Youths who present with RAP in primary care deserve careful assessment for anxiety and depressive disorders. Future studies should examine treatments that are proved to be efficacious for pediatric anxiety and/or depressive disorders as potential interventions for RAP. Longitudinal, family, and psychobiological studies are needed to illuminate the nature of observed associations among RAP, anxiety, and depression.

IMPORTANCE Little is known about recent trends in rural-urban disparities in youth suicide, particularly sex- and method-specific changes. Documenting the extent of these disparities is critical for the development of policies and programs aimed at eliminating geographic disparities. OBJECTIVE To examine trends in US suicide mortality for adolescents and young adults across the rural-urban continuum. DESIGN, SETTING, AND PARTICIPANTS Longitudinal trends in suicide rates by rural and urban areas between January 1, 1996, and December 31, 2010, were analyzed using county-level national mortality data linked to a rural-urban continuum measure that classified all 3141 counties in the United States into distinct groups based on population size and adjacency to metropolitan areas. The population included all suicide decedents aged 10 to 24 years. MAIN OUTCOMES AND MEASURES Rates of suicide per 100 000 persons. RESULTS Across the study period, 66 595 youths died by suicide, and rural suicide rates were nearly double those of urban areas for both males (19.93 and 10.31 per 100 000, respectively) and females (4.40 and 2.39 per 100 000, respectively). Even after controlling for a wide array of county-level variables, rural-urban suicide differentials increased over time for males, suggesting widening rural-urban disparities (1996-1998: adjusted incidence rate ratio [IRR], 0.98; 2008-2010: adjusted IRR, 1.19; difference in IRR, P = .02). Firearm suicide rates declined, and the rates of hanging/suffocation for both males and females increased. However, the rates of suicide by firearm (males: 1996-1998, 2.05; and 2008-2010: 2.69 times higher) and hanging/suffocation (males: 1996-1998, 1.24; and 2008-2010: 1.63 times higher) were disproportionately higher in rural areas, and rural-urban differences increased over time (P = .002 for males; P = .06 for females). CONCLUSIONS AND RELEVANCE Suicide rates for adolescents and young adults are higher in rural than in urban communities regardless of the method used, and rural-urban disparities appear to be increasing over time. Further research should carefully explore the mechanisms whereby rural residence might increase suicide risk in youth and consider suicide-prevention efforts specific to rural settings.

WHAT'S KNOWN ON THIS SUBJECT: Integrated or collaborative care intervention models have revealed gains in provider care processes and outcomes in adult, child, and adolescent populations with mental health disorders. However optimistic, conclusions are not definitive due to methodologic limitations and a dearth of studies. WHAT THIS STUDY ADDS:This randomized trial provides further evidence for the efficacy of an on-site intervention (Doctor Office Collaborative Care) coordinated by care managers for children' s behavior problems. The findings provide support for integrated behavioral health care using novel provider and caregiver outcomes.abstract OBJECTIVE: To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC). METHODS:Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 160) or enhanced usual care (EUC; n = 161). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate.RESULTS: DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P , .001) and completion (76.6% vs 11.6%, P , .001), improvement in behavior problems, hyperactivity, and internalizing problems (P , .05 to .01), and parental stress (P , .05-.001), remission in behavior and internalizing problems (P , .01, .05), goal improvement (P , .05 to .001), treatment response (P , .05), and consumer satisfaction (P , .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P , .05 to .01).CONCLUSIONS: Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services. Pediatrics 2014;133:e981-e992

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