Ethnoracial Risk Variation Across the Psychosis Continuum in the US: A Systematic Review and Meta-Analysis

Importance

Studies suggest a higher risk of schizophrenia diagnoses in Black vs White Americans, yet a systematic investigation of disparities that include other ethnoracial groups and multiple outcomes on the psychosis continuum is lacking.

Objective

To identify ethnoracial risk variation in the US across 3 psychosis continuum outcomes (ie, schizophrenia and other psychotic disorders, clinical high risk for psychosis [CHR-P], and psychotic symptoms [PSs] and psychotic experiences [PEs]).

Data Sources

PubMed, PsycINFO and Embase were searched up to December 2022.

Study Selection

Observational studies on ethnoracial differences in risk of 3 psychosis outcomes.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Using a random-effects model, estimates for ethnoracial differences in schizophrenia and PSs/PEs were pooled and moderation by sampling and setting was determined, along with the assessment of heterogeneity and risk of bias.

Main Outcomes and Measures

Risk of schizophrenia and other psychotic disorder, CHR-P, and conversion to psychosis among CHR-P and PSs/PEs.

Results

Of 64 studies in the systematic review, 47 were included in the meta-analysis comprising 54 929 people with schizophrenia and 223 097 with data on PSs/PEs. Compared with White individuals, Black individuals had increased risk of schizophrenia (pooled odds ratio [OR], 2.07; 95% CI, 1.64-2.61) and PSs/PEs (pooled standardized mean difference [SMD], 0.10; 95% CI, 0.03-0.16), Latinx individuals had higher risk of PSs/PEs (pooled SMD, 0.15; 95% CI, 0.08-0.22), and individuals classified as other ethnoracial group were at significantly higher risk of schizophrenia than White individuals (pooled OR, 1.81; 95% CI, 1.31-2.50). The results regarding CHR-P studies were mixed and inconsistent. Sensitivity analyses showed elevated odds of schizophrenia in Asian individuals in inpatient settings (pooled OR, 1.84; 95% CI, 1.19-2.84) and increased risk of PEs among Asian compared with White individuals, specifically in college samples (pooled SMD, 0.16; 95% CI, 0.02-0.29). Heterogeneity across studies was high, and there was substantial risk of bias in most studies.

Conclusions and Relevance

Findings of this systematic review and meta-analysis revealed widespread ethnoracial risk variation across multiple psychosis outcomes. In addition to diagnostic, measurement, and hospital bias, systemic influences such as structural racism should be considered as drivers of ethnoracial disparities in outcomes across the psychosis continuum in the US.

The separate and joint effects of recent interpersonal abuse and cannabis use on psychotic experiences: findings from students in higher education in the United States

BACKGROUND

Various forms of interpersonal abuse (e.g., physical, emotional, sexual) and cannabis use across the lifespan have both been known to increase odds of psychotic experiences; however, there have been few studies examining their separate and joint effects in the United States.

METHODS

We analyzed data from the Healthy Minds Study (2020-2021) and used multivariable logistic regression and interaction contrast ratios to assess separate and joint effects of interpersonal abuse (past 12 months) and cannabis use (past 30 days) on psychotic experiences (past 12 months).

RESULTS

Students who only used cannabis had significantly greater odds of psychotic experiences (aOR: 1.70; 95% CI 1.58-1.82), as well as those who only experienced interpersonal abuse (aOR: 2.40; 95% CI 2.25-2.56). However, those who reported both cannabis use and interpersonal abuse had the greatest odds, exceeding the sum of these individual effects (the combined effect aOR: 3.46; 95% CI 3.19-3.76).

CONCLUSIONS

Recent interpersonal abuse and recent cannabis use both separately and jointly increase odds of having recent psychotic experiences. Future research should continue to examine the potential interactive and additive impact of multiple known exposures to better inform primary and secondary prevention efforts.

Ethno-racial variation in psychotic experiences in the United States: Findings from the National Latino and Asian American Survey and the National Survey of American Life

BACKGROUND

Ethno-racial differences in psychosis risk are documented; however, there is less research on whether these differences extend to sub-threshold psychotic experiences, and whether there is significant variation within ethno-racial categories.

METHODS

We analyzed data from the National Latino and Asian American Survey (NLAAS) and the National Survey of American Life (NSAL). Using multivariable logistic regression, we examined the association between race/ethnicity and lifetime psychotic experiences among Latino, Asian, and Black adults in the general population, adjusting for gender, age, nativity, education level, income level, employment status, and everyday discrimination.

RESULTS

Puerto Ricans, Cubans, and other Hispanics had greater odds of lifetime psychotic experiences when compared with Mexicans, though differences diminished when adjusting for covariates. Filipino and other Asians had greater odds of lifetime psychotic experiences when compared with Chinese, though again, differences diminished when adjusting for covariates. Among Black Americans, there were no significant ethnic subgroup differences.

CONCLUSION

Ethno-racial differences extend across the psychosis continuum. There are nuanced health profiles across and within ethno-racial categories. Differences may be attributable to differences in experiences living in the US, underscoring the need for community-specific interventions.

Distress related to psychotic experiences: Enhancing the world health organization composite international diagnostic interview psychosis screen

BACKGROUND

The abbreviated version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) psychosis screen tends to yield high prevalence in online samples. Psychotic Experiences (PE) may not necessarily indicate current or imminent psychopathology; however, distressing PE appear to be more clinically informative.

METHODS

We analyzed data collected from an online survey administered to a Qualtrics panel (N = 2522 adults). Using multivariable logistic regression, we examined the association between PE (with and without associated distress) and several mental health outcomes, adjusting for age, gender, and race/ethnicity.

RESULTS

Individuals with distressing PE had greater odds of most mental health outcomes when compared with individuals with non-distressing PE. This was true for being in mental health treatment, loneliness, probable mental illness, suicidal ideation, and suicide attempt, adjusting for age, gender, race/ethnicity, and education level. The only exception was for hazardous alcohol use, for which there was no significant association with distressing PE.

CONCLUSION

As screening for PE gains traction in public health and preventive medicine, using an abbreviated version of the WHO CIDI psychosis screen may be clinically informative, especially when eliciting the distressful nature of PE.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design Setting and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15003 youths (7044 47.0%] male; 10209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.Appeared originally in JAMA Netw Open 2019; 2:e1914070.

Psychotic experiences, sexual minority status, and suicidal behavior among young adult college students in the United States

Psychotic experiences significantly predict suicidal behaviors; however, it is unknown whether these associations are conditional on sexual minority status. We analyzed cross-sectional data from the Healthy Minds Study (N = 109,975), which was collected between September 2020 and June 2021 from young adult (aged 18-34) students from across 140 colleges across the United States. Having psychotic experiences and sexual minority status were associated with significantly greater odds of reporting suicidal ideation, suicide plan, and suicide attempt, adjusting for sociodemographic characteristics. We found significant interactions between psychotic experiences and sexual minority status, such that the relations between psychotic experiences and suicidal behaviors were stronger among heterosexual students than among sexual minority students. However, the interactions disappeared for suicidal ideation and plans after adjusting for socio-behavioral risk factors. Future research can explore whether psychotic experiences predict suicide attempts among sexual minority status behavior socio-behavioral risk factors.

Latent Class Profiles of Police Violence Exposure in 4 US Cities and Their Associations with Anticipation of Police Violence and Mental Health Outcomes

While studying polyvictimization is well established within the broader violence literature and applied to other types of violence, it has yet to be documented whether polyvictimization also presents in patterns of police violence exposure (i.e., neglectful, psychological, physical, and sexual police violence). Our objective was to analyze latent patterns of co-occurring police contact and their associations with mental health. By applying latent class analysis (LCA) methods to the 2016 and 2017 Surveys of Police-Public Encounters (N = 2615), conducted in 4 Northeastern US cities, we identified classes of direct and vicarious police violence and compared sociodemographic characteristics among classes using multinomial regression. Classes were regressed on mental health outcomes. LCA identified four classes of police contact. Compared to Positive Police Contact (33.0%) class members, members of the (a) Extreme Police Violence (4.0%) class reported higher anticipation of future police victimization, psychological distress, and suicide ideations and attempts; they were more likely to be Black, cisgender men, and Latinx; (b) members of the High Police Violence (23.6%) class reported higher anticipation of future police victimization and psychological distress; they were more likely to be Black, Native American, and multiracial; members of the (c) Low Police Contact (39.5%) class had comparable mental health outcomes; they were more likely to report a household income < $19,999. Notably, no participants were unexposed to police contact. Polyvictimization presents in experiences of police violence and disproportionately impacts structurally marginalized people.

COVID-19 factors and self-injurious behaviors among US college students: findings from the healthy minds study 2020

BACKGROUND

The COVID-19 pandemic has dramatically altered the way of life in the United States, which may be linked to self-injurious behaviors.

METHODS

We conducted a secondary analysis of data from the Fall 2020 Cohort of the Healthy Minds Survey, a non-probability sample of students enrolled at one of 28 universities across the United States. Participants completed an online survey during the COVID-19 pandemic (September-December, 2020).

RESULTS

Nearly a quarter of the sample (n = 6999) reported engaging in non-suicidal self-injury (NSSI), 12.41% (n = 3819) reported suicidal ideation, 4.98% (n = 1531) reported making a suicide plan, and 1.09% (n = 334) reported a suicide attempt over the past 12 months. When accounting for all COVID-19 factors in the same model, COVID-19 related concern, COVID-19 related discrimination, financial distress, and infection were significantly associated with NSSI, suicidal ideation, and suicide plan; caregiving was significantly associated with lower odds of engaging in non-suicidal self-injury. None of the factors were associated with suicide attempt.

CONCLUSIONS

This study showed that various COVID-19 factors were related to SIB. Interventions may consider multiple dimensions of COVID-19 and their specific impacts.

Cannabis use, self-perceived risk, perceived peer approval and parental attitudes among youth at clinical high-risk for psychosis

AIM

Cannabis use is associated with greater likelihood of psychosis. The relationship between attitudes about cannabis and use has not been examined in youth at clinical high-risk (CHR) for psychosis. Additionally, the shifting legal landscape can provide a valuable context for evaluating use and related attitudes.

METHODS

This study included 174 participants (44 CHR, 43 healthy control [HC] youth-parent dyads). Youth completed measures of self-reported cannabis use confirmed with a urinalysis, self-perceived risk and perceived peer attitudes. Parents reported attitudes about youth use. Legalization occurred halfway during a 5-year study in Colorado, providing an opportunity to cross-sectionally examine its role in use and attitudes.

RESULTS

Frequency of youth reporting cannabis use was significantly higher in CHR (69%) than control group (30%). Use in CHR group was associated with higher perceived peer approval (r = .57), increased parental permissiveness (r = .28) and lower self-perceived risk (r = -.26). Comparing samples participating pre and post-legalization, use remained stable within each group. Group differences in parental permissiveness shifted; trend toward decrease in permissiveness in CHR group (η²_partial  = .07) and a significant increase in HCs (η²_partial  = .16) were observed. Post-legalization, use in CHR group correlated with higher perceived peer approval (r = .64), lower self-perceived risk (r = -.51) and higher parental permissiveness (r = .35, trend).

CONCLUSIONS

Taken together, results indicate a relationship between self and peer/parental attitudes about cannabis and use in youth at CHR for psychosis. These factors are important to consider within the legalization context given the changes in parental attitudes and a stronger association between use and attitudes in this group post-legalization.

Police Violence and Public Health

Despite their enormous potential impact on population health and health inequities, police violence and use of excessive force have only recently been addressed from a public health perspective. Moving to change this state of affairs, this article considers police violence in the USA within a social determinants and health disparities framework, highlighting recent literature linking this exposure to mental health symptoms, physical health conditions, and premature mortality. The review demonstrates that police violence is common in the USA; is disproportionately directed toward Black, Latinx, and other marginalized communities; and exerts a significant and adverse effect on a broad range of health outcomes. The state-sponsored nature of police violence, its embedding within a historical and contemporary context of structural racism, and the unique circumstances of the exposure itself make it an especially salient and impactful form of violence exposure, both overlapping with and distinct from other forms of violence. We conclude by noting potential solutions that clinicaly psychology and allied fields may offer to alleviate the impact of police violence, while simultaneously recognizing that a true solution to this issue requires a drastic reformation or replacement of the criminal justice system, as well as addressing the broader context of structural and systemic racism in the USA. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Comparing the predictive value of screening to the use of electronic health record data for detecting future suicidal thoughts and behavior in an urban pediatric emergency department: A preliminary analysis

AIM

Brief screening and predictive modeling have garnered attention for utility at identifying individuals at risk of suicide. Although previous research has investigated these methods, little is known about how these methods compare against each other or work in combination in the pediatric population.

METHODS

Patients were aged 8-18 years old who presented from January 1, 2017, to June 30, 2019, to a Pediatric Emergency Department (PED). All patients were screened with the Ask Suicide Questionnaire (ASQ) as part of a universal screening approach. For all models, we used 5-fold cross-validation. We compared four models: Model 1 only included the ASQ; Model 2 included the ASQ and EHR data gathered at the time of ED visit (EHR data); Model 3 only included EHR data; and Model 4 included EHR data and a single item from the ASQ that asked about a lifetime history of suicide attempt. The main outcome was subsequent PED visit with suicide-related presenting problem within a 3-month follow-up period.

RESULTS

Of the N = 13,420 individuals, n = 141 had a subsequent suicide-related PED visit. Approximately 63% identified as Black. Results showed that a model based only on EHR data (Model 3) had an area under the curve (AUC) of 0.775 compared to the ASQ alone (Model 1), which had an AUC of 0.754. Combining screening and EHR data (Model 4) resulted in a 17.4% (absolute difference = 3.6%) improvement in sensitivity and 13.4% increase in AUC (absolute difference = 6.6%) compared to screening alone (Model 1).

CONCLUSION

Our findings show that predictive modeling based on EHR data is helpful either in the absence or as an addition to brief suicide screening. This is the first study to compare brief suicide screening to EHR-based predictive modeling and adds to our understanding of how best to identify youth at risk of suicidal thoughts and behaviors in clinical care settings.

COVID-19 dimensions and psychotic experiences among US college students: Findings from the Healthy Mind Study 2020

BACKGROUND

The COVID-19 pandemic has caused tremendous changes in daily living, which may be related to mental health problems, including psychotic experiences, though research has only begun to assess these associations.

METHODS

We analyzed data from the Healthy Minds Survey (Fall Semester Cohort 2020), which is a non-probability sample of students attending one of 36 universities in the United States, who completed an online survey during the COVID-19 pandemic (September-December 2020). We used multivariable logistic regression to examine the associations between several COVID-19 dimensions (anxiety, discrimination, financial distress, infection, illness of loved one, death of loved one, caregiving) and 12-month psychotic experiences, adjusting for age, gender, race/ethnicity, and international student status.

RESULTS

Each individual COVID-19 dimension was significantly associated with greater odds of having 12-month psychotic experiences, with the exception of being a caregiver. When accounting for all COVID-19 dimensions simultaneously in the same model, only COVID-19 related anxiety, financial distress, and infection were associated with psychotic experiences.

CONCLUSION

COVID-19 dimensions were linked to psychotic experiences among university students, which may also apply to the larger population. This can potentially inform assessment and treatment during the pandemic.

Physical injury and psychotic experiences in 48 low- and middle-income countries

BACKGROUND

Psychotic experiences (PEs) may be associated with injuries, but studies focusing specifically on low- and middle-income countries (LAMICs) are scarce. Thus, the current study examined the link between injuries and PEs in a large number of LAMICs.

METHOD

Cross-sectional data were used from 242 952 individuals in 48 LAMICs that were collected during the World Health Survey in 2002-2004 to examine the association between traffic-related and other (non-traffic-related) forms of injury and PEs. Multivariable logistic regression analysis and meta-analysis were used to examine associations while controlling for a variety of covariates including depression.

RESULTS

In fully adjusted analyses, any injury [odds ratio (OR) 2.07, 95% confidence interval (CI) 1.85-2.31], traffic injury (OR 1.84, 95% CI 1.53-2.21) and other injury (OR 2.09, 95% CI 1.84-2.37) were associated with higher odds for PEs. Results from a country-wise analysis showed that any injury was associated with significantly increased odds for PEs in 39 countries with the overall pooled OR estimated by meta-analysis being 2.46 (95% CI 2.22-2.74) with a moderate level of between-country heterogeneity (I2 = 56.3%). Similar results were observed across all country income levels (low, lower-middle and upper-middle).

CONCLUSIONS

Different types of injury are associated with PEs in LAMICs. Improving mental health systems and trauma capacity in LAMICs may be important for preventing injury-related negative mental health outcomes.

Urban upbringing and psychotic experiences in the United States: A racial and geographic comparison

Urban upbringing has been associated with greater risk for psychotic experiences, though research is needed to confirm whether this is true in the U.S., and whether the association depends on race, type of experience, and region of the country. We analyzed data from the National Comorbidity Survey Replication (White respondents only) and the National Survey of American Life (Black respondents). Multivariable logistic regression models found that urban upbringing was not significantly associated with lifetime psychotic experiences for Whites, but was significantly associated with lower odds for Blacks, adjusting for socio-demographic covariates and common mental disorders. Rural upbringing was associated with greater odds of lifetime auditory hallucinatory experiences for Blacks. Exploratory analyses suggested growing up in a large city or 'other' environment were associated with greater odds of lifetime psychotic experiences among Whites currently residing in the Northeast, but lower odds among Whites residing in the South. For Blacks currently residing in the West, rural upbringing was associated with significantly greater odds of lifetime psychotic experiences when compared with growing up in a large city. White and Blacks may have different lived experiences in urban and rural settings, calling for more race- and location- specific research to explain these diverging patterns.

Psychotic experiences and psychiatric treatment utilization in Buenos Aires

OBJECTIVE

Psychotic experiences are associated with psychiatric treatment utilization, though findings have not been entirely consistent. Furthermore, it is unclear how psychotic experiences relate to specific types of psychiatric treatment, and whether mental illness moderates these associations.

METHODS

In total, 1,036 adult residents of Buenos Aires were recruited through convenience sampling in public places. Multivariable logistic regression models examined the associations between psychotic experiences and psychiatric treatment, adjusted for age, sex and education. Analyses were then stratified by diagnosis of mental illness.

RESULTS

Approximately 17.95% (N = 186) of the sample reported at least one psychotic experience over the past week, about 22.39% (N = 232) of the sample was receiving some psychiatric or psychological treatment and 8.59% (N = 89) was receiving psychopharmacological treatment. In the total sample, psychotic experiences were associated with greater odds of being in psychiatric/psychological treatment (adjusted odds ratio (AOR): 1.52; 95% confidence interval (CI): 1.05-2.21) and psychopharmacological treatment (AOR: 2.49; 95% CI: 1.52-4.09), adjusted for age, sex and education. Mental illness did not moderate the association between psychotic experiences and psychiatric/psychological treatment, but did moderate the association between psychotic experiences and psychopharmacological treatment. Among people with mental disorders, psychotic experiences were associated with greater odds of receiving psychopharmacological treatment (AOR: 14.63; 95% CI: 1.73-123.45) versus people without mental disorders (AOR: 1.75; 95% CI: 0.98-3.15).

CONCLUSION

Psychotic experiences are associated with psychiatric treatment utilization, particularly psychopharmacological treatment among people with a co-occurring mental illnesses. Translational research should explore the utility of psychosis screens in assessing need for medication or clinical responsiveness to medications.

Telepsychotherapy with Youth at Clinical High Risk for Psychosis: Clinical Issues and Best Practices during the COVID-19 Pandemic

Early detection and prevention of psychosis has become an international priority. Much of this work has focused on youth presenting with attenuated symptoms of psychosis-those at Clinical High Risk for psychosis (CHR)-given their elevated probability of developing the full disorder in subsequent years. Individuals at CHR may be prone to exacerbated psychological distress during the COVID-19 pandemic and its subsequent physical isolation measures, due to heightened stress sensitivity and comorbid mental health problems. Telepsychotherapy holds promise for reaching this population, especially during the current COVID-19 outbreak. However, there are limited evidence-based guidelines or interventions for use of telepsychotherapy with this population. In this paper, we review common clinical issues for individuals at CHR and how they might be exacerbated by the COVID-19 pandemic; best practices for treatment and adaptations for telepsychotherapy for individuals at CHR; and highlight real clinical issues that we are currently experiencing in a United States-based specialized CHR clinic as we conduct telepsychotherapy via videoconferencing. We conclude with questions for those in the field to contemplate, as well as potential challenges and benefits in using telepsychotherapy with individuals at CHR and their families.

Childhood neglect and suicidal behavior: Findings from the National Comorbidity Survey Replication

BACKGROUND

Although child neglect is common, there has been comparatively little research on it or its specific forms and their effects on mental health in adulthood.

OBJECTIVE

This study aimed to examine the association between exposure to different forms of childhood neglect and lifetime suicidal behavior among a nationally representative sample of adults in the U.S. general population.

METHODS

Data were analyzed from 5665 adults that were drawn from the National Comorbidity Survey Replication (NCS-R). Information was obtained on 'care', 'supervisory' and 'medical' neglect in childhood and lifetime suicidal behavior (ideation, plan, attempt). Lifetime psychiatric disorders were based on the World Mental Health - Composite International Diagnostic Interview. Logistic regression analysis was used to examine the associations.

RESULTS

In fully adjusted models, any neglect was associated with significantly increased odds for all forms of suicidal behavior (suicidal ideation, odds ratio [OR]: 1.80, 95 % confidence interval [CI]: 1.42-2.29; plan, OR: 2.27, 95 % CI: 1.78-2.91; attempt, OR: 2.05, 95 % CI: 1.63-2.59, all p < 0.001). In unadjusted analyses all individual forms of neglect were significantly associated with all forms of suicidal behavior. However, when all forms of neglect were included together in the fully adjusted models, care neglect was no longer significantly associated with any form of suicidal behavior.

CONCLUSION

Different forms of childhood neglect are associated with suicidal behavior in adults independent of common mental disorders. Future studies should focus on childhood neglect subtypes in order to better understand the effects of neglect on adult mental health.

Screening for Suicide Risk Among Youths With a Psychotic Disorder in a Pediatric Emergency Department

National Patient Safety Goal 15.01.01 requires all Joint Commission-accredited organizations to screen patients treated for behavioral health conditions for suicide risk. However, little is known about the ability of screening tools to identify suicide risk among youths with psychotic disorders. As part of this quality improvement initiative, youths in a pediatric emergency department with psychotic disorder diagnoses (N=87) were screened with the Ask Suicide-Screening Questions. Almost half (48%, N=42) screened positive. Most positive screens (62%, N=26) were not detected through treatment as usual, suggesting that systematic screening improves the detection of suicide risk among youths with psychotic disorders.

Psychotic experiences and accidents, injuries, and poisonings among adults in the United States

Psychotic experiences (PEs) have been linked to an increased risk for accidents and injuries. However, this association remains little researched in many countries. To address this research gap, the current study used cross-sectional data from the United States to examine the association between PEs and accidents, injuries, and poisoning in a general population sample. Data were analyzed from 2274 individuals who completed the psychosis screen as part of the National Comorbidity Survey Replication (NCS-R). Information was obtained on PEs (hallucinations and delusions) and the experience of past 12-month accidents, injuries, and poisoning. Logistic regression analysis was used to examine the association while adjusting for demographic variables and common mental disorders (CMDs). In a fully adjusted model past 12-month PEs were associated with almost three times higher odds for reporting accidents, injuries, and poisoning (odds ratio [OR]: 2.97, 95% confidence interval [CI]: 1.13-7.74). The results of this study indicate that PEs are associated with higher odds for accidents and injuries among adults in the United States. Research is now needed to determine the direction of this association and the factors linked to it.

Assessment of Selective and Universal Screening for Suicide Risk in a Pediatric Emergency Department

Importance

According to National Patient Safety Goal 15.01.01, all individuals being treated or evaluated for behavioral health conditions as their primary reason for care in hospitals and behavioral health care organizations accredited by The Joint Commission should be screened for suicide risk using a validated tool. Existing suicide risk screens have minimal or no high-quality evidence of association with future suicide-related outcomes.

Objective

To test the association between results of the Ask Suicide-Screening Questions (ASQ) instrument in a pediatric emergency department (ED), implemented through selective and universal screening approaches, and subsequent suicide-related outcomes.

Design, Setting, and Participants

In this retrospective cohort study at an urban pediatric ED in the United States, the ASQ was administered to youths aged 8 to 18 years with behavioral and psychiatric presenting problems from March 18, 2013, to December 31, 2016 (selective condition), and then to youths aged 10 to 18 years with medical presenting problems (in addition to those aged 8-18 years with behavioral and psychiatric presenting problems) from January 1, 2017, to December 31, 2018 (universal condition).

Exposure

Positive ASQ screen at baseline ED visit.

Main Outcomes and Measures

The main outcomes were subsequent ED visits with suicide-related presenting problems (ie, ideation or attempts) based on electronic health records and death by suicide identified through state medical examiner records. Association with suicide-related outcomes was calculated over the entire study period using survival analyses and at 3-month follow-up for both conditions using relative risk.

Results

The complete sample was 15 003 youths (7044 [47.0%] male; 10 209 [68.0%] black; mean [SD] age, 14.5 [3.1] years at baseline). The follow-up for the selective condition was a mean (SD) of 1133.7 (433.3) days; for the universal condition, it was 366.2 (209.2) days. In the selective condition, there were 275 suicide-related ED visits and 3 deaths by suicide. In the universal condition, there were 118 suicide-related ED visits and no deaths during the follow-up period. Adjusting for demographic characteristics and baseline presenting problem, positive ASQ screens were associated with greater risk of suicide-related outcomes among both the universal sample (hazard ratio, 6.8 [95% CI, 4.2-11.1]) and the selective sample (hazard ratio, 4.8 [95% CI, 3.5-6.5]).

Conclusions and Relevance

Positive results of both selective and universal screening for suicide risk in pediatric EDs appear to be associated with subsequent suicidal behavior. Screening may be a particularly effective way to detect suicide risk among those who did not present with ideation or attempt. Future studies should examine the impact of screening in combination with other policies and procedures aimed at reducing suicide risk.

Evidence for Differential Predictive Performance of the Prime Screen Between Black and White Help-Seeking Youths

OBJECTIVE

Self-report screening instruments for emerging psychosis have the potential to improve early detection efforts by increasing the number of true positives among persons deemed to be at "clinical high risk" of the disorder, but their practical utility depends on their validity across race. This study sought to examine whether a commonly used self-report screening tool for psychosis risk performed equally among black and white youths in its ability to predict clinical high-risk status.

METHODS

Black (N=58) and white (N=50) help-seeking individuals ages 12-25 (61% female) were assessed with the Prime Screen and the Structured Interview for Psychosis-Risk Syndromes (SIPS). A logistic regression model estimated race differences in the strength of the relation between Prime Screen scores and SIPS-defined risk status.

RESULTS

Higher Prime Screen scores significantly predicted clinical high-risk status among white (p<.01) but not black participants. Among black youths without clinical high risk, self-reported Prime Screen scores more closely resembled scores for youths (black or white) with clinical high risk than scores of white peers who were also without clinical high risk.

CONCLUSIONS

Results suggest that consideration of race or ethnicity and associated cultural factors is important when screening for clinical high-risk status. Findings support the need to develop culturally valid early psychosis screening tools to promote appropriately tailored early intervention efforts.

Perceived discrimination and psychotic experiences in the English general population

BACKGROUND

Perceived discrimination has been linked to psychotic experiences (PEs). However, as yet, information is lacking on the relationship between different forms of discrimination and PEs. This study examined this association in the English general population.

METHODS

Nationally representative, cross-sectional data were analyzed from 7363 adults aged 16 and above that came from the Adult Psychiatric Morbidity Survey, 2007. Self-reported information was obtained on six forms of discrimination (ethnicity, sex, religious beliefs, age, physical health problems/disability, sexual orientation), while PEs were assessed with the Psychosis Screening Questionnaire (PSQ). Multivariable logistic regression analysis was used to assess associations.

RESULTS

In a fully adjusted logistic regression analysis, any discrimination was significantly associated with PEs (odds ratio [OR]: 2.47, 95% confidence interval [CI]: 1.75-3.48). All individual forms of discrimination were significantly associated with PEs except sexual orientation. Multiple forms of discrimination were associated with higher odds for PEs in a monotonic fashion with those experiencing ≥ 3 forms of discrimination having over 5 times higher odds for any PE. In addition, experiencing any discrimination was associated with significantly increased odds for all individual forms of PE with ORs ranging from 2.16 (95%CI: 1.40-3.35) for strange experience to 3.36 (95%CI: 1.47-7.76) for auditory hallucination.

CONCLUSION

Different forms of discrimination are associated with PEs in the general population. As discrimination is common at the societal level, this highlights the importance of public policy and evidence-based interventions to reduce discrimination and improve population mental health.

Bullying Victimization and Suicide Attempt Among Adolescents Aged 12-15 Years From 48 Countries

OBJECTIVE

Adolescent suicide is a global public health problem. Bullying is a risk factor for suicidality in adolescence; however, global data on its association with suicide attempts are lacking, and data from low- and middle-income countries and non-Western settings are scarce. Thus, this study assessed the association between bullying victimization and suicide attempts using data from 48 countries (predominantly low- and middle-income countries) across multiple continents.

METHOD

Data from the Global School-based Student Health Survey were analyzed. Data on past 12-month suicide attempts and past 30-day bullying victimization were collected. Multivariable logistic regression and meta-analysis with random effects were conducted to assess the associations.

RESULTS

The final sample consisted of 134,229 adolescents 12 to 15 years of age. The overall prevalences of suicide attempts and bullying victimization were 10.7% and 30.4%, respectively. After adjustment for sex, age, and socioeconomic status, bullying victimization was significantly associated with higher odds for a suicide attempt in 47 of the 48 countries studied, with the pooled odds ratio being 3.06 (95% CI 2.73-3.43). A larger number of days bullied in the past month was dose-dependently associated with higher odds for suicide attempts. The past-year prevalence of suicide attempts ranged from 5.9% for the "no bullying" group up to 32.7% for the "being bullied for 20 to 30 days/month" group (odds ratio 5.51, 95% CI 4.56-6.65).

CONCLUSION

Bullying victimization could be an important risk factor of suicide attempts among adolescents globally. Thus, there is an urgent need to implement effective and evidence-based interventions to address bullying to prevent suicides and suicide attempts among adolescents worldwide.

Sleep problems and depression among 237 023 community-dwelling adults in 46 low- and middle-income countries

Sleep problems are considered a core symptom of depression. However, there is little information about the comorbidity of sleep problems and depression in low- and middle-income countries (LMICs), and whether sleep problems with depression confer additional risk for decrements in health compared to sleep problems alone. This study thus examined the association between sleep problems and depression and whether sleep problems with depression are associated with an increased risk for poorer health in 46 LMICs. Cross-sectional, community-based data from 237 023 adults aged ≥18 years from the World Health Survey (WHS) 2002–2004 were analyzed. Information on sleep problems (severe/extreme) and International Classification of Diseases 10th Revision depression/depression subtypes was collected. Multivariable logistic (binary and multinomial) and linear regression analyses were performed. Sleep problems were associated with subsyndromal depression (odds ratio [OR]: 2.23, 95% confidence interval [CI]: 1.84–2.70), brief depressive episode (OR = 2.48, 95% CI = 2.09–2.95) and depressive episode (OR = 3.61, 95% CI = 3.24–4.03). Sleep problems with depression (vs. sleep problems alone) conferred additional risk for anxiety, perceived stress and decrements in health in the domains of mobility, self-care, pain, cognition, and interpersonal activities. Clinicians should be aware that the co-occurrence of sleep problems and depression is associated with a variety of adverse health outcomes in LMICs. Detecting this co-occurrence may be important for treatment planning.

Fixity of thinking and the foundations of identity: An argument for the evolutionary adaptiveness of delusions

Epidemiological evidence suggests that psychosis occurs along a continuum of severity in the general population. Although clinical psychotic symptoms are associated with distress and impairment, less is known about sub-threshold delusion-like experiences. The present paper conceptually explores the possibility that fixed ideas or mildly illogical thinking may be adaptive at low to moderate severity levels. Strongly held beliefs that are resistant to reality checking may facilitate identification with particular social groups. For example, tenaciously maintaining one-sided political beliefs even in the face of contrary evidence may not be fully logical, but may provide a shared sense of group identity with others who share similar beliefs. Identifying with a group provides both emotional and instrumental sources of support in the face of adversity. Maintaining illogical fixed ideas or mildly delusion-like thoughts may be evolutionarily adaptive relative to overly logical thought or, at the other end of the spectrum, clinical delusions.

Psychotic experiences and physical health conditions in the United States

AIMS

Psychotic experiences are associated with physical health conditions, though the associations have not always been consistent in the literature. The current study examines the associations between psychotic experiences and several physical health conditions across four racial groups in the United States.

METHODS

We analyzed data from the Collaborative Psychiatric Epidemiology Surveys to examine the associations between psychotic experiences and physical health conditions across four racial groups (White, Black, Asian, Latino). We used multivariable logistic regression to calculated adjusted odds ratios and 95% Confidence Intervals.

RESULTS

Psychotic experiences were significantly associated with several physical health conditions depending on the condition and the racial group being examined. Further, the number of physical health conditions was associated with increasingly greater risk for psychotic experiences in a linear fashion.

CONCLUSIONS

Psychotic experiences may serve as useful markers for physical health conditions and overall physical health status. Future studies should examine the underlying mechanisms between psychotic experiences and health, and explore the clinical utility of psychotic experiences for preventive interventions.

Discrimination and suicidality among racial and ethnic minorities in the United States

BACKGROUND

Over the past decade, suicide rates have increased among certain racial/ethnic minority groups in the United States. To better understand suicide vulnerability among people of color, studies have examined the relations between social risk factors-such as discrimination-and suicidal thoughts and behaviors. However, the literature has been inconsistent, calling for more population studies.

METHODS

This study analyzed data from two surveys: (1) The National Survey of American Life; and (2) The National Latino and Asian American Survey, which taken together are representative of Black, Latino, and Asians in the United States. Multivariable logistic regression models were used to examine the association between levels of discrimination on the Everyday Discrimination Scale and suicidal thoughts and behaviors. Additional models tested for effect modification by race and by psychiatric diagnosis.

RESULTS

We found that individuals who reported the highest levels of discrimination had greater odds of reporting lifetime suicidal thoughts, plans, and attempts, when compared with people who did not report discrimination, after adjusting for socio-demographic characteristics. Notably, discrimination increased odds of reporting an unplanned suicide attempt and a suicide attempt without the intent to die. Adjusting for psychiatric diagnoses attenuated these effects. We found no evidence of effect modification by race or by psychiatric diagnosis.

LIMITATIONS

Data were cross-sectional, which did not allow for causal inferences.

CONCLUSIONS

Future translational research can explore how screening for discrimination may help identify individuals and groups of racial/ethnic minorities at risk for suicidal thoughts and behaviors.

Association of Exposure to Police Violence With Prevalence of Mental Health Symptoms Among Urban Residents in the United States

IMPORTANCE

Police violence is reportedly widespread in the United States and may pose a significant risk to public mental health.

OBJECTIVE

To examine the association between 12-month exposure to police violence and concurrent mental health symptoms independent of trauma history, crime involvement, and other forms of interpersonal violence exposure.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, general population survey study of 1221 eligible adults was conducted in Baltimore, Maryland, and New York City, New York, from October through December 2017. Participants were identified through Qualtrics panels, an internet-based survey administration service using quota sampling.

EXPOSURES

Past 12-month exposure to police violence, assessed using the Police Practices Inventory. Subtypes of violence exposure were coded according to the World Health Organization domains of violence (ie, physical, sexual, psychological, and neglectful).

MAIN OUTCOMES AND MEASURES

Current Kessler Screening Scale for Psychological Distress (K6) score, past 12-month psychotic experiences (World Health Organization Composite International Diagnostic Interview), and past 12-month suicidal ideation and attempts.

RESULTS

Of 1221 eligible participants, there were 1000 respondents (81.9% participation rate). The sample matched the adult population of included cities on race/ethnicity (non-Hispanic white, 339 [33.9%]; non-Hispanic black/African American, 390 [39.0%]; Hispanic/Latino, 178 [17.8%]; other, 93 [9.3%]), age (mean [SD], 39.8 [15.2] years), and gender (women, 600 [60.0%]; men, 394 [39.4%]; transgender, 6 [0.6%]) within 10% above or beyond 2010 census distributions. Twelve-month prevalence of police violence was 3.2% for sexual violence, 7.5% for physical violence without a weapon, 4.6% for physical violence with a weapon, 13.2% for psychological violence, and 14.9% for neglect. Police violence exposures were higher among men, people of color, and those identified as homosexual or transgender. Respondents reported suicidal ideation (9.1%), suicide attempts (3.1%), and psychotic experiences (20.6%). The mean (SD) K6 score was 5.8 (6.1). All mental health outcomes were associated with police violence exposure in adjusted logistic regression analyses. Physical violence with a weapon and sexual violence were associated with greater odds of psychotic experiences (odds ratio [95% CI]: 4.34 [2.05-9.18] for physical violence with a weapon; 6.61 [2.52-17.36] for sexual violence), suicide attempts (odds ratio [95% CI]: 7.30 [2.94-18.14] for physical violence with a weapon; 6.63 [2.64-16.64] for sexual violence), and suicidal ideation (odds ratio [95% CI]: 2.72 [1.30-5.68] for physical violence with a weapon; 3.76 [1.72-8.20] for sexual violence).

CONCLUSIONS AND RELEVANCE

Police violence was commonly reported, especially among racial/ethnic and sexual minorities. Associations between violence and mental health outcomes did not appear to be explained by confounding factors and appeared to be especially pronounced for assaultive forms of violence.

Sibship size, birth order and psychotic experiences: Evidence from 43 low- and middle-income countries

BACKGROUND

Sibship size and birth order may be contributing factors to the multifactorial etiology of psychosis. Specifically, several studies have shown that sibship size and birth order are associated with schizophrenia. However, there are no studies on their association with psychotic experiences (PE).

METHODS

Cross-sectional, community-based data from 43 low- and middle-income countries which participated in the World Health Survey were analyzed. The Composite International Diagnostic Interview was used to identify four types of past 12-month PE. The association of sibship size and birth order with PE was assessed with multivariable logistic regression.

RESULTS

The final sample consisted of 212,920 adults [mean (SD) age 38.1 (16.0) years; 50.7% females]. In the multivariable analysis, compared to individuals with no siblings, the OR increased linearly from 1.26 (95%CI = 1.01-1.56) to 1.72 (95%CI = 1.41-2.09) among those with 1 and ≥ 9 siblings, respectively. Compared to the first-born, middle-born individuals were more likely to have PE when having a very high number of siblings (i.e. ≥9).

CONCLUSIONS

Future studies should examine the environmental and biological factors underlying the association between sibship size/birth order and PE. Specifically, it may be important to examine the unmeasured factors, such as childhood infections and adversities that may be related to both family structure and PE.

Perceived need for care and mental health service utilization among college students with suicidal ideation

OBJECTIVE

This study aimed to identify correlates of service utilization and perceived need for care among college students with suicidal ideation.

PARTICIPANTS

Respondents were recruited from introductory psychology courses at an undergraduate college during the Fall 2014 semester.

METHODS

Independent correlates of (1) mental health service utilization, (2) self-perceived need, and (3) other-perceived need for mental health services among college students (N = 190) with suicidal ideation were identified.

RESULTS

Service utilization was associated with need for care as perceived by others. Perceived need for care by others was associated with suicidal ideation intensity and suicide attempt history. Perceived need by the respondents themselves was correlated with depression severity, sex, and race but was not independently associated with actual service utilization.

CONCLUSIONS

Perceived need by others was the sole significant correlate of service utilization, suggesting it is an important target for public health interventions aimed at facilitating pathways into mental health treatment.

Seasonal Allergies and Psychiatric Disorders in the United States

Seasonal allergies have been associated with mental health problems, though the evidence is still emergent, particularly in the United States. We analyzed data from the National Comorbidity Survey Replication and the National Latino and Asian American Survey (years 2001–2003). Multivariable logistic regression models were used to examine the relations between lifetime allergies and lifetime psychiatric disorders (each disorder in a separate model), adjusting for socio-demographic variables (including region of residence) and tobacco use. Analyses were also stratified to test for effect modification by race and sex. A history of seasonal allergies was associated with greater odds of mood disorders, anxiety disorders, and eating disorders, but not alcohol or substance use disorders, after adjusting for socio-demographic characteristics and tobacco use. The associations between seasonal allergies and mood disorders, substance use disorders, and alcohol use disorders were particularly strong for Latino Americans. The association between seasonal allergies and eating disorders was stronger for men than women. Seasonal allergies are a risk factor for psychiatric disorders. Individuals complaining of seasonal allergies should be screened for early signs of mental health problems and referred to specialized services accordingly.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.

Criminal victimization and psychotic experiences: cross-sectional associations in 35 low- and middle-income countries

OBJECTIVE

Criminal victimization has been associated with elevated risk for psychotic symptoms in the United Kingdom, but has not been studied in low- and middle-income countries (LMICs). Understanding whether crime exposure may play a role in the social etiology of psychosis could help guide prevention and intervention efforts.

METHOD

We tested the hypothesis that criminal victimization would be associated with elevated odds of psychotic experiences in 35 LMICs (N = 146 999) using cross-sectional data from the World Health Organization World Health Survey. Multivariable logistic regression analyses were used to test for associations between criminal victimization and psychotic experiences.

RESULTS

Victimization was associated with greater odds of psychotic experiences, OR (95% CI) = 1.72 (1.50-1.98), and was significantly more strongly associated with psychotic experiences in non-urban, OR (95% CI) = 1.93 (1.60-2.33), compared to urban settings, OR (95% CI) = 1.48 (1.21-1.81). The association between victimization and psychosis did not change across countries with varying aggregated levels of criminal victimization.

CONCLUSIONS

In the largest ever study of victimization and psychosis, the association between criminal victimization and psychosis appears to generalize across a range of LMICs and, therefore, across nations with a broad range of crime rates, degree of urban development, average per capita income, and racial/ethnic make-up.

Association of Urbanicity With Psychosis in Low- and Middle-Income Countries

Importance

Urban residence is one of the most well-established risk factors for psychotic disorder, but most evidence comes from a small group of high-income countries.

Objective

To determine whether urban living is associated with greater odds for psychosis in low- and middle-income countries (LMICs).

Design, Setting, and Participants

This international population-based study used cross-sectional survey data collected as part of the World Health Organization (WHO) World Health Survey from May 2, 2002, through December 31, 2004. Participants included nationally representative general population probability samples of adults (≥18 years) residing in 42 LMICs (N = 215 682). Data were analyzed from November 20 through December 5, 2017.

Exposures

Urban vs nonurban residence, determined by the WHO based on national data.

Main Outcomes and Measures

Psychotic experiences, assessed using the WHO Composite International Diagnostic Interview psychosis screen, and self-reported lifetime history of a diagnosis of a psychotic disorder.

Results

Among the 215 682 participants (50.8% women and 49.2% men; mean [SD] age, 37.9 [15.7] years), urban residence was not associated with psychotic experiences (odds ratio [OR], 0.99; 95% CI, 0.89-1.11) or psychotic disorder (OR, 0.89; 95% CI, 0.76-1.06). Results of all pooled analyses and meta-analyses of within-country effects approached a null effect, with an overall OR of 0.97 (95% CI, 0.87-1.07), OR for low-income countries of 0.98 (95% CI, 0.82-1.15), and OR for middle-income countries of 0.96 (95% CI, 0.84-1.09) for psychotic experiences and an overall OR of 0.92 (95% CI, 0.73-1.16), OR for low-income countries of 0.92 (95% CI, 0.66-1.27), and OR for middle-income countries of 0.92 (95% CI, 0.67-1.27) for psychotic disorder.

Conclusions and Relevance

Our results provide evidence that urbanicity, a well-established risk factor for psychosis, may not be associated with elevated odds for psychosis in developing countries. This finding may provide better understanding of the mechanisms by which urban living may contribute to psychosis risk in high-income countries, because urban-rural patterns of cannabis use, racial discrimination, and socioeconomic disparities may vary between developing and developed nations.

Speech illusions and working memory performance in non-clinical psychosis

Psychotic disorders are characterized by auditory verbal hallucinations (AVHs), and research has shown that AVHs are linked to deficits in working memory. Our understanding of AVHs across the psychosis continuum is limited. To date, little research has tested whether hallucination proneness (HP) is linked with abnormalities on experimental multispeaker babble tasks. Few investigations have been conducted to determine how task performance might be linked to cognitive functioning. The objective of the current study is to better understand this empirical gap. A total of 70 adults (30 healthy controls and 40 HP individuals) were administered an experimental task in which they listened to multispeaker babble and were instructed to report any words or chains of consecutive words (CCWs) perceived. Participants also were administered nonverbal and verbal working memory tasks. Findings revealed that relative to the control group, the HP individuals perceived more words and longer CCWs during the task. While there were no significant differences in working memory tasks between the HP and control groups, longer CCW's were associated with decreased verbal working memory scores in the HP group. AVH proneness may occur across a continuum of psychosis and may be linked with other theoretically relevant cognitive vulnerability factors.

Depression, sleep problems, and perceived stress among informal caregivers in 58 low-, middle-, and high-income countries: A cross-sectional analysis of community-based surveys

Caregiving has been associated with adverse health outcomes. However, there is a paucity of multi-country, population-based studies on mental health outcomes of caregivers especially from low- and middle-income countries (LMICs). Thus, we assessed the association of caregiving with depression, sleep problems, and perceived stress in 10 high-, 27 middle-, and 21 low-income countries. Cross-sectional community-based data of the World Health Survey including 258,793 adults aged ≥18 years were analyzed. Multivariable logistic and linear regression analyses were conducted to explore the association of past 12-month caregiving with past 12-month DSM-IV depression, and past 30-day perceived stress [range 0 (low)-100 (high)] and severe/extreme sleep problems. Nearly 20% of the individuals were engaged in caregiving with particularly high rates observed in high-income countries (HICs) (e.g., Finland 43.3%). Across the entire sample, after adjustment for potential confounders, caregivers had a significantly higher likelihood of having depression (OR = 1.54; 95%CI = 1.37-1.73), sleep problems (OR = 1.37; 95%CI = 1.25-1.50), while their mean perceived stress score was 3.15 (95%CI = 2.46-3.84) points higher. These associations tended to be stronger in HICs. A greater number of caregiving activities was associated with a greater likelihood of depression, sleep problems, and perceived stress regardless of country income levels. In conclusion, caregiving has a negative impact on mental health worldwide with possibly greater effects in HICs. Given the growing contribution of caregivers in long-term care, interventions and policies to alleviate the mental health burden of caregivers are urgently needed to maintain sustainable and effective care practices.

Depression comorbid with tuberculosis and its impact on health status: cross-sectional analysis of community-based data from 48 low- and middle-income countries

BACKGROUND

Depression in tuberculosis increases the risk for adverse health outcomes. However, little is known about comorbid depression and tuberculosis in the general population. Thus, we assessed the association between depression and tuberculosis, and the decrements in health status associated with this comorbidity in 48 low- and middle-income countries.

METHODS

Cross-sectional, community-based data from the World Health Survey on 242,952 individuals aged ≥ 18 years were analyzed. Based on the World Mental Health Survey version of the Composite International Diagnostic Interview, past 12-month depression was categorized into depressive episode, brief depressive episode, subsyndromal depression, and no depression. Health status across six domains (cognition, interpersonal activities, sleep/energy, self-care, mobility, pain/discomfort) was assessed. Multivariable logistic and linear regression analyses were performed to assess the associations.

RESULTS

The prevalence of depressive episode among those with and without tuberculosis was 23.7% and 6.8%, respectively (P < 0.001). Tuberculosis was associated with a 1.98 (95% CI 1.47-2.67), 1.75 (95% CI 1.26-2.42), and 3.68 (95% CI 3.01-4.50) times higher odds for subsyndromal depression, brief depressive episode, and depressive episode, respectively. Depressive episode co-occurring with tuberculosis was associated with significantly worse health status across all six domains compared to tuberculosis alone. Interaction analysis showed that depression significantly amplifies the association between TB and difficulties in self-care but not in other health domains.

CONCLUSIONS

Depression is highly prevalent in adults with tuberculosis, and is associated with worse health status compared to tuberculosis without depression. Public health efforts directed to the recognition and management of depression in people with tuberculosis may lead to better outcomes.