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The purpose of this study is to determine the associations between Vitamin D supplementation, 25(OH) blood serum levels, suicide attempts, and intentional self-harm in a population of veterans in the Department of Veterans Affairs (VA). A retrospective cohort study of US Veterans supplemented with Vitamin D. Veterans with any Vitamin D3 (cholecalciferol) or Vitamin D2 (ergocalciferol) fill between 2010 and 2018 were matched 1:1 to untreated control veterans having similar demographics and medical histories. Cox proportional hazards regression was used to estimate the time from the first Vitamin D3 (cholecalciferol) or Vitamin D2 (ergocalciferol) prescription fill to the first suicide attempt or intentional self-harm. Analyses were repeated in stratified samples to measure associations by race (Black or White), gender (male or female), blood levels (0-19 ng/ml, 20-39 ng/ml, and 40+ ng/ml), and average daily dosage. Vitamin D3 and D2 supplementation were associated with a 45% and 48% lower risk of suicide attempt and self-harm ((D2 Hazard Ratio (HR) = 0.512, [95% CI, 0.457, 0.574]; D3 HR = 0.552, [95% CI, 0.511, 0.597])). Supplemented black veterans and veterans with 0-19 ng/ml vitamin D serum levels were at ~64% lower risk relative to controls (Black Veteran HR: 0.362 [95% CI: 0.298,0.440]; 0-19 ng/ml HR: 0.359 [95% CI: 0.215,0.598]). Supplementation with higher vitamin D dosages was associated with greater risk reductions than lower dosages (Log Average Dosage HR: 0.837 [95% CI: 0.779,0.900]). Vitamin D supplementation was associated with a reduced risk of suicide attempt and self-harm in Veterans, especially in veterans with low blood serum levels and Black veterans.

Vitamin D deficiency has long been associated with reduced immune function that can lead to viral infection. Several studies have shown that Vitamin D deficiency is associated with increases the risk of infection with COVID-19. However, it is unknown if treatment with Vitamin D can reduce the associated risk of COVID-19 infection, which is the focus of this study. In the population of US veterans, we show that Vitamin D 2 and D 3 fills were associated with reductions in COVID-19 infection of 28% and 20%, respectively [(D 3 Hazard Ratio (HR) = 0.80, [95% CI 0.77, 0.83]), D 2 HR = 0.72, [95% CI 0.65, 0.79]]. Mortality within 30-days of COVID-19 infection was similarly 33% lower with Vitamin D 3 and 25% lower with D 2 (D 3 HR = 0.67, [95% CI 0.59, 0.75]; D 2 HR = 0.75, [95% CI 0.55, 1.04]). We also find that after controlling for vitamin D blood levels, veterans receiving higher dosages of Vitamin D obtained greater benefits from supplementation than veterans receiving lower dosages. Veterans with Vitamin D blood levels between 0 and 19 ng/ml exhibited the largest decrease in COVID-19 infection following supplementation. Black veterans received greater associated COVID-19 risk reductions with supplementation than White veterans. As a safe, widely available, and affordable treatment, Vitamin D may help to reduce the severity of the COVID-19 pandemic.

Objective. This scoping review updates a 2018 review of suicide prevention training programs for community and student pharmacists. Five scholarly databases were searched for articles published between January 2018 and December 2020. Articles were excluded if they did not describe an educational or training program for pharmacists or student pharmacists, did not explicitly include suicide, focused solely on attitudes, or did not provide sufficient detail to evaluate program content. The quality of each study was examined using a quality assessment tool. Findings. Seven studies met inclusion criteria. Most trainings (86%) were delivered live with interactive or role play scenarios to promote verbal and behavioral skill practice. About half (57%) assessed changes in knowledge, and fewer programs (29%) assessed changes in communication. All assessed participants’ ability to identify suicide warning signs and included referral resources. Six studies were assessed for quality, of which 67% had a rating of good and 33% were rated as fair. Summary. Given the increase in suicide rates nationally, it is likely that pharmacists will encounter a patient in need of suicide prevention services. Since 2018, seven new suicide prevention training programs for community and student pharmacists have been reported, which demonstrates growing interest in suicide prevention training in the pharmacy profession. When integrated in Doctor of Pharmacy (PharmD) curricula, trainings may help prepare the pharmacy workforce for encounters with patients in crisis. The impact of training on self-efficacy and communication skills warrants additional attention. Variation between programs should be evaluated to understand which instructional methods best prepare pharmacy professionals to engage in suicide prevention.

ImportanceGuidelines for the pharmacological treatment of chronic insomnia in adults recognize that trazodone and other off-label medications are commonly prescribed despite poor evidence. The Department of Veterans Health Affairs (VA) fills high volumes of inexpensive, over-the-counter sedating antihistamines and older antidepressants in addition to benzodiazepines and zolpidem. Yet little is known about the comparative safety of these agents with regard to suicidal behavior.ObjectivesTo assess the comparative effectiveness of the safety of medications routinely used to treat insomnia in VA.DesignComparative effectiveness using propensity score-matched samples.SettingVA.ParticipantsVA patients without any history of suicidal ideation or behavior 12 months prior to first exposure.ExposuresVA formularies and data were used to identify prescriptions for insomnia. Agents accounting for at least 1% of total insomnia fill volume were < 200 mg trazodone, hydroxyzine, diphenhydramine, zolpidem, lorazepam, diazepam, and temazepam. Exposure was defined as an incident monotherapy exposure preceded by 12 months without any insomnia medications. Subjects with insomnia polypharmacy or cross-overs in the 12 months following first exposure were excluded.Main Outcomes and MeasuresSuicide attempts within 12 months of first exposure.ResultsThree hundred forty-eight thousand four hundred forty-nine subjects met criteria and three well-balanced cohorts by drug class matched to zolpidem were created. After adjusting for days’ supply, mental health history, and pain and central nervous system medication history, hazard ratios (compared to zolpidem) were as follows: (< 200 mg) trazodone (HR = 1.61, 95% CI 1.07–2.43); sedating antihistamines (HR = 1.37, 95% CI 0.90–2.07); and benzodiazepines (HR = 1.31, 95% CI 0.85–2.08).Conclusions and RelevanceCompared to zolpidem, hazard of suicide attempt was 61% higher with trazodone (< 200 mg). No significant differences in suicide attempt risk were identified between benzodiazepines or sedating antihistamines and zolpidem, respectively. These findings provide the first comparative effectiveness evidence against the use of trazodone for insomnia.

Introduction Pharmacists are one of the most accessible health professionals in the United States, who, with training, may serve as gatekeepers who recognize suicide warning signs and refer at‐risk individuals to care. Our objective was to codesign a 30‐min online gatekeeper training module (Pharm‐SAVES) specifically for community pharmacy staff. Methods Over a period of 8 months, a nine‐member pharmacy staff stakeholder panel and the Finger Lakes (New York) Veterans Research Engagement Review Board each worked with the study team to codesign Pharm‐SAVES. Formative data from previous interviews with community pharmacists were presented to the panels and guided website development. Results Four key topics were identified for brief skills‐based modules that could be delivered asynchronously online. To help pharmacy staff understand their opportunities as gatekeepers in suicide prevention, statistics and statements from the Joint Commission and pharmacy professional organizations were highlighted in Module 1 (‘Why Me?’). Module 2 (‘What can I do?’) presents the five gatekeeping steps (SAVES): (1) Recognize suicide warning Signs, (2) Ask if someone is considering suicide, (3) Validate feelings, (4) Expedite referral, and (5) Set a reminder to follow‐up. Module 3 (‘How does it work?’) provides three video scenarios modeling SAVES steps and two interactive video cases for participant practice. Module 3 demonstrates use of the 24/7 National Suicide Prevention Lifeline, including the DOD/VA Crisis Line. Module 4 (Resources) includes links to national resources and a searchable zip code‐based provider directory. Pharm‐SAVES was codesigned with pharmacy and veteran stakeholders to deliver brief, skills‐focused, video‐based interactive training that is feasible to implement in busy community pharmacy settings. Conclusion Pharm‐SAVES is a brief, online suicide prevention gatekeeper training program codesigned by researchers, community pharmacy and veteran stakeholders. By actively engaging stakeholders at each stage of the design process, we were able to create training content that was not only realistic but more relevant to the needs of pharmacy staff. Currently, Pharm‐SAVES is being evaluated in a pilot randomized controlled trial for changes in pharmacy staff suicide prevention communication behaviors. Patient or Public Contribution Stakeholder engagement was purposefully structured to engage pharmacy staff and pharmacy consumers, with multiple opportunities for study contribution. Likewise, the involvement of patient/public contribution was paramount in study design and overall development of our study team.

We previously showed that folic acid prescriptions for any indication were associated with lower rates of suicidal behaviour. Given that future randomised clinical trials are likely to focus on psychiatric disorders carrying elevated risk for suicide, we now report on the moderating effects of prior suicidal behaviour, psychiatric diagnoses and psychotropic medications on potential antisuicidal effects of folic acid. Data were obtained from the MarketScan Commercial Claims and Encounters databases that cover 164 million insured persons from 2005–2017, from which a cohort of 866 586 patients was derived. Analysis revealed no significant moderation effects on the antisuicidal effect of folic acid. These findings indicate that the potential benefit of folic acid for preventing suicidal behaviour is comparable in psychiatric populations at higher risk of suicide and that it may be additive to any benefit from psychotropic medications.

Objectives. We evaluated the effectiveness of the US Air Force Suicide Prevention Program (AFSPP) in reducing suicide, and we measured the extent to which air force installations implemented the program. Methods. We determined the AFSPP's impact on suicide rates in the air force by applying an intervention regression model to data from 1981 through 2008, providing 16 years of data before the program's 1997 launch and 11 years of data after launch. Also, we measured implementation of program components at 2 points in time: during a 2004 increase in suicide rates, and 2 years afterward. Results. Suicide rates in the air force were significantly lower after the AFSPP was launched than before, except during 2004. We also determined that the program was being implemented less rigorously in 2004. Conclusions. The AFSPP effectively prevented suicides in the US Air Force. The long-term effectiveness of this program depends upon extensive implementation and effective monitoring of implementation. Suicides can be reduced through a multilayered, overlapping approach that encompasses key prevention domains and tracks implementation of program activities.

Gabapentin is used for the treatment of hot flashes and neuropathic pain in breast cancer survivors, and is commonly used off-label for the treatment of anxiety. Yet, clinical trial evidence to support the use of gabapentin for anxiety symptoms is lacking. In a randomized, double-blinded controlled trial we compared 300 mg gabapentin versus 900 mg gabapentin versus placebo. Subjects were 420 breast cancer patients who had completed all chemotherapy cycles. Anxiety traits and current (state) anxiety were measured using the Speilberger Strait-Trait Anxiety Inventory at baseline, 4 and 8 weeks. Pain was measured at baseline using a 10-point scale. Analyses included analysis of covariance and ordinary least squares regression. At 4 weeks, state anxiety change scores were significantly better for gabapentin 300 and 900 mg ( p  = 0.005) compared to placebo. The magnitude of improvement was proportional to baseline state anxiety. At 8 weeks, the anxiolytic effects of gabapentin compared to placebo persisted ( p  < 0.005). We found no significant interactions. The lower dose (300 mg) was associated with the best treatment outcomes for all patients except those with the highest baseline anxiety. Given its similar pharmacology, efficacy in the treatment of hot flashes, and low cost, gabapentin may provide a low cost and parsimonious alternative treatment choice for breast cancer survivors presenting in primary care practices with anxiety symptoms. Gabapentin is effective for hot flashes, and, therefore, may provide therapeutic benefit for both anxiety and hot flashes at a generic drug price. For patients reluctant to take a controlled substance, such as a benzodiazepine, gabapentin may offer an alternative therapy. Similarly, patients with a history of substance use may benefit from gabapentin without risk of addiction or abuse. For cancer survivors experiencing both hot flashes and anxiety, gabapentin may provide a single effective treatment for both and is an alternative therapy for anxiety for patients unwilling to take a benzodiazepine or those with a history of substance use.

To assess and improve student adherence to hand hygiene indications using radio frequency identification (RFID) enabled hand hygiene stations and performance report cards. Students volunteered to wear RFID-enabled hospital employee nametags to monitor their adherence to hand-hygiene indications. After training in World Health Organization (WHO) hand hygiene methods and indications, student were instructed to treat the classroom as a patient care area. Report cards illustrating individual performance were distributed via e-mail to students at the middle and end of each 5-day observation period. Students were eligible for individual and team prizes consisting of Starbucks gift cards in $5 increments. A hand hygiene station with an RFID reader and dispensing sensor recorded the nametag nearest to the station at the time of use. Mean frequency of use per student was 5.41 (range: 2-10). Distance between the student’s seat and the dispenser was the only variable significantly associated with adherence. Student satisfaction with the system was assessed by a self-administered survey at the end of the study. Most students reported that the system increased their motivation to perform hand hygiene as indicated. The RFID-enabled hand hygiene system and benchmarking reports with performance incentives was feasible, reliable, and affordable. Future studies should record video to monitor adherence to the WHO 8-step technique.