Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Firearm storage practices among military veterans in the United States: Findings from a nationally representative survey

BACKGROUND

Unsafe storage of firearms is associated with increased risk of suicide.. However, contemporary population-based data on the prevalence and correlates of firearm storage practices among veterans are limited.

METHODS

Data were from the 2022 National Health and Resilience in Veterans Study, a nationally representative sample of 2441 veterans. Analyses examined: (1) the prevalence of firearm storage practices; (2) sociodemographic, psychiatric, and clinical characteristics associated with storing firearms loaded and/or in non-secure location; and (3) associations between types of potentially traumatic events and storage practices.

RESULTS

More than half of veterans reported owning one or more personal firearms (50.9%). Among firearm owners, 52.9% reported some form of unsafe firearm storage practice (i.e., loaded and/or non-secure location), with 39.9% reporting that they stored one or more firearms loaded. After adjusting for sociodemographic characteristics, major depressive, alcohol and drug use disorders, direct trauma exposures, future suicidal intent, and traumatic brain injury were associated with storing firearms loaded and/or in a non-secure location (ORs = 1.09-7.16). Veterans with a history of specific forms of direct trauma exposure (e.g., physical assault) were more likely to store firearms unsafely.

LIMITATIONS

Cross-sectional design precludes causal inference.

CONCLUSIONS

Half of U.S. veterans who own firearms store at least one personal firearm loaded and/or in a non-secure location, with approximately four-in-ten keeping a loaded firearm in the home. These high rates underscore the importance of nationwide training initiatives to promote safe firearm storage for all service members and veterans, regardless of risk status, as well as for healthcare professionals working with veterans.

Critical appraisal of the Colombian clinical practice guide for the prevention, diagnosis and treatment of suicidal ideation and/or behaviour (adoption)

INTRODUCTION

Suicide is a complex, global public health problem. The Colombian clinical practice guideline provides relevant input for its prevention, diagnosis and treatment. The objective was to evaluate the methodological quality, credibility and applicability of the Colombian clinical practice guideline for suicidal behaviour.

METHODS

An academic group of 12 evaluators was established to assess the guide and its recommendations in a standardised way, using the AGREE-II and AGREE-REX instruments. The evaluations were given in the range of 0.0-1.0 with 0.7 as a cut-off point for appropriate quality.

RESULTS

The global assessment of the AGREE-II was greater than 0.7 in the dimensions: "scope and objective" (0.86), "clarity of presentation" (0.89), "applicability" (0.73) and "editorial independence" (0.89). The lowest scores were for "participation of those involved" (0.67) and "rigour in preparation" (0.69). With the AGREE-REX, the results in all dimensions were below 0.70, which indicates lower quality and suitability for use.

CONCLUSIONS

The adoption process of the Colombian guideline for suicidal behaviour was a rigorous methodological process, while the practice recommendations were valued as of low applicability due to low support in local evidence. It is necessary to strengthen the generation and synthesis of evidence at the national level to give greater support and applicability to the practice recommendations.

Mental Defeat and Suicidality in Chronic Pain: A Prospective Analysis

Living with chronic pain has been identified as a significant risk factor for suicide. Qualitative and cross-sectional studies have reported an association between mental defeat and suicidal thoughts and behavior in patients with chronic pain. In this prospective cohort study, we hypothesized that higher levels of mental defeat would be associated with increased suicide risk at a 6-month follow-up. A total of 524 patients with chronic pain completed online questionnaires measuring variables related to suicide risk, mental defeat, sociodemographic, psychological, pain, activity, and health variables. At 6 months, 70.8% (n = 371) of respondents completed the questionnaires again. Weighted univariate and multivariable regression models were run to predict suicide risk at 6 months. The clinical suicide risk cutoff was met by 38.55% of the participants at baseline and 36.66% at 6 months. Multivariable modeling revealed that mental defeat, depression, perceived stress, head pain, and active smoking status significantly increased the odds of reporting higher suicide risk, while older age reduced the odds. Receiver operating characteristic (ROC) analysis showed that assessment of mental defeat, perceived stress, and depression is effective in discriminating between 'low' and 'high' suicide risk. Awareness of the prospective links from mental defeat, depression, perceived stress, head pain, and active smoking status to increased suicide risk in patients with chronic pain may offer a novel avenue for assessment and preventative intervention. PERSPECTIVE: Results from this prospective cohort study suggest that mental defeat is a significant predictor of increased suicide risk among patients with chronic pain, along with depression, perceived stress, head pain, and active smoking status. These findings offer a novel avenue for assessment and preventative intervention before risk escalates.

Psychometric Properties of the Self-Injurious Thoughts and Behaviors Interview-Short Form Among U.S. Active Duty Military Service Members and Veterans

We assessed the interrater reliability, convergent validity, and discriminant validity of the Self-Injurious Thoughts and Behaviors Interview-Short Form (SITBI-SF) in a sample of 1,944 active duty service members and veterans seeking services for posttraumatic stress disorder (PTSD) and related conditions. The SITBI-SF demonstrated high interrater reliability and good convergent and discriminant validity. The measurement properties of the SITBI-SF were comparable across service members and veterans. Approximately 8% of participants who denied a history of suicidal ideation on the SITBI-SF reported suicidal ideation on a separate self-report questionnaire (i.e., discordant responders). Discordant responders reported significantly higher levels of PTSD symptoms than those who denied suicidal ideation on both response formats. Findings suggest that the SITBI-SF is a reliable and valid interview-based measure of suicide-related thoughts and behaviors for use with military service members and veterans. Suicide risk assessment might be optimized if the SITBI-SF interview is combined with a self-report measure of related constructs.

SWOT: Analysis of Strategic Approaches in Total Force Fitness and Whole Health Summit

Leaders and subject matter experts from the Department of Defense (DoD), Department of Veterans Affairs, and other organizations participated in the Total Force Fitness (TFF) and Whole Health Summit. TFF and Whole Health Summit are holistic programs designed to maximize performance and resilience through interventions across multiple domains of health, wellness, and preparedness. Findings generated from the Summit were collected and categorized using a tool known as a Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis. The SWOT analysis highlighted key beneficial points regarding implementation of TFF-Whole Health principles including (1) a strong history of collaboration between the DoD and Department of Veterans Affairs, (2) a potential boost to recruitment and retention, and (3) better support for military-to-civilian transition. Risks identified ranged from policy limitations to program development within a fiscally constrained environment. The SWOT analysis can focus future efforts.

Beyond maintaining safety: Examining the benefit of emotion-centered problem solving therapy added to safety planning for reducing late life suicide risk

Few clinical trials have examined brief non-pharmacological treatments for reducing suicide risk in older Veterans, a high-risk group. Problem Solving Therapy (PST) is a promising psychosocial intervention for reducing late life suicide risk by increasing adaptive coping to problems through effective problem solving and related coping skills. The current randomized clinical trial will compare the efficacy of six telephone-delivered sessions of Safety Planning (enhanced usual care; EUC) only or an updated version of PST (emotion-centered PST [EC-PST]) + EUC to determine the added clinical benefit of EC-PST for reducing severity of suicidal ideation and for increasing reasons for living, a critical protective factor. Participants randomized to EC-PST + EUC or EUC only will be 150 Veterans (75 each) with active suicidal ideation who are aged 60 or older; have a current DSM-5 anxiety, depressive, and/or trauma-related disorder; and without significant cognitive impairment. Primary outcomes (Geriatric Suicide Ideation Scale and Reasons for Living-Older Adults scale) will be assessed at 11 timepoints: baseline, after each of 6 treatment sessions, posttreatment, and at follow-up at 1, 3, and 6 months posttreatment, and analyzed using mixed effects modeling. Additionally, moderators and mediators of primary outcomes will be examined-functional disability, executive dysfunction, and problem-solving ability. Qualitative feedback from participants will identify potential Veteran-centric changes to the EC-PST protocol and to EUC. Ultimately, the goal of this study is to inform the evidence-based clinical practice guidelines for treatments to reduce suicide risk in older Veterans and specifically to inform clinical decision-making regarding the merit of adding EC-PST to EUC.

Postpartum Opioid-Related Mortality in Patients With Public Insurance

OBJECTIVE

To assess the incidence and risk factors for postpartum opioid overdose death and describe other causes of postpartum death in individuals with opioid use disorder (OUD).

METHODS

We conducted a cohort study that used health care utilization data from the Medicaid Analytic eXtract linked to the National Death Index in the United States from 2006 to 2013. All pregnant individuals with live births or stillbirths and continuous enrollment for 3 months before delivery were eligible, including 4,972,061 deliveries. A subcohort of individuals with a documented history of OUD in the 3 months before delivery was identified. We estimated the cumulative incidence of death as occurring between delivery and 1 year postpartum among all individuals and individuals with OUD. Risk factors for opioid overdose death were assessed using odds ratios (ORs) and descriptive statistics, including demographics, health care utilization, obstetric conditions, comorbidities, and medications.

RESULTS

The incidence of postpartum opioid overdose death per 100,000 deliveries was 5.4 (95% CI 4.5-6.4) among all individuals and 118 (95% CI 84-163) among individuals with OUD. Individuals with OUD had a sixfold higher incidence of all-cause postpartum death than all individuals. Common causes of death in individuals with OUD were other drug- and alcohol-related deaths (47/100,000), suicide (26/100,000), and other injuries, including accidents and falls (33/100,000). Risk factors strongly associated with postpartum opioid overdose death included mental health and other substance use disorders. Among patients with OUD, postpartum use of medication to treat OUD was associated with 60% lower odds of opioid overdose death (OR 0.4, 95% CI 0.1-0.9).

CONCLUSION

Postpartum individuals with OUD have a high incidence of postpartum opioid overdose death and other preventable deaths, including nonopioid substance-related injuries, accidents, and suicide. Use of medications for OUD is strongly associated with lower opioid-related mortality.

When to discharge and when to voluntary or compulsory hospitalize? Factors associated with treatment decision after self-harm

Clinicians assessing suicidal patients in emergency departments (EDs) must decide whether to admit the person to a psychiatric ward with voluntary or compulsory hospitalization or to discharge him/her as an outpatient. This cross-sectional study aimed to identify independent predictors of this decision among a large sample of self-harm (SH) patients. It used data from all patients admitted to four Swiss EDs between 2016 and 2019. Socio-demographic, clinical, and suicidal process-related characteristics data were evaluated against the decision for voluntary or compulsory hospitalization using t-tests, Chi-Square tests and logistic multiple regression. 2142 episodes from 1832 unique patients were evaluated. Independent predictors of decision to hospitalize included: male gender, advanced age, hospital location, depression and personality disorders, substance use, a difficult socio-economic condition, a clear intent to die, and a serious suicide attempt. Significant variables that emerged as independent predictors of compulsory hospitalization were hospital location, not having anxiety and personality disorders, being retired, having a clear intent to die, and making a serious suicide attempt. Hospital EDs had different rates of compulsory psychiatric admission. However, the decision to admit a patient for hospitalization, either voluntary or compulsory, was mainly based on clinical factors.

Non-response to questions about suicide ideation and attempts among veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVES

Veterans who decline to provide information on their history of self-injurious thoughts and behaviors (SITBs) may be at elevated suicide risk. We examined associations between non-response to a question assessing lifetime SITBs and proxy variables of suicide risk.

METHODS

In this population-based cross-sectional study of 4069 US veterans, responses to the Suicidal Behaviors Questionnaire-Revised were examined to group veterans into one of three categories: (1) denied lifetime SITBs, (2) reported lifetime SITBs, or (3) declined to respond.

RESULTS

Overall, 69.5% of veterans denied a SITB history, 29.5% reported a SITB history, and 1.0% declined to provide information regarding SITBs. In adjusted analyses, veterans who declined to provide information on SITBs were significantly more likely than veterans who explicitly denied lifetime SITBs to screen positive for posttraumatic stress disorder; report lifetime non-suicidal self-injury; and report elevated levels of total trauma burden, externalizing behaviors, loneliness, received social support, and provided social support. Across these constructs, veterans who declined to provide SITB information were statistically indistinguishable from veterans who explicitly reported lifetime SITBs.

CONCLUSIONS

Veterans who decline to provide information about suicidal thoughts and behaviors may represent a covert group at elevated risk for suicide.

Achieving health equity in US suicides: a narrative review and commentary

Suicide rates in the United States (US) reached a peak in 2018 and declined in 2019 and 2020, with substantial and often growing disparities by age, sex, race/ethnicity, geography, veteran status, sexual minority status, socioeconomic status, and method employed (means disparity). In this narrative review and commentary, we highlight these many disparities in US suicide deaths, then examine the possible causes and potential solutions, with the overarching goal of reducing suicide death disparities to achieve health equity.

The data implicate untreated, undertreated, or unidentified depression or other mental illness, and access to firearms, as two modifiable risk factors for suicide across all groups. The data also reveal firearm suicides increasing sharply and linearly with increasing county rurality, while suicide rates by falls (e.g., from tall structures) decrease linearly by increasing rurality, and suicide rates by other means remain fairly constant regardless of relative county urbanization. In addition, for all geographies, gun suicides are significantly higher in males than females, and highest in ages 51–85 + years old for both sexes. Of all US suicides from 1999–2019, 55% of male suicides and 29% of female suicides were by gun in metropolitan (metro) areas, versus 65% (Male) and 42% (Female) suicides by gun in non-metro areas. Guns accounted for 89% of suicides in non-metro males aged 71–85 + years old. Guns (i.e., employment of more lethal means) are also thought to be a major reason why males have, on average, 2–4 times higher suicide rates than women, despite having only 1/4—1/2 as many suicide attempts as women. Overall the literature and data strongly implicate firearm access as a risk factor for suicide across all populations, and even more so for male, rural, and older populations.

To achieve the most significant results in suicide prevention across all groups, we need 1) more emphasis on policies and universal programs to reduce suicidal behaviors, and 2) enhanced population-based strategies for ameliorating the two most prominent modifiable targets for suicide prevention: depression and firearms.

Childhood Trauma Associations With the Interpersonal Psychological Theory of Suicide and Social Cognitive Biases in Psychotic Disorders

Childhood trauma (CT) is associated with suicidal ideation and behaviors (SI/SB) in people with psychosis. The interpersonal psychological theory of suicide (IPTS) suggests that there are four factors that increase suicide risk: thwarted belongingness, perceived burdensomeness, acquired capacity for suicide, and hopelessness. The IPTS constructs and social cognitive biases are associated with SI/SB in psychotic disorders. However, the role of CT in IPTS constructs and social cognitive biases has not been examined in psychosis. In an outpatient community sample of persons with psychotic disorders (N = 96) assessed with the Childhood Trauma Questionnaire, the aims of this study were to a) evaluate rates of CT in this sample, b) determine the relationship between CT types and lifetime SI/SB, and c) explore the relationship between CT types, IPTS constructs, and social cognitive biases. All participants reported experiencing CT. Emotional abuse was associated with greater SI severity and higher rates of lifetime suicide attempts, as well as with greater perceived burdensomeness and more severe negative social cognitive biases. Other CT types were minimally associated with SI/SB or IPST constructs; hopelessness was not associated. Overall, negative interpersonal beliefs and social cognitive biases may explain how CT increases suicide risk in psychosis.

Mental Health Service Use, Suicide Behavior, and Emergency Department Visits Among Rural US Veterans Who Received Video-Enabled Tablets During the COVID-19 Pandemic

IMPORTANCE

Suicide rates are rising disproportionately in rural counties, a concerning pattern as the COVID-19 pandemic has intensified suicide risk factors in these regions and exacerbated barriers to mental health care access. Although telehealth has the potential to improve access to mental health care, telehealth's effectiveness for suicide-related outcomes remains relatively unknown.

OBJECTIVE

To evaluate the association between the escalated distribution of the US Department of Veterans Affairs' (VA's) video-enabled tablets during the COVID-19 pandemic and rural veterans' mental health service use and suicide-related outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included rural veterans who had at least 1 VA mental health care visit in calendar year 2019 and a subcohort of patients identified by the VA as high-risk for suicide. Event studies and difference-in-differences estimation were used to compare monthly mental health service utilization for patients who received VA tablets during COVID-19 with patients who were not issued tablets over 10 months before and after tablet shipment. Statistical analysis was performed from November 2021 to February 2022.

EXPOSURE

Receipt of a video-enabled tablet.

MAIN OUTCOMES AND MEASURES

Mental health service utilization outcomes included psychotherapy visits, medication management visits, and comprehensive suicide risk evaluations (CSREs) via video and total visits across all modalities (phone, video, and in-person). We also analyzed likelihood of emergency department (ED) visit, likelihood of suicide-related ED visit, and number of VA's suicide behavior and overdose reports (SBORs).

RESULTS

The study cohort included 13 180 rural tablet recipients (11 617 [88%] men; 2161 [16%] Black; 301 [2%] Hispanic; 10 644 [80%] White; mean [SD] age, 61.2 [13.4] years) and 458 611 nonrecipients (406 545 [89%] men; 59 875 [13%] Black or African American; 16 778 [4%] Hispanic; 384 630 [83%] White; mean [SD] age, 58.0 [15.8] years). Tablets were associated with increases of 1.8 psychotherapy visits per year (monthly coefficient, 0.15; 95% CI, 0.13-0.17), 3.5 video psychotherapy visits per year (monthly coefficient, 0.29; 95% CI, 0.27-0.31), 0.7 video medication management visits per year (monthly coefficient, 0.06; 95% CI, 0.055-0.062), and 0.02 video CSREs per year (monthly coefficient, 0.002; 95% CI, 0.002-0.002). Tablets were associated with an overall 20% reduction in the likelihood of an ED visit (proportion change, -0.012; 95% CI, -0.014 to -0.010), a 36% reduction in the likelihood of suicide-related ED visit (proportion change, -0.0017; 95% CI, -0.0023 to -0.0013), and a 22% reduction in the likelihood of suicide behavior as indicated by SBORs (monthly coefficient, -0.0011; 95% CI, -0.0016 to -0.0005). These associations persisted for the subcohort of rural veterans the VA identifies as high-risk for suicide.

CONCLUSIONS AND RELEVANCE

This cohort study of rural US veterans with a history of mental health care use found that receipt of a video-enabled tablet was associated with increased use of mental health care via video, increased psychotherapy visits (across all modalities), and reduced suicide behavior and ED visits. These findings suggest that the VA and other health systems should consider leveraging video-enabled tablets for improving access to mental health care via telehealth and for preventing suicides among rural residents.

Suicidal Ideation and Mental Health Help-Seeking Behaviors Among Older Chinese Adults During the COVID-19 Pandemic

OBJECTIVE

To examine prevalence and correlates of suicidal ideation in older Chinese adults (OCAs) during the COVID-19 pandemic, as well as mental health help-seeking behaviors of suicidal OCAs.

BACKGROUND

Few data on suicidal behaviors of older adults during the pandemic are available.

METHODS

In this cross-sectional survey, 1159 OCAs completed an online self-administered questionnaire between 23 February and 25 March 2020. A standardized single question and the 12-item General Health Questionnaire were used to assess the presence of suicidal ideation and common mental health problems (CMHPs), respectively. Suicidal ideators were further asked about their perceived need for mental health care and help-seeking from mental health workers.

RESULTS

4.1% of the OCAs experienced suicidal ideation during the past 2 weeks. Among the suicidal OCAs, 31.9% perceived a need for mental health care but only 10.6% had sought help from mental health workers. Factors significantly associated with suicidal ideation were a marital status of "others" (OR=2.39, P = .021), disagreement regarding the successful containment of the pandemic (OR=2.43, P = .022), physical health problems (OR=2.23, P = .012), and CMHPs (OR=4.99, P < .001).

CONCLUSIONS

During the COVID-19 pandemic, OCAs constitute a subpopulation that needs mental health services for suicidal problems but tends not to seek mental health help. Mental health services for OCAs may include mental health education, periodic evaluation of risk of suicide, expanded psychosocial support, and, when necessary, psychological crisis intervention and psychiatric treatment.

Trends in Research on Art Therapy Indexed in the Web of Science: A Bibliometric Analysis

Aim: Despite the increase in international research in art therapy, few studies have been developed with a bibliometric approach which describe the situation regarding this area of knowledge. Thus, the aim of this study is to describe and contextualize international scientific production in the visual arts modality in the context of artistic therapies, to offer a broader and more in-depth vision of the structure of this area of knowledge through of a bibliometric analysis of the publications indexed in the core collection of the Web of Science. Methods: This is a retrospective, exploratory and descriptive, cross-sectional study to analyze the bibliographic data retrieved from the databases of the core collection. The analysis parameters included the data corresponding to the production according to type of document, country, journal, and institution. In addition, the main lines of research were located and classified and the subject matter of the most cited articles in each of them was summarized. Four periods were selected, between 1994 and 2020, to facilitate the thematic analysis and offer an evolutionary perspective of art therapy research. Results: A total of 563 works were published, in 250 journals, in the 63 years between 1958, when the first document was published, and April 2021. The annual growth rate was 7.3% with a mean average of 8.7 publications per year, and 83.13% of the published works were articles. A total of 1,269 authors from 56 countries were counted. The mean number of citations per document was 5.6 and the mean number of citations per document and year was 0.6. The main research domains were psychology and/or rehabilitation and the highest production on this topic was concentrated in only three journals. In general, a high degree of variability was observed in the study topics and numerous theoretical and methodological articles. The most used visual arts modalities were in the main drawing, painting and photography. Conclusion: This work did not find previous existence of any bibliometric analysis on the international scientific production in art therapy. In general terms, there has been a substantial growth in the number of publications on the subject over the last decade. However, this research area does not appear to have peaked, but, on the contrary, is still growing and progressing despite its long history in clinical practice.

Physician Suicide Prevention and the Ethics and Role of a Healing Community: an American College of Physicians Policy Paper

Suicide is a major global public health issue, and in recent years, there has been increasing recognition of the problem of physician suicide. This American College of Physicians policy paper examines, from the perspective of ethics, the issues that arise when individuals and institutions respond to physician suicides and when they engage in broader efforts aimed at physician suicide prevention. Emphasizing the medical profession as a unique moral community characterized by ethical and professional commitments of service to patients, each other, and society, this paper offers guidance regarding physician suicide and the role of a healing community. The response to an individual physician suicide should be characterized by respect and concern for those who are grieving, the creation of a supportive environment for suicide loss survivors, and careful communication about the event. Because suicide is a complex problem, actions aimed at preventing suicide must occur at the individual, interpersonal, community, and societal levels. The medical community has an obligation to foster a culture that supports education, screening, and access to mental health treatment, beginning at the earliest stages of medical training.

Suicide in primary care: How to screen and intervene

Suicide is significant public health concern within the United States. Research results are mixed about the effectiveness of universal screening and interventions with patients who are at-risk for suicide. Primary care is a logical intervention point to mitigate risk among patients in each of these areas. The Department of Veterans Affairs and Department of Defense have developed comprehensive guidelines for the assessment and management of suicidal patients. This approach involves specific screening tools, risk stratification by categories and interventions used by clinicians to help reduce risk levels in their patients. This article aims to provide a model, built on the principles of these guidelines, which primary care physicians can use to identify, assess and intervene with patients who are at-risk for suicide.

The chiropractor's role in primary, secondary, and tertiary prevention of suicide: a clinical guide

OBJECTIVE

To provide the practicing chiropractor foundational knowledge to enhance the understanding of relevant primary, secondary, and tertiary public health measures for suicide prevention.

METHODS

A descriptive literature review was performed using keywords low back pain, neck pain, psychosocial, pain, public health, suicide, suicide risk factors, and suicide prevention. English language articles pertaining to suicide prevention and the chiropractic profession were retrieved and evaluated for relevance. Additional documents from the Centers for Disease Control, Veterans Health Administration, and the World Health Organization were reviewed. Key literature from the clinical social work and clinical psychology fields were provided by authorship team subject matter experts.

CONCLUSION

No articles reported a position statement regarding suicide prevention specific to the chiropractic profession. Risk, modifiable, and protective factors associated with self-directed violence are important clinical considerations. A proactive approach to managing patients at-risk includes developing interprofessional and collaborative relationships with mental health care professionals.

From everyday life predictions to suicide prevention: Clinical and ethical considerations in suicide predictive analytic tools

Advances in artificial intelligence and machine learning have fueled growing interest in the application of predictive analytics to identify high-risk suicidal patients. Such application will require the aggregation of large-scale, sensitive patient data to help inform complex and potentially stigmatizing health care decisions. This paper provides a description of how suicide prediction is uniquely difficult by comparing it to nonmedical (weather and traffic forecasting) and medical predictions (cancer and human immunodeficiency virus risk), followed by clinical and ethical challenges presented within a risk-benefit conceptual framework. Because the misidentification of suicide risk may be associated with unintended negative consequences, clinicians and policymakers need to carefully weigh the risks and benefits of using suicide predictive analytics across health care populations. Practical recommendations are provided to strengthen the protection of patient rights and enhance the clinical utility of suicide predictive analytics tools.

Development of a pre-hospital emergencies protocol for the management of suicidal patients in Iran

Background

Suicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in the treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation.

Method

We reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks.

Results

The basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient (behavioral and pharmacological) management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered.

Conclusion

A locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians.

Assessing Suicidal Ideation Using a Brief Self-Report Measure

Accurate assessment of suicidal thoughts is a challenge for researchers and clinicians. There is evidence that self-report and clinical interview assessment methods can result in different endorsement numbers when used to assess suicidal ideation. This study investigates endorsement rates and psychometric properties of a two-item self-report measure of suicidal ideation that distinguishes active from passive suicidal ideation, when compared with a clinical interview. Individuals presenting at an outpatient psychiatry clinic completed a measure of depression severity containing two items assessing passive and active suicidal ideation before undergoing a structured clinical interview. Self-report and clinical interview items demonstrated a low level of agreement. Self-report items were more strongly correlated with same-domain clinical interviewer ratings than different-domain ratings. These items demonstrated high negative predictive value and moderate-to-low positive predictive value for interviewer ratings. A two-item measure of suicidal ideation did not highly align with corresponding interviewer ratings, though such a measure may be useful in determining the absence of suicidal ideation, as well as distinguishing between passive and active suicidal ideation.

Telehealth in Rehabilitation Psychology and Neuropsychology

With the evolution of the COVID-19 pandemic in the United States in March 2020, most ambulatory care environments rapidly pivoted to extensive use to telehealth to protect patients and providers while continuing to provide care. This shift resulted in the expansion of telehealth platforms and workflows. Many behavioral health services can be provided in a telehealth format. The case example in this article illustrates that transition to telehealth is feasible and sustainable. Limitations include preoperative psychological assessments and certain neuropsychological tests requiring material manipulation. Careful consideration of risk factors should be exerted for more vulnerable patient populations.

Communicating suicide risk to families of chronically suicidal borderline personality disorder patients to mitigate malpractice risk

OBJECTIVE

The distinction between acute and chronic suicidality is important, because interventions designed to address acute suicidality can worsen chronic suicidality, resulting in an escalating cycle of suicide threats, suicide attempts, and futile hospitalizations. Though most chronically suicidal borderline personality disorder patients improve and do not complete suicide, the potential for suicide contributes to these hospitalizations and a paucity of outpatient services due to treaters' concern over malpractice lawsuits in case of suicide. Communicating with patients' families about the suicide risk has been suggested as a means to mitigate this malpractice risk, but the approach to such communication has not been described.

METHOD

Once chronic suicidality is identified, a stepwise approach to communicating with the patient's family is described.

RESULTS

The potential benefits of this risk communication are described, for patients, families, treaters, healthcare systems, and health and malpractice insurers.

CONCLUSION

It helps to develop an alliance with families and patients around a shared understanding of outcomes in chronic suicidality - most eventually do better, but the risk of completed suicide is real. This enables patients and families to make a more fully informed choice about treatment, which in turn can reduce litigation risk in the minority of cases where the patient completes suicide.

Can Intraoperative Low-Dose R,S-Ketamine Prevent Depressive Symptoms After Surgery? The First Meta-Analysis of Clinical Trials

Background: Postoperative depression is a common complication after surgery that profoundly affects recovery and prognosis. New research indicates that (R,S)-ketamine is a potent antidepressant that exerts a rapid and sustained antidepressive effect. However, there is no consensus on whether intraoperative low-dose (R,S)-ketamine prevents postoperative depression. Objectives: This study aimed to investigate the safety, feasibility, and short-term complications of intraoperative low-dose (R,S)-ketamine in preventing postoperative depressive symptoms. Methods: The Web of Science, Cochrane, PubMed, and CNKI databases were systematically searched (last search February 28, 2020) to identify studies involving ketamine. Sensitivity and metaregression analyses were performed to identify potential confounders. The meta-analysis was performed using Review Manager 5.3. Results: A total of 13 studies (seven in Chinese and six in English) representing 1,148 cases of patients who were treated with (R,S)-ketamine and 874 cases of patients who received other treatments were included in the meta-analysis. Anesthesia duration and blood loss did not significantly differ between the two groups, demonstrating that (R,S)-ketamine was safe (odds ratio,OR: 0.27; 95% CI: -1.14 to 1.68; P = 0.71) for prophylactic treatment of postoperative depression. Blood loss (OR: -1.83; 95% CI: -8.34 to 4.68; P = 0.58), the number of postoperative depressive patients (95% CI: 0.8-1.07; P = 0.08; (R,S)-ketamine: control = 12.9%:15.8%), and postoperative complications (OR: 0.83, 95% CI: 0.44-1.58; P = 0.57; (R,S)-ketamine: control = 19.3%:19.3%) were all similar across groups. Intra-operative low-dose (R,S)-ketamine reduced extubation time (OR: -2.84; 95% CI: -5.48 to -0.21; P = 0.03). Conclusions: The prophylactic anti-depressant effect of (R,S)-ketamine did not significantly differ between the (R,S)-ketamine and control groups in patients undergoing general or spinal anesthesia. However, (R,S)-ketamine use led to a higher incidence of adverse reactions in patients under 40 years of age who underwent a Cesarean section under spinal anesthesia.

No country for older men: ageing male suicide in New Zealand

OBJECTIVE

Suicide rates increase in late life. There is, however, a gap in understanding suicide in the very old. We aimed to underscore the evidence for high rates of death by suicide in the oldest-old men (age 85+) in New Zealand and to provide a conjectural discussion about factors driving these rates.

METHOD

Provisional suicide data were obtained from the New Zealand Coronial Services website for the period 2011-2019. Yearly suicide rates for those aged 85+ were plotted over time. Mean suicide rates were calculated for three youth and young adult male cohorts, identified by the Coroner as having very high rates, and compared with the 85+ age cohort.

RESULTS

Between 2011 and 2019, rates of death by suicide of older males remained consistently high never overlapping female suicide rates. Mean suicide deaths/100,000 population for all four age cohorts were comparable; 15-19 years: 23.5; 20-24 years: 29.0; 25-29 years: 27.0; 85+ years: 27.9.

CONCLUSIONS

Deaths by suicide are very high for older males. In addition to established risk factors, psychosocial adversity as reflected by loneliness, poverty and shift to residential care may be major reasons for the high suicide rates. Research to inform about this vulnerable population and prevention are urgently needed.

Identifying and Predicting Intentional Self-Harm in Electronic Health Record Clinical Notes: Deep Learning Approach

BACKGROUND

Suicide is an important public health concern in the United States and around the world. There has been significant work examining machine learning approaches to identify and predict intentional self-harm and suicide using existing data sets. With recent advances in computing, deep learning applications in health care are gaining momentum.

OBJECTIVE

This study aimed to leverage the information in clinical notes using deep neural networks (DNNs) to (1) improve the identification of patients treated for intentional self-harm and (2) predict future self-harm events.

METHODS

We extracted clinical text notes from electronic health records (EHRs) of 835 patients with International Classification of Diseases (ICD) codes for intentional self-harm and 1670 matched controls who never had any intentional self-harm ICD codes. The data were divided into training and holdout test sets. We tested a number of algorithms on clinical notes associated with the intentional self-harm codes using the training set, including several traditional bag-of-words-based models and 2 DNN models: a convolutional neural network (CNN) and a long short-term memory model. We also evaluated the predictive performance of the DNNs on a subset of patients who had clinical notes 1 to 6 months before the first intentional self-harm event. Finally, we evaluated the impact of a pretrained model using Word2vec (W2V) on performance.

RESULTS

The area under the receiver operating characteristic curve (AUC) for the CNN on the phenotyping task, that is, the detection of intentional self-harm in clinical notes concurrent with the events was 0.999, with an F1 score of 0.985. In the predictive task, the CNN achieved the highest performance with an AUC of 0.882 and an F1 score of 0.769. Although pretraining with W2V shortened the DNN training time, it did not improve performance.

CONCLUSIONS

The strong performance on the first task, namely, phenotyping based on clinical notes, suggests that such models could be used effectively for surveillance of intentional self-harm in clinical text in an EHR. The modest performance on the predictive task notwithstanding, the results using DNN models on clinical text alone are competitive with other reports in the literature using risk factors from structured EHR data.

Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation

BACKGROUND

Early rehabilitation after stroke is essential to help reduce disability.

PURPOSE

To summarize evidence on the benefits and harms of nonpharmacologic and pharmacologic treatments for motor deficits and mood disorders in adults who have had stroke.

DATA SOURCES

English-language searches of multiple electronic databases from April 2009 through July 2018; targeted searches to December 2018 for studies of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors.

STUDY SELECTION

19 systematic reviews and 37 randomized controlled trials addressing therapies for motor deficits or mood disorders in adults with stroke.

DATA EXTRACTION

One investigator abstracted the data, and quality and GRADE assessment were checked by a second investigator.

DATA SYNTHESIS

Most interventions (for example, SSRIs, mental practice, mirror therapy) did not improve motor function. High-quality evidence did not support use of fluoxetine to improve motor function. Moderate-quality evidence supported use of cardiorespiratory training to improve maximum walking speed and repetitive task training or transcranial direct current stimulation to improve activities of daily living (ADLs). Low-quality evidence supported use of robotic arm training to improve ADLs. Low-quality evidence indicated that antidepressants may reduce depression, whereas the frequency and severity of antidepressant-related adverse effects was unclear. Low-quality evidence suggested that cognitive behavioral therapy and exercise, including mind-body exercise, may reduce symptoms of depression and anxiety.

LIMITATION

Studies were of poor quality, interventions and comparators were heterogeneous, and evidence on harms was scarce.

CONCLUSION

Cardiorespiratory training, repetitive task training, and transcranial direct current stimulation may improve ADLs in adults with stroke. Cognitive behavioral therapy, exercise, and SSRIs may reduce symptoms of poststroke depression, but use of SSRIs to prevent depression or improve motor function was not supported.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs, Veterans Health Administration.

Building the foundation for comprehensive suicide prevention - based on intention and planning in a social-ecological context

National suicide prevention programmes that have been successful in reducing rates or keeping them low have been intentional, with collective alignment of local, regional and national priorities. Prevention efforts must begin well before individuals become suicidal, complementing readily available clinical services that address the needs of acutely distressed persons. These efforts, which focus on the antecedent risks and vulnerabilities of key populations, have the potential to diminish premature mortality from multiple causes, even as reducing suicide is the outcome of primary interest. In this commentary, I consider four key challenges that must be confronted in order to develop effective, broadly reaching systemic strategies that, at once, can be adapted locally while being implemented nationally - challenges that are framed in a social-ecological context. They involve defining the scope of the problem, meeting essential data needs, developing and modelling measurable implementation strategies and building prevention efforts based on shared culture and values.