Acute Suicidal Ideation Research Articles

Characteristics of hospital encounters and associated economic burden of patients with major depressive disorder and acute suicidal ideation or behavior

ABSTRACT Objectives Relatively little is known about the hospital experience among patients with major depressive disorder (MDD) and acute suicidal ideation or behavior (MDSI). The objectives of this study were to examine hospital encounter characteristics, including the associated economic burden and risk of subsequent hospital encounters of patients with MDSI in the US. Methods In this retrospective analysis, patients ≥18 years of age with a hospital encounter (emergency department [ED] visit or inpatient admission) were selected from the de-identified Premier Hospital database between 1 January 2017 and 30 September 2018. Patients were required to have MDD as the primary and acute suicidal ideation or behavior as a secondary discharge diagnosis or vice versa. Patient demographics and characteristics of hospital encounters were examined. Rates and costs of subsequent all-cause and MDD-related hospital encounters 6 months following initial discharge were also evaluated. Results The study population consisted of 123,179 patients with a hospital encounter for MDSI (mean age: 38 years, 50.9% female, 74.6% White); 50.2% were treated in the ED only (mean ± standard deviation cost: $693±$630), while 49.8% were admitted as inpatients ($6,478±$7,001). Among those with ED visits, very few (7.0%) received an antidepressant (AD). Among those with an inpatient admission, 87.2% received ≥1 AD and 39.0% received AD augmentation. Overall rates and costs of subsequent all-cause and MDD-related hospital encounters were 22.3% ($5,136±$11,791) and 12.0% ($3,722±$9,621), respectively; nearly half of subsequent encounters (41.3% and 44.3%, respectively) occurred in the first month following initial discharge. Conclusions This analysis of patients with MDSI presenting to US hospitals shows heterogeneity in treatment and a concentration of costly subsequent hospital encounters within 1-month post discharge, suggesting that healthcare systems may benefit from examination of current care pathways for this vulnerable patient population.

Addressing Common Challenges in the Implementation of Collaborative Care for Mental Health: The Penn Integrated Care Program.

We developed and implemented a new model of collaborative care that includes a triage and referral management system. We present initial implementation metrics using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Primary care clinicians in 8 practices referred patients with any unmet mental health needs to the Penn Integrated Care program. Assessments were conducted using validated measures. Patients were primarily triaged to collaborative care (26%) or specialty mental health care with active referral management (70%). We conducted 50 qualitative interviews to understand the implementation process and inform program refinement. Our primary outcomes were reach and implementation metrics, including referral and encounter rates derived from the electronic health record. In 12 months, 6,124 unique patients were referred. Assessed patients reported symptoms consistent with a range of conditions from mild to moderate depression and anxiety to serious mental illnesses including psychosis and acute suicidal ideation. Among patients enrolled in collaborative care, treatment entailed a mean of 7.2 (SD 5.1) encounters over 78.1 (SD 51.3) days. Remission of symptoms was achieved by 32.6% of patients with depression and 39.5% of patients with anxiety. Stakeholders viewed the program favorably and had concrete suggestions to ensure sustainability. The Penn Integrated Care program demonstrated broad reach. Implementation was consistent with collaborative care as delivered in seminal studies of the model. Our results provide insight into a model for launching and implementing collaborative care to meet the needs of a diverse group of patients with the full range of mental health conditions seen in primary care.

Ketamine for acute suicidality in the emergency department: A systematic review.

There are no emergent pharmaceutical interventions for acute suicidal ideation, a common presenting complaint in the ED. Ketamine is a NMDA agonist frequently used by ED physicians for sedation and analgesia. Prior evidence from studies conducted in inpatient psychiatry units suggests that ketamine may have a role in alleviating treatment-resistant depression as well as suicidal ideation. PubMed, MEDLINE, and Cochrane reviews were queried for articles related to keywords ketamine, suicidality, suicidal ideation, and emergency department/room. Relevant articles were selected and reviewed by two separate authors. Three relevant, prospective studies were identified with a mean sample size of 25.7. Each was performed using 0.2mg/kg ketamine for individuals receiving active treatment. Each study reported a decrease in depressive symptoms among those receiving ketamine. One study reported a significant reduction in SI when compared to placebo at 90min that became non-significant by 230min. No significant adverse events were reported in any study. Current evidence suggests that ketamine is a promising, safe potential intervention for acute suicidality in the ED. Convincing evidence for efficacy of ketamine for acute suicidal ideation remains lacking, and this promising potential intervention should be further investigated.

Psychotropic medication use for paediatric mental health patients in an emergency department.

There is paucity of evidence for psychotropic medication use in children and adolescents presenting with mental health (MH) problems to the ED. We set out to describe paediatric psychotropic medication use in the ED. We conducted a retrospective electronic medical record review of ED patients with MH discharge codes at a tertiary paediatric ED in 2018. We assessed the epidemiology and management of patients who received a psychotropic medication. We calculated the odds ratios (ORs with 95% confidence intervals [CIs]) of key demographic factors of medicated versus non-medicated MH patients. During 2018 there were 1695 MH-related presentations to the ED. Of these, 280 presentations resulted in the patient receiving a psychotropic medication (16.5%). Medicated children with MH illness were more likely to be male (OR 1.50, 95% CI 1.16-1.96), have a more acute triage category (OR 3.37, 95% CI 2.28-4.98), have an ED length of stay greater than 12 h (OR 3.96, 95% CI 2.56-6.13) and present after hours (OR 1.51, 95% CI 1.16-1.96). Most had a diagnosis of acute behavioural disturbance or suicidal ideation. A variety of treatment regimens were used but children primarily received a single oral agent (diazepam or olanzapine). Parenteral medications were given in 8.6%. No adverse events were recorded. A minority of children with MH presentations to the ED were medicated. It will require multicentre research to determine the most effective and safe acute psychotropic agents for oral and parenteral use in children in the ED.

Suicidality among adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort Study.

Suicide is a serious public health concern. An increased risk of suicide ideation previously has been reported among survivors of childhood cancer. Suicide mortality was assessed for all potentially eligible survivors (those aged ≥18 years who were ≥5 years after their cancer diagnosis; 7312 survivors). Risk factors for acute suicidal ideation were assessed among clinically evaluated survivors (3096 survivors) and the prevalence of acute ideation was compared with that of community controls (429 individuals). The prevalence of 12-month suicidality was assessed among survivors who could be compared with population data (1255 survivors). Standardized mortality ratios compared rates of suicide mortality among survivors with those of the general population. Risk ratios (RRs) and 95% confidence intervals (95% CIs) derived from generalized linear models identified risk factors associated with acute suicidal ideation. Standardized incidence ratios (SIRs) compared the prevalence of 12-month suicidality among survivors with that of a matched sample from the general population. Survivors reported a similar 12-month prevalence of ideation compared with the general population (SIR, 0.68; 95% CI, 0.35-1.01) and a lower prevalence of suicidal behaviors (planning: SIR, 0.17 [95% CI, 0.07-0.27]; attempts: SIR, 0.07 [95% CI, 0.00-0.15]) and mortality (standardized mortality ratio, 0.60; 95% CI, 0.34-0.86). Among survivors, depression (RR, 12.30; 95% CI, 7.89-19.11), anxiety (RR, 2.19; 95% CI, 1.40-3.40), and financial stress (RR, 1.47; 95% CI, 1.00-2.15) were found to be associated with a higher prevalence of acute suicidal ideation. Survivors of childhood cancer were found to be at a lower risk of suicidal behaviors and mortality, yet endorsed a prevalence of ideation similar to that of the general population. These results are in contrast to previous findings of suicidal ideation among survivors and support the need for further research to inform screening strategies and interventions. The purpose of the current study was to compare the risk of suicidal ideation, behaviors, and mortality in adult survivors of childhood cancer with those of the general population. Risk factors associated with suicidal ideation among survivors of childhood cancer also were examined. Survivors of childhood cancer reported a similar risk of ideation compared with the general population, but a lower risk of suicidal behaviors and mortality. Psychological health and financial stressors were found to be risk factors associated with suicidal ideation. Although adult survivors of childhood cancer did not report a greater risk of suicidality compared with the general population, psychosocial care in survivorship remains essential.

Risk and Protective Factors Associated with Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2015-2016.

We examined the relationship between suicide risk and disability status, as well as risk and protective factors, adjusting for demographic characteristics, among students attending 22 Tribal Colleges and Universities (TCU; 20 rural and 2 urban) across the United States in fall 2015 and 2016. Tribal college students (N = 3,239) participated in a cross-sectional online or paper survey assessing alcohol use patterns and mental health outcomes, yielding a response rate of 31.3%. Of the students surveyed, 8.8% indicated moderate or high suicide risk. Hearing impairment was significantly associated with moderate/high suicide risk (OR = 2.11; 1.24-3.61, P=.006), as was vision impairment (OR= 3.03; 1.92-4.77, P<.001), having a physical/mental/or emotional condition (OR= 2.12; 1.75-2.57, P< .001), experiencing critical appraisal (OR= 1.30; 1.24-1.36, P< .001), and experiencing critical isolation (OR= 1.83; 1.66-2.01, P< .001). Scoring high on resilience (OR= 0.93; 0.92-0.95, P< .001), reporting higher emotional social support (OR= 0.75; 0.70-0.79, P< .001), and reporting higher levels of instrumental social support (OR= 0.69, 0.62-0.76, P< .001) were significantly associated with lower suicide risk. Students attending tribal colleges who experience hearing impairment, sight impairment, or a physical/emotional/mental condition have a greater risk of suicidality. Students experiencing critical appraisal and critical isolation may benefit from behavioral health interventions to reframe these experiences and develop resiliency skills. Developing avenues of emotional and instrumental social support within TCU settings offers key protective factors to buffer the risk of suicidality. Examining additional ways to build resiliency may also offer protection from suicide risk in this population.

FDA approves esketamine treatment for MDD, suicidal ideation

The Food and Drug Administration (FDA) announced Aug. 3 approval of Janssen Pharmaceutical's supplemental new drug application (sNDA) for the expanded use of SPRAVATO esketamine Clll nasal spray for the treatment of major depressive disorder (MDD) with acute suicidal ideation or behavior. SPRAVATO was initially approved by the FDA March 5, 2019, for the treatment of treatment‐resistant depression.

Impact of spirituality and religiosity on suicidal risk among a sample of lebanese psychiatric in-patients

Objectives To evaluate the prevalence of suicidality among the psychiatric inpatients community in Lebanon, and to elucidate the effect of religiosity and spirituality on suicidal thoughts or behaviours. Methods A total sample of 159 patient consecutively admitted to a psychiatric hospital was interviewed. The Ask Suicide-screening Questionnaire (ASQ) was used to assess suicidal risk; the Mature Religiosity Scale (MRS) and the Spirituality Index for Well Being (SIWB) scales were used to assess religiosity and spirituality. Results We found that 45.6% of the participants screened positively on the ASQ, including 37.5% with acute suicidal ideation. A backward logistic regression, taking the negative/positive screening ASQ as the dependent variable, showed that a positive family history of suicide and depression were significantly associated with higher positive suicidal screening, whereas higher spirituality was significantly associated with lower positive suicidal screening. When forcing the mature religiosity scale as an independent variable, the results remained the same. Conclusion Spiritual well-being might be considered an important factor to explore among psychiatric patients. Psychiatric inpatients have a high risk for suicide; the challenge remains for clinicians to identify upon admission patients that are most likely to die from suicide. Key points A positive family history of suicide and depression was significantly associated with higher suicidality. Higher spirituality, but not religiosity, was significantly associated with lower suicidality. Spiritual well-being might be considered an important factor to explore among psychiatric patients. The challenge remains for clinicians to identify patients that are most likely to die from suicide upon admission.

Treatments for Self-Injurious Thoughts and Behaviors in Youth: Progress and Challenges

ABSTRACT Self-injurious thoughts and behaviors (SITBs) remain a common clinical problem in youth. This article reviews the state of knowledge regarding psychosocial treatments for SITBs in youth. Broadly speaking, psychosocial treatments that incorporate parents/family and that emphasize skills development (including emotion regulation and interpersonal skills) appear to produce the best outcomes. We also describe several challenges to the implementation of evidence-based psychotherapy, as well as potential solutions to these challenges, and provide an illustrative case example. Finally, because even evidence-based psychosocial treatments can take weeks to produce effects, increased attention has been given to biological approaches such as esketamine administration and transcranial direct current stimulation that have potential to yield rapid improvement for acute suicidal ideation, though evidence for the safety and efficacy of these approaches is in the early stages.

Treatment of Suicidality in Bipolar Depression With Magnetic Seizure Therapy: Clinical Effects and Neurophysiological Correlates

Electroconvulsive therapy (ECT) is highly effective for acute suicidal ideation but is limited by significant adverse cognitive effects. Magnetic Seizure Therapy (MST) is a novel convulsive treatment with more focal stimulation that has been found to have no adverse cognitive effects and may be effective in bipolar depression. There is evidence that cortical inhibition measured with transcranial magnetic stimulation and electroencephalography (TMS-EEG) may predict treatment response.

Differential diagnosis in case of overdose of antiepileptic treatment. Clinical case

Acute drug-related acute intoxications or suicidal ideation following overdose with anticonvulsants may cause major morbidity, in many cases requiring intensive care and prolonged periods of hospitalization. The case of a 35-year-old patient known for a history of epilepsy with phenobarbital and carbamazepine treatment is brought to the Emergency Unit by transfer from another hospital in a comatose state with insufficient respiratory performance, bilateral active mydriasis. From the family members' claims, the patient discontinued treatment with phenobarbital two weeks ago. Following interdisciplinary examination, hospitalization in the Neurology Department with the diagnosis of epileptic status is decided. Due to the progressive aggravation of acute respiratory insufficiency, the ventilator support is constituted. Since the biological samples related to probability diagnosis and cerebral imaging were not conclusive, toxicological samples were collected. The GC/MS analytical toxicology screening in urine reveals the presence of carbamazepine and phenobarbital and their plasma levels (5.92 and 92.3 mg/l) as determined by the FPIA method indicate an overdose of phenobarbital therapy. The patient is taken over by the Department of Clinical Toxicology where specific intensive care measures are applied. Clinical evolution is favorable. The psychiatric examination highlights the depressive idea, suicidal ideas, and uselessness. The suicide attempt is confirmed. It also presents a review of the main information about acute poisoning with anticonvulsants, but also about the analytical laboratory methods that bring precious information in establishing the diagnosis of certainty.

A suicide prevention strategy for youth presenting to the emergency department with suicide related behaviour: protocol for a randomized controlled trial

BackgroundSuicide is a leading cause of death among adolescents in North America. Youth who present to the Emergency Department (ED) with acute suicidality are at increased risk for eventual death by suicide, thereby presenting an opportunity for secondary prevention of suicide. The current study evaluates the effectiveness of a standardized individual and family-based suicidal behaviour risk reduction intervention targeting adolescents at high-risk for suicide.MethodsA randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of a manualized youth- and family- based suicide prevention strategy (SPS) as compared with case navigation (NAV) among adolescents aged 12 to 18 years of age who present to the ED with acute suicidal ideation (SI) or suicide risk behaviours (SRB). We will recruit 128 participants and compare psychiatric symptoms including SI/SRB, family communication, and functional impairment at baseline and follow-ups (post-intervention [6 weeks], 24 weeks). The primary outcome is change in suicidal ideation measured with the Suicide Ideation Questionnaire- Junior. SRBs are measured with the Suicide Behaviour Questionnaire. Secondary outcomes are change in depressive and anxious symptoms measured with semi-structured psychiatric interview and Screen for Child Anxiety Related Disorders; acute mental health crises measured by urgent medical (including ED) visits; family communication measured with Conflict Behaviour Questionnaire, functional impairment measured by Columbia Impairment Scale; cost effectiveness, and fidelity of implementation measured by audio recording and fidelity checklist.DiscussionResults of this study will inform a larger multi-centre RCT that will include both community and academic hospitals in urban and rural settings. Study results will be shared at international psychiatry and emergency medicine meetings, in local rounds, and via publication in academic journals and clinician-oriented newsletters. If effective, the intervention may provide a brief, scalable, and transportable treatment program that may be implemented in a variety of settings, including those in which access to children’s mental health care services is challenging.Trial registrationClinicalTrials.gov: NCT03488602, retrospectively registered April 4, 2018.

Prevalence of Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2014–2015

Objectives To examine the relationship between suicide risk and hazardous drinking, depression, and anxiety, adjusting for demographics, among tribal college students across the United States. Methods. We invited tribal college students enrolled in 22 tribal colleges from fall 2014 and 2015 to participate in the Creating Campus Change study, a cross-sectional online/paper survey assessing alcohol use patterns and mental health outcomes. 3,239 students participated in the survey, yielding a response rate of 31.3%. We assessed alcohol use, depression, and general anxiety, along with demographic characteristics. We used the Mini-International Neuropsychiatric Interview to assess suicide risk. Results. 8.5% indicated moderate or high suicide risk. In the final adjusted model, moderate/high depression was significantly associated with moderate/high suicide risk (OR = 6.64; 3.91–11.28, p < 0.001), as was moderate/high general anxiety (OR = 2.80; 1.58–4.97, p < 0.001), and moderate/high hazardous drinking (OR = 2.09; 1.19–3.66, p < 0.001). Conclusions. Students attending tribal colleges who report moderate/high levels of depression, anxiety, or hazardous drinking have a greater risk of suicidality. Identifying factors buffering the risk of suicidality could support policy changes necessary to address this critical public health issue.

Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial.

Depressed patients presenting to emergency departments with acute suicidal ideation are a major public health concern. Ketamine, a rapidly acting antidepressant with antisuicidal properties, might offer relief. In a randomized, double-blind, placebo-controlled, proof-of-concept trial, 18 depressed subjects with acute suicidal ideation, who required hospitalization, were randomized to either an intravenous ketamine 0.2 mg/kg group or a saline placebo group. Safety and efficacy evaluations were scheduled for 15, 30, 60, 90, 120, 180, and 240 min, and on Days 1, 2, 3, 7, and 14 after infusion. The main outcome measure was suicidal ideation with secondary measures of depression. Nine subjects were randomized to each group. There were no differences between groups at baseline in any demographic or assessment scales. A reduction in suicidal ideation was noted at 90-180 min (p < .05). Ninety minutes after infusion, 88% of the ketamine group had achieved remission of suicidal ideation compared with 33% in the placebo group (p < .05). No serious adverse events were noted. Ketamine was safe and effective for rapid reduction in suicidal ideation in depressed, highly suicidal subjects presenting to the emergency department. Our results support further study of ketamine for acute suicidal ideation.

Can acute suicidality be predicted by Instagram data? Results from qualitative and quantitative language analyses.

BackgroundSocial media has become increasingly important for communication among young people. It is also often used to communicate suicidal ideation.AimsTo investigate the link between acute suicidality and language use as well as activity on Instagram.MethodA total of 52 participants, aged on average around 16 years, who had posted pictures of non-suicidal self-injury on Instagram, and reported a lifetime history of suicidal ideation, were interviewed using Instagram messenger. Of those participants, 45.5% reported suicidal ideation on the day of the interview (acute suicidal ideation). Qualitative text analysis (software ATLAS.ti 7) was used to investigate experiences with expressions of active suicidal thoughts on Instagram. Quantitative text analysis of language use in the interviews and directly on Instagram (in picture captions) was performed using the Linguistic Inquiry and Word Count software. Language markers in the interviews and in picture captions, as well as activity on Instagram were added to regression analyses, in order to investigate predictors for current suicidal ideation.ResultsMost participants (80%) had come across expressions of active suicidal thoughts on Instagram and 25% had expressed active suicidal thoughts themselves. Participants with acute suicidal ideation used significantly more negative emotion words (Cohen’s d = 0.66, 95% CI: 0.088–1.232) and words expressing overall affect (Cohen’s d = 0.57, 95% CI: 0.001–1.138) in interviews. However, activity and language use on Instagram did not predict acute suicidality.ConclusionsWhile participants differed with regard to their use of language in interviews, differences in activity and language use on Instagram were not associated with acute suicidality. Other mechanisms of machine learning, like identifying picture content, might be more valuable.

Engagement in treatment for depression among people who inject drugs in Baltimore, Maryland

IntroductionMental health care may mitigate negative consequences related to substance use and bolster engagement in care for drug dependence. Despite the increased risk of depression among people who inject drugs (PWID), the longitudinal relationship of depression symptoms with depression and drug treatment utilization in this population remains uncharacterized. MethodsData on depressive symptoms and depression treatment from current and former PWID in the ALIVE (AIDS Linked to the IntraVenous Experience) community-based cohort who had ≥3 study visits from July 2005 to June 2016 were included. We used logistic regression analysis with generalized estimating equations to examine factors associated with depression treatment in the 12 months following reported major depressive symptoms (CES-D ≥ 23) in the absence of treatment. We further examined the association between depression, depression treatment, and subsequent engagement in drug treatment among those with active substance use or alcohol dependence. ResultsOf the 1544 participants, 34% were female, the median age was 51 years, and 91% were African-American. PWID reported major depressive symptoms at 22% of study visits. In adjusted analysis, acute emergency care, suicidal ideation, and recent alcohol or drug treatment were positively associated with initiating depression treatment. Depression was positively associated with subsequent treatment for substance dependence among those actively using (aOR = 1.30, 95% CI: 1.10–1.53). ConclusionsPWID experience a high burden of depressive symptoms with significant unmet need of treatment for depression. Our findings suggest that mental health providers should bolster connections to chronic disease and alcohol and drug treatment providers.

Intranasal Ketamine for Alleviation of Acute Suicidal Ideation. An Emergency Department, Trans-Diagnostic Approach: Randomized, Double-Blind, Placebo-Controlled, Proof-of-Concept Trial

Background: suicidal patients are often presented to the Emergency Department, where specific treatment is lacking. Ketamine, a rapidly acting antidepressant with anti-suicidal properties might offer relief. Methods: thirty eligible participants who suffered acute suicidal ideation and required hospitalization were randomized to intranasal ketamine 40mg or placebo, between August 2016 to April 2018. Safety and efficacy evaluations were scheduled for two and four hours, on days 1, 3, 7, and 21 post administration. Primary outcome was suicidal ideation four hours post administration. Randomization was carried out by the pharmacist while the rest of the study group was blinded. Outcomes: Fifteen subjects were randomised for ketamine and fifteen for control, all were analyzed for primary and secondary outcomes. Four hours post administration the mean difference in suicidal symptoms between the groups, measured by the Montgomery-Asberg Depression Rating Scale (MADRS) item of suicidal thoughts, was 1.267 (95% confident interval 0.1-2.43, P<0.05) favoring the ketamine group, with suicidal ideation remission rates of 80% of the ketamine group compares with 33% of the controls (p<0.05). The mean difference in depressive symptoms, measured by MADRS, at the same time was 9.75 (95% confident interval 0.72-18.79, P<0.05) favoring the ketamine group. The treatment was safe and well-tolerated. Interpretation: Intranasal ketamine alleviated suicidal ideation and improved depressive symptoms four hours post ketamine administration. We present an innovative paradigm for the management of suicidal individuals in emergency setting. Future larger-scale studies are warranted to establish treatment recommendation. Trial Registration Number: ClinicalTrials.gov Identifier: NCT02183272. Funding Statement: This study was supported by the American Foundation of Suicide Prevention. Declaration of Interests: All authors declare no conflict of interests. Ethics Approval Statement: This study was reviewed and approved by the University of Cincinnati Institutional Review Board.

The effects of ketamine on suicidality across various formulations and study settings.

IntroductionSuicidality and self-injurious behavior afflict patients with a wide variety of psychiatric illnesses. Currently, there are few pharmacologic treatments for suicidality and self-injurious behavior and none that treat these conditions emergently. Recently, ketamine has demonstrated efficacy in treating both depression and acute suicidal ideation. An increasing usage of ketamine, of a variety of formulations, has been studied for these indications. This article reviews the evidence for use of ketamine in self-injurious behavior and suicidality.MethodsA review of the MEDLINE database for articles relating to ketamine, self-injurious behavior, suicidality, and self-harm was conducted. Additional articles were assessed via cross-reference.ResultsA total of 24 articles that included clinical trials, meta-analyses, case series, and case reports were analyzed. The majority of studies of ketamine for suicidal ideation include the intravenous route using a dose of 0.5 mg/kg over 40 minutes. These studies suggest that intravenous ketamine may be effective at reducing suicidal ideation acutely. Data on use of ketamine in the intramuscular, intranasal, and oral forms are limited and of poorer quality. Studies on these formulations contain greater variability of positive and negative results of ketamine for reducing suicidality and self-injurious behavior. The durability of the antisuicidal effects across all formulations is limited.DiscussionKetamine may be an effective option for the treatment of suicidal ideation in patients across inpatient, outpatient, or emergent settings. At this time, more research is needed on the efficacy of ketamine across all formulations being used in clinical practice.

Using the PHQ-9 and GAD-7 to screen for acute distress in transgender youth: findings from a pediatric endocrinology clinic.

Background Transgender and gender nonconforming (TGNC) youth are at higher risk for anxiety and depression than their peers. The referral rate for those seeking specialty medical care has rapidly increased in recent years. This paper examines the use of brief screening tools with clear cutoffs to assist physicians in rapidly identifying TGNC youth in acute distress. Methods A retrospective chart review was conducted for patients aged 11-18 years being treated in a pediatric endocrinology clinic for gender dysphoria. Patient Health Questionnaires for depression (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) were collected for patients attending an initial consultation (n=79) or follow-up appointment (n=115). Results Screener data identified high rates of acute distress, including depression (47%), anxiety (61%), and suicidal ideation (30%). Distress was not associated with age or gender identity. More youth endorsed clinically significant anxiety at initial consultation appointments versus follow-up appointments. Conclusions The results support the use of the PHQ-9 and GAD-7 as brief, easy-to-use screening measures that can be administered by physicians to rapidly identify acute distress and inform treatment recommendations among TGNC youth seeking medical intervention.

Lethality of Previous Suicidal Behavior among Patients Hospitalized for Suicide Risk Predicts Lethality of Future Suicide Attempts.

A suicide attempt is an established risk factor for subsequent suicide attempts and suicide. Nonetheless, the prediction of future suicidal behavior is poor. The lethality of previous suicidal behavior may be informative to better understand future suicide risk among patients hospitalized for suicidal thoughts and behavior. The current study examined whether the lethality of patients' index (most recent suicidal episode at hospitalization), first, and worst suicidal episode predicts the lethality of one's most lethal suicide attempt during a 2-year follow-up period. A total of 98 patients hospitalized at an emergency department for high suicide risk (i.e., acute suicidal ideation or a suicide attempt) were included in the study. Results indicated that the lethality of the index suicidal episode predicted the lethality of the worst suicide attempt during a 2-year follow-up period. These findings extend a growing literature examining risk factors that influence the progression toward high lethality suicidal behavior.