See past highlights of MHRN activity in our Summer 2018 Newsletter





New MHRN Findings

The rate of youth suicide is increasing – how do pediatric primary care physicians feel about discussing firearm safety with their patients?

The rate of youth suicide has increased steadily over the past several decades. Particular attention must be paid to youth suicide attempts by firearm, given that they are a common and lethal method. There is evidence that the Firearm Safety Check intervention (which consist of screening, brief counselling around firearm safety and the provision of cable locks) is an effective safety intervention and may be a way to decrease youth firearm suicides.

But how do pediatric primary care physicians and leaders feel about discussing firearm safety promotion with parents of their patients? And how often do they do it? Two MHRN-related studies investigated attitudes, perspectives and use of firearm safety interventions in pediatric primary care. Rinad Beidas, PhD led a study to determine how acceptable primary care physicians and leaders felt it was to administer the three components of the Firearm Safety Check, and how often they were done.

The study team used an online survey in two large US health systems, inviting 204 primary care physicians and 57 leaders from 83 clinics. Respondents included 103 primary care physicians (50%), and 40 leaders (70%) from 71 clinics (86%). The respondents indicated that they found screening for firearms and brief counseling on safe storage to be highly acceptable. However, while they reported they sometimes performed screening and counseling, they noted that they did not routinely perform them. They were neutral on the acceptability of providing cable locks and indicated low usage of this intervention component.   

A second, qualitative study (described here), led by Courtney Benjamin Wolk, PhD also looked at the needs of stakeholders who would be affected by implementing an evidence-based approach to firearm safety promotion: the Firearm Safety Check.

The research team interviewed 58 stakeholders over a 7-month period from two large and diverse health systems. Participants included parents of youth; physicians; nurses and nurse practitioners; leaders of pediatric primary care practices, behavioral health, and quality improvement; system leaders; third-party payers; and members of national credentialing bodies.

Overall, stakeholders indicated that they felt firearm safety promotion should be a health system priority and reported favorable perceptions of the Firearm Safety Check approach for suicide prevention. They stressed the importance of using electronic health record systems and keeping the intervention brief due to time constraints and indicated that they found the distribution of cable locks to be the most complicated component to implement.

The results of both studies indicate acceptability of firearm safety promotion in pediatric primary care as a universal suicide prevention strategy. Both also indicate perceived barriers to providing firearm locks which provide fodder for a future implementation trial testing different approaches to implementation of the Firearm Safety Check.


What role does sleep disturbance play in the relationship between chronic pain and suicide death?

The goal of the TUBS project (“Treatment Utilization Before Suicide”) is to develop a comprehensive healthcare algorithm to predict suicide. Adding to a growing list of publications associated with this project, there is a new study led by Ashli Owen-Smith, PhD, examining the relationship between chronic pain (nonmalignant) and suicide death to examine what role sleep disturbance might play in that association.

The case-control study looked at eight Mental Health Research Network (MHRN)-affiliated healthcare systems and included 2,674 individuals who died by suicide between 2000 and 2013 and 267,400 matched individuals. After accounting for covariates, the researchers found that individuals who had a diagnosis of chronic pain were significantly more likely to have a sleep disorder diagnosis and sleep disorders were significantly associated with suicide death. Further, after adjusting for covariates, sleep disturbance fully mediated the relationship between chronic pain and suicide death, underscoring the critical role that sleep likely plays in the well-documented relationship between pain and death.

This case-control study included 2,674 individuals who died by suicide between 2000 and 2013 and 267,400 matched individuals. After accounting for covariates, they found a significant relationship between non-malignant cancer pain and sleep disturbance: those who were diagnosed with non-malignant cancer pain were more likely to develop subsequent sleep disturbance. Similarly, sleep disturbance was significantly associated with suicide death.

The results point to a need for clinicians to screen for both sleep disturbance and suicidal ideation in non-malignant cancer pain patients and for health systems to implement more widespread behavioral treatments that address comorbid sleep problems and non-malignant cancer pain.

A major goal of the TUBS project is to inform decisions about how to focus suicide prevention in medical settings and provide information in response to the 2012 National Action Alliance for Suicide Prevention and US Surgeon General report.


Project News

Practice-based research in action: MHRN Systems pursue strategies to implement risk prediction tools into population-level suicide prevention programs

MHRN health systems are pursuing a range of strategies to implement risk prediction tools into population-level suicide prevention programs.

Kaiser Permanente Washington will begin a pilot test of delivering risk scores to mental health providers this summer. Mental health therapists and psychiatrists will use scores to identify high-risk patients who would be missed by standard screening with the PHQ-9 depression scale.

At HealthPartners, MHRN investigators are collaborating with health plan leaders to develop a centralized outreach program informed by risk prediction scores – similar to the program already implemented in the Veterans Health Administration.

MHRN researchers at Kaiser Permanente Northern California are collaborating with clinical informatics leaders to fully integrate risk prediction scores into the electronic health record.


The SPOT trial: 18,889 adults enrolled! Did using real-world data improve the clinical trial design?

Enrollment is complete for the SPOT Trial, with 18,889 adults enrolled! Participants were adults whose score on item 9 of the PHQ depression scale (regarding thoughts of death or suicide) indicated an elevated risk.

The SPOT trial (“Pragmatic Trial of Population-based Programs to Prevent Suicide Attempt”) is a large, pragmatic trial, aimed at examining two population-based programs to prevent suicide attempts. Participants are randomly assigned to continue with their usual care or to usual care plus one of the two prevention programs: an outreach and care management program (via secure messaging and telephone) including structured assessment linked to specific care pathways, or an online psycho-educational program focused on development of emotion regulation skills and prevention of suicidal behaviors, supported by coaching to promote engagement and adherence.

Did using real-world data improve the clinical trial design?

The research team used real-world data to inform the clinical trial design and published a paper outlining the advantages of automated data collection and how it can be used to inform trial design. Using their experience planning the SPOT Trial, they illustrate how electronic health record data can be used to:

  • Inform the selection of trial eligibility requirements,
  • Estimate the distribution of participant characteristics over the course of the trial, and
  • Conduct power and sample size calculations.

They argue that realistic sample size calculations can be conducted using real-world data from the health systems in which the trial will be conducted, and that a data-informed trial design should yield more realistic estimates of statistical power and maximize efficiency of trial recruitment.

The trial is being conducted in four health systems: Kaiser Permanente Washington, Kaiser Permanente Colorado, Kaiser Permanente Northwest and HealthPartners.


Getting out the word on gun safety to mitigate youth suicide

John Zeber, PhD, discusses the Mental Health Research Network and recent research involving gun safety and pediatricians on the television show “Connecting Point.” In particular, he discusses how acceptable pediatricians find it to screen their patients about availability of guns in the house, counsel them about safe storage, and provide gun locks to patients.

Joel Fein, MD, MPH details efforts to apply MHRN-related research results on gun safety to get Emergency Department clinicians to educate patients and families about the risk of firearms, both for unintentional injury and for suicide.

Rinad Beidas, PhD wrote an Op Ed in the Philadelphia Inquirer about how children’s primary care doctor could prevent gun injury and death by asking parents whether their children have access to guns and providing parents with mechanisms (such as cable locks) to help store the firearms more safely.