The PHQ-9 Item 9 based screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ)-9 Item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS)

The role of thwarted belongingness and perceived burdensomeness in passive suicide ideation among Latinx and Black youth

INTRODUCTION

The interpersonal theory of suicide (IPTS) is used to evaluate suicide risk. Yet, it has not been sufficiently tested with ethnoracially minoritized youth. This study aimed to test whether thwarted belongingness (TB) and perceived burdensomeness (PB) were associated with passive suicide ideation (SI) among Latinx and Black youth.

METHODS

Data were obtained from a cross-sectional study. Some youth participants were recruited from an ongoing NIMH study of depressed Black youth in schools (N = 20). The rest were participants in a supplemental study of non-depressed Latinx and Black youth in community agencies (N = 61). Multivariate logistic regression analyses were conducted to examine the relationships between passive SI and the IPTS constructs.

RESULTS

Most participants identified as male (63.5%) and Latinx (59.5%), mean age 15.23 (SD = 1.4). Only TB remained significant when adjusting for age and gender, even after adding a measure of depression symptoms as a covariate. Notably, the interaction term (TBXPB) was not significantly associated with increased odds of passive SI in this sample.

CONCLUSION

These findings confirm the importance of examining the IPTS constructs and their relationship to passive SI in diverse populations. The relationship between TB and SI in Latinx and Black youth suggests it may be an important target for suicide prevention.

Association between bubble tea consumption and mental health among adults in mainland China: A national cross-sectional analysis of cohort study

BACKGROUND

Bubble tea has emerged as an essential beverage in the daily lives of many individuals, which is particularly pronounced among nurses. However, few studies have investigated the potential effects of bubble tea consumption on mental health among nurses. In this study, we aimed to investigate the association between bubble tea consumption and mental health among nurses.

METHODS

A cross-sectional analysis using baseline data from the Nurses' Mental Health Study (NMHS), a national cohort study. Odds ratios (ORs) were employed to evaluate the relationship between bubble tea consumption and mental health.

RESULTS

A total of 132,910 participants were enumerated nationwide in our survey. 8666 (6.52 %) were male and 124,244 (93.48 %) were female. The median age of participants was 34 years. After adjusting for potential confounders, the odds ratios (ORs) for depressive symptoms, anxiety symptoms, psychiatric diagnosis, fatigue, burnout, loneliness, and well-being trend changed across categories of bubble tea consumption. Low frequency of bubble tea consumption was associated with a lower risk of suicidal ideation, while high frequency of consumption was related to an increased suicidal risk. The relation between bubble tea and mental health varies with gender and age.

CONCLUSIONS

This large-sample cross-sectional study found that consumption of bubble tea was significantly associated with increased anxiety, depression, psychiatric diagnosis, fatigue, job burnout and loneliness, and decreased well-being among nurses. Moreover, research indicates that limited consumption of bubble tea may be correlated with a reduction in suicidal ideation, whereas excessive consumption may be linked to an increase in such ideation.

Artificial intelligence and machine learning techniques for suicide prediction: Integrating dietary patterns and environmental contaminants

Background

Suicide remains a leading cause of death globally, with nearly 800,000 deaths annually, particularly among young adults in regions like Europe, Australia, and the Middle East, highlighting the urgent need for innovative intervention strategies beyond conventional methods.

Objectives

This review aims to explore the transformative role of artificial intelligence (AI) and machine learning (ML) in enhancing suicide risk prediction and developing effective prevention strategies, examining how these technologies integrate complex risk factors, including psychiatric, socio-economic, dietary, and environmental influences.

Methods

A comprehensive review of literature from databases such as PubMed and Web of Science was conducted, focusing on studies that utilize AI and ML technologies. The review assessed the efficacy of various models, including Random Forest, neural networks, and others, in analyzing data from electronic health records, social media, and digital behaviors. Additionally, it evaluated a broad spectrum of dietary factors and their influence on suicidal behaviors, as well as the impact of environmental contaminants like lithium, arsenic, fluoride, mercury, and organophosphorus pesticides.

Conclusions

AI and ML are revolutionizing suicide prevention strategies, with models achieving nearly 90 % predictive accuracy by integrating diverse data sources. Our findings highlight the need for geographically and demographically tailored public health interventions and comprehensive AI models that address the multifactorial nature of suicide risk. However, the deployment of these technologies must address critical ethical and privacy concerns, ensuring compliance with regulations and the development of transparent, ethically guided AI systems. AI-driven tools, such as virtual therapists and chatbots, are essential for immediate support, particularly in underserved regions.

Association between frailty and suicidal ideation in older adults: A cross-sectional study

OBJECTIVES

This study seeks to investigate the potential correlation between various levels of frailty and suicidal ideation (SI) in older adults from the USA.

METHODS

Our cross-sectional study extracted data on adults ≥60 years from the NHANES in 2005-2018. Frailty levels were assessed by computing the Frailty Index, classifying individuals into robust, prefrail, and frail categories. SI was evaluated utilizing Item #9 of PHQ-9. Logistic regression and restricted cubic splines were employed for analysis.

RESULTS

The analysis comprised 8564 participants, revealing that 3.3% reported experiencing SI. The association between frailty and SI in older adults was statistically significant in crude model (OR: 5.94, 95% CI: 3.46-11.27, P < 0.001). Upon adjusting for baseline characteristics, the association remained robust (AOR: 5.35, 95% CI: 3.09-10.19, P < 0.001). Model II did not substantially alter the association between frailty and SI after further adjustment for lifestyle factors (AOR: 5.23, 95% CI: 3.02-9.98, P < 0.001). In a sensitivity analysis controlling for depression, the association remained statistically significant (AOR:3.62, 95%CI: 1.76-8.75, P = 0.001). Furthermore, the associations between the Frailty Index and SI were pronounced in the restricted cubic spline (RCS) models (P overall < 0.001, P nonlinearity = 0.771).

CONCLUSION

Frailty appears to heighten vulnerability to suicidal ideation in older adults. Training healthcare professionals to identify and address mental health issues related to frailty is crucial. Through comprehensive intervention measures, we can better safeguard the mental well-being of older adults and reduce the risk of suicide.

Prevalence and associated factors of passive suicidal ideation in a population treated by a community mental health unit

BACKGROUND

Suicide is a major public health problem affecting an increasing number of people. It is a complex and multicausal phenomenon whose first step is passive suicidal ideation (PSI). The identification of people with PSI could facilitate specific interventions with those who are at greater risk and/or suffering.

AIMS

To explore the frequency of passive suicidal ideation (PSI) and its association with sociodemographic, psychological, and psychopathological variables in a sample of persons seen in first consultation in a community mental health unit.

METHODS

Data from 2,354 persons seen in first consultation in a community mental health unit were analyzed. Descriptive statistics were used for quantitative variables, and frequency distribution was used for qualitative variables. Differences between groups were explored using the t-test for independent groups and Chi-square for qualitative variables.

RESULTS

The results showed a high frequency of these ideas in the analyzed sample, with a notable prevalence where more than half of the subjects (55.6%) reported experiencing these ideas in the last 2 weeks. There was a significant association of these ideas with sociodemographic variables such as age, type of cohabitation, and employment status. Likewise, significant positive associations were observed with symptom severity (depressive and anxious) and with the functional impact of these symptoms, with an increase in the PSI as symptom intensity and functional impact increase. Experiential avoidance and social support also showed a highly significant association with PSI. There was an increase in PSI as experiential avoidance increased and a decrease in PSI as social support increased.

CONCLUSIONS

The high prevalence of PSI within the clinical mental health sample highlights the critical need for targeted interventions. The significant associations with sociodemographic variables, symptom severity, functional impact, experiential avoidance, and social support emphasize the multifaceted nature of PSI and the importance of addressing these factors in clinical practice to effectively reduce PSI and improve overall mental health outcomes.

Comparing suicide risk screening strategies in Spanish-speaking pediatric patients

BACKGROUND

Suicide and suicidal behaviors pose significant global public health challenges, especially among young individuals. Effective screening strategies are crucial for addressing this crisis, with depression screening and suicide-specific tools being common approaches. This study compares their effectiveness by evaluating the Ask Suicide-Screening Questions (ASQ) against item 9 of the Patient Health Questionnaire-A (PHQ-A).

METHODS

This study is a secondary analysis of the Argentinean-Spanish version of the ASQ validation study, an observational, cross-sectional, and multicenter study conducted in medical settings in Buenos Aires, Argentina. A convenience sample of pediatric outpatients/inpatients aged 10 to 18 years completed the ASQ, PHQ-A, and Suicide Ideation Questionnaire (SIQ) along with clinical and sociodemographic questions.

RESULTS

A sample of 267 children and adolescents were included in this secondary analysis. Results show that the ASQ exhibited higher sensitivity (95.1%; 95% CI: 83% - 99%) compared to PHQ-A item 9 (73.1%; 95% CI: 57% - 85%), and superior performance in identifying suicide risk in youth.

LIMITATIONS

The study included a convenience sampling and was geographically restricted to Buenos Aires, Argentina. The study also lacked longitudinal follow-up to assess the predictive validity of these screening tools for suicide risk.

CONCLUSION

The study highlights the ASQ's effectiveness in identifying suicide risk among youth, emphasizing the importance of specialized screening tools over depression screening tools alone for accurate risk assessment in this population.

Suicidal ideation in male UK military personnel who sustained a physical combat injury in Afghanistan and the mediating role of leaving service: The ADVANCE cohort study

BACKGROUND/AIMS

Suicidal Ideation (SI) is a risk factor for suicide, a leading cause of death amongst young men globally. In this study we assess whether sustaining a serious physical combat injury is associated with SI and whether leaving service mediates this association.

METHODS

We analysed data from male UK Armed Forces personnel who sustained a combat injury in Afghanistan and a frequency-matched comparison group who did not sustain such an injury (the ADVANCE cohort). SI was measured from the Patient Health Questionnaire-9 item 'thoughts that you would be better off dead or of hurting yourself in some way'.

RESULTS

Approximately, 11.9% (n = 61) of the uninjured group, 15.3% (n = 83) of the overall injured group, 8.5% (n = 13) of an Amputation injury (AI) subgroup and 17.6% (n = 70) of a Non-Amputation Injury (NAI) subgroup reported SI in the past 2 weeks. The NAI subgroup reported greater likelihood of SI (Relative Risk Ratio (RR) = 1.44, 95% confidence interval (CI) [1.04, 2.00]) compared to the comparison group, whereas the overall injured group (RR = 1.23, 95% CI [0.90, 1.68]) and AI subgroup (RR = 0.65, 95% CI [0.36, 1.18]) did not. Leaving service fully mediated the association between sustaining a NAI and SI (natural direct effect RR = 1.08, 95% CI [0.69, 1.69]).

CONCLUSIONS

UK military personnel with NAI reported significantly higher rates of SI compared to demographically similar uninjured personnel, while those who sustained AIs reported no significant difference. Leaving service was associated with greater rates of SI for both injured and uninjured personnel and fully mediated the association between sustaining a NAI and SI.

Preteen Suicide Risk Screening in the Pediatric Outpatient Setting: A Clinical Pathway

We are in a youth mental health crisis with unprecedented and staggeringly high rates of suicidal ideations and suicide behaviors in preteens. In the United States, 14.5% of children aged 9-10 have experienced suicidal thoughts and behaviors, including 1.3% with a suicide attempt. American Academy of Pediatrics guidelines call for universal suicide risk screening of youth aged 12 years and older during preventative health care visits and screening in preteens aged 8-11 years when clinically indicated. However, what constitutes a clinical indication at 8-11 years can be difficult to systematically detect, and pediatric practitioners may not be equipped with necessary age-specific assessment tools. This is compounded by the lack of emphasis on preteen suicide risk screening (and focus on adolescents), which leaves practitioners without age-appropriate resources to make clinical determinations for at-risk preteens. The objective of this project was to develop an evidence-informed suicide risk screening pathway for pediatric practitioners to implement with preteen patients in outpatient settings. Suicide risk assessment in younger children (<8 years) is also briefly addressed. We convened a group of researchers and practitioners with expertise in preadolescent suicide, pediatric medicine, behavioral health screening integration with primary care, and child development. They reviewed the empirical literature and existing practice guidelines to iterate on a multi-informant clinical suicide risk screening pathway for preteens that includes both caregivers and preteens in the screening process. We also developed tools and accompanying guidelines for a preteen suicide risk screening workflow and risk determination to aid practitioners in deciding who, when, and how to screen. Finally, we provide scripts for introducing suicide risk screening to caregivers and preteens and to discuss screening findings.

Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation

BACKGROUND AND OBJECTIVES

Suicidal ideation (SI) during the postpartum phase is linked with suicide, a leading cause of death during this period. Antenatal depression and anxiety symptoms have both been linked with increased risk for postpartum SI. However, research aimed at examining the relative contributions of antenatal anxiety and depression symptoms towards postpartum SI remains nascent. In this study, we investigated the relative contribution of antenatal anxiety symptoms, depression symptoms, and SI towards postpartum SI.

DESIGN

These data are from a longitudinal study in which American mothers were assessed during pregnancy and again at six- to eight weeks postpartum.

METHODS

Data were analyzed using correlations and logistic regression models.

RESULTS

Antenatal anxiety symptoms and antenatal depression symptoms were significantly correlated with postpartum SI. Results from a logistic regression model indicated that antenatal anxiety symptoms (T1; OR = 1.185 [1.125, 1.245], p = .004), but not antenatal depression symptoms (T1; OR = 1.018 [0.943, 1.093], p = .812) or antenatal SI (T1; OR = 1.58 [0.11, 22.29], p = 0.73), were significantly associated with postpartum SI.

CONCLUSIONS

Antenatal anxiety symptoms, depression symptoms, and SI were positively associated with postpartum SI. When examined simultaneously, anxiety symptoms during the antenatal phase (but not depression symptoms or SI) predicted SI in the postpartum phase.

Measuring depression and anxiety in autistic college students: A psychometric evaluation of the PHQ-9 and GAD-7

LAY ABSTRACT

Anxiety, depression, and suicidality are major concerns among college students, though less is known about these constructs in autistic college students. Given the rising number of autistic individuals entering college, adequate screening and diagnosis of mental health difficulties is necessary to provide care to this population. For example, despite widespread usage of the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), it is unknown if the two instruments accurately measure depression and anxiety the same way between non-autistic and autistic individuals. Thus, the current study was the first to examine how these instruments measure depression and anxiety symptoms in autistic versus non-autistic college students. Utilizing tests of construct measurement in a sample of autistic (n = 477) and non-autistic (n = 429) university students aged 18-29, results showed that while the GAD-7 and PHQ-9 appear to be accurately capturing anxiety and depression in autistic college students, the PHQ-9 item assessing suicidality was found to be measuring different things. This indicates that autistic college students are not interpreting this question the way non-autistic students are, and thus, the measure is failing to capture suicidality in autistic people. Future investigators should continue to assess the appropriateness of using common screening measures, originally created by non-autistic people, in autistic populations.

Engaging primary care patients at risk for suicide in mental health treatment: user insights to inform implementation strategy design

BACKGROUND

Given that the majority of suicide decedents visit primary care in the year preceding death, primary care has been identified as a key setting in which to engage patients at risk for suicide in mental health services. The objective of this research was to identify barriers and facilitators to engagement in mental health services among primary care patients at risk for suicide to inform the development of strategies to increase engagement.

METHODS

Seventy-four semi-structured qualitative interviews were conducted with primary care patients (n = 20), primary care (n = 18) and behavioral health (n = 12) clinicians, mental health intake coordinators (n = 4), and health system and clinic leaders (n = 20). Patients who had been referred for mental health services from primary care and reported an elevated score (≥ 1) on item 9 on the Patient Health Questionnaire at the time of referral were eligible to participate. Eligible clinicians and leaders were employed in a primary care or behavioral health setting in a single large health system with an integrated mental health program. Interviews typically lasted 30-60 min, were completed over video conference or phone, and were coded by members of the research team using a rapid qualitative analysis procedure.

RESULTS

Participants were primarily female (64.9%), white (70.3%) and non-Hispanic/Latine (91.9%). The most identified barriers to mental health care engagement were waitlists, capacity limits, insurance, patient characteristics, communication, collaboration, and/or difficulties surrounding travel. The most commonly cited facilitators of engagement included telehealth, integrated care models, reminders, case management support, psychoeducation, motivational enhancement, and scheduling flexibility. Concrete suggestions for improving engagement in mental health services included increasing communication between providers, streamlining referral and intake processes, providing reminders and follow ups, and advocacy for increased reimbursement for suicide risk assessment.

CONCLUSIONS

Results underscore the myriad barriers patients at risk for suicide encounter when attempting to engage in mental health care in a primary care setting. Facilitators of engagement and suggestions for improving connections to care were also identified, which can inform the design of implementation strategies to improve engagement in mental health services among primary care patients at risk for suicide.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05021224 (Registered August 19, 2021).

Suicidal ideation among non-physician hospital system staff: Prevalence and workplace correlates

BACKGROUND

Research suggests that healthcare workers are at greater risk for suicide than other occupations, but most published studies focus on physicians. This study examines the prevalence of suicidal ideation (SI) and associated occupational factors among a broad group of non-physician healthcare staff.

METHODS

An anonymous online survey was sent to a random sample of 30 % of non-physician healthcare staff at a large urban healthcare system between September and November 2022. Weighted multivariable binary logistic regressions were conducted to determine the workplace and mental health factors associated with SI.

RESULTS

The 1084 respondents included nurses, administrative staff, research staff, medical assistants, nurse practitioners, physician assistants, and other roles. Of the sample, 8.8 % endorsed having SI over the prior two weeks. Results of the regression indicated that, after adjusting for demographic factors, greater odds of SI were associated with physical violence experienced from a patient or visitor (odds ratio [OR] = 2.15, 95 % confidence interval [CI] = 1.06-4.37), lower perceived leadership support (OR = 0.95, 95 % CI = 0.92-0.98), and positive screening for depression (OR = 4.66, 95 % CI = 2.45-8.86). Exploratory analysis suggests that depression may be a mediating factor between workplace stressors and SI.

LIMITATIONS

Limitations include the response rate, the use of a single item to assess SI, and the cross-sectional design.

CONCLUSION

Findings suggest that workplace violence and leadership support are important occupational factors associated with SI among healthcare workers. Reducing and mitigating workplace violence, enhancing leadership support, and improving access to mental health care should be considered targets for interventions to decrease suicide risk in this population.

Validation of screening instruments for common mental disorders and suicide risk in south African primary care settings

INTRODUCTION

In South Africa, there is limited mental health infrastructure and resources. Valid screening tools are needed to facilitate identification and linkage to care. We evaluated the performance of Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Primary Care Post Traumatic Stress Disorder Screen for DSM-5 (PC-PTSD-5), and the Columbia Suicide Severity Rating Scale (C-SSRS) among adults in South Africa against a diagnostic gold standard.

METHODS

Adults present at healthcare facilities were screened with the PHQ-9, GAD-7, PC-PTSD-5, and the C-SSRS. Nurses used a structured diagnostic interview to identify depression, anxiety, panic disorder, PTSD and elevated suicide risk. We assessed the internal consistency, criterion validity, and the sensitivity and specificity of these tools.

RESULTS

Of the 1885 participants, the prevalence of common mental disorders and suicide risk was 24.4 % and 14.9 %, respectively. The PHQ-9, GAD-7, and PC-PTSD-5 showed good internal consistency (0.80-0.89). All screeners demonstrated good criterion validity. For depression, a cut-off of ≥5 on the PHQ-9 yielded sensitivity of 84.24 %, while ≥10 yielded sensitivity of 48.77 %. For anxiety, the GAD-7 performed similarly. A cut-off of ≥4 on the PC-PTSD yielded sensitivity of 61.96 %. The C-SSRS yielded lower sensitivity than expected.

LIMITATIONS

The prevalence data is not generalizable to the larger South African adult population given the use of a targeted, healthcare facility-based sampling and recruitment strategy.

CONCLUSIONS

The performance of the PHQ-9, GAD-7, and PC-PTSD-5 demonstrated good internal consistency and criterion validity, though sensitivity and specificity trade-offs were enhanced with lower cut-offs. Further research into suicide risk screening is warranted.

A systematic review on passive sensing for the prediction of suicidal thoughts and behaviors

Passive sensing data from smartphones and wearables may help improve the prediction of suicidal thoughts and behaviors (STB). In this systematic review, we explored the feasibility and predictive validity of passive sensing for STB. On June 24, 2024, we systematically searched Medline, Embase, Web of Science, PubMed, and PsycINFO. Studies were eligible if they investigated the association between STB and passive sensing, or the feasibility of passive sensing in this context. From 2107 unique records, we identified eleven prediction studies, ten feasibility studies, and seven protocols. Studies indicated generally lower model performance for passive compared to active data, with three out of four studies finding no incremental value. PROBAST ratings revealed major shortcomings in methodology and reporting. Studies suggested that passive sensing is feasible in high-risk populations. In conclusion, there is limited evidence on the predictive value of passive sensing for STB. We highlight important quality characteristics for future research.

Generalized anxiety disorder screening scores are associated with greater treatment need among Veterans with depression

Comorbid anxiety and depression predict a poorer prognosis than either disorder occurring alone. It is unclear whether self-reported anxiety symptom scores identify patients with depression in need of more intensive mental health services. This study evaluated how anxiety symptoms predicted treatment receipt and outcomes among patients with new depression diagnoses in the Veterans Health Administration (VHA). Electronic medical record data from 128,917 VHA patients (71.6% assessed for anxiety, n = 92,237) with new diagnoses of depression were analyzed to examine how Generalized Anxiety Disorder-7 (GAD-7) scores predicted psychotropic medication prescriptions, psychotherapy receipt, acute care service utilization, and follow-up depression symptoms. Patients who reported severe symptoms of anxiety were significantly more likely to receive adequate acute phase and continuation phase antidepressant treatment, daytime anxiolytics/sedatives, nighttime sedative/hypnotics, and endorse more severe depression symptoms and suicidal ideation at follow-up. Patients who reported severe symptoms of anxiety at baseline were less likely to initiate psychotherapy. The GAD-7 may help identify depressed patients who have more severe disease burden and require additional mental health services.

Immigration Status, Legal Vulnerability, and Suicidal/Self-harm Ideation Disparities Among Immigrant-Origin Latinx Young Adults in the U.S

Theories of suicidality typically center intrapersonal processes, with limited attention to social determinants of mental health disparities. Using a legal vulnerability framework, we examined the association between self/parental immigration status and suicidal and self-harm ideation (SI) disparities in three groups of immigrant-origin Latinx young adults attending college in the USA: undocumented students (n = 564), US citizens with undocumented parents (n = 605), and US citizens with lawfully present parents (n = 596). We also evaluated whether self/parental immigration status differences in SI could be accounted for by six dimensions of legal vulnerability and, based on prominent theories of suicidality, explored the role of campus belongingness as a protective factor. Participants completed self-report measures, and SI was assessed using one item from the Patient Health Questionnaire-9, a screening tool that assesses the severity of depression symptomatology. Rates of SI were significantly higher among undocumented students (23.1%) and US citizens with undocumented parents (24.3%) compared to US citizens with lawfully present parents (17.8%). Immigration policy-related social exclusion and discrimination-mediated self/parental immigration status differences in SI. Although food insecurity did not differ by self/parental immigration status, greater food insecurity was associated with higher likelihood of SI. Greater campus belongingness was associated with a lower likelihood of endorsing SI for all students regardless of immigration status or legal vulnerability factors. Findings underscore the importance of examining self and parental immigration status as a social determinant of SI and the value of investigating aspects of legal vulnerability as explanatory factors.

Defining Suicidal Thought and Behavior Phenotypes for Genetic Studies

Background

Standardized definitions of suicidality phenotypes, including suicidal ideation (SI), attempt (SA), and death (SD) are a critical step towards improving understanding and comparison of results in suicide research. The complexity of suicidality contributes to heterogeneity in phenotype definitions, impeding evaluation of clinical and genetic risk factors across studies and efforts to combine samples within consortia. Here, we present expert and data-supported recommendations for defining suicidality and control phenotypes to facilitate merging current/legacy samples with definition variability and aid future sample creation.

Methods

A subgroup of clinician researchers and experts from the Suicide Workgroup of the Psychiatric Genomics Consortium (PGC) reviewed existing PGC definitions for SI, SA, SD, and control groups and generated preliminary consensus guidelines for instrument-derived and international classification of disease (ICD) data. ICD lists were validated in two independent datasets (N = 9,151 and 12,394).

Results

Recommendations are provided for evaluated instruments for SA and SI, emphasizing selection of lifetime measures phenotype-specific wording. Recommendations are also provided for defining SI and SD from ICD data. As the SA ICD definition is complex, SA code list recommendations were validated against instrument results with sensitivity (range = 15.4% to 80.6%), specificity (range = 67.6% to 97.4%), and positive predictive values (range = 0.59-0.93) reported.

Conclusions

Best-practice guidelines are presented for the use of existing information to define SI/SA/SD in consortia research. These proposed definitions are expected to facilitate more homogeneous data aggregation for genetic and multisite studies. Future research should involve refinement, improved generalizability, and validation in diverse populations.

Resilience and social support as protective factors against suicidal ideation among tertiary students during COVID-19: a cross-sectional study

BACKGROUND

Suicidal ideation is a depression symptom which represents a key (cognitive) component of suicidality and plays an important role in suicide risk detection, intervention, and prevention. Despite existing research showing the importance of certain factors of depression symptoms and suicidal ideation, less is known about the interaction between the various risk and protective factors. The aim of the study was to examine whether living conditions characteristics and personal circumstances during the COVID-19 pandemic predicted the presence of depression symptoms and suicidal ideation among tertiary students and whether resilience and social support can mitigate the detrimental effects of difficult life circumstances.

METHOD

A large online cross-sectional study was conducted in March 2021 among 4,645 Slovenian tertiary students. Hierarchical multiple regression and hierarchical logistic regression methods were used to assess and compare the effect of life circumstances variables, as opposed to resilience and social support, on depression symptoms and suicidal ideation.

RESULTS

Female gender, single relationship status, living alone, a higher degree of household conflict, having a history of mental illness and chronic disease diagnosis were significant predictors of depression scores. All but gender were also predictors of suicidal ideation. Household conflict and a history of mental illness were the factors showing the strongest effect in both cases. On the other hand, social support and, in particular, resilience proved to be strong protective factors against depression symptoms and suicidal ideation. After accounting for one's resilience and social support, the explained variance in depression scores was more than doubled, while the harmful effect of household conflict and history of mental illness significantly decreased.

CONCLUSIONS

The findings stress the importance of one's resilience and social support and explain why some people manage to maintain mental well-being despite finding themselves in difficult life circumstances, which was the case for many tertiary students during the COVID-19 pandemic. These insights may inform preventive efforts against developing suicidal ideation and may be used as support for the design and implementation of interventions for improving resilience and social support from childhood onward.

Preliminary Effectiveness of a Therapist-Supported Digital Mental Health Intervention in Reducing Suicidal Ideation

Suicidal ideation (SI) is a significant public health concern with increasing prevalence. Therapist-supported digital mental health interventions (DMHI) are an emergent modality to address common mental health problems like depression and anxiety, although less is known about SI. This study examined SI trajectories among 778 patients who participated in a therapist-supported DMHI using multilevel models during and up to 6-months post-treatment. Estimates of associated suicide attempts and deaths by suicide were calculated using published data linking PHQ-9-assessed SI to records of suicide attempts and deaths by suicide. The proportion of participants reporting no SI significantly increased between baseline and end-of-treatment (78.02% to 91.00%). Effect sizes of SI changes between baseline and end-of-treatment, 3-month, and 6-month follow-ups were 0.33 (95%CI = 0.27-0.38), 0.32 (95%CI = 0.27-0.38), and 0.32 (95%CI = 0.27-0.38), respectively. Results also indicated an estimated 30.49% reduction (95%CI = 25.15%-35.13%) in suicide attempts and death by suicide across treatment. This study provides preliminary evidence of the effectiveness of a therapist-supported DMHI in reducing SI.

Rates and correlates of study enrolment and use of a chatbot aimed to promote mental health services use for eating disorders following online screening

OBJECTIVE

We developed a chatbot aimed to facilitate mental health services use for eating disorders (EDs) and offered the opportunity to enrol in a research study and use the chatbot to all adult respondents to a publicly available online ED screen who screened positive for clinical/subclinical EDs and reported not currently being in treatment. We examined the rates and correlates of enrolment in the study and uptake of the chatbot.

METHOD

Following screening, eligible respondents (≥18 years, screened positive for a clinical/subclinical ED, not in treatment for an ED) were shown the study opportunity. Chi-square tests and logistic regressions explored differences in demographics, ED symptoms, suicidality, weight, and probable ED diagnoses between those who enroled and engaged with the chatbot versus those who did not.

RESULTS

6747 respondents were shown the opportunity (80.0% of all adult screens). 3.0% enroled, of whom 90.2% subsequently used the chatbot. Enrolment and chatbot uptake were more common among respondents aged ≥25 years old versus those aged 18-24 and less common among respondents who reported engaging in regular dietary restriction.

CONCLUSIONS

Overall enrolment was low, yet uptake was high among those that enroled and did not differ across most demographics and symptom presentations. Future directions include evaluating respondents' attitudes towards treatment-promoting tools and removing barriers to uptake.

[Sensitivity and specificity of the PHQ-9 for identifying suicidality in medical rehabilitation]

PURPOSE

Suicidality is rarely assessed in patients treated in German rehabilitation centers, although individuals with physical and mental impairments have an increased risk for suicidality. The item 9 of the 9-item depression module of the Patient Health Questionnaire (PHQ-9) asks about the desire to be dead or to harm oneself and could be used as a possible screening for suicidality. The Columbia Suicide Severity Rating Scale (C-SSRS) is a standardized interview to assess suicidality. We assessed the prevalence of suicidality in orthopedic and cardiac rehabilitation using the C-SSRS and the PHQ-9, examined the diagnostic accuracy of the item 9 of the PHQ-9 and of the PHQ-9 total score for identifying suicidality and surveyed the acceptance of the suicidality assessment by the rehabilitants.

METHODS

Study participants were screened with the PHQ-9 and subsequently interviewed using C-SSRS. Sensitivity and specificity of the item 9 of the PHQ-9 and the PHQ-9 total score were tested for the presence of suicidality assessed with the C-SSRS and in a sensitivity analysis for the presence of nonspecific active suicidal ideation (item 2 of the C-SSRS). We calculated the area under the curve (AUC) to predict the ability of the PHQ-9 to discriminate between individuals with and without acute suicidality. Screening and interview were evaluated by the rehabilitants.

RESULTS

Among 405 study participants, the prevalence of acute suicidality measured by the C-SSRS was 0.5%. 4% reported nonspecific active suicidal ideation on the C-SSRS. 10.4% reported suicidal ideation on item 9 of the PHQ-9. The sensitivity of item 9 and the PHQ-9 total score for identifying acute suicidality was only 50.0% (95% CI: 1.3% to 98.7%). However, item 9 was sensitive (81.3%, 95% CI: 54.4% to 96.0%) and specific (92.5%, 95% CI: 89.5% to 95.0%) for identifying nonspecific active suicidal ideation. Estimators for sensitivity were highly uncertain because of the low prevalence of acute suicidality. Addressing suicidality was rated as useful and helpful by study participants.

CONCLUSION

If the response to item 9 is positive, the immediate risk of suicide is low. However, PHQ-9 is suitable for identifying patients with non-specific suicidal thoughts. A conspicuous score on the item 9 of the PHQ-9 should be further clarified by a psychotherapist.

The association between urinary incontinence and suicidal ideation: Findings from the National Health and Nutrition Examination Survey

BACKGROUND

Urinary incontinence (UI) might be linked to suicidal ideation, but we do not yet have all the relevant details. This study aimed to dig deeper into the connection between UI and suicidal ideation using data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

We examined 31,891 participants aged ≥ 20 years from NHANES 2005-2018 who provided complete information. We used standardized surveys to check for UI and signs of suicidal ideation. To better understand this relationship, we used statistical tools such as multivariable logistic regression, subgroup analysis, and sensitivity analyses.

RESULTS

Among the 31,891 participants, 28.9% reported UI and 10.7% reported suicidal ideation. Those with UI exhibited a significantly greater incidence of suicidal ideation (15.5%) than did those without UI (8.8%, P < 0.001). After adjusting for various factors, including age, sex, marital status, socioeconomic status, educational level, lifestyle factors, and chronic comorbidities, UI remained significantly associated with suicidal ideation (OR:1.54, 95% CI = 1.39-1.7, P < 0.001). Among all types of UI, MUI participants were more likely to experience suicidal ideation. Compared with no UI, higher odds of suicidal ideation suffered from MUI (OR:2.11, 95%CI:1.83-2.44, P < 0.001), SUI (OR:1.4, 95%CI:1.19-1.65, P < 0.001), UUI(OR:1.37,95%CI:1.16-1.62, P < 0.001) after full adjustment. With the exception of individuals living with a partner, the remaining subgroups exhibited a positive correlation between urinary incontinence and suicidal ideation, considering that factors such as age, sex, and prevalent comorbidities such as hypertension, depression, and diabetes did not reveal any statistically significant interactions (all P > 0.05). Sensitivity analyses, incorporating imputed missing covariates, did not substantially alter the results (OR: 1.53, 95% CI: 1.4-1.68, P < 0.001).

CONCLUSION

Urinary incontinence may correlate with increased suicidal ideation risk, priority screening for suicidal ideation and timely intervention are essential for individuals with urinary incontinence, but prospective studies are needed to verify the results.

Screening for and Responding to Suicidality Among Youth Presenting to a Children's Advocacy Center (CAC)

Youth presenting to a Children's Advocacy Center (CAC) for a forensic interview are at increased risk for suicidality, but no data exist for suicidality or suicide screening and response at the time of the forensic interview. The current study applied a suicide and traumatic stress screening and response protocol, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), with youth (11-18 years) presenting for a forensic interview to one of 16 participating CAC locations, 2018-2020.46.2% of youth screened for traumatic stress and suicidality (N = 1651) endorsed thoughts of suicide or self-harm in the past two weeks, and 13.6% were assessed as high risk for suicide. High symptoms of traumatic stress increased the risk of suicidal thinking as well as of high risk suicidality. CAC workers, both clinicians and non-clinicians, facilitated screening and provided prevention response. Suicide screening and response at the CAC at the time of the forensic interview appears important and feasible.

Asynchronous Versus Synchronous Screening for Depression and Suicidality in a Primary Health Care System: Quality Improvement Study

Background

Despite being a debilitating, costly, and potentially life-threatening condition, depression is often underdiagnosed and undertreated. Previsit Patient Health Questionnaire-9 (PHQ-9) may help primary care health systems identify symptoms of severe depression and prevent suicide through early intervention. Little is known about the impact of previsit web-based PHQ-9 on patient care and safety.

Objective

We aimed to investigate differences among patient characteristics and provider clinical responses for patients who complete a web-based (asynchronous) versus in-clinic (synchronous) PHQ-9.

Methods

This quality improvement study was conducted at 33 clinic sites across 2 health systems in Northern California from November 1, 2020, to May 31, 2021, and evaluated 1683 (0.9% of total PHQs completed) records of patients endorsing thoughts that they would be better off dead or of self-harm (question 9 in the PHQ-9) following the implementation of a depression screening program that included automated electronic previsit PHQ-9 distribution. Patient demographics and providers' clinical response (suicide risk assessment, triage nurse connection, medication management, electronic consultation with psychiatrist, and referral to social worker or psychiatrist) were compared for patients with asynchronous versus synchronous PHQ-9 completion.

Results

Of the 1683 patients (female: n=1071, 63.7%; non-Hispanic: n=1293, 76.8%; White: n=831, 49.4%), Hispanic and Latino patients were 40% less likely to complete a PHQ-9 asynchronously (odds ratio [OR] 0.6, 95% CI 0.45-0.8; P<.001). Patients with Medicare insurance were 36% (OR 0.64, 95% CI 0.51-0.79) less likely to complete a PHQ-9 asynchronously than patients with private insurance. Those with moderate to severe depression were 1.61 times more likely (95% CI 1.21-2.15; P=.001) to complete a PHQ-9 asynchronously than those with no or mild symptoms. Patients who completed a PHQ-9 asynchronously were twice as likely to complete a Columbia-Suicide Severity Rating Scale (OR 2.41, 95% CI 1.89-3.06; P<.001) and 77% less likely to receive a referral to psychiatry (OR 0.23, 95% CI 0.16-0.34; P<.001). Those who endorsed question 9 "more than half the days" (OR 1.62, 95% CI 1.06-2.48) and "nearly every day" (OR 2.38, 95% CI 1.38-4.12) were more likely to receive a referral to psychiatry than those who endorsed question 9 "several days" (P=.002).

Conclusions

Shifting depression screening from in-clinic to previsit led to a dramatic increase in PHQ-9 completion without sacrificing patient safety. Asynchronous PHQ-9 can decrease workload on frontline clinical team members, increase patient self-reporting, and elicit more intentional clinical responses from providers. Observed disparities will inform future improvement efforts.

Decreased odds of depressive symptoms and suicidal ideation with higher education, depending on sex and employment status

BACKGROUND

Higher education is associated with reduced depressive symptoms and requires investment without guaranteed employment. It remains unclear how sex and employment status together contribute to the association between mental health and educational attainment. This study investigated the role of sex and employment status together in the associations of 1) depressive symptoms and 2) suicidal ideation with education.

METHODS

Using 2005-2018 National Health and Nutrition Examination Survey data, cross-sectional analyses were conducted on individuals ≥20 years who completed the depression questionnaire and reported their employment status and highest level of education. Survey-weighted multivariable logistic regression models were used to explore how depressive symptoms and suicidal ideation are associated with educational attainment in an analysis stratified by sex and employment status. To account for multiple testing, a significance level of a < 0.01 was used.

RESULTS

Participants (n = 23,669) had a weighted mean age of 43.25 (SD = 13.97) years and 47% were female. Employed females (aOR = 0.47, 95% CI 0.32, 0.69), unemployed females (aOR = 0.47, 95% CI 0.29, 0.75), and unemployed males (aOR = 0.31, 95% CI 0.17, 0.56) with college education had reduced odds of depressive symptoms compared to those with high school education. Employed females with college education also had reduced suicidal ideation odds compared to those with high school education (aOR = 0.41, 95% CI 0.22, 0.76).

CONCLUSIONS

Females demonstrated significant associations between depressive symptoms and education, regardless of employment status, whereas males demonstrated an association only if unemployed. Employed females, in particular, demonstrated a significant association between suicidal ideation and education. These findings may inform future research investigating the underlying mechanisms and etiology of these sex-employment status differences in the association between mental health and education.

Functional connectivity alterations in PTSD patients with suicidal ideation

Post-traumatic stress disorder (PTSD) is a highly prevalent psychological disorder characterized by intense feelings of fear or helplessness after experiencing a traumatic event. PTSD is highly comorbid with mood disorders and patients are at increased risk for suicide. The present study aimed to identify neural connectivity alterations associated with suicidal ideation (SI) in PTSD patients by using resting-state functional magnetic resonance imaging. Voxel-to-voxel intrinsic connectivity was compared between PTSD patients with no (N-SI; N = 26) and high (H-SI; N = 7) SI. Region-to-voxel functional connectivity analysis was performed to identify the regions that contributed to intrinsic connectivity changes. H-SI patients had increased connectivity to various brain regions representing the central executive network, salience network, and default mode network in the frontal, temporal, and occipital lobes as well as subcortical structures involved in executive and limbic functioning, and motor systems. These results suggest SI is associated with large network-level alterations in PTSD patients and is not the result of neuronal abnormalities in any one specific area.

Screening for symptoms of childhood traumatic stress in the primary care pediatric clinic

BACKGROUND

Childhood traumatic experiences may result in post-traumatic stress disorder. Although pediatricians are encouraged to address these traumas in clinical encounters, measures of childhood traumatic stress have not been adopted by primary care clinicians. In this study, we describe the feasibility and potential utility of the UCLA Brief Screen, a validated screener for childhood traumatic stress symptoms, in pediatric primary care clinics.

METHODS

Children 6-17 years of age presenting for routine well-child care in community-based pediatric clinics were eligible for traumatic stress screening. We described the feasibility and acceptability of screening based on screener adoption by eligible pediatric clinicians. We assessed the potential utility of screening based on prevalence and distribution of potentially traumatic events and traumatic stress symptoms in this general pediatric population. Finally, we compared results of the UCLA Brief Screen with those of the Patient Health Questionnaire-A to evaluate associations between symptoms of traumatic stress, depression, and suicidality among adolescents in this community setting.

RESULTS

14/18 (77.8%) pediatric clinicians in two clinics offered an adapted UCLA Brief Screen during 2359/4959 (47.6%) eligible well-child checks over 14 months. 1472/2359 (62.4%) of offered screeners were completed, returned, and scored. One-third (32.5%) of completed screeners captured a potentially traumatic event experience described by either children or caregivers. Moderate to severe traumatic stress symptoms were identified in 10.7% and 5.2% of patients, respectively. Concurrent depression screening revealed that 68.3% of adolescents with depressive symptoms reported a potentially traumatic event (PTE) and 80.5% had concurrent traumatic stress symptoms. Adolescents reporting a PTE were 3.5 times more likely to report thoughts of suicide or self-harm than those without this history.

CONCLUSIONS

Results from this pilot study suggest that traumatic stress screening in the pediatric primary care setting may be feasible and may identify and classify mental health symptoms missed with current screening practices for depression. The prevalence of PTEs and traumatic stress symptoms associated with PTEs support the potential utility of a standardized screening in early identification of and response to children with clinically important symptoms of childhood traumatic stress. Future research should evaluate meaningful clinical outcomes associated with traumatic stress screening.

Sleep disturbance and suicidal ideation mediated by psychotic-like experiences in adolescents: a two-wave longitudinal study

STUDY OBJECTIVES

Sleep disturbance may cause suicidal ideation (SI). This study aimed to examine their co-occurrence rate among adolescents and investigate whether psychotic-like experiences (PLEs) mediate this association.

METHODS

A total of 17 722 Chinese adolescents were included in this two-wave longitudinal study. The baseline survey (time 1, T1) was conducted between April 21 and May 12, 2021, and the follow-up survey (time 2, T2) was implemented between December 17 and 26, 2021. At T1, participants completed questionnaires to assess their sleep disturbance, sleep duration, PLEs, SI, depressive symptoms, and sociodemographic characteristics. At T2, participants reported their PLEs, SI, and negative life events.

RESULTS

The SI prevalence decreased from 20.2% (T1) to 18.4% (T2). Participants with SI showed significantly higher prevalence of sleep disturbance and short sleep duration compared to those without SI. Baseline sleep disturbance and short sleep duration were both associated with the increased risk of SI 6 months later. These longitudinal links were mediated by PLEs, independent of baseline covariates and negative life events.

CONCLUSIONS

These findings provide a novel insight into the mechanism linking sleep problems and suicidality, and stress the significance of assessing and addressing sleep problems and PLEs for adolescent suicide prevention and intervention.

The longitudinal association of stressful life events with depression remission among SHARP trial participants with depression and hypertension or diabetes in Malawi

Depressive disorders are leading contributors to morbidity in low- and middle-income countries and are particularly prevalent among people with non-communicable diseases (NCD). Stressful life events (SLEs) are risk factors for, and can help identify those at risk of, severe depressive illness requiring more aggressive treatment. Yet, research on the impact of SLEs on the trajectory of depressive symptoms among NCD patients indicated for depression treatment is lacking, especially in low resource settings. This study aims to estimate the longitudinal association of SLEs at baseline with depression remission achievement at three, six, and 12 months among adults with either hypertension or diabetes and comorbid depression identified as being eligible for depression treatment. Participants were recruited from 10 NCD clinics in Malawi from May 2019-December 2021. SLEs were measured by the Life Events Survey and depression remission was defined as achieving a Patient Health Questionaire-9 (PHQ-9) score <5 at follow-up. The study population (n = 737) consisted predominately of females aged 50 or higher with primary education and current employment. At baseline, participants reported a mean of 3.5 SLEs in the prior three months with 90% reporting ≥1 SLE. After adjustment, each additional SLE was associated with a lower probability of achieving depression remission at three months (cumulative incidence ratio (CIR) 0.94; 95% confidence interval: 0.90, 0.98, p = 0.002), six months (0.95; 0.92, 0.98, p = 0.002) and 12 months (0.96; 0.94, 0.99, p = 0.011). Re-expressed per 3-unit change, the probability of achieving depression remission at three, six, and 12 months was 0.82, 0.86, and 0.89 times lower per 3 SLEs (the median number of SLEs). Among NCD patients identified as eligible for depression treatment, recent SLEs at baseline were associated with lower probability of achieving depression remission at three, six, and 12 months. Findings suggest that interventions addressing SLEs during integrated NCD and depression care interventions (e.g., teaching and practicing SLE coping strategies) may improve success of depression treatment among adult patient populations in low-resource settings and may help identify those at risk of severe and treatment resistant depression.

Treating individuals with suicidal ideation in primary care: Patient-level characteristics associated with follow-up in the Collaborative Care Model

INTRODUCTION

The Collaborative Care Model (CoCM) is an evidence-based approach which embeds behavioral health providers (BHPs) into primary care. Whether patients with suicidal ideation (SI) are willing to engage in CoCM is unclear.

METHODS

Using Patient Health Questionnaire-9 (PHQ-9) administrative data from primary care practices within an urban academic health system, we identified patients with and without SI who were referred to a CoCM BHP. We compared engagement, defined as attendance at ≥1 CoCM visit, across groups.

RESULTS

Between 2018 and 2022, 7391 primary care patients were referred to a CoCM BHP. Eight hundred and ninety-two of these patients reported SI on the PHQ-9 (754 on "several days" during the previous 2 weeks and 138 on "more than half or most days"). Across groups, most patients engaged in CoCM. Patients reporting SI on several days engaged at a lower rate (61.4%) than those reporting SI on more than half or most days (65.9%). Both SI groups engaged at a lower rate than the 6499 patients who did not report SI (67.5%).

CONCLUSION

Most patients referred to a CoCM BHP engaged in ≥1 visit. Rates were lower for patients with SI, with the lowest rate among those reporting SI on several days.

Rapid screening for suicide risk: An algorithmic approach

INTRODUCTION

In the United States, primary medical care settings are the first accessed resource for both medical and behavioral health care. Thus, there is a clear need for accurate and efficient behavioral health screening in this setting, including routine surveillance screening for suicide risk. The Multidimensional Behavioral Health Screen (MBHS), a broadband but very brief screening tool developed specifically for primary care, has been updated to include an algorithm that classifies suicide risk based on the interpersonal-psychological theory of suicide, and associated interview and decision framework. This study aims to evaluate the predictive accuracy of the new MBHS 2.0 suicide risk algorithm, with actual risk determined by clinical suicide risk interview.

METHOD

Data were collected as part of a larger study that, overall, included 551 college student participants. Of these, 309 completed the MBHS 2.0 and the clinical suicide risk interview, the two measures reported here. The final participant count was 299 following the removal of incomplete or invalid cases. Predicted suicide risk as determined by the MBHS 2.0 (Low, Mild, At least Moderate) was compared to actual risk as determined by clinical interview (Low, Moderate, Severe, Extreme).

RESULTS

Utilizing chi-square analyses, data show a significant association between the predicted suicide risk category based on the MBHS 2.0 algorithm and the actual risk category based on the semi-structured clinical interview. Furthermore, classification analyses suggest that primary care providers will be able to confidently assess the suicide risk level for the majority of their patients when using the MBHS.

CONCLUSION

Findings suggest that the MBHS 2.0 can be an accurate and efficient tool for use by primary care providers in classifying suicide risk. Future research will be useful to evaluate the utility of the suicide risk algorithm among primary care populations.

How well can U.S. military veterans' suicidal ideation be predicted from static and change-based indicators of their psychosocial well-being as they adapt to civilian life?

BACKGROUND

Identifying predictors of suicidal ideation (SI) is important to inform suicide prevention efforts, particularly among high-risk populations like military veterans. Although many studies have examined the contribution of psychopathology to veterans' SI, fewer studies have examined whether experiencing good psychosocial well-being with regard to multiple aspects of life can protect veterans from SI or evaluated whether SI risk prediction can be enhanced by considering change in life circumstances along with static factors.

METHODS

The study drew from a longitudinal population-based sample of 7141 U.S. veterans assessed throughout the first three years after leaving military service. Machine learning methods (cross-validated random forests) were applied to examine the predictive utility of static and change-based well-being indicators to veterans' SI, as compared to psychopathology predictors.

RESULTS

Although psychopathology models performed better, the full set of well-being predictors demonstrated acceptable discrimination in predicting new-onset SI and accounted for approximately two-thirds of cases of SI in the top strata (quintile) of predicted risk. Greater engagement in health promoting behavior and social well-being were most important in predicting reduced SI risk, with several change-based predictors of SI identified but stronger associations observed for static as compared to change-based indicator sets as a whole.

CONCLUSIONS

Findings support the value of considering veterans' broader well-being in identifying individuals at risk for suicidal ideation and suggest the possibility that well-being promotion efforts may be useful in reducing suicide risk. Findings also highlight the need for additional attention to change-based predictors to better understand their potential value in identifying individuals at risk for SI.

An examination of the psychometric properties of the Patient Health Questionnaire-9 (PHQ-9) in a Multiracial/ethnic population in the United States

Depression and suicide are significant public health issues. The Patient Health Questionnaire-9 (PHQ-9) is commonly used to assess for symptoms of depression, but its psychometric properties within Multiracial/ethnic populations remains uncertain. In a study involving 1,012 English-speaking Multiracial/ethnic participants from the United States (US), the PHQ-9 showed strong internal consistency (α = 0.93) and supported a one-factor structure. No measurement variance was observed between Non-White and White/Non-White Multiracial/ethic subgroups. PHQ-2, with a cutoff of ≥3, identified fewer depression cases than PHQ-9 (32% vs. 40%), with sensitivities of 75-99% and specificities of 74-96%; a cutoff of ≥2 missed fewer cases. Item performance of the ninth PHQ-9 question, addressing thoughts of death or self-harm, varied across generations with younger generations more likely to endorse thoughts of death or self-harm at any level of symptom severity. The findings suggest the PHQ-9 demonstrated adequate reliability within a population of Multiracial/ethnic adults in the US; however, the use of the 9th item of the PHQ-9 may not be adequate for identifying individuals at risk for suicidal thoughts and/or behaviors, particularly for older Multiracial/ethnic adults. The lower sensitivity of the PHQ-2 with a ≥ 3 cutoff suggests a cutoff of ≥2 may be preferable to miss fewer cases of depression.

Community Efficacy for Non-Communicable Disease Management and Medication Adherence: The Sequential Mediating Role of Self-Efficacy and Depressive Symptoms

Purpose

We assess whether the sequential mediating effects of self-efficacy and depressive symptoms on the relationship between community efficacy for non-communicable disease management (COEN) and medication adherence and whether these relationships differed by sex and age.

Patients and Methods

Overall, 662 individuals from 12 communities in China were interviewed twice 1 year apart. Serial mediation analysis examined whether the relationship between COEN and medication adherence was mediated by self-efficacy and depressive symptoms. Model invariance across sex and age groups was assessed using multi-group analysis.

Results

Serial mediation analysis indicated that self-efficacy and depressive symptoms sequentially mediated relationship between COEN and medication adherence. Multi-group analysis by sex showed that the path from self-efficacy to medication adherence was significant only for females and from depressive symptoms to medication adherence was significant only for males.

Conclusion

Interventions that enhance individual self-efficacy may be beneficial in decreasing depressive symptoms and improving medication adherence.

Prevalence, characteristics, and correlates of probable avoidant/restrictive food intake disorder among adult respondents to the National Eating Disorders Association online screen: a cross-sectional study

BACKGROUND

Avoidant/restrictive food intake disorder (ARFID) is a serious, albeit under-researched, feeding or eating disorder. This exploratory study utilized data from adult respondents to the National Eating Disorders Association online eating disorder screen to validate items assessing the presence of ARFID and examine the prevalence, clinical characteristics, and correlates of a positive ARFID screen.

METHODS

Among 50,082 adult screen respondents between January 2022 and January 2023, the prevalence of a positive ARFID screen was calculated. Chi-square tests and t-tests compared demographics, eating disorder attitudes and behaviors, suicidal ideation, current eating disorder treatment status, and eating disorder treatment-seeking intentions between respondents with possible ARFID and other eating disorder diagnostic and risk categories. Clinical characteristics of respondents with possible ARFID were also examined.

RESULTS

2378 (4.7%) adult respondents screened positive for ARFID. Respondents with possible ARFID tended to be younger, male, and have lower household income, and were less likely to be White and more likely to be Hispanic/Latino than most other diagnostic/risk groups. They had lower weight/shape concerns and eating disorder behaviors than most other diagnoses and higher BMI than those with AN. 35% reported suicidal ideation, 47% reported intentions to seek treatment for an eating disorder, and 2% reported currently being in treatment. The most common clinical feature of ARFID was lack of interest in eating (80%), followed by food sensory avoidance (55%) and avoidance of food due to fear of aversive consequences (31%).

CONCLUSIONS

Findings from this study indicated that ARFID was prevalent among adult screen respondents and more common among individuals who were younger, male, non-White, Hispanic, and lower income relative to those with other eating disorders, at risk for an eating disorder, or at low risk. Individuals with possible ARFID frequently reported suicidal ideation and were rarely in treatment for an eating disorder. Further research is urgently needed to improve advances in the assessment and treatment of ARFID and improve access to care in order to prevent prolonged illness duration.

Preferred treatment focus among college students with eating disorders and comorbid mental health problems in a digital cognitive-behavioral guided self-help program

OBJECTIVE

To examine the mental health problems that college students with eating disorders (EDs) and comorbid depression and/or anxiety disorders preferred to target first in a digital treatment program and explore correlates of preferred treatment focus.

METHODS

Four hundred and eighty nine college student users of a digital cognitive-behavioral guided self-help program targeting common mental health problems (76.7% female, Mage  = 20.4 ± 4.4, 64.8% White) screened positive for an ED and ≥one other clinical mental health problem (i.e., depression, generalized anxiety disorder, social phobia, and/or panic disorder). Students also reported on insomnia, post-traumatic stress, alcohol use, and suicide risk. Before treatment, they indicated the mental health problem that they preferred to target first in treatment. Preferred treatment focus was characterized by diagnostic profile (i.e., ED + Depression, ED + Anxiety, ED + Depression + Anxiety), symptom severity, and demographics.

RESULTS

58% of students with ED + Anxiety, 47% of those with ED + Depression, and 27% of those with ED + Depression + Anxiety chose to target EDs first. Across diagnostic profiles, those who chose to target EDs first had more severe ED symptoms than those who chose to target anxiety or depression (ps < .05). Among students with ED + Depression + Anxiety, those who chose to target EDs first had lower depression symptoms than those who chose to target depression, lower generalized anxiety than those who chose to target anxiety, and lower suicidality than those who chose to target anxiety or depression (ps < .01).

CONCLUSIONS

Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles. Research should explore specific symptom presentations associated with preferred treatment focus.

PUBLIC SIGNIFICANCE

Findings indicate that a sizable percentage of college students with depression/anxiety who also have EDs prefer to target EDs first in treatment, highlighting the importance of increasing availability of ED interventions to college students. Students with EDs and comorbid depression and/or anxiety disorders showed variable preferred treatment focus across diagnostic profiles, and preference to target EDs was associated with greater ED psychopathology across diagnostic profiles.

The electronic health record Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) Brain Health Trial: Protocol for an embedded, pragmatic clinical trial of a low-cost dementia detection algorithm

BACKGROUND

About half of people living with dementia have not received a diagnosis, delaying access to treatment, education, and support. We previously developed a tool, eRADAR, which uses information in the electronic health record (EHR) to identify patients who may have undiagnosed dementia. This paper provides the protocol for an embedded, pragmatic clinical trial (ePCT) implementing eRADAR in two healthcare systems to determine whether an intervention using eRADAR increases dementia diagnosis rates and to examine the benefits and harms experienced by patients and other stakeholders.

METHODS

We will conduct an ePCT within an integrated healthcare system and replicate it in an urban academic medical center. At primary care clinics serving about 27,000 patients age 65 and above, we will randomize primary care providers (PCPs) to have their patients with high eRADAR scores receive targeted outreach (intervention) or usual care. Intervention patients will be offered a "brain health" assessment visit with a clinical research interventionist mirroring existing roles within the healthcare systems. The interventionist will make follow-up recommendations to PCPs and offer support to newly-diagnosed patients. Patients with high eRADAR scores in both study arms will be followed to identify new diagnoses of dementia in the EHR (primary outcome). Secondary outcomes include healthcare utilization from the EHR and patient, family member and clinician satisfaction assessed through surveys and interviews.

CONCLUSION

If this pragmatic trial is successful, the eRADAR tool and intervention could be adopted by other healthcare systems, potentially improving dementia detection, patient care and quality of life.

Multiphasic Personality Assessment in a Case Series of Adolescent Patients with Suicidal Ideation and/or Attempts

Suicide is an important public health issue. To examine the differences in personality characteristics between a group of adolescents with suicidal ideation (SI) and a group with a history of suicidal attempts (SA), we conducted a cross-sectional study. We enrolled 55 adolescents (51 females; 12-18 y.o.) who presented SI and/or SA. Using the Columbia Suicide Severity Rating Scale, we divided the sample into two groups: adolescents with SI and adolescents with SA. All participants filled in the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A). Adolescents in the SA group had greater difficulties in social relations, risky behaviors, and more intense suicidal ideation compared to those in the SI group. Adolescents in the SA group scored higher in Omission, in the Lie Scale, the Conduct Problem Scale, the Less Aspirations Scale, the Repression Scale in the MMPI-A, and item 283 of the MAST compared to the other group. The results suggest that using the MMPI-A to assess certain features (e.g., tendency to lie, repression) may be helpful in identifying young people who are at high risk of suicide. However, further research is required to determine the effectiveness of using this instrument.

Incidence of Suicidal Ideation and Suicide Attempt Based on Time in a Deployed Environment

INTRODUCTION

Knowing when suicidal ideation (SI) or suicide attempt (SA) is most likely to occur in a deployed environment would aid in focusing prevention efforts. This study aims to determine when evacuation for SA and SI is most likely to occur based on the absolute and relative number of months in a deployed setting.

MATERIALS AND METHODS

This is a case-control study of active-duty military personnel evacuated from the U.S. Central Command area of responsibility for SI or an SA between April 1, 2020, and March 30, 2021. The arrival month and expected departure month were identified for all the included evacuees. The month of evacuation and proportion of completed deployment were compared. Secondary outcomes of mental health diagnosis or need for a waiver was also examined.

RESULTS

A total of 138 personnel evacuated for SI or attempted suicide during the 12-month study period were included in the analysis. Evacuations occurring during month 3 of deployment were significantly higher (P < .0001) than those during other months. The 30% and 50% completion point of deployment had statistically higher frequencies of evacuations for SI/SA (<.0001). A secondary analysis revealed that 25.4% of the individuals had a documented preexisting behavioral health condition before deployment (P < .0001).

CONCLUSION

Specific points along a deployment timeline were significant predictors for being evacuated for SI and SA.

P4 suicidality screener: Literature synthesis and results from two randomized trials

OBJECTIVE

To synthesize the literature on use of the P4 suicidality screener since its introduction in 2010 and to summarize results from 2 randomized clinical trials.

METHOD

A PubMed search was conducted from 2010 to 2023 to retrieve studies reporting on use of the P4. Also, data was extracted from the CAMMPS and SCOPE trials in which the P4 was periodically administered over 12 months when the 9th item of the PHQ-9 was endorsed.

RESULTS

A total of 21 research studies using the P4 were found, of which 12 provided some data on P4 findings. Additionally, another 7 protocol papers reported intended use of the P4 as a study measure. In our 2 trials, the 9th item was endorsed 259 (12.5%) times in 2068 administrations of the PHQ-9. Higher risk suicidal ideation was identified in 4.1% (12/294) of CAMMPS participants and 2.8% (7/250) of SCOPE participants. No suicide attempts occurred over the 12 months in either trial.

CONCLUSIONS

The P4 has had moderate use as a brief suicidality screener and is an efficient way to identify the small proportion of depressed patients with higher risk suicidality. Studies comparing the P4 with other common suicidality screeners would further inform use.

Tinnitus, Suicide, and Suicidal Ideation: A Scoping Review of Primary Research

Tinnitus (the perception of sound in the absence of any corresponding external source) is highly prevalent and can be distressing. There are unanswered questions about how tinnitus, suicidal thoughts, and suicidal behaviours co-occur and interact. To establish the extent of scientific literature, this scoping review catalogued primary reports addressing the associations between tinnitus, suicidal ideation, attempted suicide, and death by suicide. We searched OvidSP, Medline, EMBASE, PsycINFO, CINAHL, Google Scholar, EThoS, and ProQuest for all studies and case reports on ideation and/or attempted and/or completed suicide in the context of tinnitus. Twenty-three studies were included, and data were charted according to study type. Several epidemiological and other observational studies gave evidence of risk factors and an association between suicidal ideation, suicidal behaviour, and tinnitus. However, there was no evidence of the direction of causality. Qualitative studies are indicated to explore the patient's experience and understand the dynamics of any interaction between tinnitus and suicidal thoughts and behaviours. A theory-informed model of tinnitus and suicide needs to be developed to inform the development of interventions and how tinnitus patients are supported clinically.

Trajectories of perinatal suicidal ideation from early pregnancy to six weeks postpartum and their influencing factors: A prospective longitudinal study

Few studies focused on the trajectory of perinatal suicidal ideation from early pregnancy and covered whole routine perinatal periods. This study aimed to investigate the prevalence of suicidal ideation from early pregnancy to six weeks postpartum, and further explore the trajectories of perinatal suicidal ideation and their risk factors. A prospective longitudinal study was conducted in a comprehensive tertiary hospital in Hunan province, China among 1089 participants. Perinatal suicidal ideation and depression were assessed by item 9 of Patient Health Questionnaire 9 and the remaining eight items. Sociodemographic and psychological factors were collected by self-reported comprehensive questionnaires. Latent Growth Curve and Growth Mixture Modeling were used to identify the trajectories of suicidal ideation and logistic regression was used to explore risk factors of trajectories. A total of 629 participants were included. The prevalence of suicidal ideation was 16.4% from early pregnancy to six weeks postpartum, with 12.1% in pregnancy and 7.8% in postpartum. Two trajectories were identified: "persistent low levels of suicidal ideation" (92.9%) and "persistent high levels of suicidal ideation" (7.1%). 40.63% of women who screened positive for suicidal ideation during early pregnancy were in the "persistent high level of suicidal ideation" trajectory. A low level of neuroticism and anxiety symptoms during early pregnancy was associated with "persistent high levels of suicidal ideation". In conclusion, suicidal ideation of women during the perinatal period was dynamic, Suicidal ideation screening and identification in early pregnancy should be addressed for perinatal women to facilitate timely early interventions.

Suicide risk among individuals at Ultra-High Risk (UHR) of psychosis in a developing North African country: A 12-month naturalistic prospective cohort study from the TRIP project

BACKGROUND

The limited studies that focused on suicidality in individuals at Ultra-High Risk (UHR) of psychosis were predominantly cross-sectional, emerging from Western countries. We aimed to examine suicide risk among Tunisian UHR and First Episode Psychosis (FEP) patients at baseline, and to evaluate the evolution and correlates of suicidal ideation over a 12-month period in the UHR group exclusively.

METHODS

35 UHR (aged 22.8 ± 4.0 years, 45.7% male) and 33 FEP (aged 27.3 ± 4.8 years, 63.6% male) participants were included. The Comprehensive Assessment of at Risk Mental States, the Positive and Negative Syndrome Scale (PANSS), The Rosenberg Self-Esteem Scale, and The Multidimensional Scale of Perceived Social Support were used.

RESULTS

No significant differences were found between the UHR and the FEP groups with regard to levels of suicidal ideation at baseline. Suicidal ideation scores showed a significant decrease over time in UHR participants (p=.014; η2=0.242). An increase in total PANSS scores at 1 year (Beta=0.03; p=.048; 95%CI 0.001, 0.060; η2=0.182) significantly increased suicidal ideation scores at 1 year in the UHR group.

CONCLUSION

Our findings contribute to the limited body of evidence on this topic by providing new prospective data from a population, country and region that has never been researched previously.

Utility of PHQ-2, PHQ-8 and PHQ-9 for detecting major depression in primary health care: a validation study in Spain

BACKGROUND

Primary health care (PHC) professionals may play a crucial role in improving early diagnosis of depressive disorders. However, only 50% of cases are detected in PHC. The most widely used screening instrument for major depression is the Patient Health Questionnaire (PHQ), including the two-, eight- and nine-item versions. Surprisingly, there is neither enough evidence about the validity of PHQ in PHC patients in Spain nor indications about how to interpret the total scores. This study aimed to gather validity evidence to support the use of the three PHQ versions to screen for major depression in PHC in Spain. Additionally, the present study provided information for helping professionals to choose the best PHQ version according to the context.

METHODS

The sample was composed of 2579 participants from 22 Spanish PHC centers participating in the EIRA-3 study. The reliability and validity of the three PHQ versions for Spanish PHC patients were assessed based on responses to the questionnaire.

RESULTS

The PHQ-8 and PHQ-9 showed high internal consistency. The results obtained confirm the theoretically expected relationship between PHQ results and anxiety, social support and health-related QoL. A single-factor solution was confirmed. Regarding to the level of agreement with the CIDI interview (used as the criterion), our results indicate that the PHQ has a good discrimination power. The optimal cut-off values were: ⩾2 for PHQ-2, ⩾7 for PHQ-8 and ⩾8 for PHQ-9.

CONCLUSIONS

PHQ is a good and valuable tool for detecting major depression in PHC patients in Spain.

Prevalence of suicide risk among a national sample of individuals referred from a primary care subpopulation, 2017-2020

Over the past decade, the age-adjusted suicide rate has increased by 35.2% in the United States. In primary care, practitioners often interact with patients at risk of dying by suicide, yet little is known about the prevalence of suicide risk in primary care populations. Patient data from 2017-2020, consisting of a national sample of patients referred from primary care and enrolled in collaborative care behavioral health services (n = 37 666), were analyzed. Controlling for demographic characteristics, logistic models were used to compare suicide risk prevalence by behavioral health diagnosis. An estimated 9.96% (95% confidence interval [CI]: 9.65-10.27)-or approximately 3751 individuals-of the total sample screened positively for suicide risk. Compared with individuals diagnosed with generalized anxiety disorder, individuals diagnosed with bipolar disorder had 8.21 times the odds (95% CI: 6.66-10.10) of screening for suicide risk. Practitioners and health care systems may benefit from adding suicide risk screeners as a standard practice for referred patients, which may lead to further development of clinical pathways and provider training. The high rate of suicide risk across the sample suggests that more research is needed to understand suicide risk prevalence across primary care and collaborative care populations.

COVID-19 Pandemic-Related Job Loss Impacts on Mental Health in South Korea

OBJECTIVE

The economic hardship brought by the coronavirus disease-2019 (COVID-2019) pandemic has caused mental health problems among people of different socioeconomic status (SES). As social support helps to buffer these problems, we investigated the association between job loss related to COVID-19 and depression, anxiety, and suicidal thoughts; the differences in the effects according to SES; and the mediating effects of social support.

METHODS

The effects of COVID-19-related job loss on depression, anxiety, and suicidal thoughts among 1,364 people were investigated through semi-structured and self-administered questionnaires: Patient Health Questionnaire-9, General Anxiety Disorder-7, and the Functional Social Support Questionnaire. Logistic regression and subgroup analyses were performed to assess the association between job loss and mental health status, and the moderating effects of income and educational levels. Moreover, the mediating effects of perceived social support on the association between job loss and depression, anxiety, and suicidal thoughts were analyzed.

RESULTS

COVID-19-related job loss increased the risk of depression and suicidal thoughts. Adults with lower income and education level were at higher risk of depression, anxiety, and suicidal thoughts; perceived social support level had significant mediating effects on the association between job loss and depression/anxiety; and income level had significant moderating effects on this mediating pathway.

CONCLUSION

COVID-19-related job loss were likely to be significantly associated with negative mental health outcomes, especially among individuals with low income and education levels. As social support had buffering effects on such outcomes, related government policies in cooperation with the governance of communities and stakeholders must be prepared.

Prevalence, Characteristics, and Correlates of Avoidant/Restrictive Food Intake Disorder among Adult Respondents to the National Eating Disorders Association Online Screen: A Cross-Sectional Study

Background

Avoidant/restrictive food intake disorder (ARFID) is a serious, albeit under-researched, feeding or eating disorder. This exploratory study utilized data from adult respondents to the National Eating Disorders Association (NEDA) online eating disorder screen to validate items assessing the presence of ARFID and examine the prevalence, clinical characteristics, and correlates of a positive ARFID screen compared to other probable eating disorder/risk categories.

Methods

Among 47,705 adult screen respondents between January 2022 and January 2023, the prevalence of a positive ARFID screen was calculated. Chi-square tests and t-tests compared demographics, eating disorder attitudes and behaviors, suicidal ideation, current eating disorder treatment status, and eating disorder treatment-seeking intentions between respondents with possible ARFID and other eating disorder diagnostic and risk categories. Clinical characteristics of respondents with possible ARFID were also examined.

Results

2,378 (5.0%) adult respondents screened positive for ARFID. Respondents with possible ARFID tended to be younger, male, and have lower household income, and were less likely to be White and more likely to be Hispanic/Latino than most other diagnostic/risk groups. They had lower weight/shape concerns and eating disorder behaviors than all other diagnoses but higher BMI than those with AN. 35% reported suicidal ideation, 47% reported intentions to seek treatment for an eating disorder, and 2% reported currently being in treatment. The most common clinical feature of ARFID was lack of interest in eating (80%), followed by food sensory avoidance (55%) and avoidance of food due to fear of aversive consequences (31%).

Conclusions

Findings from this study indicated that ARFID was prevalent among adult screen respondents and more common among individuals who were younger, male, non-White, Hispanic, and lower income relative to those with other eating disorders or at risk for an eating disorder. Individuals with possible ARFID frequently reported suicidal ideation and were rarely in treatment for an eating disorder. Further research is urgently needed to improve advances in the assessment and treatment of ARFID and improve access to care in order to prevent prolonged illness duration.

Contribution of veterans' initial post-separation vocational, financial, and social experiences to their suicidal ideation trajectories following military service

BACKGROUND

Veterans' success with navigating the challenges of transition from military service may contribute to their risk for suicidal outcomes. The concept of well-being can help to conceptualize and assess successful navigation of reintegration challenges and may serve as an optimal target for public health-oriented suicide prevention.

METHODS

The relationship between US veterans' psychosocial well-being and experiences of suicidal ideation (SI) during the first 3 years following military separation was evaluated using multinomial logistic regression predicting SI trajectories over time in a population-based, longitudinal, post-9/11 veteran cohort. At 3-months post-separation, veterans reported on their socio-material conditions, functioning, and satisfaction with respect to vocational, financial, and social domains. SI frequency was assessed at 3-, 9-, 15-, 21-, and 27-months post-separation using the Patient Health Questionnaire-9.

RESULTS

Veterans' vocational, financial, and social well-being were associated with their SI trajectories, even after accounting for mental health. Socio-material conditions, functioning, and satisfaction all emerged as important predictors of SI trajectories, although results varied across domains. Effects were largest for social well-being.

CONCLUSIONS

Suicide prevention efforts may benefit from a holistic approach that considers veterans' needs for support across their vocational, financial, and social well-being, inclusive of their socio-material conditions, functioning, and satisfaction within each domain.

Firearms Availability Among High-School Age Youth With Recent Depression or Suicidality

BACKGROUND AND OBJECTIVES

Limiting firearm access is essential to decreasing teen suicide. Previous efforts have focused on household firearms; however, less is known about firearm access and possession among teens at increased suicide risk. Our objective was to estimate prevalence of firearm possession and access among high school-aged teens with recent depression and/or lifetime history of suicidality (DLHS).

METHODS

We conducted a probability-based, cross-sectional Web survey of 1914 parent-teen dyads between June 24, 2020, and July 22, 2020, with data weighted to generate a nationally representative sample of US teenagers (aged 14-18). Logistic regression analyses examined the difference between teens with and without DLHS for: (1) personal firearm possession, (2) perceived firearm access, and (3) method of firearm attainment.

RESULTS

Among high school-aged teens, 22.6% (95% confidence interval [CI], 19.4-25.8) reported DLHS, 11.5% (95% CI, 8.7-14.3) reported personal firearm possession, and 44.2% (95% CI, 40.2-48.2) endorsed firearm access. Teens experiencing DLHS had increased perceived access (adjusted odds ratio, 1.56; 95% CI, 1.07-2.28) compared with non-DLHS peers. There was no association between DLHS and personal firearm possession (adjusted odds ratio, 0.97; 95% CI, 0.47-2.00). Among teens reporting firearm possession, those with DLHS were more likely to have acquired it by buying/trading for it (odds ratio, 5.66; 95% CI, 1.17-27.37) and less likely receiving it as a gift (odds ratio, 0.06; 95% CI, 0.01-0.36).

CONCLUSIONS

High school-aged teens experiencing DLHS have higher perceived firearm access compared with lower-risk peers. Providers should speak directly to high school-aged teens at increased suicide risk about firearm access, in addition to counseling parents.