Laurence Y. Katz

Effect of regulatory warnings on antidepressant prescription rates, use of health services and outcomes among children, adolescents and young adults

Background: Regulatory bodies worldwide, including Health Canada, have issued warnings about prescribing antidepressants to children and adolescents. We sought to determine whether the Health Canada warning had the desired effects on prescribing patterns and outcomes and whether it had any unintended health consequences. Methods: We examined data from prescription and health care databases representing more than 265 000 children, adolescents and young adults annually to determine changes in the rates of antidepressant prescription, use of health services and outcomes in these populations in the 9 years before and the 2 years after the Health Canada warning. We also examined the data for unintended changes in these rates among patients with anxiety disorders. We used young adults as the comparison group because they were not targeted by the warning. Results: Following the warning, the rate of antidepressant prescriptions decreased among children and adolescents (relative risk [RR] 0.86, 95% confidence interval [CI] 0.81–0.91) and among young adults (RR 0.90, 95% CI 0.86–0.93). Ambulatory visits because of depression decreased among children and adolescents (RR 0.90, 95% CI 0.85–0.96) and young adults (RR 0.91, 95% CI 0.87–0.96). The rate of completed suicides among children and adolescents rose significantly after the warning (RR 1.25, 95% CI 1.08–1.44; annual rate per 1000 = 0.04 before and 0.15 after the warning). There was no equivalent change in the rate of completed suicides among young adults (RR 1.01, 95% CI 0.93–1.10; annual rate per 1000 = 0.15 before and 0.22 after the warning). Among patients with an anxiety disorder, the prescription rates did not change among children and adolescents, except for a decrease in the use of selective serotonin reuptake inhibitors other than fluoxetine, but the rates among young adults changed similar to the pattern of changes in the overall prescribing of antidepressants. There was also a significant decrease in the rate of physician visits because of anxiety disorders among young adults after the warning. Interpretation: Health advisories and warnings issued by regulatory bodies may have unintended consequences on the provision of care, delivery of health services and clinical outcomes. Further efforts are required to ensure that health warnings do not result in unexpected harm.

Spirituality, religion and suicidal behavior in a nationally representative sample.

BACKGROUND Studies show that religion and spirituality are associated with decreased rates of mental illness. Some studies show decreased rates of suicide in religious populations, but the association between religion, spirituality and suicidal behaviors in people with mental illness are understudied. Few studies have examined the influence of social supports in these relationships. METHODS Data were drawn from the Canadian Community Health Survey 1.2. Logistic regression was used to examine the relationship between spiritual values and religious worship attendance with twelve-month suicidal ideation and attempts. Regressions were adjusted for sociodemographic factors and social supports. Interaction variables were then tested to examine possible effect modification by presence of a mental disorder. RESULTS Identifying oneself as spiritual was associated with decreased odds of suicide attempt (adjusted odds ratio-1 [AOR-1]=0.65, CI: 0.44-0.96) but was not significant after adjusting for social supports. Religious attendance was associated with decreased odds of suicidal ideation (AOR-1=0.64, 95% CI: 0.53-0.77) but not after adjusting for social supports. Religious attendance was associated with decreased odds of suicide attempt and remained significant after adjusting for social supports (AOR-2=0.38, 95% CI: 0.17-0.89). No significant interaction effects were observed between any of the tested mental disorders and religion, spirituality and suicidal behavior. LIMITATIONS This was a cross-sectional survey and causality of relationships cannot be inferred. CONCLUSIONS Results suggest that religious attendance is associated with decreased suicide attempts in the general population and in those with a mental illness independent of the effects of social supports.

Effect of Scattered-Site Housing Using Rent Supplements and Intensive Case Management on Housing Stability Among Homeless Adults With Mental Illness A Randomized Trial

IMPORTANCE Scattered-site housing with Intensive Case Management (ICM) may be an appropriate and less-costly option for homeless adults with mental illness who do not require the treatment intensity of Assertive Community Treatment. OBJECTIVE To examine the effect of scattered-site housing with ICM services on housing stability and generic quality of life among homeless adults with mental illness and moderate support needs for mental health services. DESIGN, SETTING, AND PARTICIPANTS The At Home/Chez Soi project was an unblinded, randomized trial. From October 2009 to July 2011, participants (N = 1198) were recruited in 4 Canadian cities (Vancouver, Winnipeg, Toronto, and Montreal), randomized to the intervention group (n = 689) or usual care group (n = 509), and followed up for 24 months. INTERVENTIONS The intervention consisted of scattered-site housing (using rent supplements) and off-site ICM services. The usual care group had access to existing housing and support services in their communities. MAIN OUTCOMES AND MEASURES The primary outcome was the percentage of days stably housed during the 24-month period following randomization. The secondary outcome was generic quality of life, assessed by a EuroQoL 5 Dimensions (EQ-5D) health questionnaire. RESULTS During the 24 months after randomization, the adjusted percentage of days stably housed was higher among the intervention group than the usual care group, although adjusted mean differences varied across sites. [table: see text] The mean change in EQ-5D score from baseline to 24 months among the intervention group was not statistically different from the usual care group (60.5 [95%CI, 58.6 to 62.5] at baseline and 67.2 [95%CI, 65.2 to 69.1] at 24 months for the intervention group vs 62.1 [95% CI, 59.9 to 64.4] at baseline and 68.6 [95%CI, 66.3 to 71.0] at 24 months for the usual care group, difference in mean changes, 0.10 [95%CI, −2.92 to 3.13], P=.95). CONCLUSIONS AND RELEVANCE Among homeless adults with mental illness in 4 Canadian cities, scattered site housing with ICM services compared with usual access to existing housing and community services resulted in increased housing stability over 24 months, but did not improve generic quality of life. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN42520374.

Comorbidity and Associated Severity of Borderline Personality Disorder and Physical Health Conditions in a Nationally Representative Sample

Objective: To investigate the comorbidity and severity of borderline personality disorder and physical health conditions in a nationally representative sample. Despite the recent trend of examining the relationship between physical and mental health, there has been limited research examining the association of physical health conditions and personality disorders, in particular, borderline personality disorder. Methods: The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave 2 (n = 34,653; cumulative response rate, 70.2%; age, ≥20 years) was used in the current study. The Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition was used to assess mental disorders, and self-reports were used to assess physical health conditions. Multiple logistic regression models examined the comorbidity of physical health conditions with borderline personality disorder and associated suicide attempts. Results: After adjusting for sociodemographic variables, common Axis I mental disorders, and Axis II personality disorders, the presence of borderline personality disorder was significantly associated with arteriosclerosis or hypertension, hepatic disease, cardiovascular disease, gastrointestinal disease, arthritis, venereal disease, and “any assessed medical condition” (adjusted odds ratios, range 1.46–2.80). In the most stringent adjusted model, diabetes, stroke, and obesity were not associated with borderline personality disorder. Furthermore, a greater likelihood of suicide attempts was associated with cardiovascular disease, venereal disease, and “any assessed medical condition” with comorbid borderline personality disorder than borderline personality disorder alone. Conclusion: Careful screening and treatment of physical health conditions among people with borderline personality disorder are warranted. BPD = borderline personality disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; NESARC = National Epidemiological Survey on Alcohol and Related Conditions; AUDADIS-IV = Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version; BMI = body mass index; HRQOL = health-related quality of life; MCS = mental health-related quality of life component score; PCS = physical health-related quality of life component score.

A systematic review of school-based suicide prevention programs

Suicide is one of the leading causes of death among youth today. Schools are a cost‐effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school‐based suicide prevention programs.

Help Seeking and Perceived Need for Mental Health Care Among Individuals in Canada With Suicidal Behaviors

OBJECTIVE This study examined and compared help seeking, perceived need, satisfaction with health professionals, and barriers to care in three groups: individuals with a mental disorder without suicidal behaviors, those with suicidal ideation with or without a mental disorder, and those with a suicide attempt with or without a mental disorder in the past year. METHODS Data came from the Canadian Community Health Survey Cycle 1.2. The sample consisted of 36,984 persons aged 15 years and older (response rate=77%). A total of 4,872 had a mental disorder without suicidal behaviors, 1,234 had suicidal ideation, and 230 had attempted suicide. Multiple logistic regressions were used to examine differences between the three groups after adjusting for sociodemographic factors and the number of mental disorders. RESULTS Individuals with suicidal ideation and those with suicide attempts were significantly more likely than those with a mental disorder but no suicidal behaviors to seek help and to perceive a need for care in the past year. However, 48% of individuals reporting suicidal ideation and 24% of individuals reporting a suicide attempt did not seek help and did not perceive a need for help in the past year. Significant differences existed between individuals in the three groups in terms of satisfaction with the care they received and barriers to receiving care in the past year. CONCLUSIONS Although suicidal ideation and suicide attempts represent a significant source of evaluated need associated with help seeking and perceived need over and above the presence and severity of mental disorders, a significant proportion of individuals with suicidal behaviors did not receive care and did not perceive a need for care. Future research should be directed toward finding better ways to identify these individuals and address barriers to their care and other factors that may interfere with their receiving help.

The Associations Between Health Risk Behaviours and Suicidal Ideation and Attempts in a Nationally Representative Sample of Young Adolescents

Objective: To examine associations between health risk behaviours and suicidal ideation and attempts in Canadian adolescents aged 12 to 13 years. Young adolescents think about and attempt suicide. However, most existing research on suicide has been conducted on individuals aged 15 years and older. Method: The present study examined a nationally representative Canadian sample of adolescents aged 12 to 13 years (n = 2090). Health risk behaviours included disruptive (shoplifting, physical fighting, damaging property, fighting with a weapon, carrying a knife, and gambling), sexual (petting below the waist and sexual intercourse), and substance use behaviours (smoking cigarettes, consuming alcohol, marijuana or hash, and glue or solvents). Unadjusted and adjusted (for all significant health risk behaviour and psychiatric symptoms) models were tested. Results: All health risk behaviours were common among male and female adolescents. In unadjusted models, almost all health risk behaviours were associated with suicidal ideation and attempts among adolescent boys. In adjusted models, only damaging property, sexual intercourse, and smoking cigarettes remained statistically associated with suicidal ideation, while smoking cigarettes and using marijuana or hash remained statistically associated with suicide attempts among adolescent boys. All health risk behaviours were statistically associated with suicidal ideation and attempts among female adolescents in unadjusted models. In adjusted models, only carrying a knife remained statistically associated with suicidal ideation, while shoplifting and gambling remained statistically associated with suicide attempts among adolescent girls. Conclusions: Health risk behaviours among young adolescents are associated with suicidal ideation and attempts among young adolescents. Recognizing health risk behaviours among young adolescents may be one means of understanding who among them is at increased risk of suicidality.

Antidepressant use in the absence of common mental disorders in the general population

OBJECTIVE To examine the prevalence of antidepressant use in the absence of lifetime mental disorders and to examine sociodemographic correlates, indicators of need (hospitalization, suicidal behavior, perceived need, subthreshold disorders, disability, traumatic events), and antidepressant characteristics of such use. METHOD Data came from the Collaborative Psychiatric Epidemiologic Surveys (N = 20,013), a nationally representative cross-sectional sample of community-dwelling adults in the United States. Sociodemographic correlates and indicators of need were examined as predictors of past-year use of antidepressants in the absence of a lifetime DSM-IV diagnosis as assessed by the World Mental Health Composite Diagnostic Interview. The surveys were conducted between 2001 and 2003. RESULTS Among individuals who took an antidepressant in the past year (n = 1,441), 396 (26.3%) did not meet criteria for any lifetime diagnosis assessed. Respondents taking antidepressants in the absence of a lifetime diagnosis tended to be older, white, and female. All indicators of need except past-year suicidal behavior were significant predictors (adjusted odds ratios ranging from 2.12 to 14.22, P < .001), with 89% of individuals taking antidepressants in the absence of a lifetime diagnosis endorsing at least 1 indicator of need. Individuals taking antidepressants in the absence of a DSM-IV disorder were more likely to have been prescribed these medications by family physicians or other doctors compared to psychiatrists. CONCLUSIONS These results suggest that antidepressant use among individuals without psychiatric diagnoses is common in the United States and is typically motivated by other indicators of need. These findings have important implications for the delivery of medical and psychiatric care and psychiatric nosology.

Suicide and suicide attempts in children and adolescents in the child welfare system

Background: Few population studies have examined the psychiatric outcomes of children and adolescents in the child welfare system, and no studies have compared outcomes before and after entry into care. Our objective was to assess the relative rate (RR) of suicide, attempted suicide, admission to hospital and visits to physicians’ offices among children and adolescents in care compared with those not in care. We also examined these outcomes within the child welfare population before and after entry into care. Methods: We used population-level data to identify children and adolescents 5 to 17 years of age who were in care in Manitoba for the first time between Apr. 1, 1997, and Mar. 31, 2006, and a comparison cohort not in care. We compared the two cohorts to obtain RRs for the specified outcomes. We also determined RRs within the child welfare population relative to the same population two years before entry into care. Results: We identified 8279 children and adolescents in care for the first time and a comparison cohort of 353 050 children and adolescents not in care. Outcome rates were higher among those in care than in the comparison cohort for suicide (adjusted RR 3.54, 95% confidence interval [CI] 2.11–5.95), attempted suicide (adjusted RR 2.11, 95% CI 1.84–2.43) and all other outcomes. However, adjusted RRs for attempted suicide (RR 0.27, 95% CI 0.21–0.34), admissions to hospital and physician visits decreased after entry into care. Interpretation: Children and adolescents in care were at greater risk of suicide and attempting suicide than those who were not in care. Rates of suicide attempts and hospital admissions within this population were highest before entry into care and decreased thereafter.

Relationship Between Adverse Childhood Experiences and Homelessness and the Impact of Axis I and II Disorders

OBJECTIVES We investigated the links between homelessness associated with serious mental and physical healthy disparities and adverse childhood experiences (ACEs) in nationally representative data, with Axis I and II disorders as potential mediators. METHODS We examined data from the National Epidemiologic Survey of Alcohol and Related Conditions in 2001-2002 and 2004-2005, and included 34,653 participants representative of the noninstitutionalized US population who were 20 years old or older. We studied the variables related to 4 classes of Axis I disorders, all 10 Axis II personality disorders, a wide range of ACEs, and a lifetime history of homelessness. RESULTS Analyses revealed high prevalences of each ACE in individuals experiencing lifetime homelessness (17%-60%). A mediation model with Axis I and II disorders determined that childhood adversities were significantly related to homelessness through direct effects (adjusted odd ratios = 2.04, 4.24) and indirect effects, indicating partial mediation. Population attributable fractions were also reported. CONCLUSIONS Although Axis I and II disorders partially mediated the relationship between ACEs and homelessness, a strong direct association remained. This novel finding has implications for interventions and policy. Additional research is needed to understand relevant causal pathways.