See past highlights of MHRN activity in our Spring Newsletter





New MHRN Findings

Using sequential analysis to rapidly assess new health policies
Properly done research studies take time, money and effort, and sometimes the results come in long after the policy has taken affect. But using the statistical technique of sequential analysis may allow policy makers to assess the impact of a new health policy in real-time.

Christine Lu, PhD, led a study that evaluated the usefulness of using sequential analysis to assess the real-time impact of a 2003 FDA advisory (stating that use of antidepressants could increase risk of suicidality in youth and explicitly recommended monitoring of patients in the initial phase of treatment), which was followed by a boxed warning in late 2004. These warnings generated media attention, which could have had the unintended consequence of distorting the FDA message. To test this, Dr. Lu used two measures of unintended impacts of the policy: psychotropic drug poisonings (as a proxy for suicide attempts) and completed suicides.

The team used historical data from 11 health systems in the US Mental Health Research Network. The study cohort included adolescents and young adults who were targeted by the warnings, and adults as a comparison group. Results indicate that there was a statistically significant signal of excess risk for suicidal behavior in adolescents and young adults within 5-7 quarters of the warnings. They also detected signals of increased risk of completed suicide in these younger age groups, but cautioned that, on its own, this finding should not be taken as conclusive evidence that the policy caused the signal since a statistical signal indicates the need for further scrutiny using rigorous quasi-experimental studies to investigate the possibility of a cause-and-effect relationship.

This was a proof-of-concept study to examine whether a prospective, periodic evaluation of administrative health care data using sequential analysis can provide timely population-based signals of effects of health policies. Results suggest that this method may be a useful tool when new policies are introduced.


How sensitive is the PHQ-9 when patients report their thoughts of death or self-harm as, “not at all”?
Although research indicates that item 9 of the Patient Health Questionnaire (PHQ-9) for depression strongly predicts subsequent suicide attempt and suicide death, over one-third of suicide attempts and death occur among patients who reported “not at all” regarding their wishes for death or thoughts of self-harm.

To explore this further, Evette Ludman, PhD and co-authors undertook a systematic re-evaluation of apparent false-negatives to explore how sensitive the PHQ-9 is when patients report thoughts of death or self-harm as, “not at all,” by reviewing full-text medical records on, or near, the date of diagnosis of apparent self-harm. The goal was to identify documentation of injury or poisoning as well as identify the treating providers’ assessment of intent (i.e., accidental, assault, intentionally self-inflicted, or undetermined).

The review of full-text medical records found that only 31% of suspected false-negative suicide attempts were clearly confirmed as self-inflicted injury or poisoning. An additional 8% appeared to be injuries or poisonings with undetermined intent, and records were unavailable for review for approximately 6%. The remaining 55% of events initially classified as false-negatives either had no documentation of injury or poisoning or had implausible injury/poisoning diagnoses for self-harm or suicide attempt.

This suggests that the false-negative rate for PHQ-9 item 9 in identifying risk of suicide attempt may not be as high as suggested by previous research. The authors conclude that the findings may offer reassurance to clinicians and health systems who use self-report questionnaires to identify people at risk for suicidal behavior.


Are patients with chronic non-cancer pain more likely to develop depression if they are prescribed opioids?
Previous studies indicate that chronic opioid analgesic use is associated with increased risk of new onset depression, but it is not clear if patients who were diagnosed with depression in the past are also at increased risk of a relapse if they begin taking opioids. Jeffrey Scherrer, PhD led a retrospective cohort study using patient data from the Veterans Health Administration and Baylor Scott & White Health to explore this question.

Dr. Scherrer collaborated with Brian Ahmedani, PhD and Laurel Copeland, PhD to demonstrate that longer duration of a new episode of prescription opioid use was associated with up to 200% increased risk of new onset depression in 3 separate patient cohorts that differed in demographic and clinical characteristics.  Maximum opioid dose was not significantly associated with risk of new onset depression.

His team then examined two patient cohorts with large differences in demographics and comorbidity burden, and noticed that patients who were in a remission from depression had an approximately twice as great a risk of depression recurrence if they started an opioid medication compared to patients who weren’t exposed to opioids. Sample size did not permit examining duration of opioid use and risk of depression recurrence.

These results suggest that opioid use doubles the risk of new onset depression and among patients in remission, doubles the risk of depression recurrence, even after controlling for pain, psychiatric disorders and opioid misuse. Repeated screening for depression after opioid initiation may be justifiable.


Long-term prescription opioid use, and new-onset depression – are there gender differences?
Although women have a higher prevalence of chronic (non-cancer) pain conditions and report more severe pain, it is not known whether there’s a gender difference with regards to the risk of a new depression episode when patients use opioid analgesics long-term.

A study, led by Joanne Salas, MPH, analyzed patient data from the Veterans Health Administration and the Henry Ford Health System to determine whether long-term opioid analgesic use and risk of new depression episode differed according to gender. Findings indicate:

  • Both genders had an increased risk of depression after >90-days opioid use.
  • Female veterans (versus male) had a greater depression risk after >90-days opioid use.
  • The researchers found no gender difference in opioid-depression risk in the private sector patients.

The authors conclude that women and men may benefit from closer monitoring of mood associated with chronic opioid use.


Project News

Two MHRN posters sweep the awards at the April 2018 HCSRN Conference
MHRN-related posters, stemming from the “Treatment Utilization Before Suicide” (TUBS) project, won “best poster” both days of the April 2018 HCSRN poster sessions. Kudos to the TUBS PI, Brian Ahmedani, PhD who created opportunities and mentored his junior colleagues towards this scientific excellence!

The two posters were:

  1. Examining How Health Service Utilization Patterns Vary Among Individuals Before Suicide. Farah Elsiss, MS, et.al. This study used data from 8 Mental Health Research Network sites. The authors examined the types and timing of health care visits before an index date for patients who died by suicide as well as for matched controls.
  2. Male-Female Differences in Diagnosed Mental Health Conditions and Risk of Suicide Mortality. Hsueh-Han Yeh, PhD. This study used 8 health care systems from the Mental Health Research Network to relate individual mental health diagnoses to the risk of suicide death.


What if researchers could create customized evidence-based treatment protocols to improve mental health?
NIH recently awarded Susan Shortreed, PhD and Erica Moodie, PhD, with a 4-year grant to develop customized treatment plans for depression as well as to develop methods to generate these plans.

Her team will use electronic health care record data to select patient characteristics for customizing treatment, assessing bias from differences between people who take different medications, and calculating how many people are needed to accurately compare customized treatment plans.

The goal is to create improved statistical tools, which address current limitations, in order to create customized treatment protocols that will have immediate impact for people living with depression, ultimately leading to customized treatment protocols for people living with a wide variety of mental health conditions.


Highlights from 24th Mental Health Services Research Conference: MHSR 2018
The National Institute of Mental Health (NIMH) sponsored the 24th Mental Health Services Research Conference: MHSR 2018 on August 1-2, 2018, in Rockville, Maryland.

This biennial conference is organized by the Services Research and Clinical Epidemiology Branch at NIMH to promote areas of high priority for services research and to identify opportunities with potential for significant impact on the health and well-being of people with mental disorders.

MHRN investigators presented two symposia: one describing research regarding first-episode psychosis and one describing research to assess and address suicide risk. Jennifer Boggs, MSW was selected to participate in the new investigator workshop.


People News

Who is the recipient of “The Biggest Reject Award”?

Only 10-20% of NIH grant applications are funded and most manuscripts are rejected by several journals before being accepted. So, each year, the HSCRN takes a moment of levity and gives “The Biggest Reject Award.” This award celebrates “the humiliation and suffering we have all chosen to repeatedly endure …. because repeated rejection is what we do.”

This year the lucky recipient was Christine Lu, PhD, from Harvard Pilgrim Health Care Institute  for her review experience on Near Real-time Surveillance for Consequences of Health Policies Using Sequential Analysis, which included a 27-page long (no, that was not a typo) reviewer comment. Greg Simon presented Dr. Lu with a Moby Dick finger puppet to remind Chris of the whale’s perspective and the value of perseverance through a seemingly endless ordeal.

Here’s to hoping that you are not the next person nominated!