OBJECTIVE:To examine rates of adherence to antidepressant management quality measures among youth initiating treatment for depression, and to identify demographic, clinical, and county-level factors associated with adherence. METHOD:This retrospective cohort study used US national Medicaid data for youth 9 to 24 years of age who were prescribed antidepressants for a new episode of major depression from January 1, 2016, to February 28, 2019 (N = 196,364). Quality measures were derived from 3 Health Effectiveness Data and Information Set (HEDIS) quality measures: (1) acute phase, the percentage of youth who remained on antidepressants for 3 months; (2) continuation phase, the percentage of youth who remained on antidepressants for 6 months; and (3) follow-up contacts, the percentage of youth who received at least 3 follow-up visits during the acute phase. Robust Poisson regression examined associations between demographic, clinical, and county-level factors and adherence. RESULTS:Approximately half (49.6%) of the youth were adherent to acute-phase medication management and 55.2% had at least 3 follow-up visits; only 26.5% met continuation phase metrics. Older age, minoritized racial/ethnic status, and substance use disorders were associated with lower adherence. In contrast, youth with chronic medical conditions, prior use of other psychotropic medications, or in foster care had higher adherence. CONCLUSION:A substantial proportion of youth with depression receiving antidepressant treatment do not receive care aligned with quality measures, with notable disparities among older youth and racial/ethnic minorities. Targeted quality improvement efforts are needed to close gaps in adherence and follow-up care, particularly for underserved populations, and to promote more consistent, equitable treatment delivery. PLAIN LANGUAGE SUMMARY:Using national Medicaid data, this study examined whether youth and young adults aged 9 to 25 years receiving antidepressants adhered to medication management quality measures for the acute phase (first 3 months after diagnosis) and continuation phase (first 6 months after diagnosis), as well as follow-up care (at least 3 outpatient visits in the first 3 months). Only about half were adherent to antidepressant medication management and follow-up during the first 3 months, and a little over a quarter adhered to quality measures for the recommended 6 months. Young adults, racial/ethnic minorities, and those with substance use disorders were less likely to adhere to quality measures. In contrast, youth with chronic medical conditions or prior use of other psychotropic medications were more likely to adhere to quality measures. These findings highlight the need for targeted efforts to improve antidepressant management, particularly for underserved populations at risk for nonadherence.

Objective: To examine individual and contextual characteristics associated with receipt of mental health treatment prior to youth suicide. Method: Data from the US National Violent Death Reporting System, Area Health Resource File, and Social Vulnerability Index were used to examine characteristics associated with receipt of mental health treatment within 2 months before death among youth suicide decedents aged 5 to 17 years from 2013 to 2020 (N = 6,229). The association between individual (demographic, precipitating circumstances, and clinical characteristics) and contextual-level variables (county health resources, Social Vulnerability Index) and mental health service use was modeled using logistic regression. Results: Mental health treatment was received by 31.6% of youth suicide decedents (n = 1,967) in the 2 months before suicide. Male individuals and youth from all racial and ethnic minority groups were less likely to receive mental health treatment in the 2 months prior to suicide, as were youth residing in non-metropolitan counties and living in counties characterized by high compared to low levels of social vulnerability. A history of family problems, a recent crisis, criminal/legal problems, and suicidal thoughts and attempts were associated with increased odds of receiving mental health services. Conclusion: Youth suicide decedents who were male, members of a racial or ethnic minority group, and residing in counties that are nonmetropolitan and/or socially disadvantaged were less likely to have received mental health services in the months prior to death. Suicide prevention efforts that focus on improving access to care are essential for these vulnerable populations at risk for suicide. Plain language summary: This study used data from the US National Violent Death Reporting System, Area Health Resource File, and Social Vulnerability Index to examine characteristics associated with mental health treatment within two months of death by suicide among 6,229 youth aged 5 to 17 years from 2013 to 2020. Mental health treatment was received by 31.6% of youth suicide decedents in the 2 months before death with male decedents and those from racial and ethnic minority groups less likely to receive mental health treatment than non-Hispanic White decedents. Youth living in nonmetropolitan areas and in counties with high Social Vulnerability Index were also less likely to receive care. Suicide prevention efforts focused on improving access to care are essential for these vulnerable populations at risk for suicide.

Purpose: This study evaluated psychometric properties of the Ask Suicide-Screening Questions (ASQ) and Item Nine of the Patient Health Questionnaire (PHQ Item 9) to detect suicide risk in rural adult primary care and whether pain and opioid screening contributed to suicide risk detection. Methods: A sample of adult rural primary care patients (N = 214) completed suicide risk, pain, and opioid screening measures electronically; 48% of participants also completed a follow-up survey. Using the Adult Suicidal Ideation Questionnaire (ASIQ) as the criterion measure, psychometric properties for the ASQ and the PHQ Item 9 were compared using McNemar's test for proportions. Bivariate and multivariable regression analyses explored associations between suicide risk, pain, opioid measures, and ASIQ results. Findings: Approximately 4% (N = 8) of participants screened positive for suicide risk on the ASIQ relative to 11.7% (N = 25) on the ASQ and 3.7% (N = 8) on the PHQ Item 9. The ASQ had higher sensitivity (75.0%) than the PHQ Item 9 (50.0%); the difference was not statistically significant but may have clinical relevance. The PHQ Item 9 had significantly higher specificity (98.1%) than the full ASQ (91.0%, p < 0.001). The ASQ, PHQ Item 9, depression scores, and LGBTQ+ status were significant predictors of ASIQ scores. Pain and opioid misuse were not. Conclusions: Findings from this small sample provide preliminary support for the ASQ and PHQ Item 9 as suicide risk screens in rural adult primary care, but psychometric studies in larger samples are needed.

Objective: To identify correlates of deliberate self-harm (DSH) in youth with autism and/or intellectual disability (ID). Method: This retrospective longitudinal cohort analysis used claims data for youth ages 5 to 24 years continuously enrolled in Medicaid in a midwestern state for 6 months and diagnosed with autism and/or ID between 2010 and 2020 (N 1/4 41,230). Cox proportional hazards regression examined associations between demographic and clinical variables and time to DSH for study cohorts with autism and/or ID. Results: Autism was diagnosed in 34.3% of the sample, ID was diagnosed in 30.6%, and both autism and ID were diagnosed in 35.1%. Sample youth were predominantly male (73.4%) and had an internalizing (74.8%) or externalizing (62.1%) mental health condition. At least 1 DSH event was identified for 734 youths (2.6%) with autism and 686 youths (2.7%) with ID during follow-up. Increased risk of DSH was associated with older age; female sex; history of abuse or neglect; and co-occurring externalizing problems, internalizing problems, substance use, and thought problems for the autism cohort and ID cohort and with the presence of a chronic complex medical condition in the autism cohort. Risk of DSH was significantly lower for youth with moderate ID and youth eligible for Medicaid via disability and foster care. Conclusion: Risk factors for DSH in youth with autism and ID are similar to those in neurotypical youth and include increasing age, trauma, mental health conditions, substance use, and female sex. Clinician and consumer education regarding suicide risk and its correlates in youth with autism and ID warrants study. Plain language summary: This study of youth aged 5 to 24 enrolled in Ohio Medicaid found that 2.6% of youth with autism and 2.7% of youth with intellectual disabilities (ID) had at least one deliberate self-harm (DSH) event between 2010 and 2020. Youth who were older, female, had a history of abuse or neglect, and had co-occurring externalizing, internalizing, substance use, or thought problems, had increased risk for DSH. Risk of DSH was lower for youth with moderate ID and those eligible for Medicaid via disability and foster care.

Background: Youth with autism spectrum disorder (ASD) are over three times more likely to experience suicidal thoughts and behaviors (STB) than children in the general population. Screening to detect suicide risk is therefore critical for youth with ASD. This study examines the capacity of the Ask Suicide-Screening Questions (ASQ), a standard suicide screening tool, to detect suicide risk in children and adolescents with ASD who present to the pediatric emergency department (PED). Methods: This is a retrospective chart review of 393 (2.1%) youth with ASD and 17,964 (97.9%) youth without ASD, aged 8 to 21 years, who presented to the PED of a large urban academic medical center between 2017 and 2020. During the study period, the ASQ was universally administered to children and adolescents who presented to the PED for any reason. Data extracted from the electronic health record included demographic information, presenting concerns, ASD diagnosis, and ASQ results. Results: Autistic children and adolescents were more likely to present to the PED with STB at the first PED visit compared to non-autistic children (12.7% vs. 4.4%, p < 0.001). In both autistic and non-autistic groups, presenting concerns about STB were significantly associated with a positive ASQ screen. More autistic youth were found to have a positive ASQ without STB as their chief presenting complaint as compared to non-autistic youth (22.6% vs. 11.6%, p < 0.001). Youth with ASD endorsed each item of the ASQ at roughly twice the rate of those without ASD. Conclusion: This preliminary descriptive study indicates that the ASQ may be a promising screening tool to assess suicide risk in autistic individuals. Further research on the predictive validity and overall reliability of the ASQ in youth with ASD is recommended.

Purpose: To identify risk subgroups of youth suicide decedents using demographic and clinical psychiatric and medical diagnostic pro files to inform tailored youth suicide prevention efforts. Methods: This study linked Ohio Medicaid and death certi ficate data for Medicaid enrolled youth aged 8-25 years who died by suicide between January 1, 2010, and December 31, 2020 (N = 511). Latent class analysis was used to identify distinct clinical risk subgroups. Results: Three latent classes were identi fied. Internalizing problems were common across all classes, but especially prevalent in class 1, the High Internalizing + Multiple Comorbidities group (n = 152, 30%). A prior history of suicidal behavior was con fined to class 1 decedents, who were otherwise characterized by substance misuse, and multiple psychiatric and medical comorbidities. Class 2 decedents, the Internalizing + Externalizing group (n = 176, 34%), were more often younger, male, Black, and unlikely to have a history of substance misuse. Decedents in class 3, the Internalizing + Substance Misuse group (n = 183, 36%), were more often older and likely to have a history of substance misuse, but unlikely to exhibit other externalizing problems. Discussion: Internalizing psychopathology is particularly common among youth who die by suicide, with comorbid externalizing psychopathology, substance misuse, and medical problems contributing to youth suicide risk. Because less than a third of youth who die by suicide have a prior history of recognized suicidal thinking or behavior, universal screening for youth suicide risk should be considered, particularly in younger children, and efforts to integrate suicide prevention in traditional health care settings should be prioritized. Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Objective:Children who self-harm are at high risk for suicide attempts later in life, yet little is known about the clinical profiles of young children who self-harm. The primary aim of this study is to characterize clinical profiles associated with self-harm in preadolescent children to inform risk recognition and prevention efforts. Method:A retrospective, population-based cohort analysis of children aged 5 to 11 years who presented with self-harm in a medical setting from 2010 to 2020 (N = 878) was conducted using Ohio Medicaid data. Children were followed for 1 year after the initial self-harm event to determine subsequent self-harm events. Results:Of the 878 children with initial self-harm, 116 children (13%) self-harmed again within the following year. Latent class analyses revealed 3 distinct clinical profiles. Children in class 1 tended to be male, typically presented in mental health settings with both externalizing and internalizing disorders, and commonly reported suicidal ideation. Children in class 2 were largely female, presented with internalizing disorders, and often expressed suicidal ideation. Children in class 2 were less likely than those in class 1 to have a history of mental health treatment but were equally at risk for repetitive self-harming behaviors. Children in class 3 tended to be younger and from non-metropolitan areas, with fewer known mental health conditions. Conclusion:Study findings show that children who self-harm have distinct clinical profiles that are associated with elevated risk of future self-harm. Findings underscore the importance of comprehensive risk assessment to guide clinical decision making for young children who self-harm.

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Sofia Chaudhary, MD; Jennifer A. Hoffmann, MD, MS; Christian D. Pulcini, MD, MEd, MPH; Mark Zamani, MS; Matt Hall, PhD; Kristyn N. Jeffries, MD; Rachel Myers, MSCE; Joel Fein, MD, MPH; Bonnie T. Zima, MD, MPH; Peter F. Ehrlich, MD, MSc; Elizabeth R. Alpern, MD, MSCE; Stephen Hargarten, MD, MPH; Karen M. Sheehan, MD, MPH; Eric W. Fleegler, MD, MPH; Monika K. Goyal, MD, MSCE; Children's Hospital Association Research in Gun Related Events (CHARGE) Collaborative

The collaborative care (CoC) model spans multidisciplinary practice arrangements that increase access to mental health services by supporting primary providers to deliver care. It is critical given the increasing demand of mental health care in the face of limited specialist access, which is especially pronounced within child and adolescent psychiatry. Data to date support its feasibility, provider satisfaction, and positive patient outcomes, yet funding issues and stakeholder hesitance continues to limit implementation.

Medically unexplained symptoms or somatic symptoms refer to physical symptoms that do not align with known anatomy or pathology and whose precise etiology is unknown. The DSM-5 now classifies these conditions under the category of somatic symptoms and related disorders. Symptoms often vary, with pain being the most predominant one. These symptoms are common complaints in community and inpatient settings among children and adolescents (Morabito et al, 2021). The impact on the patient and family can be quite detrimental with significant functional impairment, poor school attendance, impaired social interactions, increased healthcare use, impaired family dynamics, and economic burden on the family (Ibeziako et al, 2020). These symptoms can often be challenging to treat with patients frequently presenting with more than 1 complaint. In this session, the presenters will use their clinical expertise to discuss the assessment and management of patients with somatic symptoms across the continuum of care. Presenters will use the most updated literature and their clinical expertise to discuss assessment and management of patients with somatic symptoms across multiple settings. Souraya Torbey, MD, will discuss approaches to assessment and treatment in the ambulatory setting including the unique challenges faced in that setting. Nadia Zaim, MD, will review the role of the inpatient consultation-liaison psychiatry team in assessment as well as creating a constructive dialogue for patients and families. Mirabelle Mattar, MD, will discuss treatment plans for these patients in a medical psychiatric unit. Andrew Gill, PhD, will provide psychological recommendations for establishing care for patients with somatic symptoms and related disorders in the ambulatory setting in addition to higher levels of care. John Campo, MD, concludes with discussant-led synthesis and guides a subsequent question-and-answer session to further facilitate understanding of the topic. The learner will be equipped with the tools necessary to adequately assess and treat patients with somatic symptom and related disorders in all settings.

OBJECTIVE:To identify potential differential changes in youth suicide deaths associated with the coronavirus disease (COVID-19) pandemic to better inform suicide prevention strategies. METHODS:This cross-sectional study analyzed national suicide data for US youth aged 5 to 24 years from 2015 to 2020. Annual and monthly numbers of suicides were extracted overall and by sex, age, race and ethnicity, and method. Expected suicides were modeled from the trend in monthly deaths before COVID-19 (January 1, 2015-February 29, 2020), by using interrupted time-series analyses with quasi-Poisson regression. Rate ratios (RR) and corresponding 95% confidence intervals (CI) were used to compare expected and observed suicides during the first 10 months of COVID-19 (March 1, 2020-December 31, 2020). RESULTS:Among 5568 identified youth suicides during the 2020 pandemic, 4408 (79.2%) were male, 1009 (18.1%) Hispanic, 170 (3.3%) non-Hispanic American Indian/Alaska Native, 262 (4.7%) Asian/Pacific Islander, 801 (14.4%) Black, and 3321 (59.6%) white. There was a significant increase in overall observed versus expected youth suicides during the COVID-19 pandemic (RR = 1.04, 95% CI = 1.01-1.07), equivalent to an estimated 212 excess deaths. Demographic subgroups including males (RR = 1.05, 95% CI = 1.02-1.08), youth aged 5 to 12 years (RR = 1.20, 95% CI = 1.03-1.41) and 18 to 24 years (RR =1.05, 95% CI = 1.02-1.08), non-Hispanic AI/AN youth (RR = 1.20, 95% CI = 1.03-1.39), Black youth (RR = 1.20, 95% CI = 1.12-1.29), and youth who died by firearms (RR = 1.14, 95% CI = 1.10-1.19) experienced significantly more suicides than expected. CONCLUSIONS:Suicide deaths among US youth increased during COVID-19, with substantial variation by sex, age, race and ethnicity, and suicide method. Suicide prevention strategies must be tailored to better address disparities in youth suicide risk.

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

There are currently no national data regarding U.S. Primary Care Physicians' (PCPs') suicide screening practices. This study surveyed 302 U.S. PCPs about their current suicide screening practices to identify service gaps and intervention points for social workers. Although one-third of PCPs reported providing screening and safety planning, few were using evidence-based tools. Factors that increased the likelihood of routine screening were belief in the importance of screening (p < .01), time (p < .01), and access to co-located behavioral health (p < .01). Findings support the role of social workers in primary care and suggest areas for training and collaboration.

Introduction: Deaths of despair (i.e., suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis) have been increasing over the past 2 decades. However, no large-scale studies have examined geographic patterns of deaths of despair in the U.S. This ecologic study identifies geographic and temporal patterns of individual and co-occurring clusters of deaths of despair. Methods: All individuals aged & GE;10 years who died in the U.S. between 2000 and 2019 and resided within the 48 contiguous states and Washington, District of Columbia were included (N=2,171,105). Causes of death were limited to deaths of despair, namely suicide, drug/alcohol overdose, and chronic liver disease and cirrhosis. Univariate and multivariate space-time scan statistics were used to identify individual and co-occurring clusters with excess risk of deaths of despair. County-level RRs account for heterogeneity within each cluster. Analyses were conducted from late 2021 to early 2022. Results: Six suicide clusters, four overdose clusters, nine liver disease clusters, and three co-occurring clusters of all three types of deaths were identified. A large portion of the western U.S., southeastern U.S., and Appalachia/rust belt were contained within the co-occurring clusters. The cooccurring clusters had average county RRs ranging from 1.17 (p<0.001) in the southeastern U.S. to 4.90 (p<0.001) in the western U.S. Conclusions: Findings support identifying and targeting risk factors common to all types of deaths of despair when planning public health interventions. Resources and policies that address all deaths of despair simultaneously may be beneficial for the areas contained within the co-occurring highrisk clusters. Am J Prev Med 2023;65(2):192-200. & COPY; 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

OBJECTIVE:Individuals with psychosis are at increased risk for suicide, with the greatest risk being present during the first few months after diagnosis. The authors aimed to examine whether treatment initiation within 14 days of diagnosis and treatment engagement within 90 days of initiation reduce the risk for deliberate self-harm (DSH) among individuals with first-episode psychosis (FEP).METHODS:A retrospective longitudinal cohort design was adopted by using Ohio Medicaid claims for 6,349 adolescents and young adults ages 15-24 years with FEP. Logistic regression was used to examine factors associated with treatment initiation and engagement. Cox proportional hazard models were used to estimate the impact of treatment initiation and engagement on DSH. Propensity score weighting was used to control for sociodemographic and clinical covariates.RESULTS:Approximately 70% of the sample initiated treatment, 55% of whom engaged in treatment. Treatment initiation and engagement were associated with both demographic and clinical variables. Treatment initiation significantly reduced the hazard of DSH (average treatment effect in the entire population: hazard ratio [HR]=0.62, 95% CI=0.47-0.81; average treatment effect among those treated: HR=0.64, 95% CI=0.52-0.80). In contrast, treatment engagement was not significantly associated with DSH.CONCLUSIONS:These results suggest that the initial treatment contact is essential for reducing DSH among adolescents and young adults with FEP. Additionally, the finding that treatment engagement did not reduce DSH suggests that standard clinical care may not be sufficient for reducing DSH in this population. These findings highlight the need for suicide-specific interventions for individuals with FEP.

OBJECTIVE:Suicide rates and frequency of pediatric emergency department (ED) visits for suicidal thoughts and behaviors have increased among Black preadolescents in the United States in recent years. This study examined whether characteristics of ED visits and treatment management of preadolescents with suicidal thoughts and behaviors differed by race. METHODS:An electronic medical record query identified patients ages 8-12 (N=504) who visited a pediatric ED with a psychiatric-related chief complaint in 2019. The authors examined suicidal thoughts and behaviors that were reported with the Ask Suicide-Screening Questions tool, ED clinical impression, and ED disposition overall and by race. RESULTS:Compared with other racial groups, Black preadolescents were less likely to report suicidal thoughts, despite equivalent lifetime histories of suicide attempts, and were more likely to be brought to the ED by police and discharged (instead of being admitted to inpatient psychiatric care). CONCLUSIONS:Research to better understand racial disparities in suicide risk among preadolescents can inform prevention efforts.

AbstractThis chapter synthesizes data on health disparities in suicide rates and lack of service access and discusses current gaps in research, training, and program implementation for underserved populations. We highlight emerging best practices in underserved communities that are innovative and low cost (e.g., frugal interventions) and discuss their implications for the suicide prevention field. Themes covered include the urgency of utilizing a community-based framework, the importance of early identification and upstream approaches to drive down suicide rates, the value of a comprehensive/holistic approach that is strengths-based and includes culture/spirituality, and the critical role of innovative service delivery models.

Key Points Medically unexplained symptoms (MUS) may include pain, fatigue, or urinary, cardiovascular, rheumatologic, or gastrointestinal concerns.Medically unexplained symptoms are often associated with mental health problems, especially with anxiety and depression. Only a small minority of MUS are due to unrecognized physical disease.Assess for physical conditions, yet avoid unnecessary medical tests.Review symptom characteristics and their effect on functioning.Consider using screening tools to help clarify the diagnosis (eg, general psychosocial screening tools, Children’s Somatization Inventory, Functional Disability Inventory).Include the diagnosis of somatic symptom and related disorders from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, in the differential diagnosis, not merely as an excluded diagnosis.Intervention by the pediatric clinician can include all the following steps:Empathetically acknowledging distress caused by MUSReaching agreement with the patient and family on incremental steps toward improving functioning and addressing co-occurring mental health concerns and improving the family’s mental health generally (see General Treatment Approach: Universal Strategies to Reinforce Strengths and Promote Emotional Health Within Families")Encouraging the family to reinforce healthy behaviors and minimize secondary gainConveying optimism that distress will decrease with interventionEducating the patient and familyCoordinating with other clinicians involved in the child’s care to prevent unnecessary attention to physical concerns and costly, intrusive workupsWhen severe impairment occurs, refer to mental health professionals for evidence-based therapy and ensure treatment of co-occurring mental health conditions.