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CFHA Abstract Summaries, Vol 3, Summer 2017

Compiled by: H. Jasna Haller, Brooke Palmer, and Patti Robinson

 

CLINICAL

Rhee, T.G., Capistrant, B.D., Schommer, J.C. Hadsall, R.S., & Uden, D.L. (2017, April 14). Effects of depression screening on diagnosing and treating mood disorder among older adults in office-based primary care outpatient settings: An instrumental variable analysis. Preventative Medicine, 100, 101-111. doi: 10.1016/j.ypmed.2017.04.015

 

OBJECTIVE: The objective of this study is to determine the efficacy of using depression screening assessments within a primary care setting for diagnosing and treating mood disorders among the elderly population.

 

METHODS: An instrumental variable design method is used to control for selection bias.. Data was analyzed using information from the 2010-2012 National Ambulatory Medical Care Survey. The sample size was n=9,313 unweighted. Injury prevention and stress management were the variables used.

 

RESULTS: The study showed mixed findings. Based on depression screening alone, a negative correlation to potentially inappropriate antidepressant prescriptions was seen and no significant correlation to diagnosing of mood disorders in relation to overall prescriptions.

CONCLUSION: PCPs and care-team members should actively utilize depression assessments as a screening tool to minimize inappropriate dispensing of unnecessary antidepressant prescriptions in the elderly population.

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Newby, J. M., Mewton, L., & Andrews, G. (2017). Transdiagnostic versus disorder-specific internet-delivered cognitive behaviour therapy for anxiety and depression in primary care. Journal of anxiety disorders, 46, 25-34.doi: 10.1016/j.janxdis.2016.06.002

 

OBJECTIVE: To compare effectiveness of disorder-specific versus transdiagnostic internet cognitive behavior therapy (iCBT) for anxiety and depression in primary care settings.

 

METHODS: Patient characteristics, adherence and effectiveness of Transdiagnostic iCBT (n=1005) were compared to disorder-specific programs for generalized anxiety disorder (GAD) (n=738) and depression (n=366) in a naturalistic non-randomised comparison study. Patients completed their iCBT program in primary care. The PHQ-9 (depression), GAD-7 (generalized anxiety), K-10 (distress), and the WHODAS-II (disability) were measured at pre- and post treatment.

 

RESULTS: Patients in the Transdiagnostic program had higher comorbidity rates and baseline distress. All programs were associated with medium to large within-group effect sizes for improving anxiety, depression and distress between pre- and post-treatment (d's=0.64-1.39). Controlling for baseline group differences in severity, we found small effect sizes favoring the Transdiagnostic program over the GAD program in reducing PHQ-9 (d=0.44, 95%CI: 0.34-0.53), K-10 (d=0.21, 95%CI: 0.16-0.35) and WHODAS scores (d=0.20, 95%CI: 0.10-0.29), and small effect sizes favoring the Transdiagnostic program over the Depression program in reducing GAD-7 scores (d=0.48, 95%CI: 0.36-0.60). A smaller proportion of patients completed the Transdiagnostic program (44.9%) compared to the depression (51.6%) and GAD (49.2%) programs, which was attributable to baseline differences in age and symptom severity.

 

CONCLUSIONS: Both Transdiagnostic iCBT and disorder-specific iCBT programs are effective in primary care, but there appears to be small effects favoring Transdiagnostic iCBT. Methods to increase adherence are needed to optimize the benefits to patients, and these findings await replication in a RCT.

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Cano-Garcia, F.J., Gonzalez-Ortega, M.D., Sanduvete-Chaves, S. Chacon-Moscoso, S., & Moreno-Borrego, R. (2017, March 23). Evaluation of a psychological intervention for patients with chronic pain in primary care. Front Pschol., 8: 435. doi: 10.3389/fpsyg.2017.00435

 

OBJECTIVE: To evaluate the use of psychological interventions with patients being treated for chronic pain in a primary care setting.

 

METHODS: The sample pool consisted of 40 patients who were being treated for chronic pain, not related to cancer, in a primary care setting in Seville, Spain. Criteria included: they were an adult, the patient was not currently in an employment dispute, they were not diagnosed with a psychopathology, and not currently receiving psychological treatment. Patients participated in 10 group sessions which were held once per week. Groups were limited to no more than 14 participants. Sessions covered psychoeducation addressing self-management practices and coping strategies such as: breathing and relaxation, attention management, cognitive restructuring, problem solving, dealing with emotions, social and adaptive skills training and life-coaching and goal setting. A functional assessment was completed upon initial interview and at the 6-month follow-up meeting.

 

RESULTS: Based on the results of the study, although initial analysis showed the intervention to be successful, improvement declined with follow-up.

 

CONCLUSION: The results were analyzed statistically and clinically using IMMPACT standards. Data was collected using a high degree of standardization and specificity. Based on the detailed design of the intervention assessment, using psychological interventions in a primary care setting to treat chronic pain patients appears to be an effective strategy.

 

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Erickson, Z. D., Kwan, C. L., Gelberg, H. A., Arnold, I. Y., Chamberlin, V., Rosen, J. A., ... & Kunkel, C. F. (2017). A randomized, controlled multisite study of behavioral interventions for Veterans with mental illness and antipsychotic medication-associated obesity. Journal of General Internal Medicine, 32(1), 32-39. doi: 10.1007/s11606-016-3960-3

 

OBJECTIVE: Due to weight gain and other metabolic sequelae of antipsychotic medications which impact patient health and quality of life, researchers investigated efficacy of a behavioral weight management intervention for veterans with mental illness who were taking antipsychotic medications across four medical centers within the Veterans Affairs (VA) Healthcare System.

 

METHODS: Overweight veterans (and some non-veteran women) diagnosed with mental illness that required ongoing antipsychotic therapy (n = 121) were randomized into either a more intensive “Lifestyle Balance” intervention group (LB, n = 62) or the less intensive “Usual Care” group (UC, n = 59). Study participation lasted for 12 months. LB was modified from the Diabetes Prevention Program and consisted of classes and individual nutritional counseling with a dietitian. UC consisted of weight monitoring and provision of self-help skills. Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly.

 

RESULTS: Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p < 0.001] and percent body fat [F(1,1121) = 4.3, p = 0.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246) = 13.9, p < 0.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243) = 22.5, p < 0.001 and F(1,1221) = 4.8, p = 0.029, respectively]. The majority of LB 3 participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (p < 0.001).

CONCLUSIONS: Behavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. "Lifestyle Balance" integrates well with VA healthcare's patient-centered "Whole Health" approach.

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Acosta, M. C., Possemato, K., Maisto, S. A., Marsch, L. A., Barrie, K., Lantinga, L., ... & Rosenblum, A. (2017). Web-delivered CBT reduces heavy drinking in OEF-OIF veterans in primary care with symptomatic substance use and PTSD. Behavior Therapy, 48(2), 262-276. doi: 10.1016/j.beth.2016.09.001

 

OBJECTIVE: In order to increase access to behavioral health treatment for veterans, researchers sought to evaluate a novel web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care.

 

METHODS: Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined.

 

RESULTS: Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future.

 

CONCLUSION: These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns.

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Mavandadi, S., Wright, E. M., Graydon, M. M., Oslin, D. W., & Wray, L. O. (2017). A randomized pilot trial of a telephone-based collaborative care management program for caregivers of individuals with dementia. Psychological Services, 14(1), 102-111. doi: 10.1037/ser0000118.

 

OBJECTIVE: To assess the effectiveness of an accessible, telephone-based, patient- and caregiver(CG)-centered, collaborative care management program that involves CG education and psychosocial support in improving CG and patient outcomes.

 

METHODS: CBs (n = 75) of older veterans with dementia receiving care from Veterans Affairs (VA) Medical Center primary care practices were randomized to receive either dementia care management or usual care (UC). Of interest in this study were the frequency and severity of patients’ dementia-related symptoms, CG distress related to patients’ behavioral and neuropsychiatric symptoms (primary outcomes), and CG coping and mastery (secondary outcomes).

 

RESULTS: Adjusted, intention-to-treat longitudinal models suggest that CGs receiving care management reported significantly greater reductions in distress due to patients’ dementia-related (p = .05) and neuropsychiatric (p = .01) symptoms compared with CGs in UC. Additionally, CGs in the intervention reported significantly larger improvements in their ability to cope (p = .03) and caregiving mastery (p = .03). No significant group differences were found in CG burden or patients’ dementia-related symptom frequency or severity over time.

 

CONCLUSION: Findings suggest that CGs of veterans with dementia may benefit from a telephone-delivered care management program in improving CG-related outcomes. They highlight the potential for such programs as adjuncts to dementia care offered in primary care practices.

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Van Orden, M., Leone, S., Haffmans, J., Spinhoven, P., & Hoencamp, E. (2017). Predication of mental health services use one year after regular referral to specialized care versus referral to stepped collaborative care. Community Men. Health J., 53(3): 316-323. doi: 10.1007/s10597-016-0046-y

 

OBJECTIVE: To determine the referring patients with common mental health disorders to the collaborative mental health care-team within primary care setting as opposed direct referral to specialized practitioners would lower enabling factors identified as service use and treatment delay.

 

METHODS: A post-hoc analysis of baseline characteristics was used to evaluate treatment intensity (number of visits) during 1-year follow-up. Multilevel multivariate regression analyses of baseline data were taken into consideration and this data counted as potential predicators of visit counts.

 

RESULTS: Showed the enabling factors service concept and referral delay for treatment had a significant correlation to mental health visit counts, particularly when the results were dichotomized over five or more visits. By including outcome variables as a count variable affirmed the predictive value of the enabling factors (service concept and referral delay) and added marital status as a significant predicator.

 

CONCLUSION: Enabling factors appear to be key predicators of mental health services use.

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Kelly, E., Duan, L., Cohen, H., Kiger, H., Pancake, L., & Brekke, J. (2017, April). Integrating behavioral healthcare for individuals with serious mental illness: A randomized controlled trial of a peer health navigator intervention. Schizophr Res., 182: 135-141. doi: 10.1016/j.schres.2016.10.031

 

OBJECTIVE: To determine if populations dually diagnosed with a mental-physical health condition would be better served through interventions which improve health and health-care self-management skills.

 

METHODS: For this study, 151 consumers diagnosed with serious mental illnesses randomly received either standard mental healthcare plus the Bridge intervention (n=76) or standard mental healthcare while on a 6-month waitlist (n=75). Those on a waitlist received services post-waitlist period.

 

RESULTS: A comparison of the results for the two groups showed those receiving immediate treatment (the non-waitlist group) had greater improvement in access and use of needed healthcare services, better patient-practitioner relationships, less propensity towards emergency or urgent care use, and improved self-management practices.

 

CONCLUSION: Based on the study results, using manualized treatment plans to address general medical care of individuals who have serious mental illnesses improved outcomes.

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Hiratsuka, V. Y., Moore, L., Dillard, D. A., Avey, J. P., Dirks, L. G., Beach, B., & Novins, D. (2017). Development of a screening and brief intervention process for symptoms of psychological trauma among primary care patients of two American Indian and Alaska native health systems. The Journal of Behavioral Health Services & Research, 44(2), 224-241. doi:10.1007/s11414-016-9519-6

 

OBJECTIVE: To review key points and considerations as made by patients, health care-team members, and tribal leaders with regards to factors which need to be included in the assessment and intervention process when treating adult trauma patients referred to two large American Indian/Alaska native (AI/AN) primary care systems.

 

METHODS: Data was collected and analyzed using a qualitative and iterative method using a community based participatory approach directed by a cross-site steering committee. A total of 24 leaders and providers each participated in the interview process. Thirteen patients participated in four focus groups.

 

RESULTS: Based on the data collected and using a thematic approach, a preliminary trauma screening assessment, intervention guidelines and materials were developed for use when treating patients from the AI/AN community.

 

CONCLUSION: Although the preliminary study proved to be productive in developing a screening tool and brief intervention process, it was determined that based on the nature of the traumas experienced by this population further research would need to be conducted in these health systems to determine efficacy.

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Mendoza, K., Ulloa, A., Saaveda, N., Galvan, J., & Berenson, S. (2016). Predicting womens utilization of primary care mental health services in Mexico City. Journal of Primary Care & Community Health. doi: 10.1177/2150131916678497

 

OBJECTIVE: To see if by analyzing social-cultural factors associated with Mexican women seeking primary care mental health services (PCMHS), a hypothesis could be postulated to increase PCMHS utilization.

 

METHODS: A questionnaire was administered to 456 female patients in a Mexico City primary care clinic. A chi-square analysis was conducted using social-cultural variables which included demographics, perceptions of and experiences with PCMHS. Based on the results and subsequent literature review a logistic regression model was created.

 

RESULTS: Based on the study results, women who had good coping skills and were not intimidated by talking to a mental health practitioner (MHP), those who did not identify loneliness as a concern, and followed the doctor’s treatment plan, were more likely to pursue PCMHS.

CONCLUSION: It was determined in this population PCP’s play a vital role in a women’s decision to seek mental health services. Consequently, it is important to consider socio-cultural dynamics and proper referrals to PCMHS.

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Lagomasino, I. T., Dwight-Johnson, M., Green, J. M., Tang, L., Zhang, L., Duan, N., & Miranda, J. (2017). Effectiveness of collaborative care for depression in public-sector primary care clinics serving Latinos. Psychiatric Services, 68(4), 353-359. doi:10.1176/appi.ps.201600187

 

OBJECTIVE: To determine the impact of a collaborative care intervention for depression that was tailored for low-income Latino patients in public-sector clinics.

 

METHODS: 400 depressed patients from three public-sector primary care clinics were enrolled in a randomized controlled trial of a tailored collaborative care intervention versus enhanced usual care. Social workers without previous mental health experience served as depression care specialists for the intervention patients (N = 196). Depending on patient preference, they delivered a cognitive-behavioral therapy (CBT) intervention or facilitated antidepressant medication given by primary care providers or both. In enhanced usual care, patients (N = 204) received a pamphlet about depression, a letter for their primary care provider stating that they had a positive depression screen, and a list of local mental health resources. Intent-to-treat analyses examined clinical and process-of-care outcomes at 16 weeks.

 

RESULTS: Compared with patients in the enhanced usual care group, patients in the intervention group had significantly improved depression, quality of life, and satisfaction outcomes (p<.001 for all). Intervention patients also had significantly improved quality-of-care indicators, including the proportion of patients receiving either psychotherapy or antidepressant medication (77% versus 21%, p<.001).

CONCLUSIONS: Collaborative care for depression can greatly improve care and outcomes in public-sector clinics. Social workers without prior mental health experience can effectively provide CBT and manage depression care.

 

 

 

 


   

EDUCATIONAL

Anderson, P., Kaner, E., Keurhorst, M., Bendtsen, P., Steenkiste, B. V., Reynolds, J., ... & Drummond, C. (2017). Attitudes and learning through practice are key to delivering brief interventions for heavy drinking in primary health care: Analyses from the odhin five country cluster randomized factorial trial. International Journal of Environmental Research and Public Health, 14(2), 121. doi:10.3390/ijerph14020121.

 

OBJECTIVE: In order to increase the frequency and confidence with which primary care providers screen and refer patients for heavy drinking behaviors, researchers analyzed relationships between receipt of training, financial reimbursement, and primary care provider attitudes towards working with patients.

 

METHODS: 756 primary health care providers were recruited from 120 primary health care units (PHCUs) in different locations throughout Catalonia, England, The Netherlands, Poland, and Sweden. Our interventions were training and support and financial reimbursement to providers. Our design was a randomized factorial trial with baseline measurement period, 12-week implementation period, and 9-month follow-up measurement period. Our outcome measures were: attitudes of individual providers in working with drinkers as measured by the Short Alcohol and Alcohol Problems Perception Questionnaire; and the proportion of consulting adult patients (age 18+ years) who screened positive and were given advice to reduce their alcohol consumption (intervention activity).

 

RESULTS: We found that more positive attitudes were associated with higher intervention activity, and higher intervention activity was then associated with more positive attitudes. Training and support was associated with both positive changes in attitudes and higher intervention activity. Financial reimbursement was associated with more positive attitudes through its impact on higher intervention activity.

CONCLUSION: Improving primary health care providers' screening and brief advice activity for heavy drinking requires a combination of training and support and on-the-job experience of actually delivering screening and brief advice activity.

 


     

FINANCIAL

 

Duarte, A., Walker, S., Littlewood, E., Brabyn, S., Hewitt, C., Gilbody, S., & Palmer, S. (2017). Cost-effectiveness of computerized cognitive–behavioural therapy for the treatment of depression in primary care: findings from the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Psychological Medicine, 1-11. doi: 10.1017/S0033291717000289. [Epub ahead of print]

 

OBJECTIVE: To assess the cost-effectiveness of computerized cognitive-behavioural therapy (cCBT) as an adjunct to usual general practitioner (GP) care compared with usual GP care alone and to establish the differential cost-effectiveness of a free-to-use cCBT programme (MoodGYM) in comparison with a commercial programme (Beating the Blues) in primary care.


METHODS:
Costs were estimated from a healthcare perspective and outcomes measured using quality-adjusted life years (QALYs) over 2 years. The incremental cost-effectiveness of each cCBT programme was compared with usual GP care. Uncertainty was estimated using probabilistic sensitivity analysis and scenario analyses were performed to assess the robustness of results.

 

RESULTS: Neither cCBT programme was found to be cost-effective compared with usual GP care alone. At a £20 000 per QALY threshold, usual GP care alone had the highest probability of being cost-effective (0.55) followed by MoodGYM (0.42) and Beating the Blues (0.04). Usual GP care alone was also the cost-effective intervention in the majority of scenario analyses. However, the magnitude of the differences in costs and QALYs between all groups appeared minor (and non-significant).

CONCLUSION: Technically supported cCBT programmes do not appear any more cost-effective than usual GP care alone. No cost-effective advantage of the commercially developed cCBT programme was evident compared with the free-to-use cCBT programme. Current UK practice recommendations for cCBT may need to be reconsidered in the light of the results.

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Basu, S., Jack, H. E., Arabadjis, S. D., & Phillips, R. S. (2017). Benchmarks for reducing emergency department visits and hospitalizations through community health workers integrated into primary care: A cost-benefit analysis. Medical Care, 55(2), 140-147. doi: 10.1097/MLR.0000000000000618.

 

OBJECTIVE: To determine how much community health workers (CHWs) would need to reduce emergency department (ED) visits and associated hospitalizations among their assigned patients to be cost-neutral from a payer's perspective.

 

METHODS: Using a microsimulation of patient health care utilization, costs, and revenues, we estimated what portion of ED visits and hospitalizations for different conditions would need to be prevented by a CHW program to fully pay for the program's expenses. The model simulated CHW programs enrolling patients with a history of at least 1 ED visit for a chronic condition in the prior year, utilizing data on utilization and cost from national sources.

 

RESULTS: CHWs assigned to patients with uncontrolled hypertension and congestive heart failure, as compared with other common conditions, achieve cost-neutrality with the lowest number of averted visits to the ED. To achieve cost-neutrality,4-5 visits to the ED would need to be averted per year by a CHW assigned a panel of 70 patients with uncontrolled hypertension or congestive heart failure-approximately 3%-4% of typical ED visits among such patients, respectively. Most other chronic conditions would require between 7% and 12% of ED visits to be averted to achieve cost-savings.

CONCLUSIONS: Offsetting costs of a CHW program is theoretically feasible for many common conditions. Yet the benchmark for reducing ED visits and associated hospitalizations varies substantially by a patient's primary diagnosis.

 


     

OPERATIONAL

 

Drummond, K. L., Painter, J. T., Curran, G. M., Stanley, R., Gifford, A. L., Rodriguez-Barradas, M., ... & Pyne, J. M. (2017). HIV patient and provider feedback on a telehealth collaborative care for depression intervention. AIDS Care, 29(3), 290-298. doi: 10.1080/09540121.2016.1255704

 

OBJECTIVE: In the HIV Translating Initiatives for Depression into Effective Solutions project, we conducted a randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care in Veterans Health Administration HIV clinics in the US.

 

METHODS: An offsite HIV depression care team including a psychiatrist, a depression care manager (DCM), and a clinical pharmacist provided collaborative care using a stepped-care model of treatment and made recommendations to providers through the electronic health record system. The DCM delivered care management to HIV patients through phone calls, performing routine assessments and providing counseling in self-management and problem-solving. The DCM documented all calls in patients’ electronic medical records. In this paper we present results from interviews conducted with patients and clinical staff in a multi-stage formative evaluation (FE). We conducted semi-structured FE interviews with 26 HIV patients and 30 clinical staff at the three participating sites during and after the trial period to gather their experiences and perspectives concerning the intervention components. Interviews were transcribed verbatim and analyzed using rapid content analysis techniques.

 

RESULTS: Patients reported high satisfaction with DCM phone calls. Both HIV and mental health providers reported that the DCM's chart notes in the electronic health record were very helpful, and most felt that a dedicated DCM for HIV patients is ideal to meet patient needs. Sites encountered barriers to achieving and maintaining universal depression screening, but had greater success when such screening was incorporated into routine intake processes.

 

CONCLUSION: FE results demonstrated that depression care management via telehealth from an offsite team is acceptable and helpful to both HIV patients and their providers. Given that a centralized offsite depression care team can deliver effective, cost-effective, cost-saving services for multiple HIV clinics in different locations with high patient and provider satisfaction, broad implementation should be considered.

 


     

POLICY

 

King, C. A., Horwitz, A., Czyz, E., & Lindsay, R. (2017). Suicide risk screening in healthcare settings: Identifying males and females at risk. Journal of Clinical Psychology in Medical Settings, 24(1), 8-20. doi: 10.1007/s10880-017-9486-y.

 

OBJECTIVE: Make a case for importance of addressing suicidality in United States and paying attention to gender differences in suicidal patients. Set forth practice recommendations based on National Action Alliance for Suicide Preventions “Zero Suicide” goal complete with screening schools and steps to take when a patient screens positive for suicide risk.

 

METHODS: Literature review conducted and practice recommendations made.

 

RESULTS: Given the substantially higher suicide rate among males than females, we argue that it is important to consider how we could optimize suicide risk screening strategies to identify males at risk and females at risk. Further research is needed to accomplish this goal. It is recommended that we consider multi-factorial suicide risk screens that incorporate risk factors known to be particularly important for males as well as computerized, adaptive screens that are tailored for the specific risk considerations of the individual patient, male or female. These strategies are not mutually exclusive.

CONCLUSION: universal suicide risk screening in healthcare settings, especially primary care, specialty medical care, and emergency department settings, is recommended

 

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