Mental health follow-up and treatment engagement following suicide risk screening in the Veterans Health Administration.

IMPORTANCE: Understanding the extent to which population-level suicide risk screening facilities follow-up and engagement in mental health treatment is important as engaging at-risk individuals in treatment is critical to reducing suicidal behaviors. OBJECTIVE: To evaluate mental health follow-up and treatment engagement in the Veterans Health Administration (VHA) following administration of the Columbia-Suicide Severity Rating Scale (C-SSRS) screen, a component of the VHA's universal suicide risk screening program. DESIGN: This cross-sectional study used data from VA's Corporate Data Warehouse. SETTINGS: 140 VHA Medical Centers. PARTICIPANTS: Patients who completed the C-SSRS screen in ambulatory care between October 1, 2018-September 30, 2020. EXPOSURE: Standardized suicide risk screening. MAIN OUTCOMES AND MEASURES: Mental health follow-up (one or more visits within 30 days of C-SSRS screening) and treatment engagement (two or more visits within 90 days of C-SSRS screening) were examined. RESULTS: 97,224 Veterans in Fiscal Year 2019 (FY19) (mean age 51.4 years; 86.8% male; 64.8% white, 22.4% African-American) and 58,693 Veterans in FY20 (mean age 49.6 years; 85.5% male; 63.4% white, 21.9% African-American) received the C-SSRS screen. Across FYs, a positive C-SSRS screen was associated with increased probability of mental health follow-up and treatment engagement. Patients who were not seen in mental health in the year prior to screening had the greatest increase in probability of mental health follow-up and engagement following a positive screen (P<0.001). For FY19, a positive C-SSRS screen in non-mental health connected patients was associated with an increased probability of follow-up from 49.8% to 79.5% (relative risk = 1.60) and engagement from 39.5% to 63.6% (relative risk = 1.61). For mental health-connected patients, a positive C-SSRS screen was associated with a smaller increase in probability of follow-up from 75.8% to 87.6% (relative risk = 1.16) and engagement from 63.3% to 76.4% (relative risk = 1.21). Results for FY20 were similar. CONCLUSIONS AND RELEVANCE: Identification of suicide risk through population-level screening was associated with increased mental health follow-up and engagement, particularly for non-mental health connected patients. Findings support the use of a standardized, comprehensive suicide risk screening program for managing elevated suicide risk in a large healthcare system.

The long-term efficacy of cannabidiol in the treatment of refractory epilepsy.

OBJECTIVE: Cannabidiol (CBD) has been shown to reduce seizures among patients with refractory epilepsies of various etiologies in recent clinical trials and an expanded access program (EAP). Most studies report efficacy over short time periods (<1 year), with little published on longer term efficacy. Here, we investigate the efficacy of CBD for a treatment period of up to 60 months (median = 45.5 months). METHODS: We conducted a retrospective review of patient-reported seizure logs and medical records for 54 subjects with refractory epilepsy who enrolled in the Massachusetts General Hospital's open-label EAP for CBD as a new treatment for epilepsy. We analyzed the effect of CBD on seizure frequencies and concomitant antiepileptic drug (AED) use at 1 year after starting treatment and the most recent study visit. RESULTS: Our results indicate that CBD maintains its efficacy for controlling seizures from Year 1 to the most recent study visit. The percentage of seizure responders remained similar at these time points (41.7%-42.6%), and the seizure response rate was also maintained (p = .12). Efficacy was also seen over a broad dose range, and up to 50 mg/kg/day. CBD was particularly effective for controlling seizures in the setting of tuberous sclerosis complex and for reducing epileptic spasms and absence seizures. Although CBD use did not lead to an overall decrease in concomitant AEDs, most subjects reduced the dose of at least one concomitant AED compared to baseline. CBD was generally well tolerated, with drowsiness and diarrhea as the primary adverse reactions. SIGNIFICANCE: This study demonstrates CBD does not lose its efficacy in controlling seizures over a treatment period of up to 60 months. Taken alongside other results on the efficacy and tolerability of CBD in the treatment of refractory epilepsies, our results provide evidence that CBD is an effective, safe, and well-tolerated AED for long-term use.

Lack of recovery of the long-spined sea urchin Diadema antillarum Philippi in Puerto Rico 33 years after the Caribbean-wide mass mortality.

Caribbean populations of the long-spined black sea urchin Diadema antillarum Philippi were decimated by a disease-induced mass mortality in the early 1980's. The present study provides an updated status of the D. antillarum recovery and population characteristics in La Parguera Natural Reserve, Puerto Rico. The last detailed study to assess population recovery in 2001, indicated a slow, and modest recovery, albeit densities remained far below pre-mass mortality levels. Population densities were assessed along three depth intervals in six reef localities and one depth in three lagoonal sea-grass mounds using ten 20 m2 (10 × 2 m) belt-transects at each depth interval. Most of these were previously surveyed in 2001. All individuals encountered along the belt transects were sized in situ with calipers and rulers to characterize the size (age) structure of each population and get insight into the urchin's population dynamics and differences across localities in the area. Habitat complexity (rugosity) was assessed in all depth intervals. No significant differences in population densities between reef zones (inner shelf and mid-shelf) were observed, but significantly higher densities were found on shallow habitats (<5 m depth; 2.56 ± 1.6 ind/m2) compared to intermediate (7-12 m; 0.47 ± 0.8 ind/m2) and deep (>12 m; 0.04 ± 0.08 ind/m2) reef habitats in almost all sites surveyed. Habitat complexity had the greatest effect on population densities at all levels (site, zone and depth) with more rugose environments containing significantly higher densities and wider size structures. Comparison between survey years revealed that D. antillarum populations have not increased since 2001, and urchins seem to prefer shallower, more complex and productive areas of the reef. Populations were dominated by medium to large (5-9 cm in test diameter) individuals and size-frequency distributions indicated that smaller juveniles were virtually absent compared to 2001, which could reflect a recruitment-limited population and explain in part, the lack of increase in population densities. The limited temporal scale of this study, high horizontal movement of individuals along the complex, shallower reef and inshore habitats could also explain the general decline in mean densities. Other extrinsic factors affecting reproductive output and/or succesful recruitment and survival of juveniles likely contribute to the high variablility in population densities observed over time.

Assault-related mild traumatic brain injury, expectations of injury outcome, and the effect of different perpetrators: A vignette study.

Few studies have examined the effect of varying the assault perpetrator on expectations of outcome from mild TBI. Using a cross sectional between groups design, individuals with no history of mild TBI were randomly allocated to one of two vignette conditions. The vignette depicted a mild TBI with fixed injury parameters and a different assault perpetrator (partner, n = 27; or stranger, n = 27). The participants were instructed to imagine that they had been injured as per the depiction, and then to anticipate the injury consequences 6-months later. An online questionnaire was used including: the Neurobehavioral Symptom Inventory, the Posttraumatic Stress Disorder Checklist-Civilian Version, the Impact of Events Scale-Revised, and the Perceived Ability to Cope with Trauma. The depicted injury was rated for the extent to which it was perceived as life-threatening, the subsequent diagnosis, and the global recovery prospects. The anticipated consequences of the injury (symptoms and trauma variables) did not differ across the conditions, all p's > 0.05. The expected outcomes for an assault-related mild TBI were not affected by perpetrator type. However, the study had several limitations and further consideration of this factor may still be warranted.

Does the cause of the mild traumatic brain injury affect the expectation of persistent postconcussion symptoms and psychological trauma?

INTRODUCTION: A controlled experiment of the effect of injury cause on expectations of outcome from mild traumatic brain injury (TBI) was conducted. METHOD: Ninety-three participants were randomly assigned to one of four conditions. The participants read a vignette that described a mild TBI (with fixed injury parameters) from a different cause (sport, domestic assault, fall, or motor vehicle accident). The effect of the manipulation on expectations of persistent postconcussion symptoms and psychological trauma was assessed with standard measures and a novel "threat-to-life" measure. RESULTS: The Kruskal-Wallis H test for group differences revealed a significant but selective effect of group on symptom and trauma outcomes (ŋ2s ≥ .10; large effects). Post hoc pairwise tests showed that, in most cases, there was an expectation of a worse outcome following mild TBI from a domestic assault than from the other causes (small-to-medium effects). CONCLUSION: Expectations were selectively altered by an experimental manipulation of injury cause. Given that expectations of outcome are known to affect mild TBI prognosis, the findings suggest the need for greater attention to injury cause.

Detection of human-derived fecal contamination in Puerto Rico using carbamazepine, HF183 Bacteroides, and fecal indicator bacteria.

The level of fecal pollution in 17 sites in Puerto Rico was determined by Escherichia coli (E.coli) enumeration using an enzyme substrate medium and Quanti-Tray®/2000. Human fecal pollution was identified using an enzyme-linked immunosorbent assay for the detection of carbamazepine (CBZ) and quantitative polymerase chain reaction (qPCR) detection of the human Bacteroides marker, HF183. Carbamazepine was detected in 16 out of 17 sites, including Condado Lagoon, a popular recreational area. Elevated E.coli levels (>410 CFU 100 mL(-1)) were detected in 13 sites. Average CBZ concentrations ranged from 0.005 µg L(-1) to 0.482 µg L(-1) and 7 sites were positive for HF183. Higher CBZ concentrations were associated with the detection of HF183 (Mann-Whitney test; U=42.0; df=7; 1-tailed P value=0.013). This was the second study to determine surface water concentrations of CBZ in the Caribbean and the first in Puerto Rico.