Demographic predictors of emergency service utilization patterns in youth at risk of suicide

OBJECTIVE

To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors).

METHODS

Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period.

RESULTS

Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission.

CONCLUSIONS

Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.

Risk factors observed in the last 30 days of life among student suicides: distinguishing characteristics of college and university student suicides

Purpose: Studies of college and university student suicide have identified predictors only of suicide ideation and attempts and have relied solely on self-report data. This study explores risk factors observed in the last 30 days of life of college and university students who died by suicide, compared to those of high school and middle school students. Methods: Retrospective chart reviews of 16 college and university students (aged 19-26) were abstracted and compared to those of 24 middle and high school students (aged 12-18), all in, or recently in, clinical care. Results: Near-term risk factors for deaths by suicide largely were equivalent in compared groups, with only sleep problems, conduct problems, and passive suicide ideation found to be significantly different between student cohorts. Conclusions: These preliminary findings are hypotheses-generating for larger studies of more restricted age ranged youth cohorts needed to better differentiate near-term risk factors for suicide.

Suicide and Life Insurance

Much has been written about the history of suicide and, notably, about societies that condemned both the act and the actor, resulting in a perpetuation of suicide being stigmatized in many cultures. One aspect of this perceived stigmatization involves exclusionary clauses in life insurance policies that reject paying benefits to survivor-beneficiaries of the decedent if the decedent has died by suicide within a prescribed time frame. From the perspective of the individual, life insurance is designed to protect the estate of a decedent from a significant financial burden. From the insurer's perspective, there are essentially 2 reasons for having a suicide exclusion clause: limiting risk and preventing or discouraging fraud. This column examines these rationales in light of the estimated few suicides that do occur during exclusionary clause time frames. Observations are made about the effect of these clauses on those impacted by the loss of a loved one who died by suicide within the exclusionary time frame. An examination of the perspectives of both the life insurance industry and the impacted survivors of suicide decedents raises questions about what are reasonable and appropriate exclusionary clause time frames that protect both the insurer and survivor-beneficiaries. The forensic expert consulting on such cases should be cognizant of these competing perspectives and engage in therapeutic assessment whenever possible, identifying opportunities to promote thoughtful suicide postvention.

Proximal risk for suicide in correctional settings: A call for priority research

Suicide is the leading cause of death among jail detainees and the third leading cause of death among state prison inmates. These populations have been recognized as a high-risk group deserving special clinical attention. The literature on deaths by suicide in correctional settings has identified numerous risk factors for eventual death, but few of these risk factors are specific to the last days of life to aid clinicians in estimating near-term risk of serious self-injury or death. The poor understanding of near-term risk is particularly important in jail settings where many suicide deaths occur within 24 hr of entry. Although screening instruments for suicide risk factors are commonly used with jail/prison populations, few have been validated in those settings and all have poor positive predictive value. We call for a focused research effort to improve the identification of those at risk of near-term suicide and to produce tools for clinicians that will reduce the burden of suicide among jail and prison inmates. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Technological Advances and the Future of Suicide Prevention: Ethical, Legal, and Empirical Challenges

Technological advancements have brought multiple and diverse benefits to our human existence. In suicide prevention, new technologies have spurred great interest in and reports of the applicability to assessing, monitoring, and intervening in various community and clinical populations. We argue in this article that we need to better understand the complexities of implementation of technological advances; especially the accuracy, effectiveness, safety, ethical, and legal issues, even as implementation occurs at individual, clinical, and population levels, in order to achieve that measure of public health impact we all desire (i.e., greater benefit than harm).

Near Term Suicide Risk Assessment: A Commentary on the Clinical Relevance of Protective Factors

In this article we examine the clinical relevance of protective factors to the assessment and formulation of near-term risk of death by suicide. Contrary to current clinical belief and practice, we posit that there is no evidence base to support these factors as mitigating or buffering risk for suicide for the individual patient, especially in the near-term assessment of that suicide risk. We show that evidence-based protective factors derive from population-based studies and, applicably, have relevance to public health promotion/primary prevention and are significant in informing treatment/secondary prevention, but they lack evidence to support their often-proposed role in mitigating or buffering risk for suicide on an individual basis, especially when applied to the assessment of near-term risk of suicide. Accordingly, we argue for the need for empirical study of the role protective factors may or may not play in the formulation of a patient's risk for suicide and, in the interim, for clinical caution in assuming that protective factors have any significant buffering effect on a patient's level of near-term risk.

Risk Factors Proximate to Suicide and Suicide Risk Assessment in the Context of Denied Suicide Ideation

Health care providers have significant opportunities to identify individuals at near-term risk for suicide, but lack empirical data on near-term risk factors. This study aimed to identify dynamic, state-related risk factors observed by clinical practitioners within the last 30 days of life of 157 patients who died by suicide and to compare these near-term risk factors among patients who denied versus responded positively to having suicide ideation (SI) when last asked by a clinical practitioner prior to their death. Risk factors charted for the majority of all decedents were a history of prior suicide ideation and/or suicide attempt, current anxiety/agitation and sleep problems, current interpersonal problems or job/financial strain, current comorbid diagnoses, current social isolation/withdrawal, and a family history of mental disorder. Two-thirds of patients denied having SI when last asked and one-half of these patients were dead by suicide within 2 days. Decedents who denied having SI were quite similar in charted diagnoses, symptoms, behaviors, and environmental circumstances to decedents who responded affirmatively to having SI. Reliance on verbalized or reported SI as a gateway to a suicide risk assessment is questioned and the need for better understanding near-term risk for suicide, particularly in the absence of stated SI, is highlighted.

Changing the Direction of Suicide Prevention in the United States

It is axiomatic that the goal of suicide prevention is the prevention of suicide. Yet in spite of significant efforts to this end since the middle of the last century, and most notably in the last decade, the rate of suicide in the U.S. has not declined; rather, it has increased. To address this issue, Suicide Awareness Voices of Education (SAVE) brought together leading prevention specialists from other public health problems where successes have been achieved, representatives from countries where suicide rates have declined, and U.S. based suicide prevention researchers and program directors, to "think outside the box" and propose innovative, scalable approaches that might better drive success in achieving desired results from U.S. suicide prevention efforts. The recommendations should challenge our preconceptions and force us outside our own mental constraints to broaden our perspectives and suggest catalysts for real change in suicide prevention.

Smoking Behavior: How is it Related to Locus of Control, Death Anxiety, and Belief in Afterlife?

Studies relating smoking behavior to personality and attitudinal measures have given inconsistent results. The present study investigated the degree of relationship between smoking behavior and four dependent measures of life, death, and afterlife beliefs. Results from a sample of 300 college-age Ss indicated that none of the hypothesized relationships reached statistical significance. A trend toward significance was found in the degree of relationship between smoking and an external locus of control belief, while education was the only demographic variable to show a significant relationship to smoking behavior. Implications were drawn to explain the ineffectiveness of anti-smoking campaigns in spite of the known hazards of smoking behavior.

Belief in Afterlife, Religion, Religiosity and Life-Threatening Experiences

The interrelated effects of religion, religiosity, belief in afterlife, and life-threatening experiences were studied to empirically test a number of previously untested propositions raised in the literature. The experience of a prior, subjectively perceived, inevitable death-threat had no effect on subsequent beliefs in a life after death (BA). On the other hand, BA was found to be primarily related to an ordered interaction among religions and religious activity. While religious activity appears not to serve to defend against an initially experienced stress reaction, the recall and report of life-threatening experiences over time occurs less frequently among religious versus non-religious Ss.

Social Schemas: An Investigation of Age and Socialization Variables

The Felt Figure Replacement Technique (FFRT) was administered to 160 normally adjusted male Ss in three distinct chronological age groups. It was hypothesized that the existence of common social schemas would vary with age and that a neutral-latency group of Ss (aged 9.5 to 10.5 yr.) would produce different schematic reconstructions based on relative degrees of perceived maternal warmth. Chi-square analyses did not support the hypotheses. The results were interpreted as consistent with studies of perceptual accuracy and at odds with the use of the FFRT by groups of normal children. Contrasts were made with the positive findings of other researchers using deviant and/or mature normal Ss.

Suicide on railroad rights-of-way: a psychological autopsy study

Findings from 55 psychological autopsies of decedents who perished on U.S. railroad rights-of-way between October 1, 2007, and September 30, 2010 are reported. Described are distal, proximal, and contextual factors of risk; understandings of why these suicides occurred on railroad rights-of-way; and opportunities for prevention of similar suicides. International comparisons of suicides on railroad rights-of-way are made to highlight distinct findings regarding U.S. cases. Decedents studied exhibited considerable predisposing risk for suicide, with a high prevalence of severe mental disorders and substance abuse. In addition, a number of acute risk factors were commonly observed, notably suicide ideation, hopelessness, anxiety, and anger. In the context of that acute risk, associated situational variables and a relative absence of protective factors are described.

Training for suicide risk assessment and suicide risk formulation

Suicide and suicidal behaviors are highly associated with psychiatric disorders. Psychiatrists have significant opportunities to identify at-risk individuals and offer treatment to reduce that risk. Although a suicide risk assessment (SRA) is a core competency requirement, many lack the requisite training and skills to appropriately assess for suicide risk. Moreover, the standard of care requires psychiatrists to foresee the possibility that a patient might engage in suicidal behavior, hence to conduct a suicide risk formulation (SRF) sufficient to guide triage and treatment planning. An SRA gathers data about observable and reported symptoms, behaviors, and historical factors that are associated with suicide risk and protection, ascertained by way of psychiatric interview; collateral information from family, friends, and medical records; and psychometric scales and/or screening tools. Based on data collected via an SRA, an SRF is a process whereby the psychiatrist forms a judgment about a patient's foreseeable risk of suicidal behavior in order to inform triage decisions, safety and treatment plans, and interventions to reduce risk. This paper addresses the need for a revised training model in SRA and SRF, and proposes a model of training that incorporates the acquisition of skills, relying heavily on case application exercises.

Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force

BACKGROUND

The National Action Alliance for Suicide Prevention Research Prioritization Task Force (RPTF) has created a prioritized national research agenda with the potential to rapidly and substantially reduce the suicide burden in the U.S. if fully funded and implemented.

PURPOSE

Viable, sustainable scientific research agendas addressing challenging public health issues such as suicide often need to incorporate perspectives from multiple stakeholder groups (e.g., researchers, policymakers, and other end-users of new knowledge) during an agenda-setting process. The Stakeholder Survey was a web-based survey conducted and analyzed in 2011-2012 to inform the goal-setting step in the RPTF agenda development process. The survey process, and the final list of "aspirational" research goals it produced, are presented here.

METHODS

Using a modified Delphi process, diverse constituent groups generated and evaluated candidate research goals addressing pressing suicide prevention research needs.

RESULTS

A total of 716 respondents representing 49 U.S. states and 18 foreign countries provided input that ultimately produced 12 overarching, research-informed aspirational goals aimed at reducing the U.S. suicide burden. Highest-rated goals addressed prevention of subsequent suicidal behavior after an initial attempt, strategies to retain patients in care, improved healthcare provider training, and generating care models that would ensure accessible treatment.

CONCLUSIONS

The Stakeholder Survey yielded widely valued research targets. Findings were diverse in focus, type, and current phase of research development but tended to prioritize practical solutions over theoretical advancement. Other complex public health problems requiring input from a broad-based constituency might benefit from web-based tools that facilitate such community input.

Suicide risk assessment and risk formulation part I: a focus on suicide ideation in assessing suicide risk

The main procedure used by clinicians to determine whether an individual may be at risk of suicidal behaviors is the suicide risk assessment (SRA). The purpose of the SRA is to identify risk and protective factors that then provide the data for the formulation of suicide risk. The suicide risk formulation (SRF) assigns a level of suicide risk that ideally leads to triage and treatment deemed appropriate for that level of risk. Some of the problems with the SRA are explored here, with an emphasis on addressing the over reliance on communicated suicide ideation, and recommendations are made for improvements. Part II of this article (Berman & Silverman, 2013, also appears in this issue of STLB) examines the process of an SRF and, similarly, makes recommendations to improve clinical practice toward the desired end of saving lives.

Suicide risk assessment and risk formulation part II: Suicide risk formulation and the determination of levels of risk

The suicide risk formulation (SRF) is dependent on the data gathered in the suicide risk assessment. The SRF assigns a level of suicide risk that is intended to inform decisions about triage, treatment, management, and preventive interventions. However, there is little published about how to stratify and formulate suicide risk, what are the criteria for assigning levels of risk, and how triage and treatment decisions are correlated with levels of risk. The salient clinical issues that define an SRF are reviewed and modeling is suggested for an SRF that might guide clinical researchers toward the refinement of an SRF process.

Estimating the population of survivors of suicide: seeking an evidence base

Shneidman (1973) derived an estimate of six survivors for every suicide that, in the ensuing years, has become an assumed fact underlying public health messaging campaigns in support of suicide prevention and postvention programs worldwide, in spite of it lacking either empirical testing or validation. This report offers a first test designed to derive estimates of suicide survivors and raises an array of empirical questions needing further study to reasonably address the impact of suicide on others.

Establishing standards for the assessment of suicide risk among callers to the national suicide prevention lifeline

The National Suicide Prevention Lifeline was launched in January 2005. Lifeline, supported by a federal grant from the Substance Abuse and Mental Health Services Administration, consists of a network of more than 120 crisis centers located in communities across the country that are committed to suicide prevention. Lifeline's Certification and Training Subcommittee conducted an extensive review of research and field practices that yielded the Lifeline's Suicide Risk Assessment Standards. The authors of the current paper provide the background on the need for these standards; describe the process that produced them; summarize the research and rationale supporting the standards; review how these standard assessment principles and their subcomponents can be weighted in relation to one another so as to effectively guide crisis hotline workers in their everyday assessments of callers to Lifeline; and discuss the implementation process that will be provided by Lifeline.

Reducing firearm violence: a research agenda

In the United States, firearms are involved in tens of thousands of deaths and injuries each year. The magnitude of this problem prompted the National Academy of Sciences (NAS) to issue a report in 2004 detailing the strengths and limitations of existing research on the relationship between firearms and violence. In response, a multidisciplinary group of experts in the field of firearms and violence formed the National Research Collaborative on Firearm Violence. The Collaborative met for 2 days in June 2005 to (1) critically review the main findings of the NAS report and (2) define a research agenda that could fill research and data gaps and inform policy that reduces gun-related crime, deaths and injuries. This article summarizes the Collaborative's conclusions and identifies priorities for research and funding.

Standardizing the psychological autopsy: addressing the Daubert standard

The psychological autopsy, as a research, clinical, and forensic tool, has gained widespread usage in suicidology over the last half century. In forensic settings, the lack of standardization and problems determining the procedure's validity and reliability pose significant issues for the procedure's admissibility under the Daubert standard of evidence. The Daubert standard requires that evidence must be founded on scientific knowledge and established five guidelines for judicial decisions regarding the admissibility of expert testimony. In this paper we examine expert opinion regarding the psychological autopsy and recommend a standardized protocol or template regarding areas and lines of inquiry for a psychological autopsy used in legal cases.

Warning signs for suicide on the Internet: a descriptive study

The issue of suicide warning signs on the Internet is considered. In addition to reviewing some of the relevant conceptual issues about warning signs, a random sample of Internet sites was selected and reviewed. Warning signs were grouped and agreement across sites was examined, with results confirming broad disparity in what is presented to the public. The implications of a lack of consensus on warning signs for suicide are discussed.

The emotional impact and ease of recall of warning signs for suicide: a controlled study

In light of concerns about potential iatrogenic effects of information about suicide, in the current study we examined the emotional impact of reading a list of warning signs for suicide in comparison to comparable lists for heart attacks and diabetes. All participants read two sets of warning signs, with the experimental group reading the suicide warning signs. Results confirm no difference in emotional impact across groups, along with providing evidence that warning signs for suicide are as easy to recall after exposure as warning signs for heart attack. Implications for pubic health campaigns are discussed.

Warning signs for suicide: theory, research, and clinical applications

The current article addresses the issue of warning signs for suicide, attempting to differentiate the construct from risk factors. In accordance with the characteristic features discussed, a consensus set of warning signs identified by the American Association of Suicidology working group are presented, along with a discussion of relevant clinical and research applications.

Risk management with suicidal patients

The patient who is at-risk for suicide is complex and is difficult to evaluate and treat effectively. Should suicidal behavior occur, the clinician faces the potential wrath of bereaved survivors and their externalized blame exercised through a malpractice suit. The clinician's duty of care to a patient is to act affirmatively to protect a patient from violent acts against self. A finding of malpractice is established if the court finds that this duty was breached, through an act of omission or commission relative to the standard of care, and that this breach was proximately related to the patient's suicidal behavior. This article discusses the standard of care and factors that determine liability in a suicide death of a patient. An extensive list of recommendations for competent caregiving for the at-risk patient and risk management guidelines are then presented.

A general systems approach to suicide prevention: lessons from cardiac prevention and control

The pathology of cardiac disease includes genetic, physical, biochemical, psychological, social, and environmental vectors. Factors contributing to suicide have been identified in these same areas. Survival from an acute cardiac event requires a systematized and multisectoral response. Communities that do not have systematized response capabilities to acute cardiac events have poorer survival outcomes. Suicide prevention and control may also be responsive to an integrated community response system. This paper examines the development of a community cardiac care model, explores potential parallels for a community suicide prevention and control model, and outlines a general systems theory framework for a suicide prevention and control system.

The LSARS-II: Lethality of Suicide Attempt Rating Scale-Updated

The concept of lethality is essential to the assessment of suicide risk; yet operational definitions of lethality for purposes of its measurement have been loose and varied. A number of scaling measures have been published in the literature, with no relative consensus on the best of these. In addition, only a few of these scales have published data on their psychometric properties. Of these, we argue that the best is the Lethality of Suicide Attempt Rating Scale (LSARS; Smith, Conroy, & Ehler, 1984). Presented here is a significantly revised and redesigned listing of drugs and chemicals and lethal ranges of ingestion (in caps, tabs, or ounces) by body weight to update that scale.

Clinicians' decision making about involuntary commitment

OBJECTIVE

Clinicians' decision making about involuntary commitment was examined, with a focus on the effects of patient and clinician characteristics and bed availability on decisions to detain patients, the first step in involuntary commitment.

METHODS

Eighteen psychologists and social workers in the emergency service of a community mental health center completed the Risk Assessment Questionnaire for 169 consecutive patients they deemed to present some degree of risk. Forty-two patients were detained.

RESULTS

Three underlying constructs were significantly associated with a patient's overall risk rating, which in turn predicted the decision to detain. Two were clinician characteristics: the clinician detention ratio, which reflects the proportion of patients detained by the clinician in the past three months, and the setting in which the evaluation occurred, either an in-house emergency service or a mobile crisis unit. The availability of detention beds in the community was also a significant predictor of whether a patient would be detained. No patient characteristic, including diagnosis, sex, age, or insurance status, was significantly related to the detention decision.

CONCLUSIONS

The findings suggest that the decision-making process is influenced by multiple factors, such as setting, the clinician's tendency to detain patients, and the availability of detention beds.

Levofloxacin population pharmacokinetics and creation of a demographic model for prediction of individual drug clearance in patients with serious community-acquired infection

Population pharmacokinetic modeling is a useful approach to obtaining estimates of both population and individual pharmacokinetic parameter values. The potential for relating pharmacokinetic parameters to pharmacodynamic outcome variables, such as efficacy and toxicity, exists. A logistic regression relationship between the probability of a successful clinical and microbiological outcome and the peak concentration-to-MIC ratio (and also the area under the plasma concentration-time curve [AUC]/MIC ratio) has previously been developed for levofloxacin; however, levofloxacin assays for determination of the concentration in plasma are not readily available. We attempted to derive and validate demographic variable models to allow prediction of the peak concentration in plasma and clearance (CL) from plasma for levofloxacin. Two hundred seventy-two patients received levofloxacin intravenously for the treatment of community-acquired infection of the respiratory tract, skin or soft tissue, or urinary tract, and concentrations in plasma, guided by optimal sampling theory, were obtained. Patient data were analyzed by the Non-Parametric Expectation Maximization approach. Maximum a posteriori probability Bayesian estimation was used to generate individual parameter values, including CL. Peak concentrations were simulated from these estimates. The first 172 patients were used to produce demographic models for the prediction of CL and the peak concentration. The remaining 100 patients served as the validation group for the model. A median bias and median precision were calculated. A two-compartment model was used for the population pharmacokinetic analysis. The mean CL and the mean volume of distribution of the central compartment (V1) were 9.27 liters/h and 0.836 liter/kg, respectively. The mean values for the intercompartmental rate constants, the rate constant from the central compartment to the peripheral compartment (Kcp) and the rate constant from the peripheral compartment to the central compartment (Kpc), were 0.487 and 0.647 h(-1), respectively. The mean peak concentration and the mean AUC values normalized to a dosage of 500 mg every 24 h were 8.67 microg/ml and 72.53 microg x h/ml, respectively. The variables included in the final model for the prediction of CL were creatinine clearance (CLCR), race, and age. The median bias and median precision were 0.5 and 18.3%, respectively. Peak concentrations were predicted by using the demographic model-predicted parameters of CL, V1, Kcp and Kpc, in the simulation. The median bias and the median precision were 3.3 and 21.8%, respectively. A population model of the disposition of levofloxacin has been developed. Population demographic models for the prediction of peak concentration and CL from plasma have also been successfully developed. However, the performance of the model for the prediction of peak concentration was likely insufficient to be of adequate clinical utility. The model for the prediction of CL was relatively robust, with acceptable bias and precision, and explained a reasonable amount of the variance in the CL of levofloxacin from plasma in the population (r2 = 0.396). Estimated CLCR, age, and race were the final model covariates, with CLCR explaining most of the population variance in the CL of levofloxacin from plasma. This model can potentially optimize the benefit derived from the pharmacodynamic relationships previously developed for levofloxacin.

Pharmacodynamics of levofloxacin: a new paradigm for early clinical trials

CONTEXT

One purpose of early clinical trials is to establish the appropriate dose of an antibiotic for phase 3 trials. Development of a relationship between the ratio of drug exposure to organism minimum inhibitory concentration (MIC) and therapeutic response early in the development process would allow an optimal choice of dose to maximize response.

OBJECTIVE

To prospectively quantitate the relationship between plasma levels of levofloxacin and successful clinical and/or microbiological outcomes and occurrence of adverse events in infected patients.

DESIGN

Multicenter open-label trial.

SETTING

Twenty-two enrolling university-affiliated medical centers.

PATIENTS

A total of 313 patients with clinical signs and symptoms of bacterial infections of the respiratory tract, skin, or urinary tract.

MAIN OUTCOME MEASURES

Clinical response and microbiological eradication of pathogenic organisms.

RESULTS

Of 313 patients, 272 had plasma concentration-time data obtained. Of these, 134 patients had a pathogen recovered from the primary infection site and had an MIC of the pathogen to levofloxacin determined. These patients constituted the primary analysis group for clinical outcome. Groups of 116 and 272 patients, respectively, were analyzed for microbiological outcome and incidence of adverse events. In a logistic regression analysis, the clinical outcome was predicted by the ratio of peak plasma concentration to MIC (Peak/MIC) and site of infection (P<.001). Microbiological eradication was predicted by the Peak/MIC ratio (P<.001). Both clinical and microbiological outcomes were most likely to be favorable if the Peak/MIC ratio was at least 12.2.

CONCLUSIONS

Levofloxacin generated clinical and microbiological response rates of 95% and 96%, respectively. These response rates included fluoroquinolone "problem pathogens," such as Streptococcus pneumoniae and Staphylococcus aureus. Exposure to levofloxacin was significantly associated with successful clinical and microbiological outcomes. The principles used in these analyses can be applied to other classes of drugs to develop similar relationships between exposure and outcome. This pharmacokinetic modeling could be used to determine optimal treatment dose in clinical trials in a shorter time frame with fewer patients. This modeling also should be evaluated for its potential to improve outcomes (maximizing therapeutic response, preventing emergence of resistance, and minimizing adverse events) of patients treated with this drug.

The adolescent: the individual in cultural perspective

Case vignettes are presented to highlight the idiosyncratic dynamics and special cultural influences that describe adolescent suicides. Extrapolated from these cases are a series of aphorisms about the study of adolescent suicide and about adolescence, meant to inform both clinicians and researchers on the need to better attend to the individual in context of his or her cultural influences.

The Kurt Cobain suicide crisis: perspectives from research, public health, and the news media

The suicide of rock star Kurt Cobain in 1994 raised immediate concerns among suicidologists and the public at large about the potential for his death to spark copycat suicides, especially among vulnerable youth. The Seattle community, where Cobain lived and died, was especially affected by his sudden death. An overview of Cobain's life and death is presented and various crisis center and community-based interventions that occurred are discussed. Preliminary data collected from the Seattle Medical Examiner's Office and from the Seattle Crisis Center to assess the potential impact of Cobain's death on completed suicides and the incidence of suicide crisis calls are presented. The data obtained from the Seattle King County area suggest that the expected "Werther effect" apparently did not occur, but there was a significant increase in suicide crisis calls following his death. It is hypothesized that the lack of an apparent copycat effect in Seattle may be due to various aspects of the media coverage, the method used in Cobain's suicide, and the crisis center and community outreach interventions that occurred. The Cobain suicide and the role of media influence on copycat suicides are further discussed in commentaries from public health and news media perspectives.