Authors evaluate whether token-based and large language model scoring of research domain criteria (RDoC) can be successfully applied to law enforcement and coroner or medical examiner death narratives in the U.S. National Violent Death Reporting System (NVDRS), and (2) investigate sex and age differences in clinically relevant scores to illuminate underidentified dimensions of mental health dysfunction proximal to suicide. This cross-sectional study drew on death records in the restricted-access 2020 to 2021 NVDRS. Participants were limited to suicide decedents aged 12 years and older from all 50 states whose death record included a law enforcement and coroner or medical examiner death narrative of 20 words or more. Main outcomes and measures were RDoC symptom scores and mental health status measures in death records (mental health diagnosis, current depressed mood, and alcohol or drug misuse).

Findings: Using both a token-based system and a large language model approach, law enforcement and coroner or medical examiner narratives of 72,585 suicide decedents were scored (mean [SD] age, 46.3 [19.3] years; 57,770 [80.6%] male). Both methods were previously validated with psychiatric electronic health records. To validate this approach, token density and large language model scores were compared with current NVDRS mental health status measures. Both scoring methods correlated with precoded measures and demonstrated levels of neurobehavioral dysfunction at the time of death similar to psychiatric inpatients on admission. Sex- and age-related differences in clinically relevant dysfunction showed the highest levels among female vs male and younger vs older decedents after adjusting for demographic confounding.

Authors found that information relevant to RDoC domains is encoded in NVDRS death narratives and can be extracted using large language models. The approach used here observed more pervasive neurobehavioral dysfunction among suicide decedents than that captured by currently employed NVDRS measures of mental health. 

This article features Vickie M. Mays, senior fellow at the UCLA Center for Health Policy Research (CHPR).

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) classification system contains more specificity than its predecessor ICD-9-CM. A stated reason for transitioning to ICD-10-CM was to increase the availability of detailed data. This study aims to determine whether the increased specificity contained in ICD-10-CM is utilized in the ambulatory care setting and inform an evidence-based approach to evaluate ICD-11 content for implementation planning in the United States.

Diagnosis codes and text descriptions were extracted from a 25% random sample of the IQVIA Ambulatory EMR-US database for 2014 and 2019. Code utilization data was analyzed for the total and unique number of codes. Frequencies and tests of significance determined the percentage of available codes utilized and the unspecified code rates for both code sets in each year.

Findings: Only 44.6% of available ICD-10-CM codes were used compared to 91.5% of available ICD-9-CM codes. Of the total codes used, 14.5% ICD-9-CM codes were unspecified, while 33.3% ICD-10-CM codes were unspecified.

Even though greater detail is available, a 108.5% increase in using unspecified codes with ICD-10-CM was found. The utilization data analyzed in this study does not support a rationale for the large increase in the number of codes in ICD-10-CM. New technologies and methods are likely needed to fully utilize detailed classification systems.

These results help evaluate the content needed in the United States national ICD standard. This analysis of codes in the current ICD standard is important for ICD-11 evaluation, implementation, and use.

Despite research linking chemical and physical restraints to negative outcomes, including unplanned intubations and psychological distress, there is little guidance for their use in the care of trauma patients. Authors used institutional data to describe recent trends in chemical and physical restraint in the emergency department evaluation and treatment of trauma patients and to identify characteristics associated with their use.

This study includes adult trauma activations at a United States urban level I trauma center from January 2016 to July 2022. Data were collected from the trauma registry and medical record. Researchers assessed the use of chemical restraints and physical restraints during care provided in the trauma resuscitation bay and emergency department.

Findings: Of the 8,112 patients, most were male (74.8%), white (55.8%), and privately insured (35.2%). Overall, 8.1% were restrained with 7.1% chemically restrained and 2.7% physically restrained. Overall restraint use increased 254% from 2016 to 2022 driven primarily by a 460% increase in chemical restraint use including a 630% increase in ketamine administrations. Use of restraints was associated with pre-existing psychotic disorders, intoxication, altered mental status, increasing injury severity, and Medicaid insurance. Chemical restraint administration was associated with a 3.5 percentage point increase in the probability of ICU admission and a 1.0 day increase in hospitalization duration.

In this institutional study, nearly 1 in 12 trauma patients were restrained during emergency department evaluation and treatment. Restraint utilization increased during the study driven primarily by increases in ketamine and restraints utilized during trauma bay evaluation and resuscitation.

Future research should assess the generalizability of these findings. It is important that rigorous guidelines are established to ensure the safe and effective use of restraints in trauma.

This special issue of the American Journal of Public Health (AJPH), co-edited by UCLA Professor and UCLA CHPR Senior Fellow Vickie Mays, PhD, and UCLA Professor Susan Cochran, PhD, addresses improving the conditions that promote mental health and prevent mental disorders.

The papers explore innovations to infuse a public mental health agenda more thoroughly into interventions, research, and legislative and social policies.

Topics include the impact of COVID-19 on youths and the need for public health policy advisories that focus on mental health consequences in addition to infection control; the increasing rates of suicide among Black youths, some as young as 5 years of age; the importance of primary care referrals that consider gendered differences in the expression of distress; the history of racism that continues to affect the diagnoses and treatment of African Americans; and the impact of the devastating fire in Lahaina on residents' well-being.