depressive episodes may be substance induced or occur independent of substance use. Studies of the roles of substance-induced depression (SID) and independent depression (IND) in suicidal behavior are limited to retrospective reports. The purpose of this study was to examine proximal (i.e., acute) risk for suicide attempts associated with SID and IND. METHOD: Individuals who had attempted suicide (n = 100) and nonsuicidal controls (n = 100) matched for site were recruited from residential substance use treatment programs. Participants were ages 18 and older and screened positive for potential alcohol use disorder. Validated semistructured interviews were used to assess SID, IND, and suicide attempts. Analyses of individual-level risk for attempts were based on multivariate logistic regression that adjusted for risk factors. Population-level attributable risk (PAR) fractions for suicide attempts were also calculated to provide estimates of the percentage of attempts in the study population attributable to SID and IND, respectively. RESULTS: SID was identified in 60% of attempters and 35% of controls and IND in 13% of attempters and 3% of controls. Both variables conferred risk for suicide attempt (SID: odds ratio [OR] = 3.73, 95% CI [1.84, 7.58]; IND: OR = 10.38, 95% CI [2.48, 43.49]. PAR for suicide attempts associated with SID and IND was 0.44 and 0.12, respectively. CONCLUSIONS: Both SID and IND confer proximal risk for suicide attempts after adjusting for other risk factors. SID also contributes substantial risk in this population overall. Future research should test the hypothesis that IND confers greater risk than SID at the individual level.

A pilot study of interpersonal psychotherapy for alcohol-dependent women with co-occurring major depression.

BACKGROUND: Co-occurring major depression is prevalent among alcohol-dependent women and is a risk factor for poor treatment outcomes. This uncontrolled pilot study tested the feasibility, acceptability, and initial effects of interpersonal psychotherapy (IPT) for women with co-occurring alcohol dependence and major depression (AD-MD) in an outpatient community addiction treatment program. METHODS: Fourteen female patients with concurrent diagnoses of alcohol dependence and major depression participated. Assessments were conducted at baseline, midtreatment (8 and 16 weeks), posttreatment (24 weeks), and follow-up (32 weeks). RESULTS: Participants attended a mode of 8 out of 8 possible sessions of IPT in addition to their routine addiction care, and reported high treatment satisfaction on the Client Satisfaction Questionnaire-8. Women's drinking behavior, depressive symptoms, and interpersonal functioning improved significantly over the treatment period and were sustained at follow-up. CONCLUSIONS: These preliminary findings suggest that IPT is a feasible, highly acceptable adjunctive behavioral intervention for AD-MD women.

Self-Esteem Reactivity Among Mothers of Children with Attention-Deficit/Hyperactivity Disorder: The Moderating Role of Depression History.

This study examined self-esteem reactivity to a variety of contextual cues in a sample of women prone to depression. Participants were 49 mothers of children with attention-deficit/hyperactivity disorder. Across a 9-month time-period, participants completed weekly measures of self-esteem, perceived stress, positive and negative affect, and child disruptive behavior. Results indicated that mothers reported lower self-esteem during weeks they experienced greater stress, lower positive affect, higher negative affect, and more inattentive, overactive, and oppositional behavior in their children. Depression history moderated these relationships such that mothers with prior histories of depression reported greater self-esteem reactivity to these cues than never depressed mothers.

Predictors of treatment outcomes among depressed women with childhood sexual abuse histories.

BACKGROUND: A notable portion (21%) of female patients receiving treatment for depression in community mental health centers (CMHC) has childhood sexual abuse (CSA) histories. Treatment outcomes in this population are heterogeneous; identifying factors associated with differential outcomes could inform treatment development. This exploratory study begins to address the gap in what is known about predictors of treatment outcomes among depressed women with sexual abuse histories. METHOD: Seventy women with major depressive disorder and CSA histories in a CMHC were randomly assigned to interpersonal psychotherapy (n = 37) or usual care (n = 33). Using generalized estimating equations, we examined four pretreatment predictor domains (i.e. sociodemographic characteristics, clinical features, social and physical functioning, and trauma features) potentially related to depression treatment outcomes. RESULTS: Among sociodemographic characteristics, Black race/ethnicity, public assistance income, and unemployment were associated with less depressive symptom reduction over the course of treatment. Two clinical features, chronic depression and borderline personality disorder, were also related to less reduction in depressive symptoms across the treatment period. CONCLUSION: Our results demonstrate the clinical relevance of attending to predictors of depressed women with CSA histories being treated in public sector mental health centers. Particular sociodemographic characteristics and clinical features among these women may be significant indicators of risk for relatively poorer treatment outcomes.

The relationships of attachment style and social maladjustment to death ideation in depressed women with a history of childhood sexual abuse.

The current study examined the interaction of attachment orientation and acute social maladjustment as risk factors for death ideation in a sample of women with Major Depression and histories of childhood sexual abuse. Social maladjustment was associated with greater endorsement of death ideation. Avoidant and anxious attachment orientations moderated the social maladjustment and death ideation associations in some domains. Work-related maladjustment was associated with greater odds of death ideation for those with higher attachment avoidance. Parent-role maladjustment was associated with greater odds of death ideation for those with lower attachment anxiety. Findings demonstrate strong associations between death ideation and social maladjustment, and suggest that death ideation may be specific to certain domains of adjustment for anxious and avoidant attachment styles.

Stressful life events and suicidal behavior in adults with alcohol use disorders: role of event severity, timing, and type.

BACKGROUND: Stressful life events (SLEs) play a key role in suicidal behavior among adults with alcohol use disorders (AUD), yet there are meager data on the severity of SLEs preceding suicidal behavior or the timing of such events. METHOD: Patients in residential substance use treatment who made a recent suicide attempt (cases, n=101) and non-suicidal controls matched for site (n=101) were recruited. SLEs that occurred within 30 days of the attempt and on the day of the attempt in cases were compared to SLEs that occurred in the corresponding periods in controls. SLEs were categorized by type (interpersonal, non-interpersonal) and severity (major, minor) and were dated to assess timing. Degree of planning of suicide attempts was also assessed. RESULTS: Major interpersonal SLEs conferred risk for a suicide attempt, odds ratio (95% CI)=5.50 (1.73, 17.53), p=0.005. Cases were also more likely to experience an SLE on the day of the attempt than on the corresponding day in controls, OR (95% CI)=6.05 (1.31, 28.02), p=0.021. However, cases that made an attempt on the day of a SLE did not make lower planned suicide attempts compared to other cases, suggesting that suicide attempts that are immediately preceded by SLEs cannot be assumed to be unplanned. CONCLUSIONS: Results suggest the central importance of major interpersonal SLEs in risk among adults with AUD, a novel finding, and documents that SLEs may lead to suicide attempts within a short window of time (i.e., same day), a daunting challenge to prevention efforts.

Attachment and alliance in the treatment of depressed, sexually abused women.

BACKGROUND: Depression among women with sexual abuse histories is less treatment responsive than in general adult samples. One contributor to poorer treatment outcomes may be abused women's difficulties in forming and maintaining secure relationships, as reflected in insecure attachment styles, which could also impede the development of a positive therapeutic alliance. The current study examines how attachment orientation (i.e. anxiety and avoidance) and development of the working alliance are associated with treatment outcomes among depressed women with histories of childhood sexual abuse. METHOD: Seventy women seeking treatment in a community mental health center who had Major Depressive Disorder and a childhood sexual abuse history were randomized to Interpersonal Psychotherapy or treatment as usual. RESULTS: Greater attachment avoidance and weaker working alliance were each related to worse depression symptom outcomes; these effects were independent of the presence of comorbid Borderline Personality Disorder and Post-Traumatic Stress Disorder. The effect of avoidant attachment on outcomes was not mediated by the working alliance. Further, working alliance had a stronger effect on depression outcomes in the Interpersonal Psychotherapy group. CONCLUSION: Understanding the influence of attachment style and the working alliance on treatment outcomes can inform efforts to improve the treatments for depressed women with a history of childhood sexual abuse.

Domain-specific social functioning improvements during treatment of depressed women with histories of childhood sexual abuse.

BACKGROUND: Deterioration in social functioning and depression are often intertwined, particularly for women with histories of childhood sexual abuse (CSA). Among women with CSA histories, some relationship domains may be more modifiable than others during time-limited depression treatment. Women with CSA histories often report long-standing interpersonal difficulties in close relationships. Thus, we expected that patients' relationships with immediate family and intimate partners would be less likely to improve during treatment than relationships with co-workers, friends, or extended family, unless patients received an interpersonally-focused intervention that targeted close relationships. METHODS: To examine domain-specific social functioning improvements and determine whether some domains were more likely than others to respond to an interpersonally-focused intervention, we analyzed data from a randomized controlled trial investigating Interpersonal Psychotherapy (IPT) vs. usual care (UC) in 69 depressed women with CSA histories. Participants completed the Social Adjustment Scale-SR at pretreatment, 10-, 24-, and 36-weeks. RESULTS: Consistent with our hypotheses, patients reported significant improvements in work roles, leisure activities with friends, and relationships with extended family members over the course of treatment. Relationships with immediate family members and intimate partners did not improve in the overall sample. However, relationships with immediate family improved significantly more among IPT than UC patients. LIMITATIONS: The sample size is small and generalizability may be limited. CONCLUSIONS: Social functioning improvements during depression treatment may be domain-specific among depressed women with CSA histories. IPT is more effective than UC at improving relationships with close family members in this population.

Interpersonal Psychotherapy for Co-occurring Depression and Chronic Pain.

Up to 37% of individuals experience chronic pain during their lifetimes. Approximately one-fourth of primary care patients with chronic pain also meet criteria for major depression. Many of these individuals fail to receive psychotherapy or other treatment for their depression; moreover when they do, physical pain is often not addressed directly. Women, socioeconomically disadvantaged individuals, African Americans and Latinos all report higher rates of pain and depression compared to other groups. This article describes a version of Interpersonal Psychotherapy tailored for patients with comorbid depression and chronic pain, Interpersonal Psychotherapy for Depression and Pain (IPT-P). While IPT-P potentially could be delivered to many different patient populations in a range of clinical settings, this article focuses on its delivery within primary care settings for socioeconomically disadvantaged women. Adaptations include a brief 8-session protocol that incorporates strategies for anticipating barriers to psychotherapy, accepting patients' conceptualization of their difficulties, encouraging patients to consider the impact of their pain on their roles and relationships, emphasizing self-care, incorporating pain management techniques, and flexible scheduling. In addition, IPT-P is designed as an adjunct to usual medical pain treatment, and seeks to engage non-treatment seeking patients in psychotherapy by focusing on accessibility and relevance of the intervention to concerns common among patients with pain. Identifying patients with comorbid depression and chronic pain and offering IPT-P as a treatment option has the potential to improve clinical outcomes for individuals with depression and chronic pain.

Interpersonal psychotherapy for women with comorbid depression and chronic pain.

Chronic pain is prevalent among patients with depression and a risk factor for poor depression treatment outcomes. No known psychotherapy approaches have been developed to target the needs of patients with comorbid depression and chronic pain. This study's goals were to evaluate feasibility, acceptability, and initial effects of interpersonal psychotherapy adapted for women with depression and chronic pain. Seventeen women with major depression and chronic pelvic pain were offered 8 sessions of individual treatment, interpersonal psychotherapy for depression and pain (IPT-P). Participants were recruited from a women's health clinic, were predominantly low-income and minority, and generally did not initially self-identify as depressed. Large effect sizes with significant improvements were found for depression severity and social adjustment; pain interference remained unchanged. Most enrolled patients reported a high level of satisfaction with IPT-P. This pilot study provides preliminary support for the use of IPT-P for patients with comorbid depression and chronic pain.

Effects of pretreatment and posttreatment depressive symptoms on alcohol consumption following treatment in Project MATCH.

OBJECTIVE: This study examined the associations of pretreatment and posttreatment depressive symptoms with drinking outcomes in the year following treatment in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a multisite clinical trial of behavioral treatments for alcohol-use disorders. METHOD: Data from 1,726 participants were modeled using generalized estimating equations to examine drinking frequency and intensity, as reflected by percentage days abstinent (PDA) and average drinks per drinking day (DDD). We predicted that patients who reported more pretreatment and posttreatment depressive symptoms would report greater drinking frequency (PDA) and more intense drinking (DDD) across the 12-month follow-up period. RESULTS: Pretreatment Beck Depression Inventory (BDI) scores predicted more frequent and intense drinking in the year following treatment, although not after accounting for posttreatment BDI scores, which were associated with the drinking outcomes as hypothesized. Patients who reported more depressive symptoms in the year following treatment reported less abstinence (PDA) and more intense drinking (DDD) than patients with fewer posttreatment depressive symptoms. CONCLUSIONS: Our findings underscore the importance of obtaining repeated assessments of depression during the course of substance use treatment. Moreover, the data suggest the potential utility of augmenting standard chemical dependency care with depression-focused interventions for alcohol-dependent patients whose depressive symptoms do not subside during treatment.

Meta-analysis of depression and substance use among individuals with alcohol use disorders.

The relationships of depression with alcohol and drug use and impairment were examined. Additional analyses were conducted to examine moderators of these associations. Empirical reports on adults with alcohol abuse or dependence published in English in peer-reviewed journals since 1986 that contained data on depression and substance use variable(s) were obtained using a systematic search. The search yielded 74 studies including 58 reports from clinical venues, 10 that were community based, and 6 with subjects from both settings. As hypothesized, the analyses showed that depression is associated with concurrent alcohol use and impairment and drug use and impairment. Effect sizes were small. Depression was also related to future alcohol use and impairment, an earlier age of onset of an alcohol use disorder, and higher treatment participation. Age moderated the association between depression and alcohol use and impairment such that the association was stronger in older samples.

Concordance about childhood sexual abuse among depressed patients 50 and over and their family and friends.

In post-mortem studies of suicide, informant sources are often relied upon to provide information to identify correlates of suicide and suicidal behavior. While previous research has shown that informants can supply reliable information about patients' recent stressful life events, it is unknown whether informants and patients provide concordant data about adverse early life experiences such as childhood sexual abuse. This study examined concordance between patient and informant reports of childhood sexual abuse in a sample of depressed patients 50 years and older. Patients and informants (n=88 pairs) independently responded to items from the Childhood Trauma Questionnaire. Informants' reports of patients' severe sexual abuse histories were in high agreement with patients' reports; concordance was significantly lower, however, for milder forms of sexual abuse. These findings demonstrate the feasibility and limitations of collecting sensitive information about patients' early life experiences in research designs utilizing informant report, including postmortem studies of suicide that use psychological autopsy methodology.

Transitions to, and correlates of, suicidal ideation, plans, and unplanned and planned suicide attempts among 3,729 men and women with alcohol dependence.

OBJECTIVE: Using a heuristic model of suicidal ideation and behavior, the two objectives were to identify correlates of (1) unique suicide-related outcomes (ideation, planning, planned attempt, unplanned attempt) and (2) specific transitions from one suicide-related category to the next. METHOD: Analyses were conducted with data from the Collaborative Study on the Genetics of Alcoholism (COGA), a six-site family pedigree study of individuals in treatment for alcoholism, their relatives, and control families. There were 3,729 subjects in the analysis; all were age 18 years or older with a diagnosis of current alcohol dependence according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Lifetime suicidal ideation, planning, and attempts were analyzed retrospectively. Correlates of each lifetime transition were analyzed using a series of multivariate logistic regressions. Multivariate multinomial regression analysis was used to examine correlates of each lifetime outcome. RESULTS: Female gender is uniquely associated with transitions to unplanned and planned attempts. Independent depression and substance-induced depression are associated with transitions to ideation and planning, whereas alcohol-related aggression is correlated with transitions to unplanned attempts. Analyses of suicide-related outcomes show that women are at higher risk for unplanned and planned attempts. Substance use and impairment are related to suicidal plans and attempts but not ideation. Independent and substance-induced depressions are associated with each suicide-related outcome, whereas alcohol-related aggression is uniquely related to unplanned attempts. CONCLUSIONS: Data underscore the heterogeneity of suicidal ideation and behavior among alcoholics and indicate the need to make clear distinctions between types of suicidal ideation and behavior in research and prevention efforts.

Cognitive-behavioral depression treatment for mothers of children with attention-deficit/hyperactivity disorder.

An adaptation of the Coping With Depression Course (CWDC) was evaluated in mothers of children with attention-deficit/hyperactivity disorder (ADHD), a population at risk for depression. Mothers were randomly assigned to receive the CWDC either immediately following an intensive summer treatment program targeting their child's behavior or after a wait-list period. Measures of maternal functioning, cognitions about child behavior, parent-child and marital relationship quality, child behavior, and ADHD-related family impairment were obtained at pretreatment, posttreatment, and 5-month follow-up. The CWDC resulted in improvements in maternal depressive symptoms, maternal self-esteem, child-related cognitions, and family impairment at posttreatment compared to a wait-list control group that were maintained at follow-up. Findings suggest that the CWDC is a promising intervention for mothers of children with ADHD, particularly those with current depressive symptomatology.

Childhood sexual abuse and depressive symptom severity: the role of neuroticism.

This study examined neuroticism's role in the association between childhood sexual abuse and severity of depressive symptoms in a sample of 105 psychiatric patients 50 years of age and older diagnosed with major depressive disorder. As hypothesized, men and women who reported histories of childhood sexual abuse had more severe depressive symptoms than those without abuse histories. Further, neuroticism partially accounted for the association between severe childhood sexual abuse and depressive symptom severity. Self-consciousness, a facet of neuroticism conceptually related to shame, also partially accounted for that relationship. These findings suggest that neuroticism may be one way in which childhood sexual abuse contributes to depressive symptoms in later life. Prospective studies are needed.