Implementation of Concussion Management Policies in High Schools: The Critical Role of School Nurses.

Evidence-based practices in concussion management (CM) have been codified into legislation. However, legislation is varied, and implementation is narrowly evaluated. School nurses hold a unique position to assess the implementation of health policies. The implementation of concussion management policies across Massachusetts high schools was evaluated by the school nurse. A cross-sectional survey was sent to school nurses (N = 304), and responses (n = 201; 68.1% response rate) were tallied whereby higher scores indicated more practices being implemented. One open-text question was included to encourage nurses to provide context regarding implementation in their school. Descriptive statistics and thematic analysis were used to assess current implementation and nursing perspectives. Findings indicate that the degree of implementation varies, and some nurses reported difficulty with mobilizing clinical uptake of concussion management practices in their schools. Further implementation research is needed, and school nurses are an important stakeholder to include when assessing the clinical uptake of concussion management policies in schools.

The Relations of Cognitive, Behavioral, and Physical Activity Variables to Depression Severity in Traumatic Brain Injury: Reanalysis of Data From a Randomized Controlled Trial.

OBJECTIVE: To explore the relations of cognitive, behavioral, and physical activity variables to depression severity among people with traumatic brain injury (TBI) undergoing a depression treatment trial. SETTING: Community. PARTICIPANTS: Adults (N = 88) who sustained complicated mild to severe TBI within the past 10 years, met criteria for major depressive disorder, and completed study measures. DESIGN: Randomized controlled trial. METHODS: Participants were randomized to cognitive-behavioral therapy (n = 58) or usual care (n = 42). Outcomes were measured at baseline and 16 weeks. We combined the groups and used regressions to explore the relations among theoretical variables and depression outcomes. MAIN MEASURES: Depression severity was measured with the Hamilton Depression Rating Scale and Symptom Checklist-20. Theory-based measures were the Dysfunctional Attitudes Scale (DAS), Automatic Thoughts Questionnaire (ATQ), Environmental Rewards Observation Scale (EROS), and the International Physical Activity Questionnaire (IPAQ). RESULTS: Compared with non-TBI norms, baseline DAS and ATQ scores were high and EROS and IPAQ scores were low. All outcomes improved from baseline to 16 weeks except the DAS. The ATQ was an independent predictor of baseline depression. An increase in EROS scores was correlated with decreased depression. CONCLUSIONS: Increasing participation in meaningful roles and pleasant activities may be a promising approach to treating depression after TBI.

Evaluating the Psychometric Properties of 3 Depression Measures in a Sample of Persons With Traumatic Brain Injury and Major Depressive Disorder.

OBJECTIVES: To explore the psychometric properties of 3 widely used measures of depression in a sample of individuals with traumatic brain injury (TBI) and major depressive disorder and refine them to maximize efficiency. DESIGN: Secondary analysis of data from a randomized controlled trial of cognitive-behavioral therapy for depression after TBI. SETTING: Nationwide recruitment from community and clinical settings. PARTICIPANTS: One hundred adults within 10 years of complicated mild to severe TBI. INTERVENTION: Telephone and in-person cognitive-behavioral therapy. MAIN MEASURES: Patient Health Questionnaire-9 (PHQ-9), Symptom Checklist-20, and Hamilton Depression Rating Scale. RESULTS: We used Rasch rating scale analysis and multilevel modeling to investigate the 3 measures. Measurement properties of each of the depression measures were strong. We explored modifications to the rating scales to improve efficiency while retaining strong psychometric characteristics. Correlations among these revised measures were high. Treatment effects of each revised depression measure were compared using a multilevel model, and effect size estimates were comparable among the revised PHQ-9, Symptom Checklist-20, and Hamilton Depression Rating Scale. CONCLUSIONS: Although each of the 3 measures demonstrated adequate reliability, the efficiency of all 3 instruments was improved with rating scale analysis. The PHQ-9 required the fewest modifications and functions well as a measure of depression among those with TBI.

The experience of primary care providers with an integrated mental health care program in safety-net clinics.

Primary care providers participating in a statewide implementation of an integrated mental health care program for "safety-net" patients in primary care clinics were surveyed to elicit their experiences and level of satisfaction. Quantitative analyses were performed to identify respondent characteristics and satisfaction with the program. Qualitative analyses were done to identify common themes in response to the question "How could psychiatric consultation [in the program] be improved?" Primary care providers were generally satisfied with the integrated mental health care program and raised several concerns that suggest important principles for successful future implementations of these types of programs.

Characteristics, management, and depression outcomes of primary care patients who endorse thoughts of death or suicide on the PHQ-9.

BACKGROUND: With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts. OBJECTIVE: To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program. DESIGN: Observational analysis of data collected from a patient registry. PARTICIPANTS: Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP). INTERVENTIONS: MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review. MAIN MEASURES: The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10). KEY RESULTS: SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001). CONCLUSIONS: Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

Activity scheduling as a core component of effective care management for late-life depression.

BACKGROUND: Activity scheduling is an established component of evidenced-based treatment for late-life depression in primary care. We examined participant records from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self-reported activity engagement, and depression outcomes. METHODS: This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Logistic regression was used to evaluate associations between activity scheduling, activity engagement, and depression outcomes at 12 months. All relevant institutional review boards approved the research protocol. RESULTS: Seventeen distinct activity categories were generated. Most patients worked on at least one social and one solitary activity during their course of treatment. Common activity categories included physical activity (32%), medication management (22%), active-non-physical (19%), and passive (14%) activities. We found significant, positive associations between activity scheduling, self-reported engagement in activities at 12 months, and depression outcomes at 12 months. CONCLUSION: Older primary care patients in CM for depression worked on a wide range of activities. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities. Care managers should encourage patients to balance instrumental activities (e.g., attending to medical problems) with social activities targeting direct interpersonal engagement.

Now what should I do? Primary care physicians' responses to older adults expressing thoughts of suicide.

BACKGROUND: Many older adults who die by suicide have had recent contact with a primary care physician. As the risk-assessment and referral process for suicide is not readily comparable to procedures for other high-risk behaviors, it is important to identify areas in need of quality improvement (QI). OBJECTIVE: Identify patterns in physician-patient communication regarding suicide to inform QI interventions. DESIGN: Qualitative thematic analysis of video-taped clinical encounters in which suicide was discussed. PARTICIPANTS: Adult primary care patients (n = 385) 65 years and older and their primary care physicians. RESULTS: Mental health was discussed in 22% of encounters (n = 85), with suicide content found in less than 2% (n = 6). Three patterns of conversation were characterized: (1) Arguing that "Life's Not That Bad." In this scenario, the physician strives to convince the patient that suicide is unwarranted, which results in mutual fatigue and discouragement. (2) "Engaging in Chitchat." Here the physician addresses psychosocial matters in a seemingly aimless manner with no clear therapeutic goal. This results in a superficial and misleading connection that buries meaningful risk assessment amidst small talk. (3) "Identify, assess, and…?" This pattern is characterized by acknowledging distress, communicating concern, eliciting information, and making treatment suggestions, but lacks clearly articulated treatment planning or structured follow-up. CONCLUSIONS: The physicians in this sample recognized and implicitly acknowledged suicide risk in their older patients, but all seemed unable to go beyond mere assessment. The absence of clearly articulated treatment plans may reflect a lack of a coherent framework for managing suicide risk, insufficient clinical skills, and availability of mental health specialty support required to address suicide risk effectively. To respond to suicide's numerous challenges to the primary care delivery system, QI strategies will require changes to physician education and may require enhancing practice support.

Hopelessness and suicidal ideation in Iraq and Afghanistan War Veterans reporting subthreshold and threshold posttraumatic stress disorder.

We examined hopelessness and suicidal ideation in association with subthreshold and threshold posttraumatic stress disorder (PTSD) in a sample of Iraq and Afghanistan War Veterans (U.S., N = 275) assessed within a specialty VA postdeployment health clinic. Veterans completed paper-and-pencil questionnaires at intake. The military version of the PTSD Checklist was used to determine PTSD levels (No PTSD; subthreshold PTSD; PTSD), and endorsement of hopelessness or suicidal ideation were used as markers of elevated suicide risk. Veterans were also asked if they received mental health treatment in the prior 6 months. Veterans reporting subthreshold PTSD were 3 times more likely to endorse these markers of elevated suicide risk relative to the Veterans without PTSD. We found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment. Clinicians should be attentive to suicide risk in returned Veterans reporting both subthreshold and threshold PTSD.

Opportunities and challenges of implementing collaborative mental health care in post-Katrina New Orleans.

OBJECTIVES: To describe participants' experiences with training on, and implementation of, a collaborative care mental health approach for treating depression and anxiety in post-disaster New Orleans. DESIGN: Healthcare providers from three organizations that participated in the Mental Health Infrastructure and Training (MHIT) program underwent semi-structured interviews. SETTING: The MHIT program provided training and clinical support to community-based agencies. PARTICIPANTS: Social workers, care/case managers, primary care providers, and a psychiatrist that participated in trainings. INTERVENTION: The MHIT project consisted of a series of trainings and clinical support designed in collaboration with specialists from Tulane University, RAND/UCLA, the University of Washington, and local community organizations with the goal of creating local resources to provide screening, diagnosis, triage, and treatment for depression and anxiety. MAIN OUTCOME MEASURES: Interview participants were asked to describe the impacts of training on the following areas: delivery of mental health services, ability to implement elements of the collaborative care model, care of clients/patients, and development of networks. RESULTS: Interview transcript analysis identified themes highlighting the opportunities and challenges of implementing a collaborative care model. CONCLUSION: Implementation of a collaborative care model for treating depression and anxiety was possible in post-Katrina/Rita New Orleans and has potential for implementation in future post-disaster recovery settings.

Building community resilience through mental health infrastructure and training in post-Katrina New Orleans.

OBJECTIVE: To describe a disaster recovery model focused on developing mental health services and capacity-building within a disparities-focused, community-academic participatory partnership framework. DESIGN: Community-based participatory, partnered training and services delivery intervention in a post-disaster setting. SETTING: Post-Katrina Greater New Orleans community. PARTICIPANTS: More than 400 community providers from more than 70 health and social services agencies participated in the trainings. INTERVENTION: Partnered development of a training and services delivery program involving physicians, therapists, community health workers, and other clinical and non-clinical personnel to improve access and quality of care for mental health services in a post-disaster setting. MAIN OUTCOME MEASURE: Services delivery (outreach, education, screening, referral, direct treatment); training delivery; satisfaction and feedback related to training; partnered development of training products. RESULTS: Clinical services in the form of outreach, education, screening, referral and treatment were provided in excess of 110,000 service units. More than 400 trainees participated in training, and provided feedback that led to evolution of training curricula and training products, to meet evolving community needs over time. Participant satisfaction with training generally scored very highly. CONCLUSION: This paper describes a participatory, health-focused model of community recovery that began with addressing emerging, unmet mental health needs using a disparities-conscious partnership framework as one of the principle mechanisms for intervention. Population mental health needs were addressed by investment in infrastructure and services capacity among small and medium sized non-profit organizations working in disaster-impacted, low resource settings.

Community-based participatory development of a community health worker mental health outreach role to extend collaborative care in post-Katrina New Orleans.

OBJECTIVES: The REACH NOLA Mental Health Infrastructure and Training Project (MHIT) aimed to reduce disparities in access to and quality of services for depression and posttraumatic stress disorder (PTSD) in post-Katrina New Orleans by developing a mental health outreach role for community health workers (CHWs) and case managers as a complement to the collaborative care model for depression treatment. INTERVENTION: Community agency leaders, academics, healthcare organizations, and CHWs engaged in a community participatory process to develop a CHW training program. DESIGN: A review of qualitative data including semi-structured interviews, project team conference calls, email strings, and meeting minutes was conducted to document CHW input into training and responses to implementation. RESULTS: CHW contributions resulted in a training program focused on community engagement, depression screening, education, referral assistance, collaboration with clinical teams, and self-care. CHWs reported use of screening tools, early client successes in spite of challenges with client engagement, increase in networking and collaboration with other community agencies and providers, and ongoing community hurricane recovery issues. CONCLUSIONS: This intervention development approach and model may be used to address post-disaster mental health disparities and as a complement to traditional implementation of collaborative care.

Suicide inquiry in primary care: creating context, inquiring, and following up.

PURPOSE: We wanted to describe the vocabulary and narrative context of primary care physicians' inquiries about suicide. METHODS: One hundred fifty-two primary care physicians (53% to 61% of those approached) were randomly recruited from 4 sites in Northern California and Rochester, New York, to participate in a study assessing the effect of a patient's request for antidepressant medication on a physician's prescribing behavior. Standardized patients portraying 2 conditions (carpal tunnel syndrome and major depression, or back pain and adjustment disorder with depressed mood) and 3 antidepressant request types (brand-specific, general, or none) made 298 unannounced visits to these physicians between May 2003 and May 2004. Standardized patients were instructed to deny suicidality if the physician asked. We identified the subset of transcripts that contained a distinct suicide inquiry (n = 91) for inductive analysis and review. Our qualitative analysis focused on elucidating the narrative context in which inquiries are made, how physicians construct their inquiries, and how they respond to a patient's denial of suicidality. RESULTS: Most suicide inquiries used clear terminology related to self-harm, suicide, or killing oneself. Three types of inquiry were identified: (1) straightforward (eg, "Are you feeling like hurting yourself?"); (2) supportive framing (eg, "Sometimes depression gets so bad that people feel that life is no longer worth living. Have you felt this way?"); and (3) no problem preferred (eg, "You're not feeling suicidal, are you?"). Four inquiries were glaringly awkward, potentially inhibiting a patient's disclosure. Most (79%) suicide inquiries were preceded by statements focusing on psychosocial concerns, and most (86%) physician responses to a standardized patient's denial of ideation were followed up with relevant statements (eg, "I hope you would tell me if you did."). CONCLUSION: Although most suicide inquiries by primary care physicians are sensitive, clear, and supportive, some language is used that may inhibit suicide disclosure. Some physician responses may unintentionally reinforce patients for remaining silent about their risk. This study will inform future research in the development of quality improvement interventions to support primary care physicians in making clear, appropriate, and sensitive inquires about suicide.

Does PTSD moderate the relationship between social support and suicide risk in Iraq and Afghanistan War Veterans seeking mental health treatment?

OBJECTIVE: This study examined posttraumatic stress disorder (PTSD) as a potential moderating variable in the relationship between social support and elevated suicide risk in a sample of treatment-seeking Iraq and Afghanistan War Veterans. METHOD: As part of routine care, self-reported marital status, satisfaction with social networks, PTSD, and recent suicidality were assessed in Veterans (N=431) referred for mental health services at a large Veteran Affairs Medical Center. Logistic regression analyses were conducted using this cross-sectional data sample to test predictions of diminished influence of social support on suicide risk in Veterans reporting PTSD. RESULTS: Thirteen percent of Veterans were classified as being at elevated risk for suicide. Married Veterans were less likely to be at elevated suicide risk relative to unmarried Veterans and Veterans reporting greater satisfaction with their social networks were less likely to be at elevated risk relative to Veterans reporting lower satisfaction. Satisfaction with social networks was protective for suicide risk in PTSD and non-PTSD cases, but was significantly less protective for veterans reporting PTSD. CONCLUSIONS: Veterans who are married and Veterans who report greater satisfaction with social networks are less likely to endorse suicidal thoughts or behaviors suggestive of elevated suicide risk. However, the presence of PTSD may diminish the protective influence of social networks among treatment-seeking Veterans.

Course of suicide ideation and predictors of change in depressed older adults.

BACKGROUND: Rates of suicide among older adults in the United States are higher than that of other age groups. Therefore, it is critically important to deepen understanding of the processes that drive suicide risk among at-risk older patients. To this end, we examined the longitudinal course of suicide ideation in a sample of treatment-seeking depressed adults 60 years of age or older. METHODS: Secondary analyses were conducted with a longitudinal dataset including 343 older adults seeking treatment for depression in the context of a naturalistic treatment setting. Participants completed assessments of depressive symptoms and thoughts of suicide every three months for one year. Multi-level mixed models were used to examine the trajectory of suicide ideation over five waves. RESULTS: Depressive symptoms contributed significantly to change in thoughts of suicide early in treatment for depression. Age-related differences were also observed, such that increasing age was associated with significantly greater reports of suicide ideation. LIMITATIONS: Use of a single measure to ascertain severity of depressive symptoms and thoughts of suicide. CONCLUSIONS: Clinicians should expect to see the most pronounced decrease in thoughts of suicide during the first two months of depression treatment for older adults. Further, clinicians should be especially vigilant to monitor suicide ideation for adults, with increasing vigilance for those at more advanced ages.

Care management for depression and osteoarthritis pain in older primary care patients: a pilot study.

OBJECTIVE: To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis. METHODS: Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months. RESULTS: Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests. CONCLUSION: The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.

Effectiveness of problem-solving therapy for older, primary care patients with depression: results from the IMPACT project.

PURPOSE: We compared a primary-care-based psychotherapy, that is, problem-solving therapy for primary care (PST-PC), to community-based psychotherapy in treating late-life major depression and dysthymia. DESIGN AND METHODS: The data here are from the IMPACT study, which compared collaborative care within a primary care clinic to care as usual in the treatment of 1,801 primary care patients, 60 years of age or older, with major depression or dysthymia. This study is a secondary data analysis (n = 433) of participants who received either PST-PC (by means of collaborative care) or community-based psychotherapy (by means of usual care). RESULTS: Older adults who received PST-PC had more depression-free days at both 12 and between 12 and 24 months (beta = 47.5, p <.001; beta = 47.0, p <.001), and they had fewer depressive symptoms and better functioning at 12 months (beta(dep) = -0.36, p <.001; beta(func) = -0.94, p <.001), than those who received community-based psychotherapy. We found no differences at 24 months. IMPLICATIONS: Results suggest that PST-PC as delivered in primary care settings is an effective method for treating late-life depression.

Variation in analytic transparency in recent efficacy studies of antidepressant medication.

The validity of clinical trial results is influenced by researchers' decisions regarding the management of missing data. Inadequate management of missing data has been identified as a significant source of bias that can result in an overestimation of drug efficacy. Transparency related to the management of missing data is essential to assess the strength of evidence reported in publications. In a subset of 17 randomised clinical trials for two new antidepressant medications, we present a case study in which we examined investigators' decisions regarding how to handle missing data and if their chosen method took into account, possible violations of analytic requirements that could affect results. The majority of trials (76%) concluded that there was a benefit of antidepressant treatment and in 94% the methodology for handling missing data was identifiable. Of these, 50% imputed data using the last observation carried forward and half used a mixed-effects model repeated measure approach. Most reports did not provide a rationale for the method used, and no trials described analyses regarding differences between completers and dropouts. Sensitivity analysis was inconsistently reported and correction for multiple comparisons was not uniformly applied. Lack of transparency for analytic choices related to handling of missing data testing was common in this subset of RCTs. Because management of missing data can directly influence the quality of study results, it is critical that journal editors develop and enforce standards for methodological transparency.

The Perspective of Older Men With Depression on Suicide and Its Prevention in Primary Care.

BACKGROUND: Suicide rates in older men are higher than in the general population, yet their utilization of mental health services is lower. AIMS: This study aimed to describe: (a) what primary care providers (PCPs) can do to prevent late-life suicide, and (b) older men's attitudes toward discussing suicide with a PCP. METHOD: Thematic analysis of interviews focused on depression and suicide with 77 depressed, low-socioeconomic status, older men of Mexican origin, or US-born non-Hispanic whites recruited from primary care. RESULTS: Several themes inhibiting suicide emerged: it is a problematic solution, due to religious prohibition, conflicts with self-image, the impact on others; and, lack of means/capacity. Three approaches to preventing suicide emerged: talking with them about depression, talking about the impact of their suicide on others, and encouraging them to be active. The vast majority, 98%, were open to such conversations. An unexpected theme spontaneously arose: "What prevents men from acting on suicidal thoughts?" CONCLUSION: Suicide is rarely discussed in primary care encounters in the context of depression treatment. Our study suggests that older men are likely to be open to discussing suicide with their PCP. We have identified several pragmatic approaches to assist clinicians in reducing older men's distress and preventing suicide.

Let's not talk about it: suicide inquiry in primary care.

PURPOSE: The purpose of this study was to ascertain physician characteristics associated with exploring suicidality in patients with depressive symptoms and the influence of patient antidepressant requests. METHODS: Primary care physicians were randomly recruited from 4 sites in northern California and Rochester, NY; 152 physicians participated (53%-61% of those approached). Standardized patients portraying 2 conditions (major depression and adjustment disorder) and 3 antidepressant request types (brand specific, general, or none) made unannounced visits to these physicians between May 2003 and May 2004. We examined factors associated with physician exploration of suicidality. RESULTS: Suicide was explored in 36% of 298 encounters. Exploration was more common when the patient portrayed major depression (vs adjustment disorder) (P = .03), with an antidepressant request (vs no request) (P=.02), in academic settings (P <.01), and among physicians with personal experience with depression (P <.01). The random effects logistic model revealed a significant physician variance component with rho = 0.57 (95% confidence interval, 0.45-0.68) indicating that there were additional, unspecified physician factors determining the tendency to explore suicide risk. These factors are unrelated to physician specialty (family medicine or internal medicine), sex, communication style, or perceived barriers to or confidence in treating depression. CONCLUSIONS: When seeing patients with depressive symptoms, primary care physicians do not consistently inquire about suicidality. Their inquiries into suicidal thinking may be enhanced through advertising or public service messaging that prompts patients to ask for help. Research is needed to further elucidate physician characteristics associated with the assessment of suicidality.