. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site. KEY RESULTS: Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p<0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means. CONCLUSIONS: This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.

Prediction models incorporating both health record data and responses to self-report questionnaires substantially outperform existing suicide risk prediction tools.

Background Asthma is an inflammatory condition often punctuated by episodic symptomatic worsening, and accordingly, individuals with asthma may have waxing and waning adherence to controller therapy. Objective To measure changes in inhaled corticosteroid (ICS) adherence over time, and to estimate the effect of this changing pattern of use on asthma exacerbations. Methods ICS adherence was estimated from electronic prescription and fill information for 298 participants in the Study of Asthma Phenotypes and Pharmacogenomic Interactions by Race-ethnicity (SAPPHIRE). For each individual we calculated a moving average of ICS adherence for each day of follow-up. Asthma exacerbations were defined as the need for oral corticosteroids, an asthma-related emergency department visit, or an asthma-related hospitalization. Proportional hazard models were used to assess the relationship between ICS medication adherence and asthma exacerbations. Results Adherence to ICS medications began to increase prior to the first asthma exacerbation and continued afterward. Adherence was associated with a reduction in exacerbations, but was only statistically significant among individuals whose adherence was >75% of the prescribed dose (hazard ratio [HR] 0.61; 95% confidence interval [CI] 0.41–0.90) when compared with individuals whose adherence was ≤25%. This pattern was largely confined to individuals whose asthma was not well controlled initially. An estimated 24% of asthma exacerbations were attributable to ICS medication non-adherence. Conclusions Inhaled corticosteroid adherence varies in the time period leading up to and following an asthma exacerbation, and non-adherence likely contributes to a large number of these exacerbations. High levels of adherence are likely required to prevent these events. [ClinicalTrials.gov number NCT01142947]

PURPOSE Recent results suggests the risk of a new onset of depression increases with longer duration of opioid analgesic use. It is unclear whether new-onset depression related to opioid analgesic use is a function of the dose prescribed or the duration of use or both.METHODS Using a retrospective cohort design, we collected patient data from 2000 to 2012 from the Veterans Health Administration (VHA), and from 2003 to 2012 from both Baylor Scott & White Health (BSWH) and the Henry Ford Health System (HFHS). Patients (70,997 VHA patients,13,777 BSWH patients,and 22,981 HFHS patients) were new opioid users, aged 18 to 80 years, without a diagnosis of depression at baseline. Opioid analgesic use duration was defined as 1 to 30, 31 to 90, and more than 90 days, and morphine equivalent dose (MED) was defined as 1 to 50 mg/d, 51 to 100 mg/d, and greater than 100 mg/d of analgesic. Pain and other potential confounders were controlled for by inverse probability of treatment-weighted propensity scores.RESULTS New-onset depression after opioid analgesic use occurred in 12% of the VHA sample, 9% of the BSWH sample, and 11% of the HFHS sample. Compared with 1-to 30-day users, new-onset depression increased in those with longer opioid analgesic use. Risk of new-onset depression with 31 to 90 days of opioid analgesic use ranged from hazard ratio [HR] = 1.18 (95% CI, 1.10-1.25) in VHA to HR = 1.33 (95% CI, 1.16-1.52) in HFHS; in opioid analgesic use of more than 90 days, it ranged from HR = 1.35 (95% CI, 1.26-1.44) in VHA to HR = 2.05 (95% CI, 1.75-2.40) in HFHS. Dose was not significantly associated with a new onset of depression.CONCLUSIONS Opioid-related new onset of depression is associated with longer duration of use but not dose. Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression. Opioid analgesic use, not just pain, should be considered a potential source when patients report depressed mood. Ann Fam Med 2016;14:54-62. doi: 10.1370/afm.1885. INTRODUCTIOND epression co-occurs with chronic noncancer pain 1,2 and is known to be associated with opioid use. Patients with chronic noncancer pain and depression are more likely than those without depression to receive opioids, 3 have a longer duration of use, 4,5 take them at higher morphine equivalent doses (MEDs), 6 and misuse and or abuse opioids. 7,8 A review of psychopathology in pain 9 suggests the opioid epidemic in the United States reflects underdetected and undertreated mental illness in patients with chronic pain.Every year more than 200 million prescriptions for opioids are written in the United States. 10 Known consequences of this opioid epidemic include abuse and accidental overdose.11-13 A less understood adverse outcome and emerging line of inquiry is the association between opioid use and risk of depression. In a study of nearly 50,000 Veterans Health Administration (VHA) patients, opioid analgesic use of longer than 180 14 In a prospective study of chronic pain patients, thos...

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.

Introduction Most individuals make healthcare visits before suicide, but many do not have a diagnosed mental health condition. This study seeks to investigate suicide risk among patients with a range of physical health conditions in a U.S. general population sample and whether risk persists after adjustment for mental health and substance use diagnoses. Methods This study included 2,674 individuals who died by suicide between 2000 and 2013 along with 267,400 controls matched on year and location in a case-control study conducted in 2016 across eight Mental Health Research Network healthcare systems. A total of 19 physical health conditions were identified using diagnostic codes within the healthcare systems' Virtual Data Warehouse, including electronic health record and insurance claims data, during the year before index date. Results Seventeen physical health conditions were associated with increased suicide risk after adjustment for age and sex (p<0.001); nine associations persisted after additional adjustment for mental health and substance use diagnoses. Three conditions had a >twofold increased suicide risk, including traumatic brain injury (AOR=8.80, p<0.001), sleep disorders, and HIV/AIDS. Multimorbidity was present in 38% of cases versus 15.5% of controls, and represented nearly a twofold increased risk for suicide. Conclusions Although several individual conditions, such as traumatic brain injury, were associated with high risk of suicide, nearly all physical health conditions increased suicide risk, even after adjustment for potential confounders. In addition, having multiple physical health conditions increased suicide risk substantially. These data support suicide prevention based on the overall burden of physical health.

Objective The Joint Commission recommends all patients be screened for suicide. However, differences in suicide attempt and death rates may affect how well tools predict risk across age groups. Our objective was to determine whether item 9 of the Patient Health Questionnaire (PHQ9) predicts risk for suicide attempts and deaths across age groups. Methods PHQ9s completed by adult outpatients treated for mental health conditions in 2010–2012 at four Mental Health Research Network-affiliated healthcare systems were used to measure depression severity and suicidal ideation. Suicide attempts were identified via ICD-9 codes and suicide deaths via ICD-10 codes and state death certificates. Results In all, 939,268PHQ9s were completed by 297,290 outpatients. Compared to those without, those with nearly daily suicidal ideation were 5-to-8times more likely to attempt suicide and 3-to-11times more likely to die by suicide within 30 days, and 2-to-4times more likely to attempt suicide and 2-to-6 times more likely to die by suicide within 365 days. The increased risk of suicide death for those with any level of suicidal ideation persisted over two years. The relationships between suicide thoughts and attempts and deaths were similar across age groups. Limitations Our sample was limited to outpatients completing a PHQ9 and relied on pre-existing clinical and administrative data. Conclusions Suicidal ideation reported on the PHQ9 was a robust predictor of suicide attempts and deaths regardless of age, and this increased risk persisted for two years. Healthcare systems should address both the immediate and sustained risk for suicide for patients of all ages.

Objective The Centers for Medicare and Medicaid Services (CMS) implemented a policy in 2012 that penalizes hospitals for ‘excessive’ all-cause hospital readmissions within 30 days after discharge for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. The aim of this study is to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions for heart failure, acute myocardial infarction, and pneumonia. Methods Longitudinal study from 2009-2011 within 11 Mental Health Research Network (MHRN) affiliated health systems. Data were derived from the HMO Research Network Virtual Data Warehouse. Participants were individuals admitted to the hospital for HF, AMI, and pneumonia. All index inpatient hospitalizations for HF, AMI and pneumonia were captured (n=160,169 patient index admissions). Psychiatric diagnoses were measured for the year prior to admission. All-cause readmissions within 30 days of discharge were the outcome variable. Results Approximately 18% of all individuals with these conditions were readmitted within 30-days. The rate was 5% greater for individuals with a past-year psychiatric comorbidity (21.7%) than for those without (16.5%; p<.001). Depression, anxiety, and dementia were associated with more readmissions for those with index hospitalizations for all three conditions independently and combined (p<.05). Substance use and bipolar disorders were linked with higher readmissions for those with initial HF and pneumonia hospitalizations (p<.05). Readmission rates declined overall from 2009-2011. Conclusions Individuals with HF, AMI, and pneumonia experience high rates of readmission, but psychiatric comorbidities appear to increase that risk. Future readmission interventions should consider adding mental health components.