Contact with mental health and primary care providers before suicide: a review of the evidence

Navigating oneself through the eyes of the other - meanings of encountering ambulance clinicians while being in a suicidal process

PURPOSE

The suicidal process contains both observable and non-observable phases, and patients have described the process as characterized by loneliness and darkness. Ambulance clinicians encounter patients in all phases of the suicidal process but little is known on what meaning this encounter has to the patients. The aim of this study was to elucidate meanings of encountering ambulance clinicians while being in a suicidal process.

METHODS

Data were collected through fifteen individual interviews with eight participants who had lived experiences of encountering ambulance clinicians. Inductive design using phenomenological hermeneutical approach was used.

FINDINGS

Patients are impacted by the clinicians, both in how they find their value in the situation, but also in expected trajectory. Three themes; 'Being impacted by representatives of society', 'Being unsure of one´s own value' and 'Regaining hope in moments of togetherness' generated the main theme ´Navigating oneself through the eyes of the other´.

CONCLUSION

The way ambulance clinicians communicate impacts how patients navigate themselves in the ambivalence about living or dying, and the encounter either consolidate a feeling of being a burden, or instil hope of an endurable life. Through conversation, clinicians could support the patients in taking the first steps in the journey of recovery.

Sleep measures as a predictor of suicidal ideation among high-risk adolescents

Suicide is the second leading cause of death among youth aged 15-24 years. Identifying modifiable risk factors relevant to adolescents is crucial for suicide prevention. Sleep patterns have been linked to suicidality in adults, but lack sufficient study in youth. This ecological momentary assessment (EMA) study aimed to explore the relationship between objectively and subjectively measured sleep characteristics and next-day suicidal ideation in high-risk youth. We included 29 adolescents (12-18 years old) admitted to the inpatient psychiatric ward post-suicide attempt or due to suicidal intent within the previous month. We conducted objective (actigraphy) and subjective (sleep diary) sleep pattern assessments over ten consecutive days. Daily suicidal ideation was evaluated using a questionnaire based on the validated C-SSRS interview. A significant positive association was observed between sleep onset latency (SOL) and expressing a "death wish" the following day (OR = 1.06, 95% CI [1-1.11], p = .04), with each minute of longer SOL increased the risk for a death wish the following day by 6%. In addition, a marginally significant negative association was observed between total sleep time (TST) and expressing a "death wish" the following day (OR = 0.57, 95% CI [0.3-1.11], p = 0.1), with each one-hour decrease in objectively measured TST increasing the odds of a death wish by 43%. Our study highlights the interplay between sleep patterns and suicidal ideation, with SOL and TST playing a significant role that may function as proximal risk factors for suicidality and as a target for intervention while treating suicidal youth.

Accuracy and transportability of machine learning models for adolescent suicide prediction with longitudinal clinical records

Machine Learning models trained from real-world data have demonstrated promise in predicting suicide attempts in adolescents. However, their transportability, namely the performance of a model trained on one dataset and applied to different data, is largely unknown, hindering the clinical adoption of these models. Here we developed different machine learning-based suicide prediction models based on real-world data collected in different contexts (inpatient, outpatient, and all encounters) with varying purposes (administrative claims and electronic health records), and compared their cross-data performance. The three datasets used were the All-Payer Claims Database in Connecticut, the Hospital Inpatient Discharge Database in Connecticut, and the Electronic Health Records data provided by the Kansas Health Information Network. We included 285,320 patients among whom we identified 3389 (1.2%) suicide attempters and 66% of the suicide attempters were female. Different machine learning models were evaluated on source datasets where models were trained and then applied to target datasets. More complex models, particularly deep long short-term memory neural network models, did not outperform simpler regularized logistic regression models in terms of both local and transported performance. Transported models exhibited varying performance, showing drops or even improvements compared to their source performance. While they can achieve satisfactory transported performance, they are usually upper-bounded by the best performance of locally developed models, and they can identify additional new cases in target data. Our study uncovers complex transportability patterns and could facilitate the development of suicide prediction models with better performance and generalizability.

Using natural language processing to evaluate temporal patterns in suicide risk variation among high-risk Veterans

Measuring suicide risk fluctuation remains difficult, especially for high-suicide risk patients. Our study addressed this issue by leveraging Dynamic Topic Modeling, a natural language processing method that evaluates topic changes over time, to analyze high-suicide risk Veterans Affairs patients' unstructured electronic health records. Our sample included all high-risk patients that died (cases) or did not (controls) by suicide in 2017 and 2018. Cases and controls shared the same risk, location, and treatment intervals and received nine months of mental health care during the year before the relevant end date. Each case was matched with five controls. We analyzed case records from diagnosis until death and control records from diagnosis until matched case's death date. Our final sample included 218 cases and 943 controls. We analyzed the corpus using a Python-based Dynamic Topic Modeling algorithm. We identified five distinct topics, "Medication," "Intervention," "Treatment Goals," "Suicide," and "Treatment Focus." We observed divergent change patterns over time, with pathology-focused care increasing for cases and supportive care increasing for controls. The case topics tended to fluctuate more than the control topics, suggesting the importance of monitoring lability. Our study provides a method for monitoring risk fluctuation and strengthens the groundwork for time-sensitive risk measurement.

Last general practitioner consultation during the final month of life: a national medical record review of suicides in Sweden

OBJECTIVES

Individuals who die by suicide often consult their general practitioners (GPs) in their final weeks of life. The aim of this study was to gain a deeper knowledge of the clinical characteristics and GP assessments and treatments among individuals who consulted their GPs during the month preceding suicide. Further, we compared these features in those with and without contact with psychiatric services (PC and NPC, respectively) during the two years that preceded the suicide.

DESIGN

A nationwide retrospective explorative study investigating medical records.

SETTING

Primary care in Sweden.

PARTICIPANTS

Individuals who died by suicide in Sweden in 2015 with a GP visit within 30 days of death.

RESULTS

The study cohort corresponds to one fifth (n = 238) of all suicides that occurred in Sweden in 2015 (n = 1179), representing all those with available primary care records showing contact with a GP during the final 30 days of life (NPC: n = 125; PC: n = 113). The mean age was 58 years ± 19. Patients in the NPC group were older (NPC: 63 years ± 19 vs. PC: 53 years ± 18, p < 0.0001) and presented psychiatric symptoms less often (NPC: 50% vs. PC: 67%, p < 0.006). Somatic symptoms were as common as psychiatric symptoms for the whole sample, being present in more than half of individuals. Suicide risk was noted in only 6% of all individuals. Referral to psychiatric services occurred in 14%, less commonly for the NPC group (NPC: 6% vs. PC: 22%, p < 0.001). Cardiovascular or respiratory symptoms were noted in 19%, more often in the NPC group (NPC: 30% vs. PC: 6%, p < 0.001), as were diagnoses involving the circulatory system (all 10%, NPC:14% vs. PC: 5%, p < 0.020).

CONCLUSION

A high level of somatic symptoms was observed in primary care patients both with and without psychiatric contact, and this might have influenced GPs' management decisions. Psychiatric symptoms were noted in two thirds of those with psychiatric contact but only half of those without. While GPs noted psychiatric symptoms in over half of all individuals included in the study, they seldom noted suicide risk. These findings highlight the need for increased attention to psychiatric symptoms and suicide risk assessment, particularly among middle-aged and older individuals presenting with somatic symptoms.

STRENGTHS AND LIMITATIONS OF THIS STUDY

The National Cause of Death Register has excellent coverage of suicide deaths and access to medical records was very good. The medical record review provided detailed information regarding primary care utilization before death by suicide. Because of the lack of statistical power, due to the limited number of persons with GP contact during the last month of life, we chose not to correct for multiple comparisons. Our study approach did not capture the reasons behind GPs' documentation of elevated suicide risk. No systematic inter-rater reliability (IRR) testing was made, however, reviewers received training and continuous support from the research group.

Maternal mental health as a major contributor to maternal mortality

Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or postpartum individuals will encounter patients in these scenarios. Maternal Mortality Review Committees (MMRCs) have determined maternal mental health conditions, including SUD, to be the leading cause of preventable maternal death during pregnancy or in the first year postpartum. Lessons learned from MMRCs to prevent these deaths include the recommendation that screening and identification of mental health conditions need to be linked with evidence-based, patient-centered, and accessible treatments. Obstetricians and gynecologists, midwives, family medicine providers, and pediatricians, are in unique positions not only to screen and diagnose, but also to treat individuals with mental health concerns, including SUD, during pregnancy and postpartum.

A web-based video messaging intervention for suicide prevention in men: study protocol for a five-armed randomised controlled trial

BACKGROUND

More than 50% of people who die by suicide have not been in contact with formal mental health services. The rate of people who fly 'under the radar' of mental health services is higher among men than women, indicating a need to improve engagement strategies targeted towards men who experience suicidal thoughts and/or behaviours. In Australia, a range of mental health support services exist, designed specifically for men, yet, a substantial proportion of men do not use these services. The aim of this study is to evaluate whether a brief online video-based messaging intervention is an effective approach for encouraging men with suicidal thoughts and/or behaviours to engage with existing support services.

METHODS

Informed by a literature review, surveys, and consultation with men with a lived experience of suicidal thoughts and/or behaviours, we designed five video-based messages that will be used in this five-arm randomised controlled trial. A total of 380 (76 per arm) men aged 18 years or older with suicidal thoughts who are not currently accessing formal mental health services will be recruited online and randomly assigned to watch one of the five web-based video messages. After viewing the video, men will be presented with information about four existing Australian support services, along with links to these services. The primary outcome will be help-seeking, operationalised as a click on any one of the four support service links, immediately after viewing the video. Secondary outcomes include immediate self-reported help-seeking intentions in addition to self-reported use of the support services during a 1-week follow-up period. We will also use the Discrete Choice Experiment methodology to determine what aspects of support services (e.g. low cost, short appointment wait times) are most valued by this group of men.

DISCUSSION

This study is the first to evaluate the effectiveness of a brief web-based video messaging intervention for promoting engagement with existing support services among men with suicidal thoughts who are not currently receiving formal help. If found to be effective, this would represent a scalable, cost-effective approach to promote help-seeking for this at-risk population. Limitations and strengths of this study design are discussed.

An Environmental Scan of Suicide Prevention Resources for Older Veterans in Primary Care

OBJECTIVES

Previous research has identified the critical role of primary care for suicide prevention. Although several suicide prevention resources for primary care already exist, it is unclear how many have been created specifically for older veterans. This environmental scan sought to assemble a compendium of suicide prevention resources to be utilized in primary care.

METHODS

We searched four academic databases, Google Scholar, and Google to identify available suicide prevention resources. Data from 64 resources was extracted and summarized; 15 were general resources and did not meet inclusion criteria.

RESULTS

Our scan identified 49 resources with three resources specifically developed for older veterans in primary care. Identified resources shared overlapping content, including implementing a safety plan and lethal means reduction.

CONCLUSION

Although only 10 of the identified resources were exclusively primary care focused, many of the resources had content applicable to suicide prevention in primary care.

CLINICAL IMPLICATIONS

Primary care providers can use this compendium of resources to strengthen suicide prevention work within their clinics including: safety planning, lethal means reduction, assessing for risk factors that place older veteran at increased risk of suicide, and mitigating risk factors through referral to programs designed to support older adult health and well-being.

Predicting the Population Risk of Suicide Using Routinely Collected Health Administrative Data in Quebec, Canada: Model-Based Synthetic Estimation Study

BACKGROUND

Suicide is a significant public health issue. Many risk prediction tools have been developed to estimate an individual's risk of suicide. Risk prediction models can go beyond individual risk assessment; one important application of risk prediction models is population health planning. Suicide is a result of the interaction among the risk and protective factors at the individual, health care system, and community levels. Thus, policy and decision makers can play an important role in suicide prevention. However, few prediction models for the population risk of suicide have been developed.

OBJECTIVE

This study aims to develop and validate prediction models for the population risk of suicide using health administrative data, considering individual-, health system-, and community-level predictors.

METHODS

We used a case-control study design to develop sex-specific risk prediction models for suicide, using the health administrative data in Quebec, Canada. The training data included all suicide cases (n=8899) that occurred from January 1, 2002, to December 31, 2010. The control group was a 1% random sample of living individuals in each year between January 1, 2002, and December 31, 2010 (n=645,590). Logistic regression was used to develop the prediction models based on individual-, health care system-, and community-level predictors. The developed model was converted into synthetic estimation models, which concerted the individual-level predictors into community-level predictors. The synthetic estimation models were directly applied to the validation data from January 1, 2011, to December 31, 2019. We assessed the performance of the synthetic estimation models with four indicators: the agreement between predicted and observed proportions of suicide, mean average error, root mean square error, and the proportion of correctly identified high-risk regions.

RESULTS

The sex-specific models based on individual data had good discrimination (male model: C=0.79; female model: C=0.85) and calibration (Brier score for male model 0.01; Brier score for female model 0.005). With the regression-based synthetic models applied in the validation data, the absolute differences between the synthetic risk estimates and observed suicide risk ranged from 0% to 0.001%. The root mean square errors were under 0.2. The synthetic estimation model for males correctly predicted 4 of 5 high-risk regions in 8 years, and the model for females correctly predicted 4 of 5 high-risk regions in 5 years.

CONCLUSIONS

Using linked health administrative databases, this study demonstrated the feasibility and the validity of developing prediction models for the population risk of suicide, incorporating individual-, health system-, and community-level variables. Synthetic estimation models built on routinely collected health administrative data can accurately predict the population risk of suicide. This effort can be enhanced by timely access to other critical information at the population level.

Anxiety symptoms preceding suicide: A Swedish nationwide record review

BACKGROUND

The literature on the relationship between anxiety and suicidal behaviors is limited and findings are mixed. This study sought to determine whether physicians noted anxiety symptoms and suicidality in their patients in the weeks and months before suicide.

METHODS

Data were derived from a nationwide medical record review of confirmed suicides in Sweden in 2015. Individuals with at least one documented physician consultation in any health care setting during 12 months before suicide (N = 956) were included. Clinical characteristics were compared between decedents with and without a notation of anxiety symptoms. Odds ratios were calculated to estimate associations between anxiety symptoms and suicidality in relation to suicide proximity.

RESULTS

Anxiety symptoms were noted in half of individuals 1 week before suicide. Patients with anxiety were characterized by high rates of depressive symptoms, ongoing substance use issues, sleeping difficulties, and fatigue. After adjustment for mood disorders, the odds of having a notation of elevated suicide risk 1 week before death were doubled in persons with anxiety symptoms. Associations were similar across time periods (12 months - 1 week). Two-thirds had been prescribed antidepressants at time of death.

LIMITATIONS

Data were based on physicians' notations which likely resulted in underreporting of anxiety depending on medical specialty. Records were not available for all decedents.

CONCLUSIONS

Anxiety symptoms were common in the final week before suicide and were accompanied by increases in documented elevated suicide risk. Our findings can inform psychiatrists, non-psychiatric specialists, and GPs who meet and assess persons with anxiety symptoms.

Exploring the Role of Age and Gender on the Impact of Client Suicide in Mental Health Practitioners

Objective: Previous research has revealed that mental health professionals (MHPs) often experience severe, yet varying, levels of short-term impact in the aftermath of client suicide. Individual differences are significant, yet what factors help explain these differences remains unclear. The current study investigated the role of the MHPs' and the clients' age and gender upon the impact of client suicide. Method: An international sample of 213 MHPs, aged between 18 and 75, reported on a client's suicide and its short-term impact (IES-R). Results: The results indicate that both MHPs' and clients' gender did not affect impact. MHPs' and clients' age did not affect impact individually, although a significant interaction effect was revealed. Conclusion: Age, not gender, of the MHP and client are relevant in light of the impact of client suicide. Potential implications and suggestions for future research are discussed.

Effectiveness of a virtual patient simulation training on improving provider engagement in suicide safer care

BACKGROUND

Health care providers have a critical opportunity to mitigate the public health problem of suicide. Virtual patient simulations (VPS) allow providers to learn and practice evidence-based suicide prevention practices in a realistic and risk-free environment. The purpose of this study was to test whether receiving VPS training increases the likelihood that providers will engage in effective suicide safer care practices.

METHODS

Behavioral health and non-behavioral health providers (N = 19) at a Federally Qualified Health Center who work with patients at risk for suicide received the VPS training on risk assessment, safety planning, and motivation to engage in treatment. Providers' electronic health records were compared 6 months pre- and post-VPS training on their engagement in suicide safer care practices of screening, assessment, safety planning, and adding suicide ideation to the problem list.

RESULTS

Most behavioral health providers were already engaging in evidence-based suicide prevention care prior to the VPS training. Findings demonstrated the VPS training may impact the likelihood that non-behavioral health providers engage in suicide safer care practices.

CONCLUSION

VPS training in evidence-based suicide prevention practices can optimize and elevate all health care providers' skills in suicide care regardless of role and responsibility, demonstrating the potential to directly impact patient outcomes.

Recognising and Responding to Suicide-Risk Factors in Primary Care: A Scoping Review

The cost of one suicide is estimated to be £1.67 million (2 million euros) to the UK economy. Most people who die by suicide have seen a primary care practitioner (PCP) in the year prior to death. PCPs could aim to intervene before suicidal behaviours arise by addressing suicide-risk factors noted in primary care consultations, thereby preventing suicide and promoting health and wellbeing. This study aimed to conduct a rapid, systematic scoping review to explore how PCPs can effectively recognise and respond to suicide-risk factors. MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: suicide prevention, mental health and primary care. Two reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analysing study characteristics and findings. Forty-two studies met the eligibility criteria and were cited in this scoping review. Studies were published between 1990 and 2020 and were of good methodological quality. Six themes regarding suicide risk assessment in primary care were identified: Primary care consultations prior to suicide; Reasons for non-disclosure of suicidal behaviour; Screening for suicide risk; Training for primary care staff; Use of language by primary care staff; and, Difference in referral pathways from general practitioners or primary care practitioners. This review focused on better recognition and response to specific suicide-risk factors more widely such as poor mental health, substance misuse and long-term physical health conditions. Primary care is well placed to address the range of suicide-risk factors including biological, physical-health, psychological and socio-economic factors and therefore these findings could inform the development of person-centred approaches to be used in primary care.

Variations in healthcare utilization for mental health problems prior to suicide by socioeconomic status: a Norwegian register-based population study

BACKGROUND

Suicide poses a major public health challenge, claiming around 650 lives annually in Norway. There is limited understanding of mental healthcare utilization patterns preceding suicide, particularly relating to socioeconomic status (SES). This study analyzes mental health service use among Norwegian citizens aged 20-64 from 2009 to 2021, emphasizing disparities related to SES.

METHODS

This is a population-wide registry-based study. We include mental health consultations with both primary and specialist healthcare services, and investigate patterns of service use regarding educational attainment, employment status and income and compare this to the population in general. All suicides in the period (N = 4731) are included in the study. The aim is to investigate potential discrepancies in service use the year and month preceding suicide, seeking to enhance targeted preventive interventions.

RESULTS

Our results show significant variations in healthcare use for mental health problems the last year preceding suicide, according to the components of SES, for both men and women. Those with higher education utilize the mental healthcare services prior to suicide to a higher degree than men and women with high school education or less, whereas employed men and men with high income level have significantly lower mental healthcare usage prior to suicide both the last year and month compared to the non-employed men and men with low-income level. Employed women also had a lower mental healthcare usage, whereas the results regarding income are not significant for women.

CONCLUSION

Mental healthcare use prior to suicide varies across the SES components. Notably, the SES groups exhibit heterogeneity, with gendered patterns. Targeted interventions for low consultation rates among employed men, and men with high income and lower education are needed, while women, and men in at-risk groups, such as the non-employed and those with low income, demonstrate higher mental healthcare utilization, warranting comprehensive suicide prevention measures.

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.

The effectiveness of a suicide prevention program in primary care clinics supported by community public health resources: A difference-in-differences analysis

The importance of appropriate and intensive follow-up management for individuals identified with suicide risk through screening is highlighted. The Link between Primary Care Clinic and Public Health Resources Intervention(LinkPC-PH), a suicide prevention program in primary care clinics supported by community public health resources, was implemented at the district level in 2017. The purpose of the present study is to evaluate the effectiveness of the LinkPC-PH intervention by comparing suicide rates before(2014-2016) and after(2017-2019) implementation of the intervention using a difference-in-differences design. The LinkPC-PH comprises several dimensions of intervention including screening, risk assessment of suicidality, and referral in primary care clinics and crisis contact within 24 hours, case management, and safety planning led by public health professionals. After adjustment for district-level confounders, an intervention-implemented district had 2.87 fewer suicide deaths per 100,000 people in a population sample at post-intervention than would have been expected from the same trend in suicide rates as non-implemented intervention districts. In other words, the suicide rate in the intervention area decreased by 25% following the intervention. These results empirically substantiate suicide prevention programs in primary care clinics by community public health resources for reduced suicide rates to support effective community-based suicide prevention interventions.

Detection of Personal and Family History of Suicidal Thoughts and Behaviors using Deep Learning and Natural Language Processing: A Multi-Site Study

Objective

Personal and family history of suicidal thoughts and behaviors (PSH and FSH, respectively) are significant risk factors associated with future suicide events. These are often captured in narrative clinical notes in electronic health records (EHRs). Collaboratively, Weill Cornell Medicine (WCM), Northwestern Medicine (NM), and the University of Florida (UF) developed and validated deep learning (DL)-based natural language processing (NLP) tools to detect PSH and FSH from such notes. The tool's performance was further benchmarked against a method relying exclusively on ICD-9/10 diagnosis codes.

Materials and Methods

We developed DL-based NLP tools utilizing pre-trained transformer models Bio_ClinicalBERT and GatorTron, and compared them with expert-informed, rule-based methods. The tools were initially developed and validated using manually annotated clinical notes at WCM. Their portability and performance were further evaluated using clinical notes at NM and UF.

Results

The DL tools outperformed the rule-based NLP tool in identifying PSH and FHS. For detecting PSH, the rule-based system obtained an F1-score of 0.75 ± 0.07, while the Bio_ClinicalBERT and GatorTron DL tools scored 0.83 ± 0.09 and 0.84 ± 0.07, respectively. For detecting FSH, the rule-based NLP tool's F1-score was 0.69 ± 0.11, compared to 0.89 ± 0.10 for Bio_ClinicalBERT and 0.92 ± 0.07 for GatorTron. For the gold standard corpora across the three sites, only 2.2% (WCM), 9.3% (NM), and 7.8% (UF) of patients reported to have an ICD-9/10 diagnosis code for suicidal thoughts and behaviors prior to the clinical notes report date. The best performing GatorTron DL tool identified 93.0% (WCM), 80.4% (NM), and 89.0% (UF) of patients with documented PSH, and 85.0%(WCM), 89.5%(NM), and 100%(UF) of patients with documented FSH in their notes.

Discussion

While PSH and FSH are significant risk factors for future suicide events, little effort has been made previously to identify individuals with these history. To address this, we developed a transformer based DL method and compared with conventional rule-based NLP approach. The varying effectiveness of the rule-based tools across sites suggests a need for improvement in its dictionary-based approach. In contrast, the performances of the DL tools were higher and comparable across sites. Furthermore, DL tools were fine-tuned using only small number of annotated notes at each site, underscores its greater adaptability to local documentation practices and lexical variations.

Conclusion

Variations in local documentation practices across health care systems pose challenges to rule-based NLP tools. In contrast, the developed DL tools can effectively extract PSH and FSH information from unstructured clinical notes. These tools will provide clinicians with crucial information for assessing and treating patients at elevated risk for suicide who are rarely been diagnosed.

Recent tobacco smoking, restaurant and in-car secondhand smoke exposure are associated with depressive symptoms among young adults: a population-based cross-sectional analysis

The purpose of this study was to evaluate the association between recent tobacco smoking, household secondhand smoke exposure, confined space secondhand smoke exposure and depressive symptoms in young adults after adjustments for each other. Data from NHANES 2013-2018 were extracted. A total of 4129 young adults age 18-35 years (mean age 26.11 ± 5.39 years, 2021 males and 2108 females) were included. Depressive symptoms were screened by PHQ-9. Recent tobacco smoking was assessed through question "smoked tobacco in the last 5 days?". Household secondhand smoke exposure was assessed through question "living with a smoker who smoked inside the house?". Confined space secondhand smoke exposure was assessed by SSEQ. Binary logistic regression models were performed to analyze the associations. Significant association were observed in recent tobacco smoking (OR = 1.593, 95% CI 1.318-1.926) and confined space secondhand smoke exposure (OR = 1.399, 95% CI 1.185-1.651), but not in household secondhand smoke exposure (P = 0.108). Among the different settings of confined space secondhand smoke exposure, restaurant (OR = 1.732, 95% CI 1.120-2.678) and in-car (OR = 1.350, 95% CI 1.102-1.652) exposure were significantly associated with depressive symptom after after fully adjustments.

What Now?: Experiences of VHA patients following disclosure of suicidal ideation in primary care and mental health settings

OBJECTIVE

While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings.

METHOD

Qualitative thematic analysis using a conventional/directed hybrid approach.

RESULTS

A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options.

CONCLUSIONS

While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care.

Comorbidity profiles in older patients last seen by mental health prior to suicide attempt

OBJECTIVES

Suicide in late life is a public health concern. Determining profiles of psychiatric/medical comorbidity in those who attempt while engaged in mental health services may assist with prevention. We identified comorbidity profiles and their association with utilization, means, and fatality in a national sample who attempted suicide.

METHODS

Using latent class analysis, all patients aged ≥ 65 from the Department of Veterans Affairs (VA) healthcare services (2012-2018) last seen in mental health prior to suicide attempt were included. Diagnoses and attempt data were obtained from VA and Center for Medicare & Medicaid Services, VA Suicide Prevention Applications Network, and VA National Mortality Data Repository.

RESULTS

2,269 patients were clustered into three profiles, all with high probability of depression. Profiles included minimal comorbidity (50.4%), high medical comorbidity (28.6%), and high (psychiatric/medical) comorbidity (21.0%). Over half (61.7%) attempted suicide within one week of their visit. The class with highest comorbidity had lowest proportion of fatal attempts, while minimal comorbidity class had highest proportion.

CONCLUSIONS

Older patients last seen in mental health prior to suicide attempt were characterized by depression and varying additional comorbidity and attempt-related factors. Findings have implications for risk assessment and intervention in mental health settings, beyond depression.

Thwarted Belongingness and Suicide Risk in Primary Care: Perceived Burdensomeness and Psychache as Mediators

Suicide is a significant public health concern, particularly among primary care patients, given that many individuals who die by suicide visit their primary care provider in the months prior to their death. We examined constructs from two prominent theories of suicide, the interpersonal and psychache theories, including thwarted belongingness, perceived burdensomeness, and psychache. Among our sample (n = 224) of patients, perceived burdensomeness and psychache, individually and in serial, mediated the relation between thwarted belongingness and suicidal behavior. Thwarted belongingness was associated with greater perceived burdensomeness and, in turn, with more psychache and increased suicide risk. Our results elucidate the associations between the interpersonal and psychache theories of suicide. Clinical strategies that may reduce thwarted interpersonal needs and psychache, and which are appropriate for medical settings, are discussed.

What is the role of screening instruments in the management of psychiatric comorbidities in epilepsy? Tools and practical tips for the most common comorbidities: Depression and anxiety

Depression and anxiety are the most common psychiatric comorbidities in epilepsy and are known to increase healthcare utilization, the risk of refractory epilepsy, and anti-seizure medication intolerability. Despite this, depression and anxiety continue to be underrecognized and undertreated in people with epilepsy (PWE). Several barriers to the identification of depression and anxiety in PWE exist, including reliance on unstructured interviews rather than standardized, validated instruments. Moreover, there is a dearth of behavioral health providers to manage these comorbidities once identified. The use of validated screening instruments in epilepsy clinics can assist with both the identification of psychiatric symptoms and monitoring of treatment response by the epilepsy clinician for PWE with comorbid depression and/or anxiety. While screening instruments can identify psychiatric symptoms occurring within a specified time, they are not definitively diagnostic. Screeners can be time efficient tools to identify patients requiring further evaluation for diagnostic confirmation. This article reviews recent literature on the utility of depression and anxiety screening instruments in epilepsy care, including commonly used screening instruments, and provides solutions for potential barriers to clinical implementation. Validated depression and anxiety screening instruments can increase identification of depression and anxiety and guide epilepsy clinician management of these comorbidities which has the potential to positively impact patient care.

Suicidal Ideation in Canadian Family Caregivers for a Person with Dementia: A Portrait of the Situation

This study aimed to explore the prevalence of suicidal thoughts and potential associations (i.e., strength and direction) with caregiver characteristics or factors. A targeted survey was distributed to dementia caregivers aged 55+ years. Questions concerning psychological distress, suicidal thoughts while caregiving and antecedents of suicidal behaviours were administered. A sample of 71 French-speaking Canadian caregivers completed the survey between May and October 2019. Among them, 52.1 per cent (n = 37) reported suicidal ideation while providing care to a relative or a friend living with dementia. Caregivers who presented suicidal ideation reported more abusive behaviour toward the care recipient. Caregivers who reported suicidal thoughts were significantly more distressed than caregivers without them on measures of burden, depression, and anxiety. Suicidal thoughts in caregivers are important evaluation targets, primarily for the prevention of suicide, but also because caregivers who report suicidal thoughts also present a heightened risk for abusing the care recipient.

Previous mental health care and help-seeking experiences: Perspectives from sexual and gender minority survivors of near-fatal suicide attempts

Sexual and gender minority (SGM) populations face heightened risk of suicide compared to their heterosexual and cisgender counterparts, and a previous suicide attempt is among the strongest predictors of suicide mortality. Despite this increased risk, limited research has explored mental health help-seeking behavior and previous mental health care experiences of SGM individuals among the highest risk for suicide-individuals with a recent, near-fatal suicide attempt. This study presents thematic analysis results of interviews with 22 SGM individuals who reported at least one near-fatal suicide attempt in the past 18 months. Identified themes were (a) factors that affect help-seeking for SGM individuals with a recent, near-fatal suicide attempt, including previous mental health care experiences, support systems, and structural barriers and facilitators; (b) hospitalization is not a one-size fits all solution; and (c) recommendations for improving care for this population. Findings demonstrate that anti-SGM stigma may magnify existing barriers to mental health care across all socioecological levels. Notably, participants cited a fear of loss of autonomy from inpatient hospitalization and previous discriminatory experiences when seeking mental health care as hampering help-seeking. Given increased risk for suicide mortality, this patient population is a necessary stakeholder in suicide prevention and intervention development and policy discussions affecting mental health care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Computerized Suicide Prevention Clinical Training Simulations: A Pilot Study

Purpose

Mental health providers are well-positioned to engage in suicide prevention efforts, yet implementation depends on skill acquisition and providers often report feeling underprepared. This pilot study explored the acceptability, feasibility, and preliminary effectiveness of three suicide prevention-focused simulations with virtual clients.

Method

Students (n=22) were recruited from a MSW program, completed pre- and post-test surveys, and engaged with three simulated trainings: 1) suicide risk assessment, 2) safety planning, and 3) motivating a client to treatment.

Results

Simulations were reported to be acceptable and feasible, with strong student desire and need for greater suicide prevention training. We observed significant improvements over time in clinical skills via simulated training scores and perceptions of clinical preparedness.

Discussion

Preliminary findings indicate simulated training with virtual clients is promising and suggest the three suicide prevention simulations may be useful, scalable, and effective in social work training programs and beyond.

Prototyping the implementation of a suicide prevention protocol in primary care settings using PDSA cycles: a mixed method study

Introduction

In Canada, approximately 4,500 individuals die by suicide annually. Approximately 45% of suicide decedents had contact with their primary care provider within the month prior to their death. Current versus never smokers have an 81% increased risk of death by suicide. Those who smoke have additional risks for suicide such as depression, chronic pain, alcohol, and other substance use. They are more likely to experience adverse social determinants of health. Taken together, this suggests that smoking cessation programs in primary care could be facilitators of suicide prevention, but this has not been studied.

Study objectives

The objectives of the study are to understand barriers/facilitators to implementing a suicide prevention protocol within a smoking cessation program (STOP program), which is deployed by an academic mental health and addiction treatment hospital in primary care clinics and to develop and test implementation strategies to facilitate the uptake of suicide screening and assessment in primary care clinics across Ontario.

Methods

The study employed a three-phase sequential mixed-method design. Phase 1: Conducted interviews guided by the Consolidated Framework for Implementation Research exploring barriers to implementing a suicide prevention protocol. Phase 2: Performed consensus discussions to map barriers to implementation strategies using the Expert Recommendations for Implementing Change tool and rank barriers by relevance. Phase 3: Evaluated the feasibility and acceptability of implementation strategies using Plan Do Study Act cycles.

Results

Eleven healthcare providers and four research assistants identified lack of training and the need of better educational materials as implementation barriers. Participants endorsed and tested the top three ranked implementation strategies, namely, a webinar, adding a preamble before depression survey questions, and an infographic. After participating in the webinar and reviewing the educational materials, all participants endorsed the three strategies as acceptable/very acceptable and feasible/very feasible.

Conclusion

Although there are barriers to implementing a suicide prevention protocol within primary care, it is possible to overcome them with strategies deemed both acceptable and feasible. These results offer promising practice solutions to implement a suicide prevention protocol in smoking cessation programs delivered in primary care settings. Future efforts should track implementation of these strategies and measure outcomes, including provider confidence, self-efficacy, and knowledge, and patient outcomes.

Determining Distinct Suicide Attempts From Recurrent Electronic Health Record Codes: Classification Study

BACKGROUND

Prior suicide attempts are a relatively strong risk factor for future suicide attempts. There is growing interest in using longitudinal electronic health record (EHR) data to derive statistical risk prediction models for future suicide attempts and other suicidal behavior outcomes. However, model performance may be inflated by a largely unrecognized form of "data leakage" during model training: diagnostic codes for suicide attempt outcomes may refer to prior attempts that are also included in the model as predictors.

OBJECTIVE

We aimed to develop an automated rule for determining when documented suicide attempt diagnostic codes identify distinct suicide attempt events.

METHODS

From a large health care system's EHR, we randomly sampled suicide attempt codes for 300 patients with at least one pair of suicide attempt codes documented at least one but no more than 90 days apart. Supervised chart reviewers assigned the clinical settings (ie, emergency department [ED] versus non-ED), methods of suicide attempt, and intercode interval (number of days). The probability (or positive predictive value) that the second suicide attempt code in a given pair of codes referred to a distinct suicide attempt event from its preceding suicide attempt code was calculated by clinical setting, method, and intercode interval.

RESULTS

Of 1015 code pairs reviewed, 835 (82.3%) were nonindependent (ie, the 2 codes referred to the same suicide attempt event). When the second code in a pair was documented in a clinical setting other than the ED, it represented a distinct suicide attempt 3.3% of the time. The more time elapsed between codes, the more likely the second code in a pair referred to a distinct suicide attempt event from its preceding code. Code pairs in which the second suicide attempt code was assigned in an ED at least 5 days after its preceding suicide attempt code had a positive predictive value of 0.90.

CONCLUSIONS

EHR-based suicide risk prediction models that include International Classification of Diseases codes for prior suicide attempts as a predictor may be highly susceptible to bias due to data leakage in model training. We derived a simple rule to distinguish codes that reflect new, independent suicide attempts: suicide attempt codes documented in an ED setting at least 5 days after a preceding suicide attempt code can be confidently treated as new events in EHR-based suicide risk prediction models. This rule has the potential to minimize upward bias in model performance when prior suicide attempts are included as predictors in EHR-based suicide risk prediction models.

Continuity of care in suicide prevention: current status and future directions

Introduction

Continuity of Care (CoC) is central to suicide prevention. The present study aims to review contemporary definitions, operationalization in research, and key components of CoC in the prevention of suicide.

Methods

The present study is a narrative review. A thorough search of available literature on CoC and suicidality was conducted. Studies published between 1995 and 2021 were reviewed and selected based on relevance to CoC and suicidality. Selected research was subsequently summarized to outline definitions of CoC, its operationalization in research, and key components for suicide prevention.

Results

The definition, measurement, and operationalization of CoC in suicide prevention varies tremendously, derailing clinical practice. Key elements of CoC identified across the literature include (1) CoC across multiple levels of care, (2) the role of primary care providers and case managers in CoC of suicidal patients, (3) the importance of follow up contact with suicidal patients post-treatment, and (4) the role of national and institutional guidelines for CoC of suicidal patients. Limitations: There is a dearth of randomized controlled trials and insufficient evidence on specific populations.

Conclusion

CoC refers to a wide, complex concept that must be broken down into specific categories that can provide more nuanced guidance of research and clinical implications.

Healthcare Utilization 12 Months Prior to Fatal and Non-fatal Suicidal Behaviour in Cape Town, South Africa

The purpose of this study was to characterize healthcare use for general care and mental health one year before suicidal behavior among individuals with fatal and non-fatal suicidal behavior (NFSB) in Cape Town, South Africa. We linked electronic health records of 484 participants from a case series of 93 completed suicides on whom forensic autopsies were performed at a mortuary in Cape Town, between August 2014 and January 2016; and 391 patients admitted to hospital following NFSB between June 2014 and March 2015, and between August 2015 and August 2017. Time from last healthcare visit to date of suicidal behavior (fatal or non-fatal) was calculated, and Kaplan Meier curves were used to compare the differences by psychiatric diagnoses and study group. Overall, 64.5% of completed suicides and 65.9% of NFSB patients sought general healthcare in the year before suicidal behavior. Most of these visits occurred at hospital outpatient clinics (40.8%) and primary healthcare facilities (31.3%). The prevalence of preexisting psychiatric diagnoses and the use of mental healthcare services was lower for individuals who completed suicide compared to NFSB patients. Common reasons for a healthcare visit among individuals who completed suicide were chronic disease and assault; and psychiatric illness (depression, bipolar, and/or substance use disorders), chronic disease and HIV among NFSB patients. A large proportion of individuals with fatal and NFSB interacted with the healthcare system before suicidal behavior. These findings suggest opportunities for suicide prevention at primary healthcare facilities, antiretroviral treatment centers and emergency departments.HIGHLIGHTSHealthcare access is common among individuals with fatal and NFSB in the year before suicidal behavior.The prevalence of mental disorder diagnoses is higher among NFSB patients than among individuals who completed suicide.A greater proportion of NFSB patients accessed mental healthcare services compared to individuals who completed suicide.

Late life anxiety and depression symptoms, and suicidal behaviors in racial/ethnic minority older adults in community-based organizations and community clinics in the U.S

OBJECTIVE

Late life anxiety and depression represent a significant source of disability, with racial/ethnic minority older adults in the U.S. showing marked disparities in healthy aging. Community-based organizations (CBOs) and community clinics serve these populations for preventive care, yet few identify their mental health service needs. We examine the association between race/ethnicity and risk of mild-to-severe symptoms of anxiety and depression, and suicidal behaviors in minority older adults.

METHOD

Data come from the multisite randomized controlled trial Building Community Capacity for Disability Prevention for Minority Elders, which screened 1,057 adults (45.5% Asian, 26.8% Latinx, 15.0% non-Latinx Black, 8.5% non-Latinx White, and 4.2% American Indian) aged 60 + years at CBOs and clinics in Massachusetts, New York, Florida, and Puerto Rico. Screened participants completed the Generalized Anxiety Disorder-7 (GAD-7) for anxiety symptoms, the Geriatric Depression Scale-15 (GDS-15) for depression symptoms, and the Paykel Suicide Risk Questionnaire for suicidal behaviors.

RESULTS

28.1% of older adults reported mild-to-severe anxiety symptoms, 30.1% reported mild-to-severe depression symptoms, and 4.3% reported at least one suicidal behavior. Compared to non-Latinx Whites, Latinxs had higher odds of mild-to-severe anxiety and depression symptoms and one or more suicidal behaviors, and Asians had higher odds of mild-to-severe depression symptoms only.

CONCLUSIONS

There is an urgent need to improve outreach for screening and preventive mental health care for minority older adults. Expanding outreach and community-based capacity to identify and treat minority older adults with mental health conditions represents an opportunity to prevent disability. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Measurement Choices for Youth Suicidality

Suicide is among the leading causes of death among individuals ages 10-24, making suicidal thoughts and behaviors (STBs) a serious public health crisis among youth. Suicide risk screening and assessment are vital to addressing this public health crisis. In fact, many youths that screen positive for suicidal ideation do not have known mental health concerns and would have been missed if not asked directly. Medical settings are an optimal setting to detect suicidality early and provide appropriate follow-up monitoring and care as needed. To support effective and efficient screening and assessment of suicidal thoughts and behaviors, providers must choose measures with both strong psychometric properties and clinical utility. While measurement of STBs can vary across health settings, suicide risk screening and assessment typically involves gathering information about current suicidal ideation, suicidal behaviors, and suicidal plans via self-report questionnaires, clinical interviews, and/or computerized adaptive screens. In alignment with measurement-based care efforts, the current manuscript will provide a scoping review of measures of youth suicidal ideation, behavior, plans, and their risk factors. Specifically, the psychometric properties, clinical utility, and other key considerations for screening and assessment of adolescent suicide risk are discussed.

Early Risk Factors for Self-Injurious Thoughts and Behaviours: A UK Population-Based Study of 219,581 People

Mental disorders are a major problem among young people. To identify early risk factors of self-injurious thoughts and behaviours (SITB) among young adults with mental health problems, this case-control study drew data from the Clinical Practice Research Datalink (CPRD), a primary care database covering 8% of the UK population. We explored the role of early factors (presenting at 8-14 years old) for suicidal ideation, suicide attempts, and non-suicidal self-injury (NSSI) in young adulthood (age 18-25 years) by performing logistic regressions. Our sample consisted of 219,581 participants, of which 6.51% had at least one SITB in young adulthood. Early risk factors for SITB included early NSSI, suicidal ideation, sexual abuse, behavioural problems, and mood and psychotic symptoms. Frequency of GP visits had a protective effect. Lack of access to mortality data, ethnicity, and socioeconomic status was a limitation of the current study. In conclusion, early symptoms in late childhood/early adolescence can be the start of long-standing problems going into adult life. The training of primary care providers in suicide risk assessment and proper co-ordination with child and adolescent mental health services are crucial for suicide prevention.

Continuity of care after attempted suicide: the primary care physicians' role

BACKGROUND

Suicide prevention is an important public health concern, and primary care physicians (PCPs) often serve as the first point of contact for individuals at risk. Few interventions in the primary care setting have been linked to reduced suicide attempt (SA) rates. The Continuity of Care (COC) protocol was developed to improve the primary care treatment of high-risk suicidal patients.

OBJECTIVES

This study examined PCPs' awareness of the COC protocol, its perceived effectiveness, and PCPs' attitudes towards post-SA-discharge visits.

METHODS

A survey was administered to 64 PCPs who had a recent office visit with a patient who had attempted suicide. Data were collected between May and July 2021 and analyzed anonymously.

RESULTS

Thirty of the 64 PCPs answered the questionnaires, giving a response rate of 47%. Most were unaware of the COC protocol. Seventeen physicians (57%) felt that the visit strengthened their physician-patient relationship, and while nearly half of the physicians (47%, n = 14) agreed they had the knowledge and tools to manage a post-SA-discharge visit, 43% of them (n = 13) preferred that the visit would have been handled by a mental health professional rather than a PCP. Analysis of open-ended questions uncovered three themes: knowledge gap, system limitation, and the PCP's role in maintaining the COC.

CONCLUSION

The findings of this study highlighted the important role PCPs can play to prevent future SAs, as well as exposed gaps in the knowledge and system constraints that impede them from carrying out this role as effectively as possible.

Identifying features of risk periods for suicide attempts using document frequency and language use in electronic health records

Background

Individualising mental healthcare at times when a patient is most at risk of suicide involves shifting research emphasis from static risk factors to those that may be modifiable with interventions. Currently, risk assessment is based on a range of extensively reported stable risk factors, but critical to dynamic suicide risk assessment is an understanding of each individual patient's health trajectory over time. The use of electronic health records (EHRs) and analysis using machine learning has the potential to accelerate progress in developing early warning indicators.

Setting

EHR data from the South London and Maudsley NHS Foundation Trust (SLaM) which provides secondary mental healthcare for 1.8 million people living in four South London boroughs.

Objectives

To determine whether the time window proximal to a hospitalised suicide attempt can be discriminated from a distal period of lower risk by analysing the documentation and mental health clinical free text data from EHRs and (i) investigate whether the rate at which EHR documents are recorded per patient is associated with a suicide attempt; (ii) compare document-level word usage between documents proximal and distal to a suicide attempt; and (iii) compare n-gram frequency related to third-person pronoun use proximal and distal to a suicide attempt using machine learning.

Methods

The Clinical Record Interactive Search (CRIS) system allowed access to de-identified information from the EHRs. CRIS has been linked with Hospital Episode Statistics (HES) data for Admitted Patient Care. We analysed document and event data for patients who had at some point between 1 April 2006 and 31 March 2013 been hospitalised with a HES ICD-10 code related to attempted suicide (X60-X84; Y10-Y34; Y87.0/Y87.2).

Findings

n = 8,247 patients were identified to have made a hospitalised suicide attempt. Of these, n = 3,167 (39.8%) of patients had at least one document available in their EHR prior to their first suicide attempt. N = 1,424 (45.0%) of these patients had been "monitored" by mental healthcare services in the past 30 days. From 60 days prior to a first suicide attempt, there was a rapid increase in the monitoring level (document recording of the past 30 days) increasing from 35.1 to 45.0%. Documents containing words related to prescribed medications/drugs/overdose/poisoning/addiction had the highest odds of being a risk indicator used proximal to a suicide attempt (OR 1.88; precision 0.91 and recall 0.93), and documents with words citing a care plan were associated with the lowest risk for a suicide attempt (OR 0.22; precision 1.00 and recall 1.00). Function words, word sequence, and pronouns were most common in all three representations (uni-, bi-, and tri-gram).

Conclusion

EHR documentation frequency and language use can be used to distinguish periods distal from and proximal to a suicide attempt. However, in our study 55.0% of patients with documentation, prior to their first suicide attempt, did not have a record in the preceding 30 days, meaning that there are a high number who are not seen by services at their most vulnerable point.

Does Suicide Risk Screening Improve the Identification of Primary Care Patients Who Will Attempt Suicide Versus Depression Screening Alone?

OBJECTIVE

The effectiveness of suicide risk screening relative to depression screening alone among primary care patients has not been tested rigorously. This study compared the performance of multiple depression screening methods (Patient Health Questionnaire [PHQ]-2, PHQ-8, and PHQ-9) and multiple suicide risk screening methods (PHQ-9 item 9 and suicide-focused screening of "thoughts of killing yourself" during the entire lifespan, within the past month, and within the past week) in a convenience sample of primary care patients.

METHODS

A total of 2,744 patients (military personnel, family members, and retirees) from six military primary care clinics completed the PHQ-9 and screening for suicidal ideation (SI) during routine clinic visits. Follow-up phone interviews were conducted for one year post-baseline to assess the incidence of suicide attempts, the study's primary outcome. Sensitivity, specificity, accuracy, and F1 statistics were calculated for each screening method for identifying patients who attempted suicide.

RESULTS

More than 65% of patients who screened positive for SI also screened positive for depression on the PHQ-9. Depression screening with the PHQ-9 correctly identified more patients who attempted suicide during follow-up than the PHQ-2, past week SI, and past month SI. The PHQ-9 correctly identified more patients who attempted suicide within 3 months than lifetime SI, but lifetime SI correctly identified more patients who attempted suicide within 6 and 12 months.

CONCLUSION

Depression screening with the PHQ-9 was the most effective strategy for identifying patients who attempted suicide in the near term. Universal suicide risk screening is unlikely to meaningfully improve identification of higher-risk patients beyond PHQ-9 depression screening.

Sequential autoencoders for feature engineering and pretraining in major depressive disorder risk prediction

Objectives

We evaluated autoencoders as a feature engineering and pretraining technique to improve major depressive disorder (MDD) prognostic risk prediction. Autoencoders can represent temporal feature relationships not identified by aggregate features. The predictive performance of autoencoders of multiple sequential structures was evaluated as feature engineering and pretraining strategies on an array of prediction tasks and compared to a restricted Boltzmann machine (RBM) and random forests as a benchmark.

Materials and Methods

We study MDD patients from Vanderbilt University Medical Center. Autoencoder models with Attention and long-short-term memory (LSTM) layers were trained to create latent representations of the input data. Predictive performance was evaluated temporally by fitting random forest models to predict future outcomes with engineered features as input and using autoencoder weights to initialize neural network layers. We evaluated area under the precision-recall curve (AUPRC) trends and variation over the study population's treatment course.

Results

The pretrained LSTM model improved predictive performance over pretrained Attention models and benchmarks in 3 of 4 outcomes including self-harm/suicide attempt (AUPRCs, LSTM pretrained = 0.012, Attention pretrained = 0.010, RBM = 0.009, random forest = 0.005). The use of autoencoders for feature engineering had varied results, with benchmarks outperforming LSTM and Attention encodings on the self-harm/suicide attempt outcome (AUPRCs, LSTM encodings = 0.003, Attention encodings = 0.004, RBM = 0.009, random forest = 0.005).

Discussion

Improvement in prediction resulting from pretraining has the potential for increased clinical impact of MDD risk models. We did not find evidence that the use of temporal feature encodings was additive to predictive performance in the study population. This suggests that predictive information retained by model weights may be lost during encoding. LSTM pretrained model predictive performance is shown to be clinically useful and improves over state-of-the-art predictors in the MDD phenotype. LSTM model performance warrants consideration of use in future related studies.

Conclusion

LSTM models with pretrained weights from autoencoders were able to outperform the benchmark and a pretrained Attention model. Future researchers developing risk models in MDD may benefit from the use of LSTM autoencoder pretrained weights.

Cross-cultural adaptation of Nepalese literacy and stigma of suicide scales (LOSS-SF-Nep and SOSS-SF-Nep) among Nepalese medical and nursing students

INTRODUCTION

Nepal is a country in South-east Asia with high suicide. There is ongoing trend of emerging research on suicide from Nepal but there is lack of validated scale in measuring literacy or stigma. In the view of poor media reporting and large treatment gap, this study was conducted. All previous validation studies were done in non-Hindu populations.

METHODS

A cross-sectional study was planned where the short forms of Nepalese literacy of suicide scale (LOSS-SF-Nep) and Stigma of Suicide Scale (SOSS-SF-Nep) were validated using standard procedure at a medical college in southern Nepal. Medical and nursing students of all batches were approached offline after successful pretesting. The psychometric properties of the scales were tested, and the statuses of literacy and stigma were assessed. Patient Health Questionnaire-9 and General Anxiety Disorder Scale-7 were used for revealing depression and generalized anxiety.

RESULTS

Three hundred and nineteen Nepalese students participated and most of them were males, belonged to nuclear family, upper-middle socioeconomic status and represented 46 out of 77 districts of Nepal. The mean score of LOSS-SF-Nep was 6.36 ± 1.92 and literacy ranged from 37.9% to 89.7%. The deeper exposure to suicidal patients was associated with better literacy. Factor analysis of SOSS-SF-Nep revealed three subscales: stigmatization, isolation/depression, and normalization/glorification and had acceptable psychometric properties. Gender, occupation of head of the family, region and years of education, using mental health services, and depression were associated with variable literacy or stigma.

CONCLUSION

Literacy and stigma scales were validated in Nepali, and SOSS factor structures were revealed with modified descriptors. The literacy and stigma levels in medical students were calculated for the first time in Nepal and Hindu majority population.

Understanding suicidal transitions in Australian adults: protocol for the LifeTrack prospective longitudinal cohort study

BACKGROUND

The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide.

AIM

The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years.

METHODS

A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress.

CONCLUSION

This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

Building an Integrated Data Infrastructure to Examine the Spectrum of Suicide Risk Factors in Philadelphia Medicaid

While there are many data-driven approaches to identifying individuals at risk of suicide, they tend to focus on clinical risk factors, such as previous psychiatric hospitalizations, and rarely include risk factors that occur in nonclinical settings, such as jails or emergency shelters. A better understanding of system-level encounters by individuals at risk of suicide could help inform suicide prevention efforts. In Philadelphia, we built a community-level data infrastructure that encompassed suicide death records, behavioral health claims, incarceration episodes, emergency housing episodes, and involuntary commitment petitions to examine a broader spectrum of suicide risk factors. Here, we describe the development of the data infrastructure, present key trends in suicide deaths in Philadelphia, and, for the Medicaid-eligible population, determine whether suicide decedents were more likely to interact with the behavioral health, carceral, and housing service systems compared to Medicaid-eligible Philadelphians who did not die by suicide. Between 2003 and 2018, there was an increase in the number of annual suicide deaths among Medicaid-eligible individuals, in part due to changes in Medicaid eligibility. There were disproportionately more suicide deaths among Black and Hispanic individuals who were Medicaid-eligible, who were younger on average, compared to suicide decedents who were never Medicaid-eligible. However, when we accounted for the racial and ethnic composition of the Medicaid population at large, we found that White individuals were four times as likely to die by suicide, while Asian, Black, Hispanic, and individuals of other races were less likely to die by suicide. Overall, 58% of individuals who were Medicaid-eligible and died by suicide had at least one Medicaid-funded behavioral health claim, 10% had at least one emergency housing episode, 25% had at least one incarceration episode, and 22% had at least one involuntary commitment. By developing a data infrastructure that can incorporate a broader spectrum of risk factors for suicide, we demonstrate how communities can harness administrative data to inform suicide prevention efforts. Our findings point to the need for suicide prevention in nonclinical settings such as jails and emergency shelters, and demonstrate important trends in suicide deaths in the Medicaid population.

Are Parents the Key? How Parental Suicide Stigma and Suicide Literacy Affect Help-Seeking Attitudes and Intentions for their Child

Suicide is the leading cause of death among Australian young people, yet rates of help-seeking for suicidal ideation and behaviors in this population are concerningly low. In this study, the relationships between parental suicide stigma, parental suicide literacy, and their attitudes and intentions toward seeking professional help for their child if they were to express thoughts of suicide are investigated. Understanding this influence is critical given parents are key facilitators of their child's access to and engagement with professional mental health services. An online survey was administered to 302 parents of children aged-12-18 (Mage = 45.36, SDage = 6.23; 91.4% female). Parental suicide stigma was significantly associated with more negative help-seeking attitudes and lower help-seeking intentions. Other significant predictors of more positive help-seeking attitudes included parental self-efficacy and having a child with no history of suicidal ideation. Higher help-seeking intentions were associated with female gender, living in an urban area, and positive help-seeking attitudes. Parental suicide literacy was not significantly associated with help-seeking. Practically, outcomes of this study may inform the development and implementation of targeted education programs to increase parental help-seeking for their children.

Quantitative content analysis of Freedom of Information requests examining the extent and variations of tools and training for conducting suicide risk assessments in NHS Trusts across England

OBJECTIVES

Determining the risk for suicide is a difficult endeavour. Clinical guidance in the UK explicitly advises against using risk assessment tools and scales to determine suicide risk. Based on Freedom of Information (FoI) requests made to NHS Trusts in England, this study provides an overview of suicide risk assessment tools in use, training provided in how to use such assessments, and explores implementation of suicide risk assessment guidance in practice in English NHS Trusts.

DESIGN

A cross-sectional survey of suicide risk assessment tools and training gathered via FoI requests and subjected to a content analysis.

SETTING

FoI requests were submitted to NHS Trusts across England.

RESULTS

A wide variety of suicide risk assessments tools were identified as being used in practice, with several trusts reported using more than one tool to determine suicide risk. Forty-one trusts reported using locally developed, unvalidated, tools to assess risk of suicide and 18 stated they do not use a tool. Ten trusts stated they do not train their staff in suicide risk assessment while 13 reported use of specific suicide risk assessment training. Sixty-two trusts stated they do not centrally record the number of assessments conducted or how many individuals are identified as at risk. Content analysis indicated the frequent wider assessment of risk not restricted to suicide risk.

CONCLUSIONS

There is wide variation in suicide risk assessment tools being used in practice and some lack of specific training for healthcare staff in determining suicide risk. Few trusts routinely record the number of assessments being conducted or the number of individuals identified at high risk. Implementation of specific training is necessary for the suicide risk assessment process to identify patient needs and develop therapeutic engagement. Routinely recording how many assessments are conducted is a crucial step in improving suicide prevention.

A mixed-methods evaluation of the acceptability and fidelity of the James' Place model for men experiencing suicidal crisis

Background

Research supports development of informal, community-based suicide prevention interventions that can be tailored to suit men's unmet needs. The James' Place model (JPM) is a community-based, clinical suicide prevention intervention for men experiencing suicidal crisis. Evidence supports the efficacy of the JPM and there are plans to expand to additional sites across the UK. This study evaluates therapists perceived acceptability of the JPM, and if fidelity to the planned delivery of the model is maintained within therapeutic practice.

Method

A mixed-methods design was used. Descriptive analyses of 30 completed intervention cases were examined to review fidelity of the model against the intervention delivery plan. Eight therapists took part in semi-structured interviews between November 2021 and March 2022 exploring the perceived acceptability, and barriers and facilitators to delivering the JPM.

Results

Descriptive analyses of James' Place audit notes revealed high levels of adherence to the JPM amongst therapists, but highlighted components of the model needed to be tailored according to individual men's needs. Thematic analysis led to the development of five themes. The first theme, therapeutic environment highlighted importance of the therapy setting. The second theme identified was specialised suicide prevention training in the JPM that facilitated therapists understanding and expertise. The third theme identified was therapy engagement which discusses men's engagement in therapy. The fourth theme, person-centred care related to adaptation of delivery of JPM components. The final theme, adapting the JPM to individual needs describes tailoring of the JPM by therapists to be responsive to individual men's needs.

Conclusion

The findings evidence therapist's acceptability and their moderate adherence to the JPM. Flexibility in delivery of the JPM enables adaptation of the model and co-production of therapy to meet men's needs. Implications for clinical practice are discussed.

[Impact of the suicidal crisis intervention training program on the confidence and skills of hospital professionals in the Hauts-de-France region]

INTRODUCTION

Suicide is a major public health issue given its huge human and economic consequences. Symptoms prior to suicide are often not specific. Nevertheless, the majority of suicidal people express suicidal thoughts, and nearly one in two meet a health professional in the period preceding the act. Being able to recognize the warnings and intervene during the suicidal crisis, defined as a mental crisis where the major risk is suicide, is to seize the opportunity to postpone the suicidal plan and to gain time to implement in place lasting strategies to combat suffering. Thus, the training for suicidal crisis intervention is a major axis of the suicide prevention strategy. Recently, crisis intervention training programs have been updated with knowledge accumulated since the early 2000's. In France, one of the countries most concerned by suicide, the Hauts-de-France region is one of the most impacted. In this context, the Regional Health Agency of Hauts-de-France included in its Regional Health Program of 2018-2023 the training of healthcare workers who work with high suicidal risk patients. The suicidal crisis intervention training program (SCIT) has been introduced to hospital staffs in Hauts-de-France. The purpose of this study was to evaluate this program.

METHODS

Eight training sessions with 15 to 21 participants were carried out from 2019 November to 2021 January in the Hauts-de-France region. Participants were volunteer healthcare professionals in direct contact with suicidal crisis patients. The training included three modules. The first one concerned the suicidal crisis intervention training: definition of the suicidal crisis, typology of the crisis, vulnerability development, crisis evaluation and crisis intervention practice. The second concerned the evaluation with the RED scale (Risk-Emergency-Danger) and the adequate patient orientation to a psychiatric unit. The third was dedicated to the Gatekeeper training with the constitution of a Gatekeeper network to enhance the capacity to detect suicidal risk and to orient the concerned person towards an adequate evaluation or care organization. We evaluated the first two levels of the Kirkpatrick's model: level 1) the participant's satisfaction (rated out of 10), and level 2) the degree of confidence in their professional abilities (rated out of 10) and their skills in responding to a person in a suicidal crisis (using the SIRI-2-VF - French version of the Suicide Intervention Response Inventory-2). The participants were interviewed before (T0), just after (T1) and at one month of training (T2).

RESULTS

Among the 141 health professionals who followed the training, 139 answered the questionnaire at least one time (13 psychologists, 22 doctors, 97 nurses and 7 head nurses). The participation rates were 99.3 % at T0, 96.4 % at T1 and 46.0 % at T2. Most of the participants were nurses (69.8 %), and 33.1 % of the respondents declared they had already followed a suicidal crisis training. The satisfaction with the training was evaluated at 8.6 (± 1.3) out of 10. There was no significant difference among the professions, neither between those having already received or not a previous training. The self-perceived capacity to manage a suicidal crisis was rate 6.8 (± 1.8) out of 10 at T0. There was a significant increase just after the training (8.1±1.2 vs 6,8±1,8, p<0,001) which persisted at 1 month (8.1±1.1 vs 6.8±1.8, P<0.001). The score at the SIRI-2-VF was 15.0 (± 4.2) out of 30 at T0. There was a significant increase just after the training (17.5±3.5 vs 15.0±4.2, P<0.001), which persisted at 1 month (17.0±4.0 vs 15.0±4.2, P<0.001).

DISCUSSION

This is the first evaluation of the suicidal crisis intervention training program. This program increased and homogenized the competency of the participants to manage suicidal ideation and behaviors. Those who followed a previous training maintained higher scores than the others, which shows the importance of repeated training to maintain a satisfying level of knowledge over the long term. One of the strengths of this training is the use of roleplay which enhances the learning and abilities to interact with people at suicidal risk. It seems important to integrate a suicidal crisis intervention training in the cursus of health students to avoid suicide and the dramatic consequences for the entourage and the health professionals who are confronted with it.

CONCLUSION

The SCIT program showed encouraging results in terms of confidence and capacity of the healthcare professionals to intervene in suicidal crisis.

Impact of Sources of Strength on adolescent suicide deaths across three randomized trials

Universal interventions are key to reducing youth suicide rates, yet no universal intervention has demonstrated reduction in suicide mortality through an RCT. This study pooled three cluster-RCTs of Sources of Strength (n=78 high schools), a universal social network-informed intervention. In each trial, matched pairs of schools were assigned to immediate intervention or wait-list. Six schools were assigned without a pair due to logistical constraints. During the study period, no suicides occurred in intervention schools vs four in control schools, that is, suicide rates of 0 vs. 20.86/100,000, respectively. Results varied across statistical tests of impact. A state-level exact test pooling all available schools showed fewer suicides in intervention vs. control schools (p=0.047); whereas a stricter test involving only schools with a randomised pair found no difference (p=0.150). Results suggest that identifying mortality-reducing interventions will require commitment to new public-health designs optimised for population-level interventions, including adaptive roll-out trials.

Understanding the Factors Contributing to Suicide Among the Geriatric Population: A Narrative Review

A critical health concern for older adults is suicide, particularly for those above the age of 60 years. Despite this, research on suicide in this age group is relatively scarce compared to studies on younger populations. This article is intended to summarize the existing literature on etiological/risk factors, including problems with one's physical and mental health, social isolation, money, and life changes like retirement and the death of a spouse and methods for preventing suicide specific to the geriatric population. We conducted a comprehensive literature search to identify the original reports and reviewed publications through various databases, including Google Scholar, PubMed, and the CDC. We gathered information on Google from reputable sources such as the WHO and the National Crime Records Bureau (NCRB). Our review found that the risk factor of suicide in the geriatric population includes physical illness, familial issues, financial issues, and hopelessness. The suicide rate for older adults declined, dropping from 16.17 per 100,000 individuals to 14.25 per 100,000 individuals aged 50 to 69 years and from 27.45 per 100,000 individuals to 24.53 per 100,000 individuals for those over 70 years. A more significant proportion of elderly suicide attempters come from rural than urban locations. Young individuals have better professional opportunities in urban areas, but older people are dispersed to underdeveloped or rural areas, where they are more likely to experience social isolation. By systematically identifying these risk factors, we can develop prevention and intervention strategies to decrease the suicide rates among the geriatric population.

Addressing Adolescent Suicidality in Pediatric Primary Care

OBJECTIVE

This study examines prevalence rates of reported suicidal ideation (SI) in 2107 adolescents, characterizes recommendations and interventions given by primary care providers (PCPs) and behavioral health clinicians (BHCs) in response to SI on the Patient Health Questionnaire 9-Item Modified for Adolescents (PHQ-9A) for 140 adolescents, and identifies factors associated with a decrease in the frequency of SI at follow-up visits for 85 adolescents.

METHODS

A retrospective mixed-method approach was taken. Clinical informatics was used to extract visit data, demographics, and PHQ-9A scores for all visits between January 3, 2017, and August 31, 2018. Conventional content analysis of electronic medical records was used to examine qualitative results, and qualitative codes were then analyzed using point-biserial correlations. The setting includes a fully integrated behavioral health team within the primary care clinic.

RESULTS

Of the 2107 adolescents, 140 (7%) endorsed SI within the past 2 weeks. Content analysis yielded 40 actions (17 PCP codes and 23 BHC codes) used in response to SI. Significant correlations were found between decreased SI frequency and the PCP referring to integrated behavioral health ( r = 0.24) and family navigators ( r = 0.26) and BHCs conducting a risk assessment ( r = 0.24), completing a safety plan ( r = 0.21), involving caregivers ( r = 0.29), sending the adolescent to the emergency department ( r = 0.28), and referring to family navigators ( r = 0.21; all p values < 0.05).

CONCLUSION

The findings from this study support screening for SI and highlight specific multidisciplinary and family-centered interventions and recommendations to address adolescent endorsement of SI in pediatric primary care settings.

Depression stigma, depression literacy, and psychological help seeking attitudes among school and university students

Very little research has specifically investigated depression stigma and its correlation with depression literacy and help-seeking attitudes among students. This study aimed to assess the levels and correlations of stigma, literacy, and psychological help-seeking attitudes related to depression among a sample of high school and university students in Jordan. A descriptive, correlational, cross-sectional design was employed using an anonymous, online, self-report survey. This study included a total of 650 students aged 16 to 24 years. The participants were found to have high levels of depression stigma, low levels of depression literacy, and negative attitudes towards seeking psychological help. The most frequently reported sources of psychological help were family members, relatives, and friends. A significant negative correlation was found between depression stigma and depression literacy. The predictive factors of depression stigma were depression literacy, age, gender, education, father's educational level, family size, and having history of mental health problems among family members, relatives, or friends. This study provides valuable information on the common mental health needs and concerns among students in Jordan. The findings also highlight the importance of developing and implementing depression awareness and prevention education campaigns for students in schools and universities. Such campaigns may increase students' knowledge about depression, enhance their use of mental healthcare services, and prevent or decrease their risk of developing depression.