MHRN study examines proportion of suicide deaths that could be prevented by limiting firearm access for people with a mental health condition or history of suicidal behavior

MHRN study examines proportion of suicide deaths that could be prevented by limiting firearm access for people with a mental health condition or history of suicidal behavior

Since firearms account for half of all suicide deaths in the United States, many assume that reducing access to firearms among at-risk patients will reduce suicide mortality, and attempts to reduce access to firearms have focused on persons with a mental health condition or a history of suicidal behavior. To examine this theory, Jennifer M. Boggs , led an MHRN manuscript, as part of the Treatment Utilization Before Suicide study, to identify the proportion of suicide deaths that could potentially be prevented by limiting firearm access for people with a mental health condition or a history of suicidal behavior.

Using medical records and claims information, the team identified a group who had a history of any mental health or substance use condition, diagnosed at any medical or mental health visit in the year preceding death. They then identified a second group who had a history   of previous suicide attempts (these were not mutually exclusive groups).

More people without a mental health or substance-use condition used firearms in their death than did people with those conditions (671 vs. 627). Also, more people without a previous suicide attempt used firearms in their death than did those with a previous attempt (1189 vs. 109). In fact, among people who died by suicide, only 4.1% had previously attempted suicide and used a firearm; 23.5% had a mental health or substance use condition and used a firearm.

Their findings indicate that, even if successful, current efforts to limit firearm access only for people with a mental health condition (including substance use disorders) or those who previously attempted suicide would prevent few suicide deaths by firearm. The authors suggest that prevention of firearm suicide should be expanded beyond the exclusive focus on patients with mental health conditions to include other persons at risk for suicide. Findings also highlight the importance of expanding attention beyond firearms—especially for persons with mental health or substance use conditions—to include other common means of suicide.


Do patients diagnosed with skin conditions have a higher risk of suicide?

Do patients diagnosed with skin conditions have a higher risk of suicide?

 

Research suggests that patients diagnosed with skin conditions may have a higher risk of comorbid psychiatric conditions and suicide-related outcomes. To examine this theory in the US general population, Deepak Prabhakar, MD, MPH, led a study to examine the risk of suicide death in patients with dermatologic conditions using a retrospective case-control study conducted in 8 US health systems. A total of 2,674 individuals who died by suicide (cases) were matched with 267,400 general population control individuals. Overall, 619 cases and 54364 controls with skin conditions were analyzed.

After adjusting for age, sex, and any mental health or substance use condition, the authors did not find an association between death by suicide and any skin condition, and the study provides no evidence of increased risk of death by suicide in individuals with major skin disorders in the US general population.


Does item 9 of the Patient Health Questionnaire (PHQ9) predict risk for suicide attempts and deaths across age groups?

Does item 9 of the Patient Health Questionnaire (PHQ9) predict risk for suicide attempts and deaths across age groups?

Does item 9 of the Patient Health Questionnaire (PHQ9) predict risk for suicide attempts and deaths across age groups?

Rebecca Rossom, MD, MS, led a study that was recently published in the Journal of Affective Disorders. The team examined PHQ9s completed by adult outpatients treated for mental health conditions in 2010-2012 at four Mental Health Research Network-affiliated healthcare systems. The goal was to examine suicidal ideation and attempts/deaths in order to determine whether item 9 of the Patient Health Questionnaire (PHQ9) predicted risk for suicide attempts and deaths across age groups. They found that those with nearly daily suicidal ideation (compared to those without) were:

  • 5-to-8 times more likely to attempt suicide and 3-to-11 times more likely to die by suicide within 30 days, and
  • 2-to-4 times more likely to attempt suicide and 2-to-6 times more likely to die by suicide within 365 days.

The study team also found that, for those with any level of suicidal ideation, the increased risk of suicide attempts and deaths persisted over two years. The absolute risk of suicide attempts generally declined with age, while the absolute risk of suicide death generally increased with age. However, the relationship between reported suicidal ideation and suicide attempts and deaths was similar across age groups. They concluded that suicidal ideation reported on the PHQ9 is a robust predictor of suicide attempts and death, regardless of age, and that healthcare systems should address both the immediate and sustained risk of suicide for patients of all ages.


Are changes in response to PHQ item #9 associated with subsequent risk of suicide attempts?

Are changes in response to PHQ item #9 associated with subsequent risk of suicide attempts?

Are changes in response to PHQ item #9 associated with subsequent risk of suicide attempts?

Although clinicians are expected to routinely assess and address suicide risk, there is little guidance regarding the significance of visit-to-visit changes in suicidal ideation.

Since healthcare systems increasingly use PHQ9 in both primary care and specialty mental health clinics in patients reporting frequent thoughts of death or self-harm, questions have arisen:  Does an apparent decrease in suicidal ideation (i.e. decreasing score on PHQ9 item 9) actually imply a decrease in risk of subsequent suicidal behavior?  Does the apparent onset of suicidal ideation imply an increase in risk compared to pre-existing or “chronic” suicidal ideation?

A study led by Greg Simon, MD, MPH suggests that current suicidal ideation is a powerful indicator of near-term risk, independent of past reports of suicidal ideation.  Individuals who reported thoughts of death or self-harm at a prior visit remained at moderately increased risk even if they reported no such thoughts at the current visit. While the apparent onset of suicidal thoughts did predict significant risk, risk was actually highest for patients reporting sustained or repeated thoughts of death or self-harm.


Where do patients first present with psychotic symptoms and what is the overall incidence?

Where do patients first present with psychotic symptoms and what is the overall incidence?

When a patient presents with psychotic symptoms, research suggests that comprehensive intervention is effective if it is delivered at the first onset.  For this reason it is important to have population-based data on the overall incidence of psychotic symptoms as well as data on where patients make their first presentation.

A recently published MHRN study found, that contrary to conventional wisdom, half of first episodes occur after age 30, and up to 25% present in primary care. Results also indicate that, when comprehensive data from large integrated health systems is used, the incidence of first-episode psychosis is higher than generally believed.

These population-based data have important implications for the design of early detection and early intervention programs and will be part of forthcoming analyses examining patterns of care, both before and after diagnoses.


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Be careful when interpreting data on self-harm or suicidal behavior

While health systems are actively looking at suicide risk and how to prevent it, researchers should be vigilant when assessing if these programs work because a recently published MHRN study indicates that coding of “self-harm” or “possible suicidal behavior” changed significantly with the transition from ICD-9-CM to ICD-10-CM.

For example, the study found that diagnoses of self-inflicted injury and poisoning appeared to increase abruptly with the coding transition, and this pattern was consistent across the ten MHRN participating health systems. Likewise, changes in coding of intent for injuries and poisonings during the fall of 2015 almost certainly represent artifacts of coding changes rather than true changes in suicidal behavior.

Although these specific findings may not generalize to other health systems, it’s important to be aware that the transition from ICD-9-CM to ICD-10-CM may affect research, surveillance, and quality improvement related to preventing suicidal behavior, and should be considered when interpreting trends during this period.


What is the extent of psychotropics use among children with autism spectrum disorder?

What is the extent of psychotropics use among children with autism spectrum disorder?

Psychotropics are frequently prescribed to children with autism spectrum disorder despite weak evidence supporting their effectiveness for such individuals. To examine the extent of psychotropic medication use, Jeanne Madden, PhD, led a study examining the health records of 7,901 children aged 1–17 with autism spectrum disorder in five health systems and compared them to matched cohorts without the disorder.

Study findings indicate that psychotropic treatment was far more prevalent among children with autism spectrum disorder, compared to children without it (48.4% versus 7.7% with some use in the study year).  The finding of widespread and intensive use held whether or not other psychiatric diagnoses were present  The most common classes of prescribed psychotropic drugs in the study population with autism spectrum disorder were:

  • Stimulants, alpha-agonists, or atomoxetine (30.2 %)
  • Antipsychotics (20.5 %)
  • Antidepressants (17.8 %)

This research highlights the challenges in the treatment of children with autism spectrum disorder as well as the need for greater investment in its evaluation.


MHRN study is first to test effectiveness of behavior activation for depression in pregnant women

MHRN study is first to test effectiveness of behavior activation for depression in pregnant women

An MHRN study is the first to test of the effectiveness of behavior activation for depression among pregnant women, as compared with usual treatment. Since depression among pregnant women is a prevalent public health problem and associated with poor mother and child development, behavior activation may be a good intervention given that it does not require pharmaceuticals.

The study found that, compared to treatment as usual, behavioral activation was effective for pregnant women and may offer significant benefits for depression, anxiety, and stress. 

A new study, funded by NIMH and implemented at the Kaiser Permanente Colorado MHRN site, aims to develop and test the effectiveness of disseminating behavioral activation using peer delivery for pregnant women with depression. 


MHRN analysis looks at depression trajectories using electronic health record data

MHRN analysis looks at depression trajectories using electronic health record data

A recent analysis using MHRN data led by researchers at the University of Washington looked at depression trajectories using electronic health record data. The study team analyzed patterns in depression trajectories in a treated population of over 3,000 patients, and compared several methods to predict individual trajectories for monitoring treatment outcomes.

They found five broad trajectory patterns: stable high, stable low, fluctuating moderate, an increasing and a decreasing group.  The authors also found that collaborative modeling outperformed other established methods. These findings indicate that a trajectory-based framework for depression assessment and prognosis is adaptable to model population heterogeneity using electronic health record data.


Four new publications on a national evidence-based collaborative care management model for patients with depression and poorly controlled diabetes and/or cardiovascular disease

Four new publications on a national evidence-based collaborative care management model for patients with depression and poorly controlled diabetes and/or cardiovascular disease

The COMPASS Initiative is a national effort to disseminate and implement an evidence-based collaborative care management model for patients with depression and poorly controlled diabetes and/or cardiovascular disease. Karen J. Coleman, PhD led a detailed description of the initiative in the August 2016 edition of General Hospital Psychiatry.It has been implemented in 18 medical groups and 172 clinics in 8 states. MHRN investigators associated with the COMPASS Initiative published four new publications on this ambitious initiative, covering a description of current conditions, an overview of the initiative, outcomes and key learnings. The goals of the initiative are to:

  • Improve depression symptoms in 40% of patients.
  • Improve diabetes and hypertension control rates by 20%.
  • Increase provider satisfaction by 20%.
  • Improve patient satisfaction with their care by 20%.
  • Demonstrate cost savings.

The impact of the COMPASS initiative is described by Rebecca Rossom, MD, MS and colleagues in the August 2016 publication of General Hospital Psychiatry. The findings indicate that the COMPASS initiative was successfully spread across diverse care systems and has demonstrated improved outcomes for complex patients with previously uncontrolled chronic disease. Specifically, they found that, in the mean follow-up period of 11 months:

  • Eighteen care systems and 172 clinics enrolled 3,609 patients across the US.
  • Of those with uncontrolled disease at enrollment,
    • 40% achieved depression remission or response.
    • 23% achieved glucose control.
    • 58% achieved blood pressure control.
  • Both patients and clinicians reported satisfaction with COMPASS care.
  • There were large variations in outcomes across medical groups.

This research indicates that large-scale implementation projects should create robust processes to identify and reduce implementation variation.

Karen J. Coleman, PhD led a study to understand how care managers implemented COMPASS and if this implementation was related to health outcomes in their patients. The team surveyed over 90 COMPASS care managers and then generated correlations between their survey responses and the average number of care management contacts, patient depression, blood pressure and glycosylated hemoglobin outcomes. They found that patients of care managers who reported spending more time on COMPASS-related had higher rates of depression improvement, remission and blood pressure control.

Robin Whitebird, PhD led a study to describe primary care clinician’s self-reports of satisfaction, burnout and barriers associated with treating complex patients. The researchers defined complex patients as patients with depression and diabetes and/or cardiovascular disease. The team surveyed over 1,500 primary care clinicians in 172 primary care clinics in 18 health care systems across 8 states. The results indicated that, of the primary care physicians who were surveyed:

    • Thirty-one percent were experiencing burnout, and this was associated with lower career satisfaction as well as lower satisfaction with their resources to treat these complex patients.
    • Less than 50% rated their ability to treat complex patients as very good to excellent, with 21% rating them ability as poor.
    • The majority (72%) thought that a collaborative model of care would be very helpful in treating complex patients.

New study finds early antidepressant non-adherence in specific minority populations

New study finds early antidepressant non-adherence in specific minority populations

Rebecca Rossom, MD, MS led a study examining antidepressant adherence across diverse populations and healthcare settings. Since research indicates that nearly 60% of patients discontinue antidepressants within three months, this study examined factors associated with poor early adherence in a large and diverse sample of patients from six MHRN healthcare systems. Findings indicate:

  • Race/ethnicity was a strong predictor of early antidepressant adherence.
  • All minority groups were less likely to be adherent, except Native Americans/Alaskan Natives
  • Age, neighborhood, education, comorbidity burden, provider type and engagement in psychotherapy were associated with adherence.

The researchers conclude that more research is needed to determine whether early non-adherence in specific minority populations is intentional, due to side effects or patient preference, or unintentional. If early non-adherence is unintentional, it could indicate that targeted interventions to improve adherence are appropriate.


PHQ9 is a strong predictor of suicide over the following 2 years

PHQ9 is a strong predictor of suicide over the following 2 years

An  MHRN study, using data from Group Health, HealthPartners, KP Colorado, and KP Southern California was recently published in the Journal of Clinical Psychiatry.  The authors examined the association between thoughts of death or self-harm reported on the Patient Health Questionnaire (PHQ) depression module and the risk of suicide attempt, or suicide death, over the subsequent 2 years.  The PHQ is used by clinicians and researchers to diagnose, monitor and measure the severity of depression.  The authors found that the response to PHQ item #9 was a strong predictor of suicide attempt and suicide death over the following 2  years in community practice and concluce that it is vital to address suicide prevention efforts in patients reporting thoughts of death or self-harm.


Use of peer support is underutilized resource for coping with suicidal thoughts

Use of peer support is underutilized resource for coping with suicidal thoughts

Greg  Simon, MD, MPH led a study with DBSA colleagues detailing the results of a survey on coping with suicidal thoughts, finding that peer support may be an underutilized resource for coping with suicidal thoughts.  Unfavorable ratings for emergency rooms and crisis clinics may indicate a need to develop more collaborative models of emergency care. Frequent use of spiritual practices suggests greater attention to spirituality may be a useful strategy in suicide prevention.