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Improved support after self-harm needed to reduce suicide risk

To reduce the high risk of suicide after hospital attendance for self-harm, improved clinical management is needed for all patients – including comprehensive assessment of the patients’ mental state, needs, and risks, as well as implementation of risk reduction strategies, including safety planning.

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Risk of suicide following hospital presentation for self-harm is very high immediately following hospital discharge, emphasising the need for provision of early follow-up care and attention to risk reduction strategies

To reduce the high risk of suicide after hospital attendance for self-harm, improved clinical management is needed for all patients – including comprehensive assessment of the patients’ mental state, needs, and risks, as well as implementation of risk reduction strategies, including safety planning.

The results are from an observational study spanning 16 years and including almost 50,000 people from five English hospitals, published in The Lancet Psychiatry journal.

“The peak in risk of suicide which follows immediately after discharge from hospital underscores the need for provision of early and effective follow-up care. Presentation to hospital for self-harm offers an opportunity for intervention, yet people in are often discharged from hospital having not received a formal assessment of their problems and needs, and without specific aftercare arrangements. As specified in national guidance, a comprehensive assessment of the patients’ mental state, needs, and risks is essential to devise an effective plan for their follow-up care,” says study author Dr. Galit Geulayov, Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK.

It has been estimated that every year there are approximately 200,000 presentations to emergency departments in hospitals across England following acts of non-fatal self-harm. Self-harm is associated with increased mortality, especially by suicide. Approximately 50% of individuals who die by suicide have a history of self-harm, with hospital presentation for self-harm often occurring shortly before suicide.

The new study compared the risk of suicide following hospital presentation for self-harm according to patient characteristics, method of self-harm, and socioeconomic deprivation. It also estimated the incidence of suicide by time after hospital attendance, adjusting for gender, age, previous self-harm, and psychiatric treatment.

The study included 49,783 people aged over 15 years who presented to hospital after non-fatal self-harm a total of 90,614 times between 2000-2013. The authors followed these patients for 16 years (until the end of 2015), and the study included five hospitals (one in Oxford, three in Manchester and one in Derby).

Within the 16 year follow up, 703 out of 49,783 people died by suicide – with the incidence of suicide being 163 per 100,000 people per year.

Around a third of these deaths occurred within a year of the patient attending hospital for non-fatal self-harm (36%, 252/703 deaths), and the study confirmed the high risk of suicide in the first year after presentation to hospital for self-harm (the incidence of suicide in the year following discharge from hospital was 511 suicides per 100,000 people per year – 55.5 times higher than that of the general population).

The authors found that risk was particularly elevated in the first month (the incidence of suicide in the month following discharge from hospital was 1,787 per 100,000 people per year – close to 200 times higher than in the general population) – with 74 out of 703 people in the study dying by suicide within a month.

The authors note that men were more likely to die by suicide following hospital presentation of self-harm than women, people who attended hospital more than once for non-fatal self-harm were more likely to die by suicide than those with a single presentation, and age was associated with risk (with risk increasing 3% with each year of age).

In addition, those who lived in less deprived areas had a higher risk of death by suicide than those who lived in the most deprived areas, but this contrasts with a large body of evidence and might be explained by higher rates of psychiatric disorders in this group in this study – more research is needed. The authors also note that some forms of self-harm were more strongly linked to subsequent suicide, but advise against including detail of this kind in media reporting.

Suicide is a big issue in the LGBTQIA community. In 2018, for instance, a study found that a total of 37% of trans respondents reported having seriously considered suicide during the past 12 months and 32% had ever attempted a suicide. Offensive treatment during the past three months and lifetime exposure to trans-related violence were significantly associated with suicidality.

A study published in LGBT Health in 2016, meanwhile, emphasized the importance of strengthening family support and acceptance as part of a positive intervention.

The authors of this newer study note that holistic assessment of risk factors is required, and warn that no single characteristic will help predict later suicide.

“While awareness of characteristics which increase the risk of subsequent suicide can assist as part of this assessment, previous studies indicate that individual factors related to self-harm are a poor means to evaluate the risk of future suicide. These factors need to be considered together, followed by risk reduction strategies, including safety planning, for all patients,” says Professor Hawton, Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK.

The authors note that their study focuses on three cities in England and the findings may not necessarily apply to the whole of the country.

Writing in a linked comment, Dr. Annette Erlangsen, Danish Research Institute for Suicide Prevention, Denmark, notes that there is a range of treatment options available following presentation of self-harm in emergency departments (including referrals to psychiatric wards after psychosocial assessments, outpatient treatment for patients not under immediate risk of self-harming, and – in some countries – specialized suicide prevention clinics) but many countries send patients home with a referral to their GP or do not refer at all.

She says: “The bottom line is–while the body of evidence of effective intervention is growing, we need to help people who present with self-harm. Operating in such a scenario is challenging but the numbers are clear; we need to ensure that patients receive support immediately when presenting and implement a continuation of care after discharge.”

Health & Wellness

Loneliness in youth could impact mental health over the long term

Loneliness is associated with mental health problems, including depression and anxiety-potentially affecting them years later.

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The COVID-19 pandemic has necessitated widespread social isolation, affecting all ages of global society. A new rapid review in the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP), published by Elsevier, reports on the available evidence about children and young people specifically, stating that loneliness is associated with mental health problems, including depression and anxiety-potentially affecting them years later.

The review, which synthesizes over 60 pre-existing, peer-reviewed studies on topics spanning isolation, loneliness and mental health for young people aged between 4 and 21 years of age, found extensive evidence of an association between loneliness and an increased risk of mental health problems for children and young people.

“As school closures continue, indoor play facilities remain closed and at best, young people can meet outdoors in small groups only, chances are that many are lonely (and continue to be so over time),” said lead author, Maria Loades, DClinPsy, Senior Lecturer in Clinical Psychology at the University of Bath, UK.

“This rapid review of what is known about loneliness and its impact on mental health in children and young people found that loneliness is associated with both depression and anxiety. This occurs when studies measured both loneliness and mental health at the same point in time; when loneliness was measured separately; and when depression and anxiety were measured subsequently, up to 9 years later,” Dr. Loades added. “Of relevance to the COVID-19 context, we found some evidence that it is the duration of loneliness that is more strongly associated with later mental health problems.”

From the selected studies there was evidence that children and young people who are lonely might be as much as three times more likely to develop depression in the future, and that the impact of loneliness on mental health outcomes like depressive symptoms could last for years. There was also evidence that the duration of loneliness may be more important, than the intensity of loneliness, in increasing the risk of future depression among young people.

For many young people, loneliness will decrease as they re-establish social contacts and connections as lockdown eases (e.g., as they return to school or college). For some a sense of loneliness may persist as they struggle to resume social life, particularly for those who were more vulnerable to being socially isolated before lockdown.

“It’s key that children and young people are allowed to return to activities such as playing together, even if outdoors, as soon as possible, and that they are able to resume attending school, which gives them a structure for their day, and provides them with opportunities to see peers and to get support from adults outside of the nuclear family,” said Dr. Loades. Furthermore, she added “children need more in their strategy for easing lockdown. Alongside this, the government could target children’s wellbeing in public health messaging. And meanwhile, we should also continue to embrace technology as a way to keep in touch.”

So whilst we do what we can to mitigate the effects of loneliness and re-establish social connections, we also need to prepare for an increase in mental health problems, in part due to loneliness, and also due to the other unintended consequences of lockdown, such as a lack of structure, physical inactivity and social and/separation anxiety that might be triggered when resuming social interactions outside of the home.

There are several levels at which we can prepare for the heightened demand:

  • Take a universal approach to promoting wellbeing through public messaging, and by schools doing activities to promote wellbeing in children and young people as they resume normal activities.
  • Seek to identify those who are struggling with loneliness as early as possible and do so by targeted interventions to help them overcome their struggles. This may be through the provision of extra support in schools, helping them overcome anxieties about returning to school, or giving them an extra hand with reconnecting socially with peers.

For those who continue to struggle over time, and can’t get back to doing the things they normally do as a result of their struggles, we need to ensure that they are made aware that services are open, and can provide specialist help, and to make sure that they know how to access this help and are supported to do so.

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Health & Wellness

Lesbian, gay, bisexual communities more at-risk for dementia – study

Social inequality makes less privileged groups, including sexual minorities, more prone to develop cognitive impairment. So making the society more just and more accepting of diverse sexuality may help prevent dementia and reduce related health care burden on society.

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Lesbian, gay and bisexual — or LGB — people are more vulnerable to one of the fastest-growing health concerns in the country: dementia, according to research from Michigan State University.

“Our study speaks to the unaddressed questions about whether members the LGB community are more likely to develop cognitive impairment at older ages and, if so, what factors contribute to their poorer cognitive health, ” said Ning Hsieh, an assistant professor of sociology at MSU and lead author of the study published in the journal, The Gerontologist.

“We knew that stress and depression are risk factors for many chronic health problems, including cognitive impairment, in later life. LGB people experience more stressful events and have higher rates of depression compared to their heterosexual counterparts,” she said.

Analyzing the elevated cognitive health risks among older members of the LGB community, the study was the first to use a national sample and screening tool to gauge cognitive health disparities between LGB and heterosexual older adults.

Hsieh and MSU colleagues Hui Liu, professor of sociology, and Wen-Hua Lai, a Ph.D. student of sociology — compared cognitive skills of 3,500 LGB and heterosexual adults using a screening tool and questionnaire that tests for six domains. Those areas included temporal orientation; language; visuospatial skills; executive function; attention, concentration and working memory; and short-term memory.

Social inequality makes less privileged groups, including sexual minorities, more prone to develop cognitive impairment. So making the society more just and more accepting of diverse sexuality may help prevent dementia and reduce related health care burden on society.

The researchers found that on average, older LGB adults were more likely to fall into categories for mild cognitive impairment or early dementia compared to heterosexual older adults. The team also tested for specific health and social factors — such as physical conditions, mental health conditions, living a healthy lifestyle and social connections — and the only factor related to cognitive differences for sexual minorities was depression.

“Our findings suggest that depression may be one of the important underlying factors leading to cognitive disadvantages for LGB people,” Hsieh said. “They may experience higher rates of depression than their heterosexual peers for many reasons, including not being accepted by parts of society, feeling ashamed of their sexual orientation or trying to hide their romantic relationships and being treated unfairly in school or at work.”

The researchers felt surprised that other factors — such as fewer social connections, drinking or smoking — didn’t have as great of an effect on LGB people’s cognitive function later in life. But, they also recognized the need for additional research to understand how the stressors sexual minorities experience earlier in life can lead to cognitive impairments as they age. Additionally, Hsieh said, they hope that the study’s findings shed light on the need for greater inclusivity for sexual minorities, as it can have an influence on their mental and cognitive well-being.

“Social inequality makes less privileged groups, including sexual minorities, more prone to develop cognitive impairment,” Hsieh said. “Making the society more just and more accepting of diverse sexuality may help prevent dementia and reduce related health care burden on society.”

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Health & Wellness

Many transgender people who receive hormone therapy have unaddressed heart disease risks

The researchers found that more than half of the study participants (56.5%) had been previously diagnosed with a mental health disorder such as anxiety or depression, which is also associated with increased risk of heart disease.

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Many transgender people who receive gender-affirming hormone therapy already have unaddressed heart disease risk factors such as high blood pressure and high cholesterol, even during young adulthood, according to new research presented via the American Heart Association.

“Previous research has shown that transgender individuals are less likely to have access to health care or to utilize health care for a variety of reasons, including stigma and fear of mistreatment,” said Kara J. Denby, M.D., lead study author and a clinical fellow in cardiovascular medicine at the Cleveland Clinic Foundation in Cleveland, Ohio. “Since transgender individuals have frequent physician visits while taking hormone therapy, this seems an opportune time to screen for cardiovascular risk factors and treat previously undiagnosed cardiovascular disease that can lead to poor health outcomes in the future.”

The researchers examined risk factors and medical history for more than 400 adults (56% assigned male sex at birth, mostly in their 20s and 30s) when they first sought care at the multidisciplinary transgender program at the Cleveland Clinic Foundation.

The researchers found that more than half of the study participants (56.5%) had been previously diagnosed with a mental health disorder such as anxiety or depression, which is also associated with increased risk of heart disease.

For participants without current heart disease, two scoring systems were used to estimate their risk of developing heart disease. The researchers found: 6.8% had undiagnosed high blood pressure; and 11.3% had undiagnosed high cholesterol.

Of those already diagnosed with high blood pressure, more than one-third had not been receiving recommended treatment. And, of those already diagnosed with high cholesterol, more than three-quarters had not been receiving recommended treatment.

“When we calculated the risk for developing a heart attack or stroke over 10 years, the risk for transgender men and women was higher than that reported for the average (person) of their age and gender. We also found that, even in the highest risk individuals, many were not receiving recommended treatment,” said Denby.

In addition, the researchers found that more than half of the study participants (56.5%) had been previously diagnosed with a mental health disorder such as anxiety or depression, which is also associated with increased risk of heart disease.

“Transgender individuals face numerous barriers and biases to access the health care they need. We owe it to them to improve access and care so they can improve their CVD health and overall well-being. Policies and health care structures that are safe and supportive are critical for the transgender population to achieve health equity,” Denby said.

The study, however, is limited by being a retrospective review of medical records. The results cannot be used to prove a cause-and-effect relationship between being transgender and the presence of heart disease risk factors.

Co-authors include Meghana Patil, M.D.; Karlo Toljan, M.D.; Leslie Cho, M.D.; and Cecile A. Ferrando, M.D., M.P.H. Author disclosures are in the abstract. The researchers reported no external funding sources.

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Health & Wellness

Underinsured transgender people more likely to turn to riskier sources for hormones

About 9% of transgender people – in the US alone, translating to nearly 170,000 individuals – access hormones from non-licensed sources like friends or online.

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People who are transgender continue to face insurance barriers in accessing the health care services they need. And those who lack access to insurance coverage for gender-affirming hormone therapy are more likely to turn to sources other than a licensed health care provider, compared to those with insurance coverage.

This is according to a Michigan Medicine-led study, “Insurance Coverage and Use of Hormones Among Transgender Respondents to a National Survey”, which found that about 9% of transgender people – in the US alone, translating to nearly 170,000 individuals – access hormones from non-licensed sources like friends or online. The study was published in the Annals of Family Medicine.

“Transgender and nonbinary people face major barriers to insurance coverage for their needed care, with many people still lacking or being denied coverage for gender-affirming care,” says lead author Daphna Stroumsa, M.D., M.P.H., an obstetrician gynecologist at Michigan Medicine Von Voigtlander Women’s Hospital and researcher with the U-M Institute for Healthcare Policy and Innovation.

“Those barriers affect transgender people’s ability to receive the care they need. Those who can’t, may seek alternative ways to get their medications, which can increase their risks for negative health outcomes.”

Transgender people face a host of structural barriers combined with barriers to insurance coverage that limit access to gender-affirming hormones. These limitations may have broad implications for the health and safety of transgender people.

Not only may medications be unchecked for content, quality, formulation and dosing, but the use of non-prescription hormones likely means providers aren’t as involved in monitoring hormone levels and mitigating potential harm, Stroumsa says.

Researchers evaluated national data and found that 84% of the 27,715 respondents were interested in using hormones, while only 55 % were using hormones. Overall, 3,362 (15%) of respondents were uninsured, compared with about 13 % of all Americans at the time of the survey in 2015.

Among insured respondents, 21% reported that their claims for gender affirming hormones were denied.

Nonprescription hormone use was most common among respondents assigned male at birth, and differed by race.

Among all who had interest in taking hormones, those who were uninsured were less likely to use hormones in general compared with insured counterparts, which experts say could negatively impact mental and emotional health.

When respondents were asked to evaluate the most pressing issues affecting transgender people in the U.S., they listed insurance coverage as one of most important (among 44 % of respondents). It ranked second only to violence against people who are transgender.

Many major medical societies and associations, including the American Academy of Family Physicians, have issued statements in support of insurance coverage for gender-affirming care. Clear guidelines also support the provision of gender-affirming hormones for transgender people who seek them, which is associated with improved mental health outcomes.

But significant barriers to accessing these health services still exist, experts say.

For example, transgender people often face employment discrimination leading to un-insurance and those who are insured often encounter insurance policies with specific exclusions or barriers for coverage of gender-affirming therapy.

There are structural barriers too. These include high rates of homelessness secondary to stigma, rejection and discrimination, a lack of knowledgeable and supportive clinicians, and transphobia and direct discrimination in health care settings.

About 9% of transgender people – in the US alone, translating to nearly 170,000 individuals – access hormones from non-licensed sources like friends or online.

“Transgender people face a host of structural barriers combined with barriers to insurance coverage that limit access to gender-affirming hormones,” says senior author Caroline Richardson, M.D., family medicine physician at Michigan Medicine and IHPI researcher. “These limitations may have broad implications for the health and safety of transgender people.”

When people are unable to fill a prescription through a regulated process, Stroumsa notes, they are left with options that increase negative health risks.

“People who need hormones for gender affirmation may either turn to risker sources or forgo hormones altogether, which means losing the opportunity for affirmation and improvement in their mental health and well-being,” Stroumsa says. “Ensuring access to hormones can decrease the economic burden and greatly improve health and quality of life for people who are transgender.”

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Many college students aren’t tested for STIs despite high rates; self-tests offer promise

The study offers important takeaways not just regarding the use of self-testing services among asymptomatic students, but also for increasing STI testing in clinical settings more broadly. It suggests that college students may be more likely to pursue STI testing if their contact with clinical staff could be reduced.

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Sexually transmitted infections (STIs) are at record levels in various parts of the world, with the Centers for Disease Control and Prevention reporting recent “steep and sustained” increases in the US, for instance. STIs are particularly common among young adults (aged 18-24 years), yet most sexually active college students have never been tested. This presents an urgent challenge, as well as a unique opportunity, for universities to increase STI testing among their students.

New research led by George Mason University’s College of Health and Human Services found that the vast majority of sexually active students (88%) said they were “likely” or “extremely likely” to use STI self-testing services if they could take a test kit home and test themselves in the privacy of their own home/residence, while 59% said they would use STI self-testing services if they could test themselves in a private room at Student Health Services.

Dr. Lisa Lindley led the study published in the Journal of American College Health this week. This is the first study to explore college students’ comfort with and intention to use self-collection STI testing services on campus, and to identify students’ questions and concerns about the “self-testing” process before offering the service.

The researchers conducted an online survey of more than 400 students at a large mid-Atlantic university to assess their HIV/STI testing behaviors, comfort with self-collection procedures, and intention to use self-collection services for STI testing if offered on campus.

“We already know that in settings where self-collection options have been made available, there have been significant increases in testing and the detection of STIs,” explains Lindley. “This presents an opportunity to increase the detection of asymptomatic infections among sexually active students who traditionally don’t get tested, link these students to care, and prevent further transmission, as well as harmful health outcomes of untreated infections.”

Most sexually active college students have never been tested. This presents an urgent challenge, as well as a unique opportunity, for universities to increase STI testing among their students.

Students who were older (25+ years), lived off campus, and identified as “lesbian, gay, bisexual, or an identity other than heterosexual” were significantly more likely to have ever been tested for HIV and other STIs than students who were younger (18-24 years), lived on campus, and identified as heterosexual.

“We hope to be able to offer STI self-testing options on campus in the near future and encourage other universities to consider the same, as we found that most students, regardless of age, sexual experience, and previous testing experience, were interested in self-testing,” explains Lindley. “These findings are especially timely during the COVID-19 pandemic, as access to HIV/STI testing in traditional settings has become more challenging and the CDC is recommending at-home HIV tests.”

Collection of specimens for some of the most common STIs (chlamydia and gonorrhea) as well as those for HIV can easily be collected by most people. Tests for others–such as syphilis, genital herpes, and human papilloma virus (HPV)–will continue to be conducted by clinicians due to the procedures required for sample collection.

The study offers important takeaways not just regarding the use of self-testing services among asymptomatic students, but also for increasing STI testing in clinical settings more broadly. It suggests that college students may be more likely to pursue STI testing if their contact with clinical staff could be reduced.

Lindley recommends using online registration and sexual risk assessments, where appropriate, to collect necessary information and reduce interactions students find particularly embarrassing.

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Depression and anxiety more frequently diagnosed in women

Gender is a significant determining factor in mental health and in how it is managed by the healthcare services.

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Gender is a significant determining factor in mental health and in how it is managed by the healthcare services.

This is according to recent studies conducted by UPV/EHU’s research group OPIK, Social Determinants of Health and Demographic Change, a multidisciplinary group comprising research personnel in the field of social and health sciences.

The group used health questionnaires completed in the Basque Autonomous Community (2018) and in Spain (2017), and on the Spanish sample corresponding to the European Health Survey (2014).

What stood out in the analysis of these three databases is the higher prevalence of poor mental health among women of all ages and across all social groups. In addition, there is a multiplier effect due to the accumulation of experiences of inequality. This reality also appears to be unequal in terms of the age and socioeconomic level of the patients.

According to Dr. Amaia Bacigalupe, one of the authors of the study: “Women are more frequently diagnosed with depression and anxiety and the taking of prescribed psychotropic drugs is also significantly higher, even if there is no difference with men with respect to mental health equality, diagnoses and frequency of visits to healthcare centers. All this could point to the existence of a medicalization process of mental health in women, but interpreting its origin is complex since the processes involving the high prevalence of diagnosis and overprescription undoubtedly play a role, but maybe also due to infra-diagnosis and lower prescription rates in men.”

There is a multiplier effect due to the accumulation of experiences of inequality. This reality also appears to be unequal in terms of the age and socioeconomic level of the patients.

Bacigalupe added that these aspects should be tackled in greater depth in future studies.

The research group also highlighted that reducing gender inequalities in mental health will need to be the result of policy intervention on various levels.

In the field of mental health in which the medicalization of malaise is especially common, far from addressing the cause of the problem, some problems of a social origin end up receiving psychiatric or psychological treatment.

“There is a clear relationship between the degree of gender inequality in society and gender inequalities in mental health,” said Bacigalupe, “so all those policies designed to combat the discrimination endured by women on the labour market, in the responsibility for domestic and care work, in the use of time and, generally, relating to those that empower women on the basis of their greater political representation and making them more socially visible, will exert a positive effect on the reduction in mental inequalities between men and women.”

Another aspect highlighted in the study is the need to make commitments starting from an institutional level and geared towards curbing the medicalization of everyday malaise from a clear gender perspective.

“In the field of mental health in which the medicalization of malaise is especially common, far from addressing the cause of the problem, some problems of a social origin end up receiving psychiatric or psychological treatment,” said the researcher in the Department of Sociology 2 at the UPV/EHU.

For this study, it would also be necessary to encourage spaces for reflection in the clinical setting designed to help to collectively deconstruct certain aspects that have become natural in gender binarism and which have underpinned the definitions of psychopathology and its current treatment.

Bacigalupe also stated that “the actual incorporation into clinical practice of the biopsychosocial model, as well as the implementing of strategies to promote health and emotional well-being from a community health approach based on assets, could prevent the over-pathologization and over-medicalization of everyday malaise once a global view of how the social context influences health is acquired.”

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