Suicide among male veterans: a prospective population-based study

OBJECTIVES

To assess the risk of mortality from suicide among male veteran participants in a large population-based health survey.

DESIGN AND SETTING

A prospective follow-up study in the US. Data were obtained from the US National Health Interview Surveys 1986-94 and linked to the Multiple Cause of Death file (1986-97) through the National Death Index.

PARTICIPANTS

The sample comprised 320 890 men, aged >/=18 years at baseline. The participants were followed up with respect to mortality for 12 years.

RESULTS

Cox proportional hazards analysis showed that veterans who were white, those with >/=12 years of education and those with activity limitations (after adjusting for medical and psychiatric morbidity) were at a greater risk for completing suicide. Veterans were twice as likely (adjusted hazard ratio 2.13, 95% CI 1.14 to 3.99) [corrected] to die of suicide compared with non-veterans in the general population. The risk of death from "natural" causes (diseases) and the risk of death from "external" causes did not differ between the veterans and the non-veterans. Interestingly, male veterans who were overweight had a significantly lower risk of completing suicide than those who were of normal weight.

CONCLUSIONS

Veterans in the general US population, whether or not they are affiliated with the Department of Veterans Affairs (VA), are at an increased risk of suicide. With a projected rise in the incidence of functional impairment and psychiatric morbidity among veterans of the conflicts in Afghanistan and Iraq, clinical and community interventions that are directed towards patients in both VA and non-VA healthcare facilities are needed.

Racial differences in the characteristics of firearm suicide decedents in the United States

Focusing on the reported growing use of firearms to complete suicide among African Americans, this article analyzes the 1993 National Mortality Followback Survey to examine the association of firearm suicide with race, education, geographic region, access to a firearm, depressive symptoms, and mental health service utilization on decedents aged 15 years and older. After controlling for demographic, socioeconomic, and clinical variables, the analysis indicates that African American men were twice as likely as White men to use a firearm to complete suicide. The findings suggest the importance for clinicians to screen for the presence of firearms in depressed African Americans and to reduce their access to firearms. In addition, clinicians, social workers, and public health professionals should consider racial differences in correlates of firearm suicide when designing prevention and intervention initiatives.

Physical illness, functional limitations, and suicide risk: a population-based study

The purpose of this study was to assess the independent association of physical illness and functional limitations with suicide mortality risk. The Cox proportional hazards model was used with data from the 1986-1994 National Health Interview Survey linked to the 1986-1997 National Death Index to analyze the effects of chronic physical illness and functional limitations on suicide deaths (ICD-9 E950-959). After controlling for potential confounders at baseline, functional limitations were shown to be a significant predictor of suicide. Also, psychiatric comorbidity increased the risk of completing suicide. Interestingly, chronic conditions alone were not predictive of suicide completion when functional limitation was added to the model. Implications for the clinical management of suicidal behavior among patients with chronic conditions are discussed.

Sooner versus later: factors associated with temporal sequencing of suicide

There are few (if any) population-based prospective studies that provide information on factors associated with temporal sequencing of suicide. In this prospective population-based study, the National Health Interview Survey (NHIS), 1986-1994, was linked to the National Death Index (NDI), 1986-1997, to assess factors that predict recent (within 12 months of interview, termed sooner) suicide versus suicide further in the future (more than 12 months after interview, termed later). Of the 653 completed suicides in the NHIS cohort, 13.4 percent completed suicide within a year of interview, and 86.6 percent did so after a year. Sooner decedents were more likely to be White, less educated, unemployed, and to use firearms than any other method compared with later decedents. Surprisingly, sooner decedents had higher levels of self-rated health at baseline. These results have substantial implications for clinicians and other professionals who interact with people at highest risk of suicide. Unfortunately, it may be unrealistic to expect that health care providers can modify the behavior of individuals at highest risk of suicide.

The health consciousness myth: implications of the near independence of major health behaviors in the North American population

Analysis of over 250,000 respondents from four of the largest epidemiological surveys in North America indicates that major health behaviors are largely unrelated to one another. On average, the percentage of shared variance among smoking, exercise, diet and alcohol consumption is approximately 1%. While many of these relationships are statistically significant, suggesting that the associations are nonzero in the population, they represent minute effect sizes. The weak associations among these behaviors are unlikely to be due to incorrect functional form of the relationship, measurement error, or biases in responding. The findings have implications for health behavior theories and interventions predicated on the notion that the health conscious individual attempts to improve his or her health by engaging in more than one of these behaviors at a time.

The association between length of residence and obesity among Hispanic immigrants

BACKGROUND

Newly arrived Hispanic immigrants are generally healthier than the U.S.-born population, but this distinction tends to diminish over time as immigrants adapt to a new and different sociocultural environment.

OBJECTIVE

This study sought to determine whether length of residence in the United States was associated with obesity (body mass index [BMI]>30 kg/m(2)) among Hispanic immigrants.

METHODS

Data for 2420 foreign-born Hispanic adults aged > or =18 years were obtained from the 1998 National Health Interview Survey.

RESULTS

The prevalence of obesity among those with 0 to 4, 5 to 9, 10 to 14, and > or =15 years of residence in the United States was 9.4%, 14.5%, 21.0%, and 24.2%, respectively. A logistic regression model adjusted for smoking, physical inactivity, self-assessed health, chronic conditions, functional limitations, nonspecific psychological distress, several sociodemographic characteristics, and access to health services found that longer-term Hispanic immigrants (> or =15 years) experienced a nearly four-fold greater risk of obesity than did recent immigrants (<5 years).

CONCLUSIONS

The higher risk for obesity associated with length of residence may be due to acculturation processes such as the adoption of the unhealthy dietary practices (i.e., a diet high in fat and low in fruits and vegetables) and sedentary lifestyles of the host country. The results of this study may facilitate the planning of public health interventions that are directed at subgroups of the Hispanic population.

Health Behaviors in a Representative Sample of Older Canadians: Prevalences, Reported Change, Motivation to Change, and Perceived Barriers

PURPOSE

Prevalence estimates of healthy behaviors and preventive care among older adults have not received sufficient attention, despite important health benefits such as longevity and better quality of life. Moreover, little is known about general population prevalences of older adults' efforts to change behavior, motivations to improve health behaviors, and perceived barriers to change.

DESIGN AND METHODS

This study estimates the prevalence of a wide range of health behaviors and preventive-care activities, self-reported behavior change, and perceived barriers to change in a 1996-1997 population-based survey of 17,354 Canadian adults aged 60 and older.

RESULTS

The findings indicate that a substantial proportion of older adults lead relatively inactive lives and often fall short of recommended standards for preventive health-care visits and screening tests. Moreover, nearly two thirds (63.2%) of older adults reported no efforts in the prior year to make changes to improve their health, and similar numbers (66.7%) indicated they thought no changes were needed. Differences in prevalences were found by gender, age, and education.

IMPLICATIONS

Results from this study are useful for policy makers who need to prioritize public health efforts, researchers studying interventions, and health professionals developing preventive-care guidelines.

Prevalence and correlates of overweight and obesity among older adults: findings from the Canadian National Population Health Survey

BACKGROUND

The prevalence of obesity among elderly persons in industrialized countries ranges from 15% to 20%. Little is known about variations of overweight within subgroups of the elderly population. This study examined the factors associated with overweight and obesity among older men and women.

METHODS

Data for 12,823 community-dwelling persons aged 65 and older from the 1996-1997 Canadian National Population Health Survey were examined. Predictors of overweight (body mass index [BMI] = 25.0-29.9 kg/m2) and obesity (BMI = >30 kg/m2) relative to normal weight (BMI = 20.0-24.9 kg/m2) were examined using logistic regression analyses. Analyses were stratified by gender. The predictor variables included age, education, marital status, place of birth, region, smoking status, alcohol use, chronic conditions, physical activity, functional limitations, self-rated health, social support, and psychological distress.

RESULTS

Overall, 39% and 13% of Canadian older adults were classified as overweight and obese, respectively. Some of the risk factors for overweight were male gender, low education, being married, Canadian born, residence in the Atlantic provinces, no use of alcohol, comorbidity, physical inactivity, and limited functional status. Risk factors for obesity were similar to those for overweight except for being unmarried; American, European, and Australian born; lower and higher levels of alcohol use; poor self-rated health; and psychological distress.

CONCLUSIONS

The results could lead to more effective weight-control interventions that are designed to promote increased physical activity and healthy eating habits among obese older individuals.

Characteristics of physically inactive older adults with arthritis: results of a population-based study

BACKGROUND

Arthritis is the most prevalent chronic condition among persons age 65 and older in North America. Physical inactivity in this population is linked to functional limitations, increased risk for cardiovascular disease, diminished quality of life, and disability. The purpose of this study was to identify risk factors for inactivity.

METHODS

National data for 6256 community-dwelling older adults with arthritis from the 1996-1997 Canadian National Population Health Survey were examined using logistic regression analyses. The independent variables included sociodemographic characteristics, health status, psychosocial factors, health behaviors, and medication use.

RESULTS

Inactive persons were significantly (P < 0.05) more likely to be women, older (75+), have functional limitations, be underweight (BMI < 20) or overweight (BMI > 25), have severe pain, or not have prescription drug insurance coverage. The same group was less likely to be unmarried, well educated, from western provinces, attend church frequently, consume alcohol infrequently, have higher levels of social support, have better self-rated health, or use pain medication.

CONCLUSIONS

The profile presented in this study should be fully considered by health care providers when educating patients with arthritis about the adverse health effects of sedentary behavior. Prescription drug insurance coverage may facilitate activity among elders with arthritis.

The psychosocial determinants of hypertension

AIM

To present currently available evidence on the role that adverse psychosocial factors play in the pathogenesis of hypertension. The specific objectives of the review were to (1) provide a picture of what is known about the relationship between psychosocial factors and hypertension, (2) summarize the major methodological and conceptual pitfalls, and (3) identify gaps in the literature and suggest areas for future research.

DATA SYNTHESIS

The scope of the literature review was adults and the literature published since 1990 (acknowledging that some articles published earlier would need to be taken into account). A number of journal searches were carried out. They included Medline, PsychInfo, and SocioFile, with keywords, such as hypertension, blood pressure, psychosocial, psychological, social, acculturation, occupation, socio-economic status, social class, education, depression, anger, and anxiety. The search included articles related to hypertension in developed countries and was limited to studies in the English language.

CONCLUSION

A growing body of evidence supports the thesis that psychosocial factors play a role in the pathogenesis for hypertension.

Older adults' contact with health practitioners: is there an association with smoking practices?

BACKGROUND

Approximately 12% of the North American population aged 65 and older smoke cigarettes daily. Late-life smokers represent an important population for intervention by health practitioners. The objective of this study was to determine the extent to which contact with health practitioners (dentists or physicians) affects smoking status among older adults.

METHODS

We used data on a probability-based sample of community-dwelling elderly respondents (N = 13,363) from the Canadian 1996-1997 National Population Health Survey. Descriptive statistics were calculated, and multivariate logistic regression analysis was performed to examine the associations between current tobacco use and contact with health care practitioners controlling for potential confounders, especially sociodemographic characteristics, selected health conditions, self-reported health, body mass index, functional status, perceived social support, and psychological distress.

RESULTS

Older adults without a regular physician (adjusted odds ratio [AOR], 1.33; 95% confidence interval [CI], 1.11-1.59), with infrequent physical (AOR, 1.22; 95% CI, 1.07-1.40), and dental (AOR, 2.68; 95% CI, 2.07-3.47) checkups were more likely to be current smokers. Age (younger), church attendance (infrequent), drinking behavior (former or occasional), body mass index (normal weight), and psychological distress were all independently related to current smoking.

CONCLUSIONS

Results indicate that patients' contact with health care providers is strongly negatively associated with smoking. More specific data are needed to learn the frequency with which physicians and dental professionals attempt to modify older individuals' smoking behavior and the degree to which such efforts are effective.

Firearm-related suicide among young african-american males

National trends in firearm-related suicides among African-American and white males in the age groups 15 to 19 years and 20 to 24 years from 1979 to 1997 were examined. The rates and percentages of suicide by firearms increased significantly more among African-American males than among white males. During the 19-year period, firearms accounted for about 70 percent and 64 percent of all suicides among males aged 15 to 19 years and 20 to 24 years, respectively. The results support the Surgeon General's 1999 call for greater awareness of the suicide risk among African-American males.

The paraphilic and hypersexual disorders: an overview

In this article, the first of a two-part series, the authors present reasons for considering the paraphilic and hypersexual disorders together and provide an overview of these disorders. The DSM-IV diagnostic criteria for paraphilias are reviewed, and proposed criteria for hypersexual disorders are presented. The question of whether the paraphilic and hypersexual disorders should be considered within the spectrum of obsessive-compulsive disorders is considered. The authors then review the epidemiology of these disorders, and discuss some implications of recent sexual predator legislation. The authors discuss the etiology of the paraphilias and hypersexual disorders, and consider the role of endocrinological function, findings from brain imaging and neuropsychological testing, findings from primate research, the monoamine hypothesis, the imprinting hypothesis, social learning theory, the concept of courtship disorder, the role of obsessive-compulsive elements, psychodynamic theories, and genetic factors. The phenomenology of the paraphilias and hypersexual disorders is discussed, including the tendency for multiple paraphilias to co-occur, the lack of a specific offender profile, the predominance of males among those with paraphilias, the incidence of a history of victimization in individuals with paraphilias and compulsive sexual disorders, the onset and course of both types of disorders, and the lack of internal motivation for change in individuals with paraphilias and hypersexual disorders. The authors then discuss disorders that commonly co-occur with paraphilias and compulsive sexual disorders, including mood disorders, substance abuse and dependence disorders, attention-deficit/hyperactivity disorder, anxiety and impulse control disorders, and personality disorders. The second article in the series will discuss the clinical assessment and the behavioral and psychopharmacological treatment of these disorders. A guide for clinicians and patients on where and how to find specialized clinicians and treatment resources in the United States will also be provided.

Demographic and psychosocial correlates of physical activity in late life

INTRODUCTION

According to the Centers for Disease Control and Prevention and the World Health Organization, increasing physical activity may help prolong health and preserve the quality of life in late adulthood. Physical activity has taken center stage as the behavior most likely to alter health. However, there is little recent population-wide information about the demographic and psychosocial correlates of physical activity in the elderly population. The purpose of the study was to identify the factors associated with older adults' frequency of physical activity. The study may have implications for preventive interventions.

METHODS

Data for 12,611 community-dwelling people aged > or = 65 from the 1996-1997 Canadian National Population Health Survey were examined. Predictors of frequent versus infrequent self-reported physical activity lasting > 15 minutes were examined using logistic regression analyses. The predictor variables included geographic location, psychological distress (Generalized Distress Scale), demographic factors (age, gender, educational level, and marital status), perceived social support, chronic medical conditions, physical limitations due to injury, functional limitations, smoking behavior, and body mass index (BMI).

RESULTS

Gender (male); younger age; higher levels of education; being unmarried; absence of chronic conditions, injuries, and functional limitations; lower BMI; social support (females); nonsmoking; region; and lower levels of psychological distress were associated with frequent physical activity in late life. Older adults in western Canadian provinces were more active than those in eastern provinces.

CONCLUSIONS

The results will be useful for the design of interventions aimed at improving older adults' health behavior and other health and functional outcomes, especially for subgroups in particular need. Recommendations for further longitudinal research are presented.

Environment complexity stimulates visual cortex neurogenesis: death of a dogma and a research career

Over the past few years, the classic idea that no new nerve cells are born in the adult mammalian brain has finally and conclusively been refuted by the scientific community. Yet, the first indications that neurogenesis occurs in the brain of adult mammals were obtained using light and electron microscopy over two decades ago. Why this went unrecognized is described in a personal account by the researcher who pioneered those studies: Michael Kaplan.

Depot-leuprolide acetate for treatment of paraphilias: a report of twelve cases

A new class of antiandrogen medications, gonadotropin-releasing hormone agonists, offers promise in the treatment of the paraphilias, with substantially less side effects than medroxyprogesterone acetate or cyproterone acetate. This paper reports the results of treatment using a depot suspension of leuprolide acetate on 12 patients with paraphilic disorders or with sexual disorders not otherwise specified to suppress or help these individuals control their deviant sexual behavior or impulses. The method involved uncontrolled observations of individuals treated with depot-leuprolide acetate for various lengths of time, from 6 months to 5 years, with the follow-up intervals ranging from 6 months to 6 years. Leuprolide acetate resulted in a significant suppression of deviant sexual interests and behavior as measured by self-report and was well tolerated. However, the three patients who were on long-term therapy developed bone demineralization, suggesting that this is a significant side effect of prolonged therapy. Leuprolide acetate shows promise as a treatment for the paraphilias.

Confidence of primary care physicians in assessing the suicidality of geriatric patients

This study examined the confidence levels of physicians in assessing the risk of suicide among older adults in clinical settings. Of the 300 physicians who were selected from a population of 4980 family practice, internal medicine, and geriatric physicians in Illinois, 63% responded to the mail survey. Several categorical items inquired about specific assessment and treatment approaches, referral resources used, barriers to meeting the mental health needs of older patients, and sources of training in suicide risk assessment. All the training items (suicide assessment in medical school, residency, and CME courses; rating of medical school training; and insufficient training in geriatric mental health) were significantly (p < 0.01) associated with confidence in assessing suicidality. The overall model consisting of six variables explained 57% of the variation in confidence scores [F (6, 130) = 28.48, p < 0.001]. Three variables accounted for 50% of the explained variance: confidence in diagnosing depression, residency training in the assessment of suicide risk, and assessment of the intentional misuse of medication. Confidence in diagnosing depression (beta = 0.38, p < 0.001) was the strongest predictor. More effective mental health care will require specific preparation in treating geriatric patients through the full spectrum of medical training, including medical school, residency, and CME courses. Improved prevention of elderly suicide hinges on the enhancement of clinical skills in diagnosing and treating geriatric depression.

Caring for depressed and suicidal older patients: a survey of physicians and nurse practitioners

OBJECTIVE

This study sought to describe patterns of mental health care for depressed and suicidal geriatric patients by primary care physicians (MDs) and nurse practitioners (NPs).

METHODS

A probability sample of 300 Illinois MDs from the AMA Physician Masterfile and a national sample of 595 NPs from the American Academy of Nurse Practitioners were surveyed. Sixty-three percent of MDs and 61 percent of NPs responded regarding their approaches to assessing, treating, and referring older adult patients who were depressed or suicidal. Respondents rated their confidence in assessing and treating depression and suicidality and identified barriers to mental health treatment in a primary care setting.

RESULTS

Both similarities and differences were found among MDs and NPs in their patterns of managing depressed and suicidal older adults. NPs used more varied approaches in assessing, treating, and referring their geriatric patients with mental health problems. MDs relied more heavily on psychotropic medications for the treatment of depression and on psychiatrists when referring suicidal older patients. NPs were more likely than MDs to note lack of training and referral resources as barriers to treating depression of older patients. NPs rated their training in geriatric mental health more favorably than MDs.

CONCLUSIONS

In terms of assessment of depression, preferred treatment approaches, the use of referral resources, and perceived barriers to mental health care, there appears to be a greater orientation towards a psychosocial approach among NPs. Primary care MDs and NPs often have different perspectives that in combination could enhance the mental health care of geriatric patients.