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.

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.

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.

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.

Under Reporting of Suicide Ideation in US Army Population Screening: An Ongoing Challenge.

Previous research in US Army Soldiers shows rates of mental health concerns as two to four times higher on anonymous surveys than on postdeployment health assessments. In this study, Soldiers presenting for health reassessment completed two questionnaires on suicide risk factors: one linked to the health assessment and one anonymous. About 5.1% of respondents reported suicide ideation on the anonymous questionnaire, 3.0% on the linked questionnaire, and 0.9% on the health reassessment. About 56.4% who reported suicide ideation anonymously told nobody of their thoughts. Current screening procedures identify only one in seven Soldiers experiencing suicide ideation and highlight the need for alternative risk-detection strategies.

Suicide After Evaluation for Involuntary Psychiatric Commitment-Who Gets Them and What Influences Survival Time?

Although involuntary psychiatric hospitalizations are associated with suicide risk, little is known about the relationship between evaluation for involuntary detention and suicide. We analyzed data on 10,082 suicides from 2000 to 2011 to examine demographics related to evaluation for detention and the association between demographics and evaluation dispositions on survival time. Evaluation preceded 11% of suicides; 53.8% of deaths occurred within 365 days, 6.5 times the expected rate. Males and older individuals were least likely to have been evaluated. Minority status and referral disposition influence 30-day survival time. Risk is highly concentrated in the first year following evaluation.

What factors determine disclosure of suicide ideation in adults 60 and older to a treatment provider?

Correlates of patient disclosure of suicide ideation to a primary care or mental health provider were identified. Secondary analyses of IMPACT trial data were conducted. Of the 107 patients 60 years of age or older who endorsed thoughts of ending their life at least "a little bit" during the past month, 53 indicated they had disclosed these thoughts to a mental health or primary care provider during this period. Multiple logistic regression was used to identify predictors of disclosure to a provider. Significant predictors included poorer quality of life and prior mental health specialty treatment. Among participants endorsing thoughts of suicide, the likelihood of disclosing these thoughts to a provider was 2.96 times higher if they had a prior history of mental health specialty treatment and 1.56 times higher for every one-unit decrease in quality of life. Variation in disclosure of thoughts of suicide to a mental health or primary care provider depends, in part, on patient characteristics. Although the provision of evidence-based suicide risk assessment and guidelines could minimize unwanted variation and enhance disclosure, efforts to routinize the process of suicide risk assessment should also consider effective ways to lessen potential unintended consequences.

Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis.

Objective To characterise suicide-risk discussions in depressed primary-care patients. Design Secondary analysis of recordings and self reports by physicians and patients. Descriptive statistics of depression and suicide-related discussion, with qualitative extraction of disclosure, enquiry and physician response. Setting 12 primary-care clinics between July 2003 and March 2005. Participants 48 primary-care physicians and 1776 adult patients. Measures Presence of depression or suicide-related discussions during the encounter; patient and physician demographics; depression symptom severity and suicide ideation as measured by the Patient Health Questionnaire (PHQ9); physician's decision-making style as measured by the Medical Outcomes Study Participatory Decision-Making Scale; support for autonomy as measured by the Health Care Climate Questionnaire; trust in their physician as measured by the Primary Care Assessment Survey; physician response to suicide-related enquiry or disclosure. Results Of the 1776 encounters, 128 involved patients scoring >14 on the PHQ9. These patients were seen by 43 of the 48 physicians. Suicide ideation was endorsed by 59% (n=75). Depression was discussed in 52% of the encounters (n=66). Suicide-related discussion occurred in only 11% (n=13) of encounters. 92% (n=12) of the suicide discussions occurred with patients scoring <2 on PHQ9 item 9. Suicide was discussed in only one encounter with a male. Variation in elicitation and response styles demonstrated preferred and discouraged interviewing strategies. Conclusions Suicide ideation is present in a significant proportion of depressed primary care patients but rarely discussed. Men, who carry the highest risk for suicide, are unlikely to disclose their ideation or be asked about it. Patient-centred communication and positive healthcare climate do not appear to increase the likelihood of suicide related discussion. Physicians should be encouraged to ask about suicide ideation in their depressed patients and, when disclosure occurs, facilitate discussion and develop targeted treatment plans.

A learning collaborative of CMHCs and CHCs to support integration of behavioral health and general medical care.

OBJECTIVE: Integration of general medical and mental health services is a growing priority for safety-net providers. The authors describe a project that established a one-year learning collaborative focused on integration of services between community health centers (CHCs) and community mental health centers (CMHCs). Specific targets were treatment for general medical and psychiatric symptoms related to depression, bipolar disorder, alcohol use disorders, and metabolic syndrome. METHODS: This observational study used mixed methods. Quantitative measures included 15 patient-level health indicators, practice self-assessment of resources and support for chronic disease self-management, and participant satisfaction. RESULTS: Sixteen CHC-CMHC pairs were selected for the learning collaborative series. One pair dropped out because of personnel turnover. All teams increased capacity on one or more patient health indicators. CHCs scored higher than CMHCs on support for chronic disease self-management. Participation in the learning collaborative increased self-assessment scores for CHCs and CMHCs. Participant satisfaction was high. Observations by faculty indicate that quality improvement challenges included tracking patient-level outcomes, workforce issues, and cross-agency communication. CONCLUSIONS: Even though numerous systemic barriers were encountered, the findings support existing literature indicating that the learning collaborative is a viable quality improvement approach for enhancing integration of general medical and mental health services between CHCs and CMHCs. Real-world implementation of evidence-based guidelines presents challenges often absent in research. Technical resources and support, a stable workforce with adequate training, and adequate opportunities for collaborator communications are particular challenges for integrating behavioral and general medical services across CHCs and CMHCs.

Advantages of using estimated depression-free days for evaluating treatment efficacy.

OBJECTIVE: Several common methods for measuring treatment response present a snapshot of depression symptoms. The construct of estimated depression-free days (DFDs) simultaneously captures treatment outcome and estimates the patient's experience of depression over time. The study compared this measure with traditional measures used in depression treatment research. METHODS: This secondary data analysis was based on data from the Improving Mood-Promoting Access to Collaborative Treatment trial, a multisite depression treatment study conducted in 18 primary care clinics in five states and representing eight health care systems. The sample of older adults (N=906) had been randomly assigned to receive collaborative care for depression. Participants were aged 60 or older and met criteria for major depressive disorder, dysthymia, or both. Exclusion criteria included severe cognitive impairment, active substance abuse, active suicidal behavior, severe mental illness, and active treatment from a psychiatrist. The Patient Health Questionnaire (PHQ-9) and the Hopkins Symptom Checklist (HSCL-20) were used as outcome measures at four assessment points (baseline, three months, six months, and 12 months). Outcomes were computed for relative change, standardized differences, the proportion of improvement in depression, and DFDs. RESULTS: Using four assessment points improved the agreement between DFDs and the course of symptom change between pre- and posttest measures. CONCLUSIONS: The DFD is a valid measure for estimating treatment outcomes that reflects the course of symptom change over time. When multiple assessments were conducted between the pre- and posttest periods, DFDs incorporated additional data yet remained easily interpreted. The DFD should be considered for reporting outcomes in depression research.

Professional perspectives on sexual sadism.

Significant controversy surrounds the diagnosis of sexual sadism. Research suggests that many characteristics attributed to sexual sadists fail to differentiate sexual offenders with and without this diagnosis. Furthermore, when there are differences between sadists and nonsadists, "sadistic" features are frequently associated with nonsadists. Finally, diagnosticians appear to use idiosyncratic methods to diagnose sexual sadism. These findings raise concerns about the reliability and validity of a diagnosis of sexual sadism, particularly with respect to how professionals conceptualize this diagnosis. This study examines how professionals understand the relative importance of behaviors associated with sadistic versus nonsadistic sexual offending. Professionals rated behaviors according to their "essentialness" for this diagnosis. Results show that professionals rated behaviors associated with three out of four conceptualizations of sexual sadism as significantly more essential to making a diagnosis of sexual sadism, compared to behaviors associated with nonsadistic sexual offending. Results suggest that professionals reliably discriminate between sadistic and nonsadistic offense behaviors.

The relationship between suicide ideation and late-life depression.

OBJECTIVE: To describe the course of suicide ideation (SI) in primary-care based late-life depression treatment, identify predictors of SI, characterize the dynamic relationship between depression and SI, and test the hypothesis that collaborative care decreases the likelihood of reporting SI by decreasing the severity of depressive symptoms. METHODS: This was a secondary analysis of a randomized controlled trial comparing collaborative care to usual care for late-life depression. Participants were 1,801 adults age 60 and older from eight diverse primary-care systems. Depression was measured using the Hopkins Symptoms Checklist (HSCL-20). SI was operationalized using one item from the HSCL-20. Predictors of incident SI were identified by a series of univariate analyses followed by multiple logistic regression. A mediator analysis was conducted to test the hypothesis that the effect of collaborative care on SI can be ascribed to the intervention's effect on depressive symptoms. RESULTS: The prevalence of SI was 14% (N = 253); the cumulative incidence over 24 months was 21% (385). The likelihood that SI emerged after baseline was highly dependent on change in depression (odds ratio: 5.38, 95% confidence interval: 3.93-7.36, df = 81, t = 10.66, p <0.0001). As hypothesized, the effect of collaborative care on SI was mediated by the treatment's effect on depression. CONCLUSION: SI is not uncommon in depressed older adults being treated in primary care. The likelihood that depressed older adults will report SI is strongly determined by the course of their depression symptoms. Providers should monitor SI throughout the course of depression treatment.