Effects of Recreational Cannabis Legalization on Mental Health: Scoping Review.

OBJECTIVE: Recreational cannabis legalization (RCL) is expanding rapidly. RCL's effects on mental health issues are of particular concern because cannabis use is more frequent among people receiving psychiatric care and is associated with several psychiatric disorders. The authors conducted a scoping review to examine the evidence and discern gaps in the literature concerning the effects of RCL on mental health and to assess the factors responsible for an observed heterogeneity in research results. METHODS: This scoping literature review followed PRISMA guidelines. Five databases-MEDLINE, CINAHL, Embase, APA PsycInfo, and Web of Science-were searched for English- or French-language reports published between January 1, 2012, and April 30, 2023. RESULTS: Twenty-eight studies from the United States and Canada were found. The studies were classified by category of the study's data (patients receiving psychiatric care [k=1], death records [k=4], emergency department or hospital records [k=10], and the general population [k=13]) and by the diagnosis (schizophrenia or psychoses, mood disorders, anxiety disorders and symptoms, suicide or suicidal ideation, or other mental health issues) examined. The review findings revealed a paucity of research and indicated mixed and largely inconclusive results of the studies examined. Research gaps were found in the examination of potential changes in cannabis use patterns among people receiving psychiatric care and in the availability of longitudinal studies. CONCLUSIONS: Clinicians, researchers, and policy makers need to collaborate to address the research gaps and to develop evidence-based policies that reflect a thorough understanding of the effects associated with RCL.

Prevalence of Opioid Use Disorder and Opioid Overdose Rates Among People With Mental Illness.

OBJECTIVE: The authors examined the prevalence and correlates of co-occurring opioid use disorder and opioid overdose among individuals receiving psychiatric services. METHODS: This was a cross-sectional study of adults with continuous enrollment in New York State Medicaid who received at least one psychiatric service in 2020 (N=523,885). Logistic regression models were used to examine the correlates of both opioid use disorder and overdose. RESULTS: In the study sample, the prevalence rate of opioid use disorder was 8.1%; within this group, 7.7% experienced an opioid overdose in the study year. Opioid use disorder rates were lower among younger (18-24 years; 2.0%) and older (≥65 years; 3.1%) adults and higher among men (11.1%) and among those residing in rural areas (9.9%). Compared with Whites (9.4%), opioid use disorder rates were lower for Asian Americans (2.0%, adjusted odds ratio [AOR]=0.22) and Blacks (6.8%, AOR=0.76) and higher for American Indians (13.2%, AOR=1.43) and Hispanics (9.6%, AOR=1.29). Individuals with any substance use (24.9%, AOR=5.20), posttraumatic stress (15.7%, AOR=2.34), bipolar (14.9%, AOR=2.29), or anxiety (11.3%, AOR=2.18) disorders were more likely to have co-occurring opioid use disorder; those with conduct (4.5%, AOR=0.51), adjustment (7.4%, AOR=0.88), or schizophrenia spectrum (7.4%, AOR=0.87) disorders were less likely to have opioid use disorder. Those with suicidality (23.9%, AOR=3.83) or economic instability (23.7%, AOR=3.35) had higher odds of having opioid use disorder. Overdose odds were higher among individuals with suicidality (34.0%, AOR=6.82) and economic instability (16.0%, AOR=2.57). CONCLUSIONS: These findings underscore the importance of providing opioid use disorder screening and treatment for patients receiving psychiatric services.

Suicide Screening, Risk Assessment, and Lethal Means Counseling During Zero Suicide Implementation.

OBJECTIVE: The authors measured implementation of Zero Suicide (ZS) clinical practices that support identification of suicide risk and risk mitigation, including screening, risk assessment, and lethal means counseling, across mental health specialty and primary care settings. METHODS: Six health care systems in California, Colorado, Michigan, Oregon, and Washington participated. The sample included members ages ≥13 years from 2010 to 2019 (N=7,820,524 patients). The proportions of patients with suicidal ideation screening, suicide risk assessment, and lethal means counseling were estimated. RESULTS: In 2019, patients were screened for suicidal ideation in 27.1% (range 5.0%-85.0%) of mental health visits and 2.5% (range 0.1%-35.0%) of primary care visits among a racially and ethnically diverse sample (44.9% White, 27.2% Hispanic, 13.4% Asian, and 7.7% Black). More patients screened positive for suicidal ideation in the mental health setting (10.2%) than in the primary care setting (3.8%). Of the patients screening positive for suicidal ideation in the mental health setting, 76.8% received a risk assessment, and 82.4% of those identified as being at high risk received lethal means counseling, compared with 43.2% and 82.4%, respectively, in primary care. CONCLUSIONS: Six health systems that implemented ZS showed a high level of variation in the proportions of patients receiving suicide screening and risk assessment and lethal means counseling. Two opportunities emerged for further study to increase frequency of these practices: expanding screening beyond patients with regular health care visits and implementing risk assessment with lethal means counseling in the primary care setting directly after a positive suicidal ideation screening.

Impact of Implementation Facilitation on the REACH VET Clinical Program for Veterans at Risk for Suicide.

OBJECTIVE: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. METHODS: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. RESULTS: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. CONCLUSIONS: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.

Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use.

OBJECTIVE: The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients' receipt of recent mental health care. METHODS: Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined. RESULTS: During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission. CONCLUSIONS: Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

Stability of Suicide Risk Prediction Models During Changes in Health Care Delivery.

OBJECTIVE: The authors aimed to use health records data to examine how the accuracy of statistical models predicting self-harm or suicide changed between 2015 and 2019, as health systems implemented suicide prevention programs. METHODS: Data from four large health systems were used to identify specialty mental health visits by patients ages ≥11 years, assess 311 potential predictors of self-harm (including demographic characteristics, historical risk factors, and index visit characteristics), and ascertain fatal or nonfatal self-harm events over 90 days after each visit. New prediction models were developed with logistic regression with LASSO (least absolute shrinkage and selection operator) in random samples of visits (65%) from each calendar year and were validated in the remaining portion of the sample (35%). RESULTS: A model developed for visits from 2009 to mid-2015 showed similar classification performance and calibration accuracy in a new sample of about 13.1 million visits from late 2015 to 2019. Area under the receiver operating characteristic curve (AUC) ranged from 0.840 to 0.849 in the new sample, compared with 0.851 in the original sample. New models developed for each year for 2015-2019 had classification performance (AUC range 0.790-0.853), sensitivity, and positive predictive value similar to those of the previously developed model. Models selected similar predictors from 2015 to 2019, except for more frequent selection of depression questionnaire data in later years, when questionnaires were more frequently recorded. CONCLUSIONS: A self-harm prediction model developed with 2009-2015 visit data performed similarly when applied to 2015-2019 visits. New models did not yield superior performance or identify different predictors.

Racial-Ethnic Differences in Receipt of Past-Year Health Care Services Among Suicide Decedents: A Case-Control Study.

OBJECTIVE: Suicide remains an urgent public health crisis. Although some sociodemographic characteristics are associated with greater suicide risk in the general population, it is unclear whether individuals utilizing health care in the United States have similar suicide incidence patterns. The authors examined whether race-ethnicity is associated with suicide death among patients seeking health care and investigated health care utilization patterns. METHODS: Data were collected from electronic health records and government mortality records for patients seeking health care across nine health care systems in the United States. Patients who died by suicide (N=1,935) were matched with patients in a control group (N=19,350) within each health care system. RESULTS: Patients who died by suicide were significantly more likely to be White, older, male, living in low-education areas, living in rural areas, or diagnosed as having mental health conditions or were significantly less likely to have commercial insurance (p<0.05). Among most racial-ethnic groups, those who died by suicide had a higher number of past-year mental health, primary care, and total health care visits; for American Indian/Alaska Native patients, the number of health care visits tended to be lower among suicide decedents. CONCLUSIONS: These findings suggest that higher past-year health care utilization was associated with increased likelihood of suicide death across several racial-ethnic groups. This observation underscores the need for identifying and managing suicide risk in health care settings, including outside of mental health visits, among most racial-ethnic groups.

Association of Arizona's Implementation of a Behavioral Health Crisis Response System With Suicide Hospitalizations.

OBJECTIVE: In July 2022, the 988 Suicide and Crisis Lifeline went live. The Lifeline is part of larger federal and state efforts to build comprehensive behavioral health crisis response systems that include mobile crisis units and crisis diversion and stabilization centers. Comprehensive response systems are anticipated to reduce hospitalizations for suicide and other behavioral health crises; however, research testing this assumption has been limited. The authors used Arizona-a state known for its comprehensive crisis system-to determine the association between state implementation of a comprehensive behavioral health crisis response system and suicide-related hospitalizations. METHODS: A comparative interrupted time-series (CITS) design was used to compare changes in suicide-related hospitalizations after the 2015 implementation of Arizona's crisis response system (N=215,063). Data were from the 2010-2019 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Nevada (N=84,091 hospitalizations) was used as a comparison state because it is a western state that had not yet implemented a comprehensive crisis system and had available HCUP SID data. The CITS model included controls for time-varying differences in state demographic composition. RESULTS: From 2010 to 2014 to 2019, annual suicide-related hospitalizations in Arizona increased from 122.0 to 324.2 to 584.5, respectively, per 100,000 people, and in Nevada, hospitalizations increased from 94.7 to 263.2 to 595.5, respectively, per 100,000 people. Arizona's crisis response system was associated with a significant relative decrease in the quarterly trend of 2.57 suicide-related hospitalizations per 100,000 people (p=0.033). CONCLUSIONS: More research is needed to understand how the implementation of a comprehensive crisis response system may affect suicide-related hospitalizations.

Patients' Perspectives on Medication-Related Suicide Prevention Interventions Delivered in Emergency Settings.

OBJECTIVE: Encouraging patients at risk for suicide to reduce access to potentially lethal medications and drugs is a key component of evidence-based suicide prevention. However, little research has been done to inform interventions for reducing intentional self-harm. METHODS: Semistructured interviews were conducted with 28 U.S. veterans who sought emergency care from the Veterans Health Administration between 2021 and 2023 to explore veterans' perspectives on medication-related interventions, including opinions on intervention components (e.g., medication return envelopes). Matrix analysis was used to aggregate data into categories, which were predefined by using constructs from the health belief model (e.g., perceived benefits). RESULTS: The participating veterans generally endorsed interventions as acceptable and were particularly supportive of distributing medication return envelopes. However, they often conceptualized these efforts as steps to prevent unintentional overdose or theft-not necessarily to prevent suicide-and rarely indicated that such interventions were appropriate for themselves. Across the interviews, participants identified important facilitators to care, such as ensuring that interventions were convenient and accounted for the perceived cost of disposing medications. Perspectives on engaging family or friends in interventions were mixed. The importance of the interventions was more readily acknowledged among participants with previous opioid use exposure-perspectives that appeared to stem from lived experiences. CONCLUSIONS: This study contributes important foundational knowledge that can be used to inform research and clinical initiatives aimed at preventing medication- and drug-related suicides.

Prevalência e fatores pessoais associados à violência autoprovocada em adolescentes / Prevalence and personal factors associated with self-harm in adolescents / Prevalencia y factores personales asociados a la violencia autoinflingida en adolescentes

RESUMO Objetivo: identificar a prevalência e os fatores pessoais associados à violência autoprovocada em adolescentes. Método: estudo observacional analítico, do tipo transversal. A população foi composta pelas notificações de violência interpessoal ou autoprovocada em adolescentes no Brasil, oriundas do Sistema de Informação de Agravos de Notificação. Foram incluídas as notificações ocorridas entre 2009 e 2021 no Brasil, em adolescentes de 10 a 19 anos. Os dados foram analisados com estatística descritiva e inferencial. Resultados: a prevalência de violência autoprovocada foi de 27,39% no Brasil. Adolescentes pretos aumentam a prevalência de violência autoprovocada em 3%, e os pardos e indígenas em 2%; mais de 8 anos de escolaridade constitui fator de proteção em relação à violência autoprovocada, reduzindo em 12% a prevalência de violência autoinfligida. Conclusão: os resultados indicam a necessidade de que sejam traçadas políticas e estratégias eficazes que auxiliem no cuidado a esse público.

ABSTRACT Objective: To identify the prevalence and personal factors associated with self-harm in adolescents. Method: A cross-sectional analytical observational study. The population consisted of notifications of interpersonal or self-harm violence in adolescents in Brazil from the Notifiable Diseases Information System. Notifications between 2009 and 2021 in Brazil were included in adolescents aged 10 to 19. The data was analyzed using descriptive and inferential statistics. Results: The prevalence of self-harm was 27.39% in Brazil. Black adolescents increase the prevalence of self-harm violence by 3% and brown and indigenous adolescents by 2%; more than eight years of schooling is a protective factor in relation to self-harm violence, reducing the prevalence of self-inflicted violence by 12%. Conclusion: The results indicate the need for effective policies and strategies to help care for this public.

RESUMEN Objetivo: identificar la prevalencia y los factores personales asociados a la violencia autoinfligida en adolescentes. Método: estudio observacional, analítico, transversal. La población estuvo constituida por notificaciones de violencia interpersonal o autoinfligida entre adolescentes de Brasil, provenientes del Sistema de Información de Enfermedades De Declaración Obligatoria. Se incluyeron las notificaciones ocurridas entre 2009 y 2021 en Brasil, en adolescentes de 10 a 19 años. Los datos fueron analizados con estadística descriptiva e inferencial. Resultados: la prevalencia de violencia autoinfligida fue del 27,39% en Brasil. Los adolescentes negros aumentan la prevalencia de la violencia autoinfligida en un 3%, y los pardos e indígenas en un 2%; más de 8 años de escolaridad constituye un factor protector en relación a la violencia autoinfligida, reduciendo en un 12% la prevalencia de la violencia autoinfligida. Conclusión: los resultados indican la necesidad de diseñar políticas y estrategias efectivas para ayudar a la atención de esta población.

Clinician Attitudes Toward Suicide Prevention Practices and Their Implementation: Findings From the System of Safety Study.

OBJECTIVE: The authors aimed to assess clinicians' attitudes toward suicide-related practices and their implementation, across roles and settings, before implementation of the Zero Suicide model in a health care system. METHODS: Clinicians (N=5,559) were invited to complete a survey assessing demographic characteristics; confidence and self-reported suicide-related practice; leadership buy-in; and attitudes toward suicide prevention, safety planning, and continuous quality improvement (CQI). RESULTS: Of 1,224 respondents, most felt confident conducting suicide screening but less confident performing other suicide-related care. Provider role and care setting were significantly associated with confidence (p<0.001, Kruskal-Wallis H test) and practice (p<0.001, Kruskal-Wallis H test) of providing suicide prevention care, with behavioral health providers and providers in the emergency department (ED) reporting the highest confidence. Attitudes toward safety planning were more positive among women (p<0.001, t test) and behavioral health providers (p<0.001, F test) than among their counterparts or peers. Positive attitudes toward CQI were significantly associated with male sex (p=0.01), non-White race (p=0.03), younger age (p=0.02), fewer years working in health care (p<0.001), administrative role (p<0.001), working in the ED (p<0.001), outpatient settings (p<0.02), and medical provider role (p<0.001). CONCLUSIONS: Behavioral health providers and those in the ED reported feeling prepared to deliver suicide-related care, with nurses feeling less confident and less supported. Initiatives to improve suicide-related care should account for clinical role and care setting during planning. CQI could help engage a broader range of clinicians in suicide-related care improvements.

[Behavior patterns of the population in relation to health].

In order to identify the basic patterns of behavior that reflect the attitude of Russians to their health, a large corpus of relevant scientific literature was analyzed, as well as actual statistical data and the results of representative sociological studies concerning various aspects of both self-preserving and self-destructive behavior of Russians. As a result, four basic models of behavior were formed and described, which differ in a set of positive and negative attitudes and characteristic lines of behavior in relation to one's health («a convinced healthy lifestyle person¼, «a beginner healthy lifestyle person¼, «irresponsible¼ and «self-destructive¼). Based on the analysis of statistics and sociological information, it was concluded that even the behavioral model of a «beginner healthy lifestyle person¼ is implemented by a very minority of Russians. At best, the majority of the population adheres to the «irresponsible¼ pattern of behavior that involves refusing or reducing the consumption of alcohol and tobacco, but not assuming a rational diet, adequate sleep, physical and medical activity. Hence the task of everyone who has the opportunity to influence citizens, including medical workers, to convey to them the idea that health and longevity are achieved only through systematic and comprehensive efforts. In addition, a number of common misconceptions and unrealistic expectations related to healthy lifestyles were highlighted. Attention is drawn to the fact that subjects capable of exerting an educational impact on citizens, including medical specialists, should not only provide patients with useful knowledge, but also try to protect them from misconceptions and unfounded expectations.

Diagnosed Posttraumatic Stress Disorder and Other Trauma-Associated Stress Disorders and Risk for Suicide Mortality.

OBJECTIVE: Strong evidence exists for posttraumatic stress disorder (PTSD) as a risk factor for suicidal thoughts and behaviors across diverse populations. However, few empirical studies have examined PTSD and other trauma-associated stress disorders as risk factors for suicide mortality among health system populations. This study aimed to assess trauma-associated stress diagnoses as risk factors for suicide mortality in a U.S. health system population. METHODS: This case-control, matched-design study examined individuals who died by suicide between 2000 and 2015 and had received care from nine U.S. health systems affiliated with the Mental Health Research Network (N=3,330). Individuals who died by suicide were matched with individuals from the general health system population (N=333,000): 120 individuals with PTSD who died by suicide were matched with 1,592 control group members, 84 with acute reaction to stress were matched with 2,218 control individuals, and 331 with other stress reactions were matched with 8,174 control individuals. RESULTS: After analyses were adjusted for age and sex, individuals with any trauma-associated stress condition were more likely to have died by suicide. Risk was highest among individuals with PTSD (adjusted OR [AOR]=10.10, 95% CI=8.31-12.27), followed by those with other stress reactions (AOR=5.38, 95% CI=4.78-6.06) and those with acute reaction to stress (AOR=4.49, 95% CI=3.58-5.62). Patterns of risk remained the same when the analyses were adjusted for any comorbid psychiatric condition. CONCLUSIONS: All trauma-associated stress disorders are risk factors for suicide mortality, highlighting the importance of health system suicide prevention protocols that consider the full spectrum of traumatic stress diagnoses.