Symptoms of a feather flock together? An exploratory secondary dynamic time warp analysis of 11 single case time series of suicidal ideation and related symptoms.

Suicidal ideation fluctuates over time, as does its related risk factors. Little is known about the difference or similarities of the temporal patterns. The current exploratory secondary analysis examines which risk symptoms have similar time dynamics using a mathematical algorithm called dynamic time warping (DTW). Ecological momentary assessment data was used of 11 depressed psychiatric outpatients with suicidal ideation who answered three daytime surveys at semi-random sampling points for a period of three to six months. Patients with 45 assessments or more were included. Results revealed significant inter-individual variability in symptom dynamics and clustering, with certain symptoms often clustering due to similar temporal patterns, notably feeling sad, hopelessness, feeling stuck, and worrying. The directed network analyses shed light on the temporal order, highlighting entrapment and worrying as symptoms strongly related to suicide ideation. Still, all patients also showed unique directed networks. While for some patients changes in entrapment directly preceded change in suicide ideation, the reverse temporal ordering was also found. Relatedly, within some patients, perceived burdensomeness played a pivotal role, whereas in others it was unconnected to other symptoms. The study underscores the individualized nature of symptom dynamics and challenges linear models of progression, advocating for personalized treatment strategies.

A first study on the usability and feasibility of four subtypes of suicidality in emergency mental health care.

BACKGROUND: Based on clinical experience, a (hypothetical) four-type model of suicidality that differentiates between subtypes with a unique pathway to entrapment ((h)4ME)was developed. The subtypes are: 1) perceptual disintegration (PD), 2) primary depressive cognition (PDC), 3) psychosocial turmoil (PT) and 4) inadequate communication/coping (IC). This study was carried out to examine the usability and feasibility of the subtypes in an absolute and dimensional way with the SUICIDI-2 instrument. OBJECTIVE: A first step was to examine the model and the SUICIDI-2 instrument for usability and feasibility in clinical practice. We aim to investigate the'real life' practical application of the model and hope the feedback we get after practical use of the model will help us with improvements for the model and the SUICIDI-2 instrument. METHODS: Discharge letters to general practitioners of 25 cases of anonymized suicidal emergency patients were independently reviewed by three psychiatrists and three nurses. Using the SUICIDI-2 instrument, describing the proposed subtypes, cases were classified by the psychiatrists and nurses. Intraclass Correlation Coefficients (ICC) for absolute/discrete and dimensional ratings were calculated to examine the model's usability and the instrument's feasibility. The study was approved by the ethical board. RESULTS: All raters were able to recognize and classify the cases in subtypes. We found an average measure of good reliability for absolute/(discrete) subtypes. For dimensional scores, we found excellent average measures for the subtype PDC, and good average measures for the subtypes PD, PT and IC. The reliability of dimensional score for the SUICIDI-2 was relatively lower than an alternative dimensional rating, but had good ICC values for all subtypes. After reviewing the results though, we found some inconsistently assessment between raters. This was ground to narrow down the criteria per subtype to describe the subtypes more precisely. This resulted in adjusted formulations for subtypes PD and IC and agreement was achieved about formulations in the revised SUICIDI-3. CONCLUSIONS: The hypothetical model of entrapment leading to suicidality shows promising results for both the usability and feasibility of the SUICIDI instrument. Follow up studies with participants with a more diverse background may show consistency and validity for the model.

[Suicidal behavior in emergency care: 10 tips for an active, empathetic and preventative approach]. / Suïcidaal gedrag op de SEH.

Patients with suicidal behaviour are frequently seen in A&E departments. Providing care for this patient group can be challenging and medical staff have often not received specialized training to improve their knowledge and skills. An empathetic approach combined with brief interventions such as safety planning, collaborating with carers and partnership with local organizations can help A&E professionals to optimize care for these patients and contribute to the prevention of future suicide attempts.

Stability of clustering of lifestyle risk factors in the Dutch adult population and the association with mental health.

BACKGROUND: Lifestyle factors often co-occur in clusters. This study examines whether clusters of lifestyle risk factors, such as smoking, alcohol use, physical inactivity, poor diet, sexual risk behaviour, cannabis and other drug use, change over time in a representative sample of Dutch adults. Additionally, the association between mental health and self-reported depression of lifestyle clusters was examined. METHODS: Each year cross-sectional data of approximately 7500 individuals of 18 years and older from the annual Dutch Health Survey of 2014-2019 were used. Clusters were determined by a two-step cluster analysis. Furthermore, regression analyses determined the association between clusters of lifestyle risk factors and mental health. RESULTS: Results show six clusters composed of one, multiple or no lifestyle risk factors. The clusters remained relatively stable over time: in some clusters, the number of people slightly changed between 2014 and 2019. More specifically, clusters that increased in size were the cluster with no lifestyle risk factors and the cluster with multiple lifestyle risk factors. Furthermore, results show that clusters with none to a few lifestyle risk factors were associated with better mental health and a lower prevalence of self-reported depression compared with clusters with multiple lifestyle risk factors. CONCLUSIONS: The clustering of lifestyle risk factors remained stable over time. People with multiple lifestyle risk factors had poorer mental health than those without risk factors. These findings may emphasize the need for intervention strategies targeting this subgroup with multiple lifestyle risk factors.

A Clinical Model for the Differentiation of Suicidality: Protocol for a Usability Study of the Proposed Model.

BACKGROUND: Even though various types of suicidality are observed in clinical practice, suicidality is still considered a uniform concept. To distinguish different types of suicidality and consequently improve detection and management of suicidality, we developed a clinical differentiation model for suicidality. We believe that the model allows for a more targeted assessment of suicidal conditions and improves the use of evidence-based treatment strategies. The differentiation model is based on the experience with suicidality that we have encountered in clinical practice. This model distinguishes 4 subtypes of entrapment leading to suicidality. The earliest description of this model and a proposal for usability research has been previously presented in a book chapter. OBJECTIVE: In this study, we present the most recent version of the 4-type differentiation model of suicidality and a protocol for a study into the usability of the proposed model. METHODS: The 4-type differentiation model of suicidality distinguishes the following subtypes: (1) perceptual disintegration, (2) primary depressive cognition, (3) psychosocial turmoil, and (4) inadequate coping or communication. We plan to test the usability of the 4 subtypes in a pilot study of 25 cases, and subsequently, we will include 75 cases in a follow-up study. We looked at the case notes of 100 anonymized patients with suicidality who presented to mental health care emergency service in The Hague International Center. The summary and conclusions of the letters sent to the patients' general practitioners after suicide risk assessment will be independently rated by 3 psychiatrists and 3 nurse-scientists for absolute and dimensional scores. The Suicidality Differentiation version 2 (SUICIDI-II) instrument, developed for this study, is used for rating all the cases. Intraclass correlation coefficients for absolute and dimensional scores will be calculated to examine type agreement between raters to examine the usability of the model and the feasibility of the SUICIDI-II instrument. RESULTS: We consider the model tentatively valid if the intraclass correlation coefficients are ≥0.70. Subsequently, if the model turns out to be valid, we plan to rate 75 other cases in a follow-up study, according to a similar or adjusted procedure. Study results are expected to be published by the end of 2023. CONCLUSIONS: The theoretical roots of the differentiation model stem from classic and contemporary theoretical models of suicidality and from our clinical practice experiences with suicidal behaviors. We believe that this model can be used to adjust the diagnosis, management, treatment, and research of suicidality, in addition to distinguishing different dynamics between practitioners and patients with suicidality and their families. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45438.

A Proof of Concept Study on Individual Trends in Suicidal Ideation: An Ecological Momentary Assessment Study of 5 Patients Over Three Months.

Background: Suicidal ideation (SI) is a significant and long-lasting mental health problem, with a third of individuals still experiencing SI after two years. To date, most Ecological Momentary Assessment (EMA) studies of SI have assessed its day-to-day course over one to four consecutive weeks and found no consistent trends in average SI severity over time. Aim: The current proof of concept study assessed daily fluctuations of SI over a time span of 3 to 6 months to explore whether individual trends in SI severity could be detected, and if so, if the trajectory of changes were gradual or sudden. The secondary aim was to explore whether changes in SI severity could be detected at an early stage. Method: Five adult outpatients with depression and SI used an EMA app on their smartphone in addition to their regular treatment for 3 to 6 months, where SI was assessed 3 times a day. To detect trends in SI for each patient, three models were tested: a null model, a gradual change model and a sudden change model. To detect changes in SI before a new plateau was reached, Early Warning Signals and Exponentially Weighted Moving Average control charts were used. Results: In each patient, average SI severity had a unique trajectory of sudden and/or gradual changes. Additionally, in some patients, increases in both sudden and gradual SI could be detected at an early stage. Conclusions: The study presents a first indication of unique individual trends in SI severity over a 3 to 6 months period. Though replication in a larger sample is needed to test how well results generalize, a first proof-of-concept is provided that both sudden and gradual changes in SI severity may be detectable at an early stage using the dynamics of time-series data.

Nudging General Practitioners to explore suicidal thoughts among depressed patients.

BACKGROUND: While frank discussion of suicidal thoughts in patients with depression is important for the prevention of suicide, suicide exploration of General Practitioners (GPs) is suboptimal. This study aimed to assess whether an intervention that prompts pop-up screens nudges GPs to more frequently explore suicidal thoughts over the course of two years. METHODS: From January 2017 to December 2018, the intervention was incorporated in the information system of the Dutch general practice sentinel network. New registration of an episode of depression triggered a pop-up screen referring to a questionnaire about GPs' behaviour with regard to exploring suicidal thoughts. In two years, 625 questionnaires were completed by GPs and analysed using multilevel logistic regression analyses. RESULTS: Compared to the first year, GPs were 50% more likely to explore suicidal thoughts among patients in the second year (OR 1.48; 95%CI 1.01-2.16). When adjusting for patients' gender and age we found that the effect of the pop-up screens disappeared (OR 1.33; 95% CI 0.90-1.97). Suicide exploration occurred less frequently in women than in men (OR 0.64; 95% CI 0.43-0.98) and in older compared to younger patients (OR 0.97; 95% CI 0.96-0.98 per year older). In addition, 26% of variation in suicide exploration was because of differences in general practice. There was no evidence that general practices developed differently over time. CONCLUSIONS: Although low cost and easy to administer, the pop-up system was not effective in nudging GPs to explore suicidality more frequently. We encourage studies to test whether implementing these nudges as part of a multifaceted approach will lead to a stronger effect. Moreover, we recommend researchers to include more variables, such as work experience or previous mental health training, to better understand the effects of the intervention on GPs' behaviour.

The role of anxiety and depression in suicidal thoughts for autistic and non-autistic people: A theory-driven network analysis.

BACKGROUND: Autistic adults experience more frequent suicidal thoughts and mental health difficulties than non-autistic adults, but research has yet to explain how these experiences are connected. This study explored how anxiety and depression contribute to suicidal thoughts according to the Interpersonal Theory of Suicide for autistic and non-autistic adults. METHODS: Participants (autistic adults n = 463, 61% female; non-autistic n = 342, 64% female) completed online measures of anxiety, depression, thwarted belonging, and perceived burdensomeness. Network analysis explored whether: (i) being autistic is a risk marker for suicide; and (ii) pathways to suicidal thoughts are consistent for autistic and non-autistic adults. RESULTS: Being autistic connected closely with feeling like an outsider, anxiety, and movement, which connected to suicidal thoughts through somatic experiences, low mood, and burdensomeness. Networks were largely consistent for autistic and non-autistic people, but connections from mood symptoms to somatic and thwarted belonging experiences were absent for autistic adults. CONCLUSION: Autistic people experience more life stressors than non-autistic people leading to reduced coping, low mood, and suicidal thoughts. Promoting belonging, reducing anxiety, and understanding the role of movement could inform suicide prevention for autistic people. Research should accurately capture autistic lived experience when modeling suicide to ensure suicide prevention meets autistic needs.

Examining the Interrelationships Among Suicide Cognitions, Suicidal Ideation, and Theoretically Derived Protective Factors.

INTRODUCTION: Several protective factors for mitigating suicidal ideation (SI) such as positive affect, reasons for living, purpose in life, meaning in life, gratitude, grit, optimism, social support, and hope have been identified and received empirical support. However, few studies have examined the interrelationships of these protective factors and the identification of protective factors most closely linked to lower levels of SI may be useful for both theory-building initiatives and improvement of suicide-specific interventions. Network analysis offers an approach for testing the relation among these constructs, SI, and suicide risk factors. METHODS: A sample N = 557 undergraduate students oversampled for lifetime SI completed a cross-sectional, online survey. The data was used to estimate an undirected, cross-sectional network of the aforementioned protective factors. RESULTS: The resulting inferred network implicates strong negative influence of suicide cognitions, but not recent SI, and the strong positive influence of presence of meaning in life, trait hope, and low negative affect. CONCLUSIONS: Implications for dimensionality of SI versus suicide cognitions, targeting presence of meaning in life, trait hope, and negative affect in treatment, and cross-cultural variations in reasons for living are discussed. The study is limited by the cross-sectional and convenience sampling methodology.HighlightsProtective factors may have less direct influence on suicidal ideationSuicide cognitions and the suicidal mode may be of phenomenological importancePresence of meaning and trait hope may be primary targets for suicide interventions.

Comparison of depression care provided in general practice in Norway and the Netherlands: registry-based cohort study (The Norwegian GP-DEP study).

BACKGROUND: Depression is highly prevalent in general practice, and organisation of primary health care probably affects the provision of depression care. General practitioners (GPs) in Norway and the Netherlands fulfil comparable roles. However, primary care teams with a mental health nurse (MHN) supplementing the GP have been established in the Netherlands, but not yet in Norway. In order to explore how the organisation of primary mental care affects care delivery, we aimed to examine the provision of GP depression care across the two countries. METHODS: Registry-based cohort study comprising new depression episodes in patients aged ≥ 18 years, 2011-2015. The Norwegian sample was drawn from the entire population (national health registries); 297,409 episodes. A representative Dutch sample (Nivel Primary Care Database) was included; 27,362 episodes. Outcomes were follow-up consultation(s) with GP, with GP and/or MHN, and antidepressant prescriptions during 12 months from the start of the depression episode. Differences between countries were estimated using negative binomial and Cox regression models, adjusted for patient gender, age and comorbidity. RESULTS: Patients in the Netherlands compared to Norway were less likely to receive GP follow-up consultations, IRR (incidence rate ratio) = 0.73 (95% confidence interval (CI) 0.71-0.74). Differences were greatest among patients aged 18-39 years (adj IRR = 0.64, 0.63-0.66) and 40-59 years (adj IRR = 0.71, 0.69-0.73). When comparing follow-up consultations in GP practices, including MHN consultations in the Netherlands, no cross-national differences were found (IRR = 1.00, 0.98-1.01). But in age-stratified analyses, Dutch patients 60 years and older were more likely to be followed up than their Norwegian counterparts (adj IRR = 1.21, 1.16-1.26). Patients in the Netherlands compared to Norway were more likely to receive antidepressant drugs, adj HR (hazard ratio) = 1.32 (1.30-1.34). CONCLUSIONS: The observed differences indicate that the organisation of primary mental health care affects the provision of follow-up consultations in Norway and the Netherlands. Clinical studies are needed to explore the impact of team-based care and GP-based care on the quality of depression care and patient outcomes.

The feasibility of using smartphone apps as treatment components for depressed suicidal outpatients.

Mental health smartphone apps could increase the safety and self-management of patients at risk of suicide, but it is still unclear whether it is feasible to integrate such apps into routine mental healthcare. This study reports on the feasibility of using a safety planning app (BackUp) and a self-monitoring app (mEMA) as components of the routine treatment of depressed outpatients with suicidal ideation. Clinicians were trained in working with both of the apps, and they invited their eligible patients with suicidal ideation for study participation. Patients used the apps for 3 months and discussed these with their clinician during treatment. Patients completed assessments at baseline (T0), 4 weeks (T1) and post-test (T2, 12 weeks after baseline). Both patients and clinicians also participated in telephone interviews. Feasibility was assessed in terms of usability (score > 70 on System Usability Scale, SUS), acceptability (score > 20 on Client Satisfaction Questionnaire-8, CSQ-8), and uptake (sufficient rates of component completion and app usage in treatment). The sample included 17 adult outpatients (52.9% male, age range 20-50 years) diagnosed with a depressive disorder and suicidal ideation at baseline. BackUp was rated by patients at above the cut-off scores for usability (SUS mean score at T1 75.63 and at T2 77.71) and acceptability (CSQ-8 mean score at T1 23.42 and at T2 23.50). mEMA was similarly rated (SUS mean score at T1 75.83 and at T2 76.25; CSQ-8 mean score at T1 23.92 and at T2 22.75). Telephone interviews with patients and clinicians confirmed the usability and acceptability. The uptake criteria were not met. Our findings suggest that mobile safety planning and mobile self-monitoring can be considered acceptable and usable as treatment components for depressed suicidal outpatients, but the integration of apps into routine treatment needs to be further explored.

Identification of Latent Alcohol Use Groups and Transitions over Time Using a 9-Year Follow-Up Study in the Adult General Population.

INTRODUCTION: Studies investigating latent alcohol use groups and transitions of these groups over time are scarce, while such knowledge could facilitate efficient use of screening and preventive interventions for groups with a high risk of problematic alcohol use. Therefore, the present study examines the characteristics, transitions, and long-term stability of adult alcohol use groups and explores some of the possible predictors of the transitions. METHODS: Data were used from the baseline, 3-, 6-, and 9-year follow-up waves of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a representative study of Dutch adults aged 18-64 at baseline (N = 6,646; number of data points: 20,574). Alcohol consumption, alcohol use disorder (AUD), and mental disorders were assessed with the Composite International Diagnostic Interview 3.0. Latent Markov Modelling was used to identify latent groups based on high average alcohol consumption (HAAC) and AUD and to determine transition patterns of people between groups over time (stayers vs. movers). RESULTS: The best fitting model resulted in four latent groups: one nonproblematic group (91%): no HAAC, no AUD; and three problematic alcohol use groups (9%): HAAC, no AUD (5%); no HAAC, often AUD (3%); and HAAC and AUD (1%). HAAC, no AUD was associated with a high mean age (55 years) and low educational level (41%), and no HAAC, often AUD with high proportions of males (78%) and people with high educational level (46%). Eighty-seven percent of all respondents - mostly people with no HAAC, no AUD - stayed in their original group during the whole 9-year period. Among movers, people in a problematic alcohol use group (HAAC and/or AUD) mostly transitioned to another problematic alcohol use group and not to the nonproblematic alcohol use group (no HAAC, no AUD). Explorative analyses suggested that lack of physical activity possibly plays a role in transitions both from and to problematic alcohol use groups over time. CONCLUSION: The detection of three problematic alcohol use groups - with transitions mostly between the different problematic alcohol use groups and not to the group without alcohol problems - points to the need to explicitly address both alcohol consumption and alcohol-related problems (AUD criteria) in screening measures and interventions in order not to miss and to adequately treat all problematic alcohol users. Moreover, explorative findings suggest that prevention measures should also include physical activity.

The inter-connections between self-harm and aggressive behaviours: A general network analysis study of dual harm.

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. This behaviour is especially prevalent within criminal justice and forensic settings. The forms of aggression that should be included in the definition of dual harm have not yet been established. This study aimed to use network analysis to inform an evidence-based definition of dual harm by assessing the relationship between self-harm and different forms of aggressive behaviour in young people (N = 3,579). We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results revealed low correlations between the variables, leading to sparse network models with weak connections. We found that when separated into their distinct forms, aggressive acts and self-harm are only weakly correlated. Our work provides preliminary evidence to assist in understanding and managing dual harm within clinical and forensic settings and informs recommendations for future research.

How chronic are depressive and anxiety disorders? 9-year general population study using narrow and broad course outcomes.

BACKGROUND: Existing studies on disease course usually apply relatively short follow-up periods and narrow definitions of disease course resulting in too optimistic views on disease prognosis. This study explores the relevance of using a longer and broader (cross-disorder) perspective. METHODS: Respondents with a 12-month disorder at baseline and available at 3-, 6- and 9-year follow-up were selected (major depressive disorder, MDD: n = 208; anxiety disorder: n = 220) from a general population study (N = 6646). DSM-IV disorders were assessed with the Composite International Diagnostic Interview. Disease course was described using a short and narrow perspective (i.e., 3-year follow-up, and considering presence of the index disorder only) and a long and broad perspective (9-year follow-up, and considering presence of any mood, anxiety or substance use disorder as outcome). RESULTS: The recovery rates of both MDD and anxiety disorder reduced by half when the perspective switched from short and narrow (MDD: 74.0 %; anxiety disorder: 79.5 %) to long and broad (35.6 % and 40.0 % respectively). At 9-year follow-up, the rates of a persistent disorder (a disorder at each follow-up assessment) tripled when the perspective switched from narrow to broad (MDD: from 4.8 % to 13.9 %; anxiety disorder: from 4.5 % to 15.5 %). LIMITATIONS: The findings are not generalizable to the most severe depressed and anxious patients. CONCLUSIONS: Most people with MDD or anxiety disorder in the general population have a rather favourable prognosis when a narrow perspective is applied, but an unfavourable prognosis when a long-term and broad perspective is applied. Consequently, MDD and anxiety disorder should not merely be perceived as episodic disorders, and require longer-term disease monitoring and management.

The interplay between psychopathological symptoms: transdiagnostic cross-lagged panel network model.

BACKGROUND: Recent paradigm shifts suggest that psychopathology manifests through dynamic interactions between individual symptoms. AIMS: To investigate the longitudinal relationships between symptoms in a transdiagnostic sample of patients with psychiatric disorders. METHOD: A two-wave, cross-lagged panel network model of 15 nodes representing symptoms of depression, (social) anxiety and attenuated psychotic symptoms was estimated, using baseline and 1-year follow-up data of 222 individuals with psychiatric disorders. Centrality indices were calculated to determine important predictors and outcomes. RESULTS: Our results demonstrated that the strongest relationships in the network were between (a) more suicidal ideation predicting more negative self-view, and (b) autoregressive relationships of social anxiety symptoms positively reinforcing themselves. Negative self-view was the most predictable node in the network as it had the highest 'in-expected influence' centrality, and may be an important transdiagnostic outcome symptom. CONCLUSIONS: The results give insight into longitudinal interactions between symptoms, which interact in ways that do not adhere to broader diagnostic categories. Our results suggest that self-view can also be a transdiagnostic outcome of psychopathology rather than just a predictor, as is normally posited, and may especially have an important relationship with suicidal ideation. Overall, our study demonstrates the dynamic complexity of psychopathology, and further supports the importance of investigating symptom interactions of different psychopathological dimensions over time and across disorders.

Internet-delivered interventions for personality disorders - A scoping review.

Background: Personality disorders (PDs) form a substantial part of the mental health disease burden. Effective therapies to treat PDs exist, but they are time-consuming, costly, and difficult to scale up. Delivery through the internet could facilitate the scalability of effective treatment methods. Objective: This review summarizes existing evidence on internet-delivered psychotherapy for personality disorders. Methods: Because few randomized controlled trials (RCTs) have been carried out, we conducted a scoping review. We performed a systematic literature search in PubMed, Embase, MEDLINE, CINAHL, PsycInfo, and Cochrane. Studies were selected if they conveyed research findings on internet-delivered PD interventions. Results: Eleven studies were included. The majority (n = 8) focused specifically on borderline personality disorder (BPD) and the other three on PD in general. The most frequently used form of intervention (n = 7) was the addition of a mobile app to a conventional evidence-based face-to-face treatment such as dialectical behavioral therapy (DBT). Most interventions (n = 8) were still in the development and piloting phase; only two RCTs were found. Usability and patient satisfaction were moderate to high in all studies. Three studies demonstrated significant decreases in borderline personality disorder symptoms.The majority of the studies found were pilot or feasibility studies, most involving mobile apps offered in addition to face-to-face treatment. The add-ons were rated feasible, acceptable, and useful by patients. Reported challenges involved technical difficulties such as programming errors and bugs. Only 45% of the included studies reported on changes in PD symptoms, all showing reduction of symptoms and absence of adverse effects. Conclusions: This scoping review found that internet interventions for PD are still under-researched, although initial outcomes show promise. The outcomes also encourage future research in terms of developing internet interventions as an add-on to existing treatments, as well as working toward the creation and testing of more encompassing internet-delivered treatments for PD.

Translating promise into practice: a review of machine learning in suicide research and prevention.

In ever more pressured health-care systems, technological solutions offering scalability of care and better resource targeting are appealing. Research on machine learning as a technique for identifying individuals at risk of suicidal ideation, suicide attempts, and death has grown rapidly. This research often places great emphasis on the promise of machine learning for preventing suicide, but overlooks the practical, clinical implementation issues that might preclude delivering on such a promise. In this Review, we synthesise the broad empirical and review literature on electronic health record-based machine learning in suicide research, and focus on matters of crucial importance for implementation of machine learning in clinical practice. The challenge of preventing statistically rare outcomes is well known; progress requires tackling data quality, transparency, and ethical issues. In the future, machine learning models might be explored as methods to enable targeting of interventions to specific individuals depending upon their level of need-ie, for precision medicine. Primarily, however, the promise of machine learning for suicide prevention is limited by the scarcity of high-quality scalable interventions available to individuals identified by machine learning as being at risk of suicide.

Competency-Based Training and Assessment of Listening Skills: A Waitlist-Controlled Study in European Telephone Emergency Services.

Background: Telephone emergency services (TES) provide an essential part of suicide prevention and emotional support services across different health care settings. TES are usually provided by paraprofessional counselors, who need specific training in listening skills to meet the demands of callers. Method: This project developed a competency-based training for listening skills which was then evaluated in a randomized controlled waitlist study across four EU countries (Germany, Hungary, Italy, and the Netherlands). Each country provided one training group and one waitlist group. Across countries, a total of 71 (trained: n = 36, waiting: n = 35) counselor trainees were assessed in a standardized, simulated emergency call with an actor client either before or after training participation. Calls were audiotaped and competencies in listening skills were evaluated by external raters using a standardized rating form. Results: Trained counselors showed significantly better listening skills than participants from the waitlist condition. Conclusion: Results provide support for the efficacy of a competency-based training for listening skills in the field of TES across Europe. Furthermore, results demonstrated that a standardized competency-based assessment with an actor client is suitable to assess listening skills.

Factors of Specialized Mental Health Care Use in the Netherlands: A Scoping Review Applying Andersen-Newman's Care Utilization Model.

As mental disorders impact quality of life and result in high costs for society, it is important patients receive timely and adequate care. This scoping review first aims to summarize which factors contribute to specialized mental health care (SMHC) use. Within the Dutch health care system, the general practitioner (GP) is the filter for SMHC and care use costs are relatively low. Second, to organize factors by Andersen and Newman's care utilization model in illness level, predisposing, and enabling factors. Third, to assess equity of access to SMHC in the Netherlands. A health care system is equitable when illness level and the demographic predisposing factors age and gender account for most variation in care use and inequitable when enabling factors and social predisposing factors such as education predominate. We identified 13 cross-sectional and cohort studies in the Netherlands published between 1970 and September 2020 with 20 assessed factors. Illness level factors, disease severity, diagnosis, personality, and comorbidity contributed the most to SMHC use. Predisposing factors related to a more solitary lifestyle contributed to a lesser degree. Enabling factors income and urbanicity contributed the least to SMHC use. These results imply inequity. Factors that did not fit the care utilization model were GP related, for example the ability to recognize mental disorders. This emphasizes their importance in a system where patients are dependent on GPs for access to SMHC. Focus should be on improving recognition of mental disorders by GPs as well as collaboration with mental health care professionals.