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Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management.We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies.About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior.Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

BACKGROUND Freely-available, asynchronous implementation supports can reduce the resource burden of evidence-based practice (EBP) training to facilitate uptake. Freely-available web-based training videos have proliferated, yet there have been no efforts to quantify their breadth, depth, and content for suicide prevention. OBJECTIVE This study presents results from a scoping review of freely-available training videos for suicide prevention EBPs and describes a methodological framework for reviewing such videos. METHODS A scoping review of freely-available training videos (≥ 2 minutes) for suicide prevention EBPs was conducted using four large video-sharing platforms: YouTube, Vimeo, Bing Video, and Google Video. Identified videos for suicide prevention (N=506) were reviewed and coded. RESULTS Most content was targeted toward gatekeepers (n = 370) versus clinical providers (n = 136). Videos most commonly provided content related to suicidal ideation and/or behaviors (n = 420). A majority of videos (54.2%) included content targeted specifically to certain communities or organizations. Only about half (45.7%) of trainings included formal clinical content pertaining to assessment or intervention for suicide prevention. CONCLUSIONS Results suggested gaps where additional production of freely-available resources is needed. A limited portion of videos provided content aimed at clinical providers delivering formal evidence-based assessments and/or interventions for suicide prevention. Development of resources to address identified gaps may be needed. Future work may leverage machine learning techniques to expedite the review process.

This PRISMA scoping review explored worldwide research on the delivery of suicide-specific interventions through an exclusive telehealth modality. Research over telehealth modalities with suicidal individuals highlights the importance of facilitating participants' access to treatments despite location and circumstances (e.g., rural, expenses related to appointments, etc.).The review sought evidence of outcomes of trials or projects in which both the patient and therapist attended sessions conjointly and openly discussed suicide over a telehealth modality (e.g., phone, zoom).To explore this topic the authors searched for research trials and quality improvement projects using Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO Social Services Abstracts, and Web of Science on 3/3/2021.Nine different articles were included that each spanned distinct treatments, with eight being research studies and one being a quality improvement project.Publications featuring ongoing or upcoming research in which complete study results were not available did not meet inclusion criteria for this review.Several important research gaps were identified. While this approach has been largely understudied, exclusive telehealth delivery of suicide-specific interventions has great potential for the prevention of suicidality, especially in the era of COVID-19 and beyond.

Objective The presence of unlocked firearms in the home is associated with increased risk of suicide and unintentional injury in youth. We adapted an evidence-based program for promoting safe firearm storage, Safety Check, to enhance its acceptability as a universal suicide prevention strategy in pediatric primary care. Methods We applied ADAPT-ITT, an established adaptation framework, to guide iterative program adaptation with ongoing input from key stakeholders. The present study describes 2 phases of ADAPT-ITT: the Production phase (generating adaptations) and the Topical Experts phase (gathering stakeholder feedback on adaptations). After generating proposed program adaptations based on 3 inputs (stakeholder feedback collected in a prior study, the behavioral science literature, and best practices in pediatric medicine), we elicited feedback from stakeholders with firearm expertise. The adaptations included changes such as clarifying firearm ownership will not be documented in the medical record and offering follow-up reminders. We also crowdsourced feedback from 337 parents to select a new name and program logo. Results Saturation was reached with 9 stakeholders. Feedback confirmed the value of adaptations that: 1) considered context (eg, reason for ownership), 2) promoted parent autonomy in decision-making, and 3) ensured privacy. The most preferred program name was Suicide and Accident prevention through Family Education (SAFE) Firearm. Conclusions Guided by an established adaptation framework that prioritized multistage stakeholder feedback, adaptations to the original Safety Check were deemed acceptable. We plan to test the SAFE Firearm program as a universal suicide prevention strategy in pediatric primary care via a hybrid effectiveness-implementation trial.

Minimal evidence exists for suicide-specific group treatment for high-risk patients offered over telehealth. This qualitative study assessed the acceptability, feasibility, and impact of a telehealth suicide safety planning intervention (SPI) multi-session group. High-risk suicidal Veterans (

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.

We identified common and unique barriers and facilitators of evidence-based suicide prevention practices across primary care practices with integrated behavioral health services and specialty mental health settings to identify generalizable strategies for enhancing future implementation efforts.Twenty-six clinicians and practice leaders from behavioral health (There were a number of similar themes associated with implementation of suicide prevention practices across settings and clinician types, such as the benefits of inter-professional collaboration and uncertainties about managing suicidality once risk was disclosed. Clinicians also highlighted barriers unique to their settings. For primary care settings, time constraints and competing demands were consistently described as barriers. For specialty mental health settings, difficulties coordinating care with schools and other providers in the community made implementation of suicide prevention practices challenging.Findings can inform the development and testing of implementation strategies that are generalizable across primary care and specialty mental health settings, as well as those tailored for unique site needs, to enhance use of evidence-based suicide prevention practices in settings where individuals at risk for suicide are especially likely to present.HIGHLIGHTSWe examined barriers and facilitators to suicide prevention across health settings.Common and unique barriers and facilitators across health-care settings emerged.Findings can enhance suicide prevention implementation across health-care settings.

BackgroundInsights 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?MethodsThe 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 receiveS.A.F.E. Firearmmaterials, 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 theS.A.F.E Firearmprogram. 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.DiscussionThe 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 registrationClinicalTrials.gov,NCT04844021. Registered 14 April 2021.

OBJECTIVES: Promoting safe firearm storage in pediatric primary care is one way to address youth suicide by firearm. The study objective is to determine perspectives of primary care physicians (PCPs) and leaders of primary care practices regarding acceptability and use of screening, counseling, and firearm locks, three components of an adapted evidence-based intervention, the Firearm Safety Check. METHODS: In 2016, an online survey was conducted in two large United States health systems. PCPs (n = 204) and leaders (n = 57) from 83 clinics were invited to participate. Respondents included 71 clinics (86%), 103 PCPs (50%), and 40 leaders (70%). Main outcomes included acceptability (1-6 Likert with higher scores indicating better acceptability) and use of the three intervention components (1-4 Likert with higher scores indicating more use) measured by an adapted validated instrument. RESULTS: Analyses were conducted in 2017. PCP acceptability of screening (M = 4.28, SD = 1.12) and counseling (M = 4.56, SD = .89) were high while acceptability for firearm lock provision was more neutral (M = 3.78, SD = 1.16). Most PCPs endorsed sometimes screening (85%) and counseling (80%). Few PCPs offered firearm locks to caregivers (15%). Leaders reported consistent information. CONCLUSION: Acceptability of screening for firearms and safe storage counseling was high; both components were used commonly but not routinely. The acceptability of providing firearm locks was neutral and use was rarely endorsed. This study provides important insights about areas of focus for future implementation efforts from policy and research perspectives. WHAT’S NEW: Evidence-based practices for safe firearm storage endorsed by the American Academy of Pediatrics are variably considered to be acceptable and are inconsistently implemented in pediatric primary care, highlighting the importance of efforts to actively increase the use of these intervention components as a universal suicide prevention strategy.

The primary objective of the current study was to examine the perspective of firearm stakeholders, including firearm safety course instructors, members of law enforcement, and firearm retailers, with regard to the implementation of an evidence-based approach to firearm safety promotion, the Firearm Safety Check, as a universal suicide prevention strategy in pediatric primary care. Twelve firearm stakeholders participated in semi-structured interviews. Using an integrated analytic approach, several themes emerged from the interviews. With regard to acceptability of the intervention, participants generally found counseling caregivers to store firearms safely and the provision of firearm locking mechanisms to be acceptable, but expressed concern about screening for firearm ownership in health systems. Participants identified distinct roles of responsibility for firearm advocacy groups, firearm owners, healthcare clinicians, and caregivers with regard to the promotion and execution of safe firearm storage. Participants called for partnerships between healthcare systems and firearm stakeholders, and also identified potential threats to these partnerships, including lack of trust firearm owners may have in health systems and the government. Finally, participants suggested strategies for preventing firearm-related suicides. Findings support a growing body of literature suggesting the value in researchers, health systems, and firearm stakeholders partnering around a shared agenda of firearm safety promotion as a strategy to prevent suicide.

Background: Thought records are a core component of Cognitive Behavior Therapy. Over time, thought records have been modified to suit various needs or preferences. A diversity of thought records have been developed, which include differing components and cognitive change strategies. Yet, due to a lack of specificity in the literature and field, different thought records are often treated as though they are interchangeable. Limited extant literature suggests that differing thought records may have unique clinical effects. However, meta-analyzing the comparable or differing effects of the distinct extant thought records is impeded by the lack of a coding system for thought records. Objective: The current study sought to prepare a way for further understanding the differential utility and effectiveness of different iterations of thought records by creating a coding system, which is described in detail. This coding system will be used to guide future research into which thought records work best for which problems. Method: Thought records were gathered from seminal texts and solicited from the certified members of the Academy of Cognitive Therapy and the American Board of Behavioral and Cognitive Psychology. Results: In total, 110 non-identical thought records were gathered and coded into 55 unique combinations. These results demonstrate that the variability of thought records used by qualified therapists extends well beyond those found in seminal CBT texts. Conclusion: This broad diversity justifies the need for a coding system to inform future lines of research.

Background Suicide is a global health issue. There are a number of evidence-based practices for suicide screening, assessment, and intervention that are not routinely deployed in usual care settings. The goal of this study is to develop and test implementation strategies to facilitate evidence-based suicide screening, assessment, and intervention in two settings where individuals at risk for suicide are especially likely to present: primary care and specialty mental health care. We will leverage methods from behavioral economics, which involves understanding the many factors that influence human decision making, to inform strategy development. Methods We will identify key mechanisms that limit implementation of evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health through contextual inquiry involving behavioral health and primary care clinicians. Second, we will use contextual inquiry results to systematically design a menu of behavioral economics-informed implementation strategies that cut across settings, in collaboration with an advisory board composed of key stakeholders (i.e., behavioral economists, clinicians, implementation scientists, and suicide prevention experts). Finally, we will conduct rapid-cycle trials to test and refine the menu of implementation strategies. Primary outcomes include clinician-reported feasibility and acceptability of the implementation strategies. Discussion Findings will elucidate ways to address common and unique barriers to evidence-based suicide screening, assessment, and intervention practices in primary care and specialty mental health care. Results will yield refined, pragmatically tested strategies that can inform larger confirmatory trials to combat the growing public health crisis of suicide.

Autistic individuals experience elevated risk for suicide ideation, attempts, and deaths. Little is known about how clinicians assess risk or intervene with suicidal autistic individuals. We surveyed 121 clinicians about use of suicide prevention practices with autistic and non-autistic clients. Clinicians reported greater self-efficacy in screening for suicide risk among non-autistic clients (p = 0.01). There were no statistically significant differences in whether they used standardized screening measures or in their reported normative pressure or attitudes towards screening. Clinicians reported similar rates of use of Safety Planning, an evidence-based suicide-prevention strategy, across groups, but greater acceptability for non-autistic clients (p

One in five suicide deaths is a Veteran and in spite of enhanced suicide prevention services in the Veterans Health Administration (VHA), twenty Veterans die by suicide each day. One component of the VHA's coordinated effort to treat high-risk suicidal Veterans, and diminish suicide risk, is the use of the safety plan. The current study aims to examine a novel intervention integrating skills training and social support with safety planning for Veterans at high-risk for suicide, “Project Life Force” (PLF). A randomized clinical trial (RCT) will be conducted examining if Veterans who are at high-risk for suicide will benefit from the novel group intervention, PLF, compared to Veterans who receive treatment as usual (TAU). We plan to randomize 265 Veterans over the course of the study. The primary outcome variable is the incidence of suicidal behavior, during follow-up, established using a rigorous, multi-method assessment. Secondary outcomes include depression, hopelessness, suicide coping and treatment utilization. Exploratory analyses include safety plan quality and belongingness for those in both arms as well as group cohesion for those in the PLF intervention. Strengths and limitations of this protocol are discussed. Keywords: Suicide, Treatment, Group, Safety plan, Depression, Veteran

Abstract. Background: External causes of injury codes (E-codes) are used in administrative and claims databases for billing and often employed to estimate the number of self-injury visits to emergency departments (EDs). Aims: This study assessed the accuracy of E-codes using standardized, independently administered research assessments at the time of ED visits. Method: We recruited 254 patients at three psychiatric emergency departments in the United States between 2007 and 2011, who completed research assessments after presenting for suicide-related concerns and were classified as suicide attempters (50.4%, n = 128), nonsuicidal self-injurers (11.8%, n = 30), psychiatric controls (29.9%, n = 76), or interrupted suicide attempters (7.8%, n = 20). These classifications were compared with their E-code classifications. Results: Of the participants, 21.7% (55/254) received an E-code. In all, 36.7% of research-classified suicide attempters and 26.7% of research-classified nonsuicidal self-injurers received self-inflicted injury E-codes. Those who did not receive an E-code but should have based on the research assessments had more severe psychopathology, more Axis I diagnoses, more suicide attempts, and greater suicidal ideation. Limitations: The sample came from three large academic medical centers and these findings may not be generalizable to all EDs. Conclusion: The frequency of ED visits for self-inflicted injury is much greater than current figures indicate and should be increased threefold.

Objective The severity of anxiety, in general, has been associated with suicide ideation (SI) among youth, but research has yet to examine the specific anxiety symptoms that may contribute to SI among youth. This study examined the severity of specific anxiety symptom clusters (i.e., tense/restless, somatic/autonomic symptoms, humiliation/rejection, performing in public, separation anxiety, perfectionism, and anxious coping) and SI in youth who met diagnostic criteria for an anxiety disorder. Method Participants (N = 87) were treatment-seeking children and adolescents ages 6-17 (M = 11.1 years, SD = 3.06; 52.9% male) diagnosed with a principal anxiety disorder. Youth and their parents completed measures of youth anxiety symptom severity, depression, and SI. Results Hierarchical linear regressions revealed that when anxiety symptom clusters were entered simultaneously, only youth self-reported (and not parent-reported) somatic/autonomic symptoms of anxiety significantly predicted SI, after controlling for depression and sex. Importantly, the relationship between somatic/autonomic symptoms of anxiety and SI was stronger than that between depression and SI. Conclusions These results suggest that assessing somatic symptoms of anxiety is especially important when quantifying suicide risk among anxiety-disordered youth.

This study aimed to identify barriers to treatment seeking and service utilization among previously deployed Army soldiers who recently experienced a suicidal crisis. Confidential interviews were conducted on a psychiatric inpatient unit with 12 Army soldiers with a deployment history following a suicidal crisis. Qualitative analysis focused on statements coded as "barriers to seeking help" and "explicit recommendations." Suicidal Army soldiers with a deployment history experienced different barriers to seeking help, including stigma and logistical challenges (e.g., long wait times for appointments). Negative and positive perceptions of support were reported for various resources - for example, family, crisis hotlines, chaplains, and command. Suicidal Army soldiers, interviewed in this study, experienced a number of challenges and frustrations associated with various helping resources. This study highlights the need for greater attention toward understanding these challenges and subsequently addressing them through appropriate resource allocation and additional training for those working directly with Army soldiers at risk for suicide.

Notwithstanding its empirical status and strong recommendation in clinical practice guidelines, cognitive behavioral therapy (CBT) continues to be delivered infrequently and with low fidelity on the clinical front lines. Recently, organized efforts and policies within the public sector to disseminate and implement CBT and other evidence-based psychotherapies have yielded encouraging results and provided optimism for bridging the research-to-practice-gap. Following from these efforts, the current article examines the initial impact and experience of the implementation of an individualized approach to CBT training and treatment within the Kaiser Permanente health care system. Initial training outcomes, including changes in general and specific competencies, were assessed using divergent assessment methods within the initial cohort of therapists undergoing training. Initial patient outcomes, including changes in depression and anxiety, were assessed among patients receiving treatment from therapists in training. Results revealed training in and implementation of CBT-D was associated with overall large improvements in therapist competencies and in clinically significant improvements in both depression and anxiety among patients. Findings from the initial phase of dissemination and implementation within a large private system provide support for, and extend recent findings related to, the feasibility and effectiveness of training in and implementation of CBT-D in a real-world context.

Optimism has been conceptualized variously as positive expectations for the future (Scheier & Carver, 1985), optimistic attributions (Peterson & Seligman, 1984), illusion of control (Alloy & Abramson, 1979), and self-enhancing biases (Weinstein, 1980). Relatively little research has examined these multiple dimensions of optimism in relation to psychological and physical health. The current study assessed the multidimensional nature of optimism within a prospective vulnerability-stress framework. Initial principal component analyses revealed the following dimensions: Positive Expectations (PE), Inferential Style (IS), Sense of Invulnerability (SI), and Overconfidence (O). Prospective follow-up analyses demonstrated that PE was associated with fewer depressive episodes and moderated the effect of stressful life events on depressive symptoms. SI also moderated the effect of life stress on anxiety symptoms. Generally, our findings indicated that optimism is a multifaceted construct and not all forms of optimism have the same effects on well-being. Specifically, our findings indicted that PE may be the most relevant to depression, whereas SI may be the most relevant to anxiety.

Attentional fixation is a cognitive process characterized by a narrowing of attention on and preoccupation with suicide as the only solution to one’s problems. The present study sought to investigate the experience of attentional fixation on suicide by establishing the psychometric properties of the Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) in a sample of 64 patients who recently attempted suicide. The AFSEQ evidenced strong psychometric properties, including good internal consistency and construct validity through moderate correlations with measures of suicidal ideation, depressive symptoms, and suicide-relevant cognitive distortions. In addition, an exploratory factor analysis of the AFSEQ identified two factors: Cognitive Dysfunction and Cognitive Stuckness. Results suggest the AFSEQ is a reliable method for assessing the experience of attentional fixation in relation to suicide. We propose future research to further examine attentional fixation as a proximal risk factor for suicidal behavior.

Introduction: Our goal was to explore whether emergency department (ED) patients would disclose their sexual orientation in a research evaluation and to examine demographic and clinical characteristics of patients by self-identified sexual orientation. Methods: Participants (n=177) presented for psychiatric treatment at three urban EDs in New York City, Rochester, NY, and Philadelphia, PA. Participants were interviewed in the context of a larger study of a standardized suicide risk assessment. We assessed participants’ willingness to answer questions regarding sexual orientation along three dimensions: a self-description of sexual orientation, a self-description of sexual attraction, and the gender of any prior sexual partners. Results: No participants (0/177) refused to respond to the categorical question about sexual orientation, 168/177 (94.9%) agreed to provide information about prior sexual partners, and 100/109 (91.7%) provided information about current sexual attraction toward either gender. Of all 177 participants, 154 (87.0%) self-identified as heterosexual, 11 (6.2%) as bisexual, 10 (5.6%) as gay or lesbian, and 2 (1.1%) indicated they were not sure. As compared with heterosexual patients, lesbian, gay and bisexual (LGB) patients were significantly younger and more likely to be non-white, but did not differ significantly in terms of education, income, employment, or religious affiliation or participation. Further, LGB participants did not differ from self-identified heterosexual participants for lifetime suicide attempt rate or lifetime history of any mood, substance-related, psychotic spectrum, or other Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) Axis I disorder. Of self-identified heterosexual participants 5.6% (5/89) reported sexual attraction as other than ‘only opposite sex,’ and 10.3% (15/142) of sexually active ‘heterosexual’ participants reported previous same-gender sexual partners. Conclusion: Assessing patients’ sexual orientation in the ED by a three-question approach appeared feasible in the ED and acceptable to ED patients. However, since many patients have sexual experiences not suggested by simple labels, self-report of sexual identity alone may not inform clinicians of health risks inherent in same or opposite gender sexual contact. [West J Emerg Med. 2015;16(1):–0.]

Although theorists have posited that suicidal individuals are more likely than non-suicidal individuals to experience cognitive distortions, little empirical work has examined whether those who recently attempted suicide are more likely to engage in cognitive distortions than those who have not recently attempted suicide. In the present study, 111 participants who attempted suicide in the 30 days prior to participation and 57 psychiatric control participants completed measures of cognitive distortions, depression, and hopelessness. Findings support the hypothesis that individuals who recently attempted suicide are more likely than psychiatric controls to experience cognitive distortions, even when controlling for depression and hopelessness. Fortune telling was the only cognitive distortion uniquely associated with suicide attempt status. However, fortune telling was no longer significantly associated with suicide attempt status when controlling for hopelessness. Findings underscore the importance of directly targeting cognitive distortions when treating individuals at risk for suicide .

OBJECTIVE Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP. METHOD Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity. RESULTS Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other). CONCLUSIONS Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

BACKGROUND: Disruptions in emotion regulation are a transdiagnostic risk factor for psychopathology. However, scant research has examined whether emotion regulation strategies are related to the onset of posttraumatic stress disorder (PTSD) symptoms among youths exposed to trauma. We investigated whether pretrauma emotion regulation strategies prospectively predicted PTSD symptom onset after the 2013 Boston Marathon terrorist attack among adolescents and whether these associations were moderated by the degree of exposure to media coverage of the attack. METHODS: A sample of 78 Boston-area adolescents (mean age = 16.72 years, 65% female) who previously participated in studies assessing emotion regulation and psychopathology were recruited following the terrorist attack. Within 4 weeks of the attack, we assessed self-reported PTSD symptoms and attack-related media exposure via an online survey. We examined the association of pretrauma emotion regulation strategies with PTSD symptom onset after adjustment for pretrauma internalizing symptoms and violence exposure. RESULTS: Greater pretrauma engagement in rumination predicted onset of PTSD symptoms following the attack. Adolescents who engaged in catastrophizing also had greater PTSD symptoms postattack, but only when exposed to high levels of media coverage of the attacks; the same pattern was observed for adolescents who engaged in low levels of cognitive reappraisal. CONCLUSIONS: Engagement in specific emotion regulation strategies prior to a traumatic event predicts the onset of PTSD symptoms among youths exposed to trauma, extending transdiagnostic models of emotion regulation to encompass trauma-related psychopathology in children and adolescents.© 2016 Wiley Periodicals, Inc. Language: en

A prospective, behavioral high-risk design provided a theoretically guided examination of vulnerability to first onset of bipolar spectrum disorder based on the Behavioral Approach System (BAS) model. Adolescents (ages 14–19) at an “age of risk” for bipolar disorder onset were screened on BAS sensitivity by interviewers blind to current symptoms, lifetime history, and family history of psychopathology. Participants were selected with high versus moderate levels of BAS sensitivity and administered a lifetime diagnostic interview. Those with a bipolar spectrum disorder, psychosis, or hypomanic episode with onset prior to the BAS sensitivity assessment were excluded. High BAS (n = 171) and Moderate BAS (n = 119) sensitivity participants in the final sample completed baseline measures of symptoms, goal-setting, and reward responsiveness and were followed prospectively with semistructured diagnostic interviews every 6 months. Consistent with the vulnerability hypothesis of the BAS model of bipolar disorder, high BAS participants had a greater likelihood, and shorter time to onset, of bipolar spectrum disorder than moderate BAS participants across an average of 12.8 months of follow-up (12.9% vs. 4.2%), controlling for baseline depressive and hypomanic symptoms, and family history of bipolar disorder. High reward responsiveness on a behavioral task and ambitious goal-striving for popular fame and financial success (but not impulsivity) also predicted first onset of bipolar spectrum disorder controlling for the covariates and BAS risk group, and ambitious goal-striving partially mediated the BAS risk group effect. We discuss implications of the findings for the BAS model of bipolar disorder and early intervention efforts.

Although past research has documented a link between adverse childhood experiences - particularly childhood emotional (CEA), physical (CPA), and sexual abuse (CSA) - and depression, relatively few studies have examined the unique impact of each of these highly co-occurring abuse types. Moreover, relatively little is known about the specific aspects of abuse experiences that increase risk for depression (e.g., number of perpetrators). The current study provides a conservative test of the association between the number of CEA, CPA, and CSA perpetrators, and depressive episodes in adulthood.Two hundred and ninety-nine participants were followed longitudinally for 2.5 years. CEA, CPA, and CSA were measured using the Lifetime Experiences Questionnaire, and depressive episodes were assessed with diagnostic interviews administered every 6 weeks.After statistically controlling for the influence of cognitive risk for depression, baseline depressive symptoms, past history of clinical depression, and total number of different types of CEA, CSA, and CPA events, the number of CEA and CSA, but not CPA, perpetrators were uniquely associated with the number of depressive episodes experienced over the prospective follow-up.These results indicate that experiencing CEA and CSA from multiple perpetrators increased risk for clinical depression beyond what is accounted for by the total number of types of abuse experiences. This study highlights the need for future research to assess the specific qualities of childhood abuse experiences that uniquely confer risk for clinical depression, as well as possible mechanisms through which they exert their deleterious effect.

This study used a behavioral high-risk design to evaluate cognitive styles relevant to the Behavioral Approach System (BAS) among individuals at high (n = 171) versus low (n = 119) risk of first onset of bipolar disorder based on BAS sensitivity, a known risk factor for bipolar disorder. Cognitive styles in high-BAS participants paralleled those implicated in bipolar disorder. Linear regressions indicated that individuals with high BAS sensitivity exhibited greater levels of goal striving, positive overgeneralization, rumination on positive affect, depressive brooding, perfectionism, and hypomanic personality. Furthermore, of the cognitive styles, emotion-focused rumination on positive affect mediated the association between BAS sensitivity and current levels of hypomanic symptoms. These results provide evidence that individuals at risk for the development of bipolar disorder have higher levels of BAS-relevant cognitive styles and hypomanic personality than do individuals with lower risk, indicating that these styles are not simply markers of prior (hypo)manic episodes.

Little longitudinal research has examined progression to more severe bipolar disorders in individuals with “soft” bipolar spectrum conditions. We examine rates and predictors of progression to bipolar I and II diagnoses in a non-patient sample of college-age participants (n = 201) with high General Behavior Inventory scores and childhood or adolescent onset of “soft” bipolar spectrum disorders followed longitudinally for 4.5 years from the Longitudinal Investigation of Bipolar Spectrum (LIBS) project. Of 57 individuals with initial cyclothymia or bipolar disorder not otherwise specified (BiNOS) diagnoses, 42.1% progressed to a bipolar II diagnosis and 10.5% progressed to a bipolar I diagnosis. Of 144 individuals with initial bipolar II diagnoses, 17.4% progressed to a bipolar I diagnosis. Consistent with hypotheses derived from the clinical literature and the Behavioral Approach System (BAS) model of bipolar disorder, and controlling for relevant variables (length of follow-up, initial depressive and hypomanic symptoms, treatment-seeking, and family history), high BAS sensitivity (especially BAS Fun Seeking) predicted a greater likelihood of progression to bipolar II disorder, whereas early age of onset and high impulsivity predicted a greater likelihood of progression to bipolar I (high BAS sensitivity and Fun-Seeking also predicted progression to bipolar I when family history was not controlled). The interaction of high BAS and high Behavioral Inhibition System (BIS) sensitivities also predicted greater likelihood of progression to bipolar I. We discuss implications of the findings for the bipolar spectrum concept, the BAS model of bipolar disorder, and early intervention efforts.

Key Points Question What are the needs of stakeholders who would be affected by implementing an evidence-based approach to firearm safety promotion in pediatric primary care as a universal suicide prevention strategy? Findings In this qualitative study of 58 stakeholders, firearm safety promotion for suicide prevention was described as acceptable, mostly feasible to implement, and a health system priority. Participants described the importance of leveraging existing infrastructures and brevity. Meaning The results of this contextual inquiry provide valuable insights toward future efforts to implement firearm safety promotion in pediatric primary care to prevent suicide., Importance The rate of youth suicide has increased steadily over the past several decades due, in part, to an increase in suicide by firearm. Implementation of evidence-based approaches to increase safe firearm storage practices are important for reducing youth suicide. Objective To assess the needs of stakeholders who would be affected by implementing an evidence-based approach to firearm safety promotion—Firearm Safety Check, which includes screening for the presence of firearms in the home, brief motivational interviewing–informed counseling regarding safe firearm storage, and provision of free firearm locks—in pediatric primary care settings. Design, Setting, and Participants In this qualitative study, 58 stakeholders were interviewed over a 7-month period across 9 stakeholder groups from 2 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. Data analysis were conducted from September 2017 to April 2018. Main Outcomes and Measures Interview guides were informed by the Consolidated Framework for Implementation Research. An integrated analysis approach was used in which a priori attributes of interest were identified (Consolidated Framework for Implementation Research constructs, eg, intervention characteristics), and an inductive approach was used with regard to new themes that emerged. Results A total of 58 stakeholders were interviewed (mean [SD] age, 48.38 [10.65] years; 27 men and 31 women). Stakeholders indicated that firearm safety promotion is a health system priority and reported favorable perceptions of the Firearm Safety Check approach for suicide prevention. The importance of leveraging existing infrastructures, such as electronic health record systems and brevity, were frequently noted. Distribution of firearm locks was endorsed as the most complicated component to implement. Conclusions and Relevance By including multiple service system stakeholder perspectives, these results support the development of implementation strategies to change clinician, organization, and system behaviors around firearm safety promotion in pediatric primary care as a universal suicide prevention strategy., This qualitative study assesses the needs of stakeholders who would be affected by implementing an evidence-based approach to firearm safety promotion in pediatric primary care settings as a youth suicide prevention strategy.

We examined concurrent and prospective associations of self-focused cognitive styles with bipolar spectrum disorders. Controlling for depressive and hypomanic/manic symptoms, 125 individuals with bipolar spectrum disorders scored higher than 149 demographically similar normal controls on the rumination scale of the Response Styles Questionnaire (RSQ) and the private self-consciousness subscale of the Self-Consciousness Scale (SCS). The two groups did not differ on the distraction scale of the RSQ or the public self-consciousness and social anxiety subscales of the SCS. In addition, among the bipolar individuals, controlling for initial depressive and hypomanic/manic symptoms, rumination predicted the number, but not the likelihood of onset, of depressive episodes, whereas private self-consciousness predicted the likelihood of onset, but not the number, of hypomanic/manic episodes over a 3.5-year follow-up.

The purpose of this study was to determine the percentage of borderline patients who first engaged in self-mutilation as children and to compare the parameters of their self-harm to those of borderline patients who first harmed themselves at an older age. Two hundred and ninety inpatients meeting both Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) and Diagnostic and Statistical Manual of Mental Disorders (3rd ed. ref.) (DSM-III-R; APA, 1987) criteria for borderline personality disorder were interviewed about their history of self-mutilation. Of the 91% with a history of self mutilation, 32.8% reported first harming themselves as children (12 years of age or younger), 30.2% as adolescents (13-17 years of age), and 37% as adults (18 or older). Using logistic regression analyses and controlling for baseline age, it was found that those with a childhood onset reported more episodes of self-harm, a longer duration of self-harm, and a greater number of methods of self-harm than either those with an adolescent or adult onset to their self-mutilation. The results of this study suggest that a sizable minority of borderline patients first engage in self-harm as children and that the course of their self-mutilation may be particularly malignant.

Introduction The promotion of safe firearm practices, or firearms means restriction, is a promising but infrequently used suicide prevention strategy in the USA. Safety Check is an evidence-based practice for improving parental firearm safety behaviour in paediatric primary care. However, providers rarely discuss firearm safety during visits, suggesting the need to better understand barriers and facilitators to promoting this approach. This study, Adolescent Suicide Prevention In Routine clinical Encounters, aims to engender a better understanding of how to implement the three firearm components of Safety Check as a suicide prevention strategy in paediatric primary care. Methods and analysis The National Institute of Mental Health-funded Mental Health Research Network (MHRN), a consortium of 13 healthcare systems across the USA, affords a unique opportunity to better understand how to implement a firearm safety intervention in paediatric primary care from a system-level perspective. We will collaboratively develop implementation strategies in partnership with MHRN stakeholders. First, we will survey leadership of 82 primary care practices (ie, practices serving children, adolescents and young adults) within two MHRN systems to understand acceptability and use of the three firearm components of Safety Check (ie, screening, brief counselling around firearm safety and provision of firearm locks). Then, in collaboration with MHRN stakeholders, we will use intervention mapping and the Consolidated Framework for Implementation Research to systematically develop and evaluate a multilevel menu of implementation strategies for promoting firearm safety as a suicide prevention strategy in paediatric primary care. Ethics and dissemination Study procedures have been approved by the University of Pennsylvania. Henry Ford Health System and Baylor Scott & White institutional review boards (IRBs) have ceded IRB review to the University of Pennsylvania IRB. Results will be submitted for publication in peer-reviewed journals.

OBJECTIVE The current study examines the predictive validity of the Beck Depression Inventory (BDI) suicide item for death by suicide and suicide attempts. METHOD The study included 2 samples: (1) 5,200 psychiatric outpatients who were evaluated between 1975 and 1995 and followed prospectively for up to 20 years (all psychiatric diagnoses based on DSM-III and DSM-III-R), and (2) 119 patients who, between 2000 and 2004, participated in a randomized controlled trial of outpatient Cognitive Therapy for Suicide Prevention after a suicide attempt and were followed for 18 months (all psychiatric diagnoses based on DSM-IV-TR). All patients completed structured diagnostic interviews, as well as the BDI and Scale for Suicide Ideation. RESULTS Cox regression models demonstrated that the BDI suicide item significantly predicted both deaths by suicide (Wald χ(2)1 = 35.67; P < .001 [N = 5,200]) and repeat suicide attempts (Wald χ(2)1 = 8.82; P < .01 [N = 119]), with each successive rating on the item conferring greater risk. Using receiver operating characteristic (ROC) curves, optimal cutoff scores of 1 and above for suicide and 2 and above for suicide attempts were identified as providing the best balance between sensitivity and specificity. CONCLUSIONS The BDI suicide item is associated with both risk of repeat suicide attempts and death by suicide. The use of the item as a brief, efficient screen for suicide risk in routine clinical care is recommended. Clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen. Future research examining the item's performance in other at-risk groups (ie, older adults, adolescents, inpatients, etc) is encouraged.

The degree of concordance between clinical and standardized assessments in the detection and classification of suicidal behavior and nonsuicidal self-injury behavior in psychiatric emergency department settings was examined.Two hundred fifty-four patients at 3 psychiatric emergency departments between 2007 and 2011 were evaluated by research staff using standardized assessments of suicidal behavior and nonsuicidal self-injury behavior. Of 254 patients, 128 (50%) made a recent suicide attempt, 30 (12%) engaged in recent nonsuicidal self-injury behavior, 20 (8%) made a recent suicide attempt interrupted by self or others, and 76 (30%) had other psychiatric symptoms in the absence of recent suicidal or nonsuicidal self-injury behavior. The classifications derived from the standardized assessments using the Centers for Disease Control and Prevention (CDC) nomenclature were compared to clinical assessments independently extracted from emergency department medical records.Agreement between clinical and standardized assessments was substantial for both suicide attempts (κ = 0.76, P.001) and nonsuicidal self-injury behavior (κ = 0.72, P.001). Importantly, 18% of patients determined to have made a suicide attempt in the past week by standardized assessment were not identified as such by clinical assessment. In addition, as measured by the Columbia Suicide Severity Rating Scale, the potential lethality of attempts for patients classified as making a recent suicide attempt by both clinician and standardized assessments was significantly greater (t120 = 2.1, P = .04) than that for patients who were classified as having made an attempt by the standardized but not clinical assessment.The use of standardized assessment measures may improve sensitivity and accuracy of identifying suicidal behavior and nonsuicidal self-injury behavior in psychiatric emergency departments.