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Lam T, Hayman J, Berecki‐Gisolf J, Sanfilippo P, Lubman DI, Nielsen S. Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids. Addiction 2022; 117:623-636. [PMID: 34338377 PMCID: PMC9292229 DOI: 10.1111/add.15653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 07/21/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Pharmaceutical opioids are a significant contributor to the global 'opioid crisis', yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population-wide indicator of non-fatal overdose. DESIGN Retrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019. SETTING Victoria, Australia. CASES ED presentations for non-fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented. MEASUREMENTS We compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply-adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation. FINDINGS There were wide differences, up to 27-fold, between supply-adjusted rates of overdose. When considering presentations with sole opioids, the highest supply-adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073-0.08) and oxycodone (OME =0.029, 95% CI = 0.027-0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003-0.006) and fentanyl (OME = 0.003, 95% CI = 0.002-0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12-34 years old), and intentional self-harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self-harm. Relative to morphine-buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR). CONCLUSIONS In Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.
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Affiliation(s)
- Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVICAustralia
| | - Jane Hayman
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVICAustralia,Victorian Injury Surveillance Unit, Monash University Accident Research CentreMonash UniversityClaytonVICAustralia
| | - Janneke Berecki‐Gisolf
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVICAustralia,Victorian Injury Surveillance Unit, Monash University Accident Research CentreMonash UniversityClaytonVICAustralia
| | - Paul Sanfilippo
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVICAustralia,Turning PointEastern HealthRichmondVICAustralia
| | - Dan I. Lubman
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVICAustralia,Turning PointEastern HealthRichmondVICAustralia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVICAustralia,Turning PointEastern HealthRichmondVICAustralia
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Syafira N, Graudins A, Yarema M, Wong A. Comparing development of liver injury using the two versus three bag acetylcysteine regimen despite early treatment in paracetamol overdose. Clin Toxicol (Phila) 2021; 60:478-485. [PMID: 34758680 DOI: 10.1080/15563650.2021.1998518] [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] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Some studies have reported that early administration of acetylcysteine using a 3-bag regimen may not fully prevent development of liver injury in some patients. We compared the incidence of acute liver injury (ALI) in patients receiving acetylcysteine within eight hours of ingestion between the two-bag acetylcysteine regimen (200 mg/kg over four hours, 100 mg/kg over 16 h) and the three-bag regimen (150 mg/kg over 1 h, 50 mg/kg over 4 h, 100 mg/kg over 16 h). METHOD This was a retrospective cohort study of the two-bag and three-bag acetylcysteine regimens from Monash Health, Victoria, Australia (2009-2020), compared to the three-bag acetylcysteine regimen data from the Canadian Acetaminophen Overdose Study (CAOS) database (1980-2005). The inclusion criteria included patients with an acute single ingestion of paracetamol; normal aminotransferases on presentation and acetylcysteine administered within eight hours post-overdose. The primary outcome was development of ALI (defined as: peak aminotransferase >150 IU/L). RESULTS At Monash Health, 191 patients were treated with the two-bag acetylcysteine regimen, and 180 patients with the three-bag regimen. The CAOS cohort provided 515 patients treated with the three-bag regimen. ALI developed in 1.6% (3/191) of the two-bag Monash Health group, 2.2% (4/180) of the three-bag Monash Health group (difference -0.6%, p 0.7), and 2.9% (15/515) of the three-bag CAOS group (difference compared to two-bag -1.3%, p 0.4). Hepatotoxicity (ALT >1000) developed in 0.5% (1/191) of patients treated with the two-bag regimen, 1.7% (3/180) in the Monash Health three-bag regimen and 1% (5/515) of the three-bag CAOS group. There were no statistically significant differences between groups. CONCLUSIONS ALI and hepatotoxicity were observed in a small, comparable percentage of patients despite early acetylcysteine administration using the two-bag and three-bag regimens. Repeating blood tests at the end of acetylcysteine treatment will identify these patients and indicate those requiring continuation of acetylcysteine.
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Affiliation(s)
- Naura Syafira
- Department of Medicine, School of Clinical Science at Monash Health, Monash University, Victoria, Australia.,Faculty of Medicine, Universitas Indonesia, Special Capital Region of Jakarta, Indonesia
| | - Andis Graudins
- Department of Medicine, School of Clinical Science at Monash Health, Monash University, Victoria, Australia.,Monash Toxicology Unit, Dandenong Hospital, Monash Health, Victoria, Australia
| | - Mark Yarema
- Poison and Drug Information Service, Alberta Health Services, Calgary, Canada.,Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - Anselm Wong
- Department of Medicine, School of Clinical Science at Monash Health, Monash University, Victoria, Australia.,Austin Toxicology Unit, Austin Health, Victoria, Australia.,Department of Critical Care, University of Melbourne, Victoria, Australia
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Edwards AC, Ohlsson H, Mościcki E, Crump C, Sundquist J, Lichtenstein P, Kendler KS, Sundquist K. On the Genetic and Environmental Relationship Between Suicide Attempt and Death by Suicide. Am J Psychiatry 2021; 178:1060-1069. [PMID: 34256608 PMCID: PMC8570976 DOI: 10.1176/appi.ajp.2020.20121705] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined the extent to which the genetic and environmental etiology of suicide attempt and suicide death is shared or unique. METHODS The authors used Swedish national registry data for a large cohort of twins, full siblings, and half siblings (N=1,314,990) born between 1960 and 1990 and followed through 2015. They conducted twin-family modeling of suicide attempt and suicide death to estimate heritability for each outcome, along with genetic and environmental correlations between them. They further assessed the relationship between suicide attempt by young people compared with adults. RESULTS In bivariate models, suicide attempt and death were moderately heritable among both women (attempt: additive genetic variance component [A]=0.52, 95% CI=0.44, 0.56; death: A=0.45, 95% CI=0.39, 0.59) and men (attempt: A=0.41, 95% CI=0.38, 0.49; death: A=0.44, 95% CI=0.43, 0.44). The outcomes were substantially, but incompletely, genetically correlated (women: rA=0.67, 95% CI=0.55, 0.67; men: rA=0.74, 95% CI=0.63, 0.87). Environmental correlations were weaker (women: rE=0.36, 95% CI=0.29, 0.45; men: rE=0.21, 95% CI=0.19, 0.27). Heritability of suicide attempt was stronger among people ages 10-24 (A=0.55-0.62) than among those age 25 and older (A=0.36-0.38), and the genetic correlation between attempt during youth and during adulthood was stronger for women (rA=0.79, 95% CI=0.72, 0.79) than for men (rA=0.39, 95% CI=0.26, 0.47). CONCLUSIONS The genetic and environmental etiologies of suicide attempt and death are partially overlapping, exhibit modest sex differences, and shift across the life course. These differences must be considered when developing prevention efforts and risk prediction algorithms. Where feasible, suicide attempt and death should be considered separately rather than collapsed, including in the context of gene identification efforts.
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Affiliation(s)
- Alexis C. Edwards
- Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA, US
| | - Henrik Ohlsson
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | | | - Casey Crump
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY, US,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, US
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden,Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY, US,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, US
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Kenneth S. Kendler
- Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University School of Medicine, Richmond, VA, US
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden,Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, NY, US,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, US
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Friðriksdóttir ÞA, Jónsdóttir F, Snook CP, Líndal H, Björnsson ES. Paracetamol poisoning: a population-based study from Iceland. Scand J Gastroenterol 2021; 56:832-839. [PMID: 33974465 DOI: 10.1080/00365521.2021.1921254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the incidence and severity of paracetamol poisoning in a population-based cohort in Iceland. A previous study showed a decrease in the incidence during a financial crisis in Iceland, by approximately half (16/100,000 annually). The aims of the study were to assess the incidence and nature of paracetamol poisoning after economic recovery in Iceland and to compare intentional and accidental poisoning. METHODS Paracetamol serum concentrations were used to identify patients in this retrospective study from 2010-2017. A search was undertaken in laboratory databases for patients with serum paracetamol concentrations, which were grouped by <66 µmol/L (below detection limit) and ≥66 µmol/L. Medical records were reviewed and relevant laboratory and clinical information obtained to determine whether paracetamol poisoning had occurred. RESULTS Altogether 542 cases of paracetamol poisoning were identified. The mean annual incidence was 27/100,000 (range 22-33). Intentional poisoning was observed in 437/542 (81%) cases, most frequently among females 16-25 years of age. Males ≥65 years were more likely to overdose by accident, which was associated with worse outcomes. Twenty-five (4.6%) patients developed severe paracetamol-induced liver injury and coagulopathy. Overall, six (1.1%) cases were fatal in which paracetamol contributed to the cause of death, with accidental poisoning found in 67% (4/6). CONCLUSIONS The incidence of paracetamol poisoning has increased in recent years associated with economic recovery in Iceland. Most patients had favourable outcomes. Intentional overdose was most common in young females, whereas accidental overdose was more common in older males and more frequently associated with a fatal outcome.
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Affiliation(s)
| | - Freyja Jónsdóttir
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland.,Hospital Pharmacy, Landspítali University Hospital, Reykjavik, Iceland
| | - Curtis P Snook
- Emergency Department, Landspítali University Hospital, Reykjavik, Iceland.,Poison Information Centre, Landspítali University Hospital, Reykjavik, Iceland
| | - Helena Líndal
- Poison Information Centre, Landspítali University Hospital, Reykjavik, Iceland
| | - Einar S Björnsson
- Division of Gastroenterology and Hepatology of the Landspítali, University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Lam T, Hayman J, Berecki-Gisolf J, Sanfilippo P, Lubman DI, Nielsen S. Comparing rates and characteristics of emergency department presentations related to pharmaceutical opioid poisoning in Australia: a study protocol for a retrospective observational study. BMJ Open 2020; 10:e038979. [PMID: 32994254 PMCID: PMC7526272 DOI: 10.1136/bmjopen-2020-038979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND AIMS Pharmaceutical opioids are an important contributor to the global 'opioid crisis', and are implicated in 70% of Australia's opioid-related mortality. However, there have been few studies which consider the relative contribution of different pharmaceutical opioids to harm.We aim to compare commonly used pharmaceutical opioids in terms of (1) rates of harm, and (2) demographic and clinical characteristics associated with that harm. METHOD AND ANALYSIS Observational study of emergency department presentations for non-fatal poisoning related to pharmaceutical opioid use. Data from 2009 to 2019 will be extracted from the Victorian Emergency Minimum Dataset which contains data from public hospitals with dedicated emergency departments in Victoria, Australia's second most populous state. A combination of free-text and International Classification of Diseases 10th Revision codes will be used to identify relevant cases, with manual screening of each case to confirm relevance. We will calculate supply-adjusted rates of presentations using Poisson regression for all pharmaceutical opioid cases identified, separately for nine commonly prescribed pharmaceutical opioids (buprenorphine, codeine, fentanyl, methadone, morphine, oxycodone, oxycodone-naloxone, tapentadol, tramadol), and for a multiple opioid category. We will use multinomial logistic regression to compare demographic and clinical characteristics, such as triage category, across opioid types. ETHICS AND DISSEMINATION This work is conducted under approval 21427 from the Monash University Human Research Ethics Committee for ongoing injury surveillance. As per conditions of approval, cells of <5 will not be reported, though zeroes will be preserved. We will present project findings in a peer-reviewed journal article as well as at relevant scientific conferences.
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Affiliation(s)
- Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
| | - Jane Hayman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
- Victorian Injury Surveillance Unit, Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | - Janneke Berecki-Gisolf
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
- Victorian Injury Surveillance Unit, Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | - Paul Sanfilippo
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Dan I Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
- Turning Point, Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
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Beauchamp GA, Carey JL, Cook MD, Cannon RD, Katz KD, Yoon J, Kincaid H, Ely BJ, Pollack E, Mazzaccaro RJ, Greenberg MR. Sex Differences in Pediatric Poisonings by Age Group: a Toxicology Investigators' Consortium (ToxIC) Analysis (2010-2016). J Med Toxicol 2020; 16:423-443. [PMID: 32488629 DOI: 10.1007/s13181-020-00781-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/13/2020] [Accepted: 04/28/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To review pediatric poisonings evaluated at the bedside by medical toxicologists and reported in the ToxIC registry, by sex and age group. METHODS Pediatric poisoning cases age ≤18 years, reported between January 2010 and December 2016, were reviewed. Descriptive statistics were used to describe study variables by age group and sex. RESULTS A total of 12,699 cases were analyzed. There were 7517 females and 5182 males. Those < 2 years old represented 12.5% of the study group (n = 1584), 17.2% were 2-6 years old (n = 2178), 8.6% were 7-12 years old (n = 1097), and 61.7% were 13-18 years old (n = 7840). The most common primary reasons for encounter were intentional pharmaceutical with 4900 females and 1836 males; intentional non-pharmaceutical with 952 females and 1213 males; unintentional pharmaceutical with 539 females and 644 males; and unintentional non-pharmaceutical with 435 females and 593 males. Overall, pharmaceuticals were the most commonly involved agents, including analgesics (20.9% of cases) and antidepressants (11% of cases): 27.8% of females and 10.7% of males were reportedly exposed to an analgesic.13.7% of females and 7.0% of males were reportedly exposed to an antidepressant. Among 1584 cases under 2 years, there were 747 females and 837 males; among 2178 cases aged 2-6 years, there were 954 females and 1224 males; among 1097 cases aged 7-12 years, there were 555 females and 542 males; and among 7840 cases aged 13-18 years, there were 5261 females and 2579 males. Death was reported in 0.7% of the cases: 20 females and 18 males. 6.1% of cases were managed with intubation: 421 females and 351 males. CONCLUSIONS Sex-based characteristics of poisonings varied by age group among pediatric poisoning presentations reported to the ToxIC registry and further research is needed to determine implications for education and prevention efforts.
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Affiliation(s)
- Gillian A Beauchamp
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA.
- Division of Medical Toxicology, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA.
| | - Jennifer L Carey
- Division of Medical Toxicology, Department of Emergency Medicine, University of Massachusetts Medical School, 55 N Lake Ave, Worcester, MA, 01655, USA
| | - Matthew D Cook
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
- Division of Medical Toxicology, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Robert D Cannon
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
- Division of Medical Toxicology, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Kenneth D Katz
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
- Division of Medical Toxicology, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Jennifer Yoon
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Hope Kincaid
- Network Office of Research Innovation, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Brittany J Ely
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Emily Pollack
- Department of Pediatrics, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Richard J Mazzaccaro
- Department of Pediatrics, Lehigh Valley Health Network/USF Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
| | - Marna Rayl Greenberg
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida (USF) Morsani College of Medicine, Cedar Crest Blvd & I-78, Allentown, PA, 18103, USA
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Nielsen S, Crossin R, Middleton M, Lam T, Wilson J, Scott D, Martin C, Smith K, Lubman D. Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Victoria, Australia from 2013 to 2018. Addiction 2020; 115:1075-1087. [PMID: 31742765 PMCID: PMC7317708 DOI: 10.1111/add.14896] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/24/2019] [Accepted: 11/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Despite increases in opioid prescribing and related morbidity and mortality, few studies have comprehensively documented harms across opioid types. We examined a population-wide indicator of extramedical pharmaceutical opioid-related harm to determine if the supply-adjusted rates of ambulance presentations, the severity of presentations or other attendance characteristics differed by opioid type. DESIGN Retrospective observational study of coded ambulance patient care records related to extramedical pharmaceutical opioid use, January 2013 to September 2018. SETTING Australia CASES: Primary analyses used Victorian data (n = 9823), with available data from other Australian jurisdictions (n = 4338) used to determine generalizability. MEASUREMENTS We calculated supply-adjusted rates of attendances using Poisson regression, and used multinomial logistic regression to compare demographic, presentation severity, mental health, substance use and other characteristics of attendances associated with seven pharmaceutical opioids. FINDINGS In Victoria, the highest rates of attendance [per 100 000 oral morphine equivalent mg (OME)] were for codeine (0.273/100 000) and oxycodone (0.113/100 000). The lowest rates were for fentanyl (0.019/100 000) and tapentadol (0.005/100 000). Oxycodone-naloxone rates (0.031/100 000) were lower than for oxycodone as a single ingredient (0.113/100 000). Fentanyl-related attendances were associated with the most severe characteristics, most likely to be an accidental overdose, most likely to have naloxone administered and least likely to be transferred to hospital. In contrast, codeine-related attendances were more likely to involve suicidal thoughts/behaviours, younger females and be transported to hospital. Supply-adjusted attendance rates for individual opioids were stable over time. Victorian states were broadly consistent with non-Victorian states. CONCLUSIONS In Australia, rates and characteristics of opioid-related harm vary by opioid type. Supply-adjusted ambulance attendance rates appear to be both stable over time and unaffected by large changes in supply.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
| | - Rose Crossin
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
| | - Melissa Middleton
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
| | - Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
| | - James Wilson
- Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
| | - Debbie Scott
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
| | - Catherine Martin
- Biostatistical Unit, Public Health and Preventative MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Karen Smith
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Ambulance VictoriaDoncasterVictoriaAustralia,Department of Community Emergency Health and Paramedic PracticeMonash UniversityFrankstonVictoriaAustralia
| | - Dan Lubman
- Monash Addiction Research Centre, Eastern Health Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Turning Point, Eastern Health and Eastern Health Clinical SchoolMonash UniversityRichmondVictoriaAustralia
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Lam T, Kuhn L, Hayman J, Middleton M, Wilson J, Scott D, Lubman DI, Smith K, Nielsen S. Recent trends in heroin and pharmaceutical opioid-related harms in Victoria, Australia up to 2018. Addiction 2020; 115:261-269. [PMID: 31465131 DOI: 10.1111/add.14784] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/20/2019] [Accepted: 08/08/2019] [Indexed: 12/14/2022]
Abstract
AIMS To characterize the trajectory in the years leading up to 2018 in pharmaceutical opioid and heroin morbidity in Victoria, Australia, and to assess the effect on that trajectory of reformulation of oxycodone to a form that could not be easily snorted or injected. DESIGN Interrupted time-series analyses of population-level data before versus after reformulation of oxycodone, stratified by sex. SETTING Victoria, Australia. PARTICIPANTS The population of Victoria aged 12+ years. MEASUREMENTS Ambulance patient care and emergency department (ED) records were examined using both fixed-code and free-text fields, with each record manually cleaned and checked by trained coders. These were used to derive the output variables providing an index of harm: rates of opioid-related ambulance attendances and ED attendances for pharmaceutical opioids and heroin. The input variable was pre- versus post-oxycodone reformulation. FINDINGS There were 30 045 opioid-related ambulance attendances from January 2012 to October 2018 (54% heroin-related), and 10 113 ED attendances from July 2008 to June 2018 (39% heroin-related). There was an increase in the rate (events per 100 000 people per year) of all opioid ED attendances from 2008 to 2018 [increase = 0.063; 95% confidence interval (CI) = 0.049, 0.078]. Pharmaceutical opioid ED attendances decreased from 2014 onwards (slope change = -0.083; 95% CI = -0.108, -0.059). Heroin-related ED attendances increased from 2014 to 2018; 11 324 heroin-related ambulance attendances and 1980 ED attendances were observed from April 2014 to June 2018, compared with the respective estimates of 8176, and 1661 had the pre-April 2014 trend continued (ambulance slope change = 0.296, 95% CI = 0.104, 0.489; ED slope change = 0.026, 95% CI = 0.005, 0.046). The inflection point of 2014 coincided with the re-formulation of oxycodone. CONCLUSION In Victoria, Australia, there appears to have been a trend starting around mid-2014 of increasing heroin-related harm, and a flattening of the increase or a decrease of harms relating to pharmaceutical opioids. These changes may, in part, reflect reformulation of oxycodone to reduce the extent to which it can be injected or snorted.
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Affiliation(s)
- Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
| | - Lisa Kuhn
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Monash Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Jane Hayman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Victorian Injury Surveillance Unit, Monash University Accident Research Centre, Monash University, Clayton, Victoria, Australia
| | - Melissa Middleton
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
| | - James Wilson
- Turning Point, Eastern Health & Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Debbie Scott
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Turning Point, Eastern Health & Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Dan I Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Turning Point, Eastern Health & Eastern Health Clinical School, Monash University, Richmond, Victoria, Australia
| | - Karen Smith
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Victoria, Australia
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Nielsen S, Crossin R, Middleton M, Martin C, Wilson J, Lam T, Scott D, Smith K, Lubman D. Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study. BMJ Open 2019; 9:e029170. [PMID: 31138584 PMCID: PMC6549600 DOI: 10.1136/bmjopen-2019-029170] [Citation(s) in RCA: 10] [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] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION AND AIMS Extramedical use of, and associated harms with pharmaceutical opioids are common. Analysis of coded ambulance clinical records provides a unique opportunity to examine a national population-level indicator of relative harms. This protocol describes an observational study with three aims: (1) to compare supply adjusted rates of pharmaceutical opioid-related ambulance attendances for buprenorphine, codeine, fentanyl, oxycodone, oxycodone-naloxone, morphine, pethidine, tramadol and tapentadol; (2) to compare presentation characteristics for these commonly used pharmaceutical opioids and (3) to describe the context surrounding ambulance presentations related to oxycodone, a widely used opioid with an established abuse liability, and tapentadol, a more recent 'atypical' opioid on the Australian market, with fewer studies that have directly examined signals of extramedical use. METHOD Trained coders extract data from clinical records for ambulance presentations relating to extramedical use of commonly used pharmaceutical opioids. These data form the basis of a large, national database that captures alcohol-related and drug-related harms. Supply adjusted rates of presentations will be examined using Poisson regression. Multinomial logistic regression will be used to compare severity and other characteristics of attendances relating to different pharmaceutical opioids. Tapentadol-related and oxycodone-related cases will be qualitatively examined to understand the situationally specific contexts of the ambulance attendances outside of the characteristics captured in routinely coded variables. ETHICS AND DISSEMINATION Ethics approval related to analysis of ambulance attendance data was obtained from the Eastern Health Human Research Ethics Committee (E122 08-09), with an amendment specific to the qualitative analysis. Findings will be submitted for peer review in 2019. The understanding of risk profiles in real-world settings is of international public health importance. The analysis and publication of findings from this national dataset of clinical records will provide one of the most nuanced analyses to date of relative harms across nine pharmaceutical opioids over a 6-year period.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- National Drug and Alcohol Research Centre, UNSW Sydney, Randwick, New South Wales, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Rose Crossin
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Melissa Middleton
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Catherine Martin
- Biostatistics Unit, Public Health and Preventative Medicine, Monash University, Melbourne, New South Wales, Australia
| | - James Wilson
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Tina Lam
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Debbie Scott
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
| | - Karen Smith
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, Victoria, Australia
| | - Dan Lubman
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- Turning Point, Monash University Eastern Health Clinical School, North Richmond, Victoria, Australia
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Abstract
Suicide morbidity and mortality are serious public health problems, accounting for over 40,000 deaths annually and over $10 billion in combined medical and work loss costs. Suicidal behavior is the outcome of a complex causal web of distal and proximal risk processes that includes a range of interacting environmental and biological determinants. We review current understanding of risk and protective factors, including recent findings on inflammatory processes, discuss recent research on environmental risks for suicidal behaviors with a focus on economic stress, and examine potential mechanisms by which external factors and internal processes such as inflammation might contribute to pathways leading to suicidal behavior. We propose a model that links changes in the default network or resting state of brain activity with corresponding changes in brain structure and function, which in turn may be influenced by diverse inflammatory mediators, and suggest a potential framework that highlights multidisciplinary opportunities for further research.
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Pillans PI, Page CB, Ilango S, Kashchuk A, Isbister GK. Self‐poisoning by older Australians: a cohort study. Med J Aust 2017; 206:164-169. [DOI: 10.5694/mja16.00484] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Peter I Pillans
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
| | - Colin B Page
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
| | | | | | - Geoffrey K Isbister
- University of Newcastle, Newcastle, NSW
- Calvary Mater Newcastle, Newcastle, NSW
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Akoz A, Gur STA, Oral E, Avsar UZ, Emet M. Can we predict agitation in patients with suicide attempts in the emergency department? Afr Health Sci 2016; 16:831-837. [PMID: 27917218 DOI: 10.4314/ahs.v16i3.25] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The agitation in patients presenting to the emergency department (ED) after suicide attempts is common and an important problem. OBJECTIVE To establish whether we can predict agitated patients among suicide attempt patients in ED. METHODS This is a cross-sectional observational study of adult suicide attempt events in ED. Information was collected prospectively on a specially designed data-collection form. Patients aged 16 years old and above who presented to the ED for care due to suicide attempts were included in the study. Suicide attempts were grouped as aggressive and non-aggressive attempts. RESULTS A total of 533 patients were included. Forty-three of these patients had agitation in ED (8%). Non-aggressive suicide attempts were referred to psychiatry services more than aggressive ones (73.6%, n=345 vs 32.8%, n=21, P<0.0001). Agitation in ED and being male increased aggressive suicide attempt risk 3.5 (95% CI:1.6-7.6) and 3.2 times (95% CI:1.8-5.5), respectively. Agitation was statistically more frequent among these patients: those on antidepressant overdose, with previous suicide attempt; with aggressive suicide attempt; and those with confusion; and unconsciousness (P<0.05). CONCLUSION Patients who attempted suicide and whose risk of harm to others included those with: antidepressant overdose, aggressive suicide attempt and the unconscious. Response teams should be prepared for these subgroups.
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Affiliation(s)
- Ayhan Akoz
- Adnan Menderes University Medicine Faculty Department of Emergency Medicine, Aydin, Turkey
| | - Sultan Tuna Akgol Gur
- Ataturk University Medicine Faculty Department of Emergency Medicine, Erzurum, Turkey
| | - Elif Oral
- Ataturk University Medicine Faculty Department of Psychiatry, Erzurum, Turkey
| | - Ummu Zeynep Avsar
- Ataturk University Medicine Faculty Department of Medical Education, Erzurum, Turkey
| | - Mucahit Emet
- Ataturk University Medicine Faculty Department of Emergency Medicine, Erzurum, Turkey
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Rahme E, Low NCP, Lamarre S, Daneau D, Habel Y, Turecki G, Bonin JP, Morin S, Szkrumelak N, Singh S, Lesage A. Correlates of Attempted Suicide from the Emergency Room of 2 General Hospitals in Montreal, Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2016; 61:382-393. [PMCID: PMC4910406 DOI: 10.1177/0706743716639054] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Introduction: The epidemiology of attempted suicide has not been well characterized because of lack of national data or an International Classification of Diseases (ICD) code for suicide attempts. We conducted a retrospective chart review in 2 adult general hospitals (tertiary and community) in Montreal, Canada, in 2009-2010 to 1) describe the characteristics of men and women who presented to the emergency department (ED) and/or were hospitalized following a suicide attempt, 2) identify factors associated with attempts requiring hospitalizations, and 3) validate the use of International Classification of Diseases, 10th Revision (ICD-10) codes for “intentional self-harm” as a method to detect suicide attempts from hospital abstract summary records. Method: All potential suicide attempts were identified from hospital abstract summary records and ED nursing triage file using ICD-10 codes and keywords suggestive of suicide attempts. All identified charts were examined, and those with confirmed suicide attempts were fully reviewed. Results: Of the 5746 identified charts, 369 were fully reviewed. Of these, 176 were for suicide attempters treated in the ED and 193 for hospitalized attempters, of whom 46% had an ICD-10 code for intentional self-harm. Poisoning (46%) was the most frequent method of suicide used. Half of attempters were younger than 34 years, 53% were female, and 75% had a history of mental disorders. Conclusion: About half of individuals who seek medical care for attempted suicide are admitted to hospital. About half of attempters use poisoning as a method of suicide, and a quarter do not have a history of mental disorders. Intentional self-harm codes capture only about half of hospitalized attempters.
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Affiliation(s)
- Elham Rahme
- Research Institute of the McGill University Health Centre, Montreal, Quebec
- Department of Medicine, McGill University, Montreal, Quebec
| | - Nancy C. P. Low
- Department of Psychiatry, McGill University Health Centre, Montreal, Quebec
| | - Suzanne Lamarre
- Department of Psychiatry, McGill University, St-Mary’s Hospital Center, Montreal, Quebec
| | - Diane Daneau
- Douglas Mental Health University Institute, Montreal, Quebec
| | - Youssef Habel
- Department of Psychiatry, McGill University Health Centre, Montreal, Quebec
| | - Gustavo Turecki
- Department of Psychiatry, McGill University Health Centre, Montreal, Quebec
| | | | - Suzanne Morin
- Research Institute of the McGill University Health Centre, Montreal, Quebec
- Department of Medicine, McGill University, Montreal, Quebec
| | - Nadia Szkrumelak
- Department of Psychiatry, McGill University Health Centre, Montreal, Quebec
| | - Santokh Singh
- Department of Psychiatry, McGill University, St-Mary’s Hospital Center, Montreal, Quebec
| | - Alain Lesage
- Department of Psychiatry, Université de Montréal, Montreal, Quebec
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Young people who self-harm: a prospective 1-year follow-up study. Soc Psychiatry Psychiatr Epidemiol 2016; 51:171-81. [PMID: 26607729 PMCID: PMC4748007 DOI: 10.1007/s00127-015-1149-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 11/08/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To explore repetition, service provision and service engagement following presentation of young people to emergency services with self-harm. METHODS 969 patients who presented to accident and emergency services after self-harm were followed up prospectively for a period of 1 year. Data on rates, method, clinical history, initial service provision, engagement and repetition (defined as re-presenting to emergency services with further self-harm) were gathered from comprehensive electronic records. RESULTS Young people were less likely to repeat self-harm compared to those aged 25 and above. A psychiatric history and a history of childhood trauma were significant predictors of repetition. Young people were more likely to receive self-help as their initial service provision, and less likely to receive acute psychiatric care or a hospital admission. There were no differences in engagement with services between young people and those aged 25 and above. CONCLUSION Younger individuals may be less vulnerable to repetition, and are less likely to represent to services with repeated self-harm. All young people who present with self-harm should be screened for mental illness and asked about childhood trauma. Whilst young people are less likely to be referred to psychiatric services, they do attend when referred. This may indicate missed opportunity for intervention.
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Rheinheimer B, Kunz M, Nicolella A, Bastos T. Trends in self-poisoning in children and adolescents in Southern Brazil between 2005 and 2013. Eur Psychiatry 2015. [DOI: 10.1016/j.eurpsy.2015.09.266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
ObjectivesTo evaluate the prevalence and associated variables of intentional self-poisoning in individuals from 8 to 17 years.MethodThis study includes 4658 cases. Analyzed variables were gender, age, agent and time (month, week day and hour).ResultsIn total, 3759 (80.70%) were girls. The rate in 100,000 children and adolescents residents grown from 25.12 in 2005 to 35.24 to 2012. The biggest incidence was in the 15 to 17 age group (63.35%). The leading agent was medications (84.6%): 1093 (23.47%) antidepressant, 967 (20.76%) benzodiazepines, 708 (15.20%) antipyretics, 606 (13.01%) anticonvulsants, 460 (9.88%) neuroleptics and 382 (8.2%) anti-inflammatory non-steroids. The antidepressant more used was amitriptyline (7.26%), followed by fluoxetine (6.57%). Growing cases involving selective serotonin reuptake inhibitors have been seen, as a fall of self-poisoning tricyclic antidepressants cases. The majority of cases was in October (10.1%), on Tuesday (15.1%), and at 18:00 to 21:00 (29.46%).ConclusionThe elevated rate of self-poisoning in children and adolescents in southern Brazil, growing each year, shows the relevance of this subject. It is important to considerate how easily these children and adolescents have access to psychotropics.
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Cobaugh DJ, Miller MJ, Pham TT, Krenzelok EP. Risk of major morbidity and death in older adults with suicidal intent: a cross-sectional analysis from the National Poison Data System, 2000-2009. J Am Geriatr Soc 2015; 63:501-7. [PMID: 25735433 DOI: 10.1111/jgs.13323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To describe suicide-related exposures in older persons according to sex, age, and substance category reported to U.S. poison control centers (PCCs) and report the crude relative risk (RR) of major effects and death from pharmaceuticals and nonpharmaceutical substances after single- and multiple-substance exposures. DESIGN Cross-sectional analysis of American Association of Poison Control Centers National Poison Data System (NPDS) data. SETTING Calls to U.S. PCCs. PARTICIPANTS NPDS cases involving individuals aged 60 and older with an exposure to a pharmaceutical or nonpharmaceutical substance and suicide as the reason (n=46,494). MEASUREMENTS Major effect and death probabilities for single- and multiple-substance exposures to pharmaceuticals and nonpharmaceuticals were determined. In the NPDS, a major effect is defined as symptoms or signs that are life-threatening or resulted in significant residual disability or disfigurement. Crude RRs of major effects or death were estimated for single and multiple pharmaceutical substances in comparison with nonpharmaceutical substances. RESULTS Single-substance exposures occurred in 53.3% of cases. Overall, 92.3% involved pharmaceuticals and 64.4% involved women. In the total sample, 12.7% (5,895/46,494) of exposures resulted in major effect, and 1.9% (884/46,494) resulted in death. The crude RR of major effects in single-substance pharmaceutical exposures was significantly lower than with nonpharmaceutical exposures (RR=0.54, 95% confidence interval (CI)=0.49-0.59), as was death (RR=0.25, 95% CI=0.20-0.30). For multiple-substance exposures, the crude RR of major effects from pharmaceuticals was similar to that for nonpharmaceuticals (RR=0.92, 95% CI=0.80-1.06), whereas the crude RR of death from pharmaceuticals was significantly lower (RR=0.55, 95% CI=0.40-0.77). CONCLUSION These findings can inform suicide prevention strategies that focus on decreasing at-risk older adults' access to dangerous medications and chemicals in the home.
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Affiliation(s)
- Daniel J Cobaugh
- American Society of Health-System Pharmacists Research and Education Foundation, Bethesda, Maryland
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Rhodes AE, Boyle MH, Bridge JA, Sinyor M, Links PS, Tonmyr L, Skinner R, Bethell JM, Carlisle C, Goodday S, Hottes TS, Newton A, Bennett K, Sundar P, Cheung AH, Szatmari P. Antecedents and sex/gender differences in youth suicidal behavior. World J Psychiatry 2014; 4:120-32. [PMID: 25540727 PMCID: PMC4274584 DOI: 10.5498/wjp.v4.i4.120] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 11/13/2014] [Accepted: 11/27/2014] [Indexed: 02/05/2023] Open
Abstract
Suicide is the second leading cause of death in youth globally; however, there is uncertainty about how best to intervene. Suicide rates are typically higher in males than females, while the converse is true for suicide attempts. We review this "gender paradox" in youth, and in particular, the age-dependency of these sex/gender differences and the developmental mechanisms that may explain them. Epidemiologic, genetic, neurodevelopmental and psychopathological research have identified suicidal behaviour risks arising from genetic vulnerabilities and sex/gender differences in early adverse environments, neurodevelopment, mental disorder and their complex interconnections. Further, evolving sex-/gender-defined social expectations and norms have been thought to influence suicide risk. In particular, how youth perceive and cope with threats and losses (including conforming to others' or one's own expectations of sex/gender identity) and adapt to pain (through substance use and help-seeking behaviours). Taken together, considering brain plasticity over the lifespan, these proposed antecedents to youth suicide highlight the importance of interventions that alter early environment(s) (e.g., childhood maltreatment) and/or one's ability to adapt to them. Further, such interventions may have more enduring protective effects, for the individual and for future generations, if implemented in youth.
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Zaheer J, Links PS, Law S, Shera W, Hodges B, Tsang AKT, Huang X, Liu P. Developing a Matrix Model of Rural Suicide Prevention. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2014. [DOI: 10.2753/imh0020-7411400403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | - Paul S. Links
- b University of Western Ontario, London, Ontario, Canada
| | - Samuel Law
- a University of Toronto, Toronto, Ontario, Canada
| | - Wes Shera
- a University of Toronto, Toronto, Ontario, Canada
| | - Brian Hodges
- a University of Toronto, Toronto, Ontario, Canada
| | | | | | - Pozi Liu
- d Department of Psychiatry, Yuquan Hospital, Tsinghua University, Beijing, China
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Fadum EA, Stanley B, Qin P, Diep LM, Mehlum L. Self-poisoning with medications in adolescents: a national register study of hospital admissions and readmissions. Gen Hosp Psychiatry 2014; 36:709-15. [PMID: 25307514 DOI: 10.1016/j.genhosppsych.2014.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 08/28/2014] [Accepted: 09/03/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine characteristics of hospital admissions and risk factors associated with rehospitalization for self-poisoning with medications in adolescents aged 10-19 years. METHOD This study used data from the Norwegian Patient Register from 2008 to 2011. The main outcome was hospital readmission within the observation period. A complementary log-log regression model was used to assess the effect of characteristics at index hospital admission on readmission. RESULTS Of 1497 patients, 76.4% were females and 89.8% were aged 15-19 years. At their first hospital admission, about one third received a secondary psychiatric diagnosis. Females (47.5%) were registered with an E-code for intentional self-harm more often than males (33.7%), and females were more often than males discharged to further treatment (27.8% vs. 21.5%). As many as 18.4% were rehospitalized for self-poisoning by medications. Significant predictors for hospital readmission were female sex [hazard ratio (HR) = 2.4, 95% confidence interval (CI) 1.7-3.6], discharge to further treatment (HR = 2.3, 95% CI 1.8-2.9) and psychiatric secondary diagnoses (HR = 1.5, 95% CI 1.2-1.9). CONCLUSION This national study demonstrated significant sex differences in adolescents treated in hospital for self-poisoning with medications. Psychiatric secondary diagnoses had a strong predictive effect on readmission, which indicates the importance of psychiatric/psychosocial assessment of adolescents who are admitted to hospital for self-poisoning with medications.
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Affiliation(s)
- Elin Anita Fadum
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway.
| | - Barbara Stanley
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway; Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA; Molecular Imaging and Neuropathology Division and Suicide Prevention Training, Implementation and Evaluation Program in the Center for Practice Innovation, New York State Psychiatric Institute, New York, NY, USA
| | - Ping Qin
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway
| | - Lien My Diep
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway; Department of Biostatistics, Epidemiology and Health Economics, Oslo University Hospital, Norway
| | - Lars Mehlum
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Norway
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Rhodes AE, Lu H, Skinner R. Time trends in medically serious suicide-related behaviours in boys and girls. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:556-60. [PMID: 25565689 PMCID: PMC4197790 DOI: 10.1177/070674371405901009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 03/01/2014] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine whether emergency department (ED) presentations for suicide-related behaviours (SRBs) in boys and girls were identified as more clinically acute in the ED in the period after the regulatory warnings against prescribing antidepressants and during the global economic recession, and to characterize the medical severity of SRBs among boys and girls to aid surveillance activities. METHOD Among Ontario boys and girls (aged 12 to 17 years) presenting to the ED with an incident (index) ED SRB event between fiscal years (FYs) 2002 to 2010, we compared the number of high (compared with lower) acuity events in FYs 2005 to 2010 to those in FYs 2002 to 2004. We described the SRB method by its acuity and tested the linearity of varying trends in the SRB method in boys and girls. RESULTS In both boys and girls, high acuity events were 50% greater after FY 2004 than before, regardless of subsequent admission, and most common among boys and girls who self-poisoned. In girls, opposing linear trends before and after FY 2004 were observed in the proportion of self-poisonings and cut (or) pierce SRB methods. Throughout the study period, there was a linear decline in the proportion of boys presenting to the ED with other methods. CONCLUSIONS The previously reported increase in hospital admissions after the warnings and during the recession is unlikely artifactual. An equivalent increase in high acuity events was also evident among those not subsequently admitted. The reasons for varying responses in boys and girls by SRB method warrant further study.
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Affiliation(s)
- Anne E Rhodes
- Research Scientist, Suicide Studies Research Unit and the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario; Associate Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario; Associate Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario; Adjunct Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Hong Lu
- Analyst, Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Robin Skinner
- Senior Injury Epidemiologist, Injury Section, Health Surveillance and Epidemiology Division, Centre for Chronic Disease Prevention, Public Health Agency of Canada, Ottawa, Ontario
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Bethell J, Bondy SJ, Lou WYW, Guttmann A, Rhodes AE. Emergency department presentations for self-harm among Ontario youth. Canadian Journal of Public Health 2013. [PMID: 23618204 DOI: 10.1007/bf03405675] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Self-harm is an important public health issue among youth, including as a major risk factor for suicide (a leading cause of death in this age group). This study used population-based emergency department data to describe clinical and demographic characteristics of emergency department presentations for self-harm among youth (12-17 year-olds) in the province of Ontario, Canada. METHODS Administrative data capturing every emergency department visit in Ontario between April 1, 2002 and March 31, 2009 were used to identify and describe self-harm presentations. RESULTS Over the 7-year period between 2002/03 and 2008/09, there were 16,835 self-harm presentations by 12,907 youth. Two thirds of self-harm presentations were self-poisonings (almost always with medicinal agents), followed by self-cutting, which accounted for about one quarter. Incidence rates were higher in girls than boys, increased with age, were inversely related to neighbourhood income and were highest in rural areas. Self-harm accounted for about 1 in 100 emergency department presentations by youth, but also a disproportionate number of presentations triaged as high acuity or admitted to hospital (about 1 in 20). CONCLUSION Self-harm is an important public health issue, requiring a comprehensive approach to prevention. Ontario has useful data with which to study emergency department presentations for self-harm, and the similarities between self-harm presentations among Ontario youth and those reported from the United States and Europe suggest generalizability of results between populations. Further research is needed to address the reasons for the geographic differences in frequency of self-harm.
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Affiliation(s)
- Jennifer Bethell
- Suicide Studies Research Unit, St. Michael's Hospital, Toronto, ON.
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Latent variable model for suicide risk in relation to social capital and socio-economic status. Soc Psychiatry Psychiatr Epidemiol 2012; 47:1205-19. [PMID: 21874524 DOI: 10.1007/s00127-011-0429-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 08/13/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is little evidence on the association between suicide outcomes (ideation, attempts, self-harm) and social capital. This paper investigates such associations using a structural equation model based on health survey data, and allowing for both individual and contextual risk factors. METHODS Social capital and other major risk factors for suicide, namely socioeconomic status and social isolation, are modelled as latent variables that are proxied (or measured) by observed indicators or question responses for survey subjects. These latent scales predict suicide risk in the structural component of the model. Also relevant to explaining suicide risk are contextual variables, such as area deprivation and region of residence, as well as the subject's demographic status. The analysis is based on the 2007 Adult Psychiatric Morbidity Survey and includes 7,403 English subjects. A Bayesian modelling strategy is used. RESULTS Models with and without social capital as a predictor of suicide risk are applied. A benefit to statistical fit is demonstrated when social capital is added as a predictor. Social capital varies significantly by geographic context variables (neighbourhood deprivation, region), and this impacts on the direct effects of these contextual variables on suicide risk. In particular, area deprivation is not confirmed as a distinct significant influence. The model develops a suicidality risk score incorporating social capital, and the success of this risk score in predicting actual suicide events is demonstrated. CONCLUSIONS Social capital as reflected in neighbourhood perceptions is a significant factor affecting risks of different types of self-harm and may mediate the effects of other contextual variables such as area deprivation.
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Evaluation of the New OneTouch Verio Versus FreeStyle Lite Glucose Meter and the Beckman DxC800 Laboratory Analyzer. POINT OF CARE 2012. [DOI: 10.1097/poc.0b013e3182479b93] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Routhier D, Leduc N, Lesage A, Benigeri M. [Portrait of the use of mental health services before and after a suicide attempt requiring hospitalization]. SANTE MENTALE AU QUEBEC 2012; 37:223-237. [PMID: 23666290 DOI: 10.7202/1014953ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Health care systems play an important role in suicide prevention. Medical and administrative data allow analysis of patterns of mental health service use before and after hospitalization following a suicide attempt among Montreal residents diagnosed with schizophrenia or depression. Some results tend to show improvement in suicide prevention, especially among men with comorbid substance abuse disorders known to be particularly vulnerable. However, other observations are somewhat worrisome. The emergency room as an introduction to mental health services did not ensure adequate aftercare. Interventions are needed to improve access and coordination between different health care services.
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Affiliation(s)
- Danielle Routhier
- Direction de la santé publique, Agence de la Santé et des Services sociaux de Montréal, Institut national de santé publique du Québec
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Spiller HA, Appana S, Brock GN. Epidemiological trends of suicide and attempted suicide by poisoning in the US: 2000-2008. Leg Med (Tokyo) 2010; 12:177-83. [PMID: 20547089 DOI: 10.1016/j.legalmed.2010.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2010] [Revised: 04/07/2010] [Accepted: 04/20/2010] [Indexed: 01/21/2023]
Abstract
UNLABELLED In the US the suicide rate on a population basis has risen and fallen over time between approximately 10 and 12 per 100,000 population. The recent trend toward an increased rate has been paralleled by an increase in emergency department visits for attempted suicide. The purpose of this study was to examine trends in suspected suicide (SS) cases reported to the National Poison Data System (NPDS), over a 9-year period (2000-2008). METHODS Data were obtained from NPDS, for all human patients between the years 2000 and 2008 with the reason for poisoning exposure recorded as "Intentional - Suspected Suicide" (ISS). Additionally, population sizes were obtained from the US Census Bureau as single annual counts by age and sex bands for the 2000-2008. RESULTS There were 1,672,324 human exposures reported to substances with the reason of SS. Sixty-five percent (1,084,669) were female. The average age of a patient was 30 years with the age groups 13-19 and 20-29 years reporting the highest SS events, 26.4% and 25.7%, respectively. From 2000 to 2008, the estimated rate of SS increased from 72.6 to 82.8 per 1000 human exposure cases. On a population basis, the estimated rate of SS increased from 55.8 to 67.9 per 100,000 population (p for trend <0.001). The relative risk of human exposures for reason of SS compared to human exposures for any other reason being reported to the NPDS is 1.13 (95% CI: [1.122-1.135], p < 0.001) for every 10 years. The relative risk for females vs. males was 1.82 for having SS as a reason for exposure (p < 0.001). However, females were also 0.82 times less likely to experience a severe medical outcome (SMO) compared to males (95% CI: [0.81-0.83], p < 0.001). We noted an increasing risk of a SMO or fatality increasing with age. CONCLUSIONS Based on the total human exposure cases reported to the NPDS, there was a suggested trend of an increase in SS rates of 13% in the next 10 years. There was a greater incidence of SS in females and younger age groups. However, the odds of a SMO or fatality were higher for males and increased with increasing age.
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Affiliation(s)
- Henry A Spiller
- Kentucky Regional Poison Control Center, Louisville, KY, USA.
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Koliou M, Ioannou C, Andreou K, Petridou A, Soteriades ES. The epidemiology of childhood poisonings in Cyprus. Eur J Pediatr 2010; 169:833-8. [PMID: 20016913 DOI: 10.1007/s00431-009-1124-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 11/30/2009] [Indexed: 11/30/2022]
Abstract
Information on childhood poisonings in Cyprus is limited. Our objective was to examine the epidemiology of poisonings among children in Cyprus. All children up to 15 years of age admitted for poisoning to the Archbishop Makarios Hospital in Nicosia, Cyprus between 2005 and 2008 were included in our study. All hospital poisoning records were reviewed. A total of 257 children were admitted for poisoning. The mean age of children was 3.1 years, of which 83.7% were below the age of 5 years old, while 53% were boys. The poisoning hospitalizations accounted for about 3% of all admissions to the pediatric department during the study period (4 years). The annual cumulative incidence of childhood poisoning hospitalizations was 116 per 100,000 children. Medications accounted for 46.1% of all poisonings, the most frequent cause being paracetamol (9.8%), cardiovascular medications (5.3%), antitussive medications (4.5%), and other painkillers (4.1%). Another 37.6% of hospitalizations involved household products such as household cleaning products (11.8%), petroleum products (11.0%), and rodenticides (5.7%). Among children who ingested petroleum distillates, 55.6% developed clinical symptomatology. The vast majority of cases were accidental (93.8%). Suicidal cases involved children 8-14 years old, mainly girls, and the most frequent poisoning ingested was paracetamol (46.7%). Poisoning hospitalizations represent an important cause of morbidity among children in Cyprus. Preventive strategies should include the education of caregivers on the handling of medications and household products as well as legislation requiring child-resistant packaging for all medications and household products including petroleum distillates.
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Affiliation(s)
- Maria Koliou
- Department of Pediatrics, Archbishop Makarios Hospital, Nicosia, Cyprus,
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Dianat S, Zarei MR, Hassanian-Moghaddam H, Rashidi-Ranjbar N, Rahimian R, Rasouli MR. Tricyclic antidepressants intoxication in Tehran, Iran: epidemiology and associated factors. Hum Exp Toxicol 2010; 30:283-8. [PMID: 20488849 DOI: 10.1177/0960327110371701] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Tricyclic antidepressant (TCA) intoxication contributes a large number of drug toxicities with serious complications. There are a few studies about factors associated with TCA intoxication. This study therefore aimed to identify determinants of this type of intoxication. METHODS A cross-sectional study was carried out at Loghman-Hakim Poison Hospital during a 6-month period. All poisoned patients aged >12 years presented to this hospital during the mentioned period were evaluated. Then, TCA-poisoned patients were compared with other drug intoxications as the control group to determine factors associated with TCA intoxications. RESULTS There were 9809 admissions, of which 1583 (16.1%) patients including 601 (38%) males were intoxicated with TCAs. Mean age of the subjects was 26.5 + 10 years. Most of the TCA intoxications (74.4%) were intentional (p = 0.01). Amitriptyline was the most frequent agent followed by Nortriptyline. There was no significant difference between TCA and non-TCA intoxications regarding the mortality (1.3% in TCA vs. 1.1% in others, p = 0.45). Logistic regression analysis revealed that sex, addiction status, and history of psychological problems have association with TCA intoxication. CONCLUSIONS The results of this study are helpful in identifying individuals who are prone to TCA intoxication and may be useful in implementation of preventive strategies.
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Affiliation(s)
- Saied Dianat
- Sina Trauma and Surgery Research Center, Sina Hospital, Tehrarn University of Medical Sciences, Tehran, Iran
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Kelly BD, Davoren M, Mhaoláin AN, Breen EG, Casey P. Social capital and suicide in 11 European countries: an ecological analysis. Soc Psychiatry Psychiatr Epidemiol 2009; 44:971-7. [PMID: 19277436 DOI: 10.1007/s00127-009-0018-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 02/18/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND "Social capital" refers to the existence of voluntary community networks and relationships based on trust, and the use of these networks and relationships to enable positive social action. Social capital is positively associated with selected indices of mental health. METHODS We performed an ecological investigation of the relationship between social trust (as one component of social capital) and national suicide rates in 11 European countries (n=22,227). RESULTS There was an inverse relationship between social trust and national suicide rates (i.e. the higher the social trust, the lower was the suicide rate), after controlling for gender, age, marriage rates, standardised income and reported sadness. CONCLUSIONS Social capital may have a protective effect against suicide at the national level. Multi-level analysis, taking into account both group-level and individual-level variables, would help clarify this relationship further and guide appropriate interventions at both the group and individual levels.
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Affiliation(s)
- Brendan D Kelly
- Department of Adult Psychiatry, University College Dublin, Mater Misericordiae University Hospital, 62/63 Eccles Street, Dublin 7, Ireland.
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Rhodes A, Bethell J, Jaakkimainen RL, Thurlow J, Spence J, Links PS, Streiner DL. The impact of rural residence on medically serious medicinal self-poisonings. Gen Hosp Psychiatry 2008; 30:552-60. [PMID: 19061682 DOI: 10.1016/j.genhosppsych.2008.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 06/28/2008] [Accepted: 06/30/2008] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Suicide rates are often high in rural areas. Despite the strong association between deliberate self-harm (DSH) and suicide, few have studied rural residence and DSH. Self-poisonings dominate DSH hospital presentations. We investigate a previously reported association between rural residence and medical severity (defined as a subsequent medical/surgical inpatient stay) among emergency department presentations for medicinal self-poisoning (SP) to determine whether differences in agents taken, mental health service use or hospital-level resources explain the relationship. METHOD A cohort of n=16,294 12-64-year olds presenting with SP to hospital emergency departments in Ontario, Canada, in 2001/2002 was linked to their service records over time. RESULTS The rural-medical severity association was best explained by differences in hospital resources; presenting to hospitals providing inpatient psychiatric services appeared to reduce medical/surgical inpatient stays in favor of psychiatric ones. Among those with a recent psychiatric admission, more intensive ambulatory psychiatric contact may be protective of a psychiatric inpatient stay subsequent to the SP presentation. Compared to nonrural residents, deliberate intent was identified less often in rural residents, particularly males. CONCLUSIONS The rural-medical severity association was best explained by disparities in the delivery systems serving rural and nonrural residents, important to rural suicide prevention efforts.
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Affiliation(s)
- Anne Rhodes
- Suicide Studies Unit, St. Michael's Hospital, Toronto, ON, Canada M5B 1W8.
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