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INTRODUCTION: In behavioral health care settings, a workforce well trained in suicide prevention is critically important for behavioral health care professionals across different disciplines and service sectors who are likely to have considerable exposure to patients at risk for suicidal behavior. This study examined the types of training behavioral health care professionals received, their self-reported skills, comfort level and confidence related to suicide prevention, the association of types and length of training with skills, comfort level and confidence, and areas in which participants would like more training. METHODS: The Zero Suicide Workforce Survey was administered electronically to behavioral health care professionals at six behavioral health treatment centers with both inpatient and ambulatory programs in Connecticut, USA. Item numbers and percentages were calculated for 847 respondents with behavioral health care roles. The chi-square tests were performed to determine the statistical significance of group differences. Non-parametric sign tests were performed to determine the statistical significance of the collective differences in direction among items between groups. RESULTS: Suicide prevention training is associated with increased levels of behavioral health care professionals' skills and confidence, but one-third of behavioral health care professionals in the sample received no formal training in suicide prevention/intervention. Even brief training appears to have a positive impact on behavioral health care professionals' assessment of their skills and confidence. Prominent topics for additional training include suicide-specific treatment approaches, suicide prevention and awareness, and identification of risk factors and warning signs. CONCLUSION: Although behavioral health care professionals may often encounter patients at risk for suicide, many have not obtained any relevant training. The findings highlight the need to strengthen suicide identification, assessment and treatment within behavioral health care treatment settings as part of an effort to prevent suicide.

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BACKGROUND: Cambodian Americans have higher rates of health problems compared with the general U.S. POPULATION: A relatively modest community capacity for collecting data contributes to these disparities. OBJECTIVES: To (1) further develop the Cambodian American community's capacity to design and conduct health research meaningful to their community via a community-based participatory research (CBPR) approach, (2) train and deploy bilingual community health workers (CHWs) to gather health-related data from their communities using mobile technology, and (3) measure the feasibility and effectiveness of our efforts. METHODS: A CBPR approach was used to engage leaders of Cambodian American communities in six states to identify their research needs, develop a short community health survey administered by CHWs, and conduct the survey using iPads programmed in Khmer spoken-language format. Administrative logs and surveys of CHWs and leaders measured feasibility and effectiveness of the project. RESULTS: CHWs, leaders, and community members reported largely positive experiences with the community health survey, despite poor/inconsistent Internet connectivity. The institutional capacity of Cambodian American community-based organizations to collect health-related data in their own communities was strengthened. Our efforts proved to be both feasible and effective. CONCLUSIONS: The use of mobile technology with spoken format can be a valuable tool in accessing input from vulnerable community members, including persons who may not be literate in any language. Trained CHWs, backed by dedicated and experienced community leaders, are an asset to their communities. Together, they are uniquely placed to make important contributions to the well-being of their community.

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This study replicated and extended previous evaluations of the Signs of Suicide (SOS) prevention program in a high school population using a more rigorous pre-test post-test randomized control design than used in previous SOS evaluations in high schools (Aseltine and DeMartino 2004; Aseltine et al. 2007). SOS was presented to an ethnically diverse group of ninth grade students in technical high schools in Connecticut. After controlling for the pre-test reports of suicide behaviors, exposure to the SOS program was associated with significantly fewer self-reported suicide attempts in the 3 months following the program. Ninth grade students in the intervention group were approximately 64% less likely to report a suicide attempt in the past 3 months compared with students in the control group. Similarly, exposure to the SOS program resulted in greater knowledge of depression and suicide and more favorable attitudes toward (1) intervening with friends who may be exhibiting signs of suicidal intent and (2) getting help for themselves if they were depressed or suicidal. In addition, high-risk SOS participants, defined as those with a lifetime history of suicide attempt, were significantly less likely to report planning a suicide in the 3 months following the program compared to lower-risk participants. Differential attrition is the most serious limitation of the study; participants in the intervention group who reported a suicide attempt in the previous 3 months at baseline were more likely to be missing at post-test than their counterparts in the control group.

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Although the Signs of Suicide (SOS) suicide prevention program has been implemented at both the middle and high school levels, its efficacy has been demonstrated previously only among high school students. The current study evaluated SOS implemented in high military impact middle schools. Compared to controls, SOS participants demonstrated improved knowledge about suicide and suicide prevention, and participants with pretest ideation reported fewer suicidal behaviors at posttest than controls with pretest ideation. These results provide preliminary evidence for SOS's efficacy as a suicide prevention program for middle school students.

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OBJECTIVE: Literature on food environments has expanded rapidly, yet most research focuses on stores and community characteristics without integrating customer-level data. The present study combines customer shopping behaviour with store food inventory data. DESIGN: Face-to-face interviews were conducted with customers shopping in corner stores to measure food shopping behaviour, household food security and demographics. Store inventories were conducted to measure availability of healthy food in corner stores. Multilevel logistic regression models estimated the probability of customers purchasing a food item given the availability of that item in the store. SETTING: Nineteen corner stores in Hartford, CT, USA, average size 669 ft(2) (62.15 m(2)). SUBJECTS: Sample of 372 customers. RESULTS: The majority of customers were Black or Hispanic (54 % and 40 %, respectively) and 61 % experienced food insecurity. For each additional type of fruits or vegetables available in the store, the estimated odds of a customer purchasing fruits increased by 12 % (P = 0.03) and the odds for purchasing vegetables increased by 15 % (P = 0.01). Customers receiving the Supplemental Nutrition Assistance Program (SNAP) were 1.7 times as likely to purchase fruit as those not receiving SNAP (P = 0.04). Greater availability of reduced-fat milk was not associated with increased likelihood of customers purchasing reduced-fat milk. CONCLUSIONS: There is a positive association between fruit and vegetable variety and the probability that a customer purchases fruits and vegetables. Increasing the selection of produce in corner stores may increase their consumption by food-insecure and low-income residents at risk for health disparities. These findings have implications for future store interventions and food policies.

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PURPOSE: To examine the association between self-reported alcohol use and suicide attempts among adolescents who did and did not report suicidal ideation during the past year. METHODS: Screening data from 31,953 students attending schools in the United States that implemented the Signs of Suicide (SOS) program in 2001-2002 were used in this analysis. Two types of alcohol use were investigated: heavy episodic drinking, and drinking while down. Self-reported suicide attempts were regressed on suicidal ideation and both measures of alcohol use, controlling for participants' levels of depressive symptoms, and demographic characteristics. RESULTS: Logistic regression analyses indicated that both drinking while down and heavy episodic drinking were significantly associated with self-reported suicide attempts. Analyses examining the conditional association of alcohol use and suicidal ideation with self-reported suicide attempts revealed that drinking while down was associated with significantly greater risk of suicide attempt among those not reporting suicidal ideation in the past year. Heavy episodic drinking was associated with increased risk of suicide attempt equally among those who did and did not report suicidal ideation. CONCLUSIONS: This study identified the use of alcohol while sad or depressed as a marker for suicidal behavior in adolescents who did not report ideating prior to an attempt, and hence, may not be detected by current strategies for assessing suicide risk. Findings from this study should provide further impetus for alcohol screening among clinicians beyond that motivated by concerns about alcohol and substance use.

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OBJECTIVE: Alcohol use is a risk factor for suicidal behavior among adolescents, but it is not clear whether this association is consistent during the adolescent period. This study examined the age-specific associations between heavy episodic drinking (HED) and self-reported suicide attempts in a large and diverse sample of adolescents. METHOD: Screening data from 32,217 students, between the ages of 11 and 19 years, in 225 schools were analyzed. Logistic regression analyses estimating the impact of HED on self-reported suicide attempts in the past year were performed. RESULTS: Heavy episodic drinking was significantly associated with self-reported suicide attempts (odds ratio 1.78, p <.05) controlling for depressive symptoms. However, there was substantial age variability in this association, with the association between HED and self-reported attempts stronger among younger adolescents. Among youths aged 13 years and younger, those who reported an episode of HED during the past year were roughly 2.6 times more likely to report an attempt than those who did not report HED in the past year, in contrast to 1.2 times among youths aged 18 years and older. CONCLUSIONS: Heavy episodic drinking is a clear risk factor for suicidal behavior among younger adolescents, beyond the risk conveyed by depressive symptoms. Further research investigating the bases for increased suicide risk among younger adolescents engaging in HED is warranted. Results provide support to AACAP's practice parameters calling for attention to substance abuse in the assessment of suicide risk and suggest that routine screening for HED by physicians may improve the detection of adolescent suicide risk, particularly among younger adolescents.

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Research studies investigating the impact of childhood cumulative adversity on adult mental health have proliferated in recent years. In general, little attention has been paid to the operationalization of cumulative adversity, with most studies operationalizing this as the simple sum of the number of occurrences of distinct events experienced. In addition, the possibility that the mathematical relationship of cumulative childhood adversity to some mental health dimensions may be more complex than a basic linear association has not often been considered. This study explores these issues with 2 waves of data drawn from an economically and racially diverse sample transitioning to adulthood in Boston, Massachusetts, USA. A diverse set of childhood adversities were reported in high school and 3 mental health outcomes -- depressed mood, drug use, and antisocial behavior -- were reported 2 years later during the transition to adulthood. Our results suggest that both operationalization and statistical modeling are important and interrelated and, as such, they have the potential to influence substantive interpretation of the effect of cumulative childhood adversity on adult mental health. In our data, total cumulative childhood adversity was related to depressive symptoms, drug use, and antisocial behavior in a positive curvilinear manner with incremental impact increasing as adversities accumulate, but further analysis revealed that this curvilinear effect was an artifact of the confounding of high cumulative adversity scores with the experience of more severe events. Thus, respondents with higher cumulative adversity had disproportionately poorer mental health because of the severity of the adversities they were exposed to, not the cumulative number of different types of adversities experienced. These results indicate that public health efforts targeting prevention of childhood adversities would best be aimed at the most severe adversities in order to have greatest benefit to mental health in young adulthood.

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AIMS: Although National Alcohol Screening Day (NASD) became the USA's largest and most visible community-based intervention targeting risky drinking over the past decade, its utility in identifying individuals who are at risk for alcohol problems and in catalyzing behaviour change has not been tested in studies including untreated controls. The purpose of this study was to assess changes in alcohol use three months following NASD participation using a quasi-experimental pretest-posttest control group design. METHODS: Participants (N = 713) were recruited from 5 NASD sites in Florida, Massachusetts, and New York, USA. Intervention subjects (N = 318) were recruited at the NASD event; control subjects (N = 395) were recruited at the same locations approximately 1 week after NASD. All participants completed brief surveys at the time of enrollment, and then again 3 months later. RESULTS: Significant decreases in the typical number of drinks consumed per occasion were observed among at-risk drinkers in the intervention group relative to controls in the 3 months following NASD. At-risk NASD participants averaged approximately 5.6 fewer drinks per week than at-risk controls. CONCLUSIONS: Findings suggest that exposure to a brief screening program with provision of feedback can result in significant reductions in alcohol consumption among risky drinkers.

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BACKGROUND: Despite their increasing share of the dental insurance market, little is known about dental practices' satisfaction with preferred provider organizations (PPOs). This analysis examined practice satisfaction with dental PPOs and the extent to which satisfaction was a function of communications from the plan, claims handling and compensation. METHODS: Data were collected through telephone surveys with dental practices affiliated with MetLife between January 2002 and December 2004. Each respondent was asked a series of questions related to their satisfaction with a systematically selected PPO with which they were affiliated. Six different PPO plans had sufficient observations to allow for comparative analysis (total n = 4582). Multiple imputation procedures were used to adjust for item non-response. RESULTS: While the average level of overall satisfaction with the target plan fell between "very satisfied" and "satisfied," regression models revealed substantial differences in overall satisfaction across the 6 PPOs (p < .05). Statistically significant differences between plans in overall satisfaction were largely explained by differences in the perceived adequacy of compensation. However, differences in overall satisfaction involving two of the PPOs were also driven by satisfaction with claims handling. CONCLUSION: Results demonstrate the importance of compensation to dental practice satisfaction with PPOs. However, these results also highlight the critical role of service-related factors in differentiating plans and suggest that there are important non-monetary dimensions of PPO performance that can be used to recruit and retain practices.

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BACKGROUND: Suicide is a leading cause of death for children and youth in the United States. Although school based programs have been the principal vehicle for youth suicide prevention efforts for over two decades, few have been systematically evaluated. This study examined the effectiveness of the Signs of Suicide (SOS) prevention program in reducing suicidal behavior. METHODS: 4133 students in 9 high schools in Columbus, Georgia, western Massachusetts, and Hartford, Connecticut were randomly assigned to intervention and control groups during the 2001-02 and 2002-03 school years. Self-administered questionnaires were completed by students in both groups approximately 3 months after program implementation. RESULTS: Significantly lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide were observed among students in the intervention group. Students' race/ethnicity, grade, and gender did not alter the impact of the intervention on any of the outcomes assessed in this analysis. CONCLUSION: This study has confirmed preliminary analysis of Year 1 data with a larger and more racially and socio-economically diverse sample. SOS continues to be the only universal school-based suicide prevention program to demonstrate significant effects of self-reported suicide attempts in a study utilizing a randomized experimental design. Moreover, the beneficial effects of SOS were observed among high school-aged youth from diverse racial/ethnic backgrounds, highlighting the program's utility as a universal prevention program. TRIAL REGISTRATION: clinicaltrials.gov NCT000387855.

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We examined social role functioning and depressive symptoms of young adults who were abused as children in data from a longitudinal community sample. Sexually abused women and men were more depressed during their senior year of high school, and this difference was more pronounced 2 years later. We then examined a mediational model to determine whether social functioning explained the course of depressive symptoms over this transitional period. Focusing only on young women, for whom the prevalence of abuse was much higher, results indicated that two-thirds of the effect of abuse on depressive symptoms was explained by experiences and choices in the domains of work, education and intimate relationships. Having less supportive intimate relationships and lower rates of attendance at 4-year colleges were particularly important. Findings reveal the key role played by early adult interpersonal and occupational development in perpetuating the mental health impact of childhood trauma.

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BACKGROUND: Adverse childhood experiences (ACEs) have been consistently linked to psychiatric difficulties in children and adults. However, the long-term effects of ACEs on mental health during the early adult years have been understudied. In addition, many studies are methodologically limited by use of non-representative samples, and few studies have investigated gender and racial differences. The current study relates self-reported lifetime exposure to a range of ACEs in a community sample of high school seniors to three mental health outcomes-depressive symptoms, drug abuse, and antisocial behavior-two years later during the transition to adulthood. METHODS: The study has a two-wave, prospective design. A systematic probability sample of high school seniors (N = 1093) was taken from communities of diverse socioeconomic status. They were interviewed in person in 1998 and over the telephone two years later. Gender and racial differences in ACE prevalence were tested with chi-square tests. Each mental health outcome was regressed on one ACE, controlling for gender, race/ethnicity, and SES to obtain partially standardized regression coefficients. RESULTS: Most ACEs were strongly associated with all three outcomes. The cumulative effect of ACEs was significant and of similar magnitude for all three outcomes. Except for sex abuse/assault, significant gender differences in the effects of single ACEs on depression and drug use were not observed. However, boys who experienced ACEs were more likely to engage in antisocial behavior early in young adulthood than girls who experienced similar ACEs. Where racial/ethnic differences existed, the adverse mental health impact of ACEs on Whites was consistently greater than on Blacks and Hispanics. CONCLUSION: Our sample of young adults from urban, socio-economically disadvantaged communities reported high rates of adverse childhood experiences. The public health impact of childhood adversity is evident in the very strong association between childhood adversity and depressive symptoms, antisocial behavior, and drug use during the early transition to adulthood. These findings, coupled with evidence that the impact of major childhood adversities persists well into adulthood, indicate the critical need for prevention and intervention strategies targeting early adverse experiences and their mental health consequences.

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This longitudinal study predicted marital outcome from communication skills gained from participation in the Prevention and Relationship Enhancement Program (PREP; H. J. Markman, S. L. Blumberg & S. M. Stanley, 1989; Stanley et al., 2001) by 39 women and 38 men. Results were in the expected direction for men but not for women. Men's pre- to posttest decrease in negative communication and increase in positive communication predicted decreased risk of marital distress onset in men. Women's pre- to posttest increase in positive communication, which was related to self-reported avoidance of problem solving, predicted an increased risk of male and female distress onset. Couples with men relatively high on premarital risk factors demonstrated a greater benefit from men's positive communication skills acquisition.

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