Short-term risk of suicide attempt associated with patterns of patient-reported alcohol use determined by routine AUDIT-C among adults receiving mental healthcare

Associations between clinical AUDIT-C screens and HDL cholesterol are observed across primary care patient subgroups

BACKGROUND

The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) is a validated, scaled marker of past-year alcohol consumption that is increasingly used in population-based screening and research. Like other screening questionnaires, AUDIT-C scores are influenced by patient and system factors affecting self-report. High-density lipoprotein (HDL) cholesterol increases with alcohol consumption and is routinely measured in primary care. Researchers using AUDIT-C scores as an outcome could potentially use HDL as a population-level check on the performance of alcohol screening, for example, to assess the extent to which changes in AUDIT-C scores after an intervention reflect changes in drinking or changes in self-report. However, the association between AUDIT-C scores and HDL has only been evaluated in limited populations.

METHODS

Cross-sectional associations between AUDIT-C scores and HDL were examined in 290,091 Kaiser Permanente Washington primary care patients who had HDL measured as part of clinical care in the 365 days before or 14 days after routine screening with the AUDIT-C. Linear regression models examined the association between AUDIT-C scores and HDL and explored effect modification by sociodemographic and clinical characteristics.

RESULTS

AUDIT-C scores were positively associated with HDL, including for subgroups defined by age, sex, race, ethnicity, geographically estimated socioeconomic status, presence of cardiovascular disease, history of alcohol or drug treatment, tobacco use, receipt of lipid-lowering medications, and, for female patients, receipt of oral estrogen or progestin medications. Effect modification analyses showed that most sociodemographic and clinical characteristics modified the association between AUDIT-C and HDL.

CONCLUSIONS

The association between AUDIT-C and HDL is present in a range of sociodemographic and clinical subgroups. However, effect modification by sociodemographic and clinical characteristics may limit the use of that association in assessing the validity of alcohol screening scores across heterogeneous populations.

Comprehensive care processes for substance use disorders in adult mental health services: A systematic review

BACKGROUND AND OBJECTIVES

Assessment and care of substance use disorder within mental health services are essential due to the high prevalence and harms associated with comorbidity. Substance use disorder assessment and care are routinely recommended in clinical guidelines; however, processes are not agreed. This systematic review of routine clinical practice in relation to substance use disorders in adult mental health service aims to identify routine assessment and diagnosis processes, the proportion of patients and service episodes in which they occur and their outputs.

METHODS

We searched MEDLINE, PsycINFO, Embase and relevant Cochrane databases for articles until July 2024 reporting on substance use assessment, diagnosis or treatment in adults receiving routine mental health service and locating additional articles by snowballing. Variables including setting, study method, period, cohort, substances, clinical assessment type, diagnosis and care pathways were compared.

RESULTS

In 137 heterogeneous studies reporting routine practice within a wide variety of adult mental health service from 29 nations, 44 (32%) expected or reported on substance use assessment in domains of pattern or impact. However, 23 studies (17%) reported structured approaches to substance use disorder assessment, while 67 (49%) reported a diagnostic structure, including classification system. Diagnostic prevalence varied markedly. Treatment was reported in 16 studies (12%) and no substance use disorder outcomes were reported.

CONCLUSION

This systematic review shows marked variation in routine practice in mental health service across a range of substance use disorder assessment and diagnosis processes. To better identify substance use disorder, enhance its care and reduce associated morbidity, adult mental health service may benefit from standardising expectations and systematically monitoring the performance of substance use assessment and diagnosis.

Major Depression in Comorbidity with Substance use Disorders: Patients' Features and Clinical-Neurobiological Rationale of Antidepressant Treatments

The frequent co-occurrence of major depressive disorder (MDD) and substance use disorders (SUDs) entails significant clinical challenges. Compared to patients with MDD alone, patients with MDD and SUD often show increased anhedonia, emotional blunting, and impaired cognitive function. These symptoms lead to an inability to control cravings, more substance use, increased relapse rates, and poor adherence to the treatment. This fosters a detrimental cycle leading to more severe depressive symptoms, functional impairment, and chronicity, culminating in heightened morbidity, mortality, and healthcare resource utilization. Data on antidepressant treatment of MDD-SUD patients are inconclusive and often conflicting because of a number of confounding factors in clinical trials or difficulty in dissecting the specific contributions of pharmacological versus psychological interventions in real-world studies. The patient's unique clinical features and specific SUD and MDD subtypes must be considered when choosing treatments. Ideally, drug treatment for MDD-SUD should act on both conditions and address core symptoms such as anhedonia, craving, and cognitive dysfunction while ensuring minimal emotional blunting, absence of drug interactions, and no addictive potential. This approach aims to address unmet needs and optimize the outcomes in a clinical population often underrepresented in treatment paradigms.

Effectiveness of Integrating Suicide Care in Primary Care : Secondary Analysis of a Stepped-Wedge, Cluster Randomized Implementation Trial

BACKGROUND

Primary care encounters are common among patients at risk for suicide.

OBJECTIVE

To evaluate the effectiveness of implementing population-based suicide care (SC) in primary care for suicide attempt prevention.

DESIGN

Secondary analysis of a stepped-wedge, cluster randomized implementation trial. (ClinicalTrials.gov: NCT02675777).

SETTING

19 primary care practices within a large health care system in Washington State, randomly assigned launch dates.

PATIENTS

Adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018.

INTERVENTION

Practice facilitators, electronic medical record (EMR) clinical decision support, and performance monitoring supported implementation of depression screening, suicide risk assessment, and safety planning.

MEASUREMENTS

Clinical practice and patient measures relied on EMR and insurance claims data to compare usual care (UC) and SC periods. Primary outcomes included documented safety planning after population-based screening and suicide risk assessment and suicide attempts or deaths (with self-harm intent) within 90 days of a visit. Mixed-effects logistic models regressed binary outcome indicators on UC versus SC, adjusted for randomization stratification and calendar time, accounting for repeated outcomes from the same site. Monthly outcome rates (percentage per 10 000 patients) were estimated by applying marginal standardization.

RESULTS

During UC, 255 789 patients made 953 402 primary care visits and 228 255 patients made 615 511 visits during the SC period. The rate of safety planning was higher in the SC group than in the UC group (38.3 vs. 32.8 per 10 000 patients; rate difference, 5.5 [95% CI, 2.3 to 8.7]). Suicide attempts within 90 days were lower in the SC group than in the UC group (4.5 vs. 6.0 per 10 000 patients; rate difference, -1.5 [CI, -2.6 to -0.4]).

LIMITATION

Suicide care was implemented in combination with care for depression and substance use.

CONCLUSION

Implementation of population-based SC concurrent with a substance use program resulted in a 25% reduction in the suicide attempt rate in the 90 days after primary care visits.

PRIMARY FUNDING SOURCE

National Institute of Mental Health.

Prevalence of work hour alcohol use and associated factors among psychiatrists in China

BACKGROUND

Since 2012, work-hour alcohol use (WHAU) has been prohibited in China. However, there is a lack of national data on WHAU among healthcare workers, including psychiatrists.

METHODS

We collected data from psychiatrists in 41 tertiary psychiatric hospitals using an online questionnaire, which included demographics, work-related factors, WHAU, and the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C).

RESULTS

Out of 2911 psychiatrists who completed the survey, 4.29% reported having heard (3.13%) or witnessed (1.17%) WHAU among colleagues, and .51% (95% CI: .26%-.78%) admitted to their own WHAU. Most participants (95.57%) reported awareness of the policy against WHAU. Poisson regression demonstrated the unawareness of WHAU policy (incidence-rate ratios [IRR] 11.08; 95% CI: 3.56-34.52; P < .001), lower income (IRR .87; 95% CI: .79-0.96; P = .008), and higher AUDIT-C scores (IRR 1.48; 95% CI: 1.22-1.80; P < .001) were significantly associated with WHAU occurrences.

CONCLUSIONS

The survey indicates that WHAU among psychiatrists is more prevalent than expected, correlating with insufficient awareness of hospital policies. This suggests a need for targeted educational interventions.

Outcomes following suicidal crisis among hazardous and harmful alcohol users in the Crisis Resolution Team

Despite associations between alcohol use and suicidal acts, little research measures prognoses of alcohol-using patients treated by Crisis Resolution Teams (CRTs), an intensive community-based intervention. We estimated the association of alcohol use amongst patients accepted following suicidal acts or ideation in four London-based Crisis Resolution Teams, with death-by-any-cause or recontact with crisis care. We analysed the electronic health records of 1615 CRT patients accepted following suicidal acts or ideation over 38 months, following STROBE guidelines. Using logistic regression we estimated the association of alcohol use (indicated by risk-assessment, AUDIT, or ICD-10 diagnosis) with death-or-recontact at (i) 30-days and (ii) 1-year after treatment start, adjusted for age, sex, ethnicity, psychiatric diagnosis, and severity of need. Hazardous, harmful, or dependent drinking was identified in 270 cases at baseline (16.7%); 73 (4.5%) were alcohol dependent. By 1-year, 622 patients (38.5%) had recontacted crisis care or died. After adjustment, alcohol use at a hazardous, harmful, or dependent level was not associated with increased odds of death-or-recontact at 30-days (AOR 1.17, 95%CI 0.73, 1.88) or 1-year (AOR 1.17, 95%CI 0.85, 1.60). Patients with hazardous, harmful, and dependent alcohol use are a small proportion of CRT patients, despite being more commonly encountered in emergency settings from which patients may be referred to CRTs, indicating a potential gap in provision. Those who are included in CRTs are not at increased risk of death-or-recontact within 1 year of treatment, suggesting that their inclusion can work, at least in a sample with predominantly hazardous or harmful alcohol use.

Substance use disorder screening and brief intervention in routine clinical practice in specialist adult mental health services: A systematic review

BACKGROUND AND OBJECTIVES

Substance use disorders co-occurring with other mental health disorders are common and harmful. Clinical guidelines often recommend substance use screening and brief intervention though evidence about screening practice in mental health services is limited. This systematic review of routine clinical practice in adult mental health services aims to identify (a) proportions of screening and brief intervention, (b) how they are practised and (c) their outcomes.

METHODS

We searched MEDLINE, PsycINFO and Embase and relevant Cochrane databases for articles until 31 July 2021 reporting on adults in English, regardless of geographical location. Backward snowball methods were used to locate additional articles. Screening, brief intervention and mental health services were defined. Data were extracted and variables compared related to setting, period, patient cohort, substances routine substance use disorder care pathways, and study quality was assessed.

RESULTS

We identified 17 articles reporting routine screening within adult mental health services. Studies in community settings mainly reported on screening for alcohol and other substance use disorders, while studies from inpatient settings reported mainly on tobacco. There was marked variation in methods and screening proportions. Only two studies reported on brief intervention.

CONCLUSION

This systematic review shows marked variation in mental health services routine screening practices with early focus on alcohol but more recently tobacco screening. We suggest approaches to enhancing implementation of screening and brief intervention in routine care, particularly using electronic health records.

Predictive Model of Suicide Risk in Young People: The Mediating Role of Alcohol Consumption

Suicidal behavior is one of the public health problems that cause most deaths in young people and has been associated with emotional and affective problems, so predictive models are required to account for the relationship between depression, anxiety, hopelessness, and alcohol consumption to propose actions for its prevention. The Plutchik Suicide Risk Scale, the CAGE Questionnaire, the Hopelessness Scale, the Depression Inventory and the Beck Anxiety Scale were applied. A total of 1.379 young people (M = 20.45; SD = 3.23) from the cities of Manizales (n = 739; 53.6%) and Medellín (n = 640; 46.5%) in Colombia were evaluated. The variables of anxiety, hopelessness and depression explained 51% (R² = 0.509; 95% CI = 0.467-0.552; p = 0.001) of the variation in suicidal risk. Likewise, alcohol consumption is a mediating variable between depression and anxiety in the prediction of suicidal risk, whose total, direct and indirect effects are statistically significant. The findings support the role of alcohol consumption as a mediating variable between anxiety, depression, hopelessness and suicidal risk in young people, given the difficulties it causes in information processing, regulation of emotions and therefore in having an adequate coping with the demands of the environment. This justifies the importance of directing suicide prevention actions through strategies for the reduction of alcohol consumption and the management of emotions in young people. HIGHLIGHTSAlcohol modulates the effect of depression and anxiety on suicide riskThis is a study on the risk of suicide in young people in ColombiaThe findings have implications for timely clinical interventions.

Association Between Patterns of Alcohol Use and Short-Term Risk of Suicide Attempt Among Patients With and Without Reported Suicidal Ideation

OBJECTIVE

To evaluate the association between patterns of alcohol use and short-term risk of suicide attempt among patients with and without reported suicidal ideation.

METHODS

Kaiser Permanente Washington electronic health record data were used to identify mental health visits (1/1/2010-6/30/2015) with documented assessments for unhealthy alcohol use (AUDIT-C) and suicidal ideation (PHQ-9 ninth question). Logistic regression fit using generalized estimating equations were used to conduct visit-level analyses, accounting for correlation between individuals' assessments. Separate models evaluated the association between (1) level of alcohol consumption and (2) frequency of heavy episodic drinking (HED), in combination with suicidal ideation (any vs none), with suicide attempt within 90 days following each visit. Primary models adjusted for age, gender, race/ethnicity and visit year.

RESULTS

Of 59,705 visits (43,706 unique patients), 372 (0.62%) were followed by a suicide attempt within 90 days. The risk of suicide attempt was significantly higher for patients reporting suicidal ideation across all levels of alcohol consumption compared to patients reporting low-level alcohol use and no suicidal ideation, particularly high-level use (OR 9.77, 95% CI, 6.23-15.34). Similarly, risk of suicide attempt was higher for patients reporting suicidal ideation across all levels of HED relative to those reporting no HED or suicidal ideation, particularly HED monthly or more (OR 6.80, 95% CI 4.77-9.72). Among patients reporting no suicidal ideation, no associations were observed.

CONCLUSIONS

Findings underscore the potential value of offering alcohol-related care to patient reporting suicidal ideation. Additional strategies are needed to identify suicide risk among those reporting no suicidal ideation.

An implementation evaluation of "Zero Suicide" using normalization process theory to support high-quality care for patients at risk of suicide

Background

Suicide rates continue to rise across the United States, galvanizing the need for increased suicide prevention and intervention efforts. The Zero Suicide (ZS) model was developed in response to this need and highlights four key clinical functions of high-quality health care for patients at risk of suicide. The goal of this quality improvement study was to understand how six large health care systems operationalized practices to support these functions-identification, engagement, treatment and care transitions.

Methods

Using a key informant interview guide and data collection template, researchers who were embedded in each health care system cataloged and summarized current and future practices supporting ZS, including, (1) the function addressed; (2) a description of practice intent and mechanism of intervention; (3) the target patient population and service setting; (4) when/how the practice was (or will be) implemented; and (5) whether/how the practice was documented and/or measured. Normalization process theory (NPT), an implementation evaluation framework, was applied to help understand how ZS had been operationalized in routine clinical practices and, specifically, what ZS practices were described by key informants (coherence), the current state of norms/conventions supporting these practices (cognitive participation), how health care teams performed these practices (collective action), and whether/how practices were measured when they occurred (reflexive monitoring).

Results

The most well-defined and consistently measured ZS practices (current and future) focused on the identification of patients at high risk of suicide. Stakeholders also described numerous engagement and treatment practices, and some practices intended to support care transitions. However, few engagement and transition practices were systematically measured, and few treatment practices were designed specifically for patients at risk of suicide.

Conclusions

The findings from this study will support large-scale evaluation of the effectiveness of ZS implementation and inform recommendations for implementation of high-quality suicide-related care in health care systems nationwide.