Shari Jager-Hyman - US grants

PROJECT SUMMARY/ABSTRACT Over half a million people in the U.S. present annually to Emergency Departments (EDs) for suicidal ideation (SI) and/or suicidal behavior (SB). After leaving the ED, their short-term risk of repeated self-harm and death by suicide are exceptionally high. Individuals with autism spectrum disorder (ASD) are disproportionally represented among those seen in the ED for suicide-related emergencies. Individuals with ASD are up to nine times more likely to experience SI and up to five times more likely to attempt suicide than the general population. Despite their increased risk for suicide and high rates of suicide-related ED visits, little is known about the experiences or outcomes of suicidal individuals with ASD seeking emergency care. The proposed mixed methods study will contribute to long-term efforts to reduce deaths by suicide by informing the adaptation and implementation of evidence-based practices for suicide prevention for individuals with ASD. The study objectives are: (a) to use a retrospective, longitudinal design to compare the experiences and outcomes of individuals with and without ASD who sought care for SI or SB in EDs nationwide; and (b) to interview key stakeholders about ways to improve ED-based suicide prevention practices and increase post-ED mental health treatment engagement for individuals with ASD. Claims records from over 100 million publicly- and privately-insured individuals will be used to ascertain and follow a diverse national cohort of patients with a suicide-related ED visit. Hospital- and county-level information will be drawn from the American Hospital Association Annual Survey Database, SAMHSA National Survey of Mental Health Treatment Facilities, and Area Resource File. Outcome variables include ED discharge disposition, outpatient mental health service utilization, SI or SB recurrence, and death by suicide (from the National Death Index). Semi-structured interviews with individuals with ASD and suicide-related ED visits, their family members, and ED physicians will elaborate upon the quantitative findings and inform potential targets for future ED-based intervention and implementation strategies. Results will help policy makers and healthcare workers across the U.S. to better understand critical points of prevention and intervention for suicidal individuals with ASD. This project is well- aligned with the Interagency Autism Coordinating Committee's objective to reduce disabling co-occurring mental health conditions and premature mortality in people with ASD, and NIMH's Strategic Objective 4 focused on strengthening the public health impact of NIMH-funded research.

PROJECT SUMMARY Patients at high risk for suicide are less likely to die by suicide if they engage in mental health treatment. Suicidal individuals have difficulty initiating and sustaining involvement in mental health services, yet no studies have systematically developed and tested strategies to increase treatment initiation for suicidal patients. Consistent with NIMH?s Strategic Objective 4 to strengthen the public health impact of NIMH-supported research, the primary objective of this study is to develop acceptable, feasible, low-cost, and effective strategies that increase patients? attendance at a first mental health visit following identification of suicide risk in primary care. We will partner with a large, diverse health system that has implemented collaborative care in eight urban primary care practices to rapidly prototype and test promising strategies to achieve this objective. Rapid prototyping involves a series of rigorous experiments to optimize operations in the early-study stages. Industries outside of healthcare commonly use this approach to learn quickly and ?de-risk? decision-making on a short timeline prior to a large rollout. The strategies we develop and test will be informed by behavioral economics and implementation science methods, leveraging the University of Pennsylvania?s P50 ALACRITY center, and will include strategies that target key mechanisms that impede treatment attendance. First, we will identify characteristics of patients who do or do not attend a first mental health visit following referral using medical records and claims data. Then, we will apply established approaches to contextual inquiry to identify barriers and facilitators to mental health treatment attendance for individuals at risk of suicide. We will use direct observation and brief interviews with key stakeholders (from within and outside of the Penn health system) to understand key barriers and facilitators to engaging patients at risk for suicide in mental health services. Finally, we will rapidly prototype and test strategies to optimize engagement. Using established procedures from implementation science and behavioral economics, relevant theories and frameworks and the extant literature, we will identify preliminary strategies to support attendance at first mental health visit. Strategies will also be developed in collaboration with a team of experts in suicide, implementation science, behavioral economics, and primary and mental health care. Based on the literature and our previous work, we anticipate that strategies that increase motivation (e.g., financial incentives) and foster connectedness (e.g., Caring Contacts) will be needed. We will then iteratively test and refine these preliminary strategies. Throughout this process, we expect to uncover additional barriers and facilitators that will allow us to further refine and optimize implementation strategies. The primary output will be a menu of the most promising and feasible implementation strategies to support the initiation of mental health services for patients at risk of suicide that will be tested in a subsequent trial. The long-term goal of this work is to increase engagement in mental health services for suicidal individuals.