Lessons learned in conducting youth suicide prevention research in emergency departments.

INTRODUCTION: To address youth suicide, we recruited seven emergency departments (EDs) for what we believe is the first controlled trial of an intervention to promote safer firearm and medication storage after a child was seen in an ED by a behavioural health clinician. We provided training and a common protocol that required behavioural health clinicians to counsel about reducing access to household firearms and medication and provide locking devices. This paper examines how we addressed implementation challenges and considers how lessons learnt might inform future studies and interventions. METHODS: We tracked enrolment numbers and documented, through project records, the challenges in recruiting and developing partnerships with hospitals, as well as implementing the intervention and carrying out data collection. RESULTS: We encountered challenges identifying hospitals with sufficient patient volumes to meet our analytic requirements, obtaining contact information from families in the ED and providing supplies to the sites. These challenges were compounded by lack of uniformity in data systems, making it difficult to estimate total ED encounters meeting our eligibility criteria, and by differences in patterns of behavioural healthcare delivery across sites. The strategies we devised to address these challenges included creating visual materials that appealed to parents' altruistic desire to help other families, laminated 'cheat sheets' and hang tags for clinician badges reminding them of the key points of the intervention and contracting with a distribution centre to coordinate shipping. DISCUSSION: Despite the challenges noted, we found that the behavioural health clinicians in the EDs followed the protocol and found it useful in engaging families in discussions about both firearm and medication storage. Several hospitals intend to continue the intervention on their own as the new usual care, suggesting that the challenges encountered can be and are worth tackling.

Firearms training: what is actually taught?

INTRODUCTION: Firearm safety instructors and public health professionals are natural allies in the quest to prevent firearm injuries. We audited basic firearm classes to provide information that can help familiarise public health professionals and others with the content covered. METHODS: With the advice of expert instructors, we created an audit form. Volunteers audited 20 basic firearm classes in seven north-eastern states. RESULTS: All trainers covered a wide variety of safety issues. Some specific basics were covered in 90+% of the classes, including how to safely load/unload a gun, keeping your finger off the trigger until ready to shoot, and being aware of your target and what is behind it. In 50%-75% of the classes, the trainer covered topics such as operating a safety, clearing jams and cartridge malfunctions, and recommended storing guns unloaded and locked when not in use. Few instructors covered firearm suicide prevention (10%) or domestic violence (10%). Most encouraged gun ownership, gun carrying, gun use in self-defence and membership in a gun rights group. DISCUSSION: From a public health standpoint, we would like to see more instructors covering topics such as firearm suicide and alternatives to gun use in self-defence, and to recommend safer storage of firearms.

Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy.

IMPORTANCE: The unprecedented increase in unintentional overdose events that has occurred in tandem with escalating sales of prescription opioids over the past 2 decades has raised concerns about whether the therapeutic use of opioids has contributed to increases in overdose injury. Few controlled studies have examined the extent to which ecologic measures of increases in opioid prescribing and overdose injuries reflect risk among patients prescribed opioids, let alone whether some opioid regimens are safer than others. OBJECTIVE: To examine whether the risk of unintentional overdose injury is associated with the duration of opioid action (ie, long-acting vs short-acting formulations). DESIGN, SETTING, AND PARTICIPANTS: A propensity score-adjusted cohort study was conducted using population-based health care utilization data from the Veterans Administration Healthcare System. The patients were veterans with chronic painful conditions who began therapy with opioid analgesics between January 1, 2000, and December 31, 2009. MAIN OUTCOMES AND MEASURES: Unintentional overdoses that are explicitly coded using International Classification of Disease, Ninth Revision codes as drug or medication poisonings of accidental intent (E850.x-860.x) or undetermined intent (E980.x or drug poisoning [960.x-980.x] without an accompanying external cause of injury code). RESULTS: A total of 319 unintentional overdose events were observed. Patients initiating therapy with long-acting opioids were more than twice as likely to overdose compared with persons initiating therapy with short-acting opioids. After adjustment for age, sex, opioid dose, and other clinical characteristics, patients receiving long-acting opioids had a significantly higher rate of overdose injury than did those receiving short-acting opioids (hazard ratio [HR], 2.33; 95% CI, 1.26-4.32). The risk associated with long-acting agents was particularly marked during the first 2 weeks after initiation of treatment (HR, 5.25; 1.88-14.72). CONCLUSIONS AND RELEVANCE: To our knowledge, the findings of the present study provide the first evidence that the risk of unintentional overdose injury is related to the prescribed opioid's duration of action. If replicated in other cohorts, our findings suggest that clinicians weighing the benefits and risks of initiating different opioid regimens should consider not only the daily dose prescribed but also the duration of opioid action, favoring short-acting agents whenever possible, especially during the first 2 weeks of therapy.

Reducing a suicidal person's access to lethal means of suicide: a research agenda.

Reducing the availability of highly lethal and commonly used suicide methods has been associated with declines in suicide rates of as much as 30%-50% in other countries. The theory and evidence underlying means restriction is outlined. Most evidence of its efficacy comes from population-level interventions and natural experiments. In the U.S., where 51% of suicides are completed with firearms and household firearm ownership is common and likely to remain so, reducing a suicidal person's access to firearms will usually be accomplished not by fiat or other legislative initiative but rather by appealing to individual decision, for example, by counseling at-risk people and their families to temporarily store household firearms away from home or otherwise making household firearms inaccessible to the at-risk person until they have recovered. Providers, gatekeepers, and gun owner groups are important partners in this work. Research is needed in a number of areas: communications research to identify effective messages and messengers for "lethal means counseling," clinical trials to identify effective interventions, translational research to ensure broad uptake of these interventions across clinical and community settings, and foundational research to better understand method choice and substitution. Approaches to suicide methods other than firearms are discussed. Means restriction is one of the few empirically based strategies to substantially reduce the number of suicide deaths.

Training mental healthcare providers to reduce at-risk patients' access to lethal means of suicide: evaluation of the CALM Project.

The objective of this study was to evaluate the "CALM" (Counseling on Access to Lethal Means) training, in which community-based mental health care providers were trained to work with at-risk clients and their families to assess and reduce access to lethal means of suicide, including firearms. In 2006, CALM trainers conducted workshops in 7 community-based mental health care centers in New Hampshire towns. Participants completed a post-test immediately after the workshop and a follow-up questionnaire approximately 6 weeks later. At follow-up, 65% reported that they had counseled clients' parents about access to lethal means (n = 111). Findings also indicate that the workshop influenced participants' attitudes, beliefs, and skills regarding conducting lethal means counseling.

Identification of hospitalizations for intentional self-harm when E-codes are incompletely recorded.

CONTEXT: Suicidal behavior has gained attention as an adverse outcome of prescription drug use. Hospitalizations for intentional self-harm, including suicide, can be identified in administrative claims databases using external cause of injury codes (E-codes). However, rates of E-code completeness in US government and commercial claims databases are low due to issues with hospital billing software. OBJECTIVE: To develop an algorithm to identify intentional self-harm hospitalizations using recorded injury and psychiatric diagnosis codes in the absence of E-code reporting. METHODS: We sampled hospitalizations with an injury diagnosis (ICD-9 800-995) from two databases with high rates of E-coding completeness: 1999-2001 British Columbia, Canada data and the 2004 US Nationwide Inpatient Sample. Our gold standard for intentional self-harm was a diagnosis of E950-E958. We constructed algorithms to identify these hospitalizations using information on type of injury and presence of specific psychiatric diagnoses. RESULTS: The algorithm that identified intentional self-harm hospitalizations with high sensitivity and specificity was a diagnosis of poisoning, toxic effects, open wound to elbow, wrist, or forearm, or asphyxiation; plus a diagnosis of depression, mania, personality disorder, psychotic disorder, or adjustment reaction. This had a sensitivity of 63%, specificity of 99% and positive predictive value (PPV) of 86% in the Canadian database. Values in the US data were 74, 98, and 73%. PPV was highest (80%) in patients under 25 and lowest those over 65 (44%). CONCLUSIONS: The proposed algorithm may be useful for researchers attempting to study intentional self-harm in claims databases with incomplete E-code reporting, especially among younger populations.

Firearm restriction as suicide prevention: variation in belief and practice among providers in an urban emergency department.

Providers in an urban emergency department (ED) responded to a confidential, online survey assessing their beliefs and practices with respect to reducing a suicidal person's access to lethal means of suicide. 26% of respondents (37% of ED nurses, 23% of ED physicians, and 9% of psychiatrists) believed that all of the jumpers from the Golden Gate Bridge would have found a lethal suicide alternative had a barrier been present, and an additional 38% thought that most would have. Two-thirds of respondents believed that providers in the ED should always ask suicidal patients about access to firearms, yet 52% (67% of nurses, 54% of ED physicians, and 13% of psychiatrists) reported rarely or never doing so. Psychiatrists were more likely than ED staff to report always asking. Further understanding these attitudes and behaviours could enhance suicide prevention activities in the ED.

Creating a National Violent Death Reporting System: a successful beginning.

Following the urgings of many advocates, an IOM report in 1999 called for a national data system on violent death, modeled after that existing for motor-vehicle crashes. The National Violent Death Reporting System now provides rich data on the circumstances of violent deaths in the U.S.; it is the first national system to collect in-depth information on suicides. In November 2008, the system went online (www.cdc.gov/ncipc/wisqars/), making data from 17 states available to researchers and the general public. The successful development of this system was the result of a 10-year effort begun with the support of a half-dozen foundations. Key components of the success included a high-quality pilot version of the system and the mobilization of a large, bipartisan coalition of individuals, institutions, and agencies that advocated for federal funding for the system.

Public health training on the prevention of youth violence and suicide: an overview.

Although injury is the leading cause of death for Americans aged 40 and under, curricula in U.S. Schools of Public Health rarely include training on injury prevention or control. Domestically and internationally, when the topic of injury is addressed, the focus is often on unintentional injuries. Yet intentional injuries from violence and self-harm (apart from acts of war and terrorism) and the acute and chronic health problems associated with them take a large and often hidden toll on individuals, families, and communities worldwide. Adequate education on the prevention of violence and suicide by teenagers remains missing from public health and medical training. Public health and medical practitioners are confronted by violence-related injury but are provided little formal education on youth violence or suicide, effective responses, or prevention. Adolescents' involvement in violence remains a serious public health problem. Involvement in aggression and self-harm by adolescents leaves them at immediate risk of injury and often has ongoing and negative effects on future development, involvement in community and family life, and risk of morbidity and mortality for self and others. Public health practitioners are at the nexus of health care and service provision at local, state, federal, and multinational levels, and are well suited to provide training and technical assistance on youth violence prevention across disciplines and settings. In this article, training resources, opportunities, and strategies for prevention of the high prevalence of youth violence and suicide in the U.S. are discussed and recommendations for a new public health training initiative are outlined.

Public health training online: the National Center for Suicide Prevention Training.

BACKGROUND: Suicide is a serious public health problem, and training in suicide prevention has not kept pace with recent rapid growth of the field. METHODS: To address this concern, the Harvard Injury Control Research Center and Education Development Center, Inc., launched the National Center for Suicide Prevention Training (NCSPT) with funding by the Maternal and Child Health Bureau of the Health Resources Services Administration. NCSPT offers an online professional development workshop series for public officials, service providers, and community-based coalitions involved in suicide prevention. RESULTS: Using a public health framework of prevention, the three workshops implemented to date have drawn over 1200 participants nationally and internationally over the past 3 years. Workshop participants completing the post-test and evaluation show consistent improvement in their knowledge of suicide, rate their online training experience positively, and report that they would take additional online courses if offered. A barrier to objective evaluation of the courses, however, is the high attrition rates of the courses, an expected feature of free online courses. CONCLUSIONS: Online training is a valuable option to help meet suicide prevention training needs employing flexible, easy-to-use, and inexpensive Internet technology. With its growing presence in the field, NCSPT will continue to develop new courses to improve the ability of professionals and community-based coalitions to reduce suicide and its devastating impact on public health.

Youth suicide: insights from 5 years of Arizona Child Fatality Review Team data.

Data on 153 youth suicides in Arizona (1994-1999) were used to explore demographic, behavioral, and experiential factors that distinguish between firearm suicide and suicide by other means. In bivariate analyses, White youths were more likely than non-White youths to use a firearm to commit suicide as were youths who had not experienced a life crisis or expressed suicidal thoughts in the past, relationships that hold in multivariate analyses at the p < 0.2 level. Targeted suicide prevention activities should supplement interventions focused on restricting access to highly lethal means of suicide such as firearms.