Effects of Patient Suicide on Professional Practice Among Mental Health Providers.

INTRODUCTION: The loss of a patient to suicide has an enormous impact on clinicians, but few studies have examined its effects. METHOD: In this retrospective study, we compared clinicians who have and have not experienced a patient suicide using a survey of 2157 outpatient clinicians from 169 New York clinics to determine differences in their suicide prevention knowledge, practices, training, and self-efficacy. RESULTS: Approximately 25% of the clinician respondents lost patients to suicide; psychiatrists, nurses/nurse practitioners, and those with more years of experience were disproportionately affected. After controlling for these demographic/professional differences, clinicians who had experienced patient suicide reported feeling that they had insufficient training, despite actually having more suicide prevention training, greater knowledge of suicide prevention practices, and feeling more comfortable working with suicidal patients than clinicians who had not lost a patient to suicide. There were no differences in self-efficacy or utilization of evidence-based clinical practices. CONCLUSIONS: Controlling for demographic/professional differences, clinicians who experienced a patient suicide had more training, knowledge, and felt more comfortable working with suicidal patients. It is critical that sufficient training be available to clinicians, not only to reduce patient deaths, but also to help clinicians increase their comfort, knowledge, skill, and ability to support those bereaved by suicide loss.

Association Between Tobacco Retailer Density and Smoking Among Adults With Diabetes and Serious Mental Illness in New York State.

INTRODUCTION: Smoking prevalence is high among adults with comorbid diabetes and serious mental illness. This population is at elevated risk of smoking-related health consequences and premature death. We focused on the community environment and investigated the association between tobacco retailer density and smoking in this population. METHODS: We obtained individual-level data from the 2017 Patient Characteristics Survey, a medical record-based survey of patients served by the public mental health system in New York State. We computed the density of state-authorized tobacco retailers at the 3-digit zip code level. RESULTS: The data included 19,492 adults (aged ≥18) with comorbid diabetes and serious mental illness. Of these, 55.6% resided in New York City, 53.1% were female, 38.1% were non-Hispanic White, 30.7% were non-Hispanic Black, 25.2% were Hispanic, and 38.1% were smokers, including electronic cigarette users. The density of tobacco retailers (range, 6.1-16.4 per 10,000 population) was positively associated with smoking (odds ratio = 1.05; 95% CI, 1.03-1.07) after adjusting for sex, race or ethnicity, education, employment, health insurance coverage, obesity, and region (New York City vs outside New York City). We observed no interaction between region and tobacco retailer density. CONCLUSION: Findings of this study suggest that allocating more smoking cessation resources to zip code areas with a high density of tobacco retailers, especially in rural areas, along with supporting policy change to reduce tobacco retailor density, may mitigate the negative health consequences of smoking among people with comorbid diabetes and serious mental illness.

Predictors of Intentional Self -Harm Among Medicaid Mental Health Clinic Clients In New York.

BACKGROUND: Behavioral health outpatients are at risk for self-harm. Identifying individuals or combination of risk factors could discriminate those at elevated risk for self-harm. METHODS: The study population (N = 248,491) included New York State Medicaid-enrolled individuals aged 10 to 64 with mental health clinic services between November 1, 2015 to November 1, 2016. Self-harm episodes were defined using ICD-10 codes from emergency department and inpatient visits. Multi-predictor logistic regression models were fit on a subsample of the data and compared to a testing sample based on discrimination performance (Area Under the Curve or AUC). RESULTS: Of N = 248,491 patients, 4,224 (1.70%) had an episode of intentional self-harm. Factors associated with increased self-harm risk were age 17-25, being female and having recent diagnoses of depression (AOR=4.3, 95%CI: 3.6-5.0), personality disorder (AOR=4.2, 95%CI: 2.9-6.1), or substance use disorder (AOR=3.4, 95%CI: 2.7-4.3) within the last month. A multi-predictor logistic regression model including demographics and new psychiatric diagnoses within 90 days prior to index date had good discrimination and outperformed competitor models on a testing sample (AUC=0.86, 95%CI:0.85-0.87). LIMITATIONS: New York State Medicaid data may not be generalizable to the entire U.S population. ICD-10 codes do not allow distinction between self-harm with and without intent to die. CONCLUSIONS: Our results highlight the usefulness of recency of new psychiatric diagnoses, in predicting the magnitude and timing of intentional self-harm risk. An algorithm based on this finding could enhance clinical assessments support screening, intervention and outreach programs that are at the heart of a Zero Suicide prevention model.

Is the outpatient mental health workforce ready to save lives? Suicide prevention training, knowledge, self-efficacy, and clinical practices prior to the implementation of a statewide suicide prevention initiative.

OBJECTIVE: Many public health approaches to suicide prevention emphasize connecting at-risk individuals to professional treatment. However, it is unclear to what degree the outpatient mental health workforce has the requisite knowledge and skills to provide the evidence-based care needed to help those at risk. In this project, prior to the implementation of a statewide suicide prevention initiative, we assessed the baseline suicide prevention training and clinical practices of the New York State outpatient mental health workforce, a group likely representative of the broader U.S. clinical workforce. METHOD: A workforce survey of suicide prevention training and clinical practices was administered to 2,257 outpatient clinicians, representing 169 clinics serving approximately 90,000 clients. Clinicians were asked to complete the survey online, and all responses were confidential. RESULTS: Clinicians reported substantial gaps in their suicide prevention knowledge and training. The vast majority reported moderate self-efficacy working with suicidal clients and endorsed using evidence-based assessment procedures, but varied in utilization of recommended intervention practices. CONCLUSIONS: This study highlights gaps in clinicians' training and clinical practices that need to be overcome to provide evidence-based suicide care. Promisingly, positive associations were found between training and clinician knowledge, self-efficacy, and use of evidence-based practices.

The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics.

OBJECTIVE: This study tested the hypothesis that fidelity of clinics to Zero Suicide (ZS) organizational practices is inversely related to suicidal behaviors of patients under clinical care. METHODS: Using cross-sectional analyses, the authors examined the fidelity of 110 outpatient mental health clinics to ZS organizational best practices and suicidal behaviors of clinic patients in the year before a large-scale Zero Suicide implementation. Fidelity to ZS organizational best practices was assessed over a 1-year period with an adapted version of the ZS Organizational Self-Study instrument (17 items self-rated on a Likert scale of 1-5). Suicidal behaviors of patients were identified by extracting information on suicide attempts and deaths from a mandated statewide incident-reporting system database. Clinics were dichotomized into any or no suicide incidents during the year of observation. Logistic regression analyses were used to adjust for clinic census and population type (majority child or adult). RESULTS: The clinics (N=110) served 30,257 patients per week. Clinics' total average fidelity score was 3.1±0.6 (range=1.41-4.12). For each point increase in fidelity, clinics had a significantly reduced likelihood of having a suicide incident (adjusted odds ratio=0.31, 95% confidence interval=0.14-0.69). Exploratory analysis identified significant differences for seven of 17 ZS organizational practices, with the largest effect sizes for suicide-specific quality improvement policies and activities (η2=0.097) and lethal means reduction (η2=0.073). CONCLUSIONS: These findings support an association between clinics' use of ZS organizational best practices and lower suicidal behaviors of patients under their care. Findings also support the validity of the ZS Organizational Self-Study instrument.

Most Individuals Are Seen in Outpatient Medical Settings Prior to Intentional Self-Harm and Suicide Attempts Treated in a Hospital Setting.

The objective of this quantitative retrospective study is to understand healthcare patterns prior to self-harm, which may inform prevention efforts and identify intervention sites. Medicaid claims within 30, 60, 90, and 365 days prior to hospital-treated self-harm between 11/1/2015 and 11/1/2016 in New York State (N = 7492) were examined. Numbers and proportions were calculated for all service types. Participants were predominately 15-34, female, and White. Most (97%) had prior-year services, 94% outpatient care (73% behavioral health, 90% medical), 69% emergency department (37% behavioral health, 59% medical), and 42% inpatient services (34% behavioral health, 20% medical). About 86% received services within 90 days and 80% within 60 days. Utilization was high within 30 days prior, with 69% having one or more services. Medical services were more common than behavioral health (94% versus 79% in prior year); outpatient (94%) was more common than emergency (69%) and inpatient (42%) care. Given that most patients received health services within 30 days and almost all saw providers within the year prior, the findings indicate that improved prevention efforts within the healthcare system can reduce the incidence of self-harm.

Everyday Discrimination Experience and Depressive Symptoms in Urban Black, Guyanese, Hispanic, and White Adults.

BACKGROUND: Discrimination experience is a stressor that may disproportionately affect the mental health of minority populations. AIMS: We examined the association between discrimination experience and depressive symptoms among four urban racial/ethnic groups. METHOD: Cross-sectional community-based health survey data for Black (n = 434), Guyanese (n = 180), Hispanic (n = 173), and White (n = 809) adults aged ⩾18 years were collected in Schenectady, New York, in 2013. Discrimination experience was measured with the Everyday Discrimination Scale (EDS), and depressive symptoms were measured with the Center for Epidemiologic Studies-Depression (CES-D) scale. Logistic regression models for the association between EDS and major depressive symptoms (CES-D ⩾ 16) were fitted for each racial/ethnic group. The final model adjusted for age, sex, education, income, smoking, alcohol binge drinking, emotional/social support, and perceived stress. RESULTS: The mean EDS scores varied significantly across groups (p < .001), with 2.6 in Hispanics, 2.2 in Whites, 2.0 in Blacks, and 1.1 in the Guyanese. There was a consistent and significant independent association between EDS and major depressive symptoms in the crude model and at each step of covariate adjustment in each group. Fully adjusted odds ratios were 1.28 (95% confidence interval [CI; 1.16, 1.41]) in Blacks, 1.83 in the Guyanese [1.36, 2.47], 1.23 in Hispanics [1.07, 1.41], and 1.24 [1.16, 1.33] in Whites. The presence of covariates did not significantly modify the main effect in each group. CONCLUSIONS: This study suggests that discrimination experience can be one of the fundamental social causes of depression. It may be feasible to assess discrimination experience as a risk factor of depression in individuals of all racial/ethnic backgrounds.

"Zero Suicide" - A model for reducing suicide in United States behavioral healthcare.

Suicide is a serious public health concern in the US, especially for those served in outpatient behavioral health. Over the past decade, there has been a dramatic increase in US suicide rates, and a significant proportion of those dying by or attempting suicide were treated in outpatient behavioral healthcare within the prior year. In response, the US Action Alliance released the National Strategy for Suicide Prevention in 2012, a key tenet of which is the "Zero Suicide" (ZS) model. ZS provides resources for administrators and providers to create a systematic approach to quality improvement for suicide prevention in healthcare systems via seven essential elements (Lead, Train, Identify, Engage, Treat, Transition, Improve). In this paper, we describe the ZS model, as well as our operationalization of the model in an NIMH-funded study in ~170 free-standing New York State outpatient behavioral health clinics, serving >80,000 patients. This study is the largest implementation and evaluation of the ZS approach ever conducted in outpatient behavioral health. Evaluation of ZS implementation in "real-world" clinical settings will provide crucial insight regarding broader dissemination and inform how to best adopt empirically-supported care for suicidal patients in outpatient behavioral health, thereby reducing tragic and preventable loss of life.

A Comprehensive Health Profile of Guyanese Immigrants Aged 18-64 in Schenectady, New York.

Guyanese immigrants are the 5th largest foreign-born group in NY State, but sparse literature is available on their health status and health needs. A community-based health interview survey of Schenectady NY residents aged 18-64 (N = 1861) was analyzed. Bivariate comparisons between Guyanese respondents and White, Black, and Hispanic respondents were made for each variable to identify disparities. As predominantly low SES immigrants, Guyanese adults were less likely to be covered by health insurance, have a usual place for care, and receive cancer screenings. They were more likely to engage in alcohol binge drinking, but generally in good overall physical and mental health and less likely to smoke or report disability. Stable family structure and supportive interpersonal relationships are major assets of this group. Improved access to affordable health insurance, linkages to primary care, targeted cancer screening programs, and culturally-sensitive behavioral health services are recommended for Guyanese immigrants.

The association between antidepressant use and hemoglobin A1C in older adults.

Depression is known to increase diabetes risk and worsen glycemic control in older adults, who already experience high rates of diabetes. The independent impact of antidepressants on glucose control is less clear. Data was drawn from the Health and Retirement Study, a large nationally-representative longitudinal study of retired individuals. Crude and adjusted linear models stratified by diabetes status were used to examine the cross-sectional associations between antidepressant use categorized by subclass and continuous hemoglobin A1C. The sample included 1,153 individuals, most over the age of 70. Antidepressant use was not associated with hemoglobin A1C in any model whether stratified or in the total combined sample. Antidepressants as a class were also not associated with hemoglobin A1C. These findings add to the literature suggesting that antidepressants are not associated with diabetes risk or glycemic control. Prospective studies with larger sample sizes are needed to confirm this finding.

Longitudinal Trends in Tobacco Availability, Tobacco Advertising, and Ownership Changes of Food Stores, Albany, New York, 2003-2015.

INTRODUCTION: Frequency of visiting convenience and corner grocery stores that sell tobacco is positively associated with the odds of ever smoking and the risk of smoking initiation among youth. We assessed 12-year trends of tobacco availability, tobacco advertising, and ownership changes in various food stores in Albany, New York. METHODS: Eligible stores were identified by multiple government lists and community canvassing in 2003 (n = 107), 2009 (n = 117), 2012 (n = 135), and 2015 (n = 137). Tobacco availability (all years) and advertising (2009, 2012, and 2015) were directly measured; electronic cigarettes (e-cigarettes) were included in 2015. RESULTS: Percentage of stores selling tobacco peaked at 83.8% in 2009 and declined to 74.5% in 2015 (P for trend = .11). E-cigarettes were sold by 63.7% of tobacco retailers. The largest decline in tobacco availability came from convenience stores that went out of business (n = 11), followed by pharmacies that dropped tobacco sales (n = 4). The gain of tobacco availability mostly came from new convenience stores (n = 24) and new dollar stores (n = 8). Significant declining trends (P < .01) were found in tobacco availability and any tobacco advertising in pharmacies and in low (<3 feet) tobacco advertising in convenience stores and stores overall. Only one-third of stores that sold tobacco in 2003 continued to sell tobacco with the same owner in 2015. CONCLUSION: The observed subtle declines in tobacco availability and advertising were explained in part by local tobacco control efforts, the pharmacy industry's self-regulation of tobacco sales, and an increase in the state's tobacco retailer registration fee. Nonetheless, overall tobacco availability remained high (>16 retailers per 10,000 population) in this community. The high store ownership turnover rate suggests that a moratorium of new tobacco retailer registrations would be an integral part of a multi-prong policy strategy to reduce tobacco availability and advertising.

Use of antidepressant medications not associated with A1C among individuals with diabetes in NHANES sample.

INTRODUCTION: Studies on the relationships between antidepressant medications and A1C, a measure of glucose levels over the past three months, have resulted in mixed findings. Most available research examined subclass effects. The current study aims to measure the association between individual antidepressant medications and A1C in a large nationally-representative dataset. METHODS: The sample of this study consists of 45,786 individuals who participated in the National Health and Nutrition Examination Survey between 1999 and 2012. We examined the relationships between 18 antidepressant medications and continuous A1C in crude and adjusted linear models stratified by diabetes status (ever or never diagnosed). Adjusted models included demographic covariates (age, gender, race/ethnicity, and education), smoking status, and physical activity. RESULTS: No significant associations were found for most antidepressants. However, those who used selegiline (n=11), all of whom were in the no diabetes stratum, were found to have a higher A1C compared with individuals who do not use antidepressants. DISCUSSION: The study agrees with a number of earlier findings. Most antidepressant medications do not appear to be associated with A1C levels among individuals with or without diabetes. Limitations include small numbers for some exposure categories and cross-sectional data. Strengths include use of a nationally-representative dataset and large total sample size.

The association between antidepressant use and glycemic control in the Southern Community Cohort Study (SCCS).

INTRODUCTION: Among people with diabetes, comorbid depression has been associated with suboptimal health outcomes. However, the independent impact of antidepressant use on glycemic control (A1C) has not been well understood. RESEARCH DESIGN AND METHODS: The Southern Community Cohort Study collected self-reported antidepressant use and measured continuous A1C in a sample of racially diverse adults with and without diabetes who visited community health clinics serving low-income families in the southeastern United States (N=2445). Crude and adjusted linear regression models were used to examine the relationships between using specific antidepressant subclasses and continuous A1C. RESULTS: Although use of any single antidepressant subclass was not a significant predictor of A1C level, there was a significant association between using multiple antidepressant subclasses and higher A1C, specifically among individuals with diabetes (standardized effect size=.12, p=.04). CONCLUSION: Among adults with diabetes, the use of multiple antidepressant subclasses may be a risk factor for suboptimal glycemic control. Prospective studies are needed to confirm the direction of this observation, as the present study was limited by a cross-sectional design and small sample size.

Trends of fruit and vegetable availability in neighbourhoods in Albany, NY, USA, 2003-2012.

OBJECTIVE: To investigate a 9-year trend of fresh fruit and vegetable availability and factors associated with the net availability change in two contrasting neighbourhoods. DESIGN: Longitudinal design. Data were collected in 2003, 2009 and 2012 through in-store observations. Fresh fruit and vegetable availability was presented by weight-adjusted counts of stores having designated varieties per 10 000 population. SETTING: A low-income minority neighbourhood and an adjacent middle-income racially mixed neighbourhood in Albany, NY, USA. These neighbourhoods became sites of fresh produce interventions after baseline data were collected. SUBJECTS: A total of 111, 128 and 146 eligible food stores in respective years. RESULTS: Fresh fruit availability (two or more varieties) increased in both neighbourhoods. Inventory expansion of existing stores and the convenience store intervention contributed to the significant increase (P for trend=0·04) of fresh fruit availability in the minority neighbourhood. Although not statistically significant (P>0·05), the availability of two or more dark-coloured fresh vegetables also increased in the mixed neighbourhood, but declined slightly in the minority neighbourhood. The secular (non-intervention) fresh vegetable availability rate ratio by neighbourhood reached 3·0 in 2012 (P<0·01). The net decline of fresh vegetable availability in the minority neighbourhood was primarily attributed to inventory reduction of existing stores. CONCLUSIONS: Longitudinal observations revealed narrowed neighbourhood disparities of fresh fruit availability and widened gaps of fresh vegetable availability. Inventory shifts of existing stores impacted the net availability change more profoundly than store opening or closing in the minority neighbourhood. Findings support increasing the programme capacity of the convenience store intervention to address the fresh vegetable disparity.