Longitudinal Relationship between the Introduction of Medicinal Cannabis and Polypharmacy: An Australian Real-World Evidence Study.

Background: Recent studies recommend medicinal cannabis (MC) as a potential treatment for chronic pain (CP) when conventional therapies are not successful; however, data from Australia is limited. This real-world evidence study explored how the introduction of MC related to concomitant medication use over time. Long-term safety also was examined. Methods: Data were collected by the Emerald Clinics (a network of seven clinics located across Australia) as part of routine practice from Jan 2020 toJan 2021. Medications were classified by group: antidepressants, benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and total number of medications. Adverse events (AEs) were collected at each visit and subsequently coded using the Medical Dictionary for Regulatory Activities version 23 into the system organ class (SOC) and preferred term (PT). A total of 535 patients were analyzed. Results: The most common daily oral dose was 10 mg for delta-9-tetrahydrocannabinol (THC) and 15 mg for cannabidiol (CBD). With the introduction of MC, patients' total number of medications consumed decreased over the course of one year; significant reductions in NSAIDs, benzodiazepines, and antidepressants were observed (p < .001). However, the number of prescribed opioid medications did not differ from baseline to the end of one year (p = .49). Only 6% of patients discontinued MC treatment during the study. A total of 600 AEs were reported in 310 patients during the reporting period and 97% of them were classified as nonserious. Discussion. Though observational in nature, these findings suggest MC is generally well-tolerated, consistent with the previous literature, and may reduce concomitant use of some medications. Due to study limitations, concomitant medication reductions cannot be causally attributed to MC. Nevertheless, these data underscore early signals that warrant further exploration in randomized trials.

Greater adolescent tiredness is related to more emotional arousal during a hyperventilation task: An area under the curve approach.

INTRODUCTION: Approximately 36% of adolescents report sleep problems (Crowley et al., 2018). Understanding the relation between sleep and emotional experience is crucial in understanding the high incidence of mental health concerns during adolescence. The current study sought to expand understanding in the area by testing the hypothesis that baseline tiredness ratings would predict greater emotional arousal and negative valence across the course of emotional response elicited by a voluntary hyperventilation procedure. METHODS: A community sample of 110 youth (10-18 years; 47.8% girls) provided baseline tiredness ratings and ratings of emotional valence and arousal, 2 min before, immediately after, and 3 min after a hyperventilation task. The area under the curve (AUC) was calculated using the repeated measures of valence and arousal, and correlations between the response curves and baseline tiredness were examined. RESULTS AND CONCLUSIONS: Findings indicated baseline tiredness was positively associated with AUC arousal (r = 0.23), but not valence. This suggests daytime tiredness is associated with the degree of emotional arousal elicited by a psychobiological stressor. By extension, adolescents may experience more arousing emotional reactions when tired, and thus the common sleep deprivation observed during this developmental period may increase risk for mental health problems associated with elevated emotional reactivity.

The interaction between anxiety sensitivity and cigarette smoking level in relation to sleep onset latency among adolescent cigarette smokers.

Cigarette smoking during adolescence is linked to a number of sleep disturbances and has been consistently linked to sleep onset latency among adults. However, little research has examined factors that may influence the relation between cigarette smoking level and sleep onset latency among adolescents. One factor that may be particularly important in this regard is anxiety sensitivity (AS). The current study examined whether cigarette smoking level interacted with AS in its association with sleep onset latency among 94 adolescent (Mage = 15.72) cigarette smokers. As hypothesized, AS interacted with smoking level to relate to sleep onset latency, even after controlling for age and gender. This relation was specific to sleep onset latency as opposed to other types of sleep disturbances, and that adolescents who smoked at higher levels tended to go to sleep later and wake up later than adolescents who smoked at relatively lower levels.

Posttraumatic Stress Symptoms and Nonmedical Prescription Drug Use Among College Students With Trauma Exposure.

OBJECTIVE: Nonmedical prescription drug use, defined as using the drug without a prescription or in ways for which it is not prescribed, and traumatic event exposure are highly prevalent among college students. Despite evidence that posttraumatic stress symptoms could place college students at risk for nonmedical prescription drug problems, no studies have examined this relationship. This study was a preliminary examination of posttraumatic stress symptoms, lifetime nonmedical prescription drug use, hazardous use, and dependence symptoms among college students with trauma exposure. METHODS: Participants were students attending a rural college in Virginia, recruited through psychology classes, flyers, LISTSERVs, and announcements at student events. All students who reported experiencing at least one traumatic event were included (N = 119); participants' mean age was 19.7 years (SD = 1.90), about half were women (n = 63, 53%), and most were Caucasian (n = 103, 87%). RESULTS: Nearly 60% of participants (n = 71) reported using nonmedical prescription drugs at least once during their lifetime and were more likely than those with no use to report hazardous alcohol use (p < .01) and depressive symptoms (p < .05). There were no other significant differences between those who did and did not report use of nonmedical prescription drugs. Regression analyses showed that posttraumatic stress symptom frequency was positively associated with hazardous nonmedical prescription drug use, after controlling for gender, depressive symptoms, and hazardous alcohol use (p < .001). Posttraumatic stress symptom frequency was higher for those with any nonmedical prescription drug dependence symptoms (p < .001), but was unrelated to whether the student had ever engaged in nonmedical prescription drug use. CONCLUSIONS: Findings suggest that consideration of the types of behaviors and problems a college student is experiencing related to nonmedical prescription drug use may be more relevant to posttraumatic stress symptom frequency than dichotomous measures of nonmedical prescription drug use alone. Further, the association between the frequency of posttraumatic stress symptoms and both hazardous nonmedical prescription drug use and dependence symptoms among college students with a trauma history deserves further investigation due to the resulting vulnerability to increasingly negative outcomes.

Preliminary evidence for a unique role of disgust-based conditioning in posttraumatic stress.

Independent lines of evidence have linked posttraumatic stress symptomatology to both peritraumatic disgust (i.e., disgust experienced during a traumatic event) and posttraumatic disgust reactivity in response to traumatic event cues among individuals exposed to traumatic events. Much of this work suggests disgust, defined as a rejection/revulsion response aimed at distancing oneself from a potential source of contamination, may be important in understanding the nature of posttraumatic stress reactions even after accounting for the more frequently studied affective states of fear and anxiety. The current investigation provided a preliminary test of a model of disgust in posttraumatic stress among a sample of 54 community-recruited women with a history sexual victimization. Both peritraumatic disgust (r = .31) and posttraumatic disgust reactivity (r = .42) in response to an idiographic traumatic event script were significantly associated with posttraumatic stress symptom severity. After accounting for variability-associated peritraumatic fear and posttraumatic anxious reactivity, an indirect effect of peritraumatic disgust through posttraumatic disgust reactivity also was found, suggesting that one mechanism through which peritraumatic disgust relates to posttraumatic stress is through its relation with increased posttraumatic disgust reactivity. These findings highlight the importance of further elucidating the nature of disgust in relation to traumatic events and subsequent posttraumatic stress reactions.

A Two-Phase, Dose-Ranging, Placebo-Controlled Study of the Safety and Preliminary Test of Acute Effects of Oral Δ8-Tetrahydrocannabivarin in Healthy Participants.

Introduction: Tetrahydrocannabivarin (THCV) is an understudied cannabinoid that appears to have effects that vary as a function of dose. No human study has evaluated the safety and nature of effects in a wide range of THCV doses. Methods: This was a two-phase, dose-ranging, placebo-controlled trial of the Δ8 isomer of oral THCV in healthy adults. Phase 1 utilized an unblinded, single-ascending dose design (n=3). Phase 2 used a double-blind, randomized, within-participant crossover design (n=18). Participants received single acute doses of placebo and 12.5, 25, 50, 100, and 200 mg of THCV. Safety measures and subjective and cognitive effects were assessed predose and up to 8 h postdose. Results: Most adverse events (AEs; 55/60) were mild. Euphoric mood was the most common AE. The 12.5, 25, and 200 mg doses produced significantly lower minimum times to complete the digit vigilance test (ps=0.01). The 25 mg dose showed elevations on mean ratings of "energetic" at 1-, 2-, and 4-h postdose, but the maximum postdose rating for this dose did not achieve statistical significance relative to placebo ([95% confidence interval]=3.2 [-0.5 to 6.9], p=0.116). The 100 and 200 mg doses showed elevations on ratings of "feel a drug effect" and "like the drug effect." Almost all urine drug screens (78/79) at 8 h postdose in the active THCV conditions tested positive for tetrahydrocannabinol (THC). Conclusion: All THCV doses displayed a favorable safety profile. Several THCV doses showed a preliminary signal for improved sustained attention, but the effect was not dose dependent. Though mild and not associated with impairment, THC-like effects were observed at higher THCV doses. Oral THCV-containing products could lead to positive urine drug screens for THC. ClinicalTrials.gov ID: NCT05210634.

A preliminary investigation of the simultaneous effects of cannabidiol and caffeine.

Caffeine and cannabidiol (CBD) are commonly consumed by the general population, particularly among young adults; however, there is little research on the simultaneous effects of caffeine and CBD. The present study aimed to examine the simultaneous self-reported effects of caffeine and CBD in young healthy adults. Participants (N = 54) who reported daily caffeine use (> 200 mg) attended one experimental session via Zoom and were assigned randomly to receive caffeine (200 mg) combined with either a placebo or CBD (25, 50, 80, 160, or 240 mg). Participants completed subjective drug effects measures at baseline and then ingested caffeine and their assigned CBD dose. Throughout the 140-min session, participants completed self-report measures. The primary outcomes of this study were measures of general drug effects and anxiety. After caffeine and CBD administration, few effects were observed in self-reported measures of general drug effects. No negative effects emerged as a result of combined caffeine and CBD administration. These results should be interpreted cautiously given the preliminary nature and variability in outcomes. The present study findings suggest that combinations of the tested doses of caffeine and CBD do not alter subjective drug effects; further, no negative effects emerged, providing preliminary safety evidence for using these products simultaneously. Further research is needed to examine the simultaneous and/or interactive nature of caffeine and CBD on other caffeine-induced outcomes (e.g., cognition and physiological effects) and will be critical for informing future regulatory decisions regarding caffeine: CBD mixtures. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A double-blind, randomized, placebo-controlled study of the safety and effects of CBN with and without CBD on sleep quality.

The present study sought to determine the effects of cannabinol (CBN) alone and in combination with cannabidiol (CBD) on sleep quality. This was a double-blind, randomized, placebo-controlled study conducted between May and November 2022. Participants were randomized to receive either (a) placebo, (b) 20 mg CBN, (c) 20 mg CBN + 10 mg CBD, (d) 20 mg CBN + 20 mg CBD, or (e) 20 mg CBN + 100 mg CBD for seven consecutive nights. Participants were 18-55 years of age who self-rated sleep quality as "very poor" or "poor." The primary endpoint was sleep quality, while secondary endpoints included sleep onset latency, number of awakenings, wake after sleep onset (WASO), overall sleep disturbance, and daytime fatigue. In a modified intent-to-treat analyses (N = 293), compared to placebo, 20 mg CBN demonstrated a nonsignificant but potentially meaningful effect on sleep quality (OR [95% CI] = 2.26 [0.93, 5.52], p = .082) and significantly reduced number of awakenings (95% CI [-0.96, -0.05], p = .025) and overall sleep disturbance (95% CI [-2.59, -0.14], p = .023). There was no difference from placebo among any group for sleep onset latency, WASO, or daytime fatigue (all p > .05). Individuals receiving 20 mg CBN demonstrated reduced nighttime awakenings and overall sleep disturbance relative to placebo, with no impact on daytime fatigue. The addition of CBD did not positively augment CBN treatment effects. No differences were observed for latency to sleep onset or WASO. Findings suggest 20 mg of CBN taken nightly may be helpful for improving overall sleep disturbance, including the number of times one wakes up throughout the night, without impacting daytime fatigue. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The relationship of sleep quality and PTSD to anxious reactivity from idiographic traumatic event script-driven imagery.

Poor sleep quality has been linked to posttraumatic stress disorder (PTSD). This study provided a test of how poor sleep quality relates to real-time assessment of anxious reactivity to idiographic traumatic event cues. Script-driven imagery (SDI) was employed to examine reactivity to traumatic event cues among 46 women (mean age = 27.54 years, SD = 13.62; 87% Caucasian) who had experienced either physical or sexual assault. We tested 3 hypotheses: (a) individuals with PTSD would report greater anxiety reactions to SDI than trauma-exposed individuals without PTSD, (b) poorer sleep quality would be positively related to anxiety reactions to SDI, and (c) there would be an interaction between PTSD and sleep quality such that individuals with PTSD and relatively poor sleep quality would report greater anxious reactivity to SDI than would be expected from each main effect alone. Poor sleep quality and PTSD were related to elevated anxious reactivity to trauma cues (sr(2) = .06). In addition, sleep quality was negatively associated with anxious reactivity among people without PTSD (sr(2) =.05). The current findings, in combination with longitudinal evidence, suggest that poor sleep quality following exposure to a traumatic event may be a risk factor for anxious reactivity to traumatic event cues.

An experimental test of the effects of acute sleep deprivation on affect and avoidance.

BACKGROUND AND OBJECTIVES: Avoidance and sleep have been identified as mechanisms involved in the development and maintenance of many mental health disorders. However, there has been little research into the relation between sleep and avoidance. METHODS: To address this, a randomized controlled experiment using behavioral and self-report measures of affect and avoidance was conducted. Compared to a control group, we hypothesized that sleep-deprived individuals would demonstrate increased negative, and decreased positive, affectivity, more avoidance behavior toward a negatively valenced stimulus, as well as increased self-reported avoidance. Fifty-two healthy individuals ages 18-30 years old were randomly assigned to a full night of sleep deprivation or normal sleep. They completed a baseline and post-manipulation behavioral avoidance task (BAT) using a disgusting stimulus and self-reports of avoidance and state affect. RESULTS: Repeated measures ANOVAs demonstrated negative affectivity and self-reported avoidance increased, and positive affectivity decreased, from pre-to post-manipulation in the sleep loss condition as expected. However, there were no effects of sleep deprivation on avoidance behaviors. LIMITATIONS: This study emphasized internal validity over generalizability. Additionally, the at-home sleep deprivation limited researcher control over the overnight activities of participants. CONCLUSIONS: Results replicate prior work on the affective consequences of sleep deprivation and highlight a discrepancy between the effect of sleep deprivation on behavioral avoidance toward a specific stimulus compared to self-reported cognitive and social avoidance behaviors.

A double-blind, randomized, placebo-controlled test of the effects of cannabidiol on fear elicited by a 10% carbon dioxide-enriched air breathing challenge.

OBJECTIVE: A single administration of cannabidiol (CBD) can reduce anxiety during social anxiety inductions. No study, however, has evaluated the impact of CBD on fear responding among humans. METHOD: A double-blind, randomized, placebo-controlled trial was undertaken to address this gap in the literature. Specifically, the current study tested a single oral administration of CBD (either 150 mg, 300 mg, or 600 mg), compared to placebo, for reducing fear reactivity to a well-established 5-min administration of 10% carbon dioxide (CO2)-enriched air biological challenge. CBD was administered 90 min prior to the challenge. Participants were 61 healthy young adults who self-reported fear continuously during the challenge. Heart rate also was continuously monitored, and panic symptoms were self-reported using the Diagnostic Sensations Questionnaire immediately following the procedure. RESULTS: Results indicated no effect of condition on self-reported fear, panic symptoms, or heart rate. CONCLUSION: This is the first study to document that CBD does not reduce fear reactivity in humans, thereby representing an important extension to research on the effects of CBD.

Medical cannabis authorization patterns, safety, and associated effects in older adults.

BACKGROUND: Use of medical cannabis is increasing among older adults. However, few investigations have examined cannabis use in this population. METHODS: We assessed the authorization patterns, safety, and effects of medical cannabis in a sub-analysis of 201 older adults (aged ≥ 65 years) who completed a 3-month follow-up during this observational study of patients who were legally authorized a medical cannabis product (N = 67). Cannabis authorization patterns, adverse events (AEs), Edmonton Symptom Assessment Scale-revised (ESAS-r), and Brief Pain Inventory Short Form (BPI-SF) data were collected. RESULTS: The most common symptoms for which medical cannabis was authorized were pain (159, 85.0%) and insomnia (9, 4.8%). At baseline and at the 3-month follow-up, cannabidiol (CBD)-dominant products were authorized most frequently (99, 54%), followed by balanced products (76, 42%), and then delta-9-tetrahydrocannabinol (THC)-dominant products (8, 4.4%). The most frequent AEs were dizziness (18.2%), nausea (9.1%), dry mouth (9.1%), and tinnitus (9.1%). Significant reductions in ESAS-r scores were observed over time in the domains of drowsiness (p = .013) and tiredness (p = .031), but not pain (p = .106) or well-being (p = .274). Significant reductions in BPI-SF scores over time were observed for worst pain (p = .010), average pain (p = .012), and overall pain severity (p = 0.009), but not pain right now (p = .052) or least pain (p = .141). CONCLUSIONS: Overall, results suggest medical cannabis was safe, well-tolerated, and associated with clinically meaningful reductions in pain in this sample of older adults. However, the potential bias introduced by the high subject attrition rate means that all findings should be interpreted cautiously and confirmed by more rigorous studies.

Incorporating telehealth into health service psychology training: A mixed-method study of student perspectives.

OBJECTIVE: Telehealth is increasingly recognized as an avenue for enhancing psychologists' capacities to meet the mental health needs of a diverse and underserved (due to barriers e.g., distance, transportation) public. The present study sought to inform training in telepsychology (i.e., telehealth delivery of psychological services) by using both quantitative and qualitative methods to explore the perspectives of doctoral students who have already been involved in such training. METHOD: A total of 19 predoctoral students from two universities, with at least some experience in telepsychology training, provided their perspectives on two complementary research questions: (1) How do students perceive their level of competence in various domains of telepsychology?; and (2) What are students' perspectives on the process of telepsychology competency development during their doctoral training? RESULTS: The results of our study provide early evidence that doctoral trainees are able to develop telepsychology competencies and suggest that a supportive, training-oriented environment and fit between telepsychology and existing programmatic areas of emphasis are likely key to success. CONCLUSIONS: Continued efforts to enhance training in providing telepsychology services should focus on how to best define, measure, and promote competency development in this emerging specialty area.

Practical considerations for testing the effects of cannabidiol on human anxiety.

Empirical evidence continues to accumulate suggesting cannabidiol (CBD) may have potential as an anxiolytic. Yet, research in the area is insufficient to support strong inferences. Accordingly, there is a need for additional empirical investigation. Research on the effects of CBD and anxiety requires a working knowledge of both. Understanding of contemporary CBD and anxiety research methods is critical to safely and convincingly test predictions regarding potential anxiolytic effects of CBD. The current paper outlines major design, methods, and safety considerations pertinent both to CBD administration and measuring effects on anxiety outcomes in order to facilitate needed research in this domain.

Distress Tolerance Interacts with Peritraumatic Emotions to Predict Posttraumatic Stress Symptoms Following Sexual Victimization.

The intensity of peritraumatic emotions occurring at the time of, and in the hours or days immediately following, a traumatic event prospectively predicts posttraumatic stress symptom severity. However, less is known about how the perception of one's ability to tolerate distressing emotions affects the relation between peritraumatic emotions and posttraumatic stress symptoms. Therefore, the current study investigated how perceived distress tolerance affects the association between peritraumatic emotional intensity and symptoms of posttraumatic stress. Participants included 72 adult women with a history of sexual victimization. Ratings of peritraumatic emotions (e.g., fear, anger, sadness, guilt, and shame), perceived distress tolerance, and posttraumatic stress symptoms were examined. All analyses controlled for general negative affect. Significant interactions emerged for overall peritraumatic emotional intensity, and specifically for peritraumatic anger, sadness, and shame. The associations between these peritraumatic emotions and posttraumatic stress symptoms were stronger for individuals with lower perceived ability to tolerate distress. Our results suggest that peritraumatic emotional experiences may be particularly relevant to understanding the development and maintenance of posttraumatic stress symptoms among individuals who have difficulty tolerating intense negative emotional states. Future research should examine whether perceived distress tolerance might serve as a potential target for posttraumatic stress prevention efforts.

Shame Proneness, Negative Cognitions, and Posttraumatic Stress Among Women with a History Sexual Trauma.

While fear and anger have been extensively studied as emotions involved in posttraumatic stress disorder, shame is an important emotion to examine in those who have experienced a traumatic event, as it is often associated with treatment avoidance and treatment resistance. Compared to guilt, which is associated with having participated in something that violates social/cultural norms or expectations, shame is associated with a negative perception of the self. The current paper sought to examine the role of shame proneness and guilt proneness, as it relates to posttraumatic cognitions and posttraumatic stress symptoms (PTSS) among women reporting a history of sexual trauma. Seventy-two community-recruited women with a history of sexual trauma completed self-report measures of shame and guilt proneness and negative posttraumatic cognitions as well as a semi-structured interview assessing PTSS. There was an indirect effect of shame proneness on PTSS, through its positive association with negative cognitions about the self but not others or the world. Guilt proneness was not significantly related to PTSS or negative posttraumatic cognitions. The current paper outlines the importance of these findings and future directions for continuing to better understand the relations between shame and posttraumatic stress disorder symptoms and treatment.

Test of the role of nicotine dependence in the relation between posttraumatic stress disorder and panic spectrum problems.

Posttraumatic stress disorder (PTSD) frequently co-occurs with panic spectrum problems. Relatively little empirical work has tested possible mechanisms accounting for this association. Nicotine dependence often ensues subsequent to PTSD onset and research suggests smoking high numbers of cigarettes daily may lead to panic problems. The current study tested the hypotheses that nicotine dependence partially mediates the relations between PTSD and both panic attacks and panic disorder within a nationally representative sample of 5,692 (3,020 women; M(Age) = 45, SD = 18) adults from the National Comorbidity Survey-Replication. Results were consistent with hypotheses. These findings support the theory suggesting smoking among people with PTSD may be involved in the development of panic problems.

An evaluation of the validity of a script-driven imagery procedure among traumatic event-exposed adolescents.

OBJECTIVE: Adult research employing script-driven imagery procedures has shown the method to be a valuable tool for studying the nature, correlates, and consequences of trauma and posttraumatic stress symptoms (PTSS). The purpose of the current study was to examine the validity of a trauma-focused script-driven imagery procedure among youth. METHOD: Responding to script-driven imagery was examined in relation to PTSS among 60 traumatic event-exposed adolescents, ages 10 to 17 years. RESULTS: In support of concurrent validity, PTSS was associated with self-reported anxiety, fear, disgust, and distress responses to the script. Script-elicited reexperiencing, dissociation, and total state-symptoms were associated with interview-measured severity of PTSS. However, neither script-elicited avoidance symptoms nor physiological reactivity to the script were related to PTSS. In support of discriminant validity, adolescents' self-reported thought problems were not related to script-elicited affective, physiological, or state-symptom outcomes. CONCLUSION: Research is needed to understand why certain variables, such as physiological reactivity to the script, did not relate to PTSS. However, results suggest the traumatic event-focused script driven imagery procedure is a useful method for activating a trauma-related emotion network and measuring psychological reactivity to reminders of traumatic event cues among adolescents. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Unique and Interactive Relations among Posttraumatic Stress, Distress Tolerance, and Anger Responding to Traumatic Event Cues.

Experimental and clinical studies have demonstrated an association between posttraumatic stress symptoms (PTSS) and anger. Expanding upon past research, the current study examined the interactive associations among PTSS, distress tolerance (DT), and anger responding among a sample of 95 trauma-exposed adults. This study used a personalized script-driven imagery procedure to gauge emotional responses. Results from a hierarchical linear regression demonstrated a main effect of PTSS and an interaction between PTSS and DT. Simple slope analyses indicated that PTSS level was unrelated to anger responding among traumatic event-exposed people relatively low in DT, while anger responses were positively correlated with levels of PTSS among those relatively higher in DT. These findings highlight the need for future research to consider distress tolerance as well as other emotional vulnerability factors in assessing PTSD-related anger.

Lethality of Previous Suicidal Behavior among Patients Hospitalized for Suicide Risk Predicts Lethality of Future Suicide Attempts.

OBJECTIVE: A suicide attempt is an established risk factor for subsequent suicide attempts and suicide. Nonetheless, the prediction of future suicidal behavior is poor. The lethality of previous suicidal behavior may be informative to better understand future suicide risk among patients hospitalized for suicidal thoughts and behavior. The current study examined whether the lethality of patients' index (most recent suicidal episode at hospitalization), first, and worst suicidal episode predicts the lethality of one's most lethal suicide attempt during a 2-year follow-up period. METHOD: A total of 98 patients hospitalized at an emergency department for high suicide risk (i.e., acute suicidal ideation or a suicide attempt) were included in the study. RESULTS: Results indicated that the lethality of the index suicidal episode predicted the lethality of the worst suicide attempt during a 2-year follow-up period. CONCLUSIONS: These findings extend a growing literature examining risk factors that influence the progression toward high lethality suicidal behavior.