A Comparison of Suicides in Public Safety Personnel With Suicides in the General Population in Ontario, 2014 to 2018

Background: There is conflicting evidence on the suicide rates of different public safety personnel (PSP). There have been few studies that compare suicides in PSP with the general population and none that have used a detailed comparison of coroner records. Aims: The current study estimates suicide rates among different PSP and compares PSP suicides with the general population. Method: We identified coroner records of PSP suicides from January 2014 to December 2018 and compared each one to two matched general population controls. Results: We identified 36 PSP suicides and 72 general population controls. Police had a higher suicide rate than other PSP groups. PSP were more likely to die by firearm, be separated/divorced or married, die in a motor vehicle, have problems at work, and have a PTSD diagnosis. PSP were less likely to die by jumping. Limitations: The study may have not identified all PSP suicides. Apart from the cause of death, data in coroner records are not systematically collected, so information may be incomplete. Conclusion: PSP suicides appear different than the general population. Death records need to have an occupation identifier to enable monitoring of trends in occupational groups, such as PSP.

Assessing support for mental health policies among policy influencers and the general public in Alberta and Manitoba, Canada

BACKGROUND

There is a need to improve mental health policy in Canada to address the growing population burden of mental illness. Understanding support for policy options is critical for advocacy efforts to improve mental health policy. Our purpose was to describe support for population-level healthy public policies to improve mental health among policy influencers and the general public in Alberta and Manitoba; and, identify associations between levels of support and sociodemographic variables and relative to the Nuffield Bioethics Intervention Ladder framework.

METHODS

We used data from the 2019 Chronic Disease Prevention Survey, which recruited a representative sample of the general public in Alberta (n = 1792) and Manitoba (n = 1909) and policy influencers in each province (Alberta n = 291, Manitoba n = 129). Level of support was described for 16 policy options using a Likert-style scale for mental health policy options by province, sample type, and sociodemographic variables using ordinal regression modelling. Policy options were coded using the Nuffield Council on Bioethics Intervention Ladder to classify support for policy options by level of intrusiveness.

RESULTS

Policy options were categorized as 'Provide Information' and 'Enable Choice' according to the Nuffield Intervention Ladder. There was high support for all policy options, and few differences between samples or provinces. Strong support was more common among women and among those who were more politically left (versus center). Immigrants were more likely to strongly support most of the policies. Those who were politically right leaning (versus center) were less likely to support any of the mental health policies. Mental health status, education, and Indigenous identity were also associated with support for some policy options.

CONCLUSIONS

There is strong support for mental health policy in Western Canada. Results demonstrate a gap between support and implementation of mental health policy and provide evidence for advocates and policy makers looking to improve the policy landscape in Canada.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Screening for depression in children and adolescents in primary care or non-mental health settings: a systematic review update

BACKGROUND

The transition from childhood to adolescence is associated with an increase in rates of some psychiatric disorders, including major depressive disorder, a debilitating mood disorder. The aim of this systematic review is to update the evidence on the benefits and harms of screening for depression in primary care and non-mental health clinic settings among children and adolescents.

METHODS

This review is an update of a previous systematic review, for which the last search was conducted in 2017. We searched Ovid MEDLINE® ALL, Embase Classic+Embase, PsycINFO, Cochrane Central Register of Controlled Trials, and CINAHL on November 4, 2019, and updated on February 19, 2021. If no randomized controlled trials were found, we planned to conduct an additional search for non-randomized trials with a comparator group. For non-randomized trials, we applied a non-randomized controlled trial filter and searched the same databases except for Cochrane Central Register of Controlled Trials from January 2015 to February 2021. We also conducted a targeted search of the gray literature for unpublished documents. Title and abstract, and full-text screening were completed independently by pairs of reviewers.

RESULTS

In this review update, we were unable to find any randomized controlled studies that satisfied our eligibility criteria and evaluated the potential benefits and harms of screening for depression in children and adolescents. Additionally, a search for non-randomized trials yielded no studies that met the inclusion criteria.

CONCLUSIONS

The findings of this review indicate a lack of available evidence regarding the potential benefits and harms of screening for depression in children and adolescents. This absence of evidence emphasizes the necessity for well-conducted clinical trials to evaluate the effectiveness of depression screening among children and adolescents in primary care and non-mental health clinic settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020150373 .

Reexploring Problematic Social Media Use and Its Relationship with Adolescent Mental Health. Findings from the "LifeOnSoMe"-Study

Purpose

Previous approaches used to assess problematic social media use risk inflating prevalence numbers and classifying unproblematic social media use as problematic. The main aim of this study was to take an exploratory view as to how different types of activities, experiences, and motivations on social media are associated with problematic mental health outcomes in adolescents.

Patients and Methods

This study is based on a cross-sectional survey of 2023 adolescents (mean age 17.4 years (SD 0.9), 44.4% males) from the year 2020. Exploratory graph analysis and exploratory factor analysis were performed on 28 pre-selected items assessing adolescents' use of social media, to identify underlying potentially problematic factors associated with social media use. Sets of gender-adjusted multiple linear regression analyses were performed to assess the degree to which social media factors predicted depression, anxiety, well-being, and time spent on social media.

Results

Three factors were identified: 1) "subjective overuse", 2) "social obligations", and 3) "source of concern". All three factors showed significant positive associations with mental health problems. The factor "source of concern", which identifies feelings of being overwhelmed and concerned over social media use, had the strongest association to mental health problems and simultaneously the weakest association to time spent on social media.

Conclusion

Three identified factors measuring problematic social media use showed positive associations with mental health problems. This lends support to the notion that problematic social media use is a multidimensional phenomenon and demonstrates the need to move beyond addiction criteria when assessing problematic social media use.

Associations between prenatal maternal stress, maternal inflammation during pregnancy, and children's internalizing and externalizing symptoms throughout childhood

BACKGROUND

Maternal immune activation is a potential mechanism underlying associations between maternal stress during pregnancy and offspring mental health problems. This study examined associations between prenatal maternal stress, maternal inflammation during pregnancy, and children's internalizing and externalizing symptoms from 3 to 10 years of age, and whether maternal inflammation mediated the associations between prenatal maternal stress and children's internalizing and externalizing symptoms.

METHODS

This study comprised 4,902 mother-child dyads in the Generation R study. Prenatal maternal stress was assessed using self-reported data collected during pregnancy and analyzed as a latent variable consisting of four stress domains. Maternal inflammation during pregnancy was assessed using serum concentrations of C-reactive protein (CRP) measured at a median of 13.5 weeks' gestation. Child internalizing and externalizing symptoms were assessed using the Child Behavior Checklist (CBCL) by maternal report at ages 3 years, 5 years, and 10 years; paternal-reported CBCL data were also available at 3 years and 10 years.

RESULTS

Prenatal maternal stress was associated with maternal-reported internalizing and externalizing symptoms of the child at 3, 5, and 10 years of age, and with paternal-reported internalizing and externalizing symptoms at 3 and 10 years. Prenatal maternal stress was associated with maternal CRP concentrations prior to, but not after, covariate adjustment. Maternal CRP concentrations during pregnancy were associated with paternal-reported internalizing symptoms of offspring at 10 years of age prior to, but not after, covariate adjustment. There was no evidence that CRP concentrations mediated the associations between prenatal maternal stress and children's internalizing or externalizing symptoms.

CONCLUSIONS

Maternal stress during pregnancy is associated with higher levels of internalizing and externalizing symptoms in children, but this association is not because of differences in maternal immune activation linked to maternal stress. Replication of these findings in other cohorts is required; examination of other biomarkers or variation in immune activity during pregnancy would also benefit from further exploration.

Applying the Theoretical Domains Framework to identify police, fire, and paramedic preferences for accessing mental health care in a First Responder Operational Stress Injury Clinic: a qualitative study

INTRODUCTION

First responders and other public safety personnel (PSP; e.g. correctional workers, firefighters, paramedics, police, public safety communicators) are often exposed to events that have the potential to be psychologically traumatizing. Such exposures may contribute to poor mental health outcomes and a greater need to seek mental health care. However, a theoretically driven, structured qualitative study of barriers and facilitators of help-seeking behaviours has not yet been undertaken in this population. This study used the Theoretical Domains Framework (TDF) to identify and better understand critical barriers and facilitators of help-seeking and accessing mental health care for a planned First Responder Operational Stress Injury (OSI) clinic.

METHODS

We conducted face-to-face, one-on-one semistructured interviews with 24 first responders (11 firefighters, five paramedics, and eight police officers), recruited using purposive and snowball sampling. Interviews were analyzed using deductive content analysis. The TDF guided study design, interview content, data collection, and analysis.

RESULTS

The most reported barriers included concerns regarding confidentiality, lack of trust, cultural competency of clinicians, lack of clarity about the availability and accessibility of services, and stigma within first responder organizations. Key themes influencing help-seeking were classified into six of the TDF's 14 theoretical domains: environmental context and resources; knowledge; social influences; social/professional role and identity; emotion; and beliefs about consequences.

CONCLUSION

The results identified key actions that can be utilized to tailor interventions to encourage attendance at a First Responder OSI Clinic. Such approaches include providing transparency around confidentiality, policies to ensure greater cultural competency in all clinic staff, and clear descriptions of how to access care; routinely involving families; and addressing stigma.

Psychological distress, non-medical use of prescription medications, and perceived unmet mental health care needs: a cross-sectional study of Ontario students

PURPOSE

The non-medical use of prescription medications among adolescents has become a concerning public health issue. This study assessed the prevalence of the non-medical use of prescription medications in Ontario high school students, and explored the moderating effect of this use on the relationship between psychological distress and unmet mental health needs.

METHODS

Cross-sectional data for 4896 students, age 14-18, were drawn from the 2019 Ontario Student Drug Use and Health Survey. Psychological distress was measured using the Kessler-6 Distress Scale, unmet mental health needs were defined by self-report (yes/no), and non-prescription medication use was defined by self-reported frequency of use. Using logistic regression, we explored the effect of the non-medical use of prescription medications on the relationship between psychological distress and unmet mental health needs.

RESULTS

High proportions of Ontario students reported serious psychological distress (22%), some degree of unmet mental health need (38%), and/or non-medical use of prescription medications (13%). While there were strong associations between psychological distress and unmet mental health need, this association was weaker among those reporting non-medical use of prescription medications (OR = 3.3, 95% CI 1.9-5.7) compared to non-users (OR = 5.6, 95% CI 4.5-7.1).

CONCLUSION

Our findings suggest that Ontario students experiencing distress and using non-prescribed medications are less likely to identify a need for mental health support, highlighting the consequences of apparent self-medication through misuse of prescription medications. To assist in the redirection of adolescent perceptions of healthy coping strategies, population-based educational programming, with targeted promotion of both formal and informal mental health care resources, should be considered.

Positive maternal mental health attenuates the associations between prenatal stress and children's internalizing and externalizing symptoms

Positive maternal mental health can improve perceptions of stressful situations and promote the use of adaptive coping strategies. However, few studies have examined how positive maternal mental health affects children's development. The aims of this study were to examine the associations between positive maternal mental health and children's internalizing and externalizing symptoms, and to ascertain whether positive maternal mental health moderated the associations between prenatal stress and children's internalizing and externalizing symptoms. This study is based on the Norwegian Mother, Father, and Child Cohort Study (MoBa), and comprised 36,584 mother-child dyads. Prenatal stress was assessed using 41 self-reported items measured during pregnancy. Positive maternal mental health (self-efficacy, self-esteem, and enjoyment) was assessed by maternal report during pregnancy and postpartum. Child internalizing and externalizing symptoms were assessed by maternal report at age 5. Structural equation modeling was used for analysis. Maternal self-efficacy, self-esteem, and enjoyment were negatively associated with internalizing and externalizing symptoms in males and females. The association between prenatal stress and internalizing symptoms in males was stronger at low than at high levels of maternal self-esteem and enjoyment, whereas for females, the association was stronger at low than at high levels of maternal self-esteem and self-efficacy. This study provides evidence of associations between positive maternal mental health and children's mental health, and suggests that higher positive maternal mental health may buffer against the impacts of prenatal stress. Positive maternal mental health may represent an important intervention target to improve maternal-child well-being and foster intergenerational resilience.

Heavy social media use and psychological distress among adolescents: the moderating role of sex, age, and parental support

Background

Despite increasing evidence that social media use is associated with adolescents' mental well-being, little is known about the role of various factors in modifying the effect of this association during adolescence. This study examined the association between social media use and psychological distress among adolescents and explored whether sex, age, and parental support moderate this association.

Methods

Data came from a representative sample of middle and high school students in Ontario, Canada. Cross-sectional analyses included 6,822 students derived from the 2019 Ontario Student Drug Use and Health Survey.

Results

Our results showed that 48% of adolescents used social media for 3 h or more per day, and 43.7% had moderate to severe psychological distress, with a higher prevalence among females (54%) than males (31%). After adjustment for relevant covariates, heavy social media use (≥3 h/day) was associated with increased odds of severe psychological distress [odds ratio (OR): 2.01; 95% confidence interval (CI):1.59-2.55]. The association of social media use with psychological distress was modified by age (p < 0.05) but not sex or parental support. The association was stronger among younger adolescents.

Conclusion

Heavy social media use is associated with higher levels of psychological distress, with younger adolescents being the most vulnerable. Longitudinal studies are recommended for future research to examine in more depth the role of sex, age, and parental support in the association between social media use and psychological distress to better determine the strength and of the association.

Daily changes in ambient air pollution concentrations and temperature and suicide mortality in Canada: Findings from a national time-stratified case-crossover study

INTRODUCTION

Worldwide, approximately 1900 people die by suicide daily. Daily elevations in air pollution and temperature have previously been linked to a higher risk of death from suicide. To date, there have been relatively few studies of air pollution and suicide, particularly at a national level. National analyses play an important role in shaping health policy to mitigate against adverse health outcomes.

METHODS

We used a time-stratified case-crossover study design to investigate the influence of short-term (i.e., day to day) interquartile range (IQR) increases in air pollutants (nitrogen dioxide [NO₂], ozone [O₃], and fine particulate matter [PM_2.5]) and temperature on suicide mortality in Canada between 2002 and 2015. For air pollution models, odds ratios (ORs) derived from conditional logistic regression models were adjusted for average daily temperature, and holidays. For temperature models, ORs were adjusted for holidays. Stratified analyses were undertaken by suicide type (non-violent and violent), sex, age, and season.

RESULTS

Analyses are based on 50,800 suicide deaths. Overall, temperature effects were stronger than those for air pollution. A same day IQR increase in temperature (9.6 °C) was associated with a 10.1% increase (95% confidence interval (CI): 9.0%-11.2%) of death from suicide. For 3-day average increase of O₃ (IQR = 14.1 ppb), PM_2.5 (IQR = 5.6 μg/m³) and NO₂ (IQR = 9.7 ppb) the corresponding risks were 4.7% (95% CI: 3.9, 5.6), 3.4% (95% CI: 3.0, 3.8), and 2.0% (95% CI: 1.1, 2.8), respectively. All pollutants showed stronger associations with suicide during the warmer season (April-September). Stratified analyses revealed stronger associations for both temperature and air pollution in women.

CONCLUSIONS

Daily increases in air pollution and temperature were found to increase the risk of death from suicide. Females, particularly during warmer season, were most vulnerable to these exposures. Policy decisions related to air pollution and climate change should consider effects on mental health.

Prenatal maternal stress, child internalizing and externalizing symptoms, and the moderating role of parenting: findings from the Norwegian mother, father, and child cohort study

BACKGROUND

Few studies have examined how parenting influences the associations between prenatal maternal stress and children's mental health. The objectives of this study were to examine the sex-specific associations between prenatal maternal stress and child internalizing and externalizing symptoms, and to assess the moderating effects of parenting behaviors on these associations.

METHODS

This study is based on 15 963 mother-child dyads from the Norwegian Mother, Father, and Child Cohort Study (MoBa). A broad measure of prenatal maternal stress was constructed using 41 self-reported items measured during pregnancy. Three parenting behaviors (positive parenting, inconsistent discipline, and positive involvement) were assessed by maternal report at child age 5 years. Child symptoms of internalizing and externalizing disorders (depression, anxiety, attention-deficit hyperactivity disorder, conduct disorder, and oppositional-defiant disorder) were assessed by maternal report at age 8. Analyses were conducted using structural equation modeling techniques.

RESULTS

Prenatal maternal stress was associated with child internalizing and externalizing symptoms at age 8; associations with externalizing symptoms differed by sex. Associations between prenatal maternal stress and child depression, and conduct disorder and oppositional-defiant disorder in males, became stronger as levels of inconsistent discipline increased. Associations between prenatal maternal stress and symptoms of attention-deficit hyperactivity disorder in females were attenuated as levels of parental involvement increased.

CONCLUSIONS

This study confirms associations between prenatal maternal stress and children's mental health outcomes, and demonstrates that these associations may be modified by parenting behaviors. Parenting may represent an important intervention target for improving mental health outcomes in children exposed to prenatal stress.

Young Adult Outcomes Associated With Adolescent Suicidality: A Meta-analysis

CONTEXT

Suicide is one of the leading causes of death among adolescents worldwide. Adolescents who present with suicidality may be at an increased risk for future mental illness and suicidality in young adulthood.

OBJECTIVE

The objective of this study was to systematically assess the relationship between adolescent suicidal ideation and suicide attempts (suicidality) and young adult psychopathological outcomes.

DATA SOURCES

Medline, Embase, and PsychInfo (OVID Interface) were searched for articles published before August 2021.

STUDY SELECTION

Included articles were prospective cohort studies that compared young adult (19-30 years) psychopathological outcomes between suicidal and nonsuicidal adolescents.

DATA EXTRACTION

We extracted data related to suicidality in adolescence, mental health outcomes in young adulthood, and covariates. Outcomes were analyzed via random-effect meta-analyses and reported using odds ratios.

RESULTS

Of 9401 references screened, we included 12 articles comprising over 25 000 adolescents. Four outcomes were meta-analyzed: depression, anxiety, suicidal ideation, and suicide attempt. Adjusted meta-analyses showed that adolescent suicidal ideation was associated with young adult suicide attempt (odds ratio [OR] = 2.75, 95% confidence interval [CI]:1.70-4.44), depressive disorders (OR = 1.58, 95% CI: 1.20-2.08), and anxiety disorders (OR = 1.41, 95% CI: 1.01-1.96), whereas adolescent suicide attempts were associated with young adult suicide attempt (OR = 5.71, 95% CI: 2.40-13.61), and young adult anxiety disorders (OR = 1.54, 95% CI: 1.01-2.34). Results for young adult substance use disorders were mixed.

LIMITATIONS

Significant heterogeneity between studies was observed because of differences in timing, method of assessments, and covariate adjustment.

CONCLUSIONS

Adolescents experiencing suicidal ideation or with a history of suicide attempt may have increased odds of further suicidality or mental disorders in young adulthood.

Melanin levels in relation to vitamin D among first-generation immigrants from different ethnic groups and origins: A comparative national Canadian cross-sectional study

Introduction

Immigrants to Western countries tend to have darker skin than native-born populations. We examined the relationship between skin melanin and serum vitamin D (vitD) [S-25(OH)D] levels and explored whether melanin levels explained S-25(OH)D variations between immigrants and native-born Canadians. This study offers novel findings as no such study has been conducted.

Methods

We used a national cross-sectional population-based design with data from the Canadian Health Measures Survey (CHMS). Skin melanin levels among first-generation immigrants based on their ethnicity and origin/country of birth were compared with white and native-born populations. We assessed the association between S-25(OH)D and melanin after adjusting for independent variables related to S-25(OH)D, melanin level, and immigration status.

Results

Of 11,579 participants, 21.9% were immigrants aged 3-79 years (mean age 39.23 years). Compared with non-immigrants, immigrants had lower S-25(OH)D levels (mean: 51.23 vs. 62.72; 95% CI: 8.37, 14.62; P < 0.001) but higher melanin levels (mean [SE]: 17.08 [0.25] vs. 16.29 [0.29]; 95% CI: -1.29, -0.281; P = 0.004). Melanin did not differ by length of stay in Canada but was weakly positively correlated (r = 0.088, P < 0.001) with S-25(OH)D. Sex (male), age (≥18 years), summer/fall seasons, sunlight exposure, sunscreen non-use, smoking, and alcohol consumption were associated with higher melanin levels, whereas indoor tanning use was not.

Conclusion

Skin melanin levels were associated with sociodemographic and behavioral characteristics. Immigrants had higher melanin levels, but melanin did not differ by length of stay in Canada. The weak positive correlation between melanin and S-25(OH)D suggested confounding factors may impact the relationship between melanin levels, S-25(OH)D, and immigration status.

Longitudinal associations between different types of screen use and depression and anxiety symptoms in adolescents

Background

Evidence examining the longitudinal associations between different types of screen behaviours and mental health among adolescents is limited. The present study examined the association between five types of screen behaviours and symptoms of anxiety and depression one year later. This study also assessed how changes in screen time were associated with changes in anxiety and depressive symptoms and whether the observed relationships were moderated by sex.

Methods

Longitudinal data of 17,174 students in grades 9-12 (53.5% females; mean age: 15.1 ± 0.9 years) attending high schools in Canada from two waves (year 6: 2017/18, year 7: 2018/19) of the COMPASS study were analyzed. Leisure screen time and mental health measures were self-reported. To test if the associations between screen time and anxiety, and depression vary by sex, two-way interactions were examined for sex. Analyses accounted for school clustering, race/ethnicity, sex, age, income, body mass index z-score, and previous year anxiety and depression symptoms.

Results

There were significant longitudinal associations between time spent on each type of screen and subsequent anxiety and depression symptoms. The strength of the associations varied by type of screen behaviour. Interaction analysis indicated a sex difference for television viewing and anxiety and depression symptoms, and internet surfing and anxiety symptoms. A dose-response relationship was observed between phone talking and anxiety symptoms. Beta estimates indicated that an increase in screen duration was associated with a further increase in anxiety and depression symptoms.

Conclusion

Higher screen time was longitudinally associated with higher anxiety and depression symptoms at one-year follow-up in adolescents. Time-change associations between screen usage and depressive and anxiety symptoms were observed. Also, associations differed based on sex and screen type, whereby greater increases in screen use predicted greater emotional distress. Findings from this prospective analysis suggest that screen time is an important determinant of anxiety and depressive symptoms among adolescents. Future studies are recommended to help inform programs promoting screen time reduction with a goal to enhance adolescents' mental health.

Assessment of the quality and content of clinical practice guidelines (CPGs) for vitamin D and for immigrants using the AGREE-II instrument: a protocol for systematic review

INTRODUCTION

Worldwide, more immigrants experience vitamin D (vitD) deficiency than non-immigrants, which is attributed to ethnic variations, place or region of birth, skin pigmentation, clothing style, and resettlement-related changes in diet, physical activity, and sun exposure. Current recommendations in clinical practice guidelines (CPGs) concerning vitD are inadequate to address vitD deficiency among immigrants. CPGs may also lack guidance for physicians on vitD supplementation for immigrants. Moreover, there are concerns about the overall quality of these CPGs.

OBJECTIVES

This systematic review will collate and critically appraise CPGs relevant to immigrants' health and vitD. Moreover, we will evaluate whether the CPGs of vitD including recommendations for immigrants and clarify whether the CPGs of immigrants include recommendations on vitD.

METHODS

A systematic search of Ovid MEDLINE® ALL, EMBASE, and Turning Research Into Practice (TRIP) electronic databases, guideline repositories, and gray literature will be conducted to identify relevant CPGs. Two reviewers will independently evaluate the methodological quality of the retrieved guidelines using the Appraisal of Guidelines, Research, and Evaluation-II (AGREE-II) instrument. CPGs scoring ≥60% in at least four domains, including "rigor of development," will be considered high quality.

CONCLUSION

Evaluating the quality and content of relevant CPGs may support researchers in developing national and global guidelines for immigrants. Furthermore, it may support vitD testing, nutritional counseling, and supplementation for vulnerable immigrant sub-populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021240562.

Focus on Self-Presentation on Social Media across Sociodemographic Variables, Lifestyles, and Personalities: A Cross-Sectional Study

Upward social comparison and aspects of self-presentation on social media such as feedback-seeking and strategic self-presentation may represent risk factors for experiencing negative mental health effects of social media use. The aim of this exploratory study was to assess how adolescents differ in upward social comparison and aspects of self-presentation on social media and whether these differences are linked to sociodemographic variables, lifestyle, or personality. The study was based on cross-sectional data from the "LifeOnSoMe" study performed in Bergen, Norway, including 2023 senior high school pupils (response rate 54%, mean age 17.4, 44% boys). Nine potentially relevant items were assessed using factor analysis, and latent class analysis was used to identify latent classes with distinct patterns of responses across seven retained items. The retained items converged into one factor, called "focus on self-presentation". We identified three groups of adolescents with a low, intermediate, and high focus on self-presentation. Associations between identified latent classes and covariates were assessed using regression analyses. Being a girl, higher extraversion, lower emotional stability, more frequent alcohol consumption, and having tried tobacco were associated with membership in the high-focus group. These results suggest some characteristics that are associated with a higher focus on self-presentation and that could inform targeted interventions.

Screening for depression among the general adult population and in women during pregnancy or the first-year postpartum: two systematic reviews to inform a guideline of the Canadian Task Force on Preventive Health Care

BACKGROUND

Depression affects an individual's physical health and mental well-being and, in pregnant and postpartum women, has specific adverse short- and long-term effects on maternal, child, and family health. The aim of these two systematic reviews is to identify evidence on the benefits and harms of screening for depression compared to no screening in the general adult and pregnant and postpartum populations in primary care or non-mental health clinic settings. These reviews will inform recommendations by the Canadian Task Force on Preventive Health Care.

METHODS

We searched MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library using a randomized controlled trial filter, where applicable, October 4, 2018, and updated to May 11, 2020. We also searched for gray literature (e.g., websites of organizations of health professionals and patients). Study selection for depression screening trials was performed first on title and abstract, followed by full-text screening. Data extraction, assessment of the risk of bias using the Cochrane risk of bias tool, and application of Grading of Recommendations Assessment, Development and Evaluation were performed by one reviewer and validated by a second reviewer.

RESULTS

A total of three trials were included. All three trials were included in the general adult review, while one of the three trials was included in the pregnant and postpartum review. We did not pool results due to substantial differences between studies and high risk of bias. In the general adult review, the first trial (n = 1001) evaluated whether screening for depression in adults with acute coronary syndrome compared to usual care improves health-related quality of life, depression symptoms, or harms of screening at 6, 12, and 18 months. There were little to no differences between the groups at 18 months for the outcomes. The second trial included adults (n = 1412) undergoing initial consultation for osteoarthritis, evaluated for depression and general health (mental and physical) after initial consultation and at 3, 6, and 12 months. The physical component score was statistically significantly lower (worse health) in the screened group at 6 months; however, this difference was not significant at 3 or at 12 months. There were no clinically important or statistically significant differences for other outcomes between groups at any time. The third trial (included in both reviews) reported on 462 postpartum women. At 6 months postpartum, fewer women in the screening group were identified as possibly depressed compared to the control group (RR 0.59, 95% confidence interval (CI) 0.39 to 0.89) and mean EPDS scores were also statistically significantly lower in the screened group (standardized mean difference 0.34 lower (95% CI 0.15 to 0.52 lower)). All other outcomes did not differ between groups at follow-up. There were serious concerns about the cut-offs used for the questionnaire used to screen, diagnostic confirmation, selective outcome reporting, and the reported magnitude of effects.

DISCUSSION

There are limitations of the evidence included in the reviews. There was moderate certainty in the evidence from one trial that screening for depression in the general adult population in primary care or non-mental health clinic settings likely results in little to no difference on reported outcomes; however, the evidence was uncertain from the other two included trials. The evidence is very uncertain about the effect of screening for depression in pregnant or postpartum women in primary care or non-mental health clinic settings. Well-conducted and better-reported trials are needed that meet the screening trial criteria used in this review.

SYSTEMATIC REVIEW REGISTRATION

Both protocols have been registered in the International Prospective Registry of Systematic Reviews (PROSPERO) [adult: CRD42018099690 ; pregnancy and postpartum: CRD42018099689 ] and published ( https://systematicreviewsjournal.biomedcentral.com/track/pdf/10.1186/s13643-018-0930-3 ).

Suicidality among sexual minority and transgender adolescents: a nationally representative population-based study of youth in Canada

Background:

Very little research has described risk of suicidal ideation and suicide attempt among transgender youth using high-quality, nationally representative data. We aimed to assess risk of suicidality among transgender and sexual minority adolescents in Canada.

Methods:

We analyzed a subsample of adolescents aged 15–17 years from the 2019 Canadian Health Survey on Children and Youth, a nationally representative, cross-sectional survey. We defined participants’ transgender identity (self-reported gender different from sex assigned at birth) and sexual minority status (self-reported attraction to people of the same gender) as exposures, and their self-reported previous-year suicidal ideation and lifetime suicide attempt as outcomes.

Results:

We included 6800 adolescents aged 15–17 years, including 1130 (16.5%) who indicated some degree of same-gender attraction, 265 (4.3%) who were unsure of their attraction and 50 (0.6%) who reported a transgender identity. Compared with cisgender, heterosexual adolescents, transgender adolescents showed 5 times the risk of suicidal ideation (95% confidence interval [CI] 3.63 to 6.75; 58% v. 10%) and 7.6 times the risk of suicide attempt (95% CI 4.76 to 12.10; 40% v. 5%). Among cisgender adolescents, girls attracted to girls had 3.6 times the risk of previous-year suicidal ideation (95% CI 2.59 to 5.08) and 3.3 times the risk of having ever attempted suicide (95% CI 1.81 to 6.06), compared with their heterosexual peers. Adolescents attracted to multiple genders had 2.5 times the risk of suicidal ideation (95% CI 2.12 to 2.98) and 2.8 times the risk of suicide attempt (95% CI 2.18 to 3.68). Youth questioning their sexual orientation had twice the risk of having attempted suicide in their lifetime (95% CI 1.23 to 3.36).

Interpretation:

We observed that transgender and sexual minority adolescents were at increased risk of suicidal ideation and attempt compared with their cisgender and heterosexual peers. These findings highlight the need for inclusive prevention approaches to address suicidality among Canada’s diverse youth population.

Short-term changes in meteorological conditions and suicide: A systematic review and meta-analysis

BACKGROUND

Suicide is a leading cause of death, particularly for young adults. Suicidal behaviours are influenced by a wide-range of personal, social, and cultural factors. Emerging evidence suggests that daily changes in meteorological conditions, including temperature, increases the risk of suicide.

METHODS

We conducted a systematic review and meta-analysis of studies that examined associations between either daily, or weekly, variations for eight meteorological variables and suicide outcomes (attempts, or deaths). Meta-analytic methods were applied to derive summary measures of association using random effect models. We assessed the heterogeneity in these associations by region and biological sex.

RESULTS

We identified 29 studies of suicide. Of these, 26 reported associations between temperature, while fewer studies reported on rain (n = 4), solar radiation (n = 4), humidity (n = 3), sunshine (n = 3), atmospheric pressure (n = 2), wind (n = 2) and cloud cover (n = 2). The overall relative risk for suicide deaths/attempts per 1 °C increase in ambient temperature was 1.016 (95% CI: 1.013-1.019). Subgroup analysis of temperature found stronger associations with suicide when using the maximum rather than the mean daily temperature, among men, and for completed suicides relative to attempts. Regionally, the strongest associations were found in the East Asia and Pacific region. While associations were found for solar radiation and cloud coverage and suicide, we did not undertake a meta-analysis for these exposures as it was not possible to standardize measures of association across studies. Statistically significant associations were not observed for other identified meteorological variables.

CONCLUSIONS

Our findings suggest that daily increases in temperature increase the risk of suicide, particularly, among men and in the East Asia and Pacific region.

Vitamin D and Chronic Diseases among First-Generation Immigrants: A Large-Scale Study Using Canadian Health Measures Survey (CHMS) Data

Background: Nearly 22% of the Canadian population are first-generation immigrants. We investigated immigrants’ health status and health deterioration over time in terms of the prevalence of chronic diseases (CDs) and their relationship to vitD status. Methods: We used cycles three (2012–2013) and four (2014–2015) of the Canadian Health Measures Survey. These data contained unique health information and direct physical/blood measures, including serum 25-hydroxyvitamin D (S-25(OH)D). Indicators of health status and deterioration were the prevalence of CDs diagnosed by healthcare professionals, self-reported general and mental health, and CD-related biomarkers. Results: The data (n = 11,579) included immigrants from more than 153 countries. Immigrants were healthier than non-immigrants for most health status measures. The prevalence of CDs was higher among those who migrated to Canada aged ≥ 18 years. A longer time in Canada after immigration was associated with a higher risk for CDs. The mean S-25(OH)D was lower among immigrants, higher among patients with CDs, and inversely associated with glycated hemoglobin, total cholesterol/high-density lipoprotein ratio, immunoglobulin E, serum ferritin, and blood hemoglobin. After adjusting for covariates, no association was found between S-25(OH)D and the prevalence of CDs. Conclusions: Lower levels of accumulated S-25(OH)D among immigrants may impact their health profile in terms of CD-related biomarkers, which partially explains immigrants’ health deterioration over time. We recommend further longitudinal research to investigate immigrants’ vitD and health deterioration.

The gendered relationship between illicit substance use and self-harm in university students

PURPOSE

To estimate associations between multiple forms of substance use with self-harming thoughts and behaviours, and to test whether gender is an effect modifier of these associations, both independently and along with perceived risk of cannabis use.

METHODS

Data were drawn from the 2018 Norwegian Students' Health and Wellbeing Study (SHoT 2018). A national sample of n = 50,054 full-time Norwegian students (18-35 years) pursuing higher education completed a cross-sectional student health survey, including questions on past-year self-harm: non-suicidal thoughts of self-harm, non-suicidal self-harm, suicidal thoughts, and suicide attempt. Students reported their frequency of past-year alcohol use (range: never to ≥ 4 times/ week), illicit substance consumption, and perceived risk of cannabis use. The AUDIT and CAST screening tools measured problematic alcohol and cannabis consumption, respectively. We used logistic regression modelling adjusted for age, symptoms of depression and anxiety, and financial hardship (analytic sample range: n = 48,263 to n = 48,866).

RESULTS

The most frequent alcohol consumption category (≥ 4 times/ week) was nearly always associated with more than a two-fold increased likelihood of self-harm. Less frequent alcohol consumption was associated with reduced odds of suicidal thoughts [monthly or less: OR = 0.87 (95% CI: 0.75-1.00), 2-4 times/month: OR = 0.79 (95% CI: 0.69-0.91), and 2-3 times/ week: OR = 0.83 (95% CI: 0.71-0.98)]. Problematic alcohol consumption was associated with most outcomes: odds ranging from 1.09 (95% CI: 1.01-1.18) for suicidal thoughts to 1.33 (95% CI: 1.00-1.77) for suicide attempt. There was evidence of multiple illicit substance by gender interactions: consumption of all but one illicit substance category (other drug use) was associated with all four forms of self-harm for women, but findings among men were less clear. Among men, only one illicit substance category (stimulant) was associated with most forms of self-harm. Women, but not men, who perceived cannabis use as a health risk were more likely to experience non-suicidal thoughts as cannabis consumption increased, and with harmful consumption patterns.

CONCLUSION

Frequent alcohol consumption is associated with increased risk of self-harm and suicidality for young women and men. Associations between illicit substance use and self-harm and suicidality appear stronger in women compared to men.

Spinal pain and major depression in a military cohort: bias analysis of dependent misclassification in electronic medical records

BACKGROUND

Spinal pain and major depression are prevalent conditions in adult populations and are particularly impactful in the military. However, the temporal relationship between these two conditions remains poorly understood.

METHODS

Using data extracted from electronic medical records, we assessed the association between incident diagnoses of spinal pain and major depression in a cohort of 48,007 Canadian Armed Forces personnel followed from January 2017 to August 2018. We used multivariate Poisson regression to measure the association between the period prevalence of these two conditions. We used probabilistic bias modelling to correct our estimates for misclassification of spinal pain and major depression.

RESULTS

After correcting for misclassification with probabilistic bias modelling, subjects newly diagnosed with spinal pain during the study period were 1.41 times (95% interval 1.25, 1.59) more likely also to be diagnosed with incident major depression, and personnel newly diagnosed with major depression were 1.28 times (95% interval 1.17, 1.39) more likely also to be diagnosed with spinal pain, compared to undiagnosed counterparts of the same age and sex. Without bias corrections, we would have overestimated the magnitude of the association between major depression and spinal pain by a factor of approximately 2.0.

CONCLUSION

Our results highlight a moderate and bi-directional association between two of the most prevalent disorders in military populations. Our results also highlight the importance of correcting for misclassification in electronic medical record data research.

Prenatal work stress is associated with prenatal and postnatal depression and anxiety: Findings from the Norwegian Mother, Father and Child Cohort Study (MoBa)

BACKGROUND

An emerging body of research suggests that stress experienced in the workplace can have detrimental impacts on maternal mental health, including greater risk of postnatal depression. However, few longitudinal studies have examined these associations during the perinatal period. The objective of this study was to examine the associations between prenatal work stress and subsequent depression and anxiety.

METHODS

This study is based on the Norwegian Mother, Father and Child Cohort Study (MoBa), and included 77,999 employed women recruited between 1999 and 2008. The exposure variable was prenatal work stress measured at 17 weeks' gestation, using an 8-item scale examining factors including autonomy, working relationships, and work enjoyment. Outcomes included depression and anxiety at 30 weeks' gestation and 6 months postpartum, measured using the Symptom Checklist-8. Analyses comprised of unadjusted and adjusted logistic regressions.

RESULTS

After covariate adjustment, prenatal work stress was associated with depression and anxiety at 30 weeks' gestation (OR = 1.33, 95% CI: 1.19-1.49), and 6 months postpartum (OR = 1.44, 95% CI: 1.28-1.61). Most associations remained after adjustment for additional work-related variables and maternity leave.

LIMITATIONS

Work stress was measured once during pregnancy, thus variation of associations by trimester could not be investigated. Findings are reported for a sample with high socioeconomic status, and may not generalize to other populations.

CONCLUSIONS

Women dealing with work stress during pregnancy are more likely to experience subsequent depression and anxiety. Findings can inform the development of workplace strategies to support the mental health of expecting and new mothers.

Longitudinal association between movement behaviours and depressive symptoms among adolescents using compositional data analysis

BACKGROUND

Research examining the associations between movement behaviours and mental health indicators within a compositional framework are sparse and limited by their cross-sectional study design. This study has three objectives. First, to describe the change in movement behaviour composition over time. Second, to explore the association between change in movement behaviour composition and change in depressive symptoms. Third, to explore how reallocations of time between movement behaviours are associated with changes in depressive symptoms.

METHODS

Longitudinal data of 14,620 students in grades 9-12 (mean age: 14.9 years) attending secondary schools in Canada (Ontario, British Columbia, Alberta, Quebec) were obtained from two waves (2017/18, 2018/19) of the COMPASS study. Moderate-to-vigorous physical activity (MVPA), recreational screen time, and sleep duration were self-reported. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (Revised)-10 (CESD-R-10). Compositional data analyses using pivot coordinates and compositional isotemporal substitution for longitudinal data were used to analyse the data. Analyses accounted for school clustering, were stratified by gender and age (< or ≥ 15 years), and were adjusted for race/ethnicity, body mass index z-score, baseline movement behaviour composition, and baseline depressive symptoms.

RESULTS

There were significant differences in movement behaviour composition over time across all subgroups. For example, the relative contributions of MVPA and sleep duration to the movement behaviour composition decreased over time while screen time increased among younger boys and girls and older girls. Increasing sleep duration relative to the remaining behaviours (i.e. screen time and MVPA) was associated with lower depressive symptoms among all subgroups. Increasing screen time relative to the remaining behaviours (i.e. MVPA and sleep duration) was associated with higher depressive symptoms among all subgroups. Increasing MVPA relative to the remaining behaviours (i.e. screen time and sleep duration) was associated with lower depressive symptoms in older girls only. Isotemporal substitution estimates indicated that decreasing screen time by 60 minutes/day and replacing that time with 60 minutes of additional sleep is associated with the largest change in depressive symptoms across all subgroups.

CONCLUSIONS

Findings from this prospective analysis suggest that increased sleep duration and reduced screen time are important determinants of lower depressive symptoms among adolescents.

Correlates of driving after cannabis use in high school students

Driving under the influence of cannabis is a growing public health concern among young people. This study assessed the prevalence of cannabis-impaired driving and its related sociodemographic, psychological, and knowledge-based correlates among Canadian adolescents. The sample for this study were drawn from the 2017 Ontario Student Health and Drug Use Survey (OSDUHS), consisting of high school students with valid driver's licenses (mean age = 16.8, SD = 0.71) who were asked about their driving behaviors, drug use, and attitudes regarding cannabis use (N = 1161). A multivariable logistic regression model was performed to determine the strongest correlates of driving after cannabis use. The prevalence of past-year driving within an hour of cannabis use was 10.3% (95% CI: 7.8,13.5). In the final multivariable model, probable cannabis dependence (OR = 12.7, 95%CI: 3.4,47.7), low perceived risk of cannabis use (OR = 5.3, 95%CI: 2.5,11.1), pro-legalization attitudes, (OR = 4.3, 95%CI: 2.0,9.1) and male gender (OR = 2.6, 95%CI: 1.5,4.5) were significantly associated with driving under the influence of cannabis. Other correlates of driving after cannabis user were risky driving behaviors, including past-year texting and driving and driving after alcohol use. There are various correlates of driving under the influence of cannabis, including attitudes related to cannabis which may be amenable to intervention. Future efforts should continue to monitor the prevalence of cannabis-impaired driving in this population and determine whether changes in students' attitudes surrounding cannabis are linked to behavioural changes.

Early Puberty Is Associated With Higher Academic Achievement in Boys and Girls and Partially Explains Academic Sex Differences

PURPOSE

On average, boys have lower academic achievement than girls. We investigated whether the timing of puberty is associated with academic achievement, and whether later puberty among boys contributes to the sex difference in academic achievement.

METHOD

Examination scores at age 16 were studied among 13,477 British twins participating in the population-based Twins Early Development Study. A pubertal development scale, a height-based proxy of growth spurt, and age at menarche were used as indicators of puberty. Associations between puberty, sex, and academic achievement were estimated in phenotypic mediation models and biometric twin models.

RESULTS

Earlier puberty was associated with higher academic achievement both in boys and girls. The exception was early age at menarche in girls, which associated with lower academic achievement. More than half of the sex differences in academic achievement could be linked to sex differences in pubertal development, but part of this association appeared to be rooted in prepubertal differences. The biometric twin modelling indicated that the association between puberty and academic achievement was due to shared genetic risk factors. Genetic influences on pubertal development accounted for 7%-8% of the phenotypic variation in academic achievement.

CONCLUSIONS

Pubertal maturation relates to the examination scores of boys and of girls. This can give genes related to pubertal maturation an influence on outcomes in education and beyond. Sex differences in pubertal maturation can explain parts of the sex difference in academic achievement. Grading students when they are immature may not accurately measure their academic potential.

Vitamin D Status among First-Generation Immigrants from Different Ethnic Groups and Origins: An Observational Study Using the Canadian Health Measures Survey

One in five Canadians are first-generation immigrants. Evidence suggests the baseline risk for vitamin D (vitD) deficiency is increased among immigrants who move from equatorial to northern countries. We investigated the prevalence and determinants of vitD deficiency/insufficiency among first-generation immigrants compared with native-born Canadians and identified explanatory covariables. We used a cross-sectional design with data from the national Canadian Health Measures Survey (Cycles 3 and 4) (11,579 participants aged 3-79 years). We assessed serum 25-hydroxyvitamin D (S-25(OH)D) levels, sociodemographic and environmental factors, immigration status, length of time in Canada, vitD-rich food intake, ethnicity, and place of birth. Immigrants had lower mean S-25(OH)D than non-immigrants (51.23 vs. 62.72 nmol/L, p < 0.001). Those with younger age at the time of immigration (<18 years) had a high risk for low vitD, and S-25(OH)D levels increased with the length of time they had lived in Canada. The highest deficiency levels were in immigrants born in Morocco, India, and Lebanon compared with native-born Canadians. Ethnicity was the factor most strongly associated with S-25(OH)D. Compared with the white ethnic grouping, the Japanese had the highest level of vitD deficiency, followed by Arabs and Southeast Asians. Ethnic variations, dietary intake, and lifestyle factors are the main predictors of/explanatory factors for vitD status among Canadian immigrants.

Exploring Links Between Prenatal Adversity and Adolescent Psychiatric Risk in a Canadian Population-Based Sample

OBJECTIVE

Adverse prenatal and postnatal exposures may have long-lasting effects on health and development. However, it remains unclear whether being exposed to a greater number of prenatal adversities affects mental health risk. The current study examined whether exposure to maternal health problems prenatally is associated with an increasing risk of psychiatric morbidity in adolescents.

METHODS

Using data from the 2014 Ontario Child Health Study (OCHS), we examined associations between a count of 7 prenatal risk factors (maternal hypertension, diabetes mellitus, bleeding during pregnancy, influenza, urinary tract infection, thyroid disease, and depression/anxiety) and adolescent psychiatric morbidity. Adolescents (N = 2219) aged 12 to 17 years were assessed using the Mini-International Neuropsychiatric Interview for Children and Adolescents.

RESULTS

Exposure to each additional prenatal adversity was correlated with increased odds of attention-deficit/hyperactivity disorder (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.03-1.60), generalized anxiety disorder (OR = 1.27, 95% CI = 1.05-1.55), and social anxiety disorder (OR = 1.35, 95% CI = 1.01-1.80) after adjustment for confounding variables.

CONCLUSION

Exposure to prenatal adversity in the form of maternal health problems was correlated with an increased risk of attention deficit hyperactivity disorder and anxiety disorders in adolescence. Future studies should further investigate the effects of antenatal environmental exposures on these associations to determine the potential value of close monitoring of those exposed to prenatal risks.

The Canadian 24-Hour Movement Guidelines and Psychological Distress among Adolescents: Les Directives canadiennes en matière de mouvement sur 24 heures et la détresse psychologique chez les adolescents

OBJECTIVE

The Canadian 24-Hour Movement Guidelines for Children and Youth recommend at least 60 minutes of physical activity per day, 2 hours or less of recreational screen time per day, and 9 to 11 hours of sleep per night for 5 to 13 years old and 8 to 10 hours per night for 14 to 17 years old. This study examined the association between meeting these guidelines and psychological distress among adolescents.

METHODS

The present cross-sectional sample included 6,364 students aged 11 to 20 years from the 2017 Ontario Student Drug Use and Health Survey. This provincially representative school-based survey is based on a 2-stage cluster design. A confirmatory factor analysis (CFA) was first conducted to confirm the factor structure of the K6, and structural equation modeling adjusted for age, sex, ethnoracial background, subjective socioeconomic status, and body mass index z-score was used to investigate the association between meeting the 24-Hour Movement Guidelines and K6 factors among adolescents.

RESULTS

The CFA demonstrated that a 2-factor model (representing anxiety and depressive symptoms) of the K6 fit the data well. The anxiety and depression items demonstrated a composite reliability (Cronbach's α) of 0.86 and 0.83, respectively, indicating a high level of internal consistency. Compared to meeting none of the recommendations, meeting all 3 movement behavior recommendations was associated with lower anxiety (β = -0.076; P = 0.028) and depressive symptoms (β = -0.067; P = 0.028). Meeting the screen time + sleep duration recommendations had the strongest association with anxiety (β = -0.157; P < 0.001) and depressive symptoms (β = -0.139; P < 0.001), followed by meeting the sleep duration recommendation only for both anxiety (β = -0.135; P < 0.001) and depressive symptoms (β = -0.106; P < 0.001).

CONCLUSIONS

Meeting the 24-Hour Movement Guidelines was associated with lower anxiety and depressive symptoms among adolescents, and these associations appear mainly driven by meeting the sleep duration recommendation.

The association between ambient air pollution concentrations and psychological distress

BACKGROUND

A growing number of epidemiological studies have linked air pollution exposure to psychological conditions. Laboratory studies indicate that air pollutants can activate the neuroendocrine stress axis and modulate stress hormone levels, which could contribute to the development or exacerbation of psychological distress. The present study examined the spatial associations between air pollutants (fine particulate matter [PM_2.5], nitrogen dioxide [NO₂] and ground-level ozone [O₃]) and psychological distress among subjects in the most populous provinces in Canada.

DATA AND METHODS

Subjects were sampled from the Canadian Community Health Survey in three regions (Quebec in 2005 [n=25,800], British Columbia and Alberta in 2005 [n=23,000], and Ontario in 2011 [n=36,000]), and were assigned estimates of annual exposure to three ambient air pollutants (PM_2.5, NO₂ and O₃) for the same years. Individual psychological distress was assessed using the Kessler Psychological Distress Scale (K10), based on anxiety and depressive symptoms in the past month. Regression models (both ordinary least squares and simultaneous autoregressive models) were applied to estimate associations between K10 distress scores and each air pollutant, after adjusting for individual (demographic, socioeconomic and behavioural) and neighbourhood covariates..

RESULTS

Psychological distress was positively associated with PM_2.5 and NO₂ in all three regions, and with O₃ in Quebec. However, after further adjusting for individual and neighbourhood covariates, the associations between distress and air pollution remained statistically significant only in Quebec.

DISCUSSION

Some evidence for positive associations between psychological distress and ambient air pollution after adjusting for spatial autocorrelation was found.

Nonmedical use of prescription opioids, psychological distress, and suicidality among adolescents

PURPOSE

The present study examined associations between nonmedical use of prescription opioids and serious psychological distress, suicidal ideation, and suicide attempts, and tested whether age and sex moderate these relationships.

METHODS

Data on 5582 adolescents were obtained from a representative province-wide survey of students in grades 7 through 12 (mean age: 15.3 years) across Ontario, Canada. Nonmedical use of prescribed opioids in the last 12 months was categorized in "no use", "infrequent use (1-2 times)", and "regular use (3 times or more)". Logistic regression analysis was adjusted for age, sex, ethnicity, subjective socioeconomic status, and other substance use (i.e., tobacco cigarette, alcohol, cannabis).

RESULTS

Overall, regular nonmedical use of prescription opioids was strongly associated with greater odds of serious psychological distress (OR: 3.47; 95% CI 1.42-8.45), suicidal ideation (OR: 2.73; 95% CI 1.84-4.05), and suicide attempts (OR: 3.21; 95% CI 1.40-7.37). However, infrequent nonmedical use of prescription opioids was associated with greater odds of serious psychological distress (OR: 1.79; 95% CI 1.08-2.98) and suicidal ideation (OR: 1.63; 95% CI 1.20-2.21), but not suicide attempts (OR: 1.84; 95% CI 0.76-4.45). Age-stratified analyses showed that both infrequent (OR: 1.61; 95% CI 1.01-2.58) and regular (OR: 3.40; 95% CI 2.11-5.46) nonmedical use of prescription opioids was strongly associated with greater odds of suicidal ideation among 15- to 20-year-olds, but not 11- to 14-year-olds.

CONCLUSION

These findings suggest that nonmedical use of prescription opioids is strongly associated with mental health problems among adolescents. Future research using a longitudinal design is needed to confirm age differences and temporality.

24-Hour Movement Behaviors and Internalizing and Externalizing Behaviors Among Youth

PURPOSE

The Canadian 24-Hour Movement Guidelines for Children and Youth (≥60 minutes of moderate-to-vigorous physical activity per day, ≤2 hours of recreational screen time per day, and 9-11 hours of sleep per night for 5-13 years old) are associated with better physical health, but less is known about how these behaviors are related to mental health. This study examined the association of meeting these guideline recommendations with internalizing and externalizing behaviors among youth.

METHODS

A large and broadly representative cross-sectional sample of 9- to 11-year-old U.S. youth (N = 11,875) from the Adolescent Brain and Cognitive Development study was analyzed. Internalizing and externalizing behaviors were measured using the Child Behaviour Checklist. Associations were examined using negative binomial regression adjusted for several confounders.

RESULTS

Compared to meeting none of the recommendations, meeting recommendations for screen time and sleep but not physical activity was associated with a lower prevalence ratio of total, internalizing, and externalizing behaviors. Meeting two or all three recommendations was more strongly associated with these outcomes than meeting one recommendation or none. The prevalence ratio of the group meeting all three recommendations was .77 (95% confidence interval [CI]: .68-.86) for total problem scores, .78 (95% CI: .68-.89) for internalizing problem scores, and .79 (95% CI: .68-.91) for externalizing problem scores.

CONCLUSIONS

Meeting the 24-hour movement guidelines was associated with a lower risk of internalizing and externalizing behaviors in youth. These associations were mainly explained by meeting the screen time and sleep duration recommendations.

Strategies for facilitating the delivery of cluster randomized trials in hospitals: A study informed by the CFIR-ERIC matching tool

BACKGROUND

Recruitment and engagement of clusters in a cluster randomized controlled trial can sometimes prove challenging. Identification of successful or unsuccessful strategies may be beneficial in guiding future researchers in conducting their cluster randomized controlled trial. This study aimed to identify strategies that could be used to facilitate the delivery of cluster randomized controlled trials in hospitals.

METHODS

The study employed the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool. The barriers and enablers to cluster randomized controlled trial conduct identified in our previously conducted studies served as a means of determinant identification for the conduct of cluster randomized controlled trials. These determinants were mapped to Consolidated Framework for Implementation Research constructs and then matched to Expert Recommendations for Implementing Change compilation strategies using the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool.

RESULTS

The Expert Recommendations for Implementing Change strategies matched to at least one determinant Consolidated Framework for Implementation Research construct were as follows: (1) 'Identify and prepare champions', (2) 'Conduct local needs assessment', (3) 'Conduct educational meetings', (4) 'Inform local opinion leaders', (5) 'Build a coalition', (6) 'Promote adaptability', (7) 'Develop a formal implementation blueprint', (8) 'Involve patients/consumers and family members', (9) 'Obtain and use patients/consumers and family feedback', (10) 'Develop educational materials', (11) 'Promote network weaving', (12) 'Distribute educational materials', (13) 'Access new funding' and (14) 'Develop academic partnerships'.

CONCLUSION

This study was intended as a step in the research agenda aimed at facilitating cluster randomized controlled trial delivery in hospitals and can act as a resource for future researchers when planning their cluster randomized controlled trial, with the expectation that the strategies identified here will be tailored to each context.

Parenting practices in childhood and depression, anxiety, and internalizing symptoms in adolescence: a systematic review

PURPOSE

Parenting practices represent important and modifiable factors for health and wellbeing in children and adolescents; however, strength and quality of studies examining relationships between parenting practices in childhood and risk of depression and anxiety in adolescence are unclear. The objective of this systematic review was to synthesize the longitudinal literature that describes these associations.

METHODS

Six electronic databases were searched for articles published through March 2018. Eligible articles were published in the English language, peer-reviewed, and had prospective cohort study designs. Articles eligible for inclusion examined positive and negative parenting practices of parents and/or guardians when study subjects were between 0 and 9 years of age, and symptoms of depression, anxiety, and internalizing symptoms when subjects were between 10 and 19 years of age. Heterogeneity of included articles precluded meta-analysis: findings were reported narratively.

RESULTS

4558 references were screened for inclusion, and 19 articles met eligibility criteria and were included for review. Ten articles examined positive parenting practices, and four demonstrated statistically significant associations between positive parenting practices and lower risk of adolescent depression, anxiety, and/or internalizing symptoms. Fifteen articles examined negative parenting practices, and five demonstrated significant associations between negative parenting practices and higher risk of adolescent depression, anxiety, and/or internalizing symptoms.

CONCLUSION

This review demonstrates that the evidence base supporting longitudinal associations between parenting practices in childhood and adolescent symptoms of depression, anxiety, and internalizing problems is inconsistent. Findings from this review highlight limitations of the existing literature and identify understudied parenting dimensions that require further investigation.

Screening for depression in children and adolescents: a protocol for a systematic review update

BACKGROUND

Major depressive disorder is common, debilitating, and affects feelings, thoughts, mood, and behaviors. Childhood and adolescence are critical periods for the development of depression and adolescence is marked by an increased incidence of mental health disorders. This protocol outlines the planned scope and methods for a systematic review update that will evaluate the benefits and harms of screening for depression in children and adolescents.

METHODS

This review will update a previously published systematic review by Roseman and colleagues. Eligible studies are randomized controlled trials (RCTs) assessing formal screening in primary care to identify children or adolescents not already self-reporting symptoms of, diagnosed with, or treated for depression. If no or only a single RCT is available, we will consider controlled studies without random assignment. Studies of participants with characteristics associated with an elevated risk of depression will be analyzed separately. Outcomes of interest are symptoms of depression, classification of major depressive disorder based on a validated diagnostic interview, suicidality, health-related quality of life, social function, impact on lifestyle behavior (e.g., substance use, school performance, lost time at work, or school), false-positive results, overdiagnosis, overtreatment, labeling, and other harms such as those arising from treatment. We will search MEDLINE, Embase, PsycINFO, CINAHL, the Cochrane Library, and grey literature sources. Two reviewers will independently screen the titles and abstracts using the liberal accelerated method. Full-text screening will be performed independently by two reviewers using pre-specified eligibility criteria. Data extraction and risk of bias assessments will be performed independently by two reviewers. Pre-planned analyses, including subgroup and sensitivity analyses, are detailed within this protocol. Two independent reviewers will assess and finalize through consensus the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and prepare GRADE evidence profiles and summary of findings tables for each outcome of interest.

DISCUSSION

The systematic review will provide a current state of the evidence of benefits and harms of depression screening in children and adolescents. These findings will be used by the Canadian Task Force on Preventive Health Care to inform the development of recommendations on depression screening.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020150373.

Low school belongingness and non-prescription opioid use among students in Ontario, Canada

OBJECTIVES

School belonging impacts a range of factors, including academic performance, school attendance, relationships with peers and teachers, mental and physical health, and drug and alcohol use. Previous studies have shown that a lack of belonging to one's school is associated with substance use. The objective of the study was to examine the association between low school belongingness and the use of opioids in students in grades 9 through 12 in Ontario, Canada.

METHODS

Data were gathered from 6418 participants in grades 9-12 who responded to the 2015 Ontario Student Drug Use and Health Survey (OSDUHS). Logistic regression analyses were used to model associations between low school belongingness and opioid use, adjusted for gender, grade, ethnicity, socio-economic status, and living situation.

RESULTS

Overall, low school belongingness was associated with non-prescribed opioid use (OR = 1.11, 95% CI 1.05-1.17). Feeling unsafe at school (OR = 1.43, 95% CI 1.23-1.66) was associated with elevated odds of using non-medically prescribed opioids. Girls who felt that they were not a part of their school community were at elevated odds of using opioids (OR = 1.35, 95% CI 1.16-1.56); this association was not observed among boys.

CONCLUSION

The findings suggest that low school belongingness may be associated with the use of non-prescribed opioids in students. These findings suggest that school-based interventions aimed at improving social cohesion and feelings of belongingness and safety may be beneficial in reducing the use of non-prescription opioids among adolescents.

Self-rated stress, distress, mental health, and health as modifiers of the association between long-term exposure to ambient pollutants and mortality

BACKGROUND

Individual and neighbourhood-scale socioeconomic characteristics modify associations between exposure to air pollution and mortality. The role of stress, which may integrate effects of social and environmental exposures on health, is unknown. We examined whether an individual's perspective on their own well-being, as assessed using self-rated measures of stress and health, modifies the pollutant-mortality relationship.

METHODS

The Canadian Community Health Survey (CCHS)-mortality cohort includes respondents from surveys administered between 2001 and 2012 linked to vital statistics and postal codes from 1981 until 2016. Annual fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃) exposure estimates were attached to a sample of cohort members aged 30-89 years (n = 398,300 respondents/3,848,400 person-years). We examined whether self-rated stress, distress, mental health, and general health modified associations between long-term exposure to each pollutant (three-year moving average with one-year lag) and non-accidental mortality using Cox survival models, adjusted for individual- (i.e. socioeconomic and behavioural) and neighbourhood-scale covariates.

RESULTS

In fully-adjusted models, the relationship between exposure to pollutants and mortality was stronger among those with poor self-rated mental health, including a significant difference for NO₂ (hazard ratio (HR) = 1.15, 95% CI 1.06-1.25 per IQR) compared to those with very good/excellent mental health (HR = 1.05, 95% CI 1.01-1.08; Cochran's Q = 4.01; p < 0.05). Poor self-rated health was similarly associated with higher pollutant-associated HRs, but only in unadjusted models. Stress and distress did not modify pollutant-mortality associations.

CONCLUSIONS

Poor self-rated mental and general health were associated with increased mortality attributed to exposure to ambient pollutants.

Pathways from parenting practices to adolescent suicidality: Evidence on the role of emotional and behavioral symptoms from a prospective cohort of Canadian children

OBJECTIVE

To investigate longitudinal relationships between parenting practices in childhood and adolescent suicidality, and assess the mediating role of emotional and behavioral symptoms.

METHODS

Data were drawn from the National Longitudinal Survey of Children and Youth, a Canadian population-based longitudinal cohort study. The sample included 9,490 children aged 10-11 who were followed up biennially to ages 14-15. Parents reported their positive and punitive parenting practices when children were 10-11. Adolescents self-reported symptoms of depression/anxiety, hyperactivity, conduct disorder, and social aggression at 12-13, and past-year suicidal ideation and suicide attempts at 14-15.

RESULTS

The inverse associations between positive parenting at 10-11 and suicidal behaviors at 14-15 were significantly mediated by symptoms of hyperactivity, conduct disorder, and social aggression at 12-13. Direct relationships between punitive parenting and suicidal behaviors were observed. These associations were significantly mediated by hyperactivity and, among boys only, by conduct disorder and social aggression. The association between punitive parenting and suicide attempt was additionally mediated by depression/anxiety.

CONCLUSIONS

Parenting in childhood may be associated with adolescent suicidality both directly and indirectly through emotional and behavioral symptoms. Interventions aimed at reducing the use of harsh disciplinary strategies and promoting positive parent-child interactions may reduce the burden of adolescent suicidality.

Impact of the Improper Adjustment for Age in Research on Age-Related Macular Degeneration: An Example Using Data from the Canadian Longitudinal Study on Aging

Purpose: Confounding is an important problem in observational research. Improper modeling of the confounder will lead to residual confounding that may distort results and impact inferences. An example of this will be presented from research on age-related macular degeneration and depression. Methods: A 3-year prospective cohort study was performed using data from the Canadian Longitudinal Study on Aging consisting of 30,097 individuals aged 45-85 years. Incident depression was assessed using the Center for Epidemiologic Studies Depression scale. Participants were asked if they had ever had a physician diagnosis of age-related macular degeneration (AMD). Multivariable Poisson regression was used. Age was modeled in four ways including as a linear term, as a 4-category variable, as a spline, and as a polynomial. Models were compared using the Akaike's Information Criteria (AIC) with lower scores indicating better performance. Results: The point estimates and inferences differed depending on how age was modeled. Age had a J-shape relationship with the incidence of depression. The model with the lowest AIC was when age was entered as a categorical variable. When age was modeled in this way, AMD was not significantly associated with the incidence of depression (relative risk (RR) = 1.21, 95% Confidence Interval (CI) 0.97, 1.53). By contrast, when age was modeled as a linear term, AMD was significantly associated with the incidence of depression (RR = 1.28, 95% CI 1.02, 1.61). Conclusions: Researchers should clearly report their adjustment strategies and should be cautious when modeling the relationship between age and depression in order to minimize residual confounding.

The BEACON study: protocol for a cohort study as part of an evaluation of the effectiveness of smartphone-assisted problem-solving therapy in men who present with intentional self-harm to emergency departments in Ontario

BACKGROUND

Patients who present to emergency departments after intentional self-harm are at an increased risk of dying by suicide. This applies particularly to men, who represent nearly two-thirds of those who die by suicide in Ontario. One way of potentially addressing this gap is to offer a course of blended problem-solving therapy, comprised of a brief course of evidence-based psychotherapy for individuals at risk for suicide, facilitated by the use of a patient-facing smartphone application and a clinician-facing "dashboard." This approach has the potential to combine the benefits of face-to-face therapy and technology to create a novel intervention.

METHODS

This is a cohort study nested within a larger pragmatic multicentre pre- and post-design cluster randomised trial. Suicidal ideation assessed by the Beck Scale for Suicide Ideation is the primary outcome variable. Secondary outcome measures include depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder 7-item scale), post-traumatic stress disorder (Primary Care PTSD Screen), health-related quality of life (EuroQol 5-dimension 5-level questionnaire), meaning in life (Experienced Meaning in Life Scale), perceived social supports (Multidimensional Scale of Perceived Social Support), alcohol use (Alcohol Use Disorders Identification Test), drug use (Drug Abuse Screening Test Short Form 10), problem-solving skills (Social Problem-Solving Inventory-Revised Short Form), and self-reported healthcare costs, as well as health service use measured using Ontario administrative health data. A process evaluation will also be conducted following study completion.

DISCUSSION

The cohort study will test whether better adherence to the intervention results in better outcomes. The value of the cohort study design is that we can examine in more detail certain subgroups or other variables that are not available in the larger cluster randomised trial. This trial will aim to improve standards by informing best practice in management of men who self-harm and present to hospitals in Ontario.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03473535 . Registered on March 22, 2018.

The relationship between profiles and transitions of internalizing and externalizing symptoms in children and suicidal thoughts in early adolescence

BACKGROUND

Adolescence is a high-risk period for the onset of suicidal thoughts and behaviors. Identification of preceding patterns of internalizing and externalizing symptoms that are associated with subsequent suicidal thoughts may offer a better understanding of how to prevent adolescent suicide.

METHODS

Data from the National Longitudinal Survey of Children and Youth, a prospective population-based Canadian cohort, contained Child Behavior Checklist items which were used to examine profiles and transitions of internalizing and externalizing symptoms in children, aged 6-11 years (n = 8266). The association between these profiles/transitions and suicidal thoughts in adolescents was examined using multivariate logistic regression modeling.

RESULTS

Latent profile analyses identified four measurement invariant profiles of internalizing and externalizing symptoms at ages 6/7 and 10/11: (1) low on all symptoms, (2) moderate on all symptoms, (3) high on all symptoms, and (4) high on hyperactivity/inattention and internalizing. Recurrent (homotypic or heterotypic) and increasing symptoms from 6/7 to 10/11 were associated with suicidal thoughts in adolescence, compared to those with stable low symptoms. Those with decreasing symptoms from 6/7 to 10/11 were not at increased risk of suicidal thought in adolescence.

CONCLUSIONS

While patterns of recurrent symptoms were associated with suicidal thoughts, a similar association was observed between profiles at age 10/11 years and suicidal thoughts. This suggests that the recent assessments of mental health symptoms in children may be as sufficient a predictor of adolescent suicidal thought as transition profiles.

Macrosomia and psychiatric risk in adolescence

The prenatal environment can exert important effects on mental health. While much research has linked low birth weight to psychopathology, the intrauterine environment associated with high birth weight (macrosomia; > 4000 g) is also sub-optimal and may increase risk. Given the increasing prevalence of macrosomic births, understanding the mental health outcomes of infants born macrosomic can help refine theories of etiology, predict disorder, and target preventive interventions. Using data from the 2014 Ontario Child Health Study (OCHS), we examined the risk for psychiatric disorders in adolescents born macrosomic. Youth (N = 2151) aged 12-17 years completed the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). Rates of common mental disorders assessed by the MINI-KID were compared between those born at normal birth weight (NBW; 2500-4000 g, n = 1817) and adolescents born macrosomic (> 4000 g, n = 334). These associations were then adjusted for participant age, sex, socioeconomic status (SES) of the family, parental mental health, and gestational diabetes mellitus. After adjustment for covariates, adolescents born macrosomic had higher odds of conduct disorder (CD; OR = 3.19, 95% CI: 1.37-7.43), oppositional defiant disorder (ODD; OR = 1.79, 95% CI: 1.11-2.91), and ADHD (OR = 1.77, 95% CI: 1.21-2.80). Moderation analyses revealed that males born macrosomic were more likely to have psychiatric problems than their female peers. Socioeconomic disadvantage also amplified the risk posed by macrosomia for ODD, ADHD, major depressive disorder, and generalized anxiety disorder. In this study, macrosomia was associated with an increased risk of clinically significant externalizing problems in adolescence, most notably among boys and those facing socioeconomic disadvantage.

Adolescents' knowledge of a peer's non-suicidal self-injury and own non-suicidal self-injury and suicidality

OBJECTIVE

Some research suggests that suicidal ideation and attempt among adolescents may be contagious - that is adolescents who are exposed to peers' suicidal behaviour are more likely to experience suicidal ideation or attempt suicide themselves. Less is known about the potential contagion effect of non-suicidal self-injury (NSSI). Our objective was to determine whether knowledge of a friend's NSSI is associated with adolescent's own non-suicidal self-injury and suicidal behaviours.

METHODS

Data from 1483 youth ages 14-17 years were obtained from the 2014 Ontario Child Health Study, a cross-sectional population-based survey of children and adolescents in Ontario, Canada. Logistic regression models were used to examine associations between knowledge of a friend's NSSI and adolescents' own self-reported self-injurious and suicidal behaviours. Interactions with gender, age group and presence of a mental disorder were investigated.

RESULTS

Knowledge of a friend's non-suicidal self-injury was significantly associated with the adolescent's own non-suicidal self-injury (OR = 2.03, 95% CI 1.05-3.90), suicidal ideation (OR = 3.08, 95% CI 1.50-6.30) and suicide attempt (OR = 2.87, 95% CI 1.20-6.87).

CONCLUSION

These findings suggest an apparent contagion effect for non-suicidal self-injury. Awareness of a friend's self-injurious behaviours is associated with an adolescent's own self-injury and suicidality. Interventions aimed at preventing NSSI and suicidality should consider prevention of possible contagion at the school and/or community level.

Associations between the Canadian 24 h movement guidelines and different types of bullying involvement among adolescents

BACKGROUND

The Canadian 24-Hour Movement Guidelines for Children and Youth recommend ≥60 min of physical activity per day, ≤2 h of recreational screen time per day, and 9-11 hours of sleep per night for 11-13 years old and 8-10 hours per night for 14-17 years old.

OBJECTIVE

This study examined the association between combinations of these recommendations and school bullying and cyberbullying victimization and perpetration among adolescents.

PARTICIPANTS AND SETTING

A total of 5615 Canadian students (mean age = 15.2 years) who participated in the 2017 Ontario Student Drug Use and Health Survey (OSDUHS) self-reported their physical activity, screen time, sleep duration, and their involvement in bullying.

METHODS

Logistic regression analyses were adjusted for important covariates.

RESULTS

Meeting the screen time recommendation alone was associated with lower odds of being a victim (OR: 0.64; 95 % CI: 0.46-0.88) or a bully (OR: 0.64; 95 % CI: 0.43-0.96) at school and a victim of cyberbullying (OR: 0.67; 95 % CI: 0.49-0.91). Meeting both the screen time and sleep duration recommendations was associated with lower odds of being a bully (OR: 0.51; 95 % CI: 0.30-0.88). Meeting all 3 recommendations showed stronger associations (i.e. lowest risk) with being a victim of school bullying (OR: 0.32; 95 % CI: 0.19-0.54), a bully-victim (OR: 0.25; 95 % CI: 0.08-0.78) or a victim of cyberbullying (OR: 0.37; 95 % CI: 0.17-0.84).

CONCLUSIONS

Our findings provide evidence that meeting the 24 -h movement guidelines is associated with lower odds of bullying involvement. Encouraging adherence to the 24 -h movement guidelines could be a good behavioural target to prevent involvement in both school bullying and cyberbullying.

Mental Health Service Use in Depressed Military Personnel: A Systematic Review

INTRODUCTION

Major depression is a leading cause of morbidity in military personnel and an important impediment to operational readiness in military organizations. Although treatment options are available, a large proportion of individuals with depression do not access mental health services. Quantifying and closing this treatment gap is a public health priority. However, the scientific literature on the major depression treatment gap in military organizations has never been systematically reviewed.

METHODS

We systematically searched the EMBASE, MEDLINE, and PsychINFO databases for studies measuring recent mental health service use in personnel serving in the armed forces of a Five-Eye country (Australia, Canada, New Zealand, the United Kingdom, or the United States). We excluded studies conducted with retired veterans. Because of the substantial heterogeneity in included studies, we did not pool their results. Instead, we computed median period prevalence of mental health service use.

RESULTS

Twenty-eight studies were included in the systematic review; 12 had estimated mental health service use in personnel with depression, and another 16 had estimated mental health service use in personnel with depression or another mental health disorder. The period prevalence of mental health service use in depressed military personnel ranged from 20 to 75% in 12 included studies, with a median of 48%, over 2-12 months. The other 16 studies yielded similar conclusions; they reported period prevalence of mental health service use in personnel with any mental health disorder ranging from 14 to 75%, with a median of 36%, over 1-12 months. The median was higher in studies relying on diagnostic interviews to identify depressed personnel, compared to studies relying on screening tools (60% vs. 44%).

CONCLUSIONS

There is a large treatment gap for major depression in particular, and for mental health disorders in general, among military personnel. However, our results highlight the association between the use of measurement tools and treatment gaps: estimated treatment gaps were larger when depressed patients were identified by screening tools instead of diagnostic interviews. Researchers should be wary of overestimating the mental health treatment gap when using screening tools in future studies.

Health outcomes associated with emergency department visits by adolescents for self-harm: a propensity-matched cohort study

BACKGROUND

Self-harm is increasing among adolescents, and because of changing behaviours, current data are needed on the consequences of self-harm. We sought to investigate the trends related to hospital presentation, readmission, patient outcome and medical costs in adolescents who presented with self-harm to the emergency department.

METHODS

We used administrative data on 403 805 adolescents aged 13-17 years presenting to Ontario emergency departments in 2011-2013. Adolescents with self-harm visits were 1:2 propensity matched to controls with visits without self-harm, using demographic, mental health and other clinical variables. Five years after the index presentation, hospital or emergency department admission rates for self-harm, overall mortality, suicides and conservative cost estimates were compared between the 2 groups.

RESULTS

Of 5832 adolescents who visited Ontario emergency departments in 2011-2013 after self-harm (1.4% of visits), 5661 were matched to 10 731 adolescents who presented for reasons other than self-harm. Adolescents who presented with self-harm had a shorter time to a repeat emergency department or hospital admission for self-harm (hazard ratio [HR] 4.84, 95% confidence interval [CI] 4.44-5.27), more suicides (HR 7.96, 95% CI 4.00-15.86), and higher overall mortality (HR 3.23, 95% CI 2.12-4.93; p < 0.001). The positive predictive value of self-harm-related emergency department visits for suicide was 0.7%. Adolescents with self-harm visits had mean 5-year estimates of health care costs of $30 388 compared with $19 055 for controls (p < 0.001).

INTERPRETATION

Adolescents with emergency department visits for self-harm have higher rates of mortality, suicide and recurrent self-harm, as well as higher health care costs, than matched controls. Development of algorithms and interventions that can identify and help adolescents at highest risk of recurrent self-harm is warranted.