Background: Trichotillomania is associated with psychiatric comorbidity, but downstream health care utilization after diagnosis is less well characterized. Methods: We conducted a retrospective propensity score–matched cohort study using de- identified electronic health record data. Adults with first-documented trichotillomania from 2017 to 2023 were matched 1:1 to controls on age, sex, and race. Primary outcomes were all-cause inpatient admission and emergency department utilization within 1 year. Results: Matched cohorts included 24,997 adults with trichotillomania and 24,997 controls. Trichotillomania was associated with higher 1-year inpatient utilization (8.16% vs 4.60%; hazard ratio [HR], 1.94; 95% CI, 1.78-2.12; P<.001) and emergency department utilization (9.59% vs 7.29%; HR, 1.42; 95% CI, 1.31-1.54; P<.001). Secondary analyses showed higher anxiety, depressive disorder, and obsessive-compulsive disorder incidence. Conclusions: First-documented trichotillomania was associated with increased short-term health care utilization, suggesting it may mark broader psychiatric and medical vulnerability.

OBJECTIVE:Delirium is known to be related to neuropsychiatric comorbidities as long-term consequences in adult patients. However, the risk of major neuropsychiatric disorders after pediatric delirium remains largely unexplored. METHODS:We analyzed de-identified electronic health records (2013 to 2023) from the TriNetX Research network, a network with more than 111 million patients. Patients under age 12 years with delirium and a control group without delirium were identified and matched by age, sex, race, ethnicity, and physical comorbidities at a one-to-four ratio. We applied Cox regression and Kaplan-Meier analysis to assess the risk of neuropsychiatric disorders. RESULTS:A total of 618 pediatric patients with delirium were included, demonstrating a 2.15-fold higher risk of neuropsychiatric disorders than controls without delirium (hazard ratio [HR] with 95% confidence interval [CI]: 2.15, 1.82-2.56). The 5-year freedom from these disorders was 68.5% (95% CI, 65.5-71.8) in the study cohort, whereas it was 49.8% (95% CI, 44.1-56.2) in the control cohort. Subgroup analysis showed that children aged 6 years or younger were more likely to be diagnosed with externalizing disorder, including substance use disorder (HR=4.34; 95% CI, 2.00-9.44; p<0.001), intellectual disability (HR=1.71; 95% CI, 1.27-2.30; p<0.001), and attention-deficit/hyperactivity disorder (HR=2.25; 95% CI, 1.16-4.34; p=0.02). CONCLUSION:Pediatric patients with delirium are at increased risk of major neuropsychiatric disorders compared to their control counterparts without delirium. Clinicians need to be aware of early symptoms and signs suggesting major neuropsychiatric disorders during the long-term follow-up period.

Background: Measurement-Based Care (MBC) is an evidence-based practice that has demonstrated challenges integrating into care settings even under ideal circumstances. This study uses the PRISM framework to critically examine a systematic integration of MBC as standard behavioral healthcare in an adult ambulatory psychiatric clinic. Since the initial implementation in 2018, 33 distinct implementation strategies were used to enhance the uptake of this practice. To prepare for sustainment, our team developed a digital Measurement-based care Training for Resilient Implementation in a Clinical setting (METRIC) to improve implementation. The present study evaluates the reach, implementation, and contextual domains impacting METRIC. Methods: METRIC was IRB-approved and distributed to 56 multidisciplinary clinicians through the institutional learning hub. Providers completed surveys about implementation and clinician attitudes of METRIC before, 1 month, and 3 months after training. Patient attitudes were assessed before ( n = 98) and after ( n = 80) implementation. Clinician and patient attitudes were analyzed using the Friedman and Wilcoxon tests, respectively. Results: Forty-seven out of 56 (83.9%) clinicians completed METRIC. Implementation measures suggest there were promising acceptability, appropriateness, and feasibility. Clinicians positively rated METRIC. Clinicians answered 84% of module questions correctly, though their attitudes about MBC did not significantly change after METRIC. Patient attitudes did not significantly change. Conclusions: This study evaluated the implementation of METRIC in an ambulatory mental health clinic for its feasibility, acceptability, and appropriateness. After implementing strategies to enhance provider uptake, METRIC was piloted to standardize MBC training and prepare for sustainment. METRIC was well-received and provides an opportunity for less provider reliance on system champions and academic partnerships to sustain MBC utilization in mental health settings. Our findings define positive aspects of digital MBC training and areas for additional research, which include exploring the benefits of MBC training, examining need and frequency, and whether specialized training is beneficial.

Rationale:Postictal psychosis (PIP) is a transient psychiatric phenomenon characterised by psychotic symptoms following a seizure. While its immediate manifestations have been well documented, there is limited understanding of its long-term implications, particularly its relationship with subsequent primary psychotic disorders. Methods:We conducted a retrospective cohort study using de-identified patient data from the TriNetX database (2006-2026). Individuals aged 18-65 years with a diagnosis of probable PIP (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM): F06.0, F06.2) or brief psychotic disorder within 7 days of the epileptic disorder diagnosis (ICD-10-CM: F23) were propensity-score matched 1:1 with controls without PIP based on age, sex, race, ethnicity and relevant psychiatric and chronic physical comorbidities. We excluded individuals with prior psychotic disorders or delirium. The primary outcome was any psychotic disorder diagnosis within a 5-year follow-up period. Kaplan-Meier survival analyses and HRs were calculated to assess the differences in survival probabilities. Results:A total of 1275 individuals were identified and matched for analysis. Patients with probable PIP were at significantly higher risk for subsequent psychotic disorders (HR=10.78, 95% CI 6.21 to 18.70, p=0.002). The 5-year survival probability for developing any psychotic disorder was 85.79% in the probable PIP group compared with 98.21% in controls (log-rank test, χ2=112.25; p<0.0001). Conclusions:Probable PIP is associated with a heightened risk of subsequent primary psychotic disorders, including interictal forms, within 5 years.

With rising obesity rates and increasing glucagon-like peptide-1 receptor agonist (GLP-1 RA) use, understanding perinatal prescribing patterns is important. We conducted a retrospective cohort study to examine semaglutide and tirzepatide prescribing among pregnant patients in the United States from 2019 to 2024. We analyzed prescriptions during the year before and after delivery, grouping deliveries into 6-month periods and applying segmented linear regression with data-driven change-point detection to identify prescribing-trend shifts. Prevalence of GLP-1 RA prescribing increased from 0.2 to 6.4 per 1,000 deliveries predelivery and from 0.3 to 14.6 per 1,000 deliveries postdelivery, with significant prescribing change points indicating accelerated prescribing in June 2022 for the predelivery period and in March 2021 for the postdelivery period. These findings suggest rapid adoption of GLP-1 RAs in the perinatal period and underscore the need for evidence-based safety data for these medications.

Any increase in alcohol use is associated with an increase in risk of illness and mortality and consequences of chronic alcohol use include cancer, hypertension, heart and liver disease, and Alcohol Use Disorder. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective anti-glycemic and weight-loss medications with a strong safety record. There is substantial preclinical evidence and mounting retrospective and prospective randomized controlled trial evidence that GLP-1RAs could be effective for reducing alcohol consumption. However, the mechanism by which GLP-1RAs reduce alcohol intake remains unclear. While medications that reduce alcohol intake such as naltrexone and acamprosate have central nervous system action, disulfiram reduces alcohol intake through peripheral mechanisms. Here, we test whether GLP-1RAs alter alcohol's peripheral pharmacokinetics as a potential mechanism of action for their alcohol intake suppressive effects. In this pilot study, twenty participants with obesity in the GLP-1RA or control group consumed a challenge dose of alcohol and we measured breath alcohol (BrAC) and the subjective effects of alcohol. We observed a delayed rise in BrAC and subjective effects in the GLP-1RA group as compared to controls, that was not explained by nausea. These data provide preliminary evidence that GLP-1RAs could act through peripheral mechanisms to suppress alcohol intake. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This study was funded by the Fralin Biomedical Research Institute. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Virginia Tech Institutional Review Board gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Any increase in alcohol use is associated with an increase in risk of illness and mortality and consequences of chronic alcohol use include cancer, hypertension, heart and liver disease, and Alcohol Use Disorder. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective anti-glycemic and weight-loss medications with a strong safety record. There is substantial preclinical evidence and mounting retrospective and prospective randomized controlled trial evidence that GLP-1RAs could be effective for reducing alcohol consumption. However, the mechanism by which GLP-1RAs reduce alcohol intake remains unclear. While medications that reduce alcohol intake such as naltrexone and acamprosate have central nervous system action, disulfiram reduces alcohol intake through peripheral mechanisms. Here, we test whether GLP-1RAs alter alcohol’s peripheral pharmacokinetics as a potential mechanism of action for their alcohol intake suppressive effects. In this pilot study, 20 (1:1) participants with obesity in the GLP-1RA or control group consumed a challenge dose of alcohol, and we measured breath alcohol (BrAC) and the subjective effects of alcohol. We observed a delayed rise in BrAC and subjective effects in the GLP-1RA group as compared to controls, that was not explained by nausea. These data provide preliminary evidence that GLP-1RAs could act through peripheral mechanisms to suppress alcohol intake.

Measurement-based care (MBC), while an evidence-based clinical practice, can be difficult to integrate into behavioral healthcare settings. Even when MBC has been successfully implemented in an organization, there are many challenges that create a need for rapid adaptation. As measurement feedback systems (MFSs) are increasingly hosted on dynamic digital platforms, there is always a risk of technological changes and adaptations, whether the system is prepared for them or not. This point of view is focused on managing organizational changes to continue use of MBC through a case example in adult behavioral healthcare. A hospital policy change, informed by financial considerations, led to the rapid de-implementation of the external MFS platform in favor of a system integrated into the electronic health record (EHR). Our team responsively developed a plan for maintaining MBC through this transition including written guidelines and face-to-face training to support clinical staff, while determining the best way to maintain research gains and collect data in the EHR. This manuscript discusses the challenges in switching MBC platforms and the downstream consequences of this policy change from clinical, training, and research perspectives.

OBJECTIVE:To better understand medical comorbidity in people with psychogenic non-epileptic seizures (PNES), we used real-world electronic health records (EHR) to evaluate rates of co-occurring diagnoses and psychotropic prescribing in people receiving their first diagnosis of PNES. METHODS:We conducted a descriptive analysis of the TriNetX databases, a federated network of >80 health care organizations with access to electronic health records and linked insurance claims. We identified 25,858 individuals with a new PNES diagnosis (ICD-10-CM F44.5) and  ≥5 years of EHR or claims data prior to the first PNES encounter. We subsequently evaluated baseline medical comorbidities and outpatient psychotropic prescriptions during the 5 year lookback period preceding the first PNES encounter. RESULTS:In the 5 years before the first PNES encounter, >50% of patients with PNES had encounters where mood-related disorder, anxiety-related disorder, or epilepsy was coded. Past 5-year injuries or poisonings (46.0%), benzodiazepine or Z drug prescriptions (63.5%), and opioid prescriptions (48.6%) were particularly common. Approximately one-third of the sample had past 5-year pain-related diagnoses. Prior diagnoses of PTSD (17.0%), borderline personality disorder (<5%), intellectual disability (<5%), and autism-spectrum disorders (<5%) were comparatively less common. CONCLUSION:The needs of people with PNES extend beyond psychiatric management. Clinicians should consider the impact of injuries, pain-related diagnoses, and opioid and benzodiazepine exposure in differential diagnosis.

Background:Benzodiazepines (BZDs) are widely prescribed for anxiety disorders. However, the long-term implications on mental health remain uncertain, especially the potential association between chronic BZD use and subsequent diagnosis of mood and substance use disorders (SUDs). Method:We conducted a 5-year retrospective cohort study by analyzing the TriNetX database, a real-time electronic medical record network. The study population was defined as patients aged 18-65 with anxiety disorders (ICD-10-CM: F40-F48). We employed propensity score matching to pair a BZD-exposed cohort (≥12 BZD prescriptions) with a BZD-unexposed control cohort. The outcomes were defined as depressive disorders, bipolar disorders, and SUDs. We employed Kaplan-Meier analyses to assess the survival probability over five years following diagnosis and BZD exposure; log-rank test to obtain the hazard ratio (HR) with 95 % confidence interval (CI). Results:We identified and matched 76,137 patients in the study and control cohorts. Compared to the control cohort, the BZD-exposed group exhibited significantly higher risks of being diagnosed with depressive disorders (HR, 2.64; 95 % CI, 2.59-2.68), bipolar disorders (HR, 4.39; 95 % CI, 4.15-4.64), overall substance use disorders (HR, 3.00; 95 % CI, 2.92-3.08), alcohol use disorder (HR, 3.38; 95 % CI, 3.20-3.57), stimulant use disorder (HR, 3.24; 95 % CI, 2.95, 3.55), cannabis use disorder (HR, 2.93; 95 % CI, 2.75-3.11), inhalant use disorder (HR, 4.14; 95 % CI, 3.38-5.06), and nicotine use disorder (HR, 2.72; 95 % CI, 2.63-2.81). Conclusion:Our findings demonstrate a concerning association between BZD use and an increased risk of being diagnosed with various mood disorders and SUDs.

To the editor: Two recent advisories from the US surgeon general have underscored the unprecedented public health crisis in youth mental health and emphasised the need for"timely data collec-tion and research to identify and respond to youth mental health needs more rapidly".

Observational studies suggest a potential correlation between antidepressants and increased lung cancer risks. However, existing studies are limited to small sample sizes, unadjusted covariates especially smoking status, and unclear exposure duration. We performed a large-scale retrospective cohort study to re-examine the association. We analyzed non-smokers and smokers separately to eliminate the confounding effect of smoking status. We found patients with long-term antidepressant use were at a lower risk of lung cancer in both smokers and non-smokers (odds ratio (OR), 0.61; 95% CI: 0.46-0.80, OR: 0.75; 95% CI: 0.65-0.86). None of the antidepressants was associated with an increased lung cancer risk.

Abstract Background This study examines the impact of SARS-CoV-2 (i.e., coronavirus, COVID, COVID-19) using data from a measurement-based care (MBC) system utilized in an outpatient psychiatric clinic providing telemedicine care. A novel Patient Rated Outcome Measure (PROM), the COVID-19 Events Checklist (CEC) was administered in a hospital system based ambulatory clinic beginning April 2020 to track COVID-19-19’s impact on patients’ mental, emotional, and health-related behaviors during the pandemic. The study (1) provides descriptive CEC data, and (2) compares CEC results with PROMs evaluating anxiety (Generalized Anxiety Disorder-7; GAD-7), depression (Patient Health Questionnaire; PHQ-9), and psychological distress (Brief Adjustment Scale-6; BASE-6). Methods This retrospective observational study included patient intake data collected from April 2020 to March 2021. Patient (N = 842) reports on the CEC’s five domain questions were aggregated to calculate average reports of COVID-19 related impacts at intake over the initial 12 months of the pandemic. Trends in COVID-19 related impacts were examined, and non-aggregated scores on the PHQ-9, GAD-7, and BASE-6 were compared to primary dichotomous (yes/no) CEC survey questions via Wilcoxon rand sum testing. Results Results capture the relationship between COVID-19 exposure, COVID-19- related sequelae and behaviors, and psychological symptom severity. Specifically, Wilcoxon rank-sum tests indicate that social determinants of health (SDOH), negative mental health impacts, and positive coping skill use were significantly associated with psychological symptomatology including overall psychological functioning via the BASE-6, anxiety via the GAD-7, and depressive symptoms via the PHQ-9. Results regarding SDOH were as follows: BASE-6 (w = 44,005, p < 0.001), GAD-7 (w = 44,116, p < 0.001), and PHQ-9 (w = 43,299, p < 0.001). Regarding negative mental health outcomes, the results were: BASE-6 (w = 38,374, p < 0.001), GAD-7 (w = 39,511, p < 0.001), and PHQ-9 (w = 40,154, p < 0.001). As the initial year of the pandemic elapsed, incoming patients demonstrated increased rates of suspected or confirmed exposure to COVID-19, (+2.29%, t = 3.19, p = 0.01), reported fewer negative impacts of COVID-19 on SDOH (−3.53%, t= −2.45, p = 0.034), and less engagement in positive coping strategies (−1.47%, t = −3.14, p = 0.010). Conclusions Psychosocial factors related to COVID-19 are discussed, as well as opportunities for further research on the relationship between psychological symptomatology and the impact of COVID-19 on health-related behaviors.

Objective: Little empirical evidence exists to support the effectiveness of hybrid psychiatric care, defined as care delivered through a combination of telephone, videoconferencing, and in-person visits. The authors aimed to investigate the effectiveness of hybrid psychiatric care compared with outpatient waitlist groups, assessed with patient-reported outcome measures (PROMs). Method: Participants were recruited from an adult psychiatry clinic waitlist on which the most common primary diagnoses were unipolar depression, generalized anxiety disorder, and bipolar disorder. Patients (N=148) were randomly assigned to one of two waitlist groups that completed PROMs once or monthly before treatment initiation. PROMs were used to assess symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and daily psychological functioning (Brief Adjustment Scale-6 [BASE-6]). Patient measures were summarized descriptively with means, medians, and SDs and then compared by using the KruskalWallis test; associated effect sizes were calculated. PROM scores for patients who received hybrid psychiatric treatment during a different period (N=272) were compared with scores of the waitlist groups. Results: PROM assessments of patients who engaged in hybrid care indicated significant improvements in symptom severity compared with the waitlist groups, regardless of the number of PROMs completed while patients were on the waitlist. Between the hybrid care and waitlist groups, the effect size for the PHQ-9 score was moderate (d=0.66); effect sizes were small for the GAD-7 (d=0.46) and BASE-6 (d=0.45) scores. Conclusions: The findings indicate the clinical effectiveness of hybrid care and that PROMs can be used to assess this effectiveness.

Introduction: Recent addiction and obesity-related research suggests that episodic future thinking (EFT) can serve as a promising intervention to promote healthy decision-making. We used data from a pilot study to investigate the acute neural effects of EFT in alcohol use disorder (AUD). Because of the limitations of those data, we additionally used data from a previously published functional MRI (fMRI) study in which participants had not received any intervention for their AUD. Methods: In an out-of-scanner, guided interview, participants (n = 24; median age = 37.3 years; median AUDIT = 22.5) generated scenarios and cues about their future (EFT intervention, n = 15) or recent past (control episodic thinking [CET] control intervention, n = 9). Then, they performed both resting-state and task-based (delay discounting [DD]) fMRI. We used nodes from the default mode network and salience networks as well as the hippocampus to perform seed-based analyses of the resting-state data. The results then guided psychophysiological interaction analyses in the DD task. In addition, we used data from a larger, previously reported study as a "no intervention" group of AUD participants (n = 50; median age = 43.3; median Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alcohol dependence score = 7) to reproduce and aid in interpreting our key findings. Results: EFT, but not CET, participants showed statistically improved DD rates-a behavioral marker for addiction. Resting-state analyses of the left hippocampus revealed connectivity differences in the frontal poles. The directionality of this difference suggested that EFT may reduce a hypo-connectivity relationship between these regions in AUD. We also found resting-state connectivity differences between the salience network and the right dorsolateral prefrontal cortex (R DLPFC), which then led us to discover R-to-L DLPFC psychophysiological interaction differences during DD. Moreover, the resting-state salience-to-DLPFC functional connectivity showed an inverse relationship to DD rate while hyperconnectivity between left and right DLPFC reflected slower reaction times during DD trials. Discussion: These findings suggest that previously noted benefits of EFT such as the improved DD replicated here might coincide with changes in neural connectivity patterns in AUD. The alterations in connectivity highlight potential mechanisms underlying the effectiveness of EFT in improving decision-making in AUD. Understanding these neural effects may contribute to the further development of targeted interventions for AUD and related disorders.

Traumatic brain injury (TBI) affects over 48 million people worldwide each year. Suicide is common in TBI, and there are several known contributing factors, including severe TBI, depression, alcohol use, and male sex. Impulsivity, or the tendency to act quickly with little thought, may be an early predictor of suicidality following TBI. The purpose of this study was to evaluate the risk of suicidality in patients with a prior history of impulsivity following a TBI. Using de-identified electronic health records from the TriNetX U.S. Collaborative Network with Natural Language Processing, three cohorts were generated: the impulsivity TBI cohort (I+TBI+) included subjects with a diagnosis of impulsivity before a diagnosis of TBI; the no impulsivity TBI cohort (I-TBI+) included patients with TBI but no impulsivity; the impulsivity no TBI cohort (I+TBI-) included patients with impulsivity but TBI. Two analyses were conducted, including analysis 1 (impulsivity TBI vs. no impulsivity TBI) and analysis 2 (impulsivity TBI vs. impulsivity no TBI). Patients were 1:1 matched by age, sex, race, ethnicity, psychiatric diagnoses, and antidepressant use. Outcomes included a diagnosis of self-harm, suicidal ideation, or a suicide attempt within 1 year after the index event. The all-time incidence of each outcome was assessed across different age categories. The chi-square test (categorical variables) and t-test (numerical variables) were used to assess for differences between groups. A total of 1,292,776 patients with TBI were identified in the study. After 1:1 matching, there were 20,694 patients (mean [standard deviation, SD] age, 48.1 [21.8]; 8,424 females [40.7%]) with impulsivity and TBI (I+TBI+), 1,272,082 patients (mean [SD] age, 46.0 [23.1]; 562,705 females [44.2%]) with TBI alone (I-TBI+), and 90,669 patients (mean [SD] age, 43.7 [22.6]; 45,188 females [49.8%]) with impulsivity alone (I+TBI-). Within the first year after a TBI, patients with impulsivity were more likely to exhibit self-harm (p < 0.001), suicidal ideation (p < 0.001), or a suicide attempt (p < 0.001). Compared with patients with TBI without impulsivity, those with impulsivity had a 4-fold increase in the incidence of self-harm (2.81% vs. 0.63%), an 8-fold increase in suicidal ideation (52.42% vs. 6.41%), and a 21-fold increase in suicide attempts (32.02% vs. 1.50%). This study suggests that impulsivity diagnosed before a TBI may increase the risk of post-traumatic suicidality, with a 4-fold increased risk of self-harm, an 8-fold increased risk of suicidal ideation and a 21-fold increased risk of suicide attempts. This characterizes a group of at-risk individuals who may benefit from early psychiatric support and targeted interventions following a TBI.

Background & Aims: Patient suicide, an unpredictable experience in a psychiatrist’s career, precipitates a wide range of emotions. Trainees in the earlier part of their career may be affected differently than the practicing psychiatrists. Our objective was to assess the variety of coping strategies and support systems of psychiatrists and trainees in the aftermath of patient suicide. Methods: Assessing coping mechanisms and support measures were part of a preliminary study on stress and trauma-related symptoms in psychiatrists and trainees. In this cross-sectional study, data were obtained by sending an online survey to randomly selected residency/fellowship programs and practicing psychiatrists across the United States. The Brief COPE inventory measured various coping strategies, and self-reported questionnaires assessed support measures. Results: Among 2/3 of the participants (N= 509) who experienced patient suicide, to cope with the trauma, the majority (>80%) used acceptance, followed by emotional and instrumental support, reframing, planning, active coping, religious help, self-blame, and distraction. A significantly higher proportion (p< 0.05) of trainees tried behavioral disengagement, positive reframing, and denial as major coping strategies. Both groups derived the most support from colleagues, family, and friends. Likely due to imminent availability, a higher number of trainees benefited from their supervisors and psychiatrists from family. Conclusions: Creating a safe and reliable supportive environment in institutions, preparing clinicians for pre- and post-event consequences, and providing training through a structured curriculum may help future generations maximize coping strategies following patient suicide.