Polypharmacy Among Patients With Major Depressive Disorder and Co-occurring Substance Use Disorders in a Psychiatric Hospital Setting: Prevalence and Risk Factors.

BACKGROUND: Major depressive disorder (MDD) is common among patients admitted to a psychiatric hospital who frequently present with comorbid conditions such as substance use disorders (up to 50%). Polypharmacy (ie, being prescribed 3 or more medications) may be relatively common in dual-diagnosis patients. This study sought to examine prevalence and risk factors associated with psychotropic polypharmacy in hospitalized patients with MDD and co-occurring SUDs. METHODS: An electronic chart review was conducted with 1315 individuals admitted to a psychiatric hospital; 505 (38.4%) were identified as having co-occurring MDD + SUD. We examined psychotropic polypharmacy and clinical severity to explore risk for concerning drug interactions. RESULTS: Potentially problematic polypharmacy patterns were identified among those with MDD + SUD and were related to negative clinical outcomes, particularly in terms of increased sedation potential for individuals with an opioid use disorder (OUD). Groups at the highest risk for polypharmacy included patients who were female, older in age, lower in functioning, and presenting with a co-occurring OUD. Having an OUD was associated with particularly risky polypharmacy combinations, while having a cannabis use disorder was associated with the least polypharmacy. CONCLUSIONS: Results highlight a high prevalence of polypharmacy among a group that has an elevated risk for negative outcomes. There is a continued need to improve identification of complex patient presentations and adjust medications in a hospital setting to improve treatment outcomes and reduce future mortality.

From court to the community: improving access to evidence-based treatment for underserved youth involved in the juvenile legal system at-risk for suicide.

BACKGROUND: Juvenile legal involved youth (JLIY) experience disproportionately high rates of suicidal and self-injurious thoughts and behaviors (SSITB). Many JLIY lack access to evidence-based treatment specifically designed to treat SSITB, thereby increasing the overall risk of suicide. The overwhelming majority of JLIY are not placed in secure facilities and almost all incarcerated youth are eventually released to the community. Consequently, SSITB are a major concern of JLIY residing in the community and it is critical that this population has access to evidence-based treatment for SSITB. Unfortunately, most community mental health providers who treat JLIY have not been trained in evidence-based interventions that are specifically designed to SSITB, which often leads to youth experiencing prolonged periods of SSITB. Training community mental health providers who serve JLIY in the detection and treatment of SSITB shows promise for decreasing the overall suicide risk for JLIY. METHODS: The current proposal aims to reduce SSITB among JLIY, and thus reduce mental health disparities in this vulnerable and underserved youth population, by increasing access to evidence-based treatment strategies specifically designed to treat SSITB behaviors. We will implement an agency-wide training among at least 9 distinct community mental health agencies that serve JLIY referred to treatment by a statewide court system in the Northeast. Agencies will be trained in an adapted version of the COping, Problem Solving, Enhancing life, Safety, and Parenting (COPES+) intervention. Training will be implemented via a cluster-randomized stepped wedge trial that proceeds through multiple phases. DISCUSSION: This research engages multiple systems (i.e., juvenile legal and mental health systems) serving JLIY and has the potential to directly inform treatment practices in juvenile legal and mental health systems. The current protocol has significant public health implications as the primary goals are to reduce SSITB among adolescents involved in the juvenile legal system. By implementing a training protocol with community-based providers to help them learn an evidence-based intervention, this proposal aims to reduce mental health disparities in a marginalized and underserved population. TRIAL REGISTRATION: osf.io/sq9zt.

Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol.

BACKGROUND: Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail. METHODS: This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data. CONCLUSIONS: This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

A risk calculator to predict suicide attempts among individuals with early-onset bipolar disorder.

OBJECTIVES: To build a one-year risk calculator (RC) to predict individualized risk for suicide attempt in early-onset bipolar disorder. METHODS: Youth numbering 394 with bipolar disorder who completed ≥2 follow-up assessments (median follow-up length = 13.1 years) in the longitudinal Course and Outcome of Bipolar Youth (COBY) study were included. Suicide attempt over follow-up was assessed via the A-LIFE Self-Injurious/Suicidal Behavior scale. Predictors from the literature on suicidal behavior in bipolar disorder that are readily assessed in clinical practice were selected and trichotomized as appropriate (presence past 6 months/lifetime history only/no lifetime history). The RC was trained via boosted multinomial classification trees; predictions were calibrated via Platt scaling. Half of the sample was used to train, and the other half to independently test the RC. RESULTS: There were 249 suicide attempts among 106 individuals. Ten predictors accounted for >90% of the cross-validated relative influence in the model (AUC = 0.82; in order of relative influence): (1) age of mood disorder onset; (2) non-suicidal self-injurious behavior (trichotomized); (3) current age; (4) psychosis (trichotomized); (5) socioeconomic status; (6) most severe depressive symptoms in past 6 months (trichotomized none/subthreshold/threshold); (7) history of suicide attempt (trichotomized); (8) family history of suicidal behavior; (9) substance use disorder (trichotomized); (10) lifetime history of physical/sexual abuse. For all trichotomized variables, presence in the past 6 months reliably predicted higher risk than lifetime history. CONCLUSIONS: This RC holds promise as a clinical and research tool for prospective identification of individualized high-risk periods for suicide attempt in early-onset bipolar disorder.

Prospectively ascertained mania and hypomania among young adults with child- and adolescent-onset bipolar disorder.

OBJECTIVES: While adults with bipolar disorder (BD) often report symptoms starting in childhood, continuity of mania and/or hypomania (mania/hypomania) from childhood to adulthood has been questioned. Using longitudinal data from the Course and Outcome of Bipolar Youth (COBY) study, we assessed threshold mania/hypomania in young adults who manifested BD as youth. METHODS: COBY is a naturalistic, longitudinal study of 446 youth with BD (84% recruited from outpatient clinics), 7-17 years old at intake, and over 11 years of follow-up. Focusing on youth with BD-I/II (n = 297), we examined adult mania/hypomania risk (>18 years old; mean 7.9 years of follow-up) according to child (<13 years old) versus adolescent (13-17 years old) onset. We next used penalized regression to test demographic and clinical predictors of young adult mania/hypomania. RESULTS: Most participants (64%) had child-onset mania/hypomania, 57% of whom also experienced mania/hypomania in adolescence. Among those who experienced an episode in adolescence, over 40% also had mania/hypomania during adulthood; the risk did not differ according to child versus adolescent onset. In contrast, 7% with mania/hypomania in childhood, but not adolescence, experienced mania/hypomania in adulthood. Family history (of mania and suicide attempts) predicted mania/hypomania in young adulthood (p-values <0.05); age of onset was not a significant predictor. Among participants with no mania/hypomania during adulthood, 53% (105/198) still experienced subthreshold manic episodes. DISCUSSION: We find substantial continuity across developmental stage indicating that, in this carefully characterized sample, children who experience mania/hypomania-particularly those who also experience mania/hypomania in adolescence-are likely to experience mania/hypomania in young adulthood.

A Bayesian multilevel analysis of the longitudinal associations between relationship quality and suicidal ideation and attempts among youth with bipolar disorder.

BACKGROUND: Youth with bipolar disorder (BD) are at high risk for suicidal thoughts and behaviors and frequently experience interpersonal impairment, which is a risk factor for suicide. Yet, no study to date has examined the longitudinal associations between relationship quality in family/peer domains and suicidal thoughts and behaviors among youth with BD. Thus, we investigated how between-person differences - reflecting the average relationship quality across time - and within-person changes, reflecting recent fluctuations in relationship quality, act as distal and/or proximal risk factors for suicidal ideation (SI) and suicide attempts. METHODS: We used longitudinal data from the Course and Outcome of Bipolar Youth Study (N = 413). Relationship quality variables were decomposed into stable (i.e., average) and varying (i.e., recent) components and entered, along with major clinical covariates, into separate Bayesian multilevel models predicting SI and suicide attempt. We also examined how the relationship quality effects interacted with age and sex. RESULTS: Poorer average relationship quality with parents (ß = -.33, 95% Bayesian highest density interval (HDI) [-0.54, -0.11]) or friends (ß = -.33, 95% HDI [-0.55, -0.11]) was longitudinally associated with increased risk of SI but not suicide attempt. Worsening recent relationship quality with parents (ß = -.10, 95% HDI [-0.19, -0.03]) and, to a lesser extent, friends (ß = -.06, 95% HDI [-0.15, 0.03]) was longitudinally associated with increased risk of SI, but only worsening recent relationship quality with parents was also associated with increased risk of suicide attempt (ß = -.15, 95% HDI [-0.31, 0.01]). The effects of certain relationship quality variables were moderated by gender but not age. CONCLUSIONS: Among youth with BD, having poorer average relationship quality with peers and/or parents represents a distal risk factor for SI but not suicide attempts. Additionally, worsening recent relationship quality with parents may be a time-sensitive indicator of increased risk for SI or suicide attempt.

Longitudinal course and risk factors associated with psychosis in bipolar youths.

OBJECTIVES: To compare the longitudinal clinical course of youths with bipolar disorder (BD) spectrum with lifetime (past, intake, and/or follow-up) psychosis (BDP+) to youths with BD without lifetime psychosis (BDP-). Also, to identify risk factors associated with increased risk of first onset of psychosis during prospective follow-up. METHOD: Bipolar disorder youths (BDP+ = 137, BDP- = 233), aged 7-17 years old, were followed on average every 7 months for 11.7 years and were evaluated using standardized instruments. Data were analyzed using linear and generalized linear models for the full sample, as well as for youths who developed first period of psychosis (n = 55). RESULTS: After adjusting for confounders, BDP+ youths with one, and in particular ≥2 lifetime psychotic episodes, had higher rates and more severe mood and anxiety symptoms, higher rates of suicidality, psychiatric hospitalizations, and sexual/physical abuse, and poorer psychosocial functioning than BDP- youths. Even before the first onset of psychosis during follow-up, BDP+ youths showed more psychopathology and had more family history of psychiatric illness than those who never developed psychosis. First-onset psychosis was associated with low socioeconomic status (SES), living with one parent, bipolar disorder type one and type two, comorbid anxiety, history of hospitalizations, and family history of mania and suicidality. CONCLUSION: BDP+ is associated with poor prognosis and worse clinical picture, even before the onset of psychosis, indicating the need for prompt identification and treatment of these youths. Studies aimed to treat acute symptoms of psychosis, as well as prevent the onset of psychosis, including risk factors amenable to change, are warranted.

A Novel Experiential Quality Improvement Training Program During Residency Improves Quality Improvement Confidence and Knowledge: a Prospective Cohort Study.

OBJECTIVE: The Accreditation Council for Graduate Medical Education (ACGME) mandates resident quality improvement (QI) training to improve patient safety, cost control, and efficiency. Thus, understanding this topic is crucial for early career physicians. This manuscript describes an enhanced, experiential QI curriculum for psychiatry residents and its outcomes. METHODS: Two cohorts of 12 third-year residents completed the curriculum, which included didactics, external resources, and expert guidance through small group project design, implementation, and analysis/presentation. A survey on resident confidence in QI principles and the quality improvement knowledge assessment tool-revised (QIKAT-R) was used before and after curriculum participation. Data were analyzed using parametric descriptive tests and repeated measures general linear models with Benjamini-Hochberg correction for multiple comparisons. RESULTS: Resident confidence in performing seven of the ten steps of QI and QIKAT-R scores significantly improved for both cohorts (p = .011). Eighty-nine percent of residents felt that the curriculum met their goals. CONCLUSIONS: The QI curriculum effectively improved resident QI confidence and knowledge. Residents reported that experiential engagement in the design, implementation, and analysis/presentation of their project was crucial to these achievements. This experiential QI curriculum with resident-generated QI projects addressed ACGME training requirements while integrating QI training directly into the residents' clinical activities, making the QI efforts relevant and meaningful while also achieving ACGME goals.

Complex Polypharmacy in Patients With Schizophrenia-Spectrum Disorders Before a Psychiatric Hospitalization: Prescribing Patterns and Associated Clinical Features.

BACKGROUND: Current evidence-based guidelines provide unclear support for many common polypharmacy practices in schizophrenia. Excessive or complex polypharmacy (≥4 psychotropics) has been studied in patients with bipolar disorder, but not in schizophrenia to date. METHODS: We conducted a digital medical record data extraction of 829 patients consecutively admitted to a psychiatric hospital and diagnosed as having schizophrenia-spectrum disorders. RESULTS: In those prescribed psychiatric medication preadmission, 28.1% (n = 169) met the criteria for complex polypharmacy. Complex polypharmacy patients were older, female, white, and disabled, and had more comorbidities compared with those without complex polypharmacy. In multivariable analysis, complex polypharmacy was specifically associated with being white and disabled, and having a comorbid anxiety disorder, tobacco use disorder, metabolic condition, and neurological condition compared with noncomplex polypharmacy patients. CONCLUSIONS: Although there is little evidence to support complex polypharmacy in schizophrenia, rates were relatively high in patients requiring hospitalization, especially when they are also diagnosed as having comorbid psychiatric and medical conditions. Future research is needed to study the risk-benefit profile for these patients, especially considering their higher medical burden and related health risks.

Comorbid Cannabis and Tobacco Use Disorders in Hospitalized Patients with Psychotic-Spectrum Disorders.

OBJECTIVE: Individuals with psychotic-spectrum disorders use tobacco and cannabis at higher rates than the general population and individuals with other psychiatric disorders, which may contribute to increased rates of medical problems and mortality. The present study examined whether individuals with psychosis and comorbid tobacco and/or cannabis use disorders exhibit differing clinical characteristics in terms of their sociodemographic, mental health, substance use, physical health, and medication use patterns. Elucidation of these profiles, and determining their relative severity, has important implications for treatment, including offering more targeted interventions based on type of comorbidity pattern. METHODS: We examined the electronic medical records of 829 patients with psychotic-spectrum disorders admitted to a psychiatric hospital and categorized them as having: (1) cannabis use disorder (CUD); (2) tobacco use disorder (TUD); (3) comorbid cannabis and tobacco use disorders (CUD + TUD); or (4) neither disorder (no CUD/TUD). Multinomial logistic regression was used to compare the aforementioned groups on multiple variables controlling for age and sex. RESULTS: Alcohol and stimulant use disorder diagnoses were each related to higher odds of having a CUD and CUD + TUD, relative to no CUD/TUD. Stimulant and polysubstance use disorder diagnoses were each related to higher odds of having a TUD compared to no CUD/TUD. Greater number of prescribed psychotropic medications was related to higher odds of a TUD compared to no CUD/TUD. CONCLUSIONS: Although several differences between groups were accounted for by age of cannabis versus tobacco users, findings point to the importance of considering comorbid alcohol and substance use disorders among those with psychosis and CUD/TUD, as these comorbidities have important implications for screening and treatment selection during and following acute hospitalization.

Bipolar I disorder with comorbid PTSD: Demographic and clinical correlates in a sample of hospitalized patients.

BACKGROUND: According to data from epidemiological and clinical samples, there are elevated rates of posttraumatic stress disorder (PTSD) among patients with bipolar disorder (BD). However, little is known about the clinical correlates that may distinguish patients with BD and comorbid PTSD from those without comorbid PTSD. The present study sought to elucidate those differences and examine factors, such as psychosis, history of suicide attempts, and comorbid personality disorders, which may predict comorbid PTSD in patients with BD-I. METHODS: We conducted a retrospective chart review of 230 psychiatric inpatients with BD-I. RESULTS: Patients with BD-I and comorbid PTSD were significantly more likely to be female, to be depressed (vs. manic), to have a comorbid personality disorder, and to have a history of suicide attempt. Also, BD-I patients with PTSD were significantly less likely to present for their inpatient hospital stay with psychosis. These effects remained significant after controlling for mood episode polarity, suggesting that findings were not fully explained by the higher incidence of depression in the comorbid PTSD group. CONCLUSIONS: Patients with BD-I and comorbid PTSD appear to be a high risk population with need for enhanced monitoring of suicidality. Clinical implications of these findings are discussed.

Valued Living and Its Relationship to Medication Adherence in Patients with Bipolar and Comorbid Substance Use Disorders.

Bipolar disorder with comorbid substance abuse is associated with high rates of treatment nonadherence. Adherence interventions developed to date have had mixed effects in this population. Valued living (i.e., the consistency between a patient's personal values and daily actions) represents a potentially useful treatment target that may improve adherence. We investigated the relationship between valued living, medication adherence, symptoms, and functioning in a sample of 39 patients diagnosed with bipolar disorder and a comorbid substance use disorder. Results showed that greater values-action consistency explained a unique amount of variance (R change = 15.2%) in medication adherence even after controlling for symptom severity, functional impairment, and other reported reasons for nonadherence. Drug use and treatment beliefs also predicted nonadherence. Findings suggest that valued living should be investigated further as a potentially malleable treatment target in future adherence intervention research.

Clinical characteristics and medication use patterns among hospitalized patients admitted with psychotic vs nonpsychotic major depressive disorder.

BACKGROUND: In routine practice, major depressive disorder (MDD) with psychotic features often goes under-recognized and undertreated. Previous research has specified several demographic and clinical differences in MDD patients with psychotic features compared with those without psychosis in routine outpatient practice, but there is little systematic research in modern routine hospital settings. METHODS: We conducted a retrospective electronic medical records chart review of 1,314 patients diagnosed with MDD who were admitted consecutively to a major psychiatric hospital over a 1-year period. We examined the prevalence of psychotic features in the sample and investigated the differences in demographic variables, clinical characteristics, and medication use patterns among patients with and without psychosis. RESULTS: The prevalence of psychotic features was 13.2% in the current hospital sample. Patients with psychotic depression were more likely to be older, male, a member of a racial/ethnic minority, and have more medical comorbidities and certain Axis I disorders compared with nonpsychotic patients. In addition, patients with psychotic depression were more likely to be prescribed antipsychotics and hypnotics before admission. CONCLUSIONS: Several demographic and clinical characteristics differentiate MDD patients with psychosis from those without psychosis in hospital settings that may be helpful in identifying these patients. Comparisons with outpatient samples and treatments implications are discussed.

Demographic and clinical characteristics associated with comorbid cannabis use disorders (CUDs) in hospitalized patients with bipolar I disorder.

BACKGROUND: Published data suggest that cannabis use is associated with several negative consequences for individuals with bipolar disorder (BD), including new manic episode onset, psychosis, and functional disability. Yet much less is known about cannabis use disorders (CUDs) in this population, especially in more acutely symptomatic groups. METHODS: To evaluate correlates of CUD comorbidity in BD, a retrospective chart review was conducted for 230 adult patients with bipolar I disorder (BDI) who were admitted to a university-affiliated private psychiatric hospital. Using a computer algorithm, a hospital administrator extracted relevant demographic and clinical data from the electronic medical record for analysis. RESULTS: Thirty-six (16%) had a comorbid CUD. CUD comorbidity was significantly associated with younger age, manic/mixed episode polarity, presence of psychotic features, and comorbid nicotine dependence, alcohol use disorder (AUD), and other substance use disorders, but was associated with decreased likelihood of anxiety disorder comorbidity. With the exception of manic/mixed polarity and AUD comorbidity, results from multivariate analyses controlling for the presence of other SUDs were consistent with univariate findings. CONCLUSION: Patients with BD and comorbid CUDs appear to be a complex population with need for enhanced clinical monitoring. Given increasing public acceptance of cannabis use, and the limited availability of evidenced-based interventions targeted toward CUDs in BD, psychoeducation and other treatment development efforts appear to be warranted.

Longitudinal associations between interpersonal relationship functioning and mood episode severity in youth with bipolar disorder.

This study examined the longitudinal association between mood episode severity and relationships in youth with bipolar (BP) disorder. Participants were 413 Course and Outcome of Bipolar Youth study youth, aged 12.6 ± 3.3 years. Monthly ratings of relationships (parents, siblings, and friends) and mood episode severity were assessed by the Adolescent Longitudinal Interval Follow-up Evaluation Psychosocial Functioning Schedule and Psychiatric Rating Scales, on average, every 8.2 months over 5.1 years. Correlations examined whether participants with increased episode severity also reported poorer relationships and whether fluctuations in episode severity predicted fluctuations in relationships, and vice versa. Results indicated that participants with greater mood episode severity also had worse relationships. Longitudinally, participants had largely stable relationships. To the extent that there were associations, changes in parental relationships may precede changes in episode severity, although the magnitude of this finding was small. Findings have implications for relationship interventions in BP youth.

Longitudinal risk of suicide outcomes in people with severe mental illness following an emergency department visit and the effects of suicide prevention treatment.

BACKGROUND: Individuals with severe mental illness (SMI), including bipolar disorder (BD) and schizophrenia-spectrum disorders (SSD), are at high risk for suicide. However, suicide research often excludes individuals with SMI. The current research examined differences in suicide outcomes (i.e., suicide attempt or death) for adults with and without BD and SSD diagnoses following an emergency department (ED) visit and investigated the efficacy of the Coping Long Term with Active Suicide Program (CLASP) intervention in reducing suicide outcomes among people with SMI. METHODS: 1235 adults presenting with recent suicidality were recruited from 8 different EDs across the United States. Using a quasi-experimental, stepped wedge series design, participants were followed for 52-weeks with or without subsequent provision of CLASP. RESULTS: Participants in the SSD group and the BD group had significantly shorter time to and higher rate of suicide outcomes than participants with other psychiatric diagnoses in all study phases and in non-CLASP phases, respectively. Participants with BD receiving the CLASP intervention had significantly longer time to suicide outcomes than those not receiving CLASP; these differences were not observed among those with SSD. LIMITATIONS: Study limitations include self-reported psychiatric diagnosis, exclusion of homeless participants, and small sample size of participants with SSD. CONCLUSIONS: Participants with SMI were at higher risk for suicide outcomes than participants with other psychiatric diagnoses. CLASP was efficacious among those participants with BD. Psychiatric diagnosis may be a key indicator of prospective suicide risk. More intensive and specialized follow-up mental health treatment may be necessary for those with SSD.

Comparing Experiences of Community Reintegration Following Hospitalization Versus Jail Detention During a Mental Health Crisis.

BACKGROUND: This comparative qualitative study explores the experiences of individuals transitioning back to the community after institutionalization following an episode of acute suicidality. METHODS: Semi-structured interviews were conducted with eight individuals who had either been hospitalized (n=4) or incarcerated (n=4) during a mental health crisis that involved acute suicidality. Thematic analysis was conducted first within groups and then between groups. RESULTS: The findings reveal possible disparities in social determinants of mental health, family dynamics, treatment seeking, and coping mechanisms between groups. Social isolation, barriers to socioeconomic stability, and lack of treatment access were all found to be risk factors for poor outcomes during the vulnerable transition period and were experienced by participants in this limited sample. CONCLUSIONS: Individuals transitioning from the hospital after a suicide crisis may benefit from increased family involvement, follow-up, and social support at discharge. After a suicide crisis and incarceration, there is a significant need for housing and employment support to allow for mental health treatment seeking. Future research should build on the proof of concept for comparing the experiences of individuals across institutional settings.

Share of Adult Suicides After Recent Jail Release.

Importance: Although people released from jail have an elevated suicide risk, the potentially large proportion of this population in all adult suicides is unknown. Objective: To estimate what percentage of adults who died by suicide within 1 year or 2 years after jail release could be reached if the jail release triggered community suicide risk screening and prevention efforts. Design, Setting, and Participants: This cohort modeling study used estimates from meta-analyses and jail census counts instead of unit record data. The cohort included all adults who were released from US jails in 2019. Data analysis and calculations were performed between June 2021 and February 2024. Main Outcomes and Measures: The outcomes were percentage of total adult suicides within years 1 and 2 after jail release and associated crude mortality rates (CMRs), standardized mortality ratios (SMRs), and relative risks (RRs) of suicide in incarcerated vs not recently incarcerated adults. Taylor expansion formulas were used to calculate the variances of CMRs, SMRs, and other ratios. Random-effects restricted maximum likelihood meta-analyses were used to estimate suicide SMRs in postrelease years 1 and 2 from 10 jurisdictions. Alternate estimate was computed using the ratio of suicides after release to suicides while incarcerated. Results: Included in the analysis were 2019 estimates for 7 091 897 adults (2.8% of US adult population; 76.7% males and 23.3% females) who were released from incarceration at least once, typically after brief pretrial stays. The RR of suicide was 8.95 (95% CI, 7.21-10.69) within 1 year after jail release and 6.98 (95% CI, 4.21-9.76) across 2 years after release. A total of 27.2% (95% CI, 18.0%-41.7%) of all adult suicide deaths occurred in formerly incarcerated individuals within 2 years of jail release, and 19.9% (95% CI, 16.2%-24.1%) of all adult suicides occurred within 1 year of release (males: 23.3% [95% CI, 20.8%-25.6%]; females: 24.0% [95% CI, 19.7%-36.8%]). The alternate method yielded slightly larger estimates. Another 0.8% of adult suicide deaths occurred during jail stays. Conclusions and Relevance: This cohort modeling study found that adults who were released from incarceration at least once make up a large, concentrated population at greatly elevated risk for death by suicide; therefore, suicide prevention efforts focused on return to the community after jail release could reach many adults within 1 to 2 years of jail release, when suicide is likely to occur. Health systems could develop infrastructure to identify these high-risk adults and provide community-based suicide screening and prevention.