Literature Collection

OBJECTIVE: Patients who die by suicide are often seen in primary care settings in the weeks leading to their death. There has been little study of brief interventions to prevent suicide in these settings. METHOD: We conducted a virtual, pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients who presented to a primary care mental health walk-in clinic for a new mental health intake appointment and were at risk for suicide. Our primary aim was to assess feasibility. We measured our ability to recruit 20 patients. We measured the proportion of enrolled patients who completed all study assessments. We assessed adherence among patients assigned to VA BIC. RESULTS: Twenty patients were enrolled and 95% (N = 19) completed all study assessments. Among the 10 patients assigned to VA BIC, 90% (N = 9) of patients completed all required intervention visits, and 100% (N = 10) completed ≥70% of the required interventions visits. CONCLUSION: It is feasible to conduct a virtual trial of VA BIC in an integrated care setting. Future research should clarify the role of VA BIC as a suicide prevention strategy in integrated care settings using an adequately powered design. CLINICAL TRIAL REGISTRATION: NCT04054947.

Youth internalizing symptoms (i.e., depression and anxiety), suicide ideation and attempts have been rising in recent years, including among Hispanics. Disparities in mental healthcare are concerning and require intervention, ideally prevention or early intervention. Familias Unidas is a culturally-syntonic, family-centered intervention effective in reducing youth drug use and sexual risk, with evidence of unanticipated effects on internalizing symptoms. This paper describes the systematic process used to adapt the eHealth version of the Familias Unidas intervention to more directly address internalizing symptoms and suicide risk in preparation for an effectiveness-implementation hybrid trial for youth with elevated internalizing symptoms, a history of suicide ideation/attempts, or poor parent-youth communication. The resulting eHealth Familias Unidas Mental Health intervention is described. Guided by a 4-phase framework, the steps in the adaptation process involved: assessment of the community and intervention delivery setting (pediatric primary care clinics); integration of previous intervention research, including intervention mechanisms of action; and expert and community consultation via focus groups. Focus group analyses showed that youth and parents perceived that the intervention was helpful. Their feedback was categorized into themes that were used to directly target mental health by addressing technology use, parent mental health, and social support. Effective and scalable preventive interventions are needed to address mental health disparities. The systematic adaptation process described in this paper is an efficient approach to expanding interventions while maintaining known, empirical and theoretical mechanisms of action. Findings from the ongoing effectiveness-implementation trial will be critical.; Mental health symptoms and suicide ideation and attempts have been increasing for several years. Disparities in quality and access to mental healthcare indicate that Hispanic and socioeconomically disadvantaged youth need accessible and targeted interventions, ideally preventive and early interventions. Our team adapted an existing, evidence-based prevention program for Hispanic families to specifically and directly address youth mental health to be delivered in primary healthcare settings. This paper describes the adaptation framework and steps taken to adapt the original program that was developed and tested for drug use and sexual risk behaviors, with the purpose of additionally addressing depression, anxiety, and suicide ideation and attempts. We subsequently describe the adapted program- eHealth Familias Unidas Mental Health- and discuss how it is currently being implemented and evaluated in primary healthcare settings. The paper provides information and an example of how other research teams can systematically adapt an intervention using insights from the peer-reviewed literature, participants, primary care clinic staff, and experts in youth mental health.; eng

IMPORTANCE: Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected. OBJECTIVE: To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023. EXPOSURES: Demographic, diagnostic, treatment, and health care utilization characteristics. MAIN OUTCOME(S) AND MEASURE(S): Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide. RESULTS: The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days. CONCLUSIONS AND RELEVANCE: Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

The relationship between adverse childhood experiences (ACEs) and lifetime suicide attempts among high-risk Latine remains underexplored. This study examined the understudied intersections of ACEs, Latine ethnicity, and lifetime suicide attempts among high-risk individuals entering behavioral health treatment. This secondary analysis involved 299 Latine adults entering integrated behavioral health treatment. A multivariate logistic regression analysis was conducted to assess ACE scores and lifetime suicide attempts, controlling for social drivers of health such as housing, employment, and education. Key findings show that 28% of the sample reported lifetime suicide attempts. Multivariate analysis found that for every unit increase in ACE scores, the odds of lifetime suicide attempts increased by 21% (OR = 1.21, 95% CI [1.07, 1.38]). Additionally, those who reported being unemployed were 2.39 times more likely to have attempted suicide in their lifetime compared to their counterparts, and those who self-identified as Puerto Rican were 2.04 times more likely to report a lifetime suicide attempt. This study underscores the importance of screening for ACEs and providing services such as employment training, trauma-informed care, and suicide prevention services to Latine individuals, especially those who identify as Puerto Rican. Additional research needs to be conducted on the effects of colonization on the health and mental health of individuals of Puerto Rican descent.

OBJECTIVE: To examine the short and long term adverse physical and mental health outcomes, all cause mortality, and natural and unnatural deaths in individuals with a diagnosis of an eating disorder compared with a matched cohort without these disorders. DESIGN: Primary care cohort study with linked secondary care and mortality records. SETTING: English primary care electronic health records from the Clinical Practice Research Datalink, linked to Hospital Episode Statistics for hospital records and the Office for National Statistics for mortality data, 1 January 1998 to 30 November 2018. PARTICIPANTS: 24 709 patients, aged 10-44 years, with a diagnosis of an eating disorder, matched by age, sex, and general practice with up to 20 comparators without an eating disorder (n=493 001). Disorders examined were anorexia nervosa, bulimia nervosa, binge eating disorder, and all other types combined. MAIN OUTCOME MEASURES: Physical health conditions, mental health conditions, and mortality (all cause and cause specific). Hazard ratios and cumulative incidences were calculated to compare outcomes. RESULTS: Individuals with eating disorders had substantially higher risks for coded adverse physical, mental health, and mortality outcomes. Within the first year after a diagnosis of an eating disorder, these individuals were six times more likely to develop renal failure (hazard ratio 6.0, 95% confidence interval (CI) 4.2 to 8.5; excess 15 events per 10 000 individuals, 95% CI 11 to 21) and nearly seven times more likely to develop liver disease (hazard ratio 6.7, 3.8 to 11.7; excess 6 per 10 000, 4 to 11). Risks were still increased after five years (hazard ratio for renal failure 2.6, 95% CI 2.0 to 3.4; hazard ratio for liver disease 3.7, 2.3 to 6.0), with cumulative excesses of 110 (95% CI 87 to 136) and 26 (17 to 39) per 10 000 individuals at 10 years for renal failure and liver disease, respectively. Mental health coded outcomes were markedly increased in the short term for depression (hazard ratio 7.3, 95% CI 6.6 to 8.1; excess 596 per 10 000 individuals, 95% CI 545 to 650) and self-harm (hazard ratio 9.4, 8.2 to 10.7; excess 309 per 10 000, 279 to 342) at one year. Mortality was also higher: within the first year, the risk of all cause mortality was more than fourfold (hazard ratio 4.6, 95% CI 3.1 to 7.0; excess 10 per 10 000 individuals, 95% CI 7 to 15) and was fivefold for unnatural deaths (hazard ratio 5.1, 2.2 to 11.9; excess 30 per 100 000, 13 to 61). Risks persisted beyond five years (hazard ratio 2.2, 95% CI 1.8 to 2.7 for all cause mortality; hazard ratio 3.2, 1.9 to 5.4 for unnatural deaths), corresponding to 43 (95% CI 33 to 54) excess all cause deaths per 10 000 individuals and 184 (125 to 262) excess unnatural deaths per 100 000 at five years. At 10 years, 95 (95% CI 75 to 118) excess all cause deaths per 10 000 individuals and 341 (236 to 479) unnatural deaths per 100 000 were found. Suicide risk was 13.7 times higher in the first year (95% CI 4.8 to 38.8; 24 excess deaths per 100 000 individuals, 95% CI 10 to 52) and remained increased at 10 years (hazard ratio 2.7, 1.3 to 5.8), accounting for 169 (103 to 266) excess deaths per 100 000 individuals. CONCLUSIONS: Individuals with a diagnosis of an eating disorder derived from coded primary care data were more likely to have recorded adverse physical and mental health outcomes, as well as higher mortality than individuals without an eating disorder matched by age, sex, and general practice. These findings highlight the need for integrated care strategies that deal with both the physical and mental health dimensions in the management of individuals with eating disorders.

BACKGROUND: Around 1 in 7 people in India are impacted by mental illness. The treatment gap for people with mental disorders is as high as 75-95%. Health care systems, especially in rural regions in India, face substantial challenges to address these gaps in care, and innovative strategies are needed. METHODS: We hypothesise that an intervention involving an anti-stigma campaign and a mobile-technology-based electronic decision support system will result in reduced stigma and improved mental health for adults at high risk of common mental disorders. It will be implemented as a parallel-group cluster randomised, controlled trial in 44 primary health centre clusters servicing 133 villages in rural Andhra Pradesh and Haryana. Adults aged ≥ 18 years will be screened for depression, anxiety and suicide based on Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorders (GAD-7) scores. Two evaluation cohorts will be derived-a high-risk cohort with elevated PHQ-9, GAD-7 or suicide risk and a non-high-risk cohort comprising an equal number of people not at elevated risk based on these scores. Outcome analyses will be conducted blinded to intervention allocation. EXPECTED OUTCOMES: The primary study outcome is the difference in mean behaviour scores at 12 months in the combined 'high-risk' and 'non-high-risk' cohort and the mean difference in PHQ-9 scores at 12 months in the 'high-risk' cohort. Secondary outcomes include depression and anxiety remission rates in the high-risk cohort at 6 and 12 months, the proportion of high-risk individuals who have visited a doctor at least once in the previous 12 months, and change from baseline in mean stigma, mental health knowledge and attitude scores in the combined non-high-risk and high-risk cohort. Trial outcomes will be accompanied by detailed economic and process evaluations. SIGNIFICANCE: The findings are likely to inform policy on a low-cost scalable solution to destigmatise common mental disorders and reduce the treatment gap for under-served populations in low-and middle-income country settings. TRIAL REGISTRATION: Clinical Trial Registry India CTRI/2018/08/015355 . Registered on 16 August 2018.

Children with chronic diseases, including pulmonary hypertension (PH), have an increased risk of anxiety and depression (AD), impacting mental health (MH), and quality of life (QoL). We sought to characterize the prevalence of AD in pediatric PH and identify associated factors. We developed a prospective cross-sectional study with 10 Pediatric Pulmonary Hypertension Network (PPHNet) centers. Eligible subjects aged 12-21, diagnosed with PH, and English or Spanish speaking, completed validated AD screening questionnaires during routine outpatient clinic visits. Caregivers provided socioeconomic status (SES) data and MH history via survey. Patient demographics and clinical characteristics were analyzed using standard descriptive statistics. Eighty-eight patients were enrolled (female = 54, 61%). Forty-six (51.7%) identified at least mild symptoms of AD. Females were more likely to report AD than males (OR 2.67, 95% CI 1.11-6.61, p = 0.030). There were no significant associations between AD and PH severity, MH history, family dynamics, SES status, race, or ethnicity. Twenty-seven of those patients (58.7%) received MH education/counseling by MH professionals; ten (21.7%) were referred to MH providers, and nine patients (19.6%) were assessed for suicide safety. Adolescents with PH have a high prevalence of AD. Female patients had increased AD compared to male patients; no other predictors were linked to the prevalence of AD. Routine AD screening should be integrated into outpatient PH clinic visits with a focus on psychosocial support for young females diagnosed with PH.