Predicting Outcomes of Antidepressant Treatment in Community Practice Settings

OBJECTIVE

The authors examined whether machine-learning models could be used to analyze data from electronic health records (EHRs) to predict patients' responses to antidepressant medications.

METHODS

EHR data from a Washington State health system identified patients ages ≥13 years who started an antidepressant medication in 2016 in a community practice setting and had a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥10 and at least one PHQ-9 score recorded 14-180 days later. Potential predictors of a response to antidepressants were extracted from the EHR and included demographic characteristics, psychiatric and substance use diagnoses, past psychiatric medication use, mental health service use, and past PHQ-9 scores. Random-forest and penalized regression analyses were used to build models predicting follow-up PHQ-9 score and a favorable treatment response (≥50% improvement in score).

RESULTS

Among 2,469 patients starting antidepressant medication treatment, the mean±SD baseline PHQ-9 score was 17.3±4.5, and the mean lowest follow-up score was 9.2±5.9. Outcome data were available for 72% of the patients. About 48% of the patients had a favorable treatment response. The best-fitting random-forest models yielded a correlation between predicted and observed follow-up scores of 0.38 (95% CI=0.32-0.45) and an area under the receiver operating characteristic curve for a favorable response of 0.57 (95% CI=0.52-0.61). Results were similar for penalized regression models and for models predicting last PHQ-9 score during follow-up.

CONCLUSIONS

Prediction models using EHR data were not accurate enough to inform recommendations for or against starting antidepressant medication. Personalization of depression treatment should instead rely on systematic assessment of early outcomes.

Adolescents Who Do Not Endorse Risk via the Patient Health Questionnaire Before Self-Harm or Suicide

Importance

Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected.

Objective

To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide.

Design, Setting, and Participants

This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023.

Exposures

Demographic, diagnostic, treatment, and health care utilization characteristics.

Main Outcome(s) and Measure(s)

Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide.

Results

The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days.

Conclusions and Relevance

Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters

Background

"Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians.

Objective

The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters.

Methods

The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide.

Results

The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians.

Conclusions

Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation

OBJECTIVE

The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings.

METHODS

Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated.

RESULTS

In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care.

CONCLUSIONS

Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

Factors associated with suicide mortality among reproductive age women: a case-control study

OBJECTIVE

Examine demographic, psychosocial, pregnancy-related, and healthcare utilisation factors associated with suicide mortality among reproductive age women.

METHODS

Data from nine health care systems in the Mental Health Research Network were included. A case-control study design was used in which 290 reproductive age women who died by suicide (cases) from 2000 to 2015 were matched with 2,900 reproductive age women from the same healthcare system who did not die by suicide (controls). Conditional logistic regression was used to analyse associations between patient characteristics and suicide.

RESULTS

Women of reproductive age who died by suicide were more likely to have mental health (aOR = 7.08, 95% CI: 5.17, 9.71) or substance use disorders (aOR = 3.16, 95% CI: 2.19, 4.56) and to have visited the emergency department in the year prior to index date (aOR = 3.47, 95% CI: 2.50, 4.80). Non-Hispanic White women (aOR = 0.70, 95% CI: 0.51, 0.97) and perinatal (pregnant or postpartum) women were less likely to have died by suicide (aOR = 0.27, 95% CI: 0.13, 0.58).

CONCLUSIONS

Reproductive age women with mental health and/or substance use disorders, prior emergency department encounters, or who are of racial or ethnic minority status were at increased risk of suicide mortality and may benefit from routine screening and monitoring. Future research should further examine the relationship between pregnancy-related factors and suicide mortality.

Minimal Effect of Messaging on Engagement in a Digital Anxiety Intervention

This study evaluated the effectiveness of different recruitment messages for encouraging enrollment in a digital mental health intervention (DMHI) for anxiety among 1,600 anxious patients in a large healthcare system. Patients were randomly assigned to receive a standard message, or one of five messages designed to encourage enrollment: Three messages offered varying financial incentives, one message offered coaching, and one message provided consumer testimonials. Patients could then click a link in the message to visit the DMHI website, enroll, and start the first session. We examined the effects of message features and message length (short vs. long) on rates of site clicks, enrollment, and starting the first session. We also tested whether demographic and clinical factors derived from patients' electronic health records were associated with rates of enrollment and starting the first session to understand the characteristics of patients most likely to use DMHIs in this setting. Across messages, 19.4% of patients clicked a link to visit the DMHI website, but none of the messages were significantly associated with rates of site clicks, enrollment, or starting the first session. Females (vs. males) had a greater probability of enrollment. No other demographic or clinical variables were significantly associated with enrollment or starting the first session. Findings provide guidance for resource allocation decisions in larger scale DMHI implementations in healthcare settings.

Complex modeling with detailed temporal predictors does not improve health records-based suicide risk prediction

Suicide risk prediction models can identify individuals for targeted intervention. Discussions of transparency, explainability, and transportability in machine learning presume complex prediction models with many variables outperform simpler models. We compared random forest, artificial neural network, and ensemble models with 1500 temporally defined predictors to logistic regression models. Data from 25,800,888 mental health visits made by 3,081,420 individuals in 7 health systems were used to train and evaluate suicidal behavior prediction models. Model performance was compared across several measures. All models performed well (area under the receiver operating curve [AUC]: 0.794-0.858). Ensemble models performed best, but improvements over a regression model with 100 predictors were minimal (AUC improvements: 0.006-0.020). Results are consistent across performance metrics and subgroups defined by race, ethnicity, and sex. Our results suggest simpler parametric models, which are easier to implement as part of routine clinical practice, perform comparably to more complex machine learning methods.

Equitable implementation of S.A.F.E. Firearm: A multi-method pilot study

Attention to health equity is critical in the implementation of firearm safety efforts. We present our operationalization of equity-oriented recommendations in preparation for launch of a hybrid effectiveness-implementation trial focused on firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. In Step 1 of our process, pre-trial engagement with clinican partners and literature review alerted us that delivery of a firearm safety program may vary by patients' medical complexity, race, and ethnicity. In Step 2, we selected the Health Equity Implementation Framework to inform our understanding of contextual determinants (i.e., barriers and facilitators). In Step 3, we leveraged an implementation pilot across 5 pediatric primary care clinics in 2 health system sites to study signals of inequities. Eligible well-child visits for 694 patients and 47 clinicians were included. Our results suggested that medical complexity was not associated with program delivery. We did see potential signals of inequities by race and ethnicity but must interpret with caution. Though we did not initially plan to examine differences by sex assigned at birth, we discovered that clinicians may be more likely to deliver the program to parents of male than female patients. Seven qualitative interviews with clinicians provided additional context. In Step 4, we interrogated equity considerations (e.g., why and how do these inequities exist). In Step 5, we will develop a plan to probe potential inequities related to race, ethnicity, and sex in the fully powered trial. Our process highlights that prospective, rigorous, exploratory work is vital for equity-informed implementation trials.

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention: A Qualitative Study

Importance

US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention.

Objective

To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters.

Design, Setting, and Participants

Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs).

Main Outcomes and Measures

Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives.

Results

Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews.

Conclusions and Relevance

In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.

Accuracy of ICD-10-CM encounter diagnoses from health records for identifying self-harm events

OBJECTIVE

Assess the accuracy of ICD-10-CM coding of self-harm injuries and poisonings to identify self-harm events.

MATERIALS AND METHODS

In 7 integrated health systems, records data identified patients reporting frequent suicidal ideation. Records then identified subsequent ICD-10-CM injury and poisoning codes indicating self-harm as well as selected codes in 3 categories where uncoded self-harm events might be found: injuries and poisonings coded as undetermined intent, those coded accidental, and injuries with no coding of intent. For injury and poisoning encounters with diagnoses in those 4 groups, relevant clinical text was extracted from records and assessed by a blinded panel regarding documentation of self-harm intent.

RESULTS

Diagnostic codes selected for review include all codes for self-harm, 43 codes for undetermined intent, 26 codes for accidental intent, and 46 codes for injuries without coding of intent. Clinical text was available for review for 285 events originally coded as self-harm, 85 coded as undetermined intent, 302 coded as accidents, and 438 injury events with no coding of intent. Blinded review of full-text clinical records found documentation of self-harm intent in 254 (89.1%) of those originally coded as self-harm, 24 (28.2%) of those coded as undetermined, 24 (7.9%) of those coded as accidental, and 48 (11.0%) of those without coding of intent.

CONCLUSIONS

Among patients at high risk, nearly 90% of injuries and poisonings with ICD-10-CM coding of self-harm have documentation of self-harm intent. Reliance on ICD-10-CM coding of intent to identify self-harm would fail to include a small proportion of true self-harm events.

“Lock to Live” for firearm and medication safety: Feasibility and acceptability of a suicide prevention tool in a learning healthcare system

Objective

Few patients with suicide risk are counseled on lethal means safety by health providers. This study tested the feasibility of different delivery methods for Lock to Live (L2L), a web-based decision aid of safe storage options for firearms and medications.

Methods

Patients reporting suicide ideation on the PHQ9 depression screener during outpatient health visits were included. Invitation messages to visit L2L were sent via combinations of email, text, Electronic Health Record (EHR) message, mailed letter, or provider referral, followed by a survey about storage behavior and acceptability. Provider interviews evaluated logistical considerations and acceptability.

Results

The population-based method reached 2,729 patients and the best method (EHR message plus 2 email reminders) had 11% uptake (L2L visitation rate). Provider referral had small reach (14 patients) and 100% uptake (all visited). Provider interviews identified several strategies to promote uptake including: EHR reminders, provider training, quality metrics with accountability, a clearly communicated lethal means screening/counseling policy, and strong organizational leadership support.

Conclusion

Despite the low uptake for population-based (11%), far more patients with suicide risk were engaged in the L2L tool through population-based outreach than provider-referral over the same time frame.

Machine Learning Prediction of Suicide Risk Does Not Identify Patients Without Traditional Risk Factors

Objective: To determine whether predictions of suicide risk from machine learning models identify unexpected patients or patients without medical record documentation of traditional risk factors.

Methods: The study sample included 27,091,382 outpatient mental health (MH) specialty or general medical visits with a MH diagnosis for patients aged 11 years or older from January 1, 2009, to September 30, 2017. We used predicted risk scores of suicide attempt and suicide death, separately, within 90 days of visits to classify visits into risk score percentile strata. For each stratum, we calculated counts and percentages of visits with traditional risk factors, including prior self-harm diagnoses and emergency department visits or hospitalizations with MH diagnoses, in the last 3, 12, and 60 months.

Results: Risk-factor percentages increased with predicted risk scores. Among MH specialty visits, 66%, 88%, and 99% of visits with suicide attempt risk scores in the top 3 strata (respectively, 90th-95th, 95th-98th, and ≥ 98th percentiles) and 60%, 77%, and 93% of visits with suicide risk scores in the top 3 strata represented patients who had at least one traditional risk factor documented in the prior 12 months. Among general medical visits, 52%, 66%, and 90% of visits with suicide attempt risk scores in the top 3 strata and 45%, 66%, and 79% of visits with suicide risk scores in the top 3 strata represented patients who had a history of traditional risk factors in the last 12 months.

Conclusions: Suicide risk alerts based on these machine learning models coincide with patients traditionally thought of as high-risk at their high-risk visits.

A Critical Review of Text Mining Applications for Suicide Research

Purpose of Review

Applying text mining to suicide research holds a great deal of promise. In this manuscript, literature from 2019 to 2021 is critically reviewed for text mining projects that use electronic health records, social media data, and death records.

Recent Findings

Text mining has helped identify risk factors for suicide in general and specific populations (e.g., older adults), has been combined with structured variables in EHRs to predict suicide risk, and has been used to track trends in social media suicidal discourse following population level events (e.g., COVID-19, celebrity suicides).

Summary

Future research should utilize text mining along with data linkage methods to capture more complete information on risk factors and outcomes across data sources (e.g., combining death records and EHRs), evaluate effectiveness of NLP-based intervention programs that use suicide risk prediction, establish standards for reporting accuracy of text mining programs to enable comparison across studies, and incorporate implementation science to understand feasibility, acceptability, and technical considerations.

Detecting and distinguishing indicators of risk for suicide using clinical records

Health systems are essential for suicide risk detection. Most efforts target people with mental health (MH) diagnoses, but this only represents half of the people who die by suicide. This study seeks to discover and validate health indicators of suicide death among those with, and without, MH diagnoses. This case-control study used statistical modeling with health record data on diagnoses, procedures, and encounters. The study included 3,195 individuals who died by suicide from 2000 to 2015 and 249,092 randomly selected matched controls, who were age 18+ and affiliated with nine Mental Health Research Network affiliated health systems. Of the 202 indicators studied, 170 (84%) were associated with suicide in the discovery cohort, with 148 (86%) of those in the validation cohort. Malignant cancer diagnoses were risk factors for suicide in those without MH diagnoses, and multiple individual psychiatric-related indicators were unique to the MH subgroup. Protective effects across MH-stratified models included diagnoses of benign neoplasms, respiratory infections, and utilization of reproductive services. MH-stratified latent class models validated five subgroups with distinct patterns of indicators in both those with and without MH. The highest risk groups were characterized via high utilization with multiple healthcare concerns in both groups. The lowest risk groups were characterized as predominantly young, female, and high utilizers of preventive services. Healthcare data include many indicators of suicide risk for those with and without MH diagnoses, which may be used to support the identification and understanding of risk as well as targeting of prevention in health systems.

Are People Who Die by Intentional Medication Poisoning Dispensed Those Medications in the Year Prior to Death?

OBJECTIVE

The rate of suicidal poisoning in the United States has increased substantially over the past 20 years. Understanding whether prescription medications used for self-poisoning were recently dispensed would help inform suicide prevention efforts. Alternatively, medications for self-poisoning could have been formerly dispensed or collected from friends, family, or illicit sources.

METHODS

Among those who died by intentional opioid and psychotropic poisonings, we conducted a descriptive study to determine what proportion had a recently filled prescription that could have been the means of suicide. Subjects were all people who died by intentional poisoning across nine health-care systems within the NIH-funded Mental Health Research Network.

RESULTS

Among the 3,300 people who died by suicide, 700 died by any poisoning and 194 died by intentional opioid or psychotropic/hypnotic medication poisoning. Among those who died by intentional opioid poisoning 73% were dispensed an opioid in the year prior. Among those who died by intentional psychotropic/hypnotic poisoning, 83% were dispensed any psychotropic and 61% were dispensed a hypnotic in prior year. Most people were continuously dispensed the same medications used in their intentional poisonings in the year prior to death.

CONCLUSIONS

Our results indicate that most medications used in suicidal overdose were likely recently dispensed. Therefore, future suicide prevention studies and prevention resources should focus on medication safety interventions such as lethal-means counseling for medication access, limiting quantities dispensed, opioid antagonists, and blister packs. HIGHLIGHTSUnderstanding whether medications used for self-poisoning were recently dispensed or formerly/never dispensed would help inform future studies and suicide prevention efforts.We found that most people who died by intentional poisoning with opioids or psychotropic/hypnotic medications received frequent dispensings of the medication used for self-poisoning in the year prior to death.Future suicide prevention studies and efforts should focus on medication safety interventions such as lethal-means counseling for medication access, limiting quantities dispensed, opioid antagonists, and blister packs.

Opioid-related variables did not improve suicide risk prediction models in samples with mental health diagnoses

Background

Suicide risk prediction models derived from machine learning of electronic health records and insurance claims are an innovation in suicide prevention. Some models do not include opioid-related variables despite the relationship between opioids and suicide. This study evaluated whether inclusion of opioid-related variables improved suicide risk prediction models developed by the Mental Health Research Network.

Methods

Approximately 630 opioid-related variables and interactions terms were introduced into existing suicide prediction models run in datasets of patient visits in mental health care (n = 27,755,401 visits) or primary care when a mental health diagnosis was given (n = 19,340,461 visits). Training and validation datasets were created. LASSO regression with 10-fold validation identified variables to be added to the models.

Results

The new models predicting suicide attempts and suicide deaths in the mental health specialty visit sample performed as well as the existing models (new C-statistic for attempts model = 0.855, CI: 0.853-0.857 versus original C-statistic = 0.851, CI 0.848-0.853; death model = 0.868, CI: 0.856-0.879 versus 0.861, CI 0.848-0.875). The new model for suicide death in the primary care sample improved (0.855, CI: 0.837-0.874 versus 0.833, CI 0.813-0.853) while performance of the new model for suicide attempt in that sample degraded (0.843, CI: 0.839-0.847 versus 0.853, CI 0.849-0.857).

Limitations

Analyses did not include patients without recent care, data did not include illicit opioid use or unrecognized opioid use disorder.

Conclusions

Among patients with mental health diagnoses, inclusion of opioid-related variables did not improve prediction of suicide risk beyond mental health predictors.

Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation: A Randomized Clinical Trial

IMPORTANCE

People at risk of self-harm or suicidal behavior can be accurately identified, but effective prevention will require effective scalable interventions.

OBJECTIVE

To compare 2 low-intensity outreach programs with usual care for prevention of suicidal behavior among outpatients who report recent frequent suicidal thoughts.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020.

INTERVENTIONS

Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first nonfatal or fatal self-harm. Nonfatal self-harm was ascertained from health system records, and fatal self-harm was ascertained from state mortality data. Secondary outcomes included more severe self-harm (leading to death or hospitalization) and a broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm).

RESULTS

A total of 18 644 patients (9009 [48%] aged 45 years or older; 12 543 [67%] female; 9222 [50%] from mental health specialty clinics and the remainder from primary care) contributed at least 1 day of follow-up data and were included in analyses. Thirty-one percent of participants offered care management and 39% offered skills training actively engaged in intervention programs. A total of 540 participants had a self-harm event (including 45 deaths attributed to self-harm and 495 nonfatal self-harm events) over 18 months following randomization: 172 (3.27%) in care management, 206 (3.92%) in skills training, and 162 (3.27%) in usual care. Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07; 97.5% CI, 0.84-1.37) but was significantly higher in the skills training group than in usual care (HR, 1.29; 97.5% CI, 1.02-1.64). For severe self-harm, care management vs usual care had an HR of 1.03 (97.5% CI, 0.71-1.51); skills training vs usual care had an HR of 1.34 (97.5% CI, 0.94-1.91). For the broader self-harm definition, care management vs usual care had an HR of 1.10 (97.5% CI, 0.92-1.33); skills training vs usual care had an HR of 1.17 (97.5% CI, 0.97-1.41).

CONCLUSIONS AND RELEVANCE

Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce risk of self-harm, and offering brief dialectical behavior therapy skills training significantly increased risk of self-harm, compared with usual care. These findings do not support implementation of the programs tested in this study.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02326883.

Cost-Effectiveness of a Web-Based Program for Residual Depressive Symptoms: Mindful Mood Balance

OBJECTIVE

Mindful Mood Balance (MMB) is an effective Web-based program for residual depressive symptoms that prevents relapse among patients with partial recovery from major depressive episodes. This cost-effectiveness analysis was conducted from the health plan perspective alongside a pragmatic randomized controlled trial of MMB.

METHODS

Adults were recruited from behavioral health and primary care settings in a large integrated health system and randomly assigned to MMB plus usual depression care (MMB+UDC) or UDC. Patients had at least one prior major depressive episode; a current score of 5-9 on the Patient Health Questionnaire-9, indicating residual depressive symptoms; and Internet access. Program costs included recruitment, coaching, and MMB licensing. Center for Medicare and Medicaid fee schedules were applied to electronic health record utilization data for psychotropic medications and psychiatric and psychotherapy visits. Effectiveness was measured as depression-free days (DFDs), converted from PHQ-9 scores collected monthly for 1 year. Incremental cost-effectiveness ratios were calculated with various sets of cost inputs.

RESULTS

A total of 389 patients (UDC, N=210; MMB+UDC, N=179) had adequate follow-up PHQ-9 measures for inclusion. MMB+UDC patients had 29 more DFDs during follow-up. Overall, the incremental cost of MMB+UDC was $431.54 over 12 months. Incremental costs per DFD gained ranged from $9.63 for program costs only to $15.04 when psychiatric visits, psychotherapy visits, and psychotropic medications were included.

CONCLUSIONS

MMB offers a cost-effective Web-based program for reducing residual depressive symptoms and preventing relapse. Health systems should consider adopting MMB as adjunctive to traditional mental health care services.

Connecting Research and Practice: Implementation of Suicide Prevention Strategies in Learning Health Care Systems

The health care systems affiliated with the Mental Health Research Network strive to be learning health care systems that identify and address evidence gaps of importance to clinicians, patients, and funders. This column describes how research guides clinical care and clinical care guides research in the area of suicide prevention as well as some of the challenges of conducting embedded research.

Frequency of Clinicians' Assessments for Access to Lethal Means in Persons at Risk for Suicide

OBJECTIVE

We measured the frequency of clinicians' assessments for access to lethal means, including firearms and medications in patients at risk of suicide from electronic medical and mental health records in outpatient and emergency settings.

METHODS

We included adult patients who reported suicide ideation on the PHQ-9 depression screener in behavioral health and primary care outpatient settings of a large integrated health system in the U.S. and those with suicidal behavior treated in the emergency department. Two separate natural language processing queries were developed on medical record text documentation: (1) assessment for access to firearms (8,994 patients), (2) assessment for access to medications (4,939 patients).

RESULTS

Only 35% of patients had documentation of firearm or medication assessment in the month following treatment for suicidal behavior in the emergency setting. Among those reporting suicidal ideation in outpatient setting, 31% had documentation of firearm assessment and 23% for medication assessment. The accuracy of the estimates was very good for firearm assessment (F1 = 89%) and medication assessment in the outpatient setting (F1 = 91%) and fair for medication assessment in the emergency setting (F1 = 70%) due to more varied documentation styles.

CONCLUSIONS

Lethal means assessment following report of suicidal ideation or behavior is low in a nonacademic health care setting. Until health systems implement more structured documentation to measure lethal means assessment, such as discrete data field, NLP methods may be used to conduct research and surveillance of this important prevention practice in real-world settings.

Prediction of suicidal behavior using self-reported suicidal ideation among patients with bipolar disorder

BACKGROUND

People with bipolar disorder have elevated suicide risk. We estimated the ability of the Patient Health Questionnaire (PHQ9) to predict suicide outcomes for outpatients with bipolar disorder.

METHODS

Visits by adults with bipolar disorder who completed a PHQ9 were identified using electronic health record (EHR) data. Bipolar diagnoses and suicide attempts were ascertained from EHR and claims data, and suicide deaths from state and federal records. Depression severity was assessed via the first eight items of the PHQ9, while suicidal ideation was assessed by the ninth item.

RESULTS

37,243 patients made 126,483 visits. Patients reported at least moderate symptoms of depression in 49% and suicidal ideation in 30% of visits. Risk of suicide attempt was 4.21% in the subsequent 90 days for those reporting nearly daily suicidal ideation compared to 0.74% in those reporting none. Patients with nearly daily suicidal ideation were 3.85 (95% CI 3.32-4.47) times more likely to attempt suicide and 13.78 (95% CI 6.56-28.94) times more likely to die by suicide in the subsequent 90 days than patients reporting none. Patients with self-harm in the last year were 8.86 (95% 7.84-10.02) times more likely to attempt suicide in the subsequent 90 days than those without.

LIMITATIONS

Our sample was limited to patients completing the PHQ9 and did not include data on some important social risk or protective factors.

CONCLUSIONS

The PHQ9 was a robust predictor of suicide. Suicidal ideation reported on the PHQ9 should be considered a strong indicator of suicide risk and prompt further evaluation.

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care

Background

Insights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers?

Methods

The Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning.

Discussion

The ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care.

Trial registration

ClinicalTrials.gov, NCT04844021. Registered 14 April 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01154-8.

Predicting outcomes of psychotherapy for depression with electronic health record data

Predictive analytics with electronic health record (EHR) data holds promise for improving outcomes of psychiatric care. This study evaluated models for predicting outcomes of psychotherapy for depression in a clinical practice setting. EHR data from two large integrated health systems (Kaiser Permanente Colorado and Washington) included 5,554 new psychotherapy episodes with a baseline Patient Health Questionnaire (PHQ-9) score ≥ 10 and a follow-up PHQ-9 14–180 days after treatment initiation. Baseline predictors included demographics and diagnostic, medication, and encounter history. Prediction models for two outcomes—follow-up PHQ-9 score and treatment response (≥ 50% PHQ-9 reduction)—were trained in a random sample of 70% of episodes and validated in the remaining 30%. Two methods were used for modeling: generalized linear regression models with variable selection and random forests. Sensitivity analyses considered alternate predictor, outcome, and model specifications. Predictions of follow-up PHQ-9 scores poorly estimated observed outcomes (mean squared error = 31 for linear regression, 40 for random forest). Predictions of treatment response had low discrimination (AUC = 0.57 for logistic regression, 0.61 for random forest), low classification accuracy, and poor calibration. Sensitivity analyses showed similar results. We note that prediction model performance may vary for settings with different care or EHR documentation practices. In conclusion, prediction models did not accurately predict depression treatment outcomes despite using rich EHR data and advanced analytic techniques. Health systems should proceed cautiously when considering prediction models for psychiatric outcomes using baseline intake information. Transparent research should be conducted to evaluate performance of any model intended for clinical use.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use

Question

Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond?

Findings

In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access.

Meaning

In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms.

Importance

Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown.

Objective

To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access.

Design, Setting, and Participants

Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system.

Main Outcomes and Measures

Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021.

Results

Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access.

Conclusions and Relevance

In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

Evaluation of Electronic Health Record-Based Suicide Risk Prediction Models on Contemporary Data

BACKGROUND

Suicide risk prediction models have been developed by using information from patients' electronic health records (EHR), but the time elapsed between model development and health system implementation is often substantial. Temporal changes in health systems and EHR coding practices necessitate the evaluation of such models in more contemporary data.

OBJECTIVES

A set of published suicide risk prediction models developed by using EHR data from 2009 to 2015 across seven health systems reported c-statistics of 0.85 for suicide attempt and 0.83 to 0.86 for suicide death. Our objective was to evaluate these models' performance with contemporary data (2014-2017) from these systems.

METHODS

We evaluated performance using mental health visits (6,832,439 to mental health specialty providers and 3,987,078 to general medical providers) from 2014 to 2017 made by 1,799,765 patients aged 13+ across the health systems. No visits in our evaluation were used in the previous model development. Outcomes were suicide attempt (health system records) and suicide death (state death certificates) within 90 days following a visit. We assessed calibration and computed c-statistics with 95% confidence intervals (CI) and cut-point specific estimates of sensitivity, specificity, and positive/negative predictive value.

RESULTS

Models were well calibrated; 46% of suicide attempts and 35% of suicide deaths in the mental health specialty sample were preceded by a visit (within 90 days) with a risk score in the top 5%. In the general medical sample, 53% of attempts and 35% of deaths were preceded by such a visit. Among these two samples, respectively, c-statistics were 0.862 (95% CI: 0.860-0.864) and 0.864 (95% CI: 0.860-0.869) for suicide attempt, and 0.806 (95% CI: 0.790-0.822) and 0.804 (95% CI: 0.782-0.829) for suicide death.

CONCLUSION

Performance of the risk prediction models in this contemporary sample was similar to historical estimates for suicide attempt but modestly lower for suicide death. These published models can inform clinical practice and patient care today.

Weighing the Association Between BMI Change and Suicide Mortality

OBJECTIVE

Suicide rates continue to rise, necessitating the identification of risk factors. Obesity and suicide mortality rates have been examined, but associations among weight change, death by suicide, and depression among adults in the United States remain unclear.

METHODS

Data from 387 people who died by suicide in 2000-2015 with a recorded body mass index (BMI) in the first and second 6 months preceding their death ("index date") were extracted from the Mental Health Research Network. Each person was matched with five people in a control group (comprising individuals who did not die by suicide) by age, sex, index year, and health care site (N=1,935).

RESULTS

People who died by suicide were predominantly male (71%), White (69%), and middle aged (mean age=57 years) and had a depression diagnosis (55%) and chronic health issues (57%) (corresponding results for the control group: 71% male, 66% White, 14% with depression diagnosis, and 43% with chronic health issues; mean age=56 years). Change in BMI within the year before the index date statistically significantly differed between those who died by suicide (mean change=-0.72±2.42 kg/m²) and the control group (mean change=0.06±4.99 kg/m²) (p<0.001, Cohen's d=0.17). A one-unit BMI decrease was associated with increased risk for suicide after adjustment for demographic characteristics, mental disorders, and Charlson comorbidity score (adjusted odds ratio=1.11, 95% confidence interval=1.05-1.18, p<0.001). For those without depression, a BMI change was significantly associated with suicide (p<0.001).

CONCLUSIONS

An increased suicide mortality rate was associated with weight loss in the year before a suicide after analyses accounted for general and mental health indicators.

Suicide Behavior Following PHQ-9 Screening Among Individuals With Substance Use Disorders

OBJECTIVES

Individuals with substance use disorders (SUD) are at risk for suicide, but no studies have assessed whether routinely administered screeners for suicidal ideation accurately identify outpatients with SUD who are at risk for suicide attempt or death.

METHODS

Data from more than 186,000 visits by over 55,000 patients with mental health and SUD diagnoses receiving care in 7 health systems were analyzed to determine whether responses to item 9 of the 9-item Patient Health Questionnaire, which assesses frequency of thoughts of death and self-harm, are associated with suicide outcomes after an outpatient visit. Odds of suicide attempt or death were computed using generalized estimating equations.

RESULTS

In bivariate analyses, a nearly 5-fold risk was observed for patients answering "nearly every day" relative to "not at all" among individuals who made a suicide attempt within 90 days (4.9% vs 1.1%; χ2 = 1151, P < 0.0001). At nearly half of visits (46%) followed by a suicide attempt within 90 days, patients responded "not at all." In logistic models, compared to "not at all," all other responses were associated with higher odds of suicide attempt or death within 90 days. Fully adjusted models attenuated results but odds of suicide attempt (AOR = 3.24, CI: 2.69-3.91) and suicide death (AOR = 5.67, CI: 2.0-16.1) remained high for those reporting "nearly every day."

CONCLUSIONS

In people with SUD, increasing Patient Health Questionnaire item 9 response predicts increased risk of subsequent suicidal behavior and should prompt intervention. However, clinicians should realize that those reporting "not at all" are not immune from subsequent suicide risk.

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.

A Quasi-Experimental Analysis of Lethal Means Assessment and Risk for Subsequent Suicide Attempts and Deaths

BACKGROUND

Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings.

OBJECTIVE

Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes.

DESIGN

Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment.

SETTING

Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information.

PARTICIPANTS

Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016.

INTERVENTIONS

Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program.

MEASUREMENTS

Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180 days of index PHQ-9 event.

RESULTS

We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30 days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180 days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9).

LIMITATIONS

Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed.

CONCLUSIONS

Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.

Outcomes of Online Mindfulness-Based Cognitive Therapy for Patients With Residual Depressive Symptoms: A Randomized Clinical Trial

Importance

Patients with residual depressive symptoms face a gap in care because few resources, to date, are available to manage the lingering effects of their illness.

Objective

To evaluate the effectiveness for treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only.

Design, Setting, and Participants

This randomized clinical trial was conducted in primary care and behavioral health clinics at Kaiser Permanente Colorado, Denver. Adults identified with residual depressive symptoms were recruited between March 2, 2015, and November 30, 2018. Outcomes were assessed for a 15-month period, comprising a 3-month intervention interval and a 12-month follow-up period.

Interventions

Patients were randomized to receive usual depression care (UDC; n = 230) or MMB plus UDC (n = 230), which included 8 sessions delivered online for a 3-month interval plus minimal phone or email coaching support.

Main Outcomes and Measures

Primary outcomes were reduction in residual depressive symptom severity, assessed using the Patient Health Questionaire-9 (PHQ-9); rates of depressive relapse (PHQ-9 scores ≥15); and rates of remission (PHQ-9 scores <5). Secondary outcomes included depression-free days, anxiety symptoms (General Anxiety Disorder-7 Item Scale), and functional status (12-Item Short Form Survey).

Results

Among 460 randomized participants (mean [SD] age, 48.30 [14.89] years; 346 women [75.6%]), data were analyzed for the intent-to-treat sample, which included 362 participants (78.7%) at 3 months and 330 (71.7%) at 15 months. Participants who received MMB plus UDC had significantly greater reductions in residual depressive symptoms than did those receiving UDC only (mean [SE] PHQ-9 score, 0.95 [0.39], P < .02). A significantly greater proportion of patients achieved remission in the MMB plus UDC group compared with the UDC only group (PHQ-9 score, <5: β [SE], 0.38 [0.14], P = .008), and rates of depressive relapse were significantly lower in the MMB plus UDC group compared with the UDC only group (hazard ratio, 0.61; 95% CI, 0.39-0.95; P < .03). Compared with the UDC only group, the MMB plus UDC group had decreased depression-free days (mean [SD], 281.14 [164.99] days vs 247.54 [158.32] days; difference, -33.60 [154.14] days; t = -2.33; P = .02), decreased anxiety (mean [SE] General Anxiety Disorder-7 Item Scale score, 1.21 [0.42], P = .004), and improved mental functioning (mean [SE] 12-Item Short Form Survey score, -5.10 [1.37], P < .001), but there was no statistically significant difference in physical functioning.

Conclusions and Relevance

Use of MMB plus UDC resulted in significant improvement in depression and functional outcomes compared with UDC only. The MMB web-based treatment may offer a scalable approach for the management of residual depressive symptoms.

Trial Registration

ClinicalTrials.gov identifier: NCT02190968.

Defining Success in Measurement-Based Care for Depression: A Comparison of Common Metrics

OBJECTIVE

The National Committee for Quality Assurance recommends response and remission as indicators of successful depression treatment for the Healthcare Effectiveness and Data Information Set. Effect size and severity-adjusted effect size (SAES) offer alternative metrics. This study compared measures and examined the relationship between baseline symptom severity and treatment success.

METHODS

Electronic records from two large integrated health systems (Kaiser Permanente Colorado and Washington) were used to identify 5,554 new psychotherapy episodes with a baseline Patient Health Questionnaire (PHQ-9) score of ≥10 and a PHQ-9 follow-up score from 14-180 days after treatment initiation. Treatment success was defined for four measures: response (≥50% reduction in PHQ-9 score), remission (PHQ-9 score <5), effect size ≥0.8, and SAES ≥0.8. Descriptive analyses examined agreement of measures. Logistic regression estimated the association between baseline severity and success on each measure. Sensitivity analyses evaluated the impact of various outcome definitions and loss to follow-up.

RESULTS

Effect size ≥0.8 was most frequently attained (72% across sites), followed by SAES ≥0.8 (66%), response (46%), and remission (22%). Response was the only measure not associated with baseline PHQ-9 score. Effect size ≥0.8 favored episodes with a higher baseline PHQ-9 score (odds ratio [OR]=2.3, p<0.001, for 10-point difference in baseline PHQ-9 score), whereas SAES ≥0.8 (OR=0.61, p<0.001) and remission (OR=0.43, p<0.001) favored episodes with lower baseline scores.

CONCLUSIONS

Response is preferable for comparing treatment outcomes, because it does not favor more or less baseline symptom severity, indicates clinically meaningful improvement, and is transparent and easy to calculate.

Association between suicide death and concordance with benzodiazepine treatment guidelines for anxiety and sleep disorders

OBJECTIVE

Guidelines for management of anxiety and sleep disorders emphasize antidepressant medications and/or psychotherapy as first/second-line and benzodiazepines as third-line treatments. We evaluated the association between suicide death and concordance with benzodiazepine guidelines.

METHODS

Retrospective case-control study of patients with anxiety and/or sleep disorders from health systems across 8 U.S. states within the Mental Health Research Network. Suicide death cases were matched to controls on year and health system. Appropriate benzodiazepine prescribing defined as: no monotherapy, no long duration, and/or age < 65 years. The association between guideline concordance and suicide death was evaluated, adjusting for diagnostic and treatment covariates.

RESULTS

Sample included 6960 patients with anxiety disorders (2363 filled benzodiazepine) and 6215 with sleep disorders (1237 filled benzodiazepine). Benzodiazepine guideline concordance was associated with reduced odds for suicide in patients with anxiety disorders (OR = 0.611, 95% CI = 0.392-0.953, p = 0.03) and was driven by shorter duration of benzodiazepine use with concomitant psychotherapy or antidepressant medication. The association of benzodiazepine guideline concordance with suicide death did not meet statistical significance in the sleep disorder group (OR = 0.413, 95% CI = 0.154-1.11, p = 0.08).

CONCLUSIONS

We found reduced odds for suicide in those with anxiety disorders who filled benzodiazepines in short-moderate duration with concomitant psychotherapy or antidepressant treatment.

Changes in use of opioid therapy after colon cancer diagnosis: a population-based study

PURPOSE

To describe patterns of opioid use in cancer survivors.

METHODS

In a cohort study of colon cancer patients diagnosed during 1995-2014 and enrolled at two Kaiser Permanente regions, we constructed quarterly measures of opioid use from 1 year before cancer diagnosis through 5 years after diagnosis to examine changes in use. Measures included any use, incident use, regular use (use ≥ 45 days in a 91-day quarter), and average daily dose (converted to morphine milligram equivalent, MME). We also assessed temporal trends of opioid use.

RESULTS

Of 2,039 colon cancer patients, 11-15% received opioids in the four pre-diagnosis quarters, 68% in the first quarter after diagnosis, and 15-17% in each subsequent 19 quarters. Regular opioid use increased from 3 to 5% pre-diagnosis to 5-7% post diagnosis. Average dose increased from 15 to 17 MME/day pre-diagnosis to 14-22 MME/day post diagnosis (excluding the quarter in which cancer was diagnosed). Among post-diagnosis opioid users, 73-95% were on a low dose (< 20 MME/day). Over years, regular use of opioids increased in survivorship with no change in dosage.

CONCLUSION

Opioid use slightly increased following a colon cancer diagnosis, but high-dose use was rare. Research is needed to differentiate under- versus over-treatment of cancer pain.

Cardiovascular medication use and risks of colon cancer recurrences and additional cancer events: a cohort study

Background

Cardiovascular medications may be associated with cancer development, but little is known about their association with cancer recurrence. Medications such as statins and antihypertensives may be commonly used among colon cancer survivors, who are, on average, diagnosed in their mid-60s. We described the associations between statins and antihypertensive medications and colon cancer recurrence in a large, population-based study.

Methods

We conducted a cohort study among adults with stage I-IIIA colon cancer diagnosed in 1995–2014 in two Kaiser Permanente regions, Colorado and Washington. Statin and antihypertensive use were obtained from electronic pharmacy dispensing data. People were classified as medication users on the date of their first dispensing after cohort entry, which started 90 days after completing cancer treatment, continuing through the earliest of death, health plan disenrollment, or chart abstraction. We collected outcome information from medical record abstraction and tumor registries on colon cancer recurrences and second primary cancers. Using Cox proportional hazards multivariable models, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for colon cancer recurrences and any cancer event (recurrences and new primaries at any anatomic site) comparing medication users to non-users.

Results

Among 2039 people, 937 (46%) used statins and 1425 (70%) used antihypertensives at any point during a median of 4.9 years of follow-up; 460 people had any additional cancer event, including 152 with a colon cancer recurrence. Statin use was not associated with colon cancer recurrence (HR = 1.09, 95%CI = 0.65–1.85) or any cancer event (HR = 1.12, 95%CI = 0.85–1.47), nor was antihypertensive use associated with recurrence (HR = 0.73, 95%CI = 0.44–1.21) or any cancer event (HR = 0.93, 95%CI = 0.70–1.24).

Conclusions

Our results suggest no association between cardiovascular medication use and the risk of recurrence or any additional cancer, and may provide reassurance to colon cancer survivors.

Use of antidepressants after colon cancer diagnosis and risk of recurrence

OBJECTIVE

Prior research examining the association between use of antidepressants after colon cancer diagnosis and risk of recurrence is scant. We evaluated this association among colon cancer patients diagnosed at two integrated health care delivery systems in the United States.

METHODS

We conducted a cohort study of stage I to IIIA colon cancer patients diagnosed at greater than or equal to 18 years of age at Kaiser Permanente Colorado and Kaiser Permanente Washington during 1995 to 2014. We used pharmacy records to identify dispensings for antidepressants and tumor registry records and patients' medical charts to identify cancer recurrences. Using Cox proportional hazards models, we estimated the adjusted hazard ratio (HR) of colon cancer recurrence comparing patients who used antidepressants after diagnosis to those who did not. We also evaluated the risk associated with use of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) separately.

RESULTS

Among the 1923 eligible colon cancer patients, 807 (42%) used an antidepressant after diagnosis and 139 had a colon cancer recurrence during an average 5.6 years of follow-up. Use of antidepressants after colon cancer diagnosis was not associated with risk of recurrence (HR: 1.14; 95% confidence interval [CI], 0.69-1.87). The HR for use of SSRIs was 1.22 (95% CI, 0.64-2.30), and for TCAs, it was 1.18 (95% CI, 0.68-2.07).

CONCLUSIONS

Our findings suggest that use of antidepressants after colon cancer diagnosis was common and not associated with risk of recurrence. Future larger studies with greater power to examine risk associated with individual antidepressants would be valuable additions to the evidence base.

Automated symptom and treatment side effect monitoring for improved quality of life among adults with diabetic peripheral neuropathy in primary care: a pragmatic, cluster, randomized, controlled trial

AIMS

To evaluate the effectiveness of automated symptom and side effect monitoring on quality of life among individuals with symptomatic diabetic peripheral neuropathy.

METHODS

We conducted a pragmatic, cluster randomized controlled trial (July 2014 to July 2016) within a large healthcare system. We randomized 1834 primary care physicians and prospectively recruited from their lists 1270 individuals with neuropathy who were newly prescribed medications for their symptoms. Intervention participants received automated telephone-based symptom and side effect monitoring with physician feedback over 6 months. The control group received usual care plus three non-interactive diabetes educational calls. Our primary outcomes were quality of life (EQ-5D) and select symptoms (e.g. pain) measured 4-8 weeks after starting medication and again 8 months after baseline. Process outcomes included receiving a clinically effective dose and communication between individuals with neuropathy and their primary care provider over 12 months. Interviewers collecting outcome data were blinded to intervention assignment.

RESULTS

Some 1252 participants completed the baseline measures [mean age (sd): 67 (11.7), 53% female, 57% white, 8% Asian, 13% black, 20% Hispanic]. In total, 1179 participants (93%) completed follow-up (619 control, 560 intervention). Quality of life scores (intervention: 0.658 ± 0.094; control: 0.653 ± 0.092) and symptom severity were similar at baseline. The intervention had no effect on primary [EQ-5D: -0.002 (95% CI -0.01, 0.01), P = 0.623; pain: 0.295 (-0.75, 1.34), P = 0.579; sleep disruption: 0.342 (-0.18, 0.86), P = 0.196; lower extremity functioning: -0.079 (-1.27, 1.11), P = 0.896; depression: -0.462 (-1.24, 0.32); P = 0.247] or process outcomes.

CONCLUSIONS

Automated telephone monitoring and feedback alone were not effective at improving quality of life or symptoms for people with symptomatic diabetic peripheral neuropathy.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02056431).

Risk of colon cancer recurrence in relation to diabetes

PURPOSE

To describe the association between diabetes and colon cancer recurrence.

METHODS

We conducted a cohort study at two integrated health care delivery systems in the United States. Using tumor registry data, we identified patients aged ≥ 18 years when diagnosed with stage I-IIIA adenocarcinomas of the colon during 1995-2014. Pre-existing diabetes was ascertained via diagnosis codes. Medical records were reviewed for eligibility and to abstract recurrence and covariate information. Recurrence was ascertained beginning 90 days after the end of colon cancer treatment (i.e., cohort entry). Recurrence of any cancer or a new primary cancer at any site was a secondary outcome. We used multivariable Cox proportional hazards models to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for the associations between diabetes at cohort entry and study outcomes.

RESULTS

Among the 1,923 eligible patients, 393 (16.7%) had diabetes at cohort entry. Diabetes was not associated with recurrence (HR 0.87; 95% CI 0.56-1.33) or with any subsequent cancer (HR 1.09; 95% CI 0.85-1.40). When the definition of recurrence included second primary colorectal cancer, risk was non-significantly higher in patients with diabetes than without diabetes.

CONCLUSIONS

The risk of colon cancer recurrence appears to be similar in patients with and without diabetes at diagnosis.

IMPACT

Future studies should evaluate the association between diabetes and colorectal cancer outcomes, especially second primary colon cancers, in larger populations.

General Medical, Mental Health, and Demographic Risk Factors Associated With Suicide by Firearm Compared With Other Means

OBJECTIVE

Mitigation of suicide risk by reducing access to lethal means, such as firearms and potentially lethal medications, is a highly recommended practice. To better understand groups of patients at risk of suicide in medical settings, the authors compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group).

METHODS

In a case-control study in 2016 from eight health care systems within the Mental Health Research Network, 2,674 suicide cases from 2010-2013 were matched to a control group (N=267,400). The association between suicide by firearm or other means and medical record information on demographic characteristics, general medical disorders, and mental disorders was assessed.

RESULTS

The odds of having a mental disorder were higher among cases of suicide involving a method other than a firearm. Fourteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by firearm, including traumatic brain injury (TBI) (odds ratio [OR]=23.53), epilepsy (OR=3.17), psychogenic pain (OR=2.82), migraine (OR=2.35), and stroke (OR=2.20). Fifteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by other means, with particularly high odds for TBI (OR=7.74), epilepsy (OR=3.28), HIV/AIDS (OR=6.03), and migraine (OR=3.17).

CONCLUSIONS

Medical providers should consider targeting suicide risk screening for patients with any mental disorder, TBI, epilepsy, HIV, psychogenic pain, stroke, and migraine. When suicide risk is detected, counseling on reducing access to lethal means should include both firearms and other means for at-risk groups.

Lessons learned from community-based participatory research: establishing a partnership to support lesbian, gay, bisexual and transgender ageing in place

Background

Due to a history of oppression and lack of culturally competent services, lesbian, gay, bisexual and transgender (LGBT) seniors experience barriers to accessing social services. Tailoring an evidence-based ageing in place intervention to address the unique needs of LGBT seniors may decrease the isolation often faced by this population.

Objective

To describe practices used in the formation of a community-based participatory research (CBPR), partnership involving social workers, health services providers, researchers and community members who engaged to establish a LGBT ageing in place model called Seniors Using Supports To Age In Neighborhoods (SUSTAIN).

Methods

A case study approach was employed to describe the partnership development process by reflecting on past meeting minutes, progress reports and interviews with SUSTAIN's partners.

Results

Key partnering practices utilized by SUSTAIN included (i) development of a shared commitment and vision; (ii) identifying partners with intersecting spheres of influence in multiple communities of identity (ageing services, LGBT, health research); (iii) attending to power dynamics (e.g. equitable sharing of funds); and (iv) building community capacity through reciprocal learning. Although the partnership dissolved after 4 years, it served as a successful catalyst to establish community programming to support ageing in place for LGBT seniors.

Conclusion

Multi-sector stakeholder involvement with capacity to connect communities and use frameworks that formalize equity was key to establishing a high-trust CBPR partnership. However, lack of focus on external forces impacting each partner (e.g. individual organizational strategic planning, community funding agency perspectives) ultimately led to dissolution of the SUSTAIN partnership even though implementation of community programming was realized.

A pragmatic randomized clinical trial of behavioral activation for depressed pregnant women

OBJECTIVE

Depression among pregnant women is a prevalent public health problem associated with poor maternal and offspring development. Behavioral activation (BA) is a scalable intervention aligned with pregnant women's preference for nonpharmacological depression care. This is the first test of the effectiveness of BA for depression among pregnant women, which aimed to evaluate the effectiveness of BA as compared with treatment as usual (TAU).

METHOD

Pregnant women (mean age = 28.75 years; SD = 5.67) with depression symptoms were randomly assigned to BA (n = 86) or TAU (n = 77). Exclusion criteria included known bipolar or psychotic disorder or immediate self-harm risk. Follow-up assessment occurred 5 and 10 weeks postrandomization and 3 months postpartum using self-report measures of primary and secondary outcomes and putative targets.

RESULTS

Compared with TAU, BA was associated with significantly lower depressive symptoms (d = 0.34, p = .04) and higher remission (56.3% vs. 30.3%, p = .003). BA also demonstrated significant advantage on anxiety and perceived stress. Participants attended most BA sessions and reported high satisfaction. Participants in BA reported significantly higher levels of activation (d = 0.69, p < .0002) and environmental reward (d = 0.54, p < .003) than those who received TAU, and early change in both of these putative targets significantly mediated subsequent depression outcomes.

CONCLUSIONS

BA is effective for pregnant women, offering significant depression, anxiety, and stress benefits, with mediation analyses supporting the importance of putative targets of activation and environmental reward. (PsycINFO Database Record

Perspectives of LGBTQ Older Adults on Aging in Place: A Qualitative Investigation

This qualitative study conducted by a community-research partnership used multiple types of data collection to examine variables relevant for LGBTQ older adults who wished to age in place in their urban Denver neighborhood. Focus groups, interviews, and a town hall meeting were used to identify barriers and supports to aging in place. Participants (N = 73) identified primarily as lesbian or gay, aged 50-69, and lived with a partner. Ageism, heterosexism, and cisgenderism emerged as cross-cutting themes that negatively impact access to health care, housing, social support, home assistance, and legal services. Resilience from weathering a lifetime of discrimination was identified as a strength to handle aging challenges. Recommendations for establishing an aging in place model included establishing welcoming communities and resource centers and increasing cultural competence of service providers. This study provides a unique contribution to understanding the psychosocial, medical, and legal barriers for successfully aging in place.

The Challenges of Collecting and Using Patient Care Data From Diverse Care Systems: Lessons From COMPASS

The ability to aggregate clinical data across multiple diverse organizations and to use it for performance measurement, quality improvement, evaluation, and research is rapidly becoming a national necessity, but there are few examples of how to do that. This article uses lessons from a national effort to implement the collaborative care management model for patients with both depression and diabetes or heart disease across 8 partner organizations, 18 medical groups, and more than 170 clinics in 8 states to identify the challenges and provide experience-based recommendations for those tasks. The challenges are divided into those needed for (1) collecting similar data, (2) aggregating those data across care systems, and (3) using the data to both improve and evaluate care. Start with agreement on goals, methods, transparency, and a data system integrated into the electronic medical record while promptly addressing all the legal, regulatory, and human subject requirements.