Smoking and Suicide: A Meta-Analysis

Pathways linking bullying victimisation and suicidal behaviours among adolescents

AIMS

To examine the pathways explaining the association between bullying victimisation and suicidal behaviours among school-based adolescents.

METHODS

We used data from the Global School-based Student Health Survey from 90 countries conducted between 2003 and 2017. We applied multivariate regression and generalised structural equation models to examine the pathways.

RESULTS

Of 280,076 study adolescents, 32.4% experienced bullying and 12.1%, 11.1% and 10.9% reported suicidal ideation, suicidal planning and suicidal attempt, respectively. Adolescents who experienced bullying had higher rates of hunger (8.7% vs 5.0%), drinking soft drinks (44.0% vs 40.2%), truancy (35.8% vs 22.7%), smoking (14.0% vs 6.9%), alcohol consumption (19.9% vs 11.8%), peer victimisation (54.0% vs 25.6%), peer conflict (47.4% vs 20.1%), sleep disturbance (13.7% vs 5.6%), loneliness (18.1% vs 7.6%), no close friends (7.5% vs 5.2%), lack of peer support (64.9% vs 53.3%), lack of parental connectedness (67.0% vs 60.4%) and less parental bonding (64.1% vs 55.2%). Nearly one-fourth (18.7%) of the total association between bullying and suicidal ideation was mediated by loneliness. Similarly, sleep disturbances and alcohol consumption also mediated 4 to 9% of the association between bullying and suicidal behaviours.

CONCLUSION

This study suggests targeted policies and early implementation of interventional strategies focusing on addressing loneliness, sleep disturbance and alcohol consumption to reduce the risk of adverse suicidal behaviours among adolescents.

Smoking and Neuropsychiatric Disease-Associations and Underlying Mechanisms

Despite extensive efforts to combat cigarette smoking/tobacco use, it still remains a leading cause of global morbidity and mortality, killing more than eight million people each year. While tobacco smoking is a major risk factor for non-communicable diseases related to the four main groups—cardiovascular disease, cancer, chronic lung disease, and diabetes—its impact on neuropsychiatric risk is rather elusive. The aim of this review article is to emphasize the importance of smoking as a potential risk factor for neuropsychiatric disease and to identify central pathophysiological mechanisms that may contribute to this relationship. There is strong evidence from epidemiological and experimental studies indicating that smoking may increase the risk of various neuropsychiatric diseases, such as dementia/cognitive decline, schizophrenia/psychosis, depression, anxiety disorder, and suicidal behavior induced by structural and functional alterations of the central nervous system, mainly centered on inflammatory and oxidative stress pathways. From a public health perspective, preventive measures and policies designed to counteract the global epidemic of smoking should necessarily include warnings and actions that address the risk of neuropsychiatric disease.

Education tracking and adolescent smoking: a counterfactual and prospective cohort study

BACKGROUND AND AIMS

Adolescent smoking is a health issue and a potential health inequality issue. Education tracking, which is the placement of students into different school types and curricula based on their learning needs or abilities, is an indicator of inequality and risk factor of adolescent smoking. We examined the effect of educational tracking, dividing students into vocational and academic high school tracks, on adolescent smoking in Taiwan.

DESIGN AND SETTING

Longitudinal panel data, collected annually from 2000 over a period of 6 years as part of the Taiwan Youth project, were used.

PARTICIPANTS

Adolescents (aged 13-18 years) from the first six waves of the Taiwan Youth Project were included in the project, of whom 2147 had clear information on track attendance in 10th grade, control variables in 7th/8th grades and smoking behavior in 8th grade (before track placement). Post-track smoking behavior was measured at 10th, 11th and 12th grades.

MEASUREMENTS

The outcome variable was the self-reported smoking status in the 8th grade and between 10th and 12th grades. The treatment variable of interest was education tracking (vocational versus academic), which was conducted when the student was in 10th grade. Several important confounders were used for the difference-in-differences propensity score matching (e.g. parents' education and same classroom peer smoking).

FINDINGS

Placement of a student in the vocational track increased the proportion of smokers by 3.3 percentage points in 10th grade (P = 0.039). The effect was even more pronounced in 11th grade (6.2 percentage points; P = 0.000) and 12th grade (5.9 percentage points; P = 0.003).

CONCLUSIONS

Education tracking (placement of students into different school curricula based on learning needs or abilities) appears to be a risk factor for adolescent smoking among Taiwanese adolescents.

Sociodemographic and gender determinants of late-life suicide in users and non-users of antidepressants

Background

The treatment of depression is a main strategy for suicide prevention in older adults. Our aim was to examine factors related to suicide in older adults (75+) with and without antidepressant (AD) therapy.

Methods

A national population-based register study, including all Swedish residents aged ≥75 years between 2006 and 2014 (N = 1 413 806). A nested case–control design was used to investigate sociodemographic factors associated with suicide among users and non-users of ADs. Risk estimates were calculated in adjusted conditional logistic regression models for the entire cohort and by gender.

Results

In all, 1305 individuals died by suicide (70% men). The suicide rate in men who used ADs was over four times higher than women with such treatment. Being unmarried was a risk factor for suicide in men but not in women. Being born outside of Nordic countries was associated with increased suicide risk; a 3-fold risk increase was observed in non-Nordic women without AD treatment. Lower suicide risk was observed in blue-collar women who used ADs, whereas a higher risk was found in blue-collar men who did not.

Conclusions

Our differential findings on factors associated with suicide can offer clues for gender-specific preventive strategies that go beyond the healthcare sphere.

Proposal for the Inclusion of Tobacco Use in Suicide Risk Scales: Results of a Meta-Analysis

There is an association between smoking and suicide, even though the direction and nature of this relationship remains controversial. This meta-analysis aimed to evaluate the association between smoking and suicidal behaviours (ideation, planning, suicide attempts, and death by suicide). On 24 August 2020, we searched the PubMed, Cochrane library, Scopus, Web of Science, TRIP, and SCIENCE DIRECT databases for relevant articles on this topic. Twenty prospective cohort studies involving 2,457,864 participants were included in this meta-analysis. Compared with never smokers, former and current smokers had an increased risk of death by suicide (relative risk [RR] = 1.31; 95% CI [1.13, 1.52] and RR = 2.41; 95% CI [2.08, 2.80], respectively), ideation (RR = 1.35; 95% CI [1.31, 1.39] and RR = 1.84; 95% CI [1.21, 2.78]), and attempted suicide (RR = 1.27; 95% CI [0.56, 2.87] and RR = 1.71; 95% CI [0.73, 3.97]). Moreover, compared to never smokers, current smoker women (RR = 2.51; 95% CI [2.06-3.04] had an increased risk of taking their own life (Q = 13,591.53; p < 0.001) than current smoker men (RR = 2.06; 95% CI [1.62-2.62]. Furthermore, smoking exposure (former and current smokers) was associated with a 1.74-fold increased risk (95% CI [1.54, 1.96]) of suicidal behaviour (death by suicide, ideation, planning, or attempts). Thus, because of the prospective relationship between smoking and suicidal behaviours, smoking should be included in suicide risk scales as a useful and easy item to evaluate suicide risk.

Cigarette Smoking in an Acute Partial Hospital Program

ABSTRACT

This study explored demographic and clinical features, plus clinical outcomes, in a smoke-free acute partial hospital (PH) among current smokers, former smokers, and those who had never smoked (nonsmokers). Compared with nonsmokers, current smokers were younger and more likely to be unmarried and unpartnered, unemployed, or receiving disability benefits. They had more prior inpatient (IP) and PH episodes. They also had more problems with interpersonal relationships, mood lability, psychosis, and substance use. Compared with nonsmokers, current smokers were more likely to miss PH treatment days and drop out. They also had longer time to readmission to PH or IP. Former smokers resembled nonsmokers, except that former smokers also had a high rate of dropout. Changes in symptoms and functioning for patients who completed PH were the same among all groups. In an acute PH setting, smoking is a marker for psychiatric and psychosocial impairment plus treatment interruption.

Self-reported history of intensity of smoking is associated with risk factors for suicide among high school students

OBJECTIVE

To examine the relationship between current cigarette smoking patterns and three established risk factors for suicide using nationally representative data of high school students in the United States.

METHODS

We analyzed cross-sectional data from the national Youth Risk Behavior Surveillance Survey (YRBSS)-United States, 2017. Multivariable, logistic regressions examined the association between 3 cigarette smoking behaviors [i.e., past 30-day cigarette (n = 13,731), frequent (n = 1,093) and heavy (n = 880) smoking] and 3 risk factors for suicidal outcomes [feeling sad or hopeless, suicidal ideation, suicide plan] assessed over the previous year.

RESULTS

Among high school cigarette smokers, smoking 11 or more cigarettes per day (i.e., heavy smoking) was associated with 3.43 (95% CI: 1.69, 6.94) greater odds of reporting feeling sad or hopeless, 2.97 (95% CI: 1.60, 5.51) greater odds of reporting suicidal ideations, and 2.11 (95% CI: 1.34, 3.32) greater odds of reporting having ever planned a suicide attempt, controlling for covariates.

CONCLUSIONS

Our study shows that it is not simply cigarette smoking, but heavy cigarette smoking that is a risk factor for suicidal outcomes among adolescents.

PUBLIC HEALTH IMPLICATIONS

A comprehensive plan is needed to accommodate heavy adolescent smokers who are at increased suicidal risk.

Psychosocial Correlates of Suicidal Behavior among Adolescents under Confinement Due to the COVID-19 Pandemic in Aguascalientes, Mexico: A Cross-Sectional Population Survey

Background: Suicide and suicidal behaviors were already a global public health problem, producing preventable injuries and deaths. This issue may worsen due to the COVID-19 pandemic and may differentially affect vulnerable groups in the population, including children, adolescents, and young adults. The current study evaluated the association of affective variables (depression, hopelessness, and anxiety), drug use (alcohol, tobacco, and others), emotional intelligence, and attachment with suicidal behaviors. Methods: A state-wide survey included 8033 students (51% female, 49% male; mean age of 16 years) from science and technology high-schools using a standardized questionnaire that was distributed online. Multinomial logistic regression models tested associations between suicidal behaviors and several covariates. The analyses accommodated the complex structure of the sample. Results: Approximately 21% of all students reported a suicidal behavior (11% with a low-lethality suicide attempt, 6% with self-injuries, and 4% with a high-lethality suicide attempt). Variables associated with higher odds of suicidal behavior included: female sex, depression, hopelessness, anxiety, alcohol and tobacco use, childhood trauma, and having to self-rely as issues affecting attachment, and low self-esteem. Security of attachment was associated with lower odds of suicidal behavior. Conclusions: The complexity of suicidal behavior makes it clear that comprehensive programs need to be implemented.

Association of Cigarette Type Initially Smoked With Suicidal Behaviors Among Adolescents in Korea From 2015 to 2018

IMPORTANCE

Assessment of whether past electronic cigarette (e-cigarette) use or initiating smoking with e-cigarettes is associated with suicidal behaviors among adolescents is needed to inform future research and public health interventions.

OBJECTIVE

To evaluate the association between starting smoking with e-cigarettes or conventional cigarettes and suicidal behaviors among Korean adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data on adolescents in grades 7 through 12 who participated in the nationwide Korea Youth Risk Behavior Web-Based Survey between 2015 and 2018.

EXPOSURES

Type of cigarette initially smoked: electronic or conventional.

MAIN OUTCOMES AND MEASURES

Multiple logistic regression analysis was performed to examine the association between initial cigarette type and suicidal behaviors, including suicidal ideation and suicide planning and attempts. All participants completed questionnaires about their history of suicidal behavior and were categorized into groups according to the type of cigarette used at initiation of smoking and any subsequent change (or lack of change) in the type of cigarette used.

RESULTS

A total of 255 887 Korean adolescents (51.2% male; mean (SD) age, 15.0 [1.8] years) were included in the primary analysis. Among 131 094 male adolescents, 3310 boys (2.5%) initially used e-cigarettes and 27 368 boys (20.9%) initially used conventional cigarettes. Among 124 793 female adolescents, 952 girls (0.8%) initially used e-cigarettes and 9296 girls (7.4%) initially used conventional cigarettes. Of those who initially used e-cigarettes, 178 of 3310 boys (5.4%) and 134 of 952 girls (14.1%) attempted suicide. Of those who initially used conventional cigarettes, 946 of 27 368 boys (3.5%) and 911 of 9296 girls (9.8%) attempted suicide. Adolescents who initially used e-cigarettes had a higher risk of suicidal behaviors, including suicide planning (boys: adjusted odds ratio [AOR], 1.63 [95% CI, 1.40-1.89]; P < .001; girls: AOR, 1.55 [95% CI, 1.23-1.95]; P < .001) and suicide attempts (boys: AOR, 1.55 [95% CI, 1.28-1.87]; P < .001; girls, AOR, 1.64 [95% CI, 1.29-2.10]; P < .001) compared with those who initially used conventional cigarettes. Changing from e-cigarettes to conventional cigarettes was associated with a higher risk of suicide attempts among both boys (AOR, 1.89; 95% CI, 1.39-2.57; P < .001) and girls (AOR, 2.36; 95% CI, 1.53-3.64; P < .001) compared with changing from conventional cigarettes to e-cigarettes.

CONCLUSIONS AND RELEVANCE

In this study, the initial use of e-cigarettes vs conventional cigarettes was associated with suicidal behaviors among adolescents. In future research on the association of e-cigarette use with adolescent mental health and interventions for suicide prevention, the type of cigarette initially used and changing the cigarette type should be considered.

Parental divorce and offspring smoking and alcohol use: a systematic review and meta-analysis of observational studies

OBJECTIVE

This study was conducted to investigate the relationship between parental divorce and smoking and alcohol consumption in offspring, which is based on a systematic review method and ultimately meta-analysis. Method: In a systematic search, three databases were selected. The manuscripts were searched based on the keywords and the time limit for the search was published manuscripts in English until November 2020. For the relationship between parental divorce and smoking/alcohol use in offspring, one main analysis, and four analyses based on sex, study design, adjusted level, and continents were performed. Result: Forty-three studies were synthesized from the collection of manuscripts. The odds of smoking in offspring whose parents were separated was 1.45 (CI 1.37-1.54) and this odds in men was equal to 1.38 (CI 1.11-1.71; Z = 2.91; p = 0.004; I² = 81.5%) and in women, 1.78 (CI 1.51-2.10; Z = 6.88; p < 0.001; I² = 69.6%). The odds of alcohol use in offspring whose parents were separated was 1.43 (CI 1.15-1.77) and this odds in men was equal to 1.69 (CI 1.16-2.47; Z = 2.73; p = 0.006; I² = 99.6%) and in women 1.79 (CI 1.07-2.99). Discussion: The findings of the present study can be used in health-related policies, prevention, and clinical interventions. This study was a subject with limitations, also.

Prevalence of current and former smoking in industrial workers worldwide: a systematic review and meta-analysis

OBJECTIVES

One of the health problems in recent decades is the prevalence of smoking in the world. In this study, the global prevalence of smoking in industrial workers was investigated using meta-analysis.

METHOD

The method of the present study was a systematic review and meta-analysis. Three scientific sources, PubMed, Web of Science, and Scopus, were selected for the search, and these databases were searched until September 2020. Random effects method was used for the analysis and then the analysis was performed for the type of smoking (Current, Former), gender, and continent. Heterogeneity was examined in all analyses.

RESULT

A total of 88 studies were included in the meta-analysis. The prevalence of smoking in industrial workers was 41% also the confidence interval was 35-48%. The prevalence of current smoking in industrial workers was 39% also the confidence interval was 29-48%. The prevalence of former smoking in industrial workers was 18% also the confidence interval was 13-22%. I² heterogeneity test was 99.9%.

DISCUSSION

From the findings of the present study, it can be seen that industrial workers are more exposed to smoking compared to the general population, and this can put their health at greater risk.

How Does COVID-19 Affect the Neurobiology of Suicide?

PURPOSE OF REVIEW

The aim of this review was to analyze COVID-19 effect on the biological features of suicidal vulnerability and its interaction with suicide-related biological pathways. We carried out a narrative review of international publications on the interactions of COVID-19 with the biological bases of suicide.

RECENT FINDINGS

We hypothesize that SARS-CoV-2 interacts with multiple biological processes that underlie suicidal behavior, such as the renin-angiotensin system, nicotinic receptors, and central and systemic inflammation. Social distancing measures may also worsen subjective or objective social disconnection, thus increasing the risk of suicide. Interestingly, the drugs used to prevent suicide could be promising options to counteract brain damage caused by this coronavirus. SARS-CoV-2 interacts with multiple biological pathways involved in suicide and opens a new window for understanding the suicidal process. The development of suicide prevention treatments in the context of a pandemic may benefit from knowledge on these interactions.

Association of Tobacco Use and Exposure to Secondhand Smoke With Suicide Attempts Among Adolescents: Findings From 33 Countries

INTRODUCTION

There is evidence to suggest that tobacco use is associated with suicide attempts. However, it is unclear whether such an association can be extended to include secondhand smoke exposure. Using nationally representative data of school-attending adolescents from 33 countries, we examined the association of tobacco use and exposure to secondhand smoke with suicide attempts.

METHODS

We used data from the Global School-based Student Health Survey, a cross-sectional survey conducted among adolescents 12-15 years of age. We used logistic regression to estimate the country-specific associations. We then conducted random effect meta-analyses to obtain overall and country-income level pooled estimates. Lastly, we used logistic regression analyses to investigate a dose-response association of cigarette smoking and exposure to secondhand smoke with suicide attempts.

RESULTS

A positive association between tobacco use and suicide attempts among adolescents was present regardless of country-income level (low income: odds ratio 4.98, 95% CI: 3.11-7.96; lower middle income: 3.47, 2.91-4.15; upper middle income: 3.09, 2.75-3.47; and high income: 3.18, 2.63-3.84) and gender (boys: 3.28, 2.86-3.76; girls: 3.86, 3.30-4.51). Exposure to secondhand smoke was associated with suicide attempts, albeit weakly, among girls only (1.26, 1.14-1.39; boys: 1.00, 0.87-1.15). There was some evidence that a dose-response association of cigarette smoking and exposure to secondhand smoke with suicide attempts may only exist among girls.

CONCLUSIONS

Adolescents who use tobacco, and adolescent girls exposed to secondhand smoke were found to be more likely to attempt suicide; however, future longitudinal studies are warranted to assess causality.

IMPLICATIONS

Our findings indicate that routine screening of adolescents for tobacco use should be implemented globally, especially when assessing suicidal behaviors and risk. Future longitudinal and intervention studies are warranted to assess causality and whether prevention efforts such as tobacco control interventions and programmes targeting tobacco use and exposure to secondhand smoke among adolescents could ultimately lead to a reduction in the occurrence of suicide attempts.

Examining the effect of smoking on suicidal ideation and attempts: triangulation of epidemiological approaches

BACKGROUND

Previous literature has demonstrated a strong association between cigarette smoking, suicidal ideation and suicide attempts. This association has not previously been examined in a causal inference framework and could have important implications for suicide prevention strategies.

AIMS

We aimed to examine the evidence for an association between smoking behaviours (initiation, smoking status, heaviness, lifetime smoking) and suicidal thoughts or attempts by triangulating across observational and Mendelian randomisation analyses.

METHOD

First, in the UK Biobank, we calculated observed associations between smoking behaviours and suicidal thoughts or attempts. Second, we used Mendelian randomisation to explore the relationship between smoking and suicide attempts and ideation, using genetic variants as instruments to reduce bias from residual confounding and reverse causation.

RESULTS

Our observational analysis showed a relationship between smoking behaviour, suicidal ideation and attempts, particularly between smoking initiation and suicide attempts (odds ratio, 2.07; 95% CI 1.91-2.26; P < 0.001). The Mendelian randomisation analysis and single-nucleotide polymorphism analysis, however, did not support this (odds ratio for lifetime smoking on suicidal ideation, 0.050; 95% CI -0.027 to 0.127; odds ratio on suicide attempts, 0.053; 95% CI, -0.003 to 0.110). Despite past literature showing a positive dose-response relationship, our results showed no clear evidence for a causal effect of smoking on suicidal ideation or attempts.

CONCLUSIONS

This was the first Mendelian randomisation study to explore the effect of smoking on suicidal ideation and attempts. Our results suggest that, despite observed associations, there is no clear evidence for a causal effect.

Educational attainment reduces the risk of suicide attempt among individuals with and without psychiatric disorders independent of cognition: a bidirectional and multivariable Mendelian randomization study with more than 815,000 participants

Rates of suicidal behavior are increasing in the United States and identifying causal risk factors continues to be a public health priority. Observational literature has shown that educational attainment (EA) and cognitive performance (CP) influence suicide attempt risk; however, the causal nature of these relationships is unknown. Using summary statistics from genome-wide association studies (GWAS) of EA, CP, and suicide attempt risk with > 815,000 combined white participants of European ancestry, we performed multivariable Mendelian randomization (MR) to disentangle the effects of EA and CP on attempted suicide. In single-variable MR (SVMR), EA and CP appeared to reduce suicide attempt risk (EA odds ratio (OR) per standard deviation (SD) increase in EA (4.2 years), 0.524, 95% CI, 0.412-0.666, P = 1.07 × 10-7; CP OR per SD increase in standardized score, 0.714, 95% CI, 0.577-0.885, P = 0.002). Conversely, bidirectional analyses found no effect of a suicide attempt on EA or CP. Using various multivariable MR (MVMR) models, EA seems to be the predominant risk factor for suicide attempt risk with the independent effect (OR, 0.342, 95% CI, 0.206-0.568, P = 1.61 × 10-4), while CP had no effect (OR, 1.182, 95% CI, 0.842-1.659, P = 0.333). In additional MVMR analyses accounting simultaneously for potential behavioral and psychiatric mediators (tobacco smoking; alcohol consumption; and self-reported nerves, tension, anxiety, or depression), the effect of EA was little changed (OR, 0.541, 95% CI, 0.421-0.696, P = 3.33 × 10-6). Consistency of results across complementary MR methods accommodating different assumptions about genetic pleiotropy strengthened causal inference. Our results show that even after accounting for psychiatric disorders and behavioral mediators, EA, but not CP, may causally influence suicide attempt risk among white individuals of European ancestry, which could have important implications for health policy and programs aimed at reducing the increasing rates of suicide. Future work is necessary to examine the EA-suicide relationship populations of different ethnicities.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 1. Risk factors, protective factors, and assessment

Suicide is a global public health problem that causes the loss of more than 800,000 lives each year, principally among young people. In Brazil, the average mortality rate attributable to suicide is approximately 5.23 per 100,000 population. Although many guidelines have been published for the management of suicidal behavior, to date, there are no recent guidelines based on the principles of evidence-based medicine that apply to the reality of suicide in Brazil. The objective of this work is to provide key guidelines for managing patients with suicidal behavior in Brazil. This project involved 11 Brazilian psychiatry professionals selected by the Psychiatric Emergencies Committee (Comissão de Emergências Psiquiátricas) of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. For the development of these guidelines, 79 articles were reviewed (from 5,362 initially collected and 755 abstracts). In this review, we present definitions, risk and protective factors, assessments, and an introduction to the Safety Plan.

Systematic review registry number: CRD42020206517

Prevalence and effects of suicidal ideation diagnosis code position in claims on readmission rate estimates

BACKGROUND

Suicidal ideation (SI) is a major health concern in children, adolescents, and young adults (CAYA) population. Inaccurate estimates of SI-related hospital readmission rates may contribute to inappropriate allocation of resources for the prevention of future readmissions. The estimation of these readmission rates using claims data may be sensitive to the diagnosis code position used to establish analytic cohorts.

OBJECTIVE

To examine the prevalence and effects of SI diagnosis code position in claims on 30-day readmission rates using the Nationwide Readmissions Database (NRD).

METHODS

This was a cross-sectional study using the NRD (2010-2015). We established six cohorts of hospitalized CAYA (5-24 years old) with a diagnosis of SI based on different combinations of SI diagnosis code (ICD-9 code V62.84) positions in claims. Thirty-day hospital readmission rates following an index SI discharge were estimated for each cohort. We tested the null hypothesis that hospital readmission rates following an index SI discharge are not sensitive to diagnosis code positions using a test for equality of proportions between the predefined SI cohorts.

RESULTS

The prevalence of SI diagnosis codes increased yearly from 2.9% in 2010 to 5.8% in 2015. SI hospital readmission rates ranged from 0 to 41.1 per 1000 index events based on cohort definitions (i.e. diagnosis code positions). We rejected the null hypothesis that SI-related readmission rates are not sensitive to diagnosis code positions.

CONCLUSION

SI-related readmission rate estimates are sensitive to SI diagnosis code positions. Determining appropriate diagnostic positions can further improve readmission analyses for SI and its applications in healthcare policies.

Smoking, obesity, and their co-occurrence in the U.S. military veterans: results from the national health and resilience in veterans study

BACKGROUND

Smoking and obesity are major public health concerns, though little is known about the mental and physical health burden of co-occurring obesity and smoking.

METHODS

Using a nationally representative sample of U.S. military veterans, we examined the prevalence of mental and physical co-morbidities, physical and mental functioning, and quality of life between obese only; smoking only; and obese smokers.

RESULTS

Among current smokers, 31.7% were obese; among obese veterans, 16.4% were current smokers; and in the total sample, 5.4% were obese and current smokers. Relative to the obese-only group, obese smokers were more likely to be younger, male, non-white, non-married, unemployed and VA-served, and have lower household incomes. These also reported higher levels of perceived stress and trauma and were more likely to endorsed current suicidal ideation and lifetime suicide attempts (odds ratio [OR]=2.0), medical (2.3<=OR<=3.9) and psychiatric (1.5<=OR<=2.9) comorbidities, and lower overall health status and quality of life. Compared to the smoking-only group, obese smokers were more likely to endorse current suicidal ideation (OR=2.0) and nicotine dependence (OR=1.5), and reported poorer physical health and overall quality of life. Analyses were adjusted for sociodemographic and military characteristics.

LIMITATIONS

The cross-sectional study design precludes causal inference.

CONCLUSIONS

These findings suggest that co-occurring obesity and smoking is associated with substantial mental and physical health burden in U.S. veterans. Collectively, they underscore the importance of multicomponent interventions targeting, obesity, smoking, and co-occurring issues, such as trauma and internalizing disorders, in this population.

Associations of cigarette smoking with psychiatric disorders: evidence from a two-sample Mendelian randomization study

We conducted a two-sample Mendelian randomization study to determine the association of smoking initiation with seven psychiatric disorders. We used 353 independent single-nucleotide polymorphisms associated with cigarette smoking initiation as instrumental variables at genome-wide significance threshold (p < 5 × 10⁻⁸) from a recent genome-wide association study in 1,232,091 European-origin participants. Summary-level data for seven psychiatric disorders, including anxiety, bipolar disorder, insomnia, major depressive disorder, posttraumatic stress disorder, suicide attempts, and schizophrenia, was obtained from large genetic consortia and genome-wide association studies. The odds ratios of genetically predicted smoking initiation were 1.96 for suicide attempts (95% CI 1.70, 2.27; p = 4.5 × 10⁻²⁰), 1.69 for post-traumatic stress disorder (95% CI 1.32, 2.16; p = 2.5 × 10⁻⁵), 1.54 for schizophrenia (95% CI 1.35, 1.75; p = 1.6 × 10⁻¹⁰), 1.41 for bipolar disorder (95% CI 1.25, 1.59; p = 1.8 × 10⁻⁸), 1.38 for major depressive disorder (95% CI 1.31, 1.45; p = 2.3 × 10⁻³⁸), 1.20 for insomnia (95% CI 1.14, 1.25; p = 6.0 × 10⁻¹⁴) and 1.17 for anxiety (95% CI 0.98, 1.40; p = 0.086). Results of sensitivity analyses were consistent and no horizontal pleiotropy was detected in MR-Egger analysis. However, the associations with suicide attempts, schizophrenia, bipolar disorder, and anxiety might be related to possible reverse causality or weak instrument bias. This study found that cigarette smoking was causally associated with increased risks of a number of psychiatric disorders. The causal effects of smoking on suicide attempts, schizophrenia, bipolar disorder and anxiety needs further research.

The top six risky behaviors among Iranian university students: a national survey

BACKGROUND

Multiple risk-taking behaviors are associated with increased risk of poor educational attainment, morbidity and premature mortality. This study involved a large representative sample of Iranian university students addressing multiple risk behaviors and associated factors.

METHODS

This cross-sectional study included 4261 participants, involving 13 medical universities throughout the country in 2017. The following six risky behaviors were addressed: (a) smoking cigarettes during the past month, (b) using some kinds of illicit drugs during the past month, (c) drinking alcohol during the past month, (d) engaging unprotected sex during the past year, (e) having suicidal ideation during the past month or attempting suicide in the past year, (f) and Internet addiction. The 20-item internet addiction test and the 28-item general health questionnaire were used.

RESULTS

Almost 37.3% of the participants engaged in at least one out of six risky behaviors. The prevalence of Internet addiction was 24.5%, cigarette smoking 13.5%, alcohol use 7.8%, illicit drug abuse 4.9%, unprotected sex 7.8%, suicidal ideation 7.4%, attempting suicide 1.7% and general health problems 38.9%.

CONCLUSION

A majority of the Iranian university students studied engaged in at least one risky behavior. Engaging in one risky behavior increases the risk of engaging in other risk-taking behaviors.

Determinants of Suicidality in the European General Population: A Systematic Review and Meta-Analysis

Close to one million people commit suicide each year, with suicidal attempts being the main risk factor for suicide. The aim of this systematic review and meta-analysis is to achieve a greater understanding of suicidality in the general population of Europe by studying associated factors and their statistical significance with suicidality, as well as the effect of the temporal moment in which suicidality is observed in a relationship. A search strategy was carried out in electronic databases: Proquest's Psychology Database, Scopus, PsycINFO, Medline and Embase. Odds ratios (ORs), publication bias, influential studies on heterogeneity and analysis moderators were calculated. Twenty-six studies were included after meeting the inclusion criteria. Factors statistically associated with suicidality are female gender, age over 65 years, unemployment, low social support, adulthood adversity, childhood adversity, family history of mental disorder, any affective disorder, major depression, anxiety/stress/somatoform disorders, tobacco and substance use, any mental disorder and body mass index. As a limitation, a high heterogeneity between studies was found. Factors associated with suicidality in the general population are relevant for understanding the suicidal phenomenon.

Handgun Ownership and Suicide in California

BACKGROUND

Research has consistently identified firearm availability as a risk factor for suicide. However, existing studies are relatively small in scale, estimates vary widely, and no study appears to have tracked risks from commencement of firearm ownership.

METHODS

We identified handgun acquisitions and deaths in a cohort of 26.3 million male and female residents of California, 21 years old or older, who had not previously acquired handguns. Cohort members were followed for up to 12 years 2 months (from October 18, 2004, to December 31, 2016). We used survival analysis to estimate the relationship between handgun ownership and both all-cause mortality and suicide (by firearm and by other methods) among men and women. The analysis allowed the baseline hazard to vary according to neighborhood and was adjusted for age, race and ethnic group, and ownership of long guns (i.e., rifles or shotguns).

RESULTS

A total of 676,425 cohort members acquired one or more handguns, and 1,457,981 died; 17,894 died by suicide, of which 6691 were suicides by firearm. Rates of suicide by any method were higher among handgun owners, with an adjusted hazard ratio of 3.34 for all male owners as compared with male nonowners (95% confidence interval [CI], 3.13 to 3.56) and 7.16 for female owners as compared with female nonowners (95% CI, 6.22 to 8.24). These rates were driven by much higher rates of suicide by firearm among both male and female handgun owners, with a hazard ratio of 7.82 for men (95% CI, 7.26 to 8.43) and 35.15 for women (95% CI, 29.56 to 41.79). Handgun owners did not have higher rates of suicide by other methods or higher all-cause mortality. The risk of suicide by firearm among handgun owners peaked immediately after the first acquisition, but 52% of all suicides by firearm among handgun owners occurred more than 1 year after acquisition.

CONCLUSIONS

Handgun ownership is associated with a greatly elevated and enduring risk of suicide by firearm. (Funded by the Fund for a Safer Future and others.).

Application of group smoothly clipped absolute deviation method in identifying correlates of psychiatric distress among college students

BACKGROUND

College students are at an increased risk of psychiatric distress. So, identifying its important correlates using more reliable statistical models, instead of inefficient traditional variable selection methods like stepwise regression, is of great importance. The objective of this study was to investigate correlates of psychiatric distress among college students in Iran; using group smoothly clipped absolute deviation method (SCAD).

METHODS

A number of 1259 voluntary college students participated in this cross-sectional study (Jan-May 2016) at Hamadan University of Medical Sciences, Iran. The data were collected using a self-administered questionnaire consisting of demographic information, a behavioral risk factors checklist and the GHQ-28 questionnaire (with a cut-off of 23 to measure psychiatric distress, recommended by the Iranian version of the questionnaire). Penalized logistic regression with a group-SCAD regularization method was used to analyze the data (α = 0.05).

RESULTS

The majority of students were aged 18-25 (87.61%), and 60.76% of them were female. About 41% of students had psychiatric distress. Significant correlates of psychiatric distress among college students selected by group-SCAD included the average grade, educational level, being optimistic about future, having a boy/girlfriend, having an emotional breakup, the average daily number of cigarettes, substance abusing during previous month and having suicidal thoughts ever (P < 0.05).

CONCLUSIONS

Penalized logistic regression methods such as group-SCAD and group-Adaptive-LASSO should be considered as plausible alternatives to stepwise regression for identifying correlates of a binary response. Several behavioral variables were associated with psychological distress which highlights the necessity of designing multiple factors and behavioral changes in interventional programs.

An evaluation of suicidal risk in bipolar patients with comorbid posttraumatic stress disorder

BACKGROUND

While bipolar disorder (BD) and posttraumatic stress disorder (PTSD) frequently co-occur and individually have a higher risk of suicide compared to the general population, few studies have examined the impact of comorbid PTSD on suicidal ideation in patients with BD.

METHODS

We analyzed baseline data from the Clinical and Health Outcomes Initiative in Comparative Effectiveness for bipolar disorder study (Bipolar CHOICE), a 6-month, pharmacological comparative effectiveness trial of individuals with BD. Bipolar CHOICE enrolled 482 individuals. A hierarchical multiple regression analysis assessed whether comorbid PTSD was associated with increased suicidal ideation as assessed by the Concise Health Risk Tracking Scale (CHRT) total and factor scores, while controlling for common correlates of suicidal ideation in this population such as a current major depressive episode, comorbid anxiety disorders, severity of illness and previous suicide attempts.

RESULTS

Consistent with our hypothesis, diagnosis of comorbid PTSD was a significant predictor of the CHRT total score (β=2.59, p=.03). Comorbid PTSD was also a significant predictor of the CHRT propensity factor (β=2.32, adjusted p=.04), but was not a significant predictor of the active suicidal thoughts factor. Additionally, all participants with comorbid PTSD (N = 58) endorsed current suicidal ideation (p=.005) and were more likely to have had a previous suicide attempt (p<.001) compared to those without PTSD.

LIMITATIONS

Generalizability beyond outpatient settings is limited, mixed affective states were not assessed, and analyses were cross-sectional.

CONCLUSIONS

Patients have an increased risk of suicidal ideation when PTSD is comorbid with BD.

Cigarette smoking dose-response and suicidal ideation among young people in Nepal: a cross-sectional study

Background

Worldwide, tobacco smoking is a major risk factor for morbidity and early mortality among adult population. The present study aimed to find out the association between current smoking and suicidal ideation among young people in Nepal.

Materials and Methods

A cross-sectional questionnaire-based survey was carried out among 452 youths from Pokhara, Nepal. The present study included both genders (age 18-24 years) who were smokers as well as non-smokers.

Results

Across the study period, 452 participants were identified after matching for age, and sex (226 in the smoking group and 226 in the non-smoking group). The mean age of participants was 21.6±1.2 years and 58.8% were males. The overall rate of suicidal ideation in our cohort was 8.9%. Smokers were slightly more likely to report suicidal ideation than non-smokers (aOR 1.12). The risk of developing suicidal ideation was 3.56 (95% CI 1.26-10.09) times more in individuals who smoked greater than 3.5 cigarettes per week (p=0.01).

Conclusion

The rate of suicidal ideation was slightly higher among smokers and a dose-response relationship was identified with the number of cigarettes smoked per week. Being aware of the link between smoking and suicidal ideation may help health care professionals working with young people to address more effectively the issues of mental well-being and thoughts about suicide.

Modifiable risk and protective factors for anxiety disorders among adults: A systematic review

Anxiety disorders are highly prevalent in the general population and associated with high rates of impairment and disability. This burden highlights the need to identify risk factors that individuals can modify without professional intervention. A systematic review was conducted to identify studies that examined modifiable risk and protective factors for anxiety disorders among adults in the general population. Searches were conducted in PubMed, PsycINFO and MEDLINE using medical subject headings and text words related to risk factors, protective factors, and each anxiety disorder. Screening, data extraction, and quality assessment were performed by three study authors. Modifiable risk and protective factors from 19 studies across seven countries were identified. Risk factors identified included cigarette smoking, alcohol use, cannabis use, negative appraisals of life events, avoidance, and occupational factors. Protective factors included social support, coping, and physical activity. Cigarette smoking was the most studied risk factor. Support was found for cigarette smoking as a risk factor for agoraphobia and panic disorder. Mixed results were found for generalized anxiety disorder and specific phobia. Across disorders, smoking frequency was associated with greater risk. Results indicate an important gap in the literature in that few studies have examined modifiable risk factors for anxiety disorders.

Substance use disorders and risk of suicide in a general US population: a case control study

Background

Prior research suggests that substance use disorders (SUDs) are associated with risk of suicide mortality, but most previous work has been conducted among Veterans Health Administration patients. Few studies have examined the relationship between SUDs and suicide mortality in general populations. Our study estimates the association of SUDs with suicide mortality in a general US population of men and women who receive care across eight integrated health systems.

Methods

We conducted a case–control study using electronic health records and claims data from eight integrated health systems of the Mental Health Research Network. Participants were 2674 men and women who died by suicide between 2000–2013 and 267,400 matched controls. The main outcome was suicide mortality, assessed using data from the health systems and confirmed by state death data systems. Demographic and diagnostic data on substance use disorders and other health conditions were obtained from each health system. First, we compared descriptive statistics for cases and controls, including age, gender, income, and education. Next, we compared the rate of each substance use disorder category for cases and controls. Finally, we used conditional logistic regression models to estimate unadjusted and adjusted odds of suicide associated with each substance use disorder category.

Results

All categories of substance use disorders were associated with increased risk of suicide mortality. Adjusted odds ratios ranged from 2.0 (CI 1.7, 2.3) for patients with tobacco use disorder only to 11.2 (CI 8.0, 15.6) for patients with multiple alcohol, drug, and tobacco use disorders. Substance use disorders were associated with increased relative risk of suicide for both women and men across all categories, but the relative risk was more pronounced in women.

Conclusions

Substance use disorders are associated with significant risk of suicide mortality, especially for women, even after controlling for other important risk factors. Experiencing multiple substance use disorders is particularly risky. These findings suggest increased suicide risk screening and prevention efforts for individuals with substance use disorders are needed.

Insomnia Is Associated With Frequency of Suicidal Ideation Independent of Depression: A Replication and Extension of Findings From the National Health and Nutrition Examination Survey

OBJECTIVE

Insomnia is associated with suicidality, although the mechanisms of this association are unclear. This study sought to replicate previous findings showing that insomnia symptoms but not sleep duration are associated with frequency of suicidal ideation in adults. We further investigated whether depression or sleep duration moderates the association between insomnia symptoms and frequency of suicidal ideation.

MATERIALS AND METHODS

We used the 2005-2006 cycle of the National Health and Nutrition Examination Survey to replicate previously reported findings from the 2007-2008 cycle. We used ordered logistic regression to determine whether insomnia symptoms were associated with frequency of suicidal ideation independently of depression and other potential confounds. To extend these findings, we tested whether depression or sleep duration moderated the association between insomnia symptoms and frequency of suicidal ideation. We further replicated these findings in parallel analyses using the combined data from the 2005-2006 and 2007-2008 cycles.

RESULTS

This study replicated previous results showing that insomnia symptoms are associated with frequency of suicidal ideation in the NHANES 2005-2006 cycle (OR = 1.09, p < 0.05), even after adjusting for potentially confounding variables, including depression. Neither depression nor sleep duration moderated this association. Difficulty with sleep maintenance insomnia symptoms were most robustly associated with frequency of suicidal ideation (OR ≥ 1.97, p < 0.05). Sleep duration was not robustly associated with suicidal ideation.

CONCLUSIONS

In this study, we found that insomnia symptoms were uniquely associated with frequency of suicidal ideation. This association cannot be explained by the shared association with depression or sleep duration.

Exploring the Association between Suicidality and Smoking Behavior among School-Based Children in Lao People's Democratic Republic (PDR)

This study examines the relationship between suicidality and smoking behavior. Specifically, it examines how and the degree to which suicide ideation and plan are associated with the probability of being a regular smoker among school-based children. Data come from Lao Student Health Survey (2017), a project funded by the National Research Foundation of Korea. Using primary hierarchically nested data (students clustered in classrooms across schools), we investigate the complex interplay between suicidality and smoking behavior in Lao PDR, a low-income country located in Southeast Asia. Results from fitting two-level random intercept models show that net of controls (e.g., gender, age, parental regulation, self-rated health, household SES), the likelihood of daily smoking is higher among students who have seriously considered committing suicide or have planned a suicide attempt. Controlling for individual-level factors, significant classroom-level contextual effects are also found with respect to peer relations. Finally, we observe a cross-level interaction: the positive association between suicide intent and odds of smoking is weaker in classrooms with better peer relations.

Suicide Attempts and Contributing Factors among South and North Korean-Family Youth Using the Korean Youth Risk Behavior Web-based Survey

Objectives:

There is an increasing number of North Korean adolescents in South Korea. These adolescents need clinical attention as they experience a high risk of suicidal behavior because of the childhood adversity and acculturative challenges that they face before and after arriving in South Korea. This study assessed the risk of suicide attempts among North Korean adolescents compared to South Korean adolescents, and investigated the contributing factors for each group.

Methods:

We used data from the Korean Youth Risk Behavior Web-Based Survey (KYRBS) spanning 2011 to 2018, in which 404 adolescents had a father and/or mother who was a North Korean native. Data on 1,212 propensity-matched South Korean adolescents were extracted from the 2011 to 2018 KYRBS. Prevalence was calculated and compared by group. Separate odds ratios were calculated by group.

Results:

The North Korean group had a significantly higher suicide attempt rate [unadjusted odds ratio (OR)=8.27; adjusted OR=8.45]. Multivariate analysis indicated that having a low or high socioeconomic status and depressive symptoms were significantly associated with suicide attempts in North Korean adolescents, while being female, having a high socioeconomic status, alcohol use, and depressive symptoms were significantly related to suicide attempts in South Korean adolescents.

Conclusion:

The results found similarities and differences in the factors associated with the likelihood of suicide attempts in the two groups. From these results, different approaches are needed when planning interventions for each group.

Thiazide Use and Fracture Risk: An updated Bayesian Meta-Analysis

The association between thiazide use and fracture risk is still controversial. We conducted an updated meta-analysis on the association between thiazide use and fracture risk. We systematically searched PubMed, Embase, and Cochrane library databases for all types of human studies, including observational and experimental studies that were published up until July 2019. We also manually searched the reference lists of relevant studies. The pooled relative risks (RRs) with 95% credible interval (CrI) were calculated using a Bayesian hierarchical random effect model. A total of 19 case-control (N = 496,568 subjects) and 21 cohort studies (N = 4,418,602 subjects) were included in this meta-analysis. The pooled RR for fractures associated with thiazide use was 0.87 (95% CrI: 0.70–0.99) in case-control and 0.95 (95% CrI: 0.85–1.08) in cohort studies. The probabilities that thiazide use reduces any fracture risk by more than 0% were 93% in case-control studies and 72% in cohort studies. Significant heterogeneity was found for both case-control (p < 0.001, I² = 75%) and cohort studies (p < 0.001, I² = 97.2%). Thiazide use was associated with reduced fracture risk in case-control studies, but not in cohort studies. The associations demonstrated in case-control studies might be driven by inherent biases, such as selection bias and recall bias. Thus, thiazide use may not be a protective factor for fractures.

Systematic review and meta-analysis of the association between smoking and the incidence of frailty

BACKGROUND AND OBJECTIVE

Cigarette smoking is one of the main causes of health problems in the world and can also lead to an increased risk of frailty. Our goal is to perform a systematic review and meta-analysis of the relationship between smoking and frailty.

METHODS

Researchers searched PubMed, Scopus, Google Scholar and Research Gate by using keywords through December 2018. Eligible articles were merged and a meta-analysis was conducted using the random effects method. Finally an analysis was done based on smoking status, and publication bias was assessed as well.

RESULTS

The population analyzed comprised 61,905 people. The risk ratio (RR) of frailty based on smoking was 1.22 with a confidence interval (CI) of 1.12-1.33 (p < 0.001). In current smokers, the RR was 1.63 (p < 0.001). No significant difference was found in former smokers. The results indicated a publication bias in the studies included into the meta-analysis.

DISCUSSION

Smoking increases the risk of disability; therefore, the provision of cigarette smoking cessation treatment can reduce this risk. As the results also showed, former smokers are less likely to be frail.

Suicidal motivations reported by opioid overdose survivors: A cross-sectional study of adults with opioid use disorder

BACKGROUND

Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization.

METHODS

Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die).

RESULTS

Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood.

CONCLUSIONS

Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.

Patterns and Profiles of Adolescent Tobacco Users: Results From the Virginia Youth Survey

Background

Cigarette smoking has decreased to a record low among youth across the United States, including in Virginia. Rates of alternative tobacco use, however, are rising and polytobacco use is common. A better understanding of the shifting use patterns and associated risk factors is important for informing tobacco prevention, cessation, and policy efforts.

Methods

Weighted data from the 2013 Virginia Youth Survey were used. The sample was limited to 1168 youth who reported past 30-day tobacco use of ≥1 product (cigarettes, smokeless tobacco [smokeless], or cigars/little cigars/cigarillos [cigars]). Latent class analysis categorized individuals based on current tobacco use frequency/intensity. Multivariable multinomial logistic regressions compared classes on demographics, other tobacco-related factors, other substance use, and health/psychosocial factors.

Results

The five-class model indicated the best fit with classes characterized as "Chippers" (28.0%; high probability of low-frequency/intensity cigarette use), "Moderate Poly-Users" (23.6%; low- to high-frequency/moderate intensity cigarette use; moderate probability smokeless/cigar use), "Cigar Users" (20.9%; no-low-probability cigarette/smokeless use; high-probability cigar use), "Smokeless Users" (17.3%; no-low-probability cigarette/cigar use; moderate-high-probability smokeless use), and "Heavy Poly-Users" (10.4%; daily/high-intensity cigarette use, moderate-high-probability smokeless/cigar use). Classes differed significantly by demographics and inconsistently by other tobacco-related factors. Heavy Poly-Users were more likely to engage in other substance use behaviors, report suicidal ideation, and report being bullied because of gender.

Conclusions

Classes identified indicate that a large proportion of youth engage in polytobacco use and certain subgroups may be at greater risk for negative health consequences due to elevated psychosocial and behavioral risk factors.

Implications

These findings suggest distinct patterns of current tobacco use, including a high proportion of youth engaging in polytobacco use. Heavy polytobacco use co-occurs with other health risk behaviors and may be attributed to psychosocial risk factors. Results underscore the need for detailed monitoring of shifting youth tobacco use patterns as well as targeted prevention, cessation, and policy efforts.

Prevalence of problematic internet use disorder and associated risk factors and complications among Iranian university students: a national survey

Background: Despite the growing epidemic of problematic Internet use (PIU), little information is available on PIU and related factors in Iran. Methods: This cross-sectional study was conducted on 4261 university students among 13universities throughout the country in 2017. The data collection tool included demographic characteristics, the status of using the Internet, social media, computer games, tobacco, alcohol, and illicit drugs, suicide ideation and attempt, and unprotected sex. PIU was measured using the15-item PIU questionnaire. The status of general health was evaluated using the 28-item general health questionnaire (GHQ) questionnaire. The simple and multiple logistic regression analysis were used to measure the crude and adjusted associations between various factors and PIU. Results: Of 4261 university students, 55.9% were female, 13.5% were smokers, 4.9% were drug abusers, 7.9% were alcohol abusers, 7.8% had unprotected sex in the past year, 7.4%had suicidal ideation in the past month, 1.7% had attempted suicide in the past year, and27.3% suffered from PIU. Only 61.1% had normal health. In contrast, 30.9%, 7.2%, and 0.8%had mild, moderate, and severe general health problems, respectively. There were significant relationships between PIU and age group 20-24 vs. <20 years (odds ratio [OR]=1.39; 95% CI:1.06, 1.82), single vs, married (OR=2.57; 95% CI: 1.85, 3.57), suicidal attempt (OR=2.77;95% CI: 1.47, 5.19), using online games (OR=1.31; 95% CI: 1.07, 1.60), and poor general health (OR=12.14; 95% CI: 4.53, 32.54). Conclusion: Nearly one-third of medical sciences students suffered from PIU. This unhealthy behavior was associated with poor general health and elevated risk of suicidal behaviors. This health-threatening behavior provides an early warning signal that deserves special attention, otherwise, it may threaten both college students' health and function.

Risk factors for suicidal behavior in a university population in Brazil: A retrospective study

The present study aimed to evaluate whether variables related to personal and academic characteristics, past history, habits, and addictions were associated with suicidal behavior. Medical records of patients attending the Outpatient Psychiatry Department at the State University of Maringá between July 2016 and December 2017 were included in this retrospective study. The studied population was divided into two groups: 80 employees and 158 students. After performing the univariate analysis using Pearson's chi-square test or Fischer's exact test, the variables with p < 0.30 were included in a multivariate analysis using the binary logistic regression's backward stepwise method. The covariates 'childhood and adolescence maltreatment' and 'treatment phase' were highlighted. The first variable acts as a predictor of suicide attempt, increasing its likelihood by 9.86 times in employees and 5.62 times in students. On the other hand, the treatment phase represents a risk in patients in the adjustment phase and it serves as a predictor of SITBs in employees and students, increasing its likelihood by 7.68 and 8.66 times, respectively.

Gender differences in suicidal ideation and health-risk behaviors among high school students in Beijing, China

Background

Suicide is still the leading cause of death in the 15 to 34-year age group, especially for girls aging 15 to 19-year old. In China particularly, the suicide rate of female is 60% higher than male. The gender difference on suicidal ideation and its patterns with academic, family, social and health-risk factors is unknown among adolescents in Beijing, China.

Methods

A total of 33 635 students in grades 7-12 in Beijing participated in the 2014 Chinese Youth Risk Behavior Surveillance. Data were stratified by gender and associations with suicidal ideation were analyzed using χ² test and multivariate regression analyses. The interaction effects on suicidal ideation between gender and the related behaviors were also analyzed.

Results

The prevalence of suicidal ideation was significantly higher for girls (13.3%) than boys (10.7%). The multivariate regression analyses indicated that high academic pressure, running away from home, feeling lonely or sad/hopeless, being bullied, fighting, and binge drinking were significantly associated with suicidal ideation in boys and girls. Factors more strongly associated with suicidal ideation in girls than boys were being in junior vs senior high school (girl vs boys: 1.24 vs NA), high academic pressure (2.42 vs 1.55), ever smoking (1.52 vs NA), binge drinking (1.30 vs 1.17), fighting once (1.63 vs 1.06) and being sad/hopeless (2.39 vs 2.04) and their interaction with gender were all statistically significant (P < 0.05). A lower likelihood of suicidal ideation was found among boys, but not girls, who had PE class two or more days per week.

Conclusions

Girls showed more vulnerability to suicidal ideation than boys particularly among girls in junior school, reporting high academic pressure, smoking, binge drinking and fighting. The combinations of risk factors and differential patterns for boys and girls point to high-risk groups and potential targets for gender-specific suicide prevention.

Association between body weight status and suicidal ideation among Chinese adolescents: the moderating role of the child's sex

PURPOSE

Suicidality (ranging from suicidal ideation to suicidal attempts and completed suicide) is a major and preventable public health concern, and body weight is considered a modifiable factor which might be helpful to the early risk assessment of suicidal ideation. This study aimed to comprehensively evaluate the association of body weight status with suicidal ideation across sex among Chinese adolescents.

METHODS

Data were drawn from the 2015 National School-based Chinese Adolescents Health Survey, and 54,640 students' questionnaires were completed and qualified for the survey. Body mass index z scores were calculated and categorized into four levels: underweight (less than the 5th percentile for sex and age), normal weight (between the 5th and 85th percentile), overweight (between the 85th and 95th percentile), and obese (above the 95th percentile).

RESULTS

Of the total sample, 47.3% (25,852) were boys. The weighted prevalence of suicidal ideation among Chinese adolescents is 15.7% (14.6% in boys and 17.3% in girls). After adjusting for demographics, smoking, drinking, and depressive symptoms, our final multivariate logistic regression models demonstrated that only boys identified as underweight (Adjusted odds ratio [AOR] = 1.23, 95% CI = 1.06-1.44) or obese (AOR = 1.19, 95% CI = 1.02-1.38) were at a higher risk of suicidal ideation. Additionally, the association between weight status and suicidal ideation among boys might be moderated by academic pressure, smoking, and depressive symptoms.

CONCLUSIONS

There was a significant J-shaped association between relative body weight and suicidal ideation in boys. The child's sex should be taken into consideration when developing interventions against unhealthy weight and suicidal ideation.

Sex-Specific Impact of Changes in Job Status on Suicidal Ideation

Background: Around the globe, 800,000 people die from suicide every year. Despite being one of the leading causes of death, suicide remains a low public health priority. Korea has the second highest total suicide rate among Organisation for Economic Co-operation and Development (OECD) countries. Aims: The aim of this study was to explore how changes of job status influence suicidal risk in Korea, which lags behind other OECD countries in job security because temporary and part-time jobs are more prevalent in Korea. Method: We made use of a large longitudinal dataset, the Korea Health Panel (KHP). Results: Our findings revealed that a negative change in employment status increased the risk of suicide, but only for males. Limitations: Some individuals might intentionally change their job status, but the data do not indicate why the job status of an individual changes. Conclusion: These findings provide useful insights regarding the Korean labor market. In particular, tackling the issue of job stability, providing training polices for the unemployed and under-employed, and considering social insurance schemes may help to reduce suicide risk.

Predisposing and protective factors influencing suicide ideation, attempt, and death in patients accessing substance use treatment: a systematic review and meta-analysis protocol

BACKGROUND

The lifetime risk of suicide in patients with substance use disorder is five to ten times the risk in the general population. Critically, up to 19% of patients continue to think about and attempt suicide even after accessing treatment. Therefore, suicidality represents a significant clinical concern in patients struggling with substance use that warrants careful investigation of the factors involved. While most previous research has relied on limited cross-sectional designs, a growing number of prospective studies are improving our understanding of the factors involved. However, a systematic study of these factors has not yet been conducted.

METHODS

The primary objective of this review and possible meta-analysis will be to identify key risk and protective factors for suicide ideation, attempt, and death in patients accessing substance use treatment, guided by current models of suicide. Secondary and tertiary objectives will be to obtain pooled effect sizes for the factors identified and to disaggregate factors for suicidality before and after treatment, and for suicidal thought versus action. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we will conduct an electronic search of the literature using the databases Embase, Medline, PsycINFO, and Web of Science. Two authors will independently screen studies based on pre-specified inclusion and exclusion criteria, extract relevant data, and assess study quality. Observational and randomized-controlled studies will be included, whereas case-studies and reviews will be excluded. We will extract data on risk and protective factors associated with suicide ideation, attempt (odds or risk ratios), and death (hazard ratio). Given sufficient data (> 5 studies), we will calculate pooled effects using comprehensive meta-analysis.

DISCUSSION

This systematic review will contribute to our knowledge of risk and protective factors for suicidality in patients before and after treatment. Understanding these factors will help define areas of research for further investigation to ultimately inform risk assessment and prevention strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (reference number: CRD42018076260).

Evaluation of the Taking Texas Tobacco Free Workplace Program within behavioral health centers

Despite the health benefits of tobacco control and cessation initiatives, tobacco users with behavioral health disorders (BHDs) have less access to evidence-based tobacco dependence treatment. Academic-community partnerships can help guide the translation of tobacco-related research findings and evidence-based guidelines into real-world applications. Through a comprehensive, evidence-based, multilevel, and multicomponent program, Taking Texas Tobacco Free (TTTF) facilitated the implementation of tobacco-free workplaces at 18 local mental health authorities in Texas, comprising over 250 individual community behavioral health centers. Compared with preprogram implementation, key accomplishments postimplementation include: (1) educated over 5,000 employees (nonclinical staff and providers) on the hazards of tobacco use and benefits of quitting, particularly among people with BHD; providers were additionally trained on the use of evidence based practices (EBPs; i.e. 5A's model, use of pharmacotherapy) to identify and treat tobacco use among people with BHD; (2) providers' significant increase in conducting tobacco-use assessments and using EBPs; (3) significant decrease in nonclinical staff tobacco use; (4) increase in quit attempts among consumers as evidenced by the demand for nicotine replacement therapy; and (5) reach to over 115,000 community members through outreach and education about the benefits of quitting tobacco use and maintaining a healthy lifestyle. TTTF demonstrated that the implementation of a comprehensive tobacco-free workplace program in behavioral health settings is feasible and beneficial, facilitating the capacity building of healthcare professionals and enhancing their resulting engagement in EBPs, and promoting healthier lifestyles among employees, consumers, and community members as a whole.

Injury-Related Deaths according to Environmental, Demographic, and Lifestyle Factors

Background

Environmental, demographic, and lifestyle variables have been associated with injury-related deaths. The current study identifies the simultaneous association of selected environmental, demographic, and lifestyle variables with deaths from homicide, unintentional injuries, and suicide.

Materials and Methods

Analyses are based on county-level mortality data in the contiguous United States, 2011–15. Basic summary statistics and Poisson regression were used to evaluate the data.

Results

The selected causes of death were impacted differently by age, sex, and race: for homicide, mortality rates were greater in ages 20–39, males, and blacks; for unintentional injuries, the rates increased with age, most noticeably in the oldest age group, and were highest among males and whites; and for suicide, the rates tended to increase with age and were greater in males and whites. Mortality rates from homicide were positively associated with poverty, cigarette smoking, air temperature, and leisure-time physical inactivity. They were negatively associated with precipitation and sunlight. Mortality rates from unintentional injuries were positively associated with altitude, cigarette smoking, air temperature, poverty, obesity, and precipitation. They were negatively associated with population density. Mortality rates from suicides were positively associated with altitude, cigarette smoking, obesity, air temperature, and precipitation and negatively associated with population density.

Conclusion

The results confirm and extend previous research in which death from homicide, unintentional injuries, and suicide are distinctly associated with a combination of environmental, demographic, and lifestyle variables. The findings may be useful in developing strategies for reducing injury-related deaths.

Hypoxia-related risk factors for death by suicide in a national clinical sample

The relationship between three markers of chronic hypoxia (altitude, smoking and chronic obstructive pulmonary disease (COPD)) and suicide risk has not been well-studied. We conducted a population-based cohort study evaluating the association between chronic hypoxia and suicide risk. Patients entered the cohort in their first year with a documented healthcare encounter and remained in the cohort until their death or the end of the study period. Generalized estimating equation (GEE) methodology was used to assess the association between suicide and three risk markers of chronic hypoxia. Findings were summarized using odds ratio (OR) and 95% confidence intervals (CI). Among the 9,620,944 patients in the cohort, there were 22,403 suicide deaths. There was a statistically significant progression of suicide risk as altitude rose in increments of 1000 m (OR: 1.22). There was a strong association between the number of hypoxic conditions and the odds of suicide. Patients with three markers of chronic hypoxia was nearly four times more likely to die by suicide than patients with no markers (OR: 3.96). Chronic hypoxia is a risk factor for suicide and having multiple indicators of hypoxia confers a greater risk for suicide, indicating a dose-response relationship.

Nicotine Dependence and Pre-Enlistment Suicidal Behavior Among U.S. Army Soldiers

INTRODUCTION

Identification of modifiable risk factors for suicidal behaviors is a priority for the U.S. Army. This study investigated associations of nicotine dependence with suicidal behaviors among incoming soldiers.

METHODS

Lifetime DSM-IV nicotine dependence, mental disorders, suicidal behaviors, and their ages of onset were retrospectively assessed in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) New Soldier Study. Discrete-time survival analysis of person-year data from 30,436 soldiers was performed to evaluate associations of nicotine dependence with subsequent suicidal ideation, plans, and attempts. Among respondents with lifetime ideation (n=4,060), models tested associations of nicotine dependence with progression from ideation to first onset of plan, from plan to first attempt, and, among ideators without plans, from ideation to first unplanned attempt. A hierarchy of models incorporated increasing controls for other risk factors. Data were collected in 2011-2012 and analyzed in 2017-2018.

RESULTS

In models controlling for sociodemographic characteristics, nicotine dependence was associated with onset of all suicidal behaviors (AORs, 2.07-4.08, p<0.001) and with each type of progression of suicidal behavior (AORs, 1.48-2.44, p<0.005). After adjusting for childhood adversities and mental disorders, nicotine dependence remained associated with onset of ideation (AOR=1.27, 95% CI=1.10, 1.46, p=0.001) and attempt (AOR=1.83, 95% CI=1.41, 2.37, p<0.001); and with progression from ideation to unplanned attempt (AOR=2.03, 95% CI=1.17, 1.74, p<0.001).

CONCLUSIONS

Nicotine dependence exhibited associations with onset of suicidal ideation and suicide attempt-and with progression from ideation to unplanned attempt-that were independent of other measured risk factors. Awareness of associations of nicotine dependence with suicidal behaviors may inform risk assessment, facilitate targeting of prevention efforts, and provide further impetus for reducing nicotine dependence.

The association of religiosity with suicidal ideation and suicide attempts in the United Kingdom

OBJECTIVE

The goal was to analyze the association of religiosity with suicidal ideation and suicide attempts in a UK nationally representative sample.

METHODS

This study used cross-sectional data from 7403 people who participated in the 2007 Adult Psychiatric Morbidity Survey (APMS). Religion was assessed with the question 'Do you have a specific religion?' with 'yes' and 'no' answer options. Lifetime and past 12-month suicidal ideation and suicide attempts were assessed. The association between religiosity and suicidality was studied in multivariable logistic regression models adjusted for sociodemographic, behavioural, and psychopathological factors.

RESULTS

Compared to those without a religion, the prevalence of past 12-month suicidal ideation (3.2% vs. 5.4%), past 12-month suicide attempts (0.4% vs. 0.9%), lifetime suicidal ideation (11.2% vs. 16.4%), and lifetime suicide attempts (3.6% vs. 6.0%) was lower among those with a religion. In the fully adjusted model, having a religion was significantly associated with lower odds for all types of suicidality except past 12-month suicide attempts: suicidal ideation (past 12-month: OR = 0.71, 95% CI = 0.51-0.99; lifetime: OR = 0.83, 95% CI = 0.69-0.99) and suicide attempts (past 12-month: OR = 0.71, 95% CI = 0.35-1.45; lifetime: OR = 0.69, 95% CI = 0.53-0.90).

CONCLUSION

There is a negative association between religiosity and suicidality in the UK. Future studies should focus on the underlying mechanisms.