Association Between Adverse Social Determinants of Health and Suicide Death.

OBJECTIVE: The aim of this study was to identify adverse social determinants of health (SDoH) International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code prevalence among individuals who died by suicide and to examine associations between documented adverse SDoH and suicide. RESEARCH DESIGN: A case-control study using linked medical record, insurance claim, and mortality data from 2000 to 2015 obtained from 9 Mental Health Research Network-affiliated health systems. We included 3330 individuals who died by suicide and 333,000 randomly selected controls matched on index year and health system location. All individuals in the study (cases and controls) had at least 10 months of enrollment before the study index date. The index date for the study for each case and their matched controls was the suicide date for that given case. RESULTS: Adverse SDoH documentation was low; only 6.6% of cases had ≥1 documented adverse SDoH in the year before suicide. Any documented SDoH and several specific adverse SDoH categories were more frequent among cases than controls. Any documented adverse SDoH was associated with higher suicide odds [adjusted odds ratio (aOR)=2.76; 95% CI: 2.38-3.20], as was family alcoholism/drug addiction (aOR=18.23; 95% CI: 8.54-38.92), being an abuse victim/perpetrator (aOR=2.53; 95% CI: 1.99-3.21), other primary support group problems (aOR=1.91; 95% CI: 1.32-2.75), employment/occupational maladjustment problems (aOR=8.83; 95% CI: 5.62-13.87), housing/economic problems (aOR: 6.41; 95% CI: 4.47-9.19), legal problems (aOR=27.30; 95% CI: 12.35-60.33), and other psychosocial problems (aOR=2.58; 95% CI: 1.98-3.36). CONCLUSIONS: Although documented SDoH prevalence was low, several adverse SDoH were associated with increased suicide odds, supporting calls to increase SDoH documentation in medical records. This will improve understanding of SDoH prevalence and assist in identification and intervention among individuals at high suicide risk.

Factors associated with suicide mortality among reproductive age women: a case-control study.

OBJECTIVE: Examine demographic, psychosocial, pregnancy-related, and healthcare utilisation factors associated with suicide mortality among reproductive age women. METHODS: Data from nine health care systems in the Mental Health Research Network were included. A case-control study design was used in which 290 reproductive age women who died by suicide (cases) from 2000 to 2015 were matched with 2,900 reproductive age women from the same healthcare system who did not die by suicide (controls). Conditional logistic regression was used to analyse associations between patient characteristics and suicide. RESULTS: Women of reproductive age who died by suicide were more likely to have mental health (aOR = 7.08, 95% CI: 5.17, 9.71) or substance use disorders (aOR = 3.16, 95% CI: 2.19, 4.56) and to have visited the emergency department in the year prior to index date (aOR = 3.47, 95% CI: 2.50, 4.80). Non-Hispanic White women (aOR = 0.70, 95% CI: 0.51, 0.97) and perinatal (pregnant or postpartum) women were less likely to have died by suicide (aOR = 0.27, 95% CI: 0.13, 0.58). CONCLUSIONS: Reproductive age women with mental health and/or substance use disorders, prior emergency department encounters, or who are of racial or ethnic minority status were at increased risk of suicide mortality and may benefit from routine screening and monitoring. Future research should further examine the relationship between pregnancy-related factors and suicide mortality.

Addressing Immigration-Related Stress in a Culturally Adapted Parenting Intervention for Mexican-Origin Immigrants: Initial Positive Effects and Key Areas of Improvement.

Culturally adapted evidence-based parenting interventions constitute a key strategy to reduce widespread mental health disparities experienced by Latinx populations throughout the United States. Most recently, the relevance of culturally adapted parenting interventions has become more prominent as vulnerable Latinx populations are exposed to considerable contextual stressors resulting from an increasingly anti-immigration climate in the country. The current study was embedded within a larger NIMH-funded investigation, aimed at contrasting the differential impact of two culturally adapted versions of the evidence-based parenting intervention known as GenerationPMTO©. Specifically, a sample of low-income Mexican-origin immigrants was exposed either to a culturally adapted version of GenerationPMTO primarily focused on parent training components, or to an enhanced culturally adapted version in which parenting components were complemented by sessions focused on immigration-related challenges. The sample for the study consisted of 103 Mexican-origin immigrant families (190 individual parents). Descriptive analysis and generalized estimating equations (GEEs) indicated that exposure to the enhanced intervention, which included context- and culture-specific sessions, resulted in specific benefits for parents. However, the magnitude of the impact was not uniform for mothers and fathers and differed according to the type of immigration-related stress being examined (i.e., intrafamilial vs. extrafamilial stress). Overall, findings indicate the relevance of overtly addressing contextual (e.g., discrimination) and cultural challenges in culturally adapted interventions, as well as the need to increase precision according to the extent to which immigration-related stressors impact immigrant mothers and fathers in common and contrasting ways. Implications for family therapy practice and research are discussed.

Las intervenciones basadas en evidencia, dirigidas a padres y adaptadas a la cultura son una estrategia clave para reducir las desigualdades en salud mental generalizadas que las poblaciones de latin@s experimentan en los Estados Unidos. Más recientemente, la relevancia de intervenciones dirigidas a padres adaptadas a la cultura ha adquirido más peso al estar las poblaciones de latin@s expuestas a factores estresantes contextuales considerables como resultado de un ambiente cada vez más contrario a la inmigración en el país. Este estudio fue incluido dentro de una investigación de mayor escala financiada por NIMH cuyo objetivo era contrastar el impacto diferencial de dos versiones adaptadas a la cultura de la intervención basada en evidencia y dirigida a padres conocida como GenerationPMTO© . En específico, se expuso una muestra de inmigrantes de origen mexicano de bajo ingreso, o a una versión de GenerationPMTO adaptada a la cultura y enfocada principalmente en elementos de entrenamiento de padres, o a una versión reforzada adaptada a la cultura en la cual los elementos de padres se complementaron con sesiones enfocadas en retos asociados a la inmigración. La muestra para el estudio consistió de 103 familias inmigrantes de origen mexicano (190 padres individuales). Análisis descriptivos y ecuaciones de estimación generalizadas indicaron que la exposición una intervención reforzada, que incluía sesiones contextual y culturalmente específicas, generaron beneficios específicos para los padres. Sin embargo, la magnitud del impacto no fue uniforme para madres y padres y fue distinta según el tipo de estrés por inmigración examinado (p.ej., estrés intrafamiliar versus estrés extrafamiliar). En general, los hallazgos indican la relevancia de enfrentar abiertamente retos contextuales (p.ej., discriminación) y culturales en intervenciones adaptadas a la cultura, así como la necesidad de aumentar la precisión conforme a cómo los factores estresantes asociados a la inmigración afectan a madres y padres inmigrantes de la misma y diferentes maneras. Se discuten las implicaciones para la práctica e investigación de terapia familiar.

Variation in patterns of health care before suicide: A population case-control study.

BACKGROUND: The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention. OBJECTIVE: To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population. DESIGN: Case-Control Study. SETTING: Eight healthcare systems across the United States. PARTICIPANTS: 2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation. MEASUREMENTS: Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls. RESULTS: Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide. LIMITATIONS: Participant race/ethnicity was not available. The sample did not include uninsured individuals. CONCLUSIONS: This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.

Psychiatric comorbidity and Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and other drug treatment initiation and engagement across 7 health care systems.

Background: Psychiatric comorbidity is common among patients with alcohol and other drug (AOD) use disorders. To better understand how psychiatric comorbidity influences AOD treatment access in health care systems, the present study examined treatment initiation and engagement among a large, diverse sample of patients with comorbid psychiatric and AOD use disorders. Methods: This study utilized data from a multisite observational study examining Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement in treatment (IET) among patients with AOD use disorders from 7 health care systems. Participants were aged 18 or older with at least 1 AOD index diagnosis between October 1, 2014, and August 15, 2015. Data elements extracted from electronic health records and insurance claims data included patient demographic characteristics, ICD-9 (International Classification of Diseases, Ninth Revision) diagnostic codes, and procedure codes. Descriptive analyses and multivariate logistic regression models were used to examine the relationship between patient-level factors and IET measures. Results: Across health care systems, out of a total of 86,565 patients who had at least 1 AOD index diagnosis during the study period, 66.2% (n = 57,335) patients also had a comorbid psychiatric disorder. Among patients with a comorbid psychiatric disorder, 34.9% (n = 19,998) initiated AOD treatment, and of those, 10.3% (n = 2,060) engaged in treatment. After adjusting for age, sex, and race/ethnicity, patients with comorbid psychiatric disorders were more likely to initiate (odds ratio [OR] = 3.20, 95% confidence interval [CI] = 3.08, 3.32) but no more likely to engage (OR = 0.56, 95% CI = 0.51, 0.61) in AOD treatment, compared with those without a comorbid psychiatric disorder. Conclusions: Findings suggest that identification of comorbid psychiatric disorders may increase initiation in AOD treatment. However, innovative efforts are needed to enhance treatment engagement both generally and especially for individuals without diagnosed psychiatric conditions.

A Culturally Adapted Intervention for Mexican-Origin Parents of Adolescents: The Need to Overtly Address Culture and Discrimination in Evidence-Based Practice.

Latino/a populations in the United States are negatively impacted by widespread mental health disparities. Although the dissemination of culturally relevant parent training (PT) programs constitutes an alternative to address this problem, there is a limited number of efficacious culturally adapted PT prevention interventions for low-income Latino/a immigrant families with adolescents. The current manuscript describes the level of acceptability of a version of the GenerationPMTO® intervention adapted for Latino/a immigrant families, with an explicit focus on immigration-related challenges, discrimination, and promotion of biculturalism. Qualitative reports were provided by 39 immigrant parents who successfully completed the prevention parenting program. The majority of these parents self-identified as Mexican-origin. According to qualitative findings, participants reported overall high satisfaction with immigration and culture-specific components. Parents also expressed high satisfaction with the core GenerationPMTO parenting components and provided specific recommendations for improving the intervention. Current findings indicate the need to adhere to the core components that account for the effectiveness of PT interventions. Equally important is to thoroughly adapt PT interventions according to the cultural values and experiences that are relevant to target populations, as well as to overtly address experiences of discrimination that negatively impact underserved Mexican-origin immigrant families. Due to the exploratory nature of this study, the efficacy and effectiveness of the adapted prevention intervention remains to be established in empirical research.

Las poblaciones latinas de los Estados Unidos están afectadas negativamente por desigualdades generalizadas en el área de salud mental. Aunque la difusión de programas de capacitación para padres culturalmente pertinentes constituye una alternativa para abordar este problema, existe un número limitado de capacitaciones para padres con intervenciones preventivas adaptadas culturalmente que son eficaces para familias inmigrantes latinas con adolescentes de bajos recursos. El presente manuscrito describe el nivel de aceptabilidad de una versión de la intervención GenerationPMTO® adaptada para familias inmigrantes latinas, que hace hincapié específicamente en dificultades relacionadas con la inmigración, la discriminación y la promoción del biculturalismo. Treinta y nueve padres inmigrantes que completaron satisfactoriamente el programa preventivo sobre crianza proporcionaron informes cualitativos. La mayoría de estos padres se autoidentificaron como de origen mexicano. De acuerdo con los resultados cualitativos, los participantes informaron una alta satisfacción en general con la inmigración y los componentes específicos de la cultura. Los padres también expresaron una alta satisfacción con los componentes principales relativos a la crianza de GenerationPMTO y ofrecieron recomendaciones específicas para mejorar la intervención. Los resultados actuales indican la necesidad de cumplir con los componentes principales que justifican la eficacia real de las intervenciones de capacitación para padres. Es igualmente importante adaptar totalmente las intervenciones de capacitación para padres de acuerdo con los valores culturales y las experiencias que son relevantes para las poblaciones objetivo, así como abordar expresamente las experiencias de discriminación que afectan negativamente a las familias inmigrantes de bajos recursos de origen mexicano. Debido a la índole exploratoria de este estudio, la eficacia real y la eficacia teórica de la intervención de prevención adaptada quedan por demostrarse en la investigación empírica.

Prenatal Infection and Autism Spectrum Disorders in Childhood: A Population-Based Case-Control Study in Taiwan.

BACKGROUND: Infection in pregnancy has long been linked with negative postnatal development and health. This study aims to assess the association between prenatal infections and autism spectrum disorders (ASDs) across three trimesters and to probe possible sex heterogeneity in such link. METHOD: A total of 4184 children with incident ASDs and 16,734 matched children were identified from the 2000-2007 National Health Insurance Research Database. For each child, information pertaining to the mother's infection during pregnancy, sociodemographics, and medical history was retrieved from healthcare records. Conditional logistic analyses were carried out to estimate the strength of associations with adjustment for multiple comparisons. RESULT: Pooled analyses demonstrated that having two or more outpatient visits for genital infection [adjusted odds ratio (aOR): 1.34; 95% confidence interval (95% CI) 1.12, 1.60; false discovery rate (FDR) < 0.01] and bacterial infection (aOR: 1.24; 95% CI 1.06, 1.43; FDR < 0.05) in the third trimester were slightly associated with increased risk of ASDs. No statistically significant sex differences were found. CONCLUSION: The present study contributes updated population-based evidence about the connection between prenatal infection and ASDs. Potential effect of bacterial and genital tract infections during the third trimester on risk of ASDs warrants further exploration.

The epidemiology of primary headache disorders in Zambia: a population-based door-to-door survey.

BACKGROUND: Little is known of the epidemiology of primary headache disorders in sub-Saharan Africa. We performed a population-based survey in Zambia using methods previously tested in multiple other countries. METHODS: This cross-sectional survey was conducted by visiting households unannounced, using cluster-randomized sampling, in the mostly urban Lusaka Province and mostly rural Southern Province. Within clusters, households were selected randomly, as was one adult member (18-65 years old) of each selected household. A structured questionnaire, translated into the local languages, was administered face-to-face by trained interviewers. Demographic enquiry was followed by diagnostic questions based on ICHD-II criteria. A random sub-sample of participants were invited for subsequent physician-interview to validate the diagnostic part of the questionnaire. RESULTS: Of 1,134 eligible household members contacted, 1,085 (450 male, 887 urban) consented to interview (refusal rate 4.3%). Others who had been selected but remained unavailable on three visits were not counted as refusals since their reasons were unknown, but gave rise to gender biases, being mostly male in urban areas and mostly female in rural areas. Statistical correction was applied. Adjusted for gender and habitation (urban/rural), the 1-year prevalence of any headache was 61.6%, of migraine 22.9%, of tension-type headache (TTH) 22.8%, of headache on ≥15 days/month 11.5% and of probable medication-overuse headache (pMOH) 7.1%. The adjusted point-prevalence of any headache (headache yesterday) was 19.1%. There was a small proportion (5.3%) of unclassified headache, some of which may have been secondary. The overwhelmingly strong association was between urban dwelling and pMOH (OR: 8.6; P=0.0001), with an urban prevalence of 14.5% (gender-adjusted). Validation of the questionnaire was limited by participants' reluctance to present for physician review, substantial delays in doing so and major self-selection bias among those who did. These were unavoidable problems in resource-limited Zambia. CONCLUSIONS: Primary headache disorders, common in high-income countries, are at least as prevalent in Zambia, a sub-Saharan African country. The selectively urban problem of pMOH seems likely to reflect ready availability of non-prescription analgesics, without easy access to professional health care for headache or any focused public-health education regarding correct usage of analgesics or the dangers of their overuse.

Psychotherapy Engagement Before and After a Rapid Transition to Telehealth During COVID-19 for Older Adults With Dementia.

Objective: To understand the impact of the transition to telehealth during COVID-19 on psychotherapy visits for patients with dementia. Method: Retrospective study of older adults with dementia who had at least one psychotherapy visit in the 9 months before and after the onset of COVID-19 at 3 U.S. health systems. Care disruptions were gaps of 45+ days. Descriptive statistics and logistic mixed-effects models examined factors associated with care disruption. Results: 4953 patients with dementia made 19,902 psychotherapy visits. Gaps in psychotherapy were less frequent during COVID-19 (29.4%) than before (48.9%), with the odds of a patient experiencing a care disruption during COVID-19 0.54 times the odds prior to COVID-19 (95% CI: 0.50-0.59). Almost all patient subgroups had lower adjusted odds of care disruption during COVID-19. Discussion: There were fewer disruptions in psychotherapy care following the rapid shift to virtual care. Telehealth may be a viable option for patients with dementia.

Risk factors for not reaching minimal clinically important difference at 90 days and 1 year after elective lumbar spine surgery: a cohort study.

OBJECTIVE: Patient-perceived functional improvement is a core metric in lumbar surgery for degenerative disease. It is important to identify both modifiable and nonmodifiable risk factors that can be evaluated and possibly optimized prior to elective surgery. This case-control study was designed to study risk factors for not achieving the minimal clinically important difference (MCID) in Patient-Reported Outcomes Measurement Information System Function 4-item Short Form (PROMIS PF) score. METHODS: The authors queried the Michigan Spine Surgery Improvement Collaborative database to identify patients who underwent elective lumbar surgical procedures with PROMIS PF scores. Cases were divided into two cohorts based on whether patients achieved MCID at 90 days and 1 year after surgery. Patient characteristics and operative details were analyzed as potential risk factors. RESULTS: The authors captured 10,922 patients for 90-day follow-up and 4453 patients (40.8%) did not reach MCID. At the 1-year follow-up period, 7780 patients were identified and 2941 patients (37.8%) did not achieve MCID. The significant demographic characteristic-adjusted relative risks (RRs) for both groups (RR 90 day, RR 1 year) included the following: symptom duration > 1 year (1.34, 1.41); previous spine surgery (1.25, 1.30); African American descent (1.25, 1.20); chronic opiate use (1.23, 1.25); and less than high school education (1.20, 1.34). Independent ambulatory status (0.83, 0.88) and private insurance (0.91, 0.85) were associated with higher likelihood of reaching MCID at 90 days and 1 year, respectively. CONCLUSIONS: Several key unique demographic risk factors were identified in this cohort study that precluded optimal postoperative functional outcomes after elective lumbar spine surgery. With this information, appropriate preoperative counseling can be administered to assist in shaping patient expectations.

Recorded Diagnosis of Gender Identity Disorder Is Strongly Associated with Suicide Mortality.

We assessed the association between gender identity disorder (GID) diagnosis and suicide in a retrospective case-control study (N=300,364) from nine health care systems between 2000 and 2015. Adjusting for age and sex, the odds ratio for GID was 18.6 (95% confidence interval 7.0-49.5). Adjusting additionally for comorbid psychiatric diagnoses, the odds ratio was 4.75 (1.78-12.68), higher than depressive (3.96, 3.64-4.31), alcohol use (3.42, 3.04-3.84), bipolar (2.42, 2.10-2.80), and psychotic disorders (1.44, 1.22-1.70). These U.S. data support prior research demonstrating increased suicide risk among patients with diagnosed GID, who may benefit from targeted screening and intervention within health care systems.

The rapid shift to virtual mental health care: Examining psychotherapy disruption by rurality status.

BACKGROUND: Given the low usage of virtual health care prior to the COVID-19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID-19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations. METHODS: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID-19 pandemic onset. RESULTS: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre- to post-COVID-19 onset (32.5-16.0% and 44.7-24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in-person visits compared with the rural cohort (96.6-45.0 vs. 98.0-66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre- to post-COVID-19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption. CONCLUSIONS: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits).

Increasing pre-exposure prophylaxis (PrEP) in primary care: A study protocol for a multi-level intervention using the multiphase optimization strategy (MOST) framework.

BACKGROUND: In the United States, over 1.2 million people are living with HIV. This disease disproportionately affects men who have sex with men (MSM), people of color, youth and young adults, and transgender individuals. Pre-exposure prophylaxis (PrEP) is an effective HIV prevention method. Barriers exist for both primary care providers (PCPs) to prescribe PrEP and prevent patients from initiating PrEP. METHODS: This study, MOST: PrEP, follows the multiphase optimization strategy (MOST) framework. The purpose is to identify a multi-level intervention among patients and PCPs to increase PrEP prescriptions in primary care. First, feedback will be obtained from providers and patients via focus groups, then, suggestions related to the context-specific (provider and individual level) factors of intervention component delivery will be incorporated. Subsequently, a rigorous experiment will be conducted using a 24 factorial design focusing on priority populations for PrEP initiation. Provider components include computer-based simulation training and a best practice alert. Patient components include a tailored PrEP educational video and HIV risk assessment. Finally, the facilitators and barriers to implementing the intervention components will be qualitatively examined. CONCLUSION: In this protocol paper, we describe the one of the first known multilevel MOST optimization trial in healthcare. Intervention components are to be delivered to patients and providers in a large healthcare system, based in an HIV Ending the Epidemic priority jurisdiction. If effective, this multi-level approach could be disseminated to providers and patients in other large healthcare systems to make a significant impact on HIV prevention.

Psychotherapy Disruption Before and After the Transition to Virtual Mental Health Care Induced by the COVID-19 Pandemic.

OBJECTIVE: This study aimed to examine population-level disruption in psychotherapy before and after the rapid shift to virtual mental health care induced by the onset of the COVID-19 pandemic in the United States. METHODS: This retrospective study used electronic health record and insurance claims data from three U.S. health systems. The sample included 110,089 patients with mental health conditions who were members of the health systems' affiliated health plans and attended at least two psychotherapy visits from June 14, 2019, through December 15, 2020. Data were subdivided into two 9-month periods (before vs. after COVID-19 onset, defined in this study as March 14, 2020). Psychotherapy visits were measured via health records and categorized as in person or virtual. Disruption was defined as a gap of >45 days between visits. RESULTS: Visits in the preonset period were almost exclusively in person (97%), whereas over half of visits in the postonset period were virtual (52%). Approximately 35% of psychotherapy visits were followed by a disruption in the preonset period, compared with 18% in the postonset period. Disruption continued to be less common (adjusted OR=0.45) during the postonset period after adjustment for visit, mental health, and sociodemographic factors. The magnitude of the difference in disruption between periods was homogeneous across sociodemographic characteristics but heterogeneous across psychiatric diagnoses. CONCLUSIONS: This study found fewer population-level disruptions in psychotherapy receipt after rapid transition to virtual mental health care following COVID-19 onset. These data support the continued availability of virtual psychotherapy.

Racial-Ethnic Differences in Receipt of Past-Year Health Care Services Among Suicide Decedents: A Case-Control Study.

OBJECTIVE: Suicide remains an urgent public health crisis. Although some sociodemographic characteristics are associated with greater suicide risk in the general population, it is unclear whether individuals utilizing health care in the United States have similar suicide incidence patterns. The authors examined whether race-ethnicity is associated with suicide death among patients seeking health care and investigated health care utilization patterns. METHODS: Data were collected from electronic health records and government mortality records for patients seeking health care across nine health care systems in the United States. Patients who died by suicide (N=1,935) were matched with patients in a control group (N=19,350) within each health care system. RESULTS: Patients who died by suicide were significantly more likely to be White, older, male, living in low-education areas, living in rural areas, or diagnosed as having mental health conditions or were significantly less likely to have commercial insurance (p<0.05). Among most racial-ethnic groups, those who died by suicide had a higher number of past-year mental health, primary care, and total health care visits; for American Indian/Alaska Native patients, the number of health care visits tended to be lower among suicide decedents. CONCLUSIONS: These findings suggest that higher past-year health care utilization was associated with increased likelihood of suicide death across several racial-ethnic groups. This observation underscores the need for identifying and managing suicide risk in health care settings, including outside of mental health visits, among most racial-ethnic groups.

Development and Validation of Electronic Health Record Measures of Safety Planning Practices as Part of Zero Suicide Implementation.

OBJECTIVE: Safety planning for suicide prevention is an important quality metric for Zero Suicide implementation. We describe the development, validation, and application of electronic health record (EHR) programs to measure uptake of safety planning practices across six integrated healthcare systems as part of a Zero Suicide evaluation study. METHODS: Safety planning was documented in narrative notes and structured EHR templates using the Stanley Brown Safety Planning Intervention (SBSPI) in response to a high-risk cutoff score on the Columbia Suicide Severity Rating Scale (CSSRS). Natural Language Processing (NLP) metrics were developed and validated using chart review to characterize practices documented in narrative notes. We applied NLP to measure frequency of documentation in the narrative text and standard programming methods to examine structured SBSPI templates from 2010-2022. RESULTS: Chart reviews found three safety planning practices documented in narrative notes that were delivered to at least half of patients at risk: professional contacts, lethal means counseling for firearms, and lethal means counseling for medication access/storage. NLP methods were developed to identify these practices in clinical text with high levels of accuracy (Sensitivity, Specificity, & PPV ≥ 82%). Among visits with a high-risk CSSRS, 40% (Range 2-73% by health system) had an SBSPI template within 1 year of implementation. CONCLUSIONS: This is one of the first reports describing development of measures that leverage electronic health records to track use of suicide prevention safety plans. There are opportunities to use the methods developed here in future evaluations of safety planning.

Measuring safety planning delivery in real-world systems to understand quality of suicide prevention care is challenging.Natural Language Processing (NLP) methods effectively identified some safety planning practices in electronic health records (EHR) from all notes ensuring a comprehensive measurement, but NLP will require updates/testing for local documentation practices.Structured safety planning templates in the EHR using the Stanley Brown Safety Planning Intervention improve ease and accuracy of measurement but may be less comprehensive than NLP for capturing all instances of safety planning documentation.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation.

OBJECTIVE: The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings. METHODS: Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated. RESULTS: In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care. CONCLUSIONS: Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Suicide attempts after bariatric surgery: comparison to a nonsurgical cohort of individuals with severe obesity.

BACKGROUND: The rate of suicide is higher among individuals following bariatric surgery compared with the general population; however, it is not clear whether risk is associated with bariatric surgery beyond having severe obesity. OBJECTIVE: To compare the risk of a suicide attempt among those who had bariatric surgery versus a nonsurgical cohort with severe obesity. SETTING: Aggregate count data were collected from 5 healthcare systems. METHODS: Individuals were identified in the surgical cohort if they underwent bariatric surgery between 2009 and 2017 (n = 35,522) and then were compared with a cohort of individuals with severe obesity who never had bariatric surgery (n = 691,752). Suicide attempts were identified after study enrollment date using International Classification of Diseases, Ninth and Tenth Editions (ICD-9 and ICD-10) diagnosis codes from 2009 to 2021. RESULTS: The relative risk of a suicide attempt was 64% higher in the cohort with bariatric surgery than that of the nonsurgical cohort (2.2% versus 1.3%; relative risk = 1.64; 95% CI, 1.53-1.76). Within the cohort with bariatric surgery, suicide attempts were more common among the 18- to 39-year age group (P < .001), women (P = .002), Hawaiian-Pacific Islanders (P < .001), those with Medicaid insurance (P < .001), and those with a documented mental health condition at baseline (in the previous 2 years; P < .001). CONCLUSIONS: The relative risk of suicide attempts was higher among those who underwent bariatric surgery compared with a nonsurgical cohort, though absolute risk remained low. Providers should be aware of this increased risk. Screening for suicide risk after bariatric surgery may be useful to identify high-risk individuals.

Health Diagnoses and Service Utilization in the Year Before Youth and Young Adult Suicide.

OBJECTIVE: Suicide rates among young people are rising. Health care visits provide opportunities for identification and intervention, yet studies have been limited by small or circumscribed samples. This study sought to expand the knowledge base by examining health care encounters and diagnoses among young people who later died by suicide. METHODS: This case-control study examined diagnoses of mental and general medical disorders and health care utilization in the 30 and 365 days before suicide death in nine large U.S. health care systems. Data (years 2000-2015) from 445 suicide decedents ages 10-24 years were matched with data from 4,450 control group patients. RESULTS: Suicide decedents were more likely to have at least one mental disorder diagnosis (51% vs. 16%; adjusted OR [AOR]=5.74, 95% CI=4.60-7.18) and had higher rates of nearly all mental health conditions. Substance use disorders were common (12%) and more likely (AOR=8.50, 95% CI=5.53-13.06) among suicide decedents. More than one in three (42%) suicide decedents had a health care visit in the month before death, and nearly all (88%) had a visit in the previous year. CONCLUSIONS: Despite the greater likelihood of suicide associated with mental disorder diagnoses, such disorders were present among only 51% of suicide decedents. High rates of health care utilization among suicide decedents indicate a need for improving identification of mental health conditions and suicide risk across the health care system. Increased substance use screening may help identify youths at high risk because substance use disorders were significantly more prevalent and likely among suicide decedents.