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Treatment preferences of psychotherapy patients with chronic PTSD.

Objective: Patient treatment preference may moderate treatment effect in major depressive disorder (MDD) studies. Little research has addressed preference in posttraumatic stress disorder (PTSD); almost none has assessed actual patients' PTSD psychotherapy preferences. From a 14-week trial of chronic PTSD comparing prolonged exposure, relaxation therapy, and interpersonal psychotherapy, we report treatment preferences of the 110 randomized patients, explore preference correlates, and assess effects on treatment outcome. Method: Patients recruited between 2008 and 2013 with chronic DSM-IV PTSD (Clinician-Administered PTSD Scale [CAPS] score ≥ 50) received balanced, scripted psychotherapy descriptions prerandomization and indicated their preferences. Analyses assessed relationships of treatment attitudes to demographic and clinical factors. We hypothesized that patients randomized to preferred treatments would have better outcomes, and to unwanted treatment worse outcomes. Results: Eighty-seven patients (79%) voiced treatment preferences or disinclinations: 29 (26%) preferred prolonged exposure, 29 (26%) preferred relaxation therapy, and 56 (50%) preferred interpersonal psychotherapy (Cochran Q = 18.46, P < .001), whereas 29 (26%) were disinclined to prolonged exposure, 18 (16%) to relaxation therapy, and 3 (3%) to interpersonal psychotherapy (Cochran Q = 22.71, P < .001). Several baseline clinical variables correlated with treatment preferences. Overall, treatment preference/disinclination did not predict change in CAPS score, treatment response, or dropout. Comorbidly depressed patients receiving unwanted treatment had worse final CAPS scores. Conclusion: These exploratory findings are the first relating patients' PTSD psychotherapy preferences to outcome. Despite explanations emphasizing prolonged exposure's greater empirical support, patients significantly preferred interpersonal psychotherapy. Preference subtly affected psychotherapy outcome; depression appeared an important moderator of the effect of unwanted treatment on outcome. Potential biases to avoid in future research are discussed. Trial registration: ClinicalTrials.gov identifier: NCT00739765.

The Journal of clinical psychiatry · randomised controlled trial · 30 citationsread the source →

Visual outcome in infants born to drug-misusing mothers prescribed methadone in pregnancy.

Background: Flash visual evoked potentials (VEPs) were abnormal in a cohort of 100 neonates exposed to maintenance methadone in utero. This prospective cohort study now describes clinical visual and electrophysiological outcomes at 6 months. Methods: Visual assessment included modified Atkinson test battery; strabismus, nystagmus, reduced visual acuity, delayed visual maturation or refractive error (>3 dioptres) defined a fail. Pattern-onset VEPs were recorded to 120', 60' and 15' checks. Results: 81 drug-exposed and 26 comparison infants (79% and 52% of the original cohorts) were assessed at a median age of 27 weeks (range 26-30). 90% of drug-exposed infants had been additionally exposed to illicit drugs and 41% to excess alcohol in utero. 40% of the drug-exposed cohort failed clinical visual assessment: the relative risk of abnormal assessment was 5.1 (95% CI 1.3 to 20; p=0.02). Nystagmus was particularly common. VEP peak times were slower and amplitudes smaller in drug-exposed infants, of whom 70% had one or more abnormal VEP parameter. Abnormal visual outcome at 6 months was not associated with the pattern of additional drug exposure or a history of neonatal abstinence. Conclusions: Abnormal visual electrophysiology in infants born to drug-misusing mothers prescribed maintenance methadone persists to 6 months of age, and is associated with abnormal clinical visual assessment.

The British journal of ophthalmology · cohort or longitudinal · 53 citationsread the source →

An eHealth, Positive Emotion Skills Intervention for Enhancing Psychological Well-Being in Young Adult Cancer Survivors: Results from a Multi-Site, Pilot Feasibility Trial.

Background: Young adult (YA) cancer survivors experience clinically significant distress and have limited access to psychosocial support. Given growing evidence for unique adaptive benefits of positive emotion in the context of health-related and other life stress, we developed an eHealth positive emotion skills intervention for post-treatment survivors called EMPOWER (Enhancing Management of Psychological Outcomes With Emotion Regulation) and evaluated feasibility and proof of concept for reducing distress and enhancing well-being. Method: In this single-arm pilot feasibility trial, post-treatment YA cancer survivors (ages 18-39) participated in the EMPOWER intervention which included 8 skills (e.g., gratitude, mindfulness, acts of kindness). Participants completed surveys at baseline (pre-intervention), 8 weeks (post-intervention), and 12 weeks (1-month follow-up). Primary outcomes included feasibility (assessed by participation percentage) and acceptability (would recommend EMPOWER skills to a friend). Secondary outcomes included psychological well-being (mental health, positive affect, life satisfaction, meaning/purpose, general self-efficacy) and distress (depression, anxiety, anger). Results: We assessed 220 YAs for eligibility; 77% declined. Of those screened, 44 (88%) were eligible and consented, 33 began the intervention, and 26 (79%) completed the intervention. Overall retention was 61% at 12 weeks. Average acceptability ratings were high (8.8/10). Participants (M = 30.8 years, SD = 6.6) were 77% women, 18% racial/ethnic minorities, and 34% breast cancer survivors. At 12 weeks, EMPOWER was associated with improved mental health, positive affect, life satisfaction, meaning/purpose, and general self-efficacy (ps < .05, ds = .45 to .63) and decreased anger (p < .05, d =  - 0.41). Conclusion: EMPOWER demonstrated evidence of feasibility and acceptability as well as proof of concept for enhancing well-being and reducing distress. Self-guided, eHealth interventions show promise for addressing YA cancer survivors' needs and warrant additional research to optimize survivorship care. Trial registration: ClinicalTrials .gov NCT02832154,  https://clinicaltrials.gov/ct2/show/NCT02832154.

International journal of behavioral medicine · 15 citationsread the source →

Childhood maltreatment and unfavourable clinical outcomes in bipolar disorder: a systematic review and meta-analysis.

Background: Bipolar disorder affects up to one in 25 individuals and identification of early risk indicators of negative outcomes could facilitate early detection of patients with greatest clinical needs and risk. We aimed to investigate the association between childhood maltreatment and key negative outcomes in patients with bipolar disorder. Methods: For this systematic review and meta-analysis we searched MEDLINE, PsycINFO, and Embase to identify articles published before Jan 1, 2015, examining the association of maltreatment (physical, sexual, or emotional abuse, neglect, or family conflict) before age 18 years with clinical features and course of illness in bipolar disorder. Data were extracted from published reports and any missing information was requested from investigators. We did 12 independent random-effects meta-analyses to quantify the associations between childhood maltreatment and course of illness or clinical features. Findings: We initially identified 527 records and after unsuitable studies were removed, our search yielded 148 publications of which 30 were used in the meta-analysis. Patients with bipolar disorder and history of childhood maltreatment had greater mania severity (six studies, 780 participants; odds ratio [OR] 2·02, 95% CI 1·21-3·39, p=0·008), greater depression severity (eight studies, 1007 participants; 1·57, 1·25-1·99, p=0·0001), greater psychosis severity (seven studies, 1494 participants; 1·49, 1·10-2·04, p=0·011), higher risk of comorbidity with post-traumatic stress disorder (eight studies, 2494 participants; 3·60, 2·45-5·30, p<0·0001), anxiety disorders (seven studies, 5091 participants; 1·90, 1·39-2·61, p<0·0001), substance misuse disorders (11 studies, 5469 participants; 1·84, 1·41-2·39, p<0·0001), alcohol misuse disorder (eight studies, 5040 participants; 1·44, 1·13-1·83, p=0·003), earlier age of bipolar disorder onset (14 studies, 5733 participants; 1·85, 1·43-2·40, p<0·0001), higher risk of rapid cycling (eight studies, 3010 participants; 1·89, 1·45-2·48, p<0·0001), greater number of manic episodes (seven studies, 3909 participants; 1·26, 1·09-1·47, p=0·003), greater number of depressive episodes (eight studies, 4025 participants; 1·38, 1·07-1·79, p=0·013), and higher risk of suicide attempt (13 studies, 3422 participants; 2·25, 1·88-2·70, p<0·0001) compared with those with bipolar disorder without childhood maltreatment. Overall, these associations were not explained by publication bias, undue effects of individual studies, or variation in study quality. Interpretation: Childhood maltreatment predicts unfavourable clinical features and course of illness in patients with bipolar disorder. Funding: None.

The lancet. Psychiatry · meta-analysis · 278 citationsread the source →

Efficacy and acceptability of psychosocial interventions in asylum seekers and refugees: systematic review and meta-analysis.

AimsIn the past few years, there has been an unprecedented increase in the number of forcibly displaced migrants worldwide, of which a substantial proportion is refugees and asylum seekers. Refugees and asylum seekers may experience high levels of psychological distress, and show high rates of mental health conditions. It is therefore timely and particularly relevant to assess whether current evidence supports the provision of psychosocial interventions for this population. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the efficacy and acceptability of psychosocial interventions compared with control conditions (treatment as usual/no treatment, waiting list, psychological placebo) aimed at reducing mental health problems in distressed refugees and asylum seekers. Methods: We used Cochrane procedures for conducting a systematic review and meta-analysis of RCTs. We searched for published and unpublished RCTs assessing the efficacy and acceptability of psychosocial interventions in adults and children asylum seekers and refugees with psychological distress. Post-traumatic stress disorder (PTSD), depressive and anxiety symptoms at post-intervention were the primary outcomes. Secondary outcomes include: PTSD, depressive and anxiety symptoms at follow-up, functioning, quality of life and dropouts due to any reason. Results: We included 26 studies with 1959 participants. Meta-analysis of RCTs revealed that psychosocial interventions have a clinically significant beneficial effect on PTSD (standardised mean difference [SMD] = -0.71; 95% confidence interval [CI] -1.01 to -0.41; I2 = 83%; 95% CI 78-88; 20 studies, 1370 participants; moderate quality evidence), depression (SMD = -1.02; 95% CI -1.52 to -0.51; I2 = 89%; 95% CI 82-93; 12 studies, 844 participants; moderate quality evidence) and anxiety outcomes (SMD = -1.05; 95% CI -1.55 to -0.56; I2 = 87%; 95% CI 79-92; 11 studies, 815 participants; moderate quality evidence). This beneficial effect was maintained at 1 month or longer follow-up, which is extremely important for populations exposed to ongoing post-migration stressors. For the other secondary outcomes, we identified a non-significant trend in favour of psychosocial interventions. Most evidence supported interventions based on cognitive behavioural therapies with a trauma-focused component. Limitations of this review include the limited number of studies collected, with a relatively low total number of participants, and the limited available data for positive outcomes like functioning and quality of life. Conclusions: Considering the epidemiological relevance of psychological distress and mental health conditions in refugees and asylum seekers, and in view of the existing data on the effectiveness of psychosocial interventions, these interventions should be routinely made available as part of the health care of distressed refugees and asylum seekers. Evidence-based guidelines and implementation packages should be developed accordingly.

Epidemiology and psychiatric sciences · meta-analysis · 138 citationsread the source →

Effectiveness of prescribing physical activity in parks to improve health and wellbeing - the park prescription randomized controlled trial.

Background: Programs promoting population health through physical activity (PA) and exposure to nature are popular, but few have been evaluated in randomized-controlled trials (RCTs). Objective: To investigate the effectiveness of a park prescription intervention (PPI) for improving total moderate-to-vigorous PA (MVPA), other PA related behaviors, quality of life (QoL) and cardio-metabolic health among adults. Methods: Healthy individuals aged 40 to 65 years were recruited through community health screenings and randomly assigned to 1) PPI: face-to-face Park Prescription + invitation to weekly exercise sessions in parks, or 2) control: standard PA materials. After the six-month intervention, participants completed accelerometer assessments, questionnaires on health behaviors and QoL, and health screenings. Independent sample t-tests were used to compare outcomes between groups, with secondary analysis adjusted for co-variates via multiple linear regression. A p-value <0.05 was considered statistically significant. Results: Eighty participants were allocated to each group. Participants with mean age of 51.1 (Standard Deviation: 6.3) years were predominantly female (79%) and of Chinese ethnicity (81%). Participation in the group exercise started at 48% and declined to 24% by week 26. At six-months, 145 (91%) participants attended health screenings for outcome measure collection, and 126 (79%) provided valid accelerometer data. Time spent in MVPA favored the PPI group but this difference was not statistically significant (4.4 (- 43.8, 52.7) minutes/week; when removing 2 extreme outliers 26.8 (- 9.7, 63.4) minutes/week). Time spent in parks (147.5 (2.1, 292.9) minutes/month), PA in parks (192.5 (59.5, 325.5) minutes/month), and recreational PA (48.7 (1.4, 96.0) minutes/week) were significantly greater in the PPI group. PPI also significantly improved psychological QoL (4.0 (0.0, 8.0). Discussion: PPI improved park use, PA in parks, recreational PA, and psychological QoL but not total MVPA. Future RCTs' are warranted to investigate PPI in different target populations and to provide further evidence for improvements in health outcomes. Trial registration: ClinicalTrials.gov NCT02615392, 26 November 2015.

The international journal of behavioral nutrition and physical activity · randomised controlled trial · 49 citationsread the source →

Emotional responses and psychological health among young people amid climate change, Fukushima's radioactive water release, and wars in Ukraine and the Middle East, and the mediating roles of media exposure and nature connectedness: a cross-national analysis.

Background: New global crises are emerging, while existing global crises remain unabated. Coping with climate change, the radioactive water released into the Pacific Ocean subsequent to the Fukushima nuclear accident in Japan, and the wars in Ukraine and the Middle East (hereafter referred to as the wars) as individual crises can negatively affect the psychological health of young people, but little is known about the compounded impact of multiple crises. We aimed to examine: (1) the emotional responses of young people towards each individual crisis, (2) how aggregate levels of emotional engagement in global crises might pose different potential trajectories in psychological health, and (3) the protective or exacerbating role of media exposure and nature connectedness as mediators on psychological health outcomes of young people. Methods: We conducted a cross-national online survey among young people (aged 18-29 years) from China, Portugal, South Africa, the USA, and the UK. We adopted stratified purposive sampling and distributed the survey using online platforms (www.wenjuan.com and www.prolific.com). Individuals were eligible for inclusion in our analysis if they were literate in Chinese or English and had no mental disorders diagnosed within the past 12 months. Participants were asked questions on their demographic characteristics and time spent on social media, including proportion of time exposed to media pertaining to global crises of interest, and they completed surveys based on validated scales that measure depression, anxiety, stress, and wellbeing, as well as emotional responses to each global crisis and nature relatedness. We assessed the survey results using descriptive statistics, ANOVA tests, cluster analysis for individual emotional responses, and structural equation modelling for the aggregate measure of emotional engagement towards individual global crises. Findings: Between Oct 20 and Nov 3, 2023, 2579 individuals participated in the survey, of whom 400 participants from each country (200 male and 200 female participants) were included in our analysis (mean age 24·36 years [SD 2·86]). The mean emotional engagement varied between the global crises of interest (on a scale from 0 to 68, where 0 indicates no emotional response and 68 indicates strong emotional responses across 17 different emotions; wars: 32·42 [SD 14·57]; climate change: 28·79 [14·17]; radioactive water: 21·26 [16·08]), and emotional engagement also varied by country; for instance, for respondents from China, mean emotional engagement in radioactive water was relatively high (39·15 [10·72]) compared with the other countries, and for respondents from the USA, engagement with the wars was relatively low (29·45 [15·78]). We found significant variations in the level of emotional engagement between different crises, with distinct emotional profiles observed among individual countries. To assess the role of media exposure and nature connectedness on psychological outcomes, using structural equation modelling, we constructed a multi-country model comprising Portugal, South Africa, the USA, and the UK, and a standalone model for China. These models elucidated associations between emotional engagement and psychological distress and wellbeing, explaining substantial portions of the variance in both. Notably, while greater emotional engagement in the ecological crises (ie, climate change and radioactive water) generally predicted worse psychological health outcomes, we found the direction of effect for war crises to have positive outcomes for mental health in the standalone China model. Additionally, we found that media exposure mediated the negative effect of wars on psychological distress in the multi-country model, and positive psychological wellbeing in the standalone China model. Moreover, nature connectedness emerged as a potent mediator, effectively mitigating the adverse mental health effects of emotional engagement with some crises, such as radioactive water and climate change. Interpretation: Our findings offer valuable insights into the nuanced dynamics of emotional engagement in global crises and its implications for mental health outcomes among young people across diverse global contexts. Further research is needed to understand the contribution of ongoing and new global crises towards a compounded negative future outlook on young people's mental health to identify effective communication and intervention strategies that can mitigate the effect of this global challenge. Funding: Research Grants Council of Hong Kong, China.

The Lancet. Planetary health · 9 citationsread the source →

Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial.

Background: Depression is a common, debilitating, and costly disorder. Many patients request psychological therapy, but the best-evidenced therapy-cognitive behavioural therapy (CBT)-is complex and costly. A simpler therapy-behavioural activation (BA)-might be as effective and cheaper than is CBT. We aimed to establish the clinical efficacy and cost-effectiveness of BA compared with CBT for adults with depression. Methods: In this randomised, controlled, non-inferiority trial, we recruited adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder from primary care and psychological therapy services in Devon, Durham, and Leeds (UK). We excluded people who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal or had attempted suicide in the previous 2 months, or were cognitively impaired, or who had bipolar disorder or psychosis or psychotic symptoms. We randomly assigned participants (1:1) remotely using computer-generated allocation (minimisation used; stratified by depression severity [Patient Health Questionnaire 9 (PHQ-9) score of <19 vs ≥19], antidepressant use, and recruitment site) to BA from junior mental health workers or CBT from psychological therapists. Randomisation done at the Peninsula Clinical Trials Unit was concealed from investigators. Treatment was given open label, but outcome assessors were masked. The primary outcome was depression symptoms according to the PHQ-9 at 12 months. We analysed all those who were randomly allocated and had complete data (modified intention to treat [mITT]) and also all those who were randomly allocated, had complete data, and received at least eight treatment sessions (per protocol [PP]). We analysed safety in the mITT population. The non-inferiority margin was 1·9 PHQ-9 points. This trial is registered with the ISCRTN registry, number ISRCTN27473954. Findings: Between Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to BA and 219 (50%) to CBT. 175 (79%) participants were assessable for the primary outcome in the mITT population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group. BA was non-inferior to CBT (mITT: CBT 8·4 PHQ-9 points [SD 7·5], BA 8·4 PHQ-9 points [7·0], mean difference 0·1 PHQ-9 points [95% CI -1·3 to 1·5], p=0·89; PP: CBT 7·9 PHQ-9 points [7·3]; BA 7·8 [6·5], mean difference 0·0 PHQ-9 points [-1·5 to 1·6], p=0·99). Two (1%) non-trial-related deaths (one [1%] multidrug toxicity in the BA group and one [1%] cancer in the CBT group) and 15 depression-related, but not treatment-related, serious adverse events (three in the BA group and 12 in the CBT group) occurred in three [2%] participants in the BA group (two [1%] patients who overdosed and one [1%] who self-harmed) and eight (4%) participants in the CBT group (seven [4%] who overdosed and one [1%] who self-harmed). Interpretation: We found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals. Funding: National Institute for Health Research.

Lancet (London, England) · randomised controlled trial · 354 citationsread the source →

Effect of a behavioural intervention in obese pregnant women (the UPBEAT study): a multicentre, randomised controlled trial.

Background: Behavioural interventions might improve clinical outcomes in pregnant women who are obese. We aimed to investigate whether a complex intervention addressing diet and physical activity could reduce the incidence of gestational diabetes and large-for-gestational-age infants. Methods: The UK Pregnancies Better Eating and Activity Trial (UPBEAT) is a randomised controlled trial done at antenatal clinics in eight hospitals in multi-ethnic, inner-city locations in the UK. We recruited pregnant women (15-18 weeks plus 6 days of gestation) older than 16 years who were obese (BMI ≥30 kg/m(2)). We randomly assigned participants to either a behavioural intervention or standard antenatal care with an internet-based, computer-generated, randomisation procedure, minimising by age, ethnic origin, centre, BMI, and parity. The intervention was delivered once a week through eight health trainer-led sessions. Primary outcomes were gestational diabetes (diagnosed with an oral glucose tolerance test and by criteria from the International Association of Diabetes in Pregnancy Study Groups) and large-for-gestational-age infants (≥90th customised birthweight centile). Analysis was by intention to treat. This trial is registered with Current Controlled Trials, ISCRTN89971375. Recruitment and pregnancy outcomes are complete but childhood follow-up is ongoing. Findings: Between March 31, 2009, and June 2, 2014, we assessed 8820 women for eligibility and recruited 1555, with a mean BMI of 36·3 kg/m(2) (SD 4·8). 772 were randomly assigned to standard antenatal care and 783 were allocated the behavioural intervention, of which 651 and 629 women, respectively, completed an oral glucose tolerance test. Gestational diabetes was reported in 172 (26%) women in the standard care group compared with 160 (25%) in the intervention group (risk ratio 0·96, 95% CI 0·79-1·16; p=0·68). 61 (8%) of 751 babies in the standard care group were large for gestational age compared with 71 (9%) of 761 in the intervention group (1·15, 0·83-1·59; p=0·40). Thus, the primary outcomes did not differ between groups, despite improvements in some maternal secondary outcomes in the intervention group, including reduced dietary glycaemic load, gestational weight gain, and maternal sum-of-skinfold thicknesses, and increased physical activity. Adverse events included neonatal death (two in the standard care group and three in the intervention group) and fetal death in utero (ten in the standard care group and six in the intervention group). No maternal deaths were reported. Incidence of miscarriage (2% in the standard care group vs 2% in the intervention group), major obstetric haemorrhage (1% vs 3%), and small-for-gestational-age infants (≤5th customised birthweight centile; 6% vs 5%) did not differ between groups. Interpretation: A behavioural intervention addressing diet and physical activity in women with obesity during pregnancy is not adequate to prevent gestational diabetes, or to reduce the incidence of large-for-gestational-age infants. Funding: National Institute for Health Research, Guys and St Thomas' Charity, Chief Scientist Office Scotland, Tommy's Charity.

The lancet. Diabetes & endocrinology · randomised controlled trial · 465 citationsread the source →

A co-designed mHealth programme to support healthy lifestyles in Māori and Pasifika peoples in New Zealand (OL@-OR@): a cluster-randomised controlled trial.

Background: The OL@-OR@ mobile health programme was co-designed with Māori and Pasifika communities in New Zealand, to support healthy lifestyle behaviours. We aimed to determine whether use of the programme improved adherence to health-related guidelines among Māori and Pasifika communities in New Zealand compared with a control group on a waiting list for the programme. Methods: The OL@-OR@ trial was a 12-week, two-arm, cluster-randomised controlled trial. A cluster was defined as any distinct location or setting in New Zealand where people with shared interests or contexts congregated, such as churches, sports clubs, and community groups. Members of a cluster were eligible to participate if they were aged 18 years or older, had regular access to a mobile device or computer, and had regular internet access. Clusters of Māori and of Pasifika (separately) were randomly assigned (1:1) to either the intervention or control condition. The intervention group received the OL@-OR@ mHealth programme (smartphone app and website). The control group received a control version of the app that only collected baseline and outcome data. The primary outcome was self-reported adherence to health-related guidelines, which were measured with a composite health behaviour score (of physical activity, smoking, alcohol intake, and fruit and vegetable intake) at 12 weeks. The secondary outcomes were self-reported adherence to health-related behaviour guidelines at 4 weeks; self-reported bodyweight at 12 weeks; and holistic health and wellbeing status at 12 weeks, in all enrolled individuals in eligible clusters; and user engagement with the app, in individuals allocated to the intervention. Adverse events were not collected. This study is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12617001484336. Findings: Between Jan 24 and Aug 14, 2018, we enrolled 337 Māori participants from 19 clusters and 389 Pasifika participants from 18 clusters (n=726 participants) in the intervention group and 320 Māori participants from 15 clusters and 405 Pasifika participants from 17 clusters (n=725 participants) in the control group. Of these participants, 227 (67%) Māori participants and 347 (89%) Pasifika participants (n=574 participants) in the intervention group and 281 (88%) Māori participants and 369 (91%) Pasifika participants (n=650 participants) in the control group completed the 12-week follow-up and were included in the final analysis. Relative to baseline, adherence to health-related behaviour guidelines increased at 12 weeks in both groups (315 [43%] of 726 participants at baseline to 329 [57%] of 574 participants in the intervention group; 331 [46%] of 725 participants to 369 [57%] of 650 participants in the control group); however, there was no significant difference between intervention and control groups in adherence at 12 weeks (odds ratio [OR] 1·13; 95% CI 0·84-1·52; p=0·42). Furthermore, the proportion of participants adhering to guidelines on physical activity (351 [61%] of 574 intervention group participants vs 407 [63%] of 650 control group participants; OR 1·03, 95% CI 0·73-1·45; p=0·88), smoking (434 [76%] participants vs 501 [77%] participants; 1·12, 0·67-1·87; p=0·66), alcohol consumption (518 [90%] participants vs 596 [92%] participants; 0·73, 0·37-1·44; p=0·36), and fruit and vegetable intake (194 [34%] participants vs 196 [30%] participants; 1·08, 0·79-1·49; p=0·64) did not differ between groups. We found no significant differences between the intervention and control groups in any secondary outcome. 147 (26%) intervention group participants engaged with the OL@-OR@ programme (ie, set at least one behaviour change goal online). Interpretation: The OL@-OR@ mobile health programme did not improve adherence to health-related behaviour guidelines amongst Māori and Pasifika individuals. Funding: Healthier Lives He Oranga Hauora National Science Challenge.

The Lancet. Digital health · randomised controlled trial · 45 citationsread the source →

Efficacy and cost-effectiveness of therapist-guided internet cognitive behavioural therapy for paediatric anxiety disorders: a single-centre, single-blind, randomised controlled trial.

Background: Paediatric anxiety disorders are associated with substantial disability and long-term adverse consequences, but only a small proportion of affected children have access to evidence-based treatment. Internet-delivered cognitive behavioural therapy (ICBT) could help increase accessibility but needs further rigorous assessment. We aimed to assess the efficacy and cost-effectiveness of ICBT in the treatment of paediatric anxiety disorders. Methods: We did a single-blind randomised controlled trial in a clinical research unit within the Child and Adolescent Mental Health Services in Stockholm (Sweden). Eligible participants were children aged 8-12 years with a diagnosis of a principal anxiety disorder (seperation anxiety disorder, generalised anxiety disorder, specific phobia, social anxiety disorder, or panic disorder) of at least moderate severity. We randomly allocated participants (1:1) to ICBT or internet-delivered child-directed play, an active comparator aimed to improve parent-child relationships and increase a child's self-esteem without directly targeting anxiety. Block sizes for the randomisation varied between four and six and were generated using a computer random-number generator, and the allocation was concealed from the researchers by opaque sealed envelopes. Both treatment programmes comprised 12 modules presented over 12 weeks with weekly asynchronous online therapist support, and consisted of texts, films, illustrations, and exercises. The primary outcome was severity rating of the principal anxiety disorder 12-weeks post-treatment, via the Anxiety Disorder Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders-IV (a rating of at least 4 corresponds to meeting the criteria for the principal diagnosis), assessed by clinicians masked to treatment allocation. All participants were included in the primary analysis (intention-to-treat). This trial is registered at ClinicalTrials.gov, number NCT02350257. Findings: Between March 11, 2015, and Oct 21, 2016, 131 participants were recruited and allocated to either ICBT (n=66) or internet-delivered child-directed play (n=65). The clinician-assessed severity rating of the principal anxiety disorder improved significantly after the 12-weeks treatment period for participants in both ICBT (within-group effect size 1·22, 95% CI 0·78-1·65) and the active control (0·72, 0·44-1·00) groups. However, greater improvement was seen with ICBT than with the active control (estimated mean difference 0·79, 95% CI 0·42-1·16, p=0·002; between-group effect size 0·77, 95% CI 0·40-1·15). 29 (48%) participants in the ICBT group no longer had their principal diagnosis, compared to nine (15%) in the active control group (odds ratio 5·41, 95% CI 2·26 to 12·90, p<0·0001); the number needed to treat for ICBT to gain one additional participant in remission was three (95% CI 2·85 to 3·15). ICBT resulted in an average societal-cost saving of €493·05 (95% CI 477·17 to 508·92) per participant. No severe adverse events were reported. Interpretation: ICBT is an efficacious and cost-effective treatment for paediatric anxiety disorders that should be considered for implementation in routine clinical care. Funding: The Swedish Research Council for Health, Working Life and Welfare, and Stockholm County Council.

The Lancet. Child & adolescent health · randomised controlled trial · 51 citationsread the source →

Improving quit rates of web-delivered interventions for smoking cessation: full-scale randomized trial of WebQuit.org versus Smokefree.gov.

Background and aims: Millions of people world-wide use websites to help them quit smoking, but effectiveness trials have an average 34% follow-up data retention rate and an average 9% quit rate. We compared the quit rates of a website using a new behavioral approach called Acceptance and Commitment Therapy (ACT; WebQuit.org) with the current standard of the National Cancer Institute's (NCI) Smokefree.gov website. Design: A two-arm stratified double-blind individually randomized trial (n = 1319 for WebQuit; n = 1318 for Smokefree.gov) with 12-month follow-up. Setting: United States. Participants: Adults (n = 2637) who currently smoked at least five cigarettes per day were recruited from March 2014 to August 2015. At baseline, participants were mean [standard deviation (SD)] age 46.2 years (13.4), 79% women and 73% white. Interventions: WebQuit.org website (experimental) provided ACT for smoking cessation; Smokefree.gov website (comparison) followed US Clinical Practice Guidelines for smoking cessation. Measurements: The primary outcome was self-reported 30-day point prevalence abstinence at 12 months. Findings: The 12-month follow-up data retention rate was 88% (2309 of 2637). The 30-day point prevalence abstinence rates at the 12-month follow-up were 24% (278 of 1141) for WebQuit.org and 26% (305 of 1168) for Smokefree.gov [odds ratio (OR) = 0.91; 95% confidence interval (CI) = 0.76, 1.10; P = 0.334] in the a priori complete case analysis. Abstinence rates were 21% (278 of 1319) for WebQuit.org and 23% (305 of 1318) for Smokefree.gov (OR = 0.89 (0.74, 1.07; P = 0.200) when missing cases were imputed as smokers. The Bayes factor comparing the primary abstinence outcome was 0.17, indicating 'substantial' evidence of no difference between groups. Conclusions: WebQuit.org and Smokefree.gov had similar 30-day point prevalence abstinence rates at 12 months that were descriptively higher than those of prior published website-delivered interventions and telephone counselor-delivered interventions.

Addiction (Abingdon, England) · randomised controlled trial · 71 citationsread the source →

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.

Background: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. Methods: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. Findings: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. Interpretation: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach. Funding: National Institute for Health Research, Health Technology Assessment programme.

The lancet. Psychiatry · randomised controlled trial · 192 citationsread the source →

Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial.

Background: Patients with advanced cancer have reduced quality of life, which tends to worsen towards the end of life. We assessed the effect of early palliative care in patients with advanced cancer on several aspects of quality of life. Methods: The study took place at the Princess Margaret Cancer Centre (Toronto, ON, Canada), between Dec 1, 2006, and Feb 28, 2011. 24 medical oncology clinics were cluster randomised (in a 1:1 ratio, using a computer-generated sequence, stratified by clinic size and tumour site [four lung, eight gastrointestinal, four genitourinary, six breast, two gynaecological]), to consultation and follow-up (at least monthly) by a palliative care team or to standard cancer care. Complete masking of interventions was not possible; however, patients provided written informed consent to participate in their own study group, without being informed of the existence of another group. Eligible patients had advanced cancer, European Cooperative Oncology Group performance status of 0-2, and a clinical prognosis of 6-24 months. Quality of life (Functional Assessment of Chronic Illness Therapy--Spiritual Well-Being [FACIT-Sp] scale and Quality of Life at the End of Life [QUAL-E] scale), symptom severity (Edmonton Symptom Assessment System [ESAS]), satisfaction with care (FAMCARE-P16), and problems with medical interactions (Cancer Rehabilitation Evaluation System Medical Interaction Subscale [CARES-MIS]) were measured at baseline and monthly for 4 months. The primary outcome was change score for FACIT-Sp at 3 months. Secondary endpoints included change score for FACIT-Sp at 4 months and change scores for other scales at 3 and 4 months. This trial is registered with ClinicalTrials.gov, number NCT01248624. Findings: 461 patients completed baseline measures (228 intervention, 233 control); 393 completed at least one follow-up assessment. At 3-months, there was a non-significant difference in change score for FACIT-Sp between intervention and control groups (3·56 points [95% CI -0·27 to 7·40], p=0·07), a significant difference in QUAL-E (2·25 [0·01 to 4·49], p=0·05) and FAMCARE-P16 (3·79 [1·74 to 5·85], p=0·0003), and no difference in ESAS (-1·70 [-5·26 to 1·87], p=0·33) or CARES-MIS (-0·66 [-2·25 to 0·94], p=0·40). At 4 months, there were significant differences in change scores for all outcomes except CARES-MIS. All differences favoured the intervention group. Interpretation: Although the difference in quality of life was non-significant at the primary endpoint, this trial shows promising findings that support early palliative care for patients with advanced cancer. Funding: Canadian Cancer Society, Ontario Ministry of Health and Long Term Care.

Lancet (London, England) · randomised controlled trial · 1215 citationsread the source →

Psychometric Comparison of the Generalized Anxiety Disorder Scale-7 and the Penn State Worry Questionnaire for Measuring Response during Treatment of Generalised Anxiety Disorder

The Penn State Worry Questionnaire (PSWQ) is a widely used measure of the worry characteristic of generalised anxiety disorder (GAD). The 7-item Generalized Anxiety Disorder Scale (GAD-7) is a new brief screening tool for GAD, which is being increasingly used in research and clinical practice. The present study sought to provide comparison data on the relative psychometric properties of these two scales. The data of 195 adults who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for GAD and who participated in two randomised treatment controlled trials were used. Factor analyses, internal consistency, correlational analyses, responsiveness to change, and agreement between the scales based on indentified clinical cutoffs were conducted. Factor analyses confirmed a one-factor structure for the GAD-7 and a three-factor structure involving two method factors for the PSWQ. Both the GAD-7 and the PSWQ demonstrated adequate internal consistency (Cronbach's alpha: .79-.91 and .86-.91, respectively), and moderate correlations (r = .51-.71) were observed between the scales across the treatment time points. The scales exhibited small correlations with the Sheehan Disability Scale at pretreatment (GAD-7 r = .38; PSWQ r = .26), but moderate correlations at posttreatment and follow-up (r = .59-.79). Agreement between the scales was limited using various clinical cutoffs identified within the literature. Both measures were sensitive to change, although the GAD-7 appeared to be more sensitive and may, therefore, confer some advantages in clinical work.

Cognitive Behaviour Therapy · cohort or longitudinal · 291 citationsread the source →

Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial.

OBJECTIVE Various approaches to cognitive-behavioral therapy (CBT) have been shown to be effective for social anxiety disorder. For psychodynamic therapy, evidence for efficacy in this disorder is scant. The authors tested the efficacy of psychodynamic therapy and CBT in social anxiety disorder in a multicenter randomized controlled trial. METHOD In an outpatient setting, 495 patients with social anxiety disorder were randomly assigned to manual-guided CBT (N=209), manual-guided psychodynamic therapy (N=207), or a waiting list condition (N=79). Assessments were made at baseline and at end of treatment. Primary outcome measures were rates of remission and response, based on the Liebowitz Social Anxiety Scale applied by raters blind to group assignment. Several secondary measures were assessed as well. RESULTS Remission rates in the CBT, psychodynamic therapy, and waiting list groups were 36%, 26%, and 9%, respectively. Response rates were 60%, 52%, and 15%, respectively. CBT and psychodynamic therapy were significantly superior to waiting list for both remission and response. CBT was significantly superior to psychodynamic therapy for remission but not for response. Between-group effect sizes for remission and response were small. Secondary outcome measures showed significant differences in favor of CBT for measures of social phobia and interpersonal problems, but not for depression. CONCLUSIONS CBT and psychodynamic therapy were both efficacious in treating social anxiety disorder, but there were significant differences in favor of CBT. For CBT, the response rate was comparable to rates reported in Swedish and German studies in recent years. For psychodynamic therapy, the response rate was comparable to rates reported for pharmacotherapy and cognitive-behavioral group therapy.

The American journal of psychiatry · randomised controlled trial · 133 citationsread the source →

Quantitative meta-analysis of neural activity in posttraumatic stress disorder.

Background: In recent years, neuroimaging techniques such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET) have played a significant role in elucidating the neural underpinnings of posttraumatic stress disorder (PTSD). However, a detailed understanding of the neural regions implicated in the disorder remains incomplete because of considerable variability in findings across studies. The aim of this meta-analysis was to identify consistent patterns of neural activity across neuroimaging study designs in PTSD to improve understanding of the neurocircuitry of PTSD. Methods: We conducted a literature search for PET and fMRI studies of PTSD that were published before February 2011. The article search resulted in 79 functional neuroimaging PTSD studies. Data from 26 PTSD peer-reviewed neuroimaging articles reporting results from 342 adult patients and 342 adult controls were included. Peak activation coordinates from selected articles were used to generate activation likelihood estimate maps separately for symptom provocation and cognitive-emotional studies of PTSD. A separate meta-analysis examined the coupling between ventromedial prefrontal cortex and amygdala activity in patients. Results: Results demonstrated that the regions most consistently hyperactivated in PTSD patients included mid- and dorsal anterior cingulate cortex, and when ROI studies were included, bilateral amygdala. By contrast, widespread hypoactivity was observed in PTSD including the ventromedial prefrontal cortex and the inferior frontal gyrus. Furthermore, decreased ventromedial prefrontal cortex activity was associated with increased amygdala activity. Conclusions: These results provide evidence for a neurocircuitry model of PTSD that emphasizes alteration in neural networks important for salience detection and emotion regulation.

Biology of mood & anxiety disorders · 322 citationsread the source →

The PRESERVE mortality risk score and analysis of long-term outcomes after extracorporeal membrane oxygenation for severe acute respiratory distress syndrome.

Purpose: This study was designed to identify factors associated with death by 6 months post-intensive care unit (ICU) discharge and to develop a practical mortality risk score for extracorporeal membrane oxygenation (ECMO)-treated acute respiratory distress syndrome (ARDS) patients. We also assessed long-term survivors' health-related quality of life (HRQL), respiratory symptoms, and anxiety, depression and post-traumatic stress disorder (PTSD) frequencies. Methods: Data from 140 ECMO-treated ARDS patients admitted to three French ICUs (2008-2012) were analyzed. ICU survivors contacted >6 months post-ICU discharge were assessed for HRQL, psychological and PTSD status. Results: Main ARDS etiologies were bacterial (45%), influenza A[H₁N₁] (26%) and post-operative (17%) pneumonias. Six months post-ICU discharge, 84 (60%) patients were still alive. Based on multivariable logistic regression analysis, the PRESERVE (PRedicting dEath for SEvere ARDS on VV-ECMO) score (0-14 points) was constructed with eight pre-ECMO parameters, i.e. age, body mass index, immunocompromised status, prone positioning, days of mechanical ventilation, sepsis-related organ failure assessment, plateau pressure andpositive end-expiratory pressure. Six-month post-ECMO initiation cumulative probabilities of survival were 97, 79, 54 and 16% for PRESERVE classes 0-2, 3-4, 5-6 and ≥7 (p < 0.001), respectively. HRQL evaluation in 80% of the 6-month survivors revealed satisfactory mental health but persistent physical and emotional-related difficulties, with anxiety, depression or PTSD symptoms reported, by 34, 25 or 16%, respectively. Conclusions: The PRESERVE score might help ICU physicians select appropriate candidates for ECMO among severe ARDS patients. Future studies should also focus on physical and psychosocial rehabilitation that could lead to improved HRQL in this population.

Intensive care medicine · clinical trial · 441 citationsread the source →

Young worker safety behaviors: development and validation of measures.

We conducted four studies to develop and validate measures of workplace safety-related behaviors relevant to young workers. The conceptual basis for this set of measures is a range of behavioral responses to deteriorating conditions (e.g., exit, voice, and loyalty, Hirschman, 1970; exit, voice, loyalty/patience, and neglect, Rusbult et al., 1982). In Study 1, items were generated by young workers (n=39) who participated in focus groups. The representativeness of these items was judged in Study 2 by a separate sample of young workers (n=79). In Study 3, we found support for five factors using exploratory factor analysis with a sample of young workers (n=266). Confirmatory factor analysis was conducted in Study 4 using a separate sample (n=282) and this supported the five-factor model. Self-report data on these participants and other-report (co-worker) data on a sub-sample (n=26) of the same participants provided additional support for the validity of the scales. Overall, these studies support the validity and reliability of this set of safety-related behaviors: intentions to quit an unsafe job (exit), speaking out about safety concerns (voice), adapting to a dangerous job hoping that safety conditions improve (patience), deliberately letting safety conditions worsen (neglect), and following safety policies (compliance). This set is useful for evaluating safety interventions aimed at young workers and studying safety-related behavior in a vulnerable work population.

Accident; analysis and prevention · cohort or longitudinal · 16 citationsread the source →

A planetary health model for reducing exposure to faecal contamination in urban informal settlements: Baseline findings from Makassar, Indonesia.

Background: The intense interactions between people, animals and environmental systems in urban informal settlements compromise human and environmental health. Inadequate water and sanitation services, compounded by exposure to flooding and climate change risks, expose inhabitants to environmental contamination causing poor health and wellbeing and degrading ecosystems. However, the exact nature and full scope of risks and exposure pathways between human health and the environment in informal settlements are uncertain. Existing models are limited to microbiological linkages related to faecal-oral exposures at the individual level, and do not account for a broader range of human-environmental variables and interactions that affect population health and wellbeing. Methods: We undertook a 12-month health and environmental assessment in 12 flood-prone informal settlements in Makassar, Indonesia. We obtained caregiver-reported health data, anthropometric measurements, stool and blood samples from children < 5 years, and health and wellbeing data for children 5-14 years and adult respondents. We collected environmental data including temperature, mosquito and rat species abundance, and water and sediment samples. Demographic, built environment and household asset data were also collected. We combined our data with existing literature to generate a novel planetary health model of health and environment in informal settlements. Results: Across the 12 settlements, 593 households and 2764 participants were enrolled. Two-thirds (64·1%) of all houses (26·3-82·7% per settlement) had formal land tenure documentation. Cough, fever and diarrhoea in the week prior to the survey were reported among an average of 34.3%, 26.9% and 9.7% of children aged < 5 years, respectively; although proportions varied over time, prevalence among these youngest children was consistently higher than among children 5-14 years or adult respondents. Among children < 5 years, 44·3% experienced stunting, 41·1% underweight, 12.4% wasting, and 26.5% were anaemic. There was self- or carer-reported poor mental health among 16.6% of children aged 5-14 years and 13.9% of adult respondents. Rates of potential risky exposures from swimming in waterways, eating uncooked produce, and eating soil or dirt were high, as were exposures to flooding and livestock. Just over one third of households (35.3%) had access to municipal water, and contamination of well water with E. coli and nitrogen species was common. Most (79·5%) houses had an in-house toilet, but no houses were connected to a piped sewer network or safe, properly constructed septic tank. Median monthly settlement outdoor temperatures ranged from 26·2 °C to 29.3 °C, and were on average, 1·1 °C warmer inside houses than outside. Mosquito density varied over time, with Culex quinquefasciatus accounting for 94·7% of species. Framed by a planetary health lens, our model includes four thematic domains: (1) the physical/built environment; (2) the ecological environment; (3) human health; and (4) socio-economic wellbeing, and is structured at individual, household, settlement, and city/beyond spatial scales. Conclusions: Our planetary health model includes key risk factors and faecal-oral exposure pathways but extends beyond conventional microbiological faecal-oral enteropathogen exposure pathways to comprehensively account for a wider range of variables affecting health in urban informal settlements. It includes broader ecological interconnections and planetary health-related variables at the household, settlement and city levels. It proposes a composite framework of markers to assess water and sanitation challenges and flood risks in urban informal settlements for optimal design and monitoring of interventions.

Environment international · 23 citationsread the source →

A survey of fertility and sexual health following allogeneic haematopoietic stem cell transplantation in New South Wales, Australia.

Four hundred and twenty-one adult allogeneic haematopoietic stem cell transplant (HSCT) survivors participated in a cross-sectional study to assess sexual dysfunction and infertility post-transplant. Survey instruments included the Sydney Post-Blood and Marrow Transplant (BMT) Survey, Functional Assessment of Cancer Treatment (FACT) - BMT, the Depression, Anxiety, Stress Scales (DASS 21), the Chronic Graft-versus-Host Disease (cGVHD) Activity Assessment- Patient Self Report (Form B), the Lee cGVHD Symptom Scale and The Post-Traumatic Growth Inventory. Most HSCT survivors reported sexual difficulties (51% of males; 66% of females). Men reported erectile dysfunction (79%) and decreased libido (61·6%) and women reported loss of libido (83%), painful intercourse (73%) and less enjoyment of sex (68%). Women also commonly reported vaginal dryness (73%), vaginal narrowing (34%) and vaginal irritation (26%). Woman had much higher rates of genital cGvHD than men (22% vs. 5%). Age and cGVHD were significantly associated with sexual dysfunction. Few survivors had children following transplant (3·3%). However, for those of reproductive age at HSCT, 22% reported trying to conceive, with 10·3% reporting success. This study is the largest to date exploring sexual function in survivors of allo-HSCT. This data provides the basis for health service reform to better meet the needs of HSCT survivors, including evidence to support counselling and education both pre- and post-transplant.

British journal of haematology · 31 citationsread the source →

Socioeconomic inequalities in adolescent health 2002-2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study.

Background: Information about trends in adolescent health inequalities is scarce, especially at an international level. We examined secular trends in socioeconomic inequality in five domains of adolescent health and the association of socioeconomic inequality with national wealth and income inequality. Methods: We undertook a time-series analysis of data from the Health Behaviour in School-aged Children study, in which cross-sectional surveys were done in 34 North American and European countries in 2002, 2006, and 2010 (pooled n 492,788). We used individual data for socioeconomic status (Health Behaviour in School-aged Children Family Affluence Scale) and health (days of physical activity per week, body-mass index Z score [zBMI], frequency of psychological and physical symptoms on 0-5 scale, and life satisfaction scored 0-10 on the Cantril ladder) to examine trends in health and socioeconomic inequalities in health. We also investigated whether international differences in health and health inequalities were associated with per person income and income inequality. Findings: From 2002 to 2010, average levels of physical activity (3·90 to 4·08 days per week; p<0·0001), body mass (zBMI -0·08 to 0·03; p<0·0001), and physical symptoms (3·06 to 3·20, p<0·0001), and life satisfaction (7·58 to 7·61; p=0·0034) slightly increased. Inequalities between socioeconomic groups increased in physical activity (-0·79 to -0·83 days per week difference between most and least affluent groups; p=0·0008), zBMI (0·15 to 0·18; p<0·0001), and psychological (0·58 to 0·67; p=0·0360) and physical (0·21 to 0·26; p=0·0018) symptoms. Only in life satisfaction did health inequality fall during this period (-0·98 to -0·95; p=0·0198). Internationally, the higher the per person income, the better and more equal health was in terms of physical activity (0·06 days per SD increase in income; p<0·0001), psychological symptoms (-0·09; p<0·0001), and life satisfaction (0·08; p<0·0001). However, higher income inequality uniquely related to fewer days of physical activity (-0·05 days; p=0·0295), higher zBMI (0·06; p<0·0001), more psychological (0·18; p<0·0001) and physical (0·16; p<0·0001) symptoms, and larger health inequalities between socioeconomic groups in psychological (0·13; p=0·0080) and physical (0·07; p=0·0022) symptoms, and life satisfaction (-0·10; p=0·0092). Interpretation: Socioeconomic inequality has increased in many domains of adolescent health. These trends coincide with unequal distribution of income between rich and poor people. Widening gaps in adolescent health could predict future inequalities in adult health and need urgent policy action. Funding: Canadian Institutes of Health Research.

Lancet (London, England) · 301 citationsread the source →

Mental health resilience in the adolescent offspring of parents with depression: a prospective longitudinal study.

Background: Young people whose parents have depression have a greatly increased risk of developing a psychiatric disorder, but poor outcomes are not inevitable. Identification of the contributors to mental health resilience in young people at high familial risk is an internationally recognised priority. Our objectives were to identify protective factors that predict sustained good mental health in adolescents with a parent with depression and to test whether these contribute beyond what is explained by parent illness severity. Methods: The Early Prediction of Adolescent Depression study (EPAD) is a prospective longitudinal study of offspring of parents with recurrent depression. Parents with recurrent major depressive disorder, co-parents, and offspring (aged 9-17 years at baseline) were assessed three times over 4 years in a community setting. Offspring outcomes were operationalised as absence of mental health disorder, subthreshold symptoms, or suicidality on all three study occasions (sustained good mental health); and better than expected mental health (mood and behavioural symptoms at follow-up lower than predicted given severity of parental depression). Family, social, cognitive, and health behaviour predictor variables were assessed using interview and questionnaire measures. Findings: Between February and June, 2007, we screened 337 families at baseline, of which 331 were eligible. Of these, 262 completed the three assessments and were included in the data for sustained mental health. Adolescent mental health problems were common, but 53 (20%) of the 262 adolescents showed sustained good mental health. Index parent positive expressed emotion (odds ratio 1·91 [95% CI 1·31-2·79]; p=0·001), co-parent support (1·90 [1·38-2·62]; p<0·0001), good-quality social relationships (2·07 [1·35-3·18]; p=0·001), self-efficacy (1·49 [1·05-2·11]; p=0·03), and frequent exercise (2·96 [1·26-6·92]; p=0·01) were associated with sustained good mental health. Analyses accounting for parent depression severity were consistent, but frequent exercise only predicted better than expected mood-related mental health (β=-0·22; p=0·0004) not behavioural mental health, whereas index parents' expression of positive emotions predicted better than expected behavioural mental health (β=-0·16; p=0·01) not mood-related mental health. Multiple protective factors were required for offspring to be free of mental health problems (zero or one protective factor, 4% sustained good mental health; two protective factors, 10%; three protective factors, 13%, four protective factors, 38%; five protective factors, 48%). Interpretation: Adolescent mental health problems are common, but not inevitable, even when parental depression is severe and recurrent. These findings suggest that prevention programmes will need to enhance multiple protective factors across different domains of functioning. Funding: Sir Jules Thorn Charitable Trust, Economic and Social Research Council.

The lancet. Psychiatry · 120 citationsread the source →

Cognitive and psychiatric symptom trajectories 2-3 years after hospital admission for COVID-19: a longitudinal, prospective cohort study in the UK.

Background: COVID-19 is known to be associated with increased risks of cognitive and psychiatric outcomes after the acute phase of disease. We aimed to assess whether these symptoms can emerge or persist more than 1 year after hospitalisation for COVID-19, to identify which early aspects of COVID-19 illness predict longer-term symptoms, and to establish how these symptoms relate to occupational functioning. Methods: The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study of adults (aged ≥18 years) who were hospitalised with a clinical diagnosis of COVID-19 at participating National Health Service hospitals across the UK. In the C-Fog study, a subset of PHOSP-COVID participants who consented to be recontacted for other research were invited to complete a computerised cognitive assessment and clinical scales between 2 years and 3 years after hospital admission. Participants completed eight cognitive tasks, covering eight cognitive domains, from the Cognitron battery, in addition to the 9-item Patient Health Questionnaire for depression, the Generalised Anxiety Disorder 7-item scale, the Functional Assessment of Chronic Illness Therapy Fatigue Scale, and the 20-item Cognitive Change Index (CCI-20) questionnaire to assess subjective cognitive decline. We evaluated how the absolute risks of symptoms evolved between follow-ups at 6 months, 12 months, and 2-3 years, and whether symptoms at 2-3 years were predicted by earlier aspects of COVID-19 illness. Participants completed an occupation change questionnaire to establish whether their occupation or working status had changed and, if so, why. We assessed which symptoms at 2-3 years were associated with occupation change. People with lived experience were involved in the study. Findings: 2469 PHOSP-COVID participants were invited to participate in the C-Fog study, and 475 participants (191 [40·2%] females and 284 [59·8%] males; mean age 58·26 [SD 11·13] years) who were discharged from one of 83 hospitals provided data at the 2-3-year follow-up. Participants had worse cognitive scores than would be expected on the basis of their sociodemographic characteristics across all cognitive domains tested (average score 0·71 SD below the mean [IQR 0·16-1·04]; p<0·0001). Most participants reported at least mild depression (263 [74·5%] of 353), anxiety (189 [53·5%] of 353), fatigue (220 [62·3%] of 353), or subjective cognitive decline (184 [52·1%] of 353), and more than a fifth reported severe depression (79 [22·4%] of 353), fatigue (87 [24·6%] of 353), or subjective cognitive decline (88 [24·9%] of 353). Depression, anxiety, and fatigue were worse at 2-3 years than at 6 months or 12 months, with evidence of both worsening of existing symptoms and emergence of new symptoms. Symptoms at 2-3 years were not predicted by the severity of acute COVID-19 illness, but were strongly predicted by the degree of recovery at 6 months (explaining 35·0-48·8% of the variance in anxiety, depression, fatigue, and subjective cognitive decline); by a biocognitive profile linking acutely raised D-dimer relative to C-reactive protein with subjective cognitive deficits at 6 months (explaining 7·0-17·2% of the variance in anxiety, depression, fatigue, and subjective cognitive decline); and by anxiety, depression, fatigue, and subjective cognitive deficit at 6 months. Objective cognitive deficits at 2-3 years were not predicted by any of the factors tested, except for cognitive deficits at 6 months, explaining 10·6% of their variance. 95 of 353 participants (26·9% [95% CI 22·6-31·8]) reported occupational change, with poor health being the most common reason for this change. Occupation change was strongly and specifically associated with objective cognitive deficits (odds ratio [OR] 1·51 [95% CI 1·04-2·22] for every SD decrease in overall cognitive score) and subjective cognitive decline (OR 1·54 [1·21-1·98] for every point increase in CCI-20). Interpretation: Psychiatric and cognitive symptoms appear to increase over the first 2-3 years post-hospitalisation due to both worsening of symptoms already present at 6 months and emergence of new symptoms. New symptoms occur mostly in people with other symptoms already present at 6 months. Early identification and management of symptoms might therefore be an effective strategy to prevent later onset of a complex syndrome. Occupation change is common and associated mainly with objective and subjective cognitive deficits. Interventions to promote cognitive recovery or to prevent cognitive decline are therefore needed to limit the functional and economic impacts of COVID-19. Funding: National Institute for Health and Care Research Oxford Health Biomedical Research Centre, Wolfson Foundation, MQ Mental Health Research, MRC-UK Research and Innovation, and National Institute for Health and Care Research.

The lancet. Psychiatry · 46 citationsread the source →

Suicide in children and young people in England: a consecutive case series.

Background: There is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. We have done a comprehensive national multi-agency study of suicide in under 20s in England. We aimed to establish how frequently suicide is preceded by child-specific and young person-specific suicide risk factors, as well as all-age factors, and to identify contact with health-care and social-care services and justice agencies. Methods: This study is a descriptive examination of suicide in a national consecutive sample of children and young people younger than 20 years who died by suicide in England between Jan 1, 2014, and April 30, 2015. We obtained general population mortality data from the Office for National Statistics (ONS). We collected information about antecedents considered to be relevant to suicide (eg, abuse, bullying, bereavement, academic pressures, self-harm, and physical health) from a range of investigations and inquiries, including coroner inquest hearings, child death investigations, criminal justice system reports, and the National Health Service, including data on people in contact with mental health services in the 12 months before their death. Findings: 145 suicides in people younger than 20 years were notified to us during the study period, of which we were able to obtain report data about antecedents for 130 (90%). The number of suicides rose sharply during the late teens with 79 deaths by suicide in people aged 18-19 years compared with 66 in people younger than 18 years. 102 (70%) deaths were in males. 92 (63%) deaths were by hanging. Various antecedents were reported among the individuals for whom we had report data, including academic (especially exam) pressures (35 [27%] individuals), bullying (28 [22%]), bereavement (36 [28%]), suicide in family or friends (17 [13%]), physical health conditions (47 [36%]), family problems (44 [34%]), social isolation or withdrawal (33 [25%]), child abuse or neglect (20 [15%]), excessive drinking (34 [26%]), and illicit drug use (38 [29%]). Suicide-related internet use was recorded in 30 (23%) cases. In the week before death 13 (10%) individuals had self-harmed and 35 (27%) had expressed suicidal ideas. 56 (43%) individuals had no known contact with health-care and social-care services or justice agencies. Interpretation: Improved services for self-harm and mental health are crucial to suicide prevention, but the wide range of antecedents emphasises the roles of schools, primary care, social services, and the youth justice system. Funding: The Healthcare Quality Improvement Partnership.

The lancet. Psychiatry · 71 citationsread the source →

Mental Health Response to the COVID-19 Outbreak in China

Back to table of contents Previous article Next article CommentaryFull AccessMental Health Response to the COVID-19 Outbreak in ChinaJunying Zhou, M.D., Ph.D., Liu Liu, M.D., Pei Xue, M.D., Xiaorong Yang, B.N., Xiangdong Tang, M.D., Ph.D.Junying Zhou, M.D., Ph.D., Liu Liu, M.D., Pei Xue, M.D., Xiaorong Yang, B.N., Xiangdong Tang, M.D., Ph.D.Published Online:7 May 2020https://doi.org/10.1176/appi.ajp.2020.20030304AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Transmission of the 2019 novel coronavirus (COVID-19) (1) has now widely and rapidly spread around the world. On March 11, 2020, the World Health Organization announced that COVID-19 is a pandemic (2). The rapid transmission and mortality risk of the COVID-19 infection may increase the risk of mental health problems among healthy individuals in the general public and worsen preexisting psychiatric problems in psychiatric patients, although data are still being gathered. A constellation of difficult feelings and psychological distress, including panic, worries, and depression, could be triggered by the fear of possible infection, being quarantined at hospitals and home, social isolation, and even the shortage of protective gear.A number of mental health surveys associated with the COVID-19 outbreak are being conducted in different vulnerable populations, which include infected patients, medical staff, students, and the general population. Liu et al. have reported results from a multicenter survey conducted among 1,563 medical staff members and found that the prevalence of depression and anxiety was 51% and 45%, respectively (3). So far, data on the mental health repercussions of the COVID-19 pandemic in outpatient populations have not been available. Thus, we conducted a questionnaire survey, from February 25 to March 9, 2020, among outpatients who sought care in the Departments of Psychiatry, Neurology, and Sleep Medicine in West China Hospital of Sichuan University (Chengdu, China). A self-report questionnaire was completed by outpatients, who provided consent, via the WeChat-based survey program Questionnaire Star. A total of 2,065 out of 3,441 patients completed the survey, including 589 new patients and 1,476 existing patients. The prevalence rates of mental health problems related to the COVID-19 outbreak, including anxiety (defined as a total score ≥5 on the Generalized Anxiety Disorder 7-item scale), depression (defined as a total score ≥5 on the Patient Health Questionnaire 9-item scale), and insomnia (defined as a total score ≥8 on the Insomnia Severity Index), were 25.5%, 16.9%, and 26.2%, respectively. Furthermore, 20.9% of patients (N=300) with preexisting psychiatric disorders (N=1,434) reported a deterioration of their mental health condition related to the pandemic. In particular, transportation restrictions, isolation at home, and fear of cross-infection in hospitals have inevitably become major concerns and barriers to treatment for these patients during the outbreak. Our survey also showed that 24.5% of new patients, including those with anxiety (N=46), depression (N=37), insomnia (N=79), and psychosis (N=21), could not receive timely diagnoses and treatment. Similarly, 22.0% of existing patients with diagnosed mental disorders, including depression, bipolar disorders, and schizophrenia (N=315), could not receive routine psychiatric care because of suspended hospital visits. Consequently, 18.1% of patients (N=259) have self-reduced medication dosages, and 17.2% of patients (N=247) stopped taking their medication because they could not gain access to prescriptions from physicians during the outbreak. As the lifetime prevalence of mental disorders is 16.6% among adults in China (4), millions of psychiatric patients may face barriers to help seeking for timely management of their mental health condition. The long-term repercussions of the viral pandemic on the management of psychiatric patients warrant further investigation. Nonetheless, our data reiterate the importance of implementing appropriate mental health care measures in the face of the COVID-19 pandemic. In response to the COVID-19 outbreak, there have been ongoing measures and concerted efforts in China that emphasize the importance of dealing with the potentially concurrent mental health crisis. On January 26, 2020, the National Health Commission of China released principles for emergency psychological crisis intervention for the COVID-19 pandemic (5). Mental health hotlines were quickly established across China and provided the public with counseling and psychological services. The telephone and Internet have been widely used to deliver mental health care services, and social media platforms (e.g., WeChat, Weibo) have been used to share strategies, guidelines, and education programs for managing potential mental distress. In addition, a series of self-help handbooks for psychological care associated with COVID-19 have been published by the China Association for Mental Health, medical institutions, and universities. Furthermore, a number of hospitals in China have initiated telemedicine services for patients in need during the outbreak of COVID-19. On January 26, 2020, West China Hospital of Sichuan University, as one of the leading hospitals in China, opened a free online outpatient service involving more than 100 medical doctors across specialties. This online outpatient service was created mainly to provide prescriptions to existing patients and to offer consultation to new patients. Our hospital collaborated with commercial courier services to deliver medication to patients' homes at no cost. To date, thousands of patients have received health care provided by this online outpatient service. Interestingly, only 7.4% of patients with mental disorders (N=136) in our survey have sought online help for medical care. Thus, there is a need to promote online mental health care services across China to manage mental health problems during the pandemic. The long-term outcomes of the mental health interventions in both community and hospital settings need further evaluation to determine how we can ameliorate the negative effects of viral outbreaks in the general public, especially among vulnerable patients with mental health problems. Sleep Medicine Center (Zhou, Xue, Tang), Department of Anesthesiology, Translational Neuroscience Center (Liu), and Outpatient Department (Yang), West China Hospital, Sichuan University, Chengdu, China. Send correspondence to Dr. Zhou ([email protected]).The authors report no financial relationships with commercial interests. The authors thank the clinic nurses in the Departments of Psychiatry, Neurology, and Sleep Medicine, West China Hospital, Sichuan University. References1 Lu R, Zhao X, Li J, et al.: Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 2020; 395:565–574Crossref, Medline, Google Scholar2 World Health Organization (WHO): WHO director-general's opening remarks at the media briefing on COVID-19: 11 March 2020 (https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020)Google Scholar3 Liu S, Yang L, Zhang C, et al.: Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020; 7:e17–e18Crossref, Medline, Google Scholar4 Huang Y, Wang Y, Wang H, et al.: Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry 2019; 6:211–224Crossref, Medline, Google Scholar5 National Health Commission of China: [Principles for emergency psychological crisis intervention for the new coronavirus pneumonia.] http://www.nhc.gov.cn/jkj/s3577/202001/6adc08b966594253b2b791be5c3b9467.shtml (Chinese)Google Scholar FiguresReferencesCited byDetailsCited byRelationship between depression and burnout among nurses in Intensive Care units at the late stage of COVID-19: a network analysis1 April 2024 | BMC Nursing, Vol. 23, No. 1Effects of Long COVID on Psycho-Physical Conditions in the Italian Population: A Statistical and Large Language Model Combined Description27 April 2024 | European Journal of Investigation in Health, Psychology and Education, Vol. 14, No. 5The efficacy of internet-delivered cognitive-behavioral therapy for posttraumatic stress disorder according to the mean age of patients: a systematic review and meta-analysis11 December 2023 | Psychology, Health & Medicine, Vol. 29, No. 4Descripción de un Programa de Telesalud Mental en el Marco de la Pandemia de COVID-19 en ColombiaRevista Colombiana de Psiquiatría, Vol. 53, No. 2Longitudinal trajectories of anxiety and depression in subjects with different mental disorders after one year in the COVID-19 pandemicPsychiatry Research, Vol. 334The Impact of the COVID-19 Pandemic on the Mental Health of Families16 April 2024Effect of anxiety and depression on self-reported adverse reactions to COVID-19 vaccine: a cross-sectional study in Shanghai, China3 March 2023 | BMC Public Health, Vol. 23, No. 1Evaluation of cognitive functions in a group of Egyptian recovered COVID-19 patients22 May 2023 | Middle East Current Psychiatry, Vol. 30, No. 1Trends in telemedicine utilization for mental illness during the COVID-19 pandemic: an analysis of a nationwide database in Korea24 October 2023 | BMC Psychiatry, Vol. 23, No. 1Investigating the dynamic relationship between stigma of fear, discrimination and employees performance among healthcare workers during Covid-19 pandemic31 July 2023 | Cognition, Technology & Work, Vol. 25, No. 4"I Can't See an End in Sight." 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data3 November 2022 | Social Network Analysis and Mining, Vol. 12, No. 1Association between sedentary time and metabolic syndrome: A cross-sectional study among Chinese Garze Tibetans17 November 2022 | Frontiers in Public Health, Vol. 10COVID-19 pandemic and adolescent mental health in China: Micro evidence and socioeconomic mechanisms14 November 2022 | Frontiers in Psychology, Vol. 13A deep learning-based model for detecting depression in senior population7 November 2022 | Frontiers in Psychiatry, Vol. 13Einfluss der COVID-19-Pandemie auf die ambulante psychotherapeutische Versorgung von Kindern und Jugendlichen27 June 2022 | Die Psychotherapie, Vol. 67, No. 6Family Resilience, Media Exposure, and Children's Mental Health in China During COVID-196 December 2021 | The Family Journal, Vol. 30, No. 4The associations among the stress symptoms, depressive symptoms, anxiety symptoms and insomnia symptoms in depressed patients after the first COVID-19 outbreak was initially controlled in 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Psychiatry, Vol. 76, No. 5Proposal of a Model for the Analysis of the State of the Use of ICT in Education Applied to Technological Institutes of Higher Education8 July 2022 | Computers, Vol. 11, No. Mental and COVID-19 A in the June 2022 | Frontiers in Public Health, Vol. of Psychiatric in Patients in Hospitals to COVID-19 Outbreak in A Center Longitudinal April 2022 | Vol. No. Use and Mental Health During the COVID-19 Health Vol. No. for During the COVID-19 Pandemic: A April 2022 | Frontiers in Psychiatry, Vol. post-traumatic in the general a cross-sectional study from August 2021 | Psychology, Health & Medicine, Vol. No. as in a with A Reports, Vol. 17, No. of symptoms in Internet and depression among adolescents in A network of Affective Disorders, Vol. March 2022 | University Journal of and of Social Media in for the of the Pandemic among Students27 February 2022 | International Journal of Research and Public Health, Vol. 19, No. of the during the COVID-19 Lockdown by the Mental Health by the of Psychology of March 2022 | International Journal of Research and Public Health, Vol. 19, No. symptoms during the early and late of the COVID-19 pandemic in China: a systematic review and Medicine, Vol. and Sleep of Patients with Sleep February 2022 | Journal of Sleep Medicine, Vol. 9, No. of and psychiatric symptoms in patients with psychiatric disorders during the Covid-19 May 2021 | European of Psychiatry and Vol. No. the Care and Anxiety of Patients with COVID-19 in November 2021 | Journal of and Health, Vol. No. impact of the pandemic on in the with preexisting mental health A longitudinal October 2021 | Journal of Vol. No. of Psychiatric and Psychiatric Among for During the Initial of COVID-19 Pandemic in Vol. 19, No. of the COVID-19 September to the Prevalence of of Mental in the During the COVID-19 Pandemic: December 2022 | Research, Vol. No. in the of the COVID-19 Pandemic in January 2022 | Journal of Science, Vol. No. 6Mental Health and among University during the COVID-19 Pandemic in January 2022 | Journal of Sciences, Vol. No. in the and COVID-19 among patients with psychiatric illness A study from of Psychiatry, Vol. No. on Impact of COVID-19 Pandemic on with their and with Social Psychiatry, Vol. No. and of to Department during COVID-19 Pandemic of December 2021 | Journal of Care Medicine, Vol. 25, No. impact of the COVID-19 pandemic on depression in a prospective cohort December 2021 | Medicine, Vol. impact in patients with mental disorders after of COVID-19 Vol. to the COVID-19 Pandemic Among the General February 2021 | Journal of and Studies, Vol. No. 8The impact of COVID-19 pandemic on symptoms and among patients with medication a cross-sectional May 2021 | The Journal of and Vol. 22, No. reactions and insomnia in adults with mental health disorders during the COVID-19 January 2021 | BMC Psychiatry, Vol. 21, No. and anxiety symptoms in adults before and during the COVID-19 pandemic: evidence from a September 2021 | Annals of General Psychiatry, Vol. No. 1Prevalence of psychiatric and related symptoms among patients with COVID-19 during the wave of the April 2021 | and Health, Vol. 17, No. anxiety, and post-traumatic stress symptoms and COVID-19 patients: a cross-sectional study4 May 2021 | Middle East Current Psychiatry, Vol. No. of a of patients with disorders during the first COVID-19 December 2021 | Scientific Reports, Vol. 11, No. 1Effects of COVID ‐19 pandemic on mental health outcomes in a cohort of early psychosis January 2021 | in Psychiatry, Vol. No. the psychological therapy treatment outcomes for adults who are not in of and be to November 2021 | Medicine, Vol. Health to Social During the COVID-19 Pandemic in a November 2021 | Frontiers in Public Health, Vol. between the COVID-19 and and symptoms in people with November 2021 | impact of and mental health on health during of Psychiatric Research, Vol. and of public health on public new A systematic March 2021 | International Journal of Social Psychiatry, Vol. 67, No. and disorders associated with COVID-19. disorders and Vol. of mental disorders on COVID-19 October 2021 | Neurology, Vol. 13, No. of COVID-19 pandemic on emergency community Psychiatry, Vol. and psychological impact of COVID-19 pandemic in a cohort study Vol. mental health and need for care among psychiatric outpatients during the COVID-19 pandemic: from an in Research, Vol. pandemic in January 2021 | Journal of Social and Vol. 23, No. Psychiatric and the of Mental during the COVID-19 Pandemic: A et la de la COVID-19: January 2021 | The Journal of Psychiatry, Vol. No. Media and Analysis during the Covid-19 September 2021 | Vol. 13, No. Distress During the COVID-19 Pandemic in Patients Mental August 2021 | Frontiers in Psychology, Vol. to Analysis of the of July 2021 | Vol. 13, No. of COVID-19: of and July 2021 | No. 29, of Health for the of July 2021 | Frontiers in Health, Vol. of the Patients in Hospital to the COVID-19 A July 2021 | Frontiers in Psychology, Vol. during the COVID-19 pandemic social July 2021 | Vol. No. COVID-19 in Chinese July 2021 | Frontiers in Medicine, Vol. experiences of and mental health services during the first Covid-19 of Health Vol. 9, No. Health and during the Pandemic in A Questionnaire of Mental Health and Psychiatric July 2021 | International Journal of Research and Public Health, Vol. No. of the COVID-19 pandemic on mental health service use among psychiatric outpatients in a of Affective Disorders, Vol. and Association of Life Among of Patients Psychiatric Services During the COVID-19 June 2021 | Frontiers in Psychiatry, Vol. of Anxiety to the COVID-19 Ph.D., Yang, Ph.D., Ph.D., Ph.D., Ph.D., Yang, Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., Ph.D., M.D., Ph.D., April 2021 | Journal of Psychiatry, Vol. No. in depression & anxiety among mental health service during the COVID-19 pandemicJournal of Affective Disorders, Vol. symptoms and seeking during the Covid-19 May 2021 | Translational Psychiatry, Vol. 11, No. und und February 2021 | der Vol. No. prevalence of depressive and anxiety symptoms and their associations with quality of life among patients with psychiatric disorders during the COVID-19 January 2021 | Translational Psychiatry, Vol. 11, No. COVID-19 pandemic and mental of The Vol. of COVID-19 pandemic on the mental health of May 2021 | Journal of associated with mental health and quality of life during the COVID-19 pandemic in May 2021 | Open, Vol. No. and risk of psychiatric symptoms and diagnoses before and during the COVID-19 pandemic: from the COVID-19 mental health April 2021 | Medicine, Vol. in The impact of protective and on and Medicine in Psychiatry, Vol. COVID-19 the of March 2021 | Current Psychiatry Reports, Vol. 23, No. Medicine in Psychiatry in the COVID-19 era: the impact of the pandemic on mental Medicine in Psychiatry, Vol. and in the age of October 2020 | Psychology & Vol. No. in mental health problems related to COVID-19 in Hospital Psychiatry, Vol. mental health and novel coronavirus: The risk of the Journal of Psychiatry, Vol. for and Mental On the of COVID-19 February 2021 | Frontiers in Vol. of during COVID-19: a an January 2021 | Vol. 44, No. and psychological of students during the early stage of COVID-19 outbreak in China: a cross-sectional February 2021 | BMJ Open, Vol. 11, No. an to Mental Health, and among Youth and February 2021 | International Journal of Research and Public Health, Vol. No. in the and of Mental Health November from July Disorders, and and mental illness: A systematic review and & Health, Vol. and in pandemic: the in mental health October 2020 | International Journal of Vol. No. 1Prevalence and with Insomnia Among the Chinese General Public the 2019 June 2021 | and of Vol. the of December 2021 | and of Vol. Health for to Patients in a of Pandemic: and of Patient July 2021 | Mental Health, Vol. 8, No. impact of COVID-19 pandemic on the of depression among health care cross-sectional May 2021 | Vol. Mental Health the of in the April 2021 | Journal of Education in the Health Vol. No. from November to the Mental Health of by COVID-19 in China: A December 2020 | Frontiers in Psychiatry, Vol. of in 100 Patients Disorder During the COVID-19 Pandemic in December 2020 | Frontiers in Psychiatry, Vol. in of November 2020 | Current Psychiatry Reports, Vol. 22, No. adverse with during COVID-19 Journal of Psychiatry, Vol. of patients with Journal of Psychiatry, Vol. health response for and adolescents during the COVID-19 outbreak in Research, Vol. to COVID-19 to in and from a for Sleep in December 2020 | International Journal of Research and Public Health, Vol. 17, No. awareness of suicide during the October 2020 | Reports, Vol. No. of and health anxiety during COVID pandemic among of a psychiatric an Journal of impact of COVID ‐19 on individuals with disorders: A survey of individuals in the and the July 2020 | International Journal of Disorders, Vol. 53, No. and Distress COVID-19 Among University in the October 2020 | Frontiers in Psychiatry, Vol. pandemic and mental health review of the and Vol. and to the COVID-19 crisis in the of Psychiatric Research, Vol. of COVID-19 on Youth Mental Health, and A of and de la COVID-19 la de et adolescents un et July 2020 | The Journal of Psychiatry, Vol. No. Network Analysis of During the COVID-19 October 2020 | Frontiers in Psychology, Vol. of suicide during and after the COVID ‐19 September 2020 | World Psychiatry, Vol. 19, No. psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public A systematic review and Research, Vol. changes during COVID-19 and the potential A June 2020 | Journal of Health Psychology, Vol. 25, No. and July 2020 | Journal of Psychiatry, Vol. No. COVID-19-Pandemie die und Psychotherapie, Vol. No. 2019 (COVID-19) and Psychiatric in Anxiety and Journal of Medicine, Vol. 2, No. of COVID-19 on Mental Health in the September 2020 | Journal of Internet Research, Vol. 22, No. an Outpatient Psychiatric to During the COVID-19 Pandemic: A October 2020 | Journal of Internet Research, Vol. 22, No. disorders in people infected with the coronavirus September 2020 | Journal of Public Health, Vol. No. 4 July authors thank the clinic nurses in the Departments of Psychiatry, Neurology, and Sleep Medicine, West China Hospital, Sichuan April 2020 online May 2020 in 1 July 2020

American Journal of Psychiatry · 294 citationsread the source →

Pathophysiology of the risk factors associated with osteoporosis and their correlation to the T-score value in patients with osteopenia and osteoporosis in the United Arab Emirates

INTRODUCTION Osteoporosis is a bone disorder, characterized by loss of bone strength because of an imbalance between the bone resorption and the mechanisms of bone formation, leading to increased fragility and fractures. Pathophysiological mechanisms underlying this disorder include an inadequate formation response during the remodeling process of bone formation, which is an essential factor in osteoporosis pathogenesis. This inadequacy is due to the activation of large numbers of osteoclasts as a response to initiation of hematopoietic precursor cells with failure of normal interaction with the osteoblastic lineage. This will lead to excessive bone resorption that may result in complete loss of trabecular structure and loss of template for new bone formation. The time required for osteoblastic replacement is longer than the resorption phase of bone remodeling by osteoclasts. Therefore, any increase in bone remodeling will lead to damaged architecture and loss of bone mass.[1] Recently, it has been estimated that more than 200 million people worldwide have osteoporosis. On the basis of a statistics from the International Osteoporosis Foundation in 2017, one in five men and one in three women over the age of 50 years will experience fractures during their lifetime because of osteoporosis. Furthermore, it has been found that an osteoporotic fracture occurs every 3s, with the most common fractures occurring at the hip, spine, and wrist.[23] Osteoporotic fractures may be the first manifestation of the disease, which is why it is called a silent disease. Risk factors of osteoporosis, decreased bone mineral density (BMD), and increased fragility fractures may be modifiable or non-modifiable. Among the modifiable factors are low body mass index (BMI), vitamin D deficiency, low calcium intake, excessive caffeine and alcohol consumption, smoking, sedentary life and low physical activity, endocrine disorders (such as estrogen deficiency and insulin-dependent diabetes mellitus or hyperparathyroidism), some drugs (such as corticosteroids), and previous history of fragility fractures. The non-modifiable factors include female gender, family history, race, and early menopause.[45] According to the World Health Organization (WHO) diagnostic criteria, osteoporosis is diagnosed by BMD at the hip or spine, which is below the young normal mean reference population by 2.5 standard deviations (SDs) or more. This is called the T-score, and osteopenia is diagnosed by BMD less than or equal to 1 SD.[6] The guidelines for osteoporosis screening vary greatly in various publications. In general, most organizations recommend that all adults older than 50 years of age with a history of fracture must receive BMD screening.[7] Dual-energy X-ray absorptiometry (DXA) at the hip or spine is the best test for measuring central BMD. An association is present between the T-score values in DXA in patients with osteoporosis or osteopenia and the risk of fractures. A fracture risk assessment tool (FRAX) was designed. It is estimated that for every 1 SD decline in spine BMD, the risk of having a spine fracture increases 2.3 times and the risk of having a hip fracture increases 2.6 times.[89] As the most common bone disease in humans, the prevalence of osteoporosis is steadily increasing due to a growing elderly population, and thus represents a major public health concern with reduced bone strength and a higher risk of fractures.[68] The prevalence of osteoporosis is steadily escalating due to increased life expectancy as a result of developed health services. According to the 2016 WHO report, in the United Arab Emirates (UAE), life expectancy at birth for men was 76 years and for women it was 79 years.[10] The UAE population projection showed that in 2011, 7% of the population were 50 years of age or over and less than 1% were 70 years of age or over. By 2050, it is estimated that 12% of the population will be 50 years or over and 2% will be 70 years or over.[11] MATERIALS AND METHODS Study design The study was performed in accordance with the International Conference on Harmonisation Good Clinical Practice guidelines. Ethical approval number UG-H-18-11-7-10 was obtained from the Research Ethics Committee of the college. The study was conducted on a population sample of national and nonnational people in the UAE. Both men and women were recruited in the study. Data were collected from the patients in six governmental and private hospitals. Research tools A total of 200 male and female participants between the age of 25 and 80 years were recruited in the study. Eighty percent of the sample were women and 20% were men. After obtaining the required consent, each participant was asked to fill a structured questionnaire consisting of 25 questions, which was used as the primary tool for data collection. The questions were formulated both in Arabic and English, it required 3–4min to be completed. BMD of the participants was assessed in the International Radiology Centre and correlated with their data in the questionnaires. DXA scan was used for the measurement of BMD. Data collection and data analysis After ensuring strict confidentiality, data were collected between March 20, 2016 and May 20, 2016. The following information was obtained: Demographic data (gender, age, race, BMI, and occupation) Family history of osteoporosis or osteoporotic fractures Social history and lifestyle, physical activity, and exposure to the sun Dietary habits such as calcium, caffeine, and soft drinks intake Medical history of diseases and medicines. For female participants, number of pregnancies, lactation, and age at menopause were included The following criteria were used to evaluate osteoporosis: Normal BMD: if T-score between +2.5 and –1 Osteopenia: if T-score between –1 and –2.5 Osteoporosis: if T-score below –2.5 The filled questionnaires were coded and data were analyzed statistically using the Statistical Package for the Social Sciences (SPSS) software (version 24; IBM Corporation, Newyork, USA). Spearman’s correlation test was carried out to assess the association between different variables in the study. A P value of less than 0.05 was considered significant. RESULTS Sociodemographic data The sociodemographic background of the study participants is listed in Table 1. A total of 200 participants were included in the study. The control group and the osteoporotic group consisted of 100 participants each, 20% of them were men, whereas 80% of the respondents were women. Table 1: Background demographic data of the respondentsBody mass index The patients with osteoporosis have significantly lower BMI than the control group (P < 0.05). Results showed that 72% of them have a BMI less than 25 kg/m2 (P < 0.05) [Table 2] [Figure 1].Table 2: Body mass index of the respondentsFigure 1: Body mass index (kg/m2) of the respondentsSmoking behavior Regarding smoking behavior, a significant value was evident between smoking and osteoporosis (P < 0.01) as 54% of the patients with osteoporosis were current smokers, whereas 72% of the controls had never smoked before [Table 3] [Figure 2].Table 3: Smoking behavior and intake of milk, coffee, and soft drinks by the respondentsFigure 2: Intake of milk and caffeine and smoking behavior by the respondentsDietary calcium intake The intake of milk and dairy products by the participants was used to assess the dietary calcium intake. The patients with osteoporosis have a significant low calcium intake (P < 0.01), whereas non-osteoporotic control significantly consume more milk and dairy products (P < 0.01). A positive correlation was found between the intake of milk and dairy products and the T-score value of the participants (P < 0.05) [Table 3] [Figures 2 and 3].Figure 3: Correlation between milk intake and T-score in patients with osteoporosisCaffeine consumption Caffeine intake was evaluated in this study by the amount of coffee, tea, or soft drinks consumed by the participants each day. The results showed that the patients with osteoporosis significantly consume more caffeine (P < 0.01). A negative correlation is present between the amount of caffeine intake and T-score value of the participants (P < 0.05) [Table 3] [Figures 2, 4, and 5].Figure 4: Correlation between tea/coffee intake and T-score in patients with osteoporosisFigure 5: Correlation between soft drinks intake and T-score in patients with osteoporosisExercise behavior and exposure to the sun Results showed a significant positive correlation between the duration of exercise and the T-score value of the participants (P < 0.05) [Table 4] [Figure 6].Table 4: Exercise behavior and exposure to sun of the respondentsFigure 6: Correlation between exercise duration and T-score in patients with osteoporosisRegarding the exposure to the sun, the results showed that 96% of the patients with osteoporosis were exposed to the sun for less than 15min, three to four times a week or not exposed at all, whereas most of the normal controls (72%) exposed their bodies to the sun for 16–30min/day, three to four times a week [Table 4] [Figure 7].Figure 7: Sun exposure behavior of the respondentsDiseases and medications Results of the study revealed that 46% of the patients with osteoporosis were diabetic, 42% of them were treated by antidiabetics, 18% had arthritis and 38% had been treated previously by corticosteroids [Table 5].Table 5: Distribution of patients with osteoporosis by their diseases and medicationsNumber of pregnancies and breastfeeding Female participants constituted 80% of the study sample, 75% of the females with osteoporosis were menopausal, 75% of them had three or more pregnancies, and 82.5% of them breastfed their children, whereas these values for the control group participants are 30%, 28%, and 33%, respectively. Results showed a significant positive correlation between the age at menopause and the T-score value of females with osteoporosis (P < 0.05) [Table 6] [Figure 8]. The distribution of patients according to the joint affected by Osteoporosis or Osteopenia is shown in [Figure 9] and [Table 7].Table 6: Distribution of female patients with osteoporosis by number of pregnancies and breastfeedingFigure 8: Correlation between age at menopause and T-score in female patients with osteoporosisFigure 9: Distribution of patients having osteopenia or osteoporosis in wrists, hips, or spineTable 7: Distribution of patients having osteoporosis and/or osteopenia in hips, wrists, and spineDISCUSSION To maintain normal bone structure, a remodeling process that consists of osteoclasts, removing old bone, and osteoblasts, synthesizing new bone, occurs. Hematopoietic progenitors produce osteoclasts, whereas mesenchymal stem cells called marrow stromal fibroblasts produce osteoblasts. This process is controlled by certain circulating hormones, growth factors, and locally produced cytokines through their effects on apoptosis of osteoblasts and osteoclasts. Estrogen deficiency or glucocorticoid excess leads to bone loss because of changes in the production of bone cells. This is caused by the prolongation of the life span of osteoclasts and the shortening of the life span of osteoblasts. On the contrary, drugs that aim to treat or prevent osteoporosis prevent apoptosis of osteoblasts and/or stimulate the apoptosis of osteoclasts.[12] The pathogenesis of osteoporosis is the consequence of various hormonal, genetic, dietary, lifestyle, and physical factors. Genetic factors mainly affect the BMD and bone formation, whereas low levels of estrogen increase parathyroid hormone, and local cytokines are mainly responsible for bone remodeling imbalance.[13] Age and gender In this study, 76% of the patients with osteoporosis were women at or above 50 years of age. Osteoporosis is usually considered a disease of the elderly with low BMD. In a recent study, most of the patients with osteoporosis were in the age groups of 45–49 and 50–54 years.[14] Previous studies showed that women were at an increased risk of developing osteoporosis because of their faulty behavior of physical inactivity, sun-avoidance behavior, low intake of dairy products, and poor diets.[151617] Body mass index The results of this study showed a significant number of patients of osteoporosis with BMI <25 kg/m2, where P < 0.05. Women that have low BMI are at a higher risk of developing osteoporosis. It is reported that one unit change in BMI has a larger effect on the risk of developing osteoporosis than most other modifiable risk factors. To help reduce the risk of osteoporosis, patients should be advised to maintain a weight within the normal range.[1516] The risk of osteoporotic fractures increases in adults who have low BMI of less than 20 kg/m2.[18] On the contrary, patients who are obese (BMI >30 kg/m2) are also at a high risk of developing osteoporosis and fractures because of the risk of repeated falls and the weakness of the skeletal muscles due to loss of its mass as a result of aging.[19] Exercise and physical activity The results of this study showed a significant correlation between the exercise time and the T-score value. Previous studies concluded that physical activity and exercises stimulate skeletal growth and bone strength.[45] Estrogen Estrogen deficiency has a critical effect on the pathogenesis of osteoporosis. The results of this study showed a significant positive correlation between the age at menopause and the T-score value of the female patients. Estrogen has a crucial role in bone formation and physiology. It stimulates the production of T cell cytokines, affects the osteoblastic cell by altering its production of receptor activator of nuclear factor-Kappa B ligand (RANKL) or Osteoprotegerin (OPG), inhibits the differentiation of osteoclasts by direct action, and stimulates the formation of bone performed by osteoblasts and osteocytes, which allows them to enhance their ability to respond to mechanical forces.[2021] Estrogen produces its effect through a specific cell surface receptor called the estrogen receptor alpha (ERα). This receptor binds and then transports estrogen into the nucleus of the cell where certain genes are then activated by the receptor–hormone complex. ERα receptors and estrogen receptor–related receptor alpha (ERRα) are found on the surface of osteoblasts. ERRα may play a supporting role in the regulation of bone cells.[22] Previous studies also suggest that sex hormone–binding globulin may play a significant role in regulating bone cells as well because it facilitates entry of estrogen into cells.[23] Because of the natural drop of estrogen level in postmenopausal women, they are at the highest risk of developing osteoporosis. A previous study showed that it is an increase in bone resorption that might be the driving force for bone loss during estrogen deficiency in postmenopausal women not impaired bone formation as was previously thought.[1] However, other studies indicated that both markers of bone resorption and formation also increased, leading to accelerated bone remodeling at menopause.[2425] Calcium intake and vitamin D Calcium and vitamin D are two pivotal contributors of bone formation and mineralization. The results of this study showed that the patients with osteoporosis have a significant low calcium intake, whereas controls significantly consume more milk and dairy products (P < 0.01). This significant result showed the importance of calcium intake. Results also established a positive correlation between calcium intake and the T-score value of the participants. Vitamin D plays an important role in maintaining calcium homeostasis and bone integrity as it is essential for intestinal calcium absorption.[26] It is estimated that over one billion people around the world have vitamin D deficiency.[2728] Sun exposure is considered as the source of vitamin D, the present results showed a significant value (P < 0.01) as 74% of the patients with osteoporosis exposed their bodies to the sun for 5min or less, three to four times per week, whereas 72% of controls exposed their bodies to the sun for 15–30min, 3 to 4 times a week. A previous study conducted in the UAE showed that 58.2% of the UAE nationals were vitamin D deficient compared to 45% of the patients from other nationalities.[29] In spite of living in sunny areas, such as UAE, Saudi Arabia, and India, young populations have a high prevalence of vitamin D deficiency because of insufficient knowledge and practice of vitamin D and its health implications.[3031] Decreased blood calcium level will lead to secondary hyperparathyroidism. This decrease may result from impaired intestinal calcium absorption due to vitamin D deficiency, aging, or other diseases. Calcitriol, the active form of vitamin D, stimulates the intestinal absorption of calcium and phosphorus. It has an inhibitory effect on the synthesis of parathyroid hormone as well. Therefore, calcitriol deficiency will lead to secondary hyperparathyroidism as well.[32] There is a clear evidence that the risk of having an osteoporotic fracture increases when vitamin D levels are below 50 nmol.[3334] However, a recent study showed that pathological macrophages produced by vitamin D receptor signaling play an important role in the development of myelofibrosis.[35] Smoking The results of this study showed that nicotine has a significant effect on the incidence of osteoporosis (P < 0.01). Smoking has been identified as a modifiable risk factor for low BMD and increased osteoporotic fracture risk.[3637] Smoking behavior should be evaluated when assessing the fracture risk and FRAX.[1638] The role of smoking in decreasing BMD is complicated; smoking is shown to be associated with other risk factors for osteoporosis such as decreased physical activity, low BMI, and poor diet.[38] Nicotine has both direct and indirect effects on BMD. The direct effect is on bone cell proliferation and is described to be biphasic, small doses have a stimulatory effect, whereas toxic large doses have an antiproliferative effect on the proliferation of osteoblasts.[39] This effect on osteoblasts is receptor mediated by the nicotinic acetylcholine receptors, where nicotine in low doses upregulates gene expression of alkaline phosphatase, type 1 collagen, and osteocalcin.[40] Nicotine produces an increased level of tumor necrosis factor α (TNFα) secretion that reduces bone formation by osteoblasts and increases bone resorption by osteoclasts. TNFα has a powerful osteoclastogenic effect through its stimulating effect on RANKL production and by intensifying osteoclasts production.[41] It is strongly supported that RANK/RANKL/OPG systems have a role in regulating bone resorption and the formation of osteoclasts.[42] The main predisposing factor for chronic obstructive pulmonary disease (COPD) has been found to be smoking. The most important factor in managing COPD continues to be the termination of smoking.[43] It has been shown in numerous studies that smokers with COPD have elevated levels of pro-inflammatory cytokines in the form of interleukin-6. In addition, TNFα levels are much higher in COPD smokers than in asymptomatic smokers. This indicates that COPD affects local and systemic inflammatory responses, which in turn affects bone remodeling.[4445] Nicotine has an indirect effect on BMD, which is caused by releasing calcitropic hormones and glucocorticoids, which leads to an increase in bone resorption.[43] Furthermore, smoking has been linked to an increase in the level of cortisol[4446] as well as a decrease in the level of estradiol.[47] Nicotine also harms intestinal calcium absorption, which might lessen the effectiveness of dietary calcium supplements.[48] Also, toxic carcinogenic metabolites of nicotine have also been found to increase osteoclast formation in rats.[49] Moreover, one hip fracture in eight postmenopausal women with osteoporosis is attributable to smoking. This correlation could not be explained by early menopause, low BMI, lower levels of exercise, or by the actions of nicotine on estrogen. This indicates that there is an independent negative effect of nicotine on BMD, which means that smokers lose bone at a faster rate than nonsmokers.[50] CONCLUSION Prevalence of osteoporosis is high in the UAE and is expected to grow due to increased life expectancy and faulty lifestyle of inadequate dietary habits, sun exposure, exercise behavior, and smoking. More intervention should be directed toward changing the modifiable risk factors in the patients with osteoporosis, and more studies should be directed toward osteoporosis in the UAE. Limitations of the study To make the study a polycentric research, it would require greater number of participants from all the emirates of the UAE. Financial support and sponsorship This work is self-funded by the authors. Conflicts of interest There are no conflicts of interest.

Journal of Pharmacy And Bioallied Sciences · 11 citationsread the source →

Incidence, prevalence, and co-occurrence of autoimmune disorders over time and by age, sex, and socioeconomic status: a population-based cohort study of 22 million individuals in the UK.

Background: A rise in the incidence of some autoimmune disorders has been described. However, contemporary estimates of the overall incidence of autoimmune diseases and trends over time are scarce and inconsistent. We aimed to investigate the incidence and prevalence of 19 of the most common autoimmune diseases in the UK, assess trends over time, and by sex, age, socioeconomic status, season, and region, and we examine rates of co-occurrence among autoimmune diseases. Methods: In this UK population-based study, we used linked primary and secondary electronic health records from the Clinical Practice Research Datalink (CPRD), a cohort that is representative of the UK population in terms of age and sex and ethnicity. Eligible participants were men and women (no age restriction) with acceptable records, approved for Hospital Episodes Statistics and Office of National Statistics linkage, and registered with their general practice for at least 12 months during the study period. We calculated age and sex standardised incidence and prevalence of 19 autoimmune disorders from 2000 to 2019 and used negative binomial regression models to investigate temporal trends and variation by age, sex, socioeconomic status, season of onset, and geographical region in England. To characterise co-occurrence of autoimmune diseases, we calculated incidence rate ratios (IRRs), comparing incidence rates of comorbid autoimmune disease among individuals with a first (index) autoimmune disease with incidence rates in the general population, using negative binomial regression models, adjusted for age and sex. Findings: Among the 22 009 375 individuals included in the study, 978 872 had a new diagnosis of at least one autoimmune disease between Jan 1, 2000, and June 30, 2019 (mean age 54·0 years [SD 21·4]). 625 879 (63·9%) of these diagnosed individuals were female and 352 993 (36·1%) were male. Over the study period, age and sex standardised incidence rates of any autoimmune diseases increased (IRR 2017-19 vs 2000-02 1·04 [95% CI 1·00-1·09]). The largest increases were seen in coeliac disease (2·19 [2·05-2·35]), Sjogren's syndrome (2·09 [1·84-2·37]), and Graves' disease (2·07 [1·92-2·22]); pernicious anaemia (0·79 [0·72-0·86]) and Hashimoto's thyroiditis (0·81 [0·75-0·86]) significantly decreased in incidence. Together, the 19 autoimmune disorders examined affected 10·2% of the population over the study period (1 912 200 [13·1%] women and 668 264 [7·4%] men). A socioeconomic gradient was evident across several diseases, including pernicious anaemia (most vs least deprived area IRR 1·72 [1·64-1·81]), rheumatoid arthritis (1·52 [1·45-1·59]), Graves' disease (1·36 [1·30-1·43]), and systemic lupus erythematosus (1·35 [1·25-1·46]). Seasonal variations were observed for childhood-onset type 1 diabetes (more commonly diagnosed in winter) and vitiligo (more commonly diagnosed in summer), and regional variations were observed for a range of conditions. Autoimmune disorders were commonly associated with each other, particularly Sjögren's syndrome, systemic lupus erythematosus, and systemic sclerosis. Individuals with childhood-onset type 1 diabetes also had significantly higher rates of Addison's disease (IRR 26·5 [95% CI 17·3-40·7]), coeliac disease (28·4 [25·2-32·0]), and thyroid disease (Hashimoto's thyroiditis 13·3 [11·8-14·9] and Graves' disease 6·7 [5·1-8·5]), and multiple sclerosis had a particularly low rate of co-occurrence with other autoimmune diseases. Interpretation: Autoimmune diseases affect approximately one in ten individuals, and their burden continues to increase over time at varying rates across individual diseases. The socioeconomic, seasonal, and regional disparities observed among several autoimmune disorders in our study suggest environmental factors in disease pathogenesis. The inter-relations between autoimmune diseases are commensurate with shared pathogenetic mechanisms or predisposing factors, particularly among connective tissue diseases and among endocrine diseases. Funding: Research Foundation Flanders.

Lancet (London, England) · 508 citationsread the source →

Prediction and prevention of schizophrenia: what has been achieved and where to go next?

Since the traditional clinical paradigm has been replaced by the modern molecular one, medicine set off into new directions. “Prediction”, “prevention” and “personalization” are the programmatic key words of this new approach. Like other medical disciplines, psychiatry has broadened its focus from diagnosis and treatment to the detection and estimation of the risk of disease development, the prediction of its onset and strategies to avoid its manifestation 1,2,3,4. Although treatment of schizophrenia has greatly advanced over the last decades, a significant number of patients continue to take an unfavorable chronic course 5,6. This makes schizophrenia the leading cause for permanent occupational disability among people under 40 years of age in Germany 7, and the 8th most common cause for disability adjusted life years (DALYs) lost among the 15 to 34-year olds worldwide 8, despite its low prevalence. Moreover, schizophrenia involves tremendous direct and indirect societal costs 9 and a huge burden on patients and their families 8,10. It is becoming increasingly clear that schizophrenia is a complex disorder with polygenic heredity and that its pathogenesis is greatly influenced by interactions between different genes and between genes and environment. Associations to variants of the genes for dysbindin and neuregulin-1, the genetic locus G72 and the DAOA (D-amino acid oxidase activator) gene have now been repeatedly confirmed. As with all other complex diseases, research is focusing now on characterizing the polygenetic predisposition and clarifying its influence on the development of the phenotype 11. Research methods range from molecular genetics via proteome research to cell biology, neurophysiology, brain structural and functional imaging and neuropsychology. With all these methods, several indicators for an increased risk of schizophrenia have been identified. However, the currently recognized neurobiological risk factors are not sufficiently predictive to allow the development and application of “selective” prevention measures targeting asymptomatic persons at risk. For neuro-psychological risk factors, this has just become evident in the large-scale attempt of the North American Prodrome Longitudinal Study (NAPLS) group to improve their multivariate model by integrating the examined neurocognitive variables 12. There are also established environmental risk factors for schizophrenia, such as pregnancy or birth complications, growing up in a large city, IQ low but normal and drug consumption. However, with odds ratios around 2, each of these factors appears to increase the lifetime risk of the disease only slightly 13. Thus, the currently known risk factors, either alone or taken together, cannot be used for prediction and prevention without knowledge of the complete predispositional basis and the gene-gene and gene-environment interactions, which are probably numerous. In view of this situation, it may be argued that the current efforts towards prediction and prevention are still premature and that further progress of etiological research is needed. However, a different perspective has emerged from the work of the centers for early recognition and prevention, established first in Melbourne, Australia and in Cologne, Germany in the mid 1990s, and later on in many other places around the world. This resulted from retrospective research of the early course of psychosis, in which the pathophysiologically active disturbances in brain development extend beyond early abnormalities in behavior into psychopathologically definable early risk and ultra high risk (UHR) symptoms, depending on the individual combination of stressors and resilience factors. First episode psychosis (FEP) research has shown that the outbreak of the disease is preceded in about 70% to nearly 100% of cases by an initial prodrome, which lasts for an average of five to six years. Even in highly developed health care systems, an average of one year thereafter elapses from the first manifestation of psychotic positive symptoms to the initiation of adequate treatment 14,15. The period over which the FEP remains untreated (duration of untreated psychosis, DUP) correlates with: delayed and incomplete remission of the symptoms; necessity of more protracted treatment and greater risk of relapse; lower compliance, greater burden on the family, and a higher level of “expressed emotion”; increased risk of depression and suicide; greater impact on the individual's employment or education; increased drug abuse and delinquent behavior; markedly increased costs of treatment 16. These correlations have recently been confirmed by a meta-analysis 17, with coefficients ranging from 0.285 to 0.434 (95% CI). This does not only provide strong arguments in favor of treating the FEP as early as possible, but has also led to a systematic effort to decrease the incidence of psychosis through indicated prevention. Two important studies concerning the early stage prior to the conversion to FEP have demonstrated that the earliest and most common symptoms, which generally dominate during the prodrome, are unspecific and cannot be distinguished from impairment in mood, drive, contact, and concentration of depressive episodes. These are the Age-Beginning-Course (ABC) study of schizophrenia, a retrospective study with optimized methods 14, and the Cologne Early Recognition (CER) Study, a long-term prospective study with an average follow-up period just below 10 years 18. These studies also found striking cognitive impairments in the form of self-experienced disturbances in thought, speech, and perception processes. This subgroup of so-called basic symptoms, which were found in more than a quarter of patients, had high specificity and a high positive predictive power, accompanied by only low rates of false positive predictions 19,20,21. Basic symptoms were first operationalized in the Bonn Scale for the Assessment of Basic Symptoms (BSABS). Shorter versions of the scale for adults and for children and adolescents — the Schizophrenia Proneness Instrument, Adult version (SPI-A) and the Schizophrenia Proneness Instrument, Child and Youth version (SPI-CY) — were later developed from dimensional analyses 22,23,24. While the BSABS only allows an assessment of the current state, the SPI-A and the SPI-CY also allow severity ratings according to the maximum frequency of occurrence within the past 3 months. In the CER study, 385 patients who were presumably in the prodromal phase of schizophrenia were followed up for an average of 9.6 (±7.6) years past baseline. Twenty percent of the initial criterion-positive cases (1 of 66 basic symptoms) who agreed to be followed up developed schizophrenia after 12 months, a further 17% after 24 months, a further 13% after 36 months, and finally a total of 70% after an average of 4.5 years. Thus, only 30% did not convert to schizophrenia. The overall presence/absence of at least one basic symptom correctly predicted presence/absence of a subsequent transition to schizophrenia in 78.1% of cases. From further analyses, two partially overlapping basic symptom criteria for defining at risk mental states (ARMS) for psychosis, primarily schizophrenia, were developed (Table 1). The first criterion, which consists of ten cognitive-perceptive basic symptoms and is abbreviated as COPER, was based on findings concerning the predictive accuracy of individual basic symptoms 18,25. The second was based on a methodological re-analysis of the same data set, in which a cluster of nine cognitive basic symptoms had repeatedly been selected as the most predictive. This cluster was called “cognitive disturbances” (COGDIS). In terms of general predictive accuracy, the two criteria slightly differed in the CER study, as COGDIS tended to be more conservative than COPER, i.e. to perform better in ruling in subsequent schizophrenia at the cost of performing worse in ruling it out. The transition rate throughout the average follow-up period of roughly 10 years was 65% for COPER and 79% for COGDIS, with the majority of transitions occurring within the first 3 years past baseline. In a second prospective study 26, conducted with the SPI-A and with a systematic follow-up of 24 months, 38% of the initially included 146 at-risk subjects developed a frank psychosis, mainly schizophrenia, within 12.3 (±10.4) months on average (1–48; median=9) according to COPER. Thus, the positive results of the CER study were confirmed. Again, COGDIS appeared to be more specific but less sensitive than COPER. As a consequence of these findings, predictive basic symptoms have been established as a set of criteria for risk assessment in international research on the early recognition of psychosis. In particular, the German Research Network on Schizophrenia used these symptoms, together with a combined criterion of functional deterioration and biological risk, in defining an “early at-risk of psychosis state” (ERPS), thereby suggesting a clinical risk staging model (Figure 1). Early and late initial prodromal state: a clinical staging approach The positive symptoms typical of schizophrenia — such as delusions, hallucinations or formal thought disorders — often first appear in an attenuated or transient form during the initial prodromal phase. These symptoms provide a valid prediction of conversion into FEP, particularly in the short term. Warning signs of this sort have been used as ultra-high risk (UHR) criteria 27,28. Notwithstanding their differences across studies, these criteria are generally composed of three alternative elements: attenuated positive symptoms (APS), brief limited intermittent psychotic symptoms (BLIPS), or a combination of one or more risk factors (always including genetic risk) and functional decline within a certain recent period. For the ascertainment of the UHR criteria, the Melbourne group gradually developed a specific instrument, the Comprehensive Assessment of At Risk Mental States (CAARMS) 29. Based on the Australian definition of the UHR criteria, the Structured Interview for Prodromal Syndromes (SIPS), the Scale for Prodromal Syndromes (SOPS) and, subsequently, the Criteria of Prodromal Syndromes (COPS) were developed 30,31. Different UHR-related approaches to an early detection of FEP, particularly schizophrenia, were developed by the Hillside Recognition and Prevention (RAP) program in New York 32 and the Basel Früherkennung von Psychosen (FEPSY) study 33. There have been at least 15 prediction studies using UHR criteria, some of which with large samples 34,35,36,37,38,39,40,41. The 12-month rates of transition into FEP published so far range between approximately 13% and 50%. A substantial variance is even observed with comparable observation periods in the same center 34,35. Yet, as the annual incidence for all forms of psychosis in the general population is only about 0.034% 42, even the lowest conversion rates still indicate a dramatic increase in the relative risk of illness, at least in the help-seeking samples of specialized centers. Table 2 depicts the predictive accuracy measures published so far, with the last five listed studies representing secondary predictor analyses of samples meeting at risk criteria. As a result, in the German Research Network on Schizophrenia, the UHR approach was combined with the basic symptom approach and applied in a slightly modified form for the definition of “late at-risk of psychosis state” (LRPS) (Figure 1). This clinical staging model, which suggests a syndromal sequence for the development of FEP progressing from unspecific prodromal symptoms to predictive basic symptoms, and then to APS, to BLIPS and to full-blown psychotic symptoms, was recently strongly supported 15. Universal or selective prevention measures target healthy population groups or clinically still healthy risk carriers, respectively 43. Indicated prevention, instead, targets individuals with basic symptoms and UHR symptoms. Even at the early stages when these individuals seek advice and help at the early recognition and prevention centers, they must be regarded as ill and in need of treatment. Furthermore, the impending deterioration of psychosocial performance in schizophrenia often already occurs in the initial prodromal phase, even prior to the conversion into FEP 14,15. These clinical and psychosocial impairments justify defining the interventions in EPRS and LPRS as indicated prevention, pursuing the following three objectives: a) improvement in the current burden of prodromal symptoms; b) avoidance or perhaps delay in the development of psychosocial handicap; c) prevention of or at least delay or attenuation of psychosis. Five international intervention studies have attempted to find out whether or to what extent these three objectives can be reached 44,45,46,47,48,49,50,51 (Table 3). The preventive measures used were either cognitive behavioral therapy (CBT), adapted to the requirements of the persons at risk, or atypical antipsychotics (risperidone, olanzapine, and amisulpride). These were randomized controlled studies, but there were problems with the blinding condition in the two CBT interventions. This and other methodological shortcomings currently limit conclusions and have encouraged the research groups working in this area to set up new, optimized intervention studies. For example, the protocol of the ongoing parallel group PREVENT study includes careful comparative analyses and superiority and inferiority tests of the psychological and pharmacological treatments 52. A staging of risk, thereby implying a temporal dimension, was considered for the first time in the two intervention studies of the German Research Network on Schizophrenia. One of these studies covered ERPS and only offered CBT as a preventive measure 49,50. The other study was designed for LRPS and used only preventive treatment with amisul-pride 51. When the symptom development in the initial prodromal state follows the sequence shown in Figure 1, it would be beneficial for scientific and especially ethical reasons to focus on psychological interventions in ERPS, which are well tolerated and highly accepted. As soon as the first attenuated or transient psychotic symptoms occur, it seems justifiable to apply well tolerated antipsychotics with few side effects. This differential prevention strategy is now pursued in all German early recognition centers and is also increasingly gaining support in other countries. Another pharmacological option is aripiprazole, tested in a pilot study in UHR states 53. Its possible preventive effects are currently being analyzed in the PREVENT study. Antidepressants were used in a naturalistic, non-randomized observational study of an adolescent sample employing only the APS criterion for inclusion, but, for methodological reasons, this study does not allow any conclusion about differential preventive effects of these medications 54. A critical evaluation of the achievements over the past 15 years through continuous efforts to enhance prediction and prevention of psychoses, particularly of schizophrenia, reveals quite impressive results. However, the results achieved thus far need to be evaluated in the light of the ambitious, initially mentioned objectives of modern predictive and preventive medicine. Once predictive basic symptoms and UHR symptoms have occurred, the underlying pathophysiological process might have already progressed. For such a complex disease with a long-term course and a pre-dispositional basis, this kind of risk identification and risk-oriented prevention may possibly come too late. A more substantial reduction in incidence could be reached with selective and universal prevention measures. Therefore, symptom-based prediction and prevention need to be further developed into the direction of selective prevention for symptom-free risk carriers. In the future, it is necessary to strive for: a) an improvement of risk enrichment with the inclusion of biological risk factors; b) a stronger individualization of the risk estimation by stratification; c) the inclusion of sub-psychotic mental states, as cross-sectionally by current at risk criteria, in the the application of prevention strategies more with the of the the initial prodromal phase for as as then most of the follow-up periods shown in Table 2 are not to the transition A significant number of later may be as and, the predictive of the risk may be 12. Therefore, the first and most important is to out new, optimized large-scale studies with follow-up periods the of the initial prodromal phase, as in the CER study 18. The risk enrichment can also be advanced through the inclusion of following the of recent research on the prediction of through the cognitive impairment This condition a risk for with a conversion rate comparable to the risk for the patients certain imaging and the predictive risk enrichment may be possible for using brain but also impairments of and which are with the psychosis risk and are more and in cases with a later transition to schizophrenia and other new large-scale studies with sufficiently observation periods could whether the risk enrichment can be achieved by of such The of this strategy is on the progress of research on biological and environmental risk factors and their interactions, as is currently attempted in the Network of schizophrenia study In other medical disciplines, such as or a risk which does not in a of is using for multivariate clinical staging by risk In the of study, this approach was into psychosis prediction research for the first time A clinical model was developed based on a including six variables positive disturbances Assessment of in the past and years of Based on the individual a multivariate for further the risk of transition to psychosis into risk was each a increased relative risk to the general with each This model was argued to improve the prediction of psychosis by a of the individual risk in terms of and a more risk estimation or clinical staging of risk, in studies, could the development of risk adapted inclusion criteria for randomized preventive In the first application of this approach in the only clinical and variables were It remains to be whether a model including or environmental variables would increase the predictive accuracy even In studies have to whether such can also be applied to the prediction of psychosis within different time The currently ongoing of the has a about the inclusion of a risk for psychosis in to prevention initially argued this and to the that the application of as criteria could that the high rate of predictions in would be to increase up to in general This is and prior to whether to the in the of the The on the predictive of at risk criteria, thereby the persons meeting at risk criteria already from mental and functional for which they seek Moreover, they psychological and cognitive with and functional the majority of help-seeking at risk persons general criteria for mental disorder a clinically significant behavioral or psychological with disability and have to be considered as i.e. as people with the need and to be these in there are reasons for the inclusion of a clinical in the as by current at risk criteria, not as a prodromal risk for first psychosis, but as an to medical the of such an diagnosis would have the of the by the current mental state to a and Although an increased risk of psychosis would continue to be a of such a the psychological and medical focus would be from an to and At this current state of the criteria would be the for the inclusion of this A for the and of a new of international and studies would be with this inclusion in and later on also in A new prevention approach is by the of and studies a of the onset of psychosis the with the first results are for and The transition rate was lower in an group of UHR adolescents than in a group and this was at a an was evaluated in 10 patients in an pilot and a significant improvement in different was In an study, time was in an UHR group with as with a group suggesting a of This was the first study imaging data on effects in individuals at risk. The preventive of is currently in the process of in the Australian Prodrome study With the of schizophrenia is the first mental disorder to which the prediction and prevention program of modern medicine has been The results are and justify the that in the years to come it be possible to provide preventive strategies to the individual risk of of each In to a reduction in risk assessment has to be by neurobiological and psychosocial risk factors, and indicated prevention has to be further developed towards selective prevention. This a new of large sample studies for prediction as well as prevention, with observation In these studies, of risk selected to predictive must be psychological and pharmacological interventions need to be on a long-term basis, more prevention strategies have to be In to be to and such studies, it would be to mental states, as by the currently used risk symptoms, in the of the

World Psychiatry · 127 citationsread the source →

Aging in Australia

An aging population, growing awareness of chronic disease, and access and navigation of health care services prompt much discussion regarding aging in Australia. Debate within academic and policy circles directs attention toward preventive health, with a growing interest in “healthy aging” and “active aging” where quality of life, rather than years of life, is important. There is little doubt that an aging population places pressure on governments and broader society, but these challenges also present opportunities for positive change. People older than 65 years of age account for 13% of the almost 20 million Australians, with projections suggesting an increase to 26%–28% by 2051 (Australian Bureau of Statistics [ABS], 2008). Those older than 85 years currently represent 1.6% of the population but will increase to 7%–10% by 2101 (ABS, 2008). Australians enjoy one of the longest life expectancies, 79 years for men and 84 years for women (Australian Institute of Health and Welfare [AIHW], 2006), projected to rise to 100 years by 2060 (Oeppen & Vaupel, 2002). As the population ages, there will be increased demands on the health system and on family members to care for their older relatives. The health system will be strained due to increased numbers of older people, increased expectations of older people to have control of how and where they live their lives, decreased informal caregivers and workforce shortages (Productivity Commission, 2011). Health care in Australia is delivered via the public and private sectors, with responsibility for public health policy and funding divided between the Commonwealth and the states and territories. The Australian Commonwealth government sets national health policies through the Department of Health and Ageing and funds universal medical services (Medicare) and pharmaceuticals (Pharmaceutical Benefits Scheme). It provides financial assistance to public hospitals, residential aged care facilities, and home and community care for older people as well as being the major source of funds for health research. In contrast, state and territory governments provide acute and psychiatric hospital services, and community and public health services. In 2008, the prime minister and minister for health announced the establishment of the National Health and Hospitals Reform Commission. The commission was established to develop a long-term health reform plan for Australia. As part of this reform, provision has been made for nationally consistent legislation allowing health professionals to move freely between states and territories, previously prohibitive due to cost and administrative issues (Australian Health Practitioner Regulation Agency, 2011). Activity-based funding will use the Australian-Refined Diagnostic Related Groups classification to define and count hospital “activity” in relation to the treatment of acute admitted patients. Concern has been raised that older patients may be discharged early, as this approach rewards reduced expenditure and shorter hospital stays (Eagar, 2010). Under the auspices of the Australian government, as the sole funder of a nationally consistent aged care system, the Productivity Commission’s inquiry “Caring for Older Australians” presents the greatest opportunity for radical review (Productivity Commission, 2011). Although Australians enjoy one of the longest life expectancies in the world, there continue to be many Australians dying prematurely or living with disabilities that compromise quality of life. Australia has witnessed an increased focus on healthy aging, defined as “a lifelong process of optimizing opportunities for improving and preserving health and physical, social and mental wellness, independence, quality of life and enhancing successful life-course transitions” (Health Canada, 2002). The Australian Healthy Ageing research agenda was reviewed in 2000, with an acknowledgment of a need for the promotion of more holistic healthy aging research (Kendig, Andrews, Browning, Quine, & Parsons, 2000). The National Preventive Health Strategy, released in 2009, builds on this work, espousing shared responsibility, early action that continues throughout life, engagement of communities, the influence of markets and policy direction, reducing inequity (particularly in relation to Indigenous Australians), and refocusing primary health care toward prevention (Preventative Health Taskforce, 2009). The National Chronic Disease Strategy, centered on asthma, cancer, diabetes, cardiovascular disease, and arthritis and musculoskeletal diseases, fits well with the preventive health message for older Australians. Research has focused on identifying cost-effective treatments to reduce the burden of these diseases and improve quality of life. Many innovative campaigns exist, including the “Go Red for Women,” uniting women in the fight against heart disease, simple waist measurements to highlight risk of developing diabetes, and Daffodil Day, raising awareness of cancer. The SunSmart campaign has been successful in promoting safe sun exposure and reducing skin cancer; yet, some older people who are housebound or in institutional care are at risk of vitamin D deficiency. As such, sun recommendations have been revised (Cancer Council Australia, 2010). Aged care services fall broadly under the acute, subacute, community, and residential care sectors. Residential aged care is predominantly provided by the nongovernmental sector, by religious, not-for-profit, and private sector providers. However, the Australian federal government through the Aged Care Act 1997 still governs all aspects of the provision of residential care, flexible care, and Community Aged Care Packages (CACP), including the licensing of aged care beds. Although the goal for many older Australians is to remain living independently at home, there will most likely be occasions where community and/or acute services are needed. Most community aged care services are moving toward a strengths-based, person-centered approach to maintaining or improving the independence of older people, focusing on setting achievable goals in the realm of personal, domestic, and instrumental activities of daily living (Department of Health, 2008). Community-based services are delivered to individuals after assessment. Aged Care Assessment Teams (ACAT), unique to Australia, comprise various health professionals (geriatricians, physiotherapists, occupational therapists, and social workers) (Department of Health and Ageing, 2005). The comprehensive assessment identifies the services or referrals that may be needed to enable an older person to remain living independently at home (AIHW, 2007). These packages of care include Home and Community Care services, CACP, Extended Aged Care at Home, or Extended Aged Care at Home for Dementia. Services are implemented in consultation with an individual’s general practitioner who oversees care in the community. There is a strong emphasis on promoting capacity building and restorative care. Minimizing functional decline and maintaining the ability to undertake activities of daily living is pivotal to improving outcomes for older persons in the acute hospital sector. The Department of Health in Victoria, Australia, has supported research aimed at addressing nutrition, mobility, continence, cognition, medication, skin integrity, pain management, and falls (Department of Health, 2011). Short-term transition care (up to 12 weeks) helps to enhance the functional independence of older people leaving hospital and avoid the need for longer term residential care. Under the Aged Care Act 1997, the Australian government subsidizes aged care homes, providing residential aged care to older people who can no longer remain in their own homes. Approximately 70% of the funding for residential aged care is provided by the government. Residential aged care facilities (RACFs) provide care ranging from independent living units to 24-hr nursing care. Aging in place is an option for some people. Residential aged care is predominantly provided by the nongovernmental sector, by religious, not-for-profit, and private sector providers (Cubit, 2009), but all RACFs funded by the Australian government must meet compulsory accreditation standards and show continuous improvement in the quality of care and services provided to residents (Department of Health and Ageing, 2007). Funding for RACFs is determined by the Aged Care Funding Instrument, a formula that matches funding to the care needs of residents. Quality care at the end of life is a crucial area for Australia. The National Palliative Care Strategy—Supporting Australians to Live Well at the End of Life was endorsed in November 2010 by the Australian Health Minister’s Conference. The strategy is designed to improve awareness and understanding of palliative care, building capacity in services to provide appropriate effective care (Department of Health and Ageing, 2010b). Advanced care planning, based on the principles of patient autonomy and consent, allows older Australians to express their wishes about any future health care, providing choice and control for future care options (Royal Australian College of General Practitioners, 2010). The most significant issue relating to the aged care workforce is the recruitment and retention of appropriately qualified nurses (Cubit, 2009). Within the residential care sector, the number of registered nurses has declined (AIHW, 2003), resulting in nationwide shortages (AIHW, 2007). At the same time, there has been an increase in the number of personal care assistants who provide the bulk of the hands-on care (Hogan, 2004). The resulting mix of staff makes it difficult to provide adequate care to the growing number of older people (Robinson et al., 2005, 2007). Several strategies for combating this problem have been recommended, including creating supportive work environments, increasing organizational support, generating greater acknowledgment of knowledge and skills, improving rates of pay and staffing levels, improving the image of aged care, achieving the appropriate skills mix minimizing and clarifying documentation requirements, developing a national career progression framework for nurses and carers, and developing a national research program in aged care (Pearson et al., 2002). The National Aged Care Workforce Strategy (2005) provides a framework for a sustainable and viable aged care sector, addressing these recommendations (Department of Health and Ageing, 2005). Although many of these recommendations have been implemented, the Productivity Commission concluded that recruitment and retention of appropriately qualified health professionals into the aged case sector remains problematic (Productivity Commission, 2011). Many older Australians wishing to live independently in their own home can do so only with the assistance of an informal caregiver. Australia has almost 2.6 million caregivers, of which 500,000 are primary caregivers, from diverse English and non-English-speaking backgrounds. Caregivers are usually family members (Carers Victoria, 2011) who provide about 74% of all support to older people in Australia. Their efforts save our economy more than $30.5 billion per year (Access Economics Pty Limited, 2005). Caring for an older person often takes its toll, both physically and psychologically. The Australian Unity Wellbeing Index revealed that caregivers have the lowest level of well-being recorded (Cummins et al., 2007). To assist in addressing the well-being of many caregivers, the National Respite for Carers program provides the opportunity for a break from caring, with respite available in the home, in day centers, with a host family, or in overnight residential care. The future of aged care within Australia is at a crucial juncture. Underpinning the vision of an equitable, efficient, and sustainable aged care system is evidenced-based research. The Australian government has committed $10 million to the Ageing Well, Ageing Productively Research Program, which has as its focus policy and practice outcomes that tangibly improve the lives of older Australians (National Health and Medical Research Council, 2005). The research landscape is rich with longitudinal studies that focus on the health and well-being of Australians across the life span. Dynamic Analyses to Optimise Ageing is a pooled data set of nine existing longitudinal studies (Table 1), with more than 50,000 participants. Studies Comprising the Dynamic Analyses to Optimise Ageing Project Studies Comprising the Dynamic Analyses to Optimise Ageing Project From a broader perspective, the Australian Association of Gerontology (AAG), Australia’s largest multidisciplinary professional association of people who work in, or have an interest in, aging helps to shape the research agenda by representing the views of multidisciplinary professionals across numerous sectors. Health and medical research underpins an effective and efficient aged care system, allowing individuals and the wider community to benefit from preventing or treating ill health, improving well-being, and accessing quality aged care services. The National Health and Hospitals Reform Commission (2009) supports research creating an agile self-improving health system. Its focus is on building a “vibrant culture of innovation and research” (National Health and Hospitals Reform Commission, 2009, p. 209) that permeates health services. The National Health and Medical Research Council (2010) promotes translational research, multidisciplinary approaches to research, and collaborations of research institutes across Australia. Bridging the gap between research and practice is an area for improvement within gerontology in Australia. The uptake of evidence-based practice for health professionals such as falls prevention in the hospital setting (Barker, Kamar, & Morton, 2009) and translating dementia research into practice (Draper, Low, Vickland, Withall, & Ward, 2009) together with adherence of older people to programs (Nyman & Victor, 2011) are examples of ongoing challenges. Australia has two Indigenous populations—Aboriginals and Torres Strait Islanders. First counted in the National Census in 1971, they currently number 517,200, representing 2.5% of the total Australian population (2006 Census), with approximately 90% of the Indigenous population of Aboriginal origin, 6% of Torres Strait Islander origin only, and 4% of both Aboriginal and Torres Strait Islander origin (ABS, 2007). There is an urgent need to address the health concerns of Indigenous Australians, who experience poorer health and a much lower life expectancy (a gap of 17 years) than the wider Australian community (AIHW, 2010a; Department of Health and Ageing, 2010a). This is partly attributable to chronic diseases including cardiovascular disease and diabetes, to poor access to primary health care, and to risk factors such as smoking, poor nutrition, and lack of exercise. Tobacco smoking is responsible for 20% of all deaths of Aboriginal and Torres Strait Islander peoples (Department of Health and Ageing, 2010a). These people experience a fivefold increase in the prevalence of dementia. The Koori Growing Old Well Study through Neuroscience Research Australia explores healthy aging and cognition in urban Indigenous communities. Preliminary findings suggest that negative early life experiences and lack of educational opportunities have a major impact on the brains of Indigenous children, leading to a range of health and socioeconomic problems in later life. Study leader, Professor Tony Broe (University of New South Wales), believes childhood neural defects, additional social and education deficits, and involvement in the criminal justice system are major determinants of poor adult health, possibly accelerating dementia in older Indigenous people (Broe et al., 2010). Substantial research gaps include variations in understanding about dementia, meaning and experience of caregiving, best practice for identification and assessment, and best practice for the provision of formal care (Arkles et al., 2010). Research funding is currently available through the Australian Research Council to conduct Aboriginal health-related research through the Australian National University’s Centre for Aboriginal Economic Policy Research (http://caepr.anu.edu.au). In addition, the federal government has initiated several health care programs including a Petrol Sniffing Prevention Program and a Strong Fathers Strong Families Program. More than two thirds (15.1 million) of Australians live in major cities, one in five (4.3 million) live in inner regional areas, 1 in 10 (2.1 million) in outer regional areas, and 2.3% live in remote or very remote areas (ABS, 2010). Despite having better social cohesion, people living in rural and remote areas of Australia have poorer health outcomes and less access to quality health services than their counterparts in major cities (AIHW, 2010b). Several key issues negatively affect rural and remote health care, including geographical isolation, sparse population distribution, an aging population, migration factors, poor socioeconomic status, workforce recruitment, and limited services (Henderson & Caplan, 2008). An example of current research addressing these issues is the “Linking Rural Older People to Community Through Technology” project, aiming to explore how access and connection to the wider community for older Australians in rural and remote locations could be achieved through the use of new communication technologies. Results highlighted low levels of comfort with new advances in communication technology for older people in the Murraylands region of South Australia, while offering opportunities to overcome issues of distance for older people living at home in rural regions (Feist, Parker, Howard, & Hugo, 2010). Mental health is an emerging area for older Australians. A report recently undertaken by the National Ageing Research Institute for “Beyond Blue” recommended that there be an awareness raising campaign for older age depression and anxiety among aged care service providers, mandatory mental health training for the aged care sector, improved access to information for older people and their families, and consideration of minimum guidelines for mental health training among undergraduates intending to work in the aged care sector (Dow et al., 2010). Currently, there are approximately 200,000 Australians diagnosed with dementia. Within the next 5 years, it is expected that dementia will be the leading cause of disability within Australia, surpassing cardiovascular disease, cancer, and depression (Department of Health and Ageing, 2006). The National Framework for Action on Dementia (2006–2010) was established in 2005 to address one of the most significant challenges facing an aging Australian population. The Dementia Collaborative Research Centres, set up in response to the challenge of translating research into practice in order that better care may be provided, has three sites—Assessment and Better Care, Early Diagnosis and Prevention, and Carers and Consumers (Alzheimer's Australia, 2011). Emphasis is placed on the person with dementia being valued and respected, with improved quality of life for people with dementia, their caregivers, and their families. There are numerous other areas of research being undertaken within Australia, such as E-health, falls prevention, housing and homelessness, culturally and linguistically diverse communities, nutrition, continence, veterans’ health issues, and medications/polypharmacy. This is not a comprehensive list, and it is recommended that readers approach the AAG should they wish for further information, particularly regarding the key researchers in each field. The AAG Web site can be found at http://www.aag.asn.au

The Gerontologist · 28 citationsread the source →

A short form of the General Self-Efficacy Scale (GSE-6): Development, psychometric properties and validity in an intercultural non-clinical sample and a sample of patients at risk for heart failure.

Objective: General self-efficacy has been found to be an influential variable related to the adaptation to stress and chronic illness, with the General Self-Efficacy (GSE) Scale by Jerusalem and Schwarzer being a reliable and valid instrument to assess this disposition. The aim of this study was to construct and test a short form of this scale to allow for a more economical assessment of the construct. Methods: The item characteristics of the original scale were assessed using an intercultural non-clinical sample (n=19,719). Six items with the highest coefficient of variation and good discrimination along the range of the trait were selected to build a short form of the instrument (GSE-6). Subsequently, the psychometric properties and the concurrent and predictive validity of the GSE-6 were tested in a longitudinal design with three measurements using a sample of patients with risk factors for heart failure (n=1,460). Results: Cronbach's alpha for the GSE-6 was between .79 and .88. We found negative associations with symptoms of depression (-.35 and -.45), anxiety (-.35), and vital exhaustion (-.38) and positive associations with social support (.30), and mental health (.36). In addition, the GSE-6 score was positively associated with active problem-focused coping (.26) and distraction/self-encouragement (.25) and negatively associated with depressive coping (-.34). The baseline GSE-6 score predicted mental health and physical health after 28 months, even after controlling for the respective baseline score. The relative stability over twelve and 28 months was r=.50 and r=.60, respectively, while the mean self-efficacy score did not change over time. Conclusions: The six item short form of the GSE scale is a reliable and valid instrument that is useful for the economical assessment of general self-efficacy in large multivariate studies and for screening purposes.

Psycho-social medicine · 96 citationsread the source →

Reasons for eating 'unhealthy' snacks in overweight and obese males and females.

Background: Snack foods are often high in fat and sugar. Thus, reducing snack consumption may be a useful weight management strategy. However, individuals may snack for a variety of reasons with different implications for intervention. The present study examined the perceived reasons for eating main meals, 'unhealthy' snacks (i.e. snacks high in fat or sugar) and 'healthy' snacks in overweight and obese participants. Methods: Over a period of 5 days, 28 males and 27 females completed a food diary every time they ate. As well as providing details about the type of eating episode and food eaten, they also rated their agreement with 13 different reasons for eating (identified from relevant literature and a pilot study). Results: Across a total of 1084 eating episodes, 358 were coded as snacks, 79% of which were high in either fat or sugar. The results showed that hunger and temptation (external eating) were reported as a reason for eating unhealthy snacks in 49% and 55% of all episodes, respectively. Eating because the individual was feeling fed up, bored or stressed (emotional eating) was given as a reason in 26% of episodes. Conclusions: These findings point to the potential utility of intervention strategies that target cravings, enhance self-control or promote stimulus control.

Journal of human nutrition and dietetics : the official journal of the British Dietetic Association · 78 citationsread the source →

Costs and effectiveness of neonatal male circumcision.

Objective: To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage. Design: We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty. Setting: United States. Participants: Birth cohort of men and women. Intervention: Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited). Outcomes measured: Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections. Results: Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses. Conclusion: Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Archives of pediatrics & adolescent medicine · 33 citationsread the source →