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Importance: Given that the Patient Health Questionnaire (PHQ) item 9 is commonly used to screen for risk of self-harm and suicide, it is important that clinicians recognize circumstances when at-risk adolescents may go undetected., Objective: To understand characteristics of adolescents with a history of depression who do not endorse the PHQ item 9 before a near-term intentional self-harm event or suicide., Design, Setting, and Participants: This was a retrospective cohort study design using electronic health record and claims data from January 2009 through September 2017. Settings included primary care and mental health specialty clinics across 7 integrated US health care systems. Included in the study were adolescents aged 13 to 17 years with history of depression who completed the PHQ item 9 within 30 or 90 days before self-harm or suicide. Study data were analyzed September 2022 to April 2023., Exposures: Demographic, diagnostic, treatment, and health care utilization characteristics., Main Outcome(s) and Measure(s): Responded "not at all" (score = 0) to PHQ item 9 regarding thoughts of death or self-harm within 30 or 90 days before self-harm or suicide., Results: The study included 691 adolescents (mean [SD] age, 15.3 [1.3] years; 541 female [78.3%]) in the 30-day cohort and 1024 adolescents (mean [SD] age, 15.3 [1.3] years; 791 female [77.2%]) in the 90-day cohort. A total of 197 of 691 adolescents (29%) and 330 of 1024 adolescents (32%), respectively, scored 0 before self-harm or suicide on the PHQ item 9 in the 30- and 90-day cohorts. Adolescents seen in primary care (odds ratio [OR], 1.5; 95% CI, 1.0-2.1; P = .03) and older adolescents (OR, 1.2; 95% CI, 1.0-1.3; P = .02) had increased odds of scoring 0 within 90 days of a self-harm event or suicide, and adolescents with a history of inpatient hospitalization and a mental health diagnosis had twice the odds (OR, 2.0; 95% CI, 1.3-3.0; P = .001) of scoring 0 within 30 days. Conversely, adolescents with diagnoses of eating disorders were significantly less likely to score 0 on item 9 (OR, 0.4; 95% CI, 0.2-0.8; P = .007) within 90 days., Conclusions and Relevance: Study results suggest that older age, history of an inpatient mental health encounter, or being screened in primary care were associated with at-risk adolescents being less likely to endorse having thoughts of death and self-harm on the PHQ item 9 before a self-harm event or suicide death. As use of the PHQ becomes more widespread in practice, additional research is needed for understanding reasons why many at-risk adolescents do not endorse thoughts of death and self-harm.

Introduction: With stressors that are often associated with suicide increasing during the coronavirus disease 2019 (COVID-19) pandemic, there has been concern that suicide mortality rates may also be increasing. Our objective was to determine whether suicide mortality rates increased during the COVID-19 pandemic., Methods: We conducted an interrupted time-series study using data from January 2019 through December 2020 from 2 large integrated health care systems. The population at risk included all patients or individuals enrolled in a health plan at HealthPartners in Minnesota or Henry Ford Health System in Michigan. The primary outcome was change in suicide mortality rates, expressed as annualized crude rates of suicide death per 100,000 people in 10 months following the start of the pandemic in March 2020 compared with the 14 months prior., Results: There were 6,434,675 people at risk in the sample, with 55% women and a diverse sample across ages, race/ethnicity, and insurance type. From January 2019 through February 2020, there was a slow increase in the suicide mortality rate, with rates then decreasing by 0.45 per 100,000 people per month from March 2020 through December 2020 (SE=0.19, P=0.03)., Conclusions: Overall suicide mortality rates did not increase with the pandemic, and in fact slightly declined from March to December 2020. Our findings should be confirmed across other settings and, when available, using final adjudicated state mortality data., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the association between thoughts of death or self-harm reported on item 9 of the Patient Health Questionnaire (PHQ) depression module and the risk of suicide attempt or suicide death over the following 2 years., Method: In 4 health care systems participating in the Mental Health Research Network, electronic records identified 509,945 adult outpatients completing 1,228,308 PHQ depression questionnaires during visits to primary care, specialty mental health, and other outpatient providers between January 1, 2007 and December 31, 2012. 9,203 nonfatal suicide attempts were identified using health system records of inpatient or outpatient encounters for self-inflicted injury. 484 suicide deaths were identified using cause-of-death codes from state mortality data., Results: Cumulative hazard of suicide attempt during 2 years ranged from approximately 0.5% among those reporting thoughts of death or self-harm "not at all" to 3.5% among those reporting such thoughts "nearly every day." Cumulative hazard of suicide death during 2 years ranged from approximately 0.04% among those responding "not at all" to 0.19% among those responding "nearly every day." The excess hazard associated with thoughts of death or self-harm declined with time, but remained 2- to 5-fold higher for at least 18 months. Nevertheless, 39% of suicide attempts and 36% of suicide deaths within 30 days of completing a PHQ occurred among those responding "not at all" to item 9., Conclusions: In community practice, response to PHQ item 9 is a strong predictor of suicide attempt and suicide death over the following 2 years. For patients reporting thoughts of death or self-harm, suicide prevention efforts must address this enduring vulnerability., Competing Interests: The authors have no relevant financial interests to disclose., (© Copyright 2016 Physicians Postgraduate Press, Inc.)

Objective: To investigate if the widely publicized warnings in 2003 from the US Food and Drug Administration about a possible increased risk of suicidality with antidepressant use in young people were associated with changes in antidepressant use, suicide attempts, and completed suicides among young people., Design: Quasi-experimental study assessing changes in outcomes after the warnings, controlling for pre-existing trends., Setting: Automated healthcare claims data (2000-10) derived from the virtual data warehouse of 11 health plans in the US Mental Health Research Network., Participants: Study cohorts included adolescents (around 1.1 million), young adults (around 1.4 million), and adults (around 5 million)., Main Outcome Measures: Rates of antidepressant dispensings, psychotropic drug poisonings (a validated proxy for suicide attempts), and completed suicides., Results: Trends in antidepressant use and poisonings changed abruptly after the warnings. In the second year after the warnings, relative changes in antidepressant use were -31.0% (95% confidence interval -33.0% to -29.0%) among adolescents, -24.3% (-25.4% to -23.2%) among young adults, and -14.5% (-16.0% to -12.9%) among adults. These reflected absolute reductions of 696, 1216, and 1621 dispensings per 100,000 people among adolescents, young adults, and adults, respectively. Simultaneously, there were significant, relative increases in psychotropic drug poisonings in adolescents (21.7%, 95% confidence interval 4.9% to 38.5%) and young adults (33.7%, 26.9% to 40.4%) but not among adults (5.2%, -6.5% to 16.9%). These reflected absolute increases of 2 and 4 poisonings per 100,000 people among adolescents and young adults, respectively (approximately 77 additional poisonings in our cohort of 2.5 million young people). Completed suicides did not change for any age group., Conclusions: Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting., (© Lu et al 2014.)

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. [ABSTRACT FROM AUTHOR]

Purpose: Observational studies assessing effects of medical products on suicidal behavior often rely on health record data to account for pre‐existing risk. We assess whether high‐dimensional models predicting suicide risk using data derived from insurance claims and electronic health records (EHRs) are superior to models using data from insurance claims alone. Methods: Data were from seven large health systems identified outpatient mental health visits by patients aged 11 or older between 1/1/2009 and 9/30/2017. Data for the 5 years prior to each visit identified potential predictors of suicidal behavior typically available from insurance claims (e.g., mental health diagnoses, procedure codes, medication dispensings) and additional potential predictors available from EHRs (self‐reported race and ethnicity, responses to Patient Health Questionnaire or PHQ‐9 depression questionnaires). Nonfatal self‐harm events following each visit were identified from insurance claims data and fatal self‐harm events were identified by linkage to state mortality records. Random forest models predicting nonfatal or fatal self‐harm over 90 days following each visit were developed in a 70% random sample of visits and validated in a held‐out sample of 30%. Performance of models using linked claims and EHR data was compared to models using claims data only. Results: Among 15 845 047 encounters by 1 574 612 patients, 99 098 (0.6%) were followed by a self‐harm event within 90 days. Overall classification performance did not differ between the best‐fitting model using all data (area under the receiver operating curve or AUC = 0.846, 95% CI 0.839–0.854) and the best‐fitting model limited to data available from insurance claims (AUC = 0.846, 95% CI 0.838–0.853). Competing models showed similar classification performance across a range of cut‐points and similar calibration performance across a range of risk strata. Results were similar when the sample was limited to health systems and time periods where PHQ‐9 depression questionnaires were recorded more frequently. Conclusion: Investigators using health record data to account for pre‐existing risk in observational studies of suicidal behavior need not limit that research to databases including linked EHR data. [ABSTRACT FROM AUTHOR]

Background: Few studies report on machine learning models for suicide risk prediction in adolescents and their utility in identifying those in need of further evaluation. This study examined whether a model trained and validated using data from all age groups works as well for adolescents or whether it could be improved.Methods: We used healthcare data for 1.4 million specialty mental health and primary care outpatient visits among 256,823 adolescents across 7 health systems. The prediction target was 90-day risk of suicide attempt following a visit. We used logistic regression with least absolute shrinkage and selection operator (LASSO) and generalized estimating equations (GEE) to predict risk. We compared performance of three models: an existing model, a recalibrated version of that model, and a newly-learned model. Models were compared using area under the receiver operating curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value.Results: The AUC produced by the existing model for specialty mental health visits estimated in adolescents alone (0.796; [0.789, 0.802]) was not significantly different than the AUC of the recalibrated existing model (0.794; [0.787, 0.80]) or the newly-learned model (0.795; [0.789, 0.801]). Predicted risk following primary care visits was also similar: existing (0.855; [0.844, 0.866]), recalibrated (0.85 [0.839, 0.862]), newly-learned (0.842, [0.829, 0.854]).Limitations: The models did not incorporate non-healthcare risk factors. The models relied on ICD9-CM codes for diagnoses and outcome measurement.Conclusions: Prediction models already in operational use by health systems can be reliably employed for identifying adolescents in need of further evaluation. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies report that item 9 of the Patient Health Questionnaire (PHQ9) is useful for stratifying risk of suicide attempt in adults. This study re-produced the utility of item 9 of PHQ9 in assessing risk of suicide attempt in adolescents.Materials and Methods: Individuals aged 13 to 17 years in 4 health systems with a diagnosis of depression and history of treatment were included. We estimated time to first observed fatal or non-fatal suicide attempt in the 2 years following completion of a PHQ9, stratified by response to item 9.Results: There were 51,807 PHQ9 questionnaires for 20,363 youth and 861 instances of suicide attempt. Cumulative probability of suicide attempt ranged from approximately 3.3% (95% CI, 3.0 to 3.5%) for those responding "not at all" on item 9 to 10.8% (95% CI, 9.2 to 12.4%) for those responding "nearly every day". These probabilities are more than 3 times higher than previously reported in adults.Conclusion: PHQ item 9 is useful for stratifying risk of suicide attempt in the 2 years following completion of the questionnaire. Monitoring PHQ item 9 over time for patients in treatment for depression can be useful for population health management of adolescents with depression. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the association between patterns of alcohol use and short-term risk of suicide attempt among patients with and without reported suicidal ideation. Methods: Kaiser Permanente Washington electronic health record data were used to identify mental health visits (1/1/2010-6/30/2015) with documented assessments for unhealthy alcohol use (AUDIT-C) and suicidal ideation (PHQ-9 ninth question). Logistic regression fit using generalized estimating equations were used to conduct visitlevel analyses, accounting for correlation between individuals' assessments. Separate models evaluated the association between (1) level of alcohol consumption and (2) frequency of heavy episodic drinking (HED), in combination with suicidal ideation (any vs none), with suicide attempt within 90 days following each visit. Primary models adjusted for age, gender, race/ethnicity and visit year. Results: Of 59,705 visits (43,706 unique patients), 372 (0.62%) were followed by a suicide attempt within 90 days. The risk of suicide attempt was significantly higher for patients reporting suicidal ideation across all levels of alcohol consumption compared to patients reporting low-level alcohol use and no suicidal ideation, particularly high-level use (OR 9.77, 95% CI, 6.23-15.34). Similarly, risk of suicide attempt was higher for patients reporting suicidal ideation across all levels of HED relative to those reporting no HED or suicidal ideation, particularly HED monthly or more (OR 6.80, 95% CI 4.77-9.72). Among patients reporting no suicidal ideation, no associations were observed. Conclusions: Findings underscore the potential value of offering alcohol-related care to patient reporting suicidal ideation. Additional strategies are needed to identify suicide risk among those reporting no suicidal ideation. [ABSTRACT FROM AUTHOR]

Objective: The authors sought to develop and validate models using electronic health records to predict suicide attempt and suicide death following an outpatient visit.Method: Across seven health systems, 2,960,929 patients age 13 or older (mean age, 46 years; 62% female) made 10,275,853 specialty mental health visits and 9,685,206 primary care visits with mental health diagnoses between Jan. 1, 2009, and June 30, 2015. Health system records and state death certificate data identified suicide attempts (N=24,133) and suicide deaths (N=1,240) over 90 days following each visit. Potential predictors included 313 demographic and clinical characteristics extracted from records for up to 5 years before each visit: prior suicide attempts, mental health and substance use diagnoses, medical diagnoses, psychiatric medications dispensed, inpatient or emergency department care, and routinely administered depression questionnaires. Logistic regression models predicting suicide attempt and death were developed using penalized LASSO (least absolute shrinkage and selection operator) variable selection in a random sample of 65% of the visits and validated in the remaining 35%.Results: Mental health specialty visits with risk scores in the top 5% accounted for 43% of subsequent suicide attempts and 48% of suicide deaths. Of patients scoring in the top 5%, 5.4% attempted suicide and 0.26% died by suicide within 90 days. C-statistics (equivalent to area under the curve) for prediction of suicide attempt and suicide death were 0.851 (95% CI=0.848, 0.853) and 0.861 (95% CI=0.848, 0.875), respectively. Primary care visits with scores in the top 5% accounted for 48% of subsequent suicide attempts and 43% of suicide deaths. C-statistics for prediction of suicide attempt and suicide death were 0.853 (95% CI=0.849, 0.857) and 0.833 (95% CI=0.813, 0.853), respectively.Conclusions: Prediction models incorporating both health record data and responses to self-report questionnaires substantially outperform existing suicide risk prediction tools. [ABSTRACT FROM AUTHOR]

Background: While clinicians are expected to routinely assess and address suicide risk, existing data provide little guidance regarding the significance of visit-to-visit changes in suicidal ideation.Methods: Electronic health records from four large healthcare systems identified patients completing the Patient Health Questionnaire or PHQ9 at outpatient visits. For patients completing two questionnaires within 90 days, health system records and state vital records were used to identify nonfatal and fatal suicide attempts. Analyses examined how changes in PHQ9 item 9 responses between visits predicted suicide attempt or suicide death over 90 days following the second visit.Results: Analyses included 430,701 pairs of item 9 responses for 118,696 patients. Among patients reporting thoughts of death or self-harm "nearly every day" at the first visit, risk of suicide attempt after the second visit ranged from approximately 2.0% among those reporting continued thoughts "nearly every day" down to 0.5% among those reporting a decrease to "not at all." Among those reporting thoughts of death or self-harm "not at all" at the first visit, risk of suicide attempt following the second visit ranged from approximately 0.2% among those continuing to report such thoughts "not at all" up to 1.2% among those reporting an increase to "nearly every day".Conclusions: Resolution of suicidal ideation between visits does imply a clinically important reduction in short-term risk, but prior suicidal ideation still implies significant residual risk. Onset of suicidal ideation between visits does not imply any special elevation compared to ongoing suicidal ideation. Risk is actually highest for patients repeatedly reporting thoughts of death or self-harm. [ABSTRACT FROM AUTHOR]