Developing a clinical decision support system software prototype that assists in the management of patients with self-harm in the emergency department: protocol of the PERMANENS project.

BACKGROUND: Self-harm presents a significant public health challenge. Emergency departments (EDs) are crucial healthcare settings in managing self-harm, but clinician uncertainty in risk assessment may contribute to ineffective care. Clinical Decision Support Systems (CDSSs) show promise in enhancing care processes, but their effective implementation in self-harm management remains unexplored. METHODS: PERMANENS comprises a combination of methodologies and study designs aimed at developing a CDSS prototype that assists clinicians in the personalized assessment and management of ED patients presenting with self-harm. Ensemble prediction models will be constructed by applying machine learning techniques on electronic registry data from four sites, i.e., Catalonia (Spain), Ireland, Norway, and Sweden. These models will predict key adverse outcomes including self-harm repetition, suicide, premature death, and lack of post-discharge care. Available registry data include routinely collected electronic health record data, mortality data, and administrative data, and will be harmonized using the OMOP Common Data Model, ensuring consistency in terminologies, vocabularies and coding schemes. A clinical knowledge base of effective suicide prevention interventions will be developed rooted in a systematic review of clinical practice guidelines, including quality assessment of guidelines using the AGREE II tool. The CDSS software prototype will include a backend that integrates the prediction models and the clinical knowledge base to enable accurate patient risk stratification and subsequent intervention allocation. The CDSS frontend will enable personalized risk assessment and will provide tailored treatment plans, following a tiered evidence-based approach. Implementation research will ensure the CDSS' practical functionality and feasibility, and will include periodic meetings with user-advisory groups, mixed-methods research to identify currently unmet needs in self-harm risk assessment, and small-scale usability testing of the CDSS prototype software. DISCUSSION: Through the development of the proposed CDSS software prototype, PERMANENS aims to standardize care, enhance clinician confidence, improve patient satisfaction, and increase treatment compliance. The routine integration of CDSS for self-harm risk assessment within healthcare systems holds significant potential in effectively reducing suicide mortality rates by facilitating personalized and timely delivery of effective interventions on a large scale for individuals at risk of suicide.

Emotion dysregulation in older people: validity and reliability of an 8-item version of the Difficulties in Emotion Regulation Scale.

OBJECTIVES: The abbreviated 16-item version of the Difficulties with Emotion Regulation Scale (DERS-16) is widely used to assess individuals' perceived challenges in regulating their emotions, a central aspect of psychological symptoms commonly experienced in old age. However, its psychometric properties have yet to be tested in this population. Furthermore, a shorter version of the DERS-16 could further minimize the assessment burden on older individuals. Thus, we aimed to test the DERS-16's psychometric performance and determine if any items were redundant to develop a psychometrically sound shorter version. METHODS: We enrolled 302 Portuguese older adults (Mage = 75.22; SD = 8.99 years) in a cross-sectional study. RESULTS: Exploratory factor analyses indicated a one-factor structure and a four-factor solution with eight items (69.3%-81.9% of the variance observed). The four-factor-8-item solution presented an interpretable structure and demonstrated good reliability values (> 0.70) and construct validity with the Twenty-Item Toronto Alexithymia Scale, Eight-Item Geriatric Depression Scale, and Geriatric Anxiety Inventory (r = 0.66, 0.40, 0.52; p < 0.001). CONCLUSION: The robust psychometric properties of DERS-8 make it a valuable tool for clinical and longitudinal studies, facilitating targeted interventions in older adults and allowing for precise emotion dysregulation screening.

The inner workings of anger: A network analysis of anger and emotion regulation.

OBJECTIVE: This study aimed to investigate the interrelations between emotion regulation strategies and different types of anger using network analysis. METHOD: Data were drawn from a cross-sectional sample of 538 adults (55% females; mean age = 39.8 years, SD = 12.3) seeking treatment for anger. Data were collected between March and November 2019 in Sweden. Participants completed measures of anger problems (anger expression, anger suppression, angry reactions, anger rumination, trait anger, hostility, physical aggression, and verbal aggression) and emotion regulation (cognitive reappraisal, expressive suppression, anger relaxation, and five mindfulness strategies). To determine whether distinct clusters of anger nodes would emerge, exploratory graph analysis was employed. Based on clustering of nodes, we estimated separate networks including all measures of emotion regulation. RESULTS: Two clusters emerged: one consisting primarily of cognitive components of anger, and another of behavioral. Across networks, anger nodes were strongly interconnected, and anger rumination and anger suppression were especially influential. Several direct links were found between specific emotion regulation strategies and cognitive components of anger, whereas most strategies were only indirectly related to angry behavior. Cognitive reappraisal showed no direct link with any of the anger nodes. CONCLUSIONS: Our findings reveal potential pathways by which different emotion regulation strategies may influence different types of anger, which could serve as therapeutic targets.

The Association Between Emotion Recognition and Internalizing Problems in Children and Adolescents: A Three-Level Meta-Analysis.

Numerous studies have explored the link between how well youth recognize emotions and their internalizing problems, but a consensus remains elusive. This study used a three-level meta-analysis model to quantitatively synthesize the findings of existing studies to assess the relationship. A moderation analysis was also conducted to explore the sources of research heterogeneity. Through a systematic literature search, a total of 42 studies with 201 effect sizes were retrieved for the current meta-analysis, and 7579 participants were included. Emotion recognition was negatively correlated with internalizing problems. Children and adolescents with weaker emotion recognition skills were more likely to have internalizing problems. In addition, this meta-analysis found that publication year had a significant moderating effect. The correlation between emotion recognition and internalizing problems decreased over time. The degree of internalizing problems was also found to be a significant moderator. The correlation between emotion recognition and internalizing disorders was higher than the correlation between emotion recognition and internalizing symptoms. Deficits in emotion recognition might be relevant for the development and/or maintenance of internalizing problems in children and adolescents. The overall effect was small and future research should explore the clinical relevance of the association.

Augmented pain inhibition and higher integration of pain modulatory brain networks in women with self-injury behavior.

Individuals who engage in nonsuicidal self-injury (NSSI) have demonstrated insensitivity to pain compared with individuals without NSSI. Yet, the neural mechanisms behind this difference are unknown. The objective of the present study was to determine which aspects of the pain regulatory system that account for this decreased sensitivity to pain. In a case-control design, 81 women, aged 18-35 (mean [SD] age, 23.4 [3.9]), were included (41 with NSSI and 40 healthy controls). A quantitative sensory testing protocol, including heat pain thresholds, heat pain tolerance, pressure pain thresholds, conditioned pain modulation (assessing central down-regulation of pain), and temporal summation (assessing facilitation of pain signals) was used. Pain-evoked brain responses were assessed by means of fMRI scanning during thermal pain. NSSI participants showed a more effective central down-regulation of pain, compared to controls, assessed with conditioned pain modulation. The neural responses to painful stimulation revealed a stronger relation between nociceptive and pain modulatory brain regions in NSSI compared to controls. In line with previous studies, pressure and heat pain thresholds were higher in participants with NSSI, however, there were no correlations between pain outcomes and NSSI clinical characteristics. The augmented pain inhibition and higher involvement of pain modulatory brain networks in NSSI may represent a pain insensitive endophenotype associated with a greater risk for developing self-injurious behavior.

Melatonin use and the risk of self-harm and unintentional injuries in youths with and without psychiatric disorders.

BACKGROUND: Sleep disorders in youth have been associated with increased risks of injury, including suicidal behavior. This study investigated whether melatonin, which is the most common medication for sleep disturbances in youth in Sweden, is associated with a decreased risk of injury. METHODS: This population-based cohort study included 25,575 youths who initiated melatonin treatment between ages 6 and 18. Poisson regression was used to estimate rate of injuries in the year prior to and following melatonin treatment initiation. A within-individual design was used to estimate relative risks by comparing injury risk in the last unmedicated month with injury risks in the 12 months after medication initiation. Analyses were stratified by sex, injury type, psychiatric comorbidities and age at melatonin-treatment initiation. RESULTS: While body injuries, falls and transport accident rates were comparable in the year before and after melatonin-treatment initiation, the risk of self-harm was highest in the months immediately prior to medication, and decreased thereafter. This was particularly prominent among adolescents with depression and/or anxiety, with females displaying greater absolute risks than males. Compared to the last unmedicated month, the 12 months post medication initiation had decreased relative risks for self-harm, with an IRR [95% CI] in the month following melatonin-treatment initiation of 0.46 [0.27-0.76] among adolescent females with psychiatric disorders, after excluding antidepressant users. CONCLUSIONS: Decreased risk of intentional self-harm was observed following melatonin-treatment initiation among females with depression and anxiety, suggesting that sleep interventions could be considered in an effort to reduce risk of self-harm in this population.

The Fear of Asthma Symptoms Scale and the Asthma Behavior Checklist: preliminary validity of two novel patient reported outcome measures.

Objective: The aim of this study was to investigate the preliminary validity of two novel scales, the Fear of Asthma Symptoms scale (FAS) and the Asthma Behavior Checklist (ABC). Methods: Using cross-sectional design, data was collected online from 188 adult participants (Age 18-71 years) with a diagnosis of asthma and self-reported anxiety related to asthma, recruited through social media. Confirmatory factor analysis, internal consistency and test-retest reliability were ascertained to address validity.Results: The confirmatory factor analysis demonstrated convergent validity for both the FAS (average variance extracted; AVE=.57) and the item-reduced ABC-8 (AVE=.61) as well as divergent validity for both scales. Both scales demonstrated high internal consistency (FAS: α = 0.94; ABC-8: α = 0.92). Test-retest reliability assessed after 1 week was good (FAS: r=.85; ABC-8: r=.88).Conclusions: We observed promising psychometric properties of the FAS and the ABC-8. The two novel scales could be useful to identify excessive fear and avoidance in patients with asthma and to investigate putative mechanisms in clinical research on anxiety related to asthma. Further evaluation of psychometric properties in independent samples are needed.

Risk of suicide and self-harm in university students entering different university programs - a national register-based cohort study in Sweden.

PURPOSE: It is not known whether the elevated suicide risk in certain occupations, such as health care professionals, is partly attributable to a selection of individuals with prior vulnerability. We aimed to determine the risk of suicide and self-harm already in students entering different university programs. METHODS: We used national registers to identify 621,218 Swedish residents aged 18-39 years with registration for a university program 1993-2013. Outcomes were suicide and self-harm within three years. We applied logistic regression analyses to calculate odds ratios (OR) and 95% confidence intervals (CI) of risk of suicide and self-harm, with the Education program category as a reference. Results were adjusted for sex, age, time period and for history of hospitalization due to mental disorder or self-harm, as a measure of previous vulnerability. In the second step, we stratified results by sex. RESULTS: There was a higher risk of suicide (OR 2.4) in female nursing students and natural science students (OR 4.2) and of self-harm in female and male Nursing/Health care students (OR range 1.2 -1.7). Subcategorization into nursing students only strengthened the association with self-harm for both sexes. Prior vulnerability did not fully explain the increased risk. CONCLUSION: The elevated risk of suicide in nursing and health care occupations partly has its onset in vulnerability factors present before or emerging during university studies. Increased efforts in identifying and treating mental disorders and preventing self-harm in university students could be an important step in preventing future suicides.

Obsessional jealousy in a community sample: Association with relationship factors, impairment and perceived treatment needs.

OBJECTIVES: Romantic jealousy could be understood as a continuum, from reality-based, transient and functional jealousy to a more chronic form of jealousy with varying insight, intensity and duration. The latter has some overlaps with obsessive-compulsive disorder (here termed obsessional jealousy). Little is known about the nature of obsessional jealousy and its association with functional impairment, perceived negative consequences (drinking, violence), current and past relationship factors (e.g., length of relationship, being in love, infidelity, previous jealousy) or perceived need for professional support. METHODS: Participants were 1076 adults (55% women) who filled in an anonymous survey. RESULTS: Obsessional jealousy, measured with the Obsessional Jealousy Severity Scale, was strongly associated with functional impairment and verbal violence, and more weakly with physical violence and alcohol consumption. Individuals with a history of previous jealousy had more severe symptoms and were more likely to perceive the need for psychological support. Approximately 25% of the sample expressed interest in treatment. CONCLUSIONS: The results suggest that there is a group of individuals with impairing levels of obsessional jealousy who have a perceived need for help with their difficulties. More research is needed on the prevalence and clinical characteristics of these individuals. The development of jealousy-specific psychological models and treatments is warranted.

Anger profiles among individuals seeking treatment for maladaptive anger: Associations with emotion regulation.

Individuals who experience problems with anger represent a heterogeneous group. Identifying clinically relevant subtypes of anger may advance treatment research. In the current study, latent profile analysis (LPA) was conducted to explore if distinct subtypes of anger could be identified within a sample of individuals seeking treatment for maladaptive anger (N = 538; 55.4% females; mean age = 39.78, SD = 12.28). Furthermore, the utility of the empirical classification was examined based on differences in usage of emotion regulation strategies (cognitive reappraisal, expressive suppression, mindful emotion awareness and relaxation) across subtypes. Four anger profiles were identified in the best-fitted LPA model: Low Anger (n = 153, 28.4%), Anger In (n = 91, 16.9%), Moderate Anger (n = 193, 35.9%) and High Anger (n = 101, 35.5%). Results from the multinominal regression revealed that the use of emotion regulation differed across all profiles. Participants from the High Anger and Anger In profiles exhibited distinct patterns of dysfunctional emotion regulation. The results add to the increasing amount of evidence demonstrating a link between emotion regulation strategies and maladaptive anger. Clinical implications on how to tailor treatments for individuals with maladaptive anger are discussed.

Adverse clinical outcomes among youths with nonsuicidal self-injury and suicide attempts: a longitudinal cohort study.

BACKGROUND: More knowledge about risks of clinical outcomes associated with nonsuicidal self-injury (NSSI) and suicide attempts (SAs) is needed to inform risk assessment and intervention. METHODS: Longitudinal cohort study based on 1,855 youths was clinically assessed for NSSI and SA, and followed up (from December, 2011 to December 2013) for the outcomes; diagnosed self-injury, alcohol/substance use disorder, and psychiatric inpatient care data derived from Swedish registers. Hazard ratios (HRs) and 95% confidence intervals (CIs) of the outcomes were estimated with Cox regressions, and additionally adjusted for the potential effect of sex and the number of clinical assessments. NSSI and SA were treated as time-varying covariates. RESULTS: Youths with NSSI had elevated risks of all outcomes, compared with youths without NSSI or SA; the HR was 2.3, 95% confidence interval [1.6, 3.4] for self-injury, 1.4 [0.9, 2.1] for alcohol/substance use disorder, and 1.3 [1.0, 1.7] for psychiatric inpatient care. Youths with SA displayed higher risks for the outcomes than the NSSI group; the HR was 5.5 [2.4, 12.6] for self-injury, 2.0 [0.9, 4.4] for alcohol/substance use disorder, and 2.6 [1.5, 4.5] for psychiatric inpatient care. Youths with both NSSI and SA showed similar risks as youths with SA; HR 4.1 [2.0, 8.3] for self-injury, 2.0 [1.1, 4.1] for alcohol/substance use disorder, but a higher risk of psychiatric inpatient care; HR 5.0 [3.1, 7.9]. All results remained virtually unchanged in the adjusted analyses. CONCLUSIONS: Youths with NSSI and/or SA had higher risks for subsequent adverse clinical outcomes. These excess risks were more pronounced among youths with SA and youths with both NSSI and SA, and the risk for psychiatric inpatient care was particularly high in youths with both NSSI and SA. Our findings suggest that early interventions for youths with NSSI or SA should not exclusively focus on suicide prevention, but also consider the risk of subsequent alcohol/substance use disorder.

Childhood symptoms of attention-deficit/hyperactivity disorder and borderline personality disorder.

OBJECTIVE: Childhood attention-deficit /hyperactivity disorder (ADHD) is known to be associated with adult Borderline Personality Disorder (BPD). We investigated if any of the subdimensions of childhood ADHD, that is, impulsivity, inattention, or hyperactivity was more prominent in this association. METHODS: In a nation-wide cohort (N = 13,330), we utilized parent reported symptoms of childhood ADHD and clinically ascertained adult BPD diagnoses. The summed total scores of ADHD symptoms and its three subdimensions were used and standardized for effect size comparison. Associations were analyzed using Cox regression with sex and birth-year adjustments. Secondary outcomes were BPD-associated traits (i.e., self-harm and substance use) analyzed using logistic- and linear regression respectively. RESULTS: ADHD symptom severity was positively associated with BPD with a hazard ratio (HR) of 1.47 (95% confidence interval [CI]: 1.22-1.79) per standard deviation increase in total ADHD symptoms. Impulsivity was the most prominent subdimension with the only statistically significant association when analyzed in a model mutually adjusted for all ADHD subdimensions-HR for inattention: 1.15 (95% CI: 0.85-1.55), hyperactivity: 0.94 (95% CI: 0.69-1.26), impulsivity: 1.46 (95% CI: 1.12-1.91). In secondary analyses, weak positive associations were seen between total ADHD symptom score and self-harm and substance use. In analyses by subdimensions of ADHD, associations were weak and most prominent for inattention in the model with self-harm. CONCLUSION: Childhood ADHD symptoms were associated with subsequent development of BPD diagnosis and appeared to be driven primarily by impulsivity. Our findings are important for understanding the association between childhood symptoms of ADHD and subsequent BPD.

What to target in cognitive behavioral treatment for gambling disorder-A qualitative study of clinically relevant behaviors.

BACKGROUND: From a clinical perspective, knowledge of the psychological processes involved in maintaining gambling disorder has been lacking. This qualitative study formulated hypotheses on how gambling disorder is maintained by identifying clinically relevant behaviors at an individual level, as a means to guide the development of new cognitive behavioral interventions. METHODS: Six individuals from a treatment study, diagnosed with gambling disorder and with diverse symptom profiles of psychiatric comorbidity, were recruited. Participants were interviewed using an in-depth semi-structured functional interview and completed self-report measures assessing gambling behavior. RESULTS: Functional analysis was used as a theoretical framework for a thematic analysis, which yielded the following categories: 1) antecedents that may increase or decrease gambling; 2) experiences accompanying gambling; 3) control strategies; 4) consequences of gambling behavior; and 5) events terminating gambling behavior. Few differences were identified in relation to symptom profiles of psychiatric comorbidity, although some gamblers did not report experiencing abstinence when not being able to gamble. CONCLUSIONS: Gambling is a secluded activity mainly triggered by access to money. Positive and negative emotions could be both antecedents and functions of gambling behavior. Avoidance-based strategies used to control gambling might result in a failure to learn to control gambling behavior. Anticipation, selective attention, and chasing could be important reinforcers, which should be addressed in new developments in cognitive behavioral treatment for gambling disorder.

Associations of impulsivity, hyperactivity, and inattention with nonsuicidal self-injury and suicidal behavior: longitudinal cohort study following children at risk for neurodevelopmental disorders into mid-adolescence.

BACKGROUND: The knowledge of how the separate Attention-Deficit/Hyperactivity Disorder (ADHD) subdimensions (impulsivity, hyperactivity, and inattention) are associated with nonsuicidal self-injury (NSSI) and suicidal behavior (SB) is limited. The objective of this study was to investigate the associations of childhood ADHD subdimensions with NSSI and SB in children at risk of neurodevelopmental disorders (NDDs; including ADHD). METHODS: The sample (N = 391) included twin pairs where at least one twin screened positive for at least one NDD or common comorbidity at age 9 or 12. Data on ADHD subdimensions was collected through a telephone interview with a caregiver/legal guardian at age 9 or 12, and data on NSSI and SB was collected through an in-person clinical assessment at age 15. The associations between the ADHD subdimensions and NSSI or SB were tested in three different models: (1) univariable, (2) together with the other ADHD subdimensions, and (3) in a confounder-adjusted model including other NDD symptoms in addition to ADHD subdimensions, for NSSI and SB separately. RESULTS: A total of 32 (8.2%) adolescents reported life-time engagement of NSSI, and 18 (4.6%) SB. Childhood impulsivity was associated with SB and childhood inattention with NSSI, in all models. Hyperactivity was not meaningfully associated with any of the outcomes. CONCLUSION: Impulsivity and inattention, but not hyperactivity, may be of particular importance in understanding SB and NSSI. Brief screening for impulsivity and inattention in childhood could facilitate detection of children vulnerable to NSSI and SB and indicate valuable information for preventive and intervention strategies.

Validation of child-adapted short scales for measuring gastrointestinal-specific avoidance and anxiety.

AIM: To validate child-adapted shortened versions of the Irritable Bowel Syndrome-Behavioural Responses Questionnaire (IBS-BRQ; short scale denoted BRQ-C) and the Visceral Sensitivity Index (VSI; short scale denoted VSI-C) for children with functional abdominal pain disorders (FAPDs). METHODS: A child psychologist supervised by a child gastroenterologist was responsible for shortening the scales (BRQ-C, 11 items; and VSI-C, 7 items). Then, a sample of 89 children aged 8-12 years with FAPDs was used in the validation. Construct validity was assessed with correlations. Measures included gastrointestinal symptoms, quality of life, pain intensity and anxiety. Also, internal consistency, test-retest reliability, administration time and factor structure were assessed. RESULTS: Internal consistency for the BRQ-C and the VSI-C was α = 0.84 and α = 0.80, respectively. Correlations with related scales were similar between child-adapted scales and original scales, indicating construct validity equivalence. Correlations between short scales and original scales were high. Mean administration time was reduced by 47% (BRQ-C) and 42% (VSI-C), compared with original scales. Test-retest reliability was r = 0.72 for BRQ-C and r = 0.83 for VSI-C. BRQ-C had two factors (Avoidance and Bowel control). VSI-C had a unifactorial structure. CONCLUSION: The BRQ-C and the VSI-C were found to be time-saving, reliable and valid for children with FAPDs.

Factor structure and clinical correlates of the original and 16-item version of the Difficulties In Emotion Regulation Scale in adolescent girls with eating disorders.

OBJECTIVES: The Difficulties in Emotion Regulation Scale (DERS) is increasingly used in adolescents. This study is the first to examine the factor structure, measurement, and structural invariance across age, reliability, and validity of the original 36-item and 16-item version of the DERS in adolescents with eating disorders. METHODS: Several models were examined using confirmatory factor analysis. Measurement and structural invariance were studied across age groups, and Omega, Omega Hierarchical, and criterion validity were examined. RESULTS: A bifactor model, with five subscales, showed acceptable fit in both DERS versions. Measurement and structural invariance held across age. The general factor had high reliability and accounted for a large proportion of variance in eating pathology and emotional symptoms. CONCLUSION: The Awareness subscale had a negative effect on fit in DERS, but both DERS versions were reliable and valid measures in both younger and older adolescents with eating disorders when using only five subscales.

Measures of emotion regulation: Convergence and psychometric properties of the difficulties in emotion regulation scale and emotion regulation questionnaire.

OBJECTIVE: Investigating unique and shared aspects of measures of emotion regulation (ER) advances our understanding of ER as a multidimensional construct. This study aimed to investigate psychometric properties of three ER-measures: Difficulties in Emotion Regulation Scale (DERS-36), the abbreviated version DERS-16, and Emotion Regulation Questionnaire (ERQ). METHODS: In a community sample (N = 843; 56% females) we investigated their internal consistency, factor structure, convergence, and association with symptoms of depression, anxiety, stress and substance abuse. RESULTS: The proposed factor structures of the DERS-16 and the ERQ demonstrated an adequate fit. There were moderate correlations between the two DERS versions (36 and 16) and ERQ subscales Reappraisal and Suppression. Total scores of DERS-36 and DERS-16 demonstrated preferential associations with depression and anxiety. Corresponding associations between ERQ subscales and psychiatric symptoms were weak. CONCLUSION: The results indicate that DERS-16 could be useful as an alternative, easily administered measure of ER difficulties.

Perceived causal symptom network of adolescent mental health issues.

Adolescent mental health is difficult to capture in categories such as depression or specific anxiety disorders. An alternative is to approach psychiatric symptoms as causal networks, potentially revealing feedback loops that maintain a pathological state. One approach to creating such networks, implemented in the PECAN methodology, is to ask adolescents about their perceptions of the causes to their symptoms. For this purpose, a transdiagnostic item list was created, and adolescents who screened positive for depression (N = 55) completed twice in two weeks a survey quantifying perceptions of causality between their mental health problems. A network that was averaged across all participants was reliable and revealed three strong feedback loops: a first loop running through stress, insomnia, fatigue, procrastination, and back to stress; a second loop between stress and overthinking; and a third loop between stress and procrastination. Although all adolescents in the study screened positive for depression, symptoms of depression were not particularly central to the network. Instead, the most central symptoms were procrastination and overthinking. The average test-retest reliability for individual networks was low, limiting clinical application. In conclusion, PECAN was found to be reliable and useful when creating a group-level network of adolescent mental health problems. While informative at a group level, the method should be improved before it can be used to inform treatment at the individual level.

Columbia-Suicide Severity Rating Scale Screen Version: initial screening for suicide risk in a psychiatric emergency department.

BACKGROUND: Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to evaluate the association between the novel Colombia Suicide Severity Rating Scale Screen Version (C-SSRS Screen) and subsequent clinical management and suicide within 1 week, 1 month and 1 year from screening. METHODS: Consecutive patients (N = 18 684) attending a PE department in Stockholm, Sweden between 1 May 2016 and 31 December 2017 were assessed with the C-SSRS Screen. All patients (52.1% women; mean age = 39.7, s.d. = 16.9) were followed-up in the National Cause of Death Register. Logistic regression and receiver operating characteristic curves analyses were conducted. Optimal cut-offs and accuracy statistics were calculated. RESULTS: Both suicidal ideation and behaviour were prevalent at screening. In total, 107 patients died by suicide during follow-up. Both C-SSRS Screen Ideation Severity and Behaviour Scales were associated with death by suicide within 1-week, 1-month and 1-year follow-up. The optimal cut-off for the ideation severity scale was associated with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7, 95% confidence interval 1.5-14.8). Both scales were also associated with short-term clinical management. CONCLUSIONS: The C-SSRS Screen may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide risk. Future research may investigate the utility of combining the C-SSRS Screen with a more thorough assessment.

Targeting excessive worry with internet-based extinction therapy: a randomised controlled trial with mediation analysis and economical evaluation.

BACKGROUND: Excessive worry is a common phenomenon. Our research group has previously developed an online intervention for excessive worry based on operant principles of extinction (IbET; internet-based extinction therapy) and tested it against a waiting-list. The aim of this study was to evaluate IbET against an active control comparator (CTRL). METHODS: A 10-week parallel participant blind randomised controlled trial with health-economical evaluation and mediation analyses. Participants (N = 311) were randomised (ratio 4.5:4.5:1) to IbET, to CTRL (an internet-based stress-management training program) or to waiting-list. The nation-wide trial included self-referred adults with excessive worry. The primary outcome was change in worry assessed with the Penn State Worry Questionnaire from baseline to 10 weeks. RESULTS: IbET had greater reductions in worry compared to CTRL [-3.6 point difference, (95% CI -2.4 to -4.9)] and also a significantly larger degree of treatment responders [63% v. 51%; risk ratio = 1.24 (95% CI 1.01-1.53)]. Both IbET and CTRL made large reductions in worry compared to waiting-list and effects were sustained up to 1 year. Treatment credibility, therapist attention, compliance and working alliance were equal between IbET and CTRL. Data attrition was 4% at the primary endpoint. The effects of IbET were mediated by the hypothesized causal mechanism (reduced thought suppression) but not by competing mediators. Health-economical evaluation indicated that IbET had a 99% chance of being cost-effective compared to CTRL given societal willingness to pay of 1000€. CONCLUSIONS: IbET is more effective than active comparator to treat excessive worry. Replication and extensions to real-world setting are warranted.