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Suicide rates among young people are rising. Health care visits provide opportunities for identification and intervention, yet studies have been limited by small or circumscribed samples. This study sought to expand the knowledge base by examining health care encounters and diagnoses among young people who later died by suicide.This case-control study examined diagnoses of mental and general medical disorders and health care utilization in the 30 and 365 days before suicide death in nine large U.S. health care systems. Data (years 2000-2015) from 445 suicide decedents ages 10-24 years were matched with data from 4,450 control group patients.Suicide decedents were more likely to have at least one mental disorder diagnosis (51% vs. 16%; adjusted OR [AOR]=5.74, 95% CI=4.60-7.18) and had higher rates of nearly all mental health conditions. Substance use disorders were common (12%) and more likely (AOR=8.50, 95% CI=5.53-13.06) among suicide decedents. More than one in three (42%) suicide decedents had a health care visit in the month before death, and nearly all (88%) had a visit in the previous year.Despite the greater likelihood of suicide associated with mental disorder diagnoses, such disorders were present among only 51% of suicide decedents. High rates of health care utilization among suicide decedents indicate a need for improving identification of mental health conditions and suicide risk across the health care system. Increased substance use screening may help identify youths at high risk because substance use disorders were significantly more prevalent and likely among suicide decedents.

OBJECTIVE This study was designed to assess how postoperative opioid prescription dosage could affect patient-reported outcomes after elective spine surgery. METHODS Patients enrolled in the Michigan Spine Surgery Improvement Collaborative (MSSIC) from January 2020 to September 2021 were included in this study. Opioid prescriptions at discharge were converted to total morphine milligram equivalents (MME). A reference value of 225 MME per week was used as a cutoff. Patients were divided into two cohorts based on prescribed total MME: ≤ 225 MME and > 225 MME. Primary outcomes included patient satisfaction, return to work status after surgery, and whether improvement of the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System 4-question short form for physical function (PROMIS PF) and EQ-5D was met. Generalized estimated equations were used for multivariate analysis. RESULTS Regression analysis revealed that patients who had postoperative opioids prescribed with > 225 MME were less likely to be satisfied with surgery (adjusted OR [aOR] 0.81) and achieve PROMIS PF MCID (aOR 0.88). They were also more likely to be opioid dependent at 90 days after elective spine surgery (aOR 1.56). CONCLUSIONS The opioid epidemic is a serious threat to national public health, and spine surgeons must practice conscientious postoperative opioid prescribing to achieve adequate pain control. The authors’ analysis illustrates that a postoperative opioid prescription of 225 MME or less is associated with improved patient satisfaction, greater improvement in physical function, and decreased opioid dependence compared with those who had > 225 MME prescribed.

OBJECTIVE: Suicide rates continue to rise, necessitating identification of novel risk factors to prevent suicide. Obesity and suicide mortality have been examined, but no studies have examined associations between weight change, suicide mortality, and depression among adults in the U.S. METHODS: People who died by suicide from 2000-2015 with a recorded height and weight in the first and second 6 months preceding their death (“index date”; n = 387) were extracted from a larger sample from the Mental Health Research Network; each was matched with five people in the control group by age, sex, index year, and healthcare site (n = 1,935). Data were analyzed in 2020. RESULTS: People who died by suicide were predominantly male (71%), Caucasian (69%), depressed (55%), middle aged (M = 57 years), with chronic health issues (57%), [Control: 66% Caucasian; M age = 56 years; 43% chronic health issues, 14% depressed]. T-test analyses showed BMI change within a year before the index date differed between those who died by suicide (M = −0.72±2.42 kg/m(2)) and the control group, (M = 0.06±4.99 kg/m(2)) p < 0.001, d = .17. A 1-unit decrease in BMI was associated with 9% increased risk of suicide after adjusting for demographics, mental disorders, and Charlson score (aOR = 0.91, 95% CI = 0.87-0.95, p < 0. 001). BMI change and suicide were associated for those without depression (p < 0.001). CONCLUSIONS: Weight loss in the year before suicide was associated with increased suicide mortality after accounting for physical and mental health indicators.

Study Design This is a retrospective, cohort analysis of multi-institutional database. Objective This study was designed to analyze the impact of drain use following elective anterior cervical discectomy and fusion (ACDF) surgeries. Summary of Background Data After ACDF, a drain is often placed to prevent postoperative hematoma. However, there has been no high quality evidence to support its use with ACDF despite the theoretical benefits and risks of drain placement. Methods The Michigan Spine Surgery Improvement Collaborative database was queried to identify all patients undergoing elective ACDF between February 2014 and October 2019. Cases were divided into two cohorts based on drain use. Propensity-score matching was utilized to adjust for inherent differences between the two cohorts. Measured outcomes included surgical site hematoma, length of stay, surgical site infection, dysphagia, home discharge, readmission within 30 days, and unplanned reoperation. Results We identified 7,943 patients during the study period. Propensity-score matching yielded 3,206 pairs. On univariate analysis of matched cohorts, there were no differences in rate of post-operative hematoma requiring either return to OR or readmission. We noted patients with drains had a higher rate of dysphagia (4.6% vs 6.3%; p = 0.003) and had longer hospital stay (p < 0.001). On multivariate analysis, drain use was associated with significantly increased length of stay (RR 1.23, 95% CI 1.13-1.34; p < 0.001). There were no significant differences in other outcomes measured. Conclusion Our analysis demonstrated that drain use is associated with significant longer hospital stay.

OBJECTIVEIn 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.METHODSPatient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.RESULTSPatients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).CONCLUSIONSThere was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.

The aim of this research was to examine predictors and characterize causes of suicide death in people with traumatic brain injury (TBI) and conduct sensitivity analyses with and without people whose first diagnosis of TBI occurred within 3 days of their suicide death.This case-control study examined suicide risk for people with TBI in eight Mental Health Research Network-affiliated healthcare systems. Sample 1 included 61 persons with TBI who died by suicide and their 75 matched controls with TBI who did not die by suicide between January 1, 2000, and December 31, 2013. Sample 2 excluded the 34 persons with TBI whose first TBI diagnosis occurred within 3 days of their suicide death and their 46 matched controls. Descriptive statistics characterized the sample stratified by cases and controls, while conditional logistic regression models estimated the adjusted odds of suicide.Over half of suicide deaths occurred within 3 days of a person's first diagnosis of TBI in the larger sample. After excluding these persons, people with TBI were 2.84 (95% confidence interval [CI]: 2.15-2.73) times more likely to die by suicide than were people without TBI. Among those with TBI, men were 16.39 times (95% CI: 1.89-142.15) more likely to die by suicide than were women.Accounting for TBI as a potential consequence of suicide attenuates the association between TBI and suicide, but a robust association persists-especially among men. Ultimately, all people with TBI should be carefully screened and monitored for suicide risk.HIGHLIGHTSPeople with traumatic brain injury (TBI) were at considerably elevated risk for suicide deathMen with TBI had significantly increased risk of suicide death compared to women with TBITBI timing suggests confusion of risk factors for and consequences of suicide.

Culturally adapted evidence-based parenting interventions constitute a key strategy to reduce widespread mental health disparities experienced by Latinx populations throughout the United States. Most recently, the relevance of culturally adapted parenting interventions has become more prominent as vulnerable Latinx populations are exposed to considerable contextual stressors resulting from an increasingly anti-immigration climate in the country. The current study was embedded within a larger NIMH-funded investigation, aimed at contrasting the differential impact of two culturally adapted versions of the evidence-based parenting intervention known as GenerationPMTO©. Specifically, a sample of low-income Mexican-origin immigrants was exposed either to a culturally adapted version of GenerationPMTO primarily focused on parent training components, or to an enhanced culturally adapted version in which parenting components were complemented by sessions focused on immigration-related challenges. The sample for the study consisted of 103 Mexican-origin immigrant families (190 individual parents). Descriptive analysis and generalized estimating equations (GEEs) indicated that exposure to the enhanced intervention, which included context- and culture-specific sessions, resulted in specific benefits for parents. However, the magnitude of the impact was not uniform for mothers and fathers and differed according to the type of immigration-related stress being examined (i.e., intrafamilial vs. extrafamilial stress). Overall, findings indicate the relevance of overtly addressing contextual (e.g., discrimination) and cultural challenges in culturally adapted interventions, as well as the need to increase precision according to the extent to which immigration-related stressors impact immigrant mothers and fathers in common and contrasting ways. Implications for family therapy practice and research are discussed.Las intervenciones basadas en evidencia, dirigidas a padres y adaptadas a la cultura son una estrategia clave para reducir las desigualdades en salud mental generalizadas que las poblaciones de latin@s experimentan en los Estados Unidos. Más recientemente, la relevancia de intervenciones dirigidas a padres adaptadas a la cultura ha adquirido más peso al estar las poblaciones de latin@s expuestas a factores estresantes contextuales considerables como resultado de un ambiente cada vez más contrario a la inmigración en el país. Este estudio fue incluido dentro de una investigación de mayor escala financiada por NIMH cuyo objetivo era contrastar el impacto diferencial de dos versiones adaptadas a la cultura de la intervención basada en evidencia y dirigida a padres conocida como GenerationPMTO在美国拉丁族裔人口中, 文化调适后的以实证为基础的家长干预是一个非常重要的可以减少较为广泛的心理健康方面不均衡差异的关键策略。最近, 美国国内日益兴起的反移民社会大环境给脆弱的拉丁裔人口造成了各种巨大的外界压力。这种情况下文化调适后的家长干预其相关作用越来越显著。NIMH资助的较大规模调查研究旨在针对实证为基础的家长干预即GenerationPMTO

Objective Nonadherence to pharmacotherapy for psychiatric conditions is associated with poor outcomes, including increased risk of relapse, increased health care costs, and reduced quality of life. The objective of this study was to investigate the strength of association between socioeconomic factors, race/ethnicity, and patient perceptions with medication adherence in individuals with depression. Methods Baseline surveys were sent out in 2012 to 4,216 adult patients within a large health system who presented with a clinical diagnosis of major depressive disorder (ICD-9), recorded at least twice in the electronic medical record in the year 2011. A total of 1,573 patients responded to the baseline survey. Of those, 1,209 patients who completed the survey and had used antidepressants in the last 12 months were recruited for the study. Perception of medication risk was assessed using the Beliefs About Medicines Questionnaire, and adherence to medications was assessed using the Morisky Medication Adherence Scale. Logistic regression was used to investigate the relationship between perception of medicine risk and treatment adherence. Results For non-Hispanic white individuals, medication adherence was higher among those who were least concerned about the risk of medications (64%; 95% CI, 58-70) compared to those who were most concerned (34%; 95% CI, 26-43). In the logistic regression model, less concern about medications and their side effects was associated with higher medication adherence (odds ratio = 2.6; 95% CI, 1.77-3.84; P < .0001). This association remained significant after adjustment for age, race, education level, and extramedical use of other medications or substances. Moreover, patients with older age and lower education level as well as those who were non-Hispanic white and had no extramedical use of other medications/substances were more likely to be adherent to medications. Conclusions This study contributes quantitative data on factors that impact treatment adherence. Identifying patients at increased risk of nonadherence, having discussions with patients early in the treatment process to understand their concerns regarding treatment options, being sensitive to cultural beliefs, and patiently proceeding with the decision-making process could help ensure better outcomes.

BACKGROUND Preoperative hemoglobin A1c (HbA1c) is a useful screening tool since a significant portion of diabetic patients in the United States are undiagnosed and the prevalence of diabetes continues to increase. However, there is a paucity of literature analyzing comprehensive association between HbA1c and postoperative outcome in lumbar spine surgery. OBJECTIVE To assess the prognostic value of preoperative HbA1c > 8% in patients undergoing elective lumbar spine surgery. METHODS The Michigan Spine Surgery Improvement Collaborative (MSSIC) database was queried to track all elective lumbar spine surgeries between January 2018 and December 2019. Cases were divided into 2 cohorts based on preoperative HbA1c level (≤8% and >8%). Measured outcomes include any complication, surgical site infection (SSI), readmission (RA) within 30 d (30RA) and 90 d (90RA) of index operation, patient satisfaction, and the percentage of patients who achieved minimum clinically important difference (MCID) using Patient-Reported Outcomes Measurement Information System. RESULTS We captured 4778 patients in this study. Our multivariate analysis demonstrated that patients with HbA1c > 8% were more likely to experience postoperative complication (odds ratio [OR] 1.81, 95% CI 1.20-2.73; P = .005) and be readmitted within 90 d of index surgery (OR 1.66, 95% CI 1.08-2.54; P = .021). They also had longer hospital stay (OR 1.12, 95% CI 1.03-1.23; P = .009) and were less likely to achieve functional improvement after surgery (OR 0.64, 95% CI 0.44-0.92; P = .016). CONCLUSION HbA1c > 8% is a reliable predictor of poor outcome in elective lumbar spine surgery. Clinicians should consider specialty consultation to optimize patients' glycemic control prior to surgery.

Latino/a populations in the United States are negatively impacted by widespread mental health disparities. Although the dissemination of culturally relevant parent training (PT) programs constitutes an alternative to address this problem, there is a limited number of efficacious culturally adapted PT prevention interventions for low-income Latino/a immigrant families with adolescents. The current manuscript describes the level of acceptability of a version of the GenerationPMTO(®) intervention adapted for Latino/a immigrant families, with an explicit focus on immigration-related challenges, discrimination, and promotion of biculturalism. Qualitative reports were provided by 39 immigrant parents who successfully completed the prevention parenting program. The majority of these parents self-identified as Mexican-origin. According to qualitative findings, participants reported overall high satisfaction with immigration and culture-specific components. Parents also expressed high satisfaction with the core GenerationPMTO parenting components and provided specific recommendations for improving the intervention. Current findings indicate the need to adhere to the core components that account for the effectiveness of PT interventions. Equally important is to thoroughly adapt PT interventions according to the cultural values and experiences that are relevant to target populations, as well as to overtly address experiences of discrimination that negatively impact underserved Mexican-origin immigrant families. Due to the exploratory nature of this study, the efficacy and effectiveness of the adapted prevention intervention remains to be established in empirical research.

Although mental health conditions are risk factors for suicide, limited data are available on suicide mortality associated with specific mental health conditions in the U.S. population. This study aimed to fill this gap.This study used a case-control design. Patients in the case group were those who died by suicide between 2000 and 2013 and who were patients in eight health care systems in the Mental Health Research Network (N=2,674). Each was matched with 100 general population patients from the same system (N=267,400). Diagnostic codes for five mental health conditions in the year before death were obtained from medical records: anxiety disorders, attention deficit-hyperactivity disorder (ADHD), bipolar disorder, depressive disorders, and schizophrenia spectrum disorder.Among patients in the case group, 51.3% had a recorded psychiatric diagnosis in the year before death, compared with 12.7% of control group patients. Risk of suicide mortality was highest among those with schizophrenia spectrum disorder, after adjustment for age and sociodemographic characteristics (adjusted odds ratio [AOR]=15.0) followed by bipolar disorder (AOR=13.2), depressive disorders (AOR=7.2), anxiety disorders (AOR=5.8), and ADHD (AOR=2.4). The risk of suicide death among those with a diagnosed bipolar disorder was higher in women than men.Half of those who died by suicide had at least one diagnosed mental health condition in the year before death, and most mental health conditions were associated with an increased risk of suicide. Findings suggest the importance of suicide screening and providing an approach to improve awareness of mental health conditions.

Background Psychiatric comorbidity is common among patients with alcohol and other drug (AOD) use disorders. To better understand how psychiatric comorbidity influences AOD treatment access in health care systems, the present study examined treatment initiation and engagement among a large, diverse sample of patients with comorbid psychiatric and AOD use disorders. Methods This study utilized data from a multisite observational study examining Healthcare Effectiveness Data and Information Set (HEDIS) measures of initiation and engagement in treatment (IET) among patients with AOD use disorders from 7 health care systems. Participants were aged 18 or older with at least 1 AOD index diagnosis between October 1, 2014, and August 15, 2015. Data elements extracted from electronic health records and insurance claims data included patient demographic characteristics, ICD-9 (International Classification of Diseases, Ninth Revision) diagnostic codes, and procedure codes. Descriptive analyses and multivariate logistic regression models were used to examine the relationship between patient-level factors and IET measures. Results Across health care systems, out of a total of 86,565 patients who had at least 1 AOD index diagnosis during the study period, 66.2% ( n = 57,335) patients also had a comorbid psychiatric disorder. Among patients with a comorbid psychiatric disorder, 34.9% ( n = 19,998) initiated AOD treatment, and of those, 10.3% ( n = 2,060) engaged in treatment. After adjusting for age, sex, and race/ethnicity, patients with comorbid psychiatric disorders were more likely to initiate (odds ratio [OR] = 3.20, 95% confidence interval [CI] = 3.08, 3.32) but no more likely to engage (OR = 0.56, 95% CI = 0.51, 0.61) in AOD treatment, compared with those without a comorbid psychiatric disorder. Conclusions Findings suggest that identification of comorbid psychiatric disorders may increase initiation in AOD treatment. However, innovative efforts are needed to enhance treatment engagement both generally and especially for individuals without diagnosed psychiatric conditions.

Background Infection in pregnancy has long been linked with negative postnatal development and health. This study aims to assess the association between prenatal infections and autism spectrum disorders (ASDs) across three trimesters and to probe possible sex heterogeneity in such link. Method A total of 4184 children with incident ASDs and 16 734 matched children were identified from the 2000–2007 National Health Insurance Research Database. For each child, information pertaining to the mother's infection during pregnancy, sociodemographics, and medical history was retrieved from healthcare records. Conditional logistic analyses were carried out to estimate the strength of associations with adjustment for multiple comparisons. Result Pooled analyses demonstrated that having two or more outpatient visits for genital infection [adjusted odds ratio (aOR): 1.34; 95% confidence interval (95% CI) 1.12, 1.60; false discovery rate (FDR)

Aims To identify sociodemographic and clinical factors predicting the overall risk of adverse obstetric outcomes and the length of maternal hospital stay among heroin-exposed and methadone-treated women in Taiwan. Methods Using the retrospective matched cohort study design, 396 births to women on methadone treatment during pregnancy (the methadone-treated group) and 609 to women who started methadone treatment after childbirth (the heroin-exposed group) were identified in the National Methadone Maintenance Program. Adverse pregnancy outcomes were assessed by still birth, low birth weight and preterm delivery. We used multivariate methods and zero-truncated negative binomial regression to evaluate association estimates. Finding Both heroin-exposed and methadone-treated women had 2–4-fold greater risk of adverse pregnancy outcomes. HIV infection increased the overall risk of adverse pregnancy outcome in the methadone-treated group, whereas being unmarried and having treatment history of substance use disorders increased such risk in the heroin-exposed group. Maternal ages at delivery and healthcare facility used had moderate effects on the length of maternal hospital stay; HIV infection significantly increased the length of hospital stay for women in the heroin-exposed group (adjusted relative risk=1.32, 95% CI=1.05–1.68). Conclusions Our results showed no appreciable differences in the occurrence of adverse obstetric outcomes and the length of maternity hospitalization between the methadone-treated and the heroin-exposed women; the profile of sociodemographic and clinical predictors was similar as well. Coordination of addiction treatment and prenatal care may help reduce unfavorable obstetric outcomes among female heroin addicts seeking substitution treatment.

Purpose Repeat suicidal behaviors in young people are a critical public health concern. The study investigates individual socioeconomic and episode-dependent clinical factors predicting repeat suicide attempts among youth by gender. Methods Using a retrospective cohort study, we identified a total of 4,094 male and 3,219 female youths who had the index suicide episode at the ages of 15–24 years from the 1996–2007 National Health Insurance Research Database in Taiwan. The recurrence of suicide attempt was assessed within 1 year after the index suicide. Information pertaining to suicide management and postsuicide treatment was obtained from healthcare records. Repeated event survival analyses were used to estimate episode-dependent risk of suicide attempt. Results The occurrence of repeat suicide attempts was more common in males, yet the phenomenon of risk aggravation appears more prominent in females. The estimate for peak hazard of the second repeat attempt was 2-fold higher than that of the first repeat event in males, and approximately 6-fold in females. Socioeconomic (e.g., labor market participation: adjusted Hazard Ratio [aHR] = 1.14, 95% CI = 1.01–1.28) and index suicide management characteristics (e.g., receiving treatment at clinic, aHR = 1.54, 95% CI = 1.19–1.99) were found to play important roles for repeat suicide attempts in males. For females, postsuicide treatment of mental disorders appears more influential. Conclusions The relationships between socioeconomic and clinical factors with repeat suicide attempts in young people vary by gender. School/workplace-based post suicide attempt consultation and clinical management for youth may be planned and delivered on a gender-appropriate basis.

Background The United States has experienced a significant rise in suicide. As decision makers identify how to address this national concern, healthcare systems have been identified as an optimal location for prevention. Objective To compare variation in patterns of healthcare use, by health setting, between individuals who died by suicide and the general population. Design Case-Control Study. Setting Eight healthcare systems across the United States. Participants 2674 individuals who died by suicide between 2000 and 2013 along with 267,400 individuals matched on time-period of health plan membership and health system affiliation. Measurements Healthcare use in the emergency room, inpatient hospital, primary care, and outpatient specialty setting measured using electronic health record data during the 7-, 30-, 60-, 90-, 180-, and 365-day time periods before suicide and matched index date for controls. Results Healthcare use was more common across all healthcare settings for individuals who died by suicide. Nearly 30% of individuals had a healthcare visit in the 7-days before suicide (6.5% emergency, 16.3% outpatient specialty, and 9.5% primary care), over half within 30 days, and >90% within 365 days. Those who died by suicide averaged 16.7 healthcare visits during the year. The relative risk of suicide was greatest for individuals who received care in the inpatient setting (aOR = 6.23). There was both a large relative risk (aOR = 3.08) and absolute utilization rate (43.8%) in the emergency room before suicide. Limitations Participant race/ethnicity was not available. The sample did not include uninsured individuals. Conclusions This study provides important data about how care utilization differs for those who die by suicide compared to the general population and can inform decision makers on targeting of suicide prevention activities within health systems.

This study sought to understand the stability of and change in benzodiazepine use among incident long-term benzodiazepine users over a five-year period and to investigate predictors of variation in use patterns from adolescence into adulthood.Long-term use was defined as receipt of benzodiazepine prescriptions for 31 or more cumulative days in a calendar year. Data for 1999-2005 were obtained from the National Health Insurance Research Database in Taiwan. Two age groups of incident long-term users in 2000 were identified--1,758 aged 12-15 and 5,265 aged 16-19-and their benzodiazepine prescription records from 2001 to 2005 were retrieved. Group-based trajectory analyses and polytomous logistic regression were performed to evaluate differential risk of benzodiazepine use over time.From 3% to 5% of the incident benzodiazepine users were long-term users. Four distinct groups of users emerged from the five years of study data: occasional, decelerating, accelerating, and chronic users. Overall, one-quarter were accelerating or chronic users. A history of psychosis or epilepsy, prescription by providers from multiple specialties, and receipt of benzodiazepines with a long half-life or mixed indications significantly increased one's risk of becoming a chronic or accelerating user (range of adjusted odds ratios from 2 to 6).Patient characteristics and attributes of service providers and pharmacological agents played significant roles in benzodiazepine use patterns. Prescribers can reduce the risk of long-term use by assessing whether pediatric patients have received benzodiazepines from multiple doctors for various medical conditions.

Infection in pregnancy has long been linked with negative postnatal development and health. This study aims to assess the association between prenatal infections and autism spectrum disorders (ASDs) across three trimesters and to probe possible sex heterogeneity in such link.A total of 4184 children with incident ASDs and 16,734 matched children were identified from the 2000-2007 National Health Insurance Research Database. For each child, information pertaining to the mother's infection during pregnancy, sociodemographics, and medical history was retrieved from healthcare records. Conditional logistic analyses were carried out to estimate the strength of associations with adjustment for multiple comparisons.Pooled analyses demonstrated that having two or more outpatient visits for genital infection [adjusted odds ratio (aOR): 1.34; 95% confidence interval (95% CI) 1.12, 1.60; false discovery rate (FDR) 0.01] and bacterial infection (aOR: 1.24; 95% CI 1.06, 1.43; FDR 0.05) in the third trimester were slightly associated with increased risk of ASDs. No statistically significant sex differences were found.The present study contributes updated population-based evidence about the connection between prenatal infection and ASDs. Potential effect of bacterial and genital tract infections during the third trimester on risk of ASDs warrants further exploration.

This study examined the extent to which characteristics of family and health care providers predict treatment initiation, treatment mode, and treatment termination among preschool children with newly diagnosed ADHD.A cohort of 3,583 preschoolers with ADHD was identified from the National Health Insurance Research Database of Taiwan. Individual characteristics and health care records, including medication and nonmedication treatment, were documented. Logistic regression and time-dependent survival analyses were used to evaluate association estimates.Over 80% of the children with newly diagnosed ADHD received initial treatment within a month of diagnosis, with 41% starting with combined treatment. Only one-quarter remained in treatment by the end of 12 months. In the first year, the termination rate was lowest for those who received rehabilitation treatment only (log-rank test, p.001). Predictors of termination varied by treatment mode. For combined treatment, factors that marginally increased the likelihood of treatment termination were coming from a family in poverty (adjusted hazard ratio [AHR]=1.72) or from a rural region (AHR=1.40). Receiving initial treatment from a psychiatrist was associated with an increased likelihood of treatment termination for children receiving psychosocial treatment (AHR=1.80, 95% confidence interval [CI]=1.46-2.22) and combined treatment (AHR=1.38, CI=1.20-1.60).Family and service provider characteristics appeared to have differential effects on initial receipt and mode of treatment and on one-year treatment termination among preschoolers with ADHD in Taiwan's universal health insurance program. Future efforts should aim at reducing access barriers to comprehensive and continuous health care for very young children with mental or developmental disorders.

Background Little is known of the epidemiology of primary headache disorders in sub-Saharan Africa. We performed a population-based survey in Zambia using methods previously tested in multiple other countries. Methods This cross-sectional survey was conducted by visiting households unannounced, using cluster-randomized sampling, in the mostly urban Lusaka Province and mostly rural Southern Province. Within clusters, households were selected randomly, as was one adult member (18-65 years old) of each selected household. A structured questionnaire, translated into the local languages, was administered face-to-face by trained interviewers. Demographic enquiry was followed by diagnostic questions based on ICHD-II criteria. A random sub-sample of participants were invited for subsequent physician-interview to validate the diagnostic part of the questionnaire. Results Of 1,134 eligible household members contacted, 1,085 (450 male, 887 urban) consented to interview (refusal rate 4.3%). Others who had been selected but remained unavailable on three visits were not counted as refusals since their reasons were unknown, but gave rise to gender biases, being mostly male in urban areas and mostly female in rural areas. Statistical correction was applied. Adjusted for gender and habitation (urban/rural), the 1-year prevalence of any headache was 61.6%, of migraine 22.9%, of tension-type headache (TTH) 22.8%, of headache on ≥15 days/month 11.5% and of probable medication-overuse headache (pMOH) 7.1%. The adjusted point-prevalence of any headache (headache yesterday) was 19.1%. There was a small proportion (5.3%) of unclassified headache, some of which may have been secondary. The overwhelmingly strong association was between urban dwelling and pMOH (OR: 8.6; P=0.0001), with an urban prevalence of 14.5% (gender-adjusted). Validation of the questionnaire was limited by participants’ reluctance to present for physician review, substantial delays in doing so and major self-selection bias among those who did. These were unavoidable problems in resource-limited Zambia. Conclusions Primary headache disorders, common in high-income countries, are at least as prevalent in Zambia, a sub-Saharan African country. The selectively urban problem of pMOH seems likely to reflect ready availability of non-prescription analgesics, without easy access to professional health care for headache or any focused public-health education regarding correct usage of analgesics or the dangers of their overuse.

BackgroundChronically escalated parent–child conflict has been observed to elicit maladaptive behavior and reduced psychological well-being in children and youth. In this epidemiological study, we sought to estimate the occurrence of escalated parent–child conflict for United States (US) adolescent subgroups defined by (a) ethnic self-identification, and (b) nativity (US-born versus foreign-born).MethodsUS study populations of 12-to-17-year-olds were sampled, recruited, and assessed for the National Surveys on Drug Use and Health (NSDUH), 2002–2013 (n = 111, 129). Analysis-weighted contingency table analyses contrasted US-born versus foreign-born who self-identified as: (a) Hispanic, (b) non-Hispanic African-American, (c) non-Hispanic Asian, and (c) non-Hispanic White.ResultsFrequently escalated parent–child conflict was most prevalent among US-born non-Hispanic White adolescents, from 18% at age 12 (95% CI [17.6%, 18.9%]) to 29% at age 17 (95% CI [28.3%, 29.7%]), followed by US-born Hispanic and non-Hispanic Asian children. Estimated prevalence proportions were markedly lower for African-American children, from 8% at age 12 (95% CI [6.8, 8.5]) to 16% at age 17 (95% CI [14.3, 16.7]). Broad and sometimes overlapping CI indicate that larger sample sizes are needed for complete evaluation of an apparent excess occurrence of frequent parent-child conflict among US-born versus foreign-born. Nonetheless, in the larger subgroups, the US-born show a clear excess occurrence of frequent parent-child conflict. For example, US-born Mexican children have 1.7 times higher odds of experiencing frequent parent-child conflict than foreign-born Mexican children (OR = 1.7, 95% CI [1.5, 2.0],p-value DiscussionThe main discovery from this multi-ethnic sample investigation is a rank-ordering of parent-child conflict prevalence estimates from high (non-Hispanic White) to low (non-Hispanic African-American). The pattern also suggests a possibly generalizable excess associated with US-born sub-groups. The epidemiological estimates presented here merit attention in future cross-cultural research focused on parent-child conflict.

The study aimed to assess the occurrence of overlapping prescriptions for methylphenidate among children and adolescents with newly diagnosed attention-deficit hyperactivity disorder (ADHD) and to evaluate the extent to which physician-level and patient-level characteristics affected the risk of prescription overlap during a one-year treatment period.The analytic sample comprised 3,081 incident cases of ADHD in 2002 involving children aged 17 years or younger from a retrospective cohort study in Taiwan. Medical and pharmacy claims data from 1999 to 2002 were retrieved from the National Health Insurance Program. All records of methylphenidate prescriptions within a year of treatment initiation were retrieved for each patient, and the number of overlapping days for any two successive prescriptions (new, renewal, or refill) was measured. Multilevel analyses were performed to identify predictors of methylphenidate prescription overlap.Within a year of treatment initiation, approximately 3% to 4% individuals with a new diagnosis of ADHD had experienced methylphenidate prescription overlap. Youngsters who resided in a rural region (adjusted odds ratio [AOR]=2.68) or who had ever changed prescribing doctors (AOR=3.04) were more likely to have visits with a methylphenidate prescription overlap. Receiving methylphenidate from physicians aged 46 or older was associated with 3.6-fold increased odds of prescription overlap.In an effort to improve the quality and safety of prescription of controlled substances in younger populations, interventions or policies should be devised to target both the service providers and the patients.

BackgroundThe association between autoimmune diseases and schizophrenia has rarely been systematically investigated.AimsTo investigate the association between schizophrenia and a variety of autoimmune diseases and to explore possible gender variation in any such association.MethodTaiwan's National Health Insurance Research Database was used to identify 10 811 hospital in-patients with schizophrenia and 108 110 age-matched controls. Univariate and multiple logistic regression analyses were performed, separately, to evaluate the association between autoimmune diseases and schizophrenia. We applied the false discovery rate to correct for multiple testing.ResultsWhen compared with the control group, the in-patients with schizophrenia had an increased risk of Graves' disease (odds ratio (OR) = 1.32, 95% CI 1.04–1.67), psoriasis (OR = 1.48, 95% CI 1.07–2.04), pernicious anaemia (OR = 1.71, 95% CI 1.04–2.80), celiac disease (OR = 2.43, 95% CI 1.12–5.27) and hypersensitivity vasculitis (OR = 5.00, 95% CI 1.64–15.26), whereas a reverse association with rheumatoid arthritis (OR = 0.52, 95% CI 0.35–0.76) was also observed. Gender-specific variation was found for Sjögren syndrome, hereditary haemolytic anaemia, myasthenia gravis, polymyalgia rheumatica and dermatomyositis.ConclusionsSchizophrenia was associated with a greater variety of autoimmune diseases than was anticipated. Further investigation is needed to gain a better understanding of the aetiology of schizophrenia and autoimmune diseases.

Purpose We sought to determine whether widowhood-associated excess mortality differs by gender in terms of causes of death. Methods Data were collected from a five-wave interview of approximately 2500 community-dwelling elders in the Survey of Health and Living Status of the Nearly Elderly and Elderly. Baseline characteristics were used to derive the risk score (RS) to reflect individual’s baseline pre-widowhood vulnerability. Time-dependent Cox regression analyses were used to estimate spousal loss-related mortality by causes. Results For males, the adjusted hazard ratios (aHRs) of widowhood for all-cause and some major causes of death (e.g., neoplasm) increased inversely with RS: the aHRs for all-cause death were 4.81 and 1.76 in the lowest and highest RS groups, respectively. In contrast, the corresponding aHRs were relatively homogeneous for women (1.52 and 1.70). Conclusions Identifying gender heterogeneity in widowhood effects can guide further efforts to devise gender-tailored programs to enhance healthy aging.

Previous population-based studies have identified factors accounting for differential utilization of psychotropic medications among young patients with attention-deficit/hyperactivity disorders (ADHDs); yet, few analyses have addressed changes in such factors that can occur in the help-seeking process. The aim of this study was to examine patient- and service provider-level predictors for methylphenidate (MPH) initiation and discontinuation.This cohort study included 10,153 newly diagnosed ADHD patients under 18 years of age in 2000, identified from the National Health Insurance Research Database. The risk association was estimated by time-dependent survival analyses, as indexed by hazard ratio.Approximately 30% of young people received MPH treatment within the year of their ADHD diagnosis, and virtually none remained in treatment beyond 12 months. Regardless of co-morbidity status, the following were significantly associated with earlier initiation of MPH treatment: older age (e.g., adjusted hazard ratio [aHR] for age 12-17 = 4.5-7.6), lower socioeconomic status (aHR = 1.2-1.4), southern residence (aHR = 1.4-1.6), receiving the diagnosis while school was in session (aHR = 1.3-1.4), receiving the diagnosis from a physician specializing in pediatrics or psychiatry (aHR = 7.3-16.8), and receiving the diagnosis in a district hospital/clinic (aHR = 1.3-1.7). However, once treatment started, older ages appeared to increase the risk of early discontinuation by 15%, and the corresponding estimates for receiving initial MPH in a regional hospital or district hospital/clinic were 27% and 32%, respectively. Change in treatment location upon subsequent visit was associated with a 58% reduction in early discontinuation.This information about time-varying predictors for MPH utilization throughout treatment may provide insight into the delivery of pediatric mental health services and has important implications for the design of clinical treatment programs.