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Leventhal AM, Cho J, Keyes KM, Zink J, Riehm KE, Zhang Y, Ketema E. Digital media use and suicidal behavior in U.S. adolescents, 2009-2017. Prev Med Rep 2021; 23:101497. [PMID: 34354907 PMCID: PMC8322454 DOI: 10.1016/j.pmedr.2021.101497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/10/2021] [Indexed: 12/28/2022] Open
Abstract
U.S. adolescent suicidal behavior and digital media use prevalence have contemporaneously increased this decade in population-level ecological analyses. The purpose of this study was to determine whether these two trends are directly associated by using multi-year person-level data to test whether the association of year with suicidal behavior was mediated by digital media use. Data were from the Youth Risk Behavior Surveillance System (2009-2017), a nationally-representative biennial cross-sectional self-report survey of U.S. students (N = 72,942). Mediation analysis was used to estimate the proportion of cross-year changes in suicidal behavior that were mediated by concurrent changes in leisure-time digital media use. Past-year suicidal behavior in 2011 (19.6%), 2013 (20.4%), 2015 (21.7%), and 2017 (20.5%) increased relative to 2009 (17.1%). Hours of daily digital media use in 2011 (mean[SD] = 2.65[1.86]), 2013 (mean[SD] = 3.02[2.08]), 2015 (mean[SD] = 2.97[2.12]), and 2017 (mean[SD] = 3.01[2.18) increased vs. 2009 (mean[SD] = 2.31[1.81]). The association of survey year with suicidal behavior was mediated by digital media use-20.5%(95%CI = 16.2, 24.8), 34.3%(95%CI = 24.5, 44.1), 22.8%(95%CI = 17.3, 28.0), and 41.4%(95%CI = 33.9, 49.5) of cross-year suicidal behavior prevalence increases (vs. 2009) for 2011, 2013, 2015, and 2017, respectively, were mediated by concurrent digital media use increases. Therefore, small proportions of the 2009-2017 increases in U.S. adolescent suicidal behavior are associated with concurrent increasing digital media use trends. Further exploration of these trends is warranted.
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Kreski NT, Chen Q, Olfson M, Cerdá M, Hasin D, Martins SS, Mauro PM, Keyes KM. Trends in Adolescent Online and Offline Victimization and Suicide Risk Factors. Pediatrics 2021; 148:peds.2020-049585. [PMID: 34341075 PMCID: PMC8811796 DOI: 10.1542/peds.2020-049585] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Suicidal ideation and plans are increasing among US adolescents. Changing prevalence of online victimization is frequently hypothesized as an explanation for this increase. We tested trends in online and offline victimization and whether they contribute to recent trends in adolescent suicidal outcomes. METHODS Youth Risk Behavior Survey data (2011-2019, N = 73 074) were collected biennially through national cross-sectional surveys of US school-attending adolescents. We examined trends in past-year victimization. We also examined whether the relationship between victimization and past-year suicidal ideation, plans, attempts, and injury changed over time using survey-weighted logistic regressions that adjusted for sex and race and ethnicity. We also sex-stratified results to examine sex differences. RESULTS Although suicidal ideation and plans increased among US adolescents (mainly girls), online and offline victimization prevalence did not increase over time (offline: 20.0% in 2011, 19.5% in 2019; online: 16.2% in 2011, 15.7% in 2019). Online and offline victimization were associated with suicidal outcomes, especially co-occurring online and offline victimization (eg, adjusted odds ratio [co-occurring online and offline victimization versus none, outcome: suicidal injury] = 8.37; 95% confidence interval: 7.06-9.91). The magnitude of the associations between victimization and suicidal outcomes largely remained stable over time. CONCLUSION Peer victimization prevalence has not sufficiently changed over time in concert with suicidal outcomes to explain increased suicidal outcomes. The prevalence of victimization has remained relatively invariant across time despite growing awareness and programming, making online and offline victimization consistent, socially-patterned risk factors that warrant further monitoring and interventions. Research must examine risk factors beyond victimization to explain increasing suicidal outcomes.
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Keyes KM, Platt J, Rutherford C, Patrick ME, Kloska DD, Schulenberg J, Jager J. Cohort effects on gender differences in alcohol use in the United States: How much is explained by changing attitudes towards women and gendered roles? SSM Popul Health 2021; 15:100919. [PMID: 34541283 PMCID: PMC8435695 DOI: 10.1016/j.ssmph.2021.100919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/26/2023] Open
Abstract
Gender differences in binge drinking have converged in recent cohorts, due in part to faster decreases in consumption among boys in adolescence, and faster increases in consumption among women in young to middle adulthood. Changes in education and occupation explain a portion, but not all, of these differences; the present study examines how attitudes about gender, religion and family additionally explain cohort effects in binge drinking by sex. Data were drawn from the Monitoring the Future panel studies, including >54,000 participants who were high school seniors from 1976 through 2006, followed to age 29/30 from 1988 through 2016. The main effect relationship between cohort and binge drinking was assessed, and 28 items on gender, religion and family were evaluated to determine if mediation criteria were met; mediation models assessed direct and indirect effects. Results indicated that gender, religion and family attitudes and beliefs among US adults across the 20 th and 21 st centuries have shifted dramatically but not monotonically. US adolescents and adults have largely become less religious; some attitudes on women and family have become less conservative and some more. Among men, views on marriage showed the largest mediation effects; agreeing with the statement 'one partner is too restrictive' mediated 3.35% of the cohort effect (95% C.I. 2.42, 4.31) and 'couples should live together before they are married' mediated 1.6% of the cohort effect (95% C.I. -2.37, -0.8). Among women, declines in religious service attendance mediated 2.0% of cohort effects in binge drinking (95% C.I. -3.03, -1.09), as well as similar family attitudes as men. In conclusion, changes in social roles, as well as some gender, and religious views, partially mediate cohort effects on binge drinking for men and women. The dynamic changes in how adolescents and adults view family and gender are important components of alcohol epidemiology.
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Martínez-Alés G, Pamplin JR, Rutherford C, Gimbrone C, Kandula S, Olfson M, Gould MS, Shaman J, Keyes KM. Age, period, and cohort effects on suicide death in the United States from 1999 to 2018: moderation by sex, race, and firearm involvement. Mol Psychiatry 2021; 26:3374-3382. [PMID: 33828236 PMCID: PMC8670065 DOI: 10.1038/s41380-021-01078-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/09/2021] [Accepted: 03/24/2021] [Indexed: 12/31/2022]
Abstract
The role of sex, race, and suicide method on recent increases in suicide mortality in the United States remains unclear. Estimating the age, period, and cohort effects underlying suicide mortality trends can provide important insights for the causal hypothesis generating process. We generated updated age-period-cohort effect estimates of recent suicide mortality rates in the US, examining the putative roles of sex, race, and method for suicide, using data from all death certificates in the US between 1999 and 2018. After designating deaths as attributable to suicide according to ICD-10 underlying cause of death codes X60-X84, Y87.0, and U03, we (i) used hexagonal grids to describe rates of suicide by age, period, and cohort visually and (ii) modeled sex-, race-, and suicide method-specific age, period, and cohort effects. We found that, while suicide mortality increased in the US between 1999 and 2018 across age, sex, race, and suicide method, there was substantial heterogeneity in age and cohort effects by method, sex, and race, with a first peak of suicide risk in youth, a second peak in older ages-specific to male firearm suicide, and increased rates among younger cohorts of non-White individuals. Our findings should prompt discussion regarding age-specific clinical firearm safety interventions, drivers of minoritized populations' adverse early-life experiences, and racial differences in access to and quality of mental healthcare.
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McKetta S, Prins SJ, Bates LM, Platt JM, Keyes KM. US trends in binge drinking by gender, occupation, prestige, and work structure among adults in the midlife, 2006-2018. Ann Epidemiol 2021; 62:22-29. [PMID: 34161795 DOI: 10.1016/j.annepidem.2021.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Rates of binge drinking have nearly doubled among US women ages 30-49 since 2006. Employment influences alcohol use and varies by the prestige and structure (e.g., authority, autonomy, expertise) of one's occupation. METHODS We examined trends in binge drinking among adults ages 30-49 in the labor force in 2006-2018 National Health Interview Surveys (N = 108,981) by occupation, work prestige (General Social Survey's occupational prestige score), work structure (occupational authority, autonomy, automation, expertise), and gender. We estimated odds of binge drinking by year with survey-weighted logistic regression controlled for sociodemographics, smoking, and disability. RESULTS In 2018, 30% of women and 43% of men reported binge drinking; drinking increased annually from 2006-2018 (OR for women = 1.08, OR for men = 1.03). Work status, prestige, and work structure modified the association. Women in high- (OR = 1.10, 95% CI: 1.09-1.12) versus low-prestige (OR = 1.05, 95% CI: 1.04-1.06) jobs had higher increases, as did men in high-prestige jobs (OR = 1.04, 95% CI: 1.03-1.05). Respondents in higher relative to lower authority, autonomy, and expertise jobs increased binge drinking. CONCLUSIONS Though all strata of workforce adults increased binge drinking, increases were concentrated among women in higher-status careers, implicating gendered shifts in labor as one determinant of recent national alcohol trends.
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Calvo E, Allel K, Staudinger UM, Castillo-Carniglia A, Medina JT, Keyes KM. Cross-country differences in age trends in alcohol consumption among older adults: a cross-sectional study of individuals aged 50 years and older in 22 countries. Addiction 2021; 116:1399-1412. [PMID: 33241648 PMCID: PMC8131222 DOI: 10.1111/add.15292] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/01/2020] [Accepted: 10/02/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Age-related changes in physiological, metabolic and medication profiles make alcohol consumption likely to be more harmful among older than younger adults. This study aimed to estimate cross-national variation in the quantity and patterns of drinking throughout older age, and to investigate country-level variables explaining cross-national variation in consumption for individuals aged 50 years and older. DESIGN Cross-sectional observational study using previously harmonized survey data. SETTING Twenty-two countries surveyed in 2010 or the closest available year. PARTICIPANTS A total of 106 180 adults aged 50 years and over. MEASUREMENTS Cross-national variation in age trends were estimated for two outcomes: weekly number of standard drink units (SDUs) and patterns of alcohol consumption (never, ever, occasional, moderate and heavy drinking). Human Development Index and average prices of vodka were used as country-level variables moderating age-related declines in drinking. FINDINGS Alcohol consumption was negatively associated with age (risk ratio = 0.98; 95% confidence interval = 0.97, 0.99; P-value < 0.001), but there was substantial cross-country variation in the age-related differences in alcohol consumption [likelihood ratio (LR) test P-value < 0.001], even after adjusting for the composition of populations. Countries' development level and alcohol prices explained 31% of cross-country variability in SDUs (LR test P-value < 0.001) but did not explain cross-country variability in the prevalence of heavy drinkers. CONCLUSIONS Use and harmful use of alcohol among older adults appears to vary widely across age and countries. This variation can be partly explained both by the country-specific composition of populations and country-level contextual factors such as development level and alcohol prices.
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Palamar JJ, Fitzgerald ND, Keyes KM, Cottler LB. Drug checking at dance festivals: A review with recommendations to increase generalizability of findings. Exp Clin Psychopharmacol 2021; 29:229-235. [PMID: 33600199 PMCID: PMC8282667 DOI: 10.1037/pha0000452] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Dance festival attendees are at high risk for consuming adulterated drugs. In recent years, drug checking studies have been conducted at various dance festivals to provide valuable harm reduction information to attendees regarding drug content. We conducted a review of the literature to determine the generalizability of findings to the target population of interest-festival attendees at risk for using adulterated drugs. Six published studies involving drug checking at festivals were reviewed. All relied on self-selected samples and male attendees were overrepresented based on previous research. Test methods, drugs tested, definitions of adulteration, and prevalence of adulteration varied across studies. Prevalence of detection of adulterants ranged from 11% to 55%. While the drug checking services described appear to have been beneficial for participants, results have limited generalizability to the target population. We recommend that researchers expand beyond the self-selection model in future studies and utilize recruitment methods that involve random sampling techniques such as systematic random sampling, stratified random sampling, or time-space sampling within festivals. We also recommend that individuals approached are surveyed for demographic characteristics, planned drug use at the festival, and willingness to test their drugs. These methods would help determine how representative the sample is compared to the target population and allow for more generalizable estimates. In conclusion, as these valuable harm reduction services expand, it may be possible to reach a wider portion of the population at risk and to obtain more generalizable estimates of engagement, adulteration, and reactions to learning one possesses adulterated drugs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Jager J, Keyes KM. Is substance use changing because of the COVID-19 pandemic? Conceptual and methodological considerations to delineating the impact of the COVID-19 pandemic on substance use and disorder. Addiction 2021; 116:1301-1303. [PMID: 33449443 PMCID: PMC8014674 DOI: 10.1111/add.15414] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/12/2020] [Accepted: 12/29/2020] [Indexed: 11/30/2022]
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Krueger RF, Hobbs KA, Conway CC, Dick DM, Dretsch MN, Eaton NR, Forbes MK, Forbush KT, Keyes KM, Latzman RD, Michelini G, Patrick CJ, Sellbom M, Slade T, South S, Sunderland M, Tackett J, Waldman I, Waszczuk MA, Wright AG, Zald DH, Watson D, Kotov R. Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): II. Externalizing superspectrum. World Psychiatry 2021; 20:171-193. [PMID: 34002506 PMCID: PMC8129870 DOI: 10.1002/wps.20844] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirical effort to address limitations of traditional mental disorder diagnoses. These include arbitrary boundaries between disorder and normality, disorder co-occurrence in the modal case, heterogeneity of presentation within dis-orders, and instability of diagnosis within patients. This paper reviews the evidence on the validity and utility of the disinhibited externalizing and antagonistic externalizing spectra of HiTOP, which together constitute a broad externalizing superspectrum. These spectra are composed of elements subsumed within a variety of mental disorders described in recent DSM nosologies, including most notably substance use disorders and "Cluster B" personality disorders. The externalizing superspectrum ranges from normative levels of impulse control and self-assertion, to maladaptive disinhibition and antagonism, to extensive polysubstance involvement and personality psychopathology. A rich literature supports the validity of the externalizing superspectrum, and the disinhibited and antagonistic spectra. This evidence encompasses common genetic influences, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, and treatment response. The structure of these validators mirrors the structure of the phenotypic externalizing superspectrum, with some correlates more specific to disinhibited or antagonistic spectra, and others relevant to the entire externalizing superspectrum, underlining the hierarchical structure of the domain. Compared with traditional diagnostic categories, the externalizing superspectrum conceptualization shows improved utility, reliability, explanatory capacity, and clinical applicability. The externalizing superspectrum is one aspect of the general approach to psychopathology offered by HiTOP and can make diagnostic classification more useful in both research and the clinic.
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Crowe CL, Domingue BW, Graf GH, Keyes KM, Kwon D, Belsky DW. Associations of Loneliness and Social Isolation with Healthspan and Lifespan in the US Health and Retirement Study. J Gerontol A Biol Sci Med Sci 2021; 76:1997-2006. [PMID: 33963758 DOI: 10.1093/gerona/glab128] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Loneliness and social isolation are emerging public health challenges for aging populations. METHODS We followed N=11,302 US Health and Retirement Study (HRS) participants aged 50-95 from 2006-2014 to measure persistence of experiences of loneliness and exposure to social isolation. We tested associations of longitudinal loneliness and social isolation phenotypes with disability, morbidity, mortality, and biological aging through 2018. RESULTS During follow-up, 18% of older adults met criteria for loneliness, with 6% meeting criteria at two or more follow-up assessments. For social isolation, these fractions were 21% and 8%. HRS participants who experienced loneliness and were exposed to social isolation were at increased risk for disease, disability, and mortality. Those experiencing persistent loneliness were at a 57% increased hazard of mortality compared to those who never experienced loneliness. For social isolation, the increase was 28%. Effect-sizes were somewhat larger for counts of prevalent activity limitations and somewhat smaller for counts of prevalent chronic diseases. Covariate adjustment for socioeconomic and psychological risks attenuated but did not fully explain associations. Older adults who experienced loneliness and were exposed to social isolation also exhibited physiological indications of advanced biological aging (Cohen's-d for persistent loneliness and social isolation=0.26 and 0.21, respectively). For loneliness, but not social isolation, persistence was associated with increased risk. CONCLUSION Deficits in social connectedness prevalent in a national sample of US older adults were associated with morbidity, disability, and mortality and with more advanced biological aging. Bolstering social connectedness to interrupt experiences of loneliness may promote healthy aging.
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Kaur N, Keyes KM, Hamilton AD, Chapman C, Livingston M, Slade T, Swift W. Trends in cannabis use and attitudes toward legalization and use among Australians from 2001-2016: an age-period-cohort analysis. Addiction 2021; 116:1152-1161. [PMID: 32949418 PMCID: PMC7972999 DOI: 10.1111/add.15271] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/13/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIMS Changes in cannabis legalization and availability in Australia necessitate monitoring use and attitudes. We estimated age-period-cohort effects of past-year cannabis use and attitudes toward criminalization and legalization. DESIGN Analysis of six waves of the Australian National Drug Strategy Household Survey (NDSHS) every 3 years (2001-2016). SETTING AND PARTICIPANTS The study was nationally representative of Australian households using multistage random sampling, totaling 145 168 respondents 18-79 years old. Data were collected using telephone, face-to-face, and drop-and-collect. Sample sizes per analysis varied based on data availability (~107 000-127 000 per model). MEASUREMENTS Six waves of data for past-year cannabis use (by sex and education), attitudes toward criminalization and legalization. FINDINGS Past-year cannabis use decreased in young adults ages 18-35 from 2001-2016 (25.1%-18.6%) and increased in middle adults ages 36-55 (8.6%-10.1%) and older adults ages 56-79 (0.6%-3.0%). We observed a positive period effect and negative cohort effect for recent cohorts for past-year use (e.g. 1955 cohort had 1.41 (95% CI: [1.11, 1.70]) increased log odds vs. 1998 cohort had -2.86 (95% CI: [-3.17, -2.55]) increased log odds) compared with the mean across years. Results were consistent by sex and varied by education. We observed a negative period effect for criminalization favorability (0.14 (95% CI: [0.003, 0.28]) increased log odds in 2001 vs. -0.31 (95% CI: [-0.45, -0.17]) increased log odds in 2016) and positive cohort effect for recent cohorts. Last, we observed a positive period effect for legalization support (-0.03 (95% CI: [-0.20, 0.14]) increased log odds in 2001 vs. 0.38 (95% CI: [0.22, 0.55]) increased log odds in 2016) and negative cohort effect for recent cohorts. CONCLUSION Cannabis use appears to be increasing in Australia among adults over 35, while decreasing among adolescents and young adults. Legalization support also appears to have been increasing since 2007, signaling discordance between use and attitudes among adolescents and young adults, and potentially predicting increases in use over time.
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Cerdá M, Krawczyk N, Hamilton L, Rudolph KE, Friedman SR, Keyes KM. A Critical Review of the Social and Behavioral Contributions to the Overdose Epidemic. Annu Rev Public Health 2021; 42:95-114. [PMID: 33256535 PMCID: PMC8675278 DOI: 10.1146/annurev-publhealth-090419-102727] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present trends in opioid overdose rates during this period and discuss how the proliferation of opioid prescribing to treat chronic pain, changes in the heroin and illegally manufactured opioid synthetics markets, and social factors, including deindustrialization and concentrated poverty, contributed to the rise of the overdose epidemic. We also examine how current policies implemented to address the overdose epidemic may have contributed to reducing prescription opioid overdoses but increased overdoses involving illegal opioids. Finally, we identify new directions for research to understand the causes and solutions to this critical public health problem, including research on heterogeneous policy effects across social groups, effective approaches to reduce overdoses of illegal opioids, and the role of social contexts in shaping policy implementation and impact.
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Kajeepeta S, Mauro PM, Keyes KM, El-Sayed AM, Rutherford CG, Prins SJ. Association between county jail incarceration and cause-specific county mortality in the USA, 1987-2017: a retrospective, longitudinal study. Lancet Public Health 2021; 6:e240-e248. [PMID: 33636104 PMCID: PMC8054445 DOI: 10.1016/s2468-2667(20)30283-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/03/2020] [Accepted: 11/19/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Mass incarceration has collateral consequences for community health, which are reflected in county-level health indicators, including county mortality rates. County jail incarceration rates are associated with all-cause mortality rates in the USA. We assessed the causes of death that drive the relationship between county-level jail incarceration and mortality. METHODS In this retrospective, longitudinal study, we assessed the association between county-level jail incarceration rates and county-level cause-specific mortality using county jail incarceration data (1987-2017) for 1094 counties in the USA obtained from the Vera Institute of Justice and cause-specific mortality data for individuals younger than 75 years in the total county population (1988-2018) obtained from the US National Vital Statistics System. We fitted quasi-Poisson models for nine common causes of death (cerebrovascular disease, chronic lower respiratory disease, diabetes, heart disease, infectious disease, malignant neoplasm, substance use, suicide, and unintentional injury) with county fixed effects, controlling for all unmeasured stable county characteristics and measured time-varying confounders (county median age, county poverty rate, county percentage of Black residents, county crime rate, county unemployment rate, and state incarceration rate). We lagged county jail incarceration rates by 1 year to assess the short-term, by 5 years to assess the medium-term, and by 10 years to assess the long-term associations of jail incarceration with premature mortality. FINDINGS A 1 per 1000 within-county increase in jail incarceration rate was associated with a 6·5% increase in mortality from infectious diseases (risk ratio 1·065, 95% CI 1·061-1·070), a 4·9% increase in mortality from chronic lower respiratory disease (1·049, 1·045-1·052), a 2·6% increase in mortality induced from substance use (1·026, 1·020-1·032), a 2·5% increase in suicide mortality (1·025, 1·020-1·029), and smaller increases in mortality from heart disease (1·021, 1·019-1·023), unintentional injury (1·015, 1·011-1·018), malignant neoplasm (1·014, 1·013-1·016), diabetes (1·013, 1·009-1·018), and cerebrovascular disease (1·010, 1·007-1·013) after 1 year. Associations between jail incarceration and cause-specific mortality rates weakened as time lags increased, but to a greater extent for causes of death with generally shorter latency periods (infectious disease and suicide) than for those with generally longer latency periods (heart disease, malignant neoplasm, and cerebrovascular disease). INTERPRETATION Jail incarceration rates are potential drivers of many causes of death in US counties. Jail incarceration can be harmful not only to the health of individuals who are incarcerated, but also to public health more broadly. Our findings suggest important points of intervention, including disinvestment from carceral systems and investment in social and public health services, such as community-based treatment of substance-use disorders. FUNDING US National Institute on Drug Abuse (National Institutes of Health).
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Pamplin JR, Kezios KL, Hayes-Larson E, Keyes KM, Susser ES, Factor-Litvak P, Link BG, Bates LM. Explaining the Black-white depression paradox: Interrogating the Environmental Affordances Model. Soc Sci Med 2021; 277:113869. [PMID: 33892418 DOI: 10.1016/j.socscimed.2021.113869] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 01/06/2023]
Abstract
The Environmental Affordances (EA) model posits that Black Americans' engagement with unhealthy behaviors (i.e. smoking, alcohol use, eating calorie-dense foods) to cope with stressor exposure may simultaneously account for their observed greater risk of chronic physical illness, and their observed equal or lesser prevalence of depression, relative to white Americans - the so-called "Black-white depression paradox." However, the specific mechanisms through which such effects might arise have been theorized and analyzed inconsistently across studies, raising concerns regarding the appropriateness of existing empirical tests of the model as well as the validity of the conclusions. We specify the two mechanisms most consistent with the EA model - 'Mediation-only' and 'Mediation and Modification' - and derive a priori predictions based on each. We systematically test these pathways using a subset of 559 participants of the Child Health and Development Study who were included in an adult follow-up study between 2010 and 2012 and self-identified as Black or white. Results failed to support either of the two mechanisms derived from the EA model, challenging the validity and utility of the model for explaining racial differences in depression; efforts to develop alternative hypotheses to explain the paradox are needed.
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Pillai A, Keyes KM, Susser E. Antidepressant prescriptions and adherence in primary care in India: Insights from a cluster randomized control trial. PLoS One 2021; 16:e0248641. [PMID: 33739982 PMCID: PMC7978355 DOI: 10.1371/journal.pone.0248641] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The World Health Organization recommends that treatment of depression in low and middle-income countries with a scarcity of psychiatrists could be done in primary care and should include prescription of antidepressant medications for moderate and severe depression. Little is known, however, about the actual practices of antidepressant prescription by primary care physicians in low and middle-income countries, nor about adherence by people receiving such prescriptions. In a large study of primary care clinics in Goa, India, we examined the relationship of actual to recommended prescribing practices for depression, among all patients who screened positive for common mental disorder. We also examined other patient and clinic characteristics associated with antidepressant prescription, and self-reported adherence over a one-month period. METHODS Patients attending 24 primary care clinics were screened for common mental disorders. Those who screened positive were eligible to enroll in a trial to assess the effectiveness of a collaborative stepped care (CSC) intervention for mental disorders. Physicians in the 12 intervention and 12 control clinics (usual care) were free to prescribe antidepressants and follow-up interviews were conducted at 2, 6 and 12 months. Screening results were shared with the physician, but they were blinded to the diagnosis generated later using a standardized diagnostic interview administered by a health counsellor. We categorized these later diagnoses as "moderate/severe depression", "mild depression or non-depression diagnosis", and "no diagnosis". We used a two-level hierarchical logistic regression model to examine diagnostic and other factors associated with antidepressant prescription and one-month adherence. RESULTS Overall, about 47% of screened positive patients (n = 1320) received an antidepressant prescription: 60% of those with moderate/severe depression, 48% of those with mild depression or non-depression diagnosis, and 31% with no diagnosis. Women (OR 1.29; 95%CI 1.04-1.60) and older adults (OR 1.80; 95%CI 1.32-2.47) were more likely to receive an antidepressant prescription. While the overall rate of antidepressant prescription was similar in clinics with and without CSC, patients without any diagnosis were more likely to receive a prescription (OR 2.20 95% CI 1.03-4.70) in the usual care clinics. About 47% of patients adhered to antidepressant treatment for one month or more and adherence was significantly better among older adults (OR 3.92; 95% CI 1.70-8.93) and those who received antidepressant as part of the CSC treatment model (OR 6.10 95% CI 3.67-10.14) compared with those attending the usual care clinic. CONCLUSION Antidepressants were widely prescribed following screening in primary care, but prescription patterns were in poor accord with WHO recommendations. The data suggest under-prescription for people with moderate/severe depression; over-prescription for people with mild depression or non-depression diagnoses; and over-prescription for people with no disorders. For all diagnoses adherence was low, especially in usual care clinics. To address these concerns, there is an urgent need to study and develop strategies in primary care practices to limit unnecessary antidepressant prescriptions, target prescription for those patients who clearly benefit, and to improve adherence to antidepressant treatment. ClinicalTrials.gov Identifier: NCT00446407.
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McKetta S, Morrison CN, Keyes KM. Trends in US Alcohol Consumption Frequency During the First Wave of the SARS-CoV-2 Pandemic. Alcohol Clin Exp Res 2021; 45:773-783. [PMID: 33587290 PMCID: PMC8014717 DOI: 10.1111/acer.14575] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 02/09/2021] [Indexed: 12/31/2022]
Abstract
Background The SARS‐CoV‐2 pandemic created disruptions and stressors which may have influenced alcohol consumption frequency trends. Varying COVID‐19 health burden and alcohol policies may have contributed to different consumption trends between states. The aim of this study is to assess trends in alcohol consumption and moderation by state of residence. Methods We examined trends in adult drinking days, during the first wave of the pandemic (March 10 to June 8) using longitudinal data from the Understanding America Study (N = 6,172 unique participants; N = 28,059 observations). Because state mandates were responsive to disease burden, we modeled the interaction of time by COVID‐19 burden, defined as whether the state had the median (or higher) daily incidence of COVID‐19 cases on the survey date, and state random effects. We controlled for individual sociodemographics, perceived personal/familial COVID‐19 burden, mental health symptomology, and risk avoidance. Results Drinking days increased throughout the duration (incidence risk ratio [IRR] for drinking per increase in one calendar day = 1.003, 95% CI 1.001, 1.004); trends were heterogeneous by disease burden, with individuals living in states with lower COVID‐19 burden increasing (IRR = 1.005, 95% CI 1.003, 1.007) faster than those living in states with higher COVID‐19 burden (IRR = 1.000, 95% CI 0.998, 1.002). Trends were heterogeneous between states, but there was no evidence of systematic geographic clustering of state trends. Conclusions Drinking days increased during the first months of the COVID‐19 pandemic, particularly among residents of states with lower disease burden.
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Prins SJ, McKetta S, Platt J, Muntaner C, Keyes KM, Bates LM. The Serpent of Their Agonies: Exploitation as Structural Determinant of Mental Illness. Epidemiology 2021; 32:303-309. [PMID: 33252438 PMCID: PMC7872213 DOI: 10.1097/ede.0000000000001304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Social stratification is a well-documented determinant of mental health. Traditional measures of stratification (e.g., socioeconomic status) reduce dynamic social processes to individual attributes downstream of mechanisms that generate stratification. In this study, we measure one process theorized to generate and reproduce social stratification-economic exploitation-and explore its association with mental health. METHODS Data are from the 1983 to 2017 waves of the Panel Study of Income Dynamics, a nationally representative cohort study (baseline N = 3059). We operationalized "unconcealed exploitation" as the percentage of individuals' labor income they were hypothetically not paid for productive hours. We ascertained psychologic distress and mental illness with the Kessler-6 (K6) scale. RESULTS We fit inverse probability-weighted marginal structural models and found that for each unit increase in unconcealed exploitation, psychologic distress increased by 1.6 points (95% confidence interval = 0.71, 2.5) on the K6 scale and the odds of mental illness tripled (odds ratio = 3.0, 95% confidence interval = 1.5, 6.1). Results were not driven entirely by overwork and were robust to different inverse probability-weighted estimation strategies and sensitivity analyses. CONCLUSIONS Exploitation is associated with mental illness. Focusing on exploitation rather than its consequences (e.g., socioeconomic status), shifts attention to a structural process that may be a more appropriate explanatory mechanism, and a more pragmatic intervention target, for mental illness.
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Keyes KM, Kandula S, Olfson M, Gould MS, Martínez-Alés G, Rutherford C, Shaman J. Suicide and the agent-host-environment triad: leveraging surveillance sources to inform prevention. Psychol Med 2021; 51:529-537. [PMID: 33663629 PMCID: PMC8020492 DOI: 10.1017/s003329172000536x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/14/2020] [Accepted: 01/06/2021] [Indexed: 12/11/2022]
Abstract
Suicide in the US has increased in the last decade, across virtually every age and demographic group. Parallel increases have occurred in non-fatal self-harm as well. Research on suicide across the world has consistently demonstrated that suicide shares many properties with a communicable disease, including person-to-person transmission and point-source outbreaks. This essay illustrates the communicable nature of suicide through analogy to basic infectious disease principles, including evidence for transmission and vulnerability through the agent-host-environment triad. We describe how mathematical modeling, a suite of epidemiological methods, which the COVID-19 pandemic has brought into renewed focus, can and should be applied to suicide in order to understand the dynamics of transmission and to forecast emerging risk areas. We describe how new and innovative sources of data, including social media and search engine data, can be used to augment traditional suicide surveillance, as well as the opportunities and challenges for modeling suicide as a communicable disease process in an effort to guide clinical and public health suicide prevention efforts.
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Keyes KM, Whitley R, Fink D, Santaella J, Pirkis J. The global impact of celebrity suicides: implications for prevention. World Psychiatry 2021; 20:144-145. [PMID: 33432751 PMCID: PMC7801848 DOI: 10.1002/wps.20761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Beaulieu E, DiGennaro C, Stringfellow E, Connolly A, Hamilton A, Hyder A, Cerdá M, Keyes KM, Jalali MS. Economic Evaluation in Opioid Modeling: Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:158-173. [PMID: 33518022 PMCID: PMC7864393 DOI: 10.1016/j.jval.2020.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 06/29/2020] [Accepted: 07/25/2020] [Indexed: 05/08/2023]
Abstract
OBJECTIVES The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature. METHODS A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study. RESULTS The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs. CONCLUSION The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.
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Chan CS, Sarvet AL, Basu A, Koenen K, Keyes KM. Associations of intimate partner violence and financial adversity with familial homelessness in pregnant and postpartum women: A 7-year prospective study of the ALSPAC cohort. PLoS One 2021; 16:e0245507. [PMID: 33449965 PMCID: PMC7810303 DOI: 10.1371/journal.pone.0245507] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 12/31/2020] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine whether emotional and physical intimate partner violence (IPV) and financial adversity increase risk of incident homelessness in pregnancy and the post-partum period. STUDY DESIGN Data were drawn from the Avon Longitudinal Study of Parents and Children, which starting in 1990 mailed questionnaires to 14,735 mothers in the UK, over 7 years from pregnancy onwards. Marginal structural models and multiple imputation were used to address time-varying confounding of the primary variables, testing for interaction between concurrent emotional/physical IPV and financial adversity, and adjusted for baseline age, ethnicity, education, partner's alcohol use, parity, depression, and social class. RESULTS Emotional IPV (HR 1.44 (1.13,1.84)), physical IPV (HR 2.05 (1.21,3.49)), and financial adversity (HR 1.59 (1.44,1.77)) each predicted a multiplicative increase in the discrete-time hazard of incident homelessness. We identified joint effects for concurrent emotional IPV and financial adversity (HR 2.09 (1.35,3.22)) and concurrent physical IPV and financial adversity (HR 2.79 (1.21,6.44)). We further identified a temporary decline in self-reported physical IPV among mothers during pregnancy and up to 8 months post-partum. CONCLUSIONS Emotional and physical IPV and financial adversity independently and jointly increase the risk of incident homelessness. The effects of emotional and physical IPV are comparable to or greater than the risk of financial adversity. Homelessness prevention policies should consider IPV victims as high-risk, regardless of financial status. Furthermore, self-reported physical IPV declines temporarily during pregnancy and up to 8 months post-partum. Screening for IPV in this period may miss high-risk individuals.
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Platt JM, Bates L, Jager J, McLaughlin KA, Keyes KM. Is the US Gender Gap in Depression Changing Over Time? A Meta-Regression. Am J Epidemiol 2021; 190:1190-1206. [PMID: 33423055 PMCID: PMC8484777 DOI: 10.1093/aje/kwab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 01/19/2023] Open
Abstract
The depression gap refers to higher rates of depression among women than men. Change in the depression gap over time might elucidate social causes of this disparity-such as unequal college attendance or employment status. We conducted a meta-regression analysis to estimate variation in the depression gap over time by age, accounting for potential sources of variation between studies. Electronic databases and bibliographies were searched for English-language studies from January 1980 through October 2019; 144 independent estimates from US-representative samples met selection criteria (n = 813,189). The depression gap was summarized as prevalence ratios among studies using diagnostic instruments and as standardized mean differences among symptom-based studies. Primary study measures were baseline study year (range, 1982-2017) and age (age groups ranging, in years, from 10-59 and 60 or older). Compared with respondents aged ≥60 years, depression prevalence was greater among respondents aged 10-19 (prevalence ratio = 1.26, 95% confidence interval: 1.02, 1.56). Over time, the depression gap did not change among adults, but it increased among adolescents (age-by-time interaction prevalence ratio = 1.05, 95% confidence interval: 1.01, 1.08). Results were similar for symptom-based studies. The present study finds no evidence of a change in the depression gender gap for US adults; however, the gap increased among adolescents. Greater attention to factors driving this widening disparity in adolescent depression is needed.
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Palamar JJ, Salomone A, Rutherford C, Keyes KM. Extensive Underreported Exposure to Ketamine Among Electronic Dance Music Party Attendees. J Gen Intern Med 2021; 36:235-237. [PMID: 31997140 PMCID: PMC7858731 DOI: 10.1007/s11606-020-05672-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 12/12/2019] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
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Grummitt LR, Kelly EV, Barrett EL, Keyes KM, Newton NC. Identifying Targets for Substance Use Prevention in Young People Exposed to Childhood Adversity: Protocol for a Systematic Review. JMIR Res Protoc 2020; 9:e22368. [PMID: 33275102 PMCID: PMC7748964 DOI: 10.2196/22368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 12/20/2022] Open
Abstract
Background Adverse childhood experiences are prevalent robust risk factors for the development of substance use problems. However, less is known about the causal mechanisms that explain these relationships. While directly preventing adverse childhood experiences is ideal, it is not always possible. In such cases, the mechanisms themselves may be amenable to intervention, allowing for the effective prevention of problematic substance use among children exposed to adversity. Identifying such mechanisms is therefore a critical step for efforts aiming to reduce the high individual and societal burdens associated with substance use globally. Objective This study aims to systematically identify and synthesize evidence on the modifiable mediators and moderators of the relationship between adverse childhood experiences and substance use outcomes in young people (age 10-24 years). Methods A systematic review will be conducted using PubMed, MEDLINE, PsycINFO, Web of Science, and CINAHL databases to determine the modifiable mediators and moderators of the relationship between adverse childhood experiences and substance use in young people. Data from the review will be qualitatively synthesized, unless we identify a sufficient number of studies (at least five) that examine the same type of adversity (eg, physical or sexual abuse) and the same mediator/moderator, in which case a quantitative synthesis (meta-analysis) will be conducted. If a quantitative synthesis is warranted, standardized effect estimates of the indirect (mediated) effect between adverse childhood experiences and substance use outcomes will be combined using a random-effects meta-analysis. Mediators/moderators will be grouped according to a socioecological perspective, using the four levels of individual, interpersonal, community, and public policy/culture. Results Electronic searches were completed in August 2019. A total of 4004 studies were included for screening after removing duplicates. After evaluating titles and abstracts against eligibility criteria, a further 3590 studies were excluded, leaving 415 studies for full-text screening. The results of the review are expected to be available by December 2020. Conclusions The mechanisms linking adverse childhood experiences and substance use outcomes in young people are vital targets for substance use prevention efforts. This review will provide evidence to inform the development of prevention strategies in order to interrupt the negative life trajectory that can begin with childhood adversity. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42020148773; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020148773 International Registered Report Identifier (IRRID) DERR1-10.2196/22368
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Keyes KM, Jager J, Platt J, Rutherford C, Patrick ME, Kloska DD, Schulenberg J. When does attrition lead to biased estimates of alcohol consumption? Bias analysis for loss to follow-up in 30 longitudinal cohorts. Int J Methods Psychiatr Res 2020; 29:1-9. [PMID: 32656917 PMCID: PMC7723204 DOI: 10.1002/mpr.1842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES Survey nonresponse has increased across decades, making the amount of attrition a focus in generating inferences from longitudinal data. Use of inverse probability weights [IPWs] and other statistical approaches are common, but residual bias remains a threat. Quantitative bias analysis for nonrandom attrition as an adjunct to IPW may yield more robust inference. METHODS Data were drawn from the Monitoring the Future panel studies [twelfth grade, base-year: 1976-2005; age 29/30 follow-up: 1987-2017, N = 73,298]. We then applied IPW imputation in increasing percentages, assuming varying risk differences [RDs] among nonresponders. Measurements included past-two-week binge drinking at base-year and every follow-up. Demographic and other correlates of binge drinking contributed to IPW estimation. RESULTS Attrition increased: 31.14%, base-year 1976; 61.33%, base-year 2005. The magnitude of bias depended not on attrition rate but on prevalence of binge drinking and RD among nonrespondents. The probable range of binge drinking among nonresponders was 12-45%. In every scenario, base-year and follow-up binge drinking were associated. The likely range of true RDs was 0.14 [95% CI: 0.11-0.17] to 0.28 [95% CI: 0.25-0.31]. CONCLUSIONS When attrition is present, the amount of attrition alone is insufficient to understand contribution to effect estimates. We recommend including bias analysis in longitudinal analyses.
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