Association of Problematic Internet Use With Psychotic Experiences and Depression in Adolescents: A Cohort Study.

BACKGROUND AND HYPOTHESIS: Problematic internet use (PIU) is prevalent among adolescents. Past research suggested cross-sectional associations between PIU and psychotic experiences, but little information is available on the longitudinal association. We hypothesized that PIU in adolescence may be longitudinally associated with psychotic experiences, adjusting for confounders. STUDY DESIGN: We analyzed a random sample of adolescents in the Tokyo Teen Cohort to examine how PIU at ages 10 (2012-2015), 12 (2014-2017), and 16 (2019-2021) was associated with mental health issues at age 16. PIU was evaluated by the modified Compulsive Internet Use Scale, psychotic experiences by the Adolescent Psychotic-like Symptom Screener, and depression by the Short Mood and Feelings Questionnaire. We also examined the mediating role of social withdrawal. STUDY RESULTS: We analyzed 3171 adolescents; 151 reported psychotic experiences and 327 reported depression at age 16. Compared with the lowest tertile PIU group, the highest tertile PIU group at age 12 showed an increased adjusted risk of psychotic experiences (RD 3.3%, 95% CI 2.9%-3.7%; RR 1.65, 95% CI 1.55-1.73) and depression (RD 5.9%, 95% CI 5.5%-6.3%; RR 1.61, 95% CI 1.55-1.68) at age 16. PIU at age 16 showed analogous results, while PIU at age 10 suggested a smaller impact. Social withdrawal mediated 9.4%-29.0% of the association between PIU and psychotic experiences. CONCLUSIONS: PIU is longitudinally associated with psychotic experiences and depression in adolescents. Further longitudinal and intervention studies are warranted to provide robust public health implications and foster a safer digital future.

Longitudinal associations between subjective cognitive impairment, pain and depressive symptoms in home-dwelling older adults: Modelling within-person effects.

OBJECTIVES: Cognitive impairment, pain and depressive symptoms are common and interrelated factors in older adults. However, the directionality and specificity of their association remains unclarified. This study explored whether these factors prospectively increase reciprocal risk and examined the longitudinal association between these factors and quality of life (QoL). METHODS: This study used longitudinal data from The Older Persons and Informal Caregivers Survey Minimal Data Set (TOPICS-MDS; the Netherlands). Older adults self-reported cognitive impairment, pain, depressive symptoms and QoL at baseline and after 6 and 12 months of follow-up. The Random Intercept Cross-Lagged Panel Model was used to assess the prospective association between the three factors, while a multilevel linear regression analysis in a two-level random intercept model was used to examine the longitudinal associations between the three factors and QoL at the within-person level. RESULTS: The data of 11,582 home-dwelling older adults with or without subjective cognitive impairment were analysed. At the within-person level, pain at 6 months was associated with subsequent depressive symptoms (ß = 0.04, p = 0.024). The reverse association from depression to pain, and longitudinal associations between pain and subjective cognitive impairment and between depressive symptoms and subjective cognitive impairment were non-significant. Pain, depressive symptoms and subjective cognitive impairment showed a significant association with poor QoL 6 months later. CONCLUSIONS: A directional relationship was observed from pain to depressive symptoms. Pain reduction holds a potential benefit in the prevention of depressive symptoms, ultimately optimising the QoL of older adults.

Association Between Dementia, Change in Home-Care Use, and Depressive Symptoms During the COVID-19 Pandemic: A Longitudinal Study Using Data from Three Cohort Studies.

Background: The emotional impact of the coronavirus disease 2019 (COVID-19) pandemic on people with dementia has been quantified. However, little is known about the impact of change in home-care use owing to the pandemic. Objective: To determine the longitudinal association between dementia, change in home-care use, and depressive symptoms during the pandemic. Methods: We included data of 43,782 home-dwelling older adults from the English Longitudinal Study of Ageing (ELSA), Study of Health, Ageing and Retirement in Europe (SHARE), and National Health and Aging Trends Study (NHATS). This study considered the latest main wave survey prior to the pandemic as the baseline, and the COVID-19 survey as follow-up. In a series of coordinated analyses, multilevel binomial logistic regression model was used to examine the association between baseline dementia, change in home-care use at follow-up, and presence of depressive symptoms. Results: Dementia, using the ELSA, SHARE, and NHATS datasets, was identified in 2.9%, 2.3%, and 6.5% of older adults, and home-care use reduced in 1.7%, 2.8%, and 1.1% of individuals with dementia, respectively. Dementia was significantly associated with the increased risk of depressive symptoms in all three cohorts. However, the interaction between dementia and period (follow-up) was non-significant in SHARE and NHATS. Across all three cohorts, home-care use during the pandemic, regardless of change in amount, was significantly associated with increased depressive symptoms, compared to the non-use of home care. Conclusions: These results highlight the need for tailoring dementia care at home to promote independence and provide sustainable emotional support.

A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study.

BACKGROUND: Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life. AIM: To develop a multidimensional international palliative care goals model in dementia for use in practice. DESIGN: International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified. SETTING/PARTICIPANTS: Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study. RESULTS: Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves. CONCLUSION: A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Future policy and research for advance care planning in dementia: consensus recommendations from an international Delphi panel of the European Association for Palliative Care.

Advance care planning (ACP) is increasingly recognised in the global agenda for dementia care. The European Association for Palliative Care (EAPC) Taskforce on ACP in Dementia aimed to provide recommendations for policy initiatives and future research. We conducted a four-round Delphi study with a 33-country panel of 107 experts between September, 2021, and June, 2022, that was approved by the EAPC Board. Consensus was achieved on 11 recommendations concerning the regulation of advance directives, equity of access, and dementia-inclusive approaches and conversations to express patients' values. Identified research gaps included the need for an evidence-based dementia-specific practice model that optimises engagement and communication with people with fluctuating and impaired capacity and their families to support decision making, while also empowering people to adjust their decisions if their goals or preferences change over time. Policy gaps included insufficient health services frameworks for dementia-inclusive practice. The results highlight the need for more evidence and policy development that support inclusive ACP practice models.

Consensus definition of advance care planning in dementia: A 33-country Delphi study.

INTRODUCTION: Existing advance care planning (ACP) definitional frameworks apply to individuals with decision-making capacity. We aimed to conceptualize ACP for dementia in terms of its definition and issues that deserve particular attention. METHODS: Delphi study with phases: (A) adaptation of a generic ACP framework by a task force of the European Association for Palliative Care (EAPC); (B) four online surveys by 107 experts from 33 countries, September 2021 to June 2022; (C) approval by the EAPC board. RESULTS: ACP in dementia was defined as a communication process adapted to the person's capacity, which includes, and is continued with, family if available. We identified pragmatic boundaries regarding participation and time (i.e., current or end-of-life care). Three interrelated issues that deserve particular attention were capacity, family, and engagement and communication. DISCUSSION: A communication and relationship-centered definitional framework of ACP in dementia evolved through international consensus supporting inclusiveness of persons with dementia and their family. HIGHLIGHTS: This article offers a consensus definitional framework of advance care planning in dementia. The definition covers all stages of capacity and includes family caregivers. Particularly important are (1) capacity, (2) family, (3) engagement, and communication. Fluctuating capacity was visualized in relation to roles and engaging stakeholders.

What are best practices for involving family caregivers in interventions aimed at responsive behaviour stemming from unmet needs of people with dementia in nursing homes: a scoping review.

OBJECTIVES: This study aimed to determine best practices for involving family caregivers in interventions aimed at preventing and reducing responsive behaviour stemming from unmet needs, including pain. DESIGN: Scoping review, reported according to the Preferred Reporting Items for Systematic Reviews, Meta-Analyses extension for Scoping Reviews reporting guideline. DATA SOURCES: PubMed, Embase, Emcare, Web of Science, COCHRANE Library, PsycINFO, Academic Search Premier and Cinahl searched up to 23 July 2023. ELIGIBILITY CRITERIA: Studies reporting on family involvement in interventions for nursing home residents with dementia were included. DATA EXTRACTION AND SYNTHESIS: Two researchers independently extracted the data, followed by a content analysis. RESULTS: Of the 1486 records screened, 20 studies were included. Family caregivers were involved in interventions aimed at planning care, life review (eg, documentation of life experiences of their relative), and selecting activities for their relative. Family caregivers preferred an active role in developing optimal care for their relative. Drivers of success and barriers to family involvement centred around three themes: (1) communication between all involved; (2) prerequisites (organisational and other conditions) and (3) personal circumstances (family's coping and skills). CONCLUSION: Best practices for involving family caregivers in interventions aimed at addressing responsive behaviour in residents with dementia concerned those interventions in which family caregivers were given an important role in managing responsive behaviour. This means that, in order to achieve an active role of family caregivers in the whole care process, their needs must be taken into account. TRIAL REGISTRATION NUMBER: The protocol of the review was regisered at OSF; https://osf.io/twcfq.

Rehospitalisation rates after long-term follow-up of patients with severe mental illness admitted for more than one year: a systematic review.

AIMS: This study aimed to conduct a systematic review of studies on the outcomes of long-term hospitalisation of individuals with severe mental illness, considering readmission rates as the primary outcome. METHODS: Studies considered were those in which participants were aged between 18 and 64 years with severe mental illness; exposure to psychiatric hospitals or wards was long-term (more than one year); primary outcomes were readmission rates; secondary outcomes were duration of readmission, employment, schooling, and social participation; and the study design was either observational or interventional with a randomised controlled trial (RCT) design. Relevant studies were searched using MEDLINE, PsycINFO, Web of Science, CINAHL, and the Japan Medical Abstract Society. The final search was conducted on 1 February 2022. The risk of bias in non-randomised studies of interventions was used to assess the methodological quality. A descriptive literature review is also conducted. RESULTS: Of the 11,999 studies initially searched, three cohort studies (2,293 participants) met the eligibility criteria. The risk of bias in these studies was rated as critical or serious. The 1-10 years readmission rate for patients with schizophrenia who had been hospitalised for more than one year ranged from 33 to 55%. The average of readmission durations described in the two studies was 70.5 ± 95.6 days per year (in the case of a 7.5-year follow-up) and 306 ± 399 days (in the case of a 3-8-year follow-up). None of the studies reported other outcomes defined in this study. CONCLUSIONS: The readmission rates in the included studies varied. Differences in the follow-up period or the intensity of community services may have contributed to this variability. In countries preparing to implement de-institutionalisation, highly individualised community support should be designed to avoid relocation to residential services under supervision. The length of stay for readmissions was shorter than that for index admissions. The results also imply that discharge to the community contributes to improved clinical outcomes such as improved social functioning. The validity of retaining patients admitted because of the risk of rehospitalisation was considered low. Future research directions have also been discussed.

Sex Differences in Adolescent Depression Trajectory Before and Into the Second Year of COVID-19 Pandemic.

OBJECTIVE: Evidence on the impact of the COVID-19 pandemic on adolescent mental health is mixed and does not disentangle natural age-related changes. We compared depressive symptoms among 16-year-olds surveyed, at a fourth wave, before or during the pandemic, while accounting for expected trajectories of within-person change based on 3 prior waves. METHOD: In this longitudinal cohort of 3,171 adolescents in Tokyo, Japan, adolescents were grouped based on their age 16 survey timing: pre-pandemic (February 2019 to February 2020) and during-pandemic (March 2020 to September 2021). Depressive symptoms were self-reported using the Short Mood and Feelings Questionnaire. Mixed-effect models were fitted to assess group differences while controlling for previous trends. Variations by sex, household income, and pandemic phase (early, late first-year, and second-year) were examined. RESULTS: Of 2,034 eligible adolescents, 960 (455 girls) were assessed before and 1,074 (515 girls) during the pandemic. Overall, depressive symptoms increased by 0.80 points (95% CI 0.28-1.31, 0.15 SD of the population average). This increase varied by sex and pandemic phase. For boys the increase emerged in the late first-year phase and enlarged in the second-year phase (mean difference from pre-pandemic: 1.69, 0.14-3.24), whereas for girls it decreased in the early school-closure phase (mean difference: -1.98, -3.54 to -0.41) and returned to the pre-pandemic level thereafter, with no additional increases during the pandemic. CONCLUSION: Into the second year of the COVID-19 pandemic, depressive symptoms of 16-year-olds worsened above the expected age-related change only in boys. Continuous monitoring and preventive approaches for adolescents at the population level are warranted. DIVERSITY & INCLUSION STATEMENT: We worked to ensure that the study questionnaires were prepared in an inclusive way. We worked to ensure sex and gender balance in the recruitment of human participants. One or more of the authors of this paper self-identifies as a member of one or more historically underrepresented racial and/or ethnic groups in science. We actively worked to promote sex and gender balance in our author group. The author list of this paper includes contributors from the location and/or community where the research was conducted who participated in the data collection, design, analysis, and/or interpretation of the work.

Place of death from dementia as an underlying cause during the COVID-19 pandemic in Japan: a cross-sectional study from national death certificates.

Background: The coronavirus disease (COVID-19) pandemic has challenged palliative end-of-life care for people with dementia. The site of death can be considered as an end-of-life care quality indicator. Most people with dementia prefer to die at nursing or private homes; however, in Japan, they are often hospitalized in psychiatric hospitals for management of neuropsychiatric symptoms. As palliative end-of-life care for older adults with Alzheimer's disease and related dementias has been further challenged by the COVID-19 pandemic, little is known about its effects on the place of death in patients with dementia. Objectives: This study aimed to investigate the shifts in place of death from dementia during the COVID-19 pandemic in Japan. Changes throughout the pandemic were compared between deaths from dementia and from senility. Design: Cross-sectional. Methods: Death certificate data of individuals aged 65 years or older who died in Japan between 1 January 2018, and 31 December 2021, were used to extract the cause and place of death. Differences in place of death between the periods were estimated using multinomial logistic analysis with reference to death in private homes. Results: Deaths from dementia mostly occurred in hospitals (59%), while deaths from senility were most frequent in nursing homes (37%). After adjusting for patient characteristics, the likelihood of hospital deaths significantly increased for patients with dementia during the pandemic. Meanwhile, the likelihood of senility deaths decreased in hospitals but increased in nursing homes during the pandemic. Conclusion: The shift to hospital deaths since the onset of the COVID-19 pandemic was uniquely observed in deaths from dementia. This hospital shift likely involved increased transfers from nursing and private homes to psychiatric hospitals. Further investigation is needed to examine the association between the pandemic-related change in long-term care workforce and palliative care practice in people with dementia.

Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing.

BACKGROUND: Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner. METHODS: Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction. DISCUSSION: In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful. TRIAL REGISTRATION: The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.

Longitudinal Relationships Between Help-Seeking Intentions and Depressive Symptoms in Adolescents.

PURPOSE: Cross-sectional studies have shown an association between lower help-seeking intentions and greater depressive symptoms among adolescents. However, no longitudinal study has examined the direction of this association. The current study investigated whether help-seeking intentions and depressive symptoms are reciprocally associated at the within-person (individual) level during early to mid-adolescence. METHODS: Longitudinal data on help-seeking intentions and depressive symptoms in adolescents were obtained from a population-based birth cohort study (Tokyo Teen Cohort; N = 3,171) at four time points (10y, 12y, 14y, and 16y). A random intercept cross-lagged panel model was used to evaluate the within-person prospective associations between help-seeking intentions and depressive symptoms. RESULTS: At the within-person level, significant associations were consistently observed between antecedent greater depressive symptoms and subsequent lower help-seeking intentions across all time points (10y-12y: standardized regression coefficient (ß) = -0.12, p < .001; 12y-14y: ß = -0.07, p < .05; and 14y-16y: ß = -0.09, p < .01). Meanwhile, significant within-person associations were partly observed between antecedent lower help-seeking intentions and subsequent greater depressive symptoms from 10y to 12y (ß = -0.07, p < .05) and from 14y to 16y (ß = -0.12, p < .001). These prospective associations were almost the same when adjusted for the number of potential confidants as a time-varying confounder. DISCUSSION: Adolescents with worsening depressive symptoms may become increasingly reluctant to seek help over time. Proactive early recognition and intervention with support from parents, teachers, and other individuals may facilitate the management of depression in adolescents.

Association between menopause and suicidal ideation in mothers of adolescents: A longitudinal study using data from a population-based cohort.

BACKGROUND: Midlife suicide among women has attracted increasing research attention. This study aimed to investigate the longitudinal association between menopause and suicidal ideation among middle-aged women. METHODS: Our data were derived from the Tokyo Teen Cohort, a population-based survey of early adolescents (N = 3171) and their primary caregivers (typically, mothers) in Japan. A total of 2944 mothers (baseline mean age = 44.0 years) were included in the analysis. The baseline assessment in this study was performed at second-wave survey from July 2014 to January 2017. A follow-up assessment was conducted at fourth-wave survey from February 2019 to September 2021. Suicidal ideation at baseline and follow-up was assessed using the Suicidal Ideation subscale of the 28-item General Health Questionnaire. Menopausal stage was classified based on self-report at fourth-wave survey. RESULTS: Participants who started the perimenopausal stage after baseline were significantly more likely to have suicidal ideation at follow-up than those who did not have experienced menopausal transition yet. Participants with greater social support were less likely to report suicidal ideation at follow-up, even after adjusting for baseline suicidal ideation. LIMITATIONS: This study was based on self-report regarding menopausal stage and only included mothers of adolescents from Japan. An exact length of time from the onset to the presence of suicidal ideation was unavailable. CONCLUSIONS: Women who have experienced the onset of menopausal transition presented an increased risk of suicidal ideation. Psychosocial interventions to increase social support may be beneficial in preventing mental health inequalities during menopausal transitions.

Informal Caregiving in Adolescents from 10 to 16 Years Old: A Longitudinal Study Using Data from the Tokyo Teen Cohort.

There is growing evidence of the impact of informal caregiving on adolescent mental health, and its role is often hidden unintentionally or intentionally, which may hamper early identification and support for young informal caregivers. However, the quantitative evidence regarding household factors relating to informal caregiving has mostly been based on cross-sectional findings. This study examines the longitudinal associations between household characteristics and the duration of informal caregiving in adolescents from 10 to 16 years of age. Child-household respondent pairs (n = 2331) from the Tokyo Teen Cohort in Japan were followed every 2 years from 10 to 16 years of age. Informal caregiving was assessed repeatedly based on the household respondent's survey responses. Persistent caregiving was defined as daily caregiving at two or more waves. There were 2.2% of children who gave daily care at two or more waves. Cross-sectional associations with daily informal caregiving at each wave were found with girls, low household income, and cohabiting with grandparents. A significant association with persistent caregiving was found only in cohabiting with grandparents at 10 years of age after adjusting for sex, number of siblings, single parent, and household income. Our longitudinal examination highlighted cohabiting with grandparents as a preceding factor for persistent caregiving. Identification and support for young informal caregivers should be integrated into social care service systems for older adults. The mechanism of persistent caregiving requires clarification.

Depression and Anxiety in Older Adults with Dementia During the COVID-19 Pandemic.

This study examined the longitudinal association between dementia, activity participation, the coronavirus disease 2019 pandemic period, and 1-year mental health changes. We obtained data from the National Health and Aging Trends Study in the United States. We included 4,548 older adult participants of two or more survey rounds between 2018 and 2021. We identified baseline dementia status, and assessed depressive symptoms and anxiety at baseline and follow-up. Dementia and poor activity participation were independently associated with an increased prevalence of depressive symptoms and anxiety. Dementia care and support should address emotional and social needs under continued public health restrictions.

Association between advance care planning and depressive symptoms among community-dwelling people with dementia: An observational cross-sectional study during the COVID-19 pandemic in Japan.

Objectives: Advance care planning (ACP) is an increasing priority for people with dementia during the COVID-19 pandemic. This study evaluated the association between ACP initiation and depressive symptoms among home-dwelling people living with dementia. Methods: An internet-based questionnaire survey was conducted with Japanese family caregivers of home-dwelling persons with dementia in June 2021. Family caregivers evaluated the level of depressive symptoms in persons with dementia using the Neuropsychiatric Inventory (NPI). Caregivers also rated the quality of life of persons with dementia using the EQ-5D-5L. Results: A total of 379 family caregivers participated in the survey. Depressive symptoms were reported in 143 persons with dementia (37.7%). A total of 155 persons with dementia (40.9%) had initiated ACP, of which 88 (56.8%) had care professionals involved in ACP conversation. After adjusting for the characteristics of persons with dementia and caregivers, persons with professional involvement showed significantly more severe depressive symptoms compared to those who did not initiate ACP. There was no significant difference in the quality of life of persons with dementia according to ACP initiation. Conclusions: Many home-dwelling persons with dementia experienced depressive symptoms during the COVID-19 pandemic, especially in cases where care professionals were involved in ACP conversations. Optimal and proactive ACP approaches need to be developed to prevent depressive symptoms in newly diagnosed persons.

Quality of End-of-Life Care for Older Adults with Dementia during the COVID-19 Pandemic.

OBJECTIVES: End-of-life (EOL) care during the coronavirus disease 2019 (COVID-19) pandemic has been a concern under the overwhelming pressure of health care service systems. People with dementia often receive suboptimal EOL care; thus, they may be at particular risk of poor care quality during the COVID-19 pandemic. This study investigated the interaction between dementia and pandemic on the proxies' overall ratings and ratings for 13 indicators. DESIGN: A longitudinal study. SETTING AND PARTICIPANTS: Data were collected from 1050 proxies for deceased participants in the National Health and Aging Trends Study, a nationally representative sample of community-dwelling Medicare beneficiaries aged ≥65 years. Participants were included if they had died between 2018 and 2021. METHODS: Participants were categorized into 4 groups depending on the period of death (before vs during the COVID-19 pandemic) and having no vs probable dementia, as defined by a previously validated algorithm. The quality of EOL care was assessed through postmortem interviews with bereaved caregivers. Multivariable binomial logistic regression analyses were performed to examine the main effects of dementia and pandemic period, and the interaction between dementia and pandemic on ratings of quality indicators. RESULTS: A total of 423 participants had probable dementia at the baseline. People with dementia who died were less likely to talk about religion in the last month of life than those without dementia. Decedents during the pandemic were more likely to have an overall rating of care as being not excellent than those before the onset of the pandemic. However, the interaction between dementia and pandemic was not significant in the 13 indicators and the overall rating of EOL care quality. CONCLUSION AND IMPLICATIONS: Most EOL care indicators preserved the level of quality, regardless of dementia and the COVID-19 pandemic. Disparities in spiritual care may exist across people with and without dementia.

N-Acetylcysteine Suppresses Microglial Inflammation and Induces Mortality Dose-Dependently via Tumor Necrosis Factor-α Signaling.

N-acetylcysteine (NAC) is an antioxidant that prevents tumor necrosis factor (TNF)-α-induced cell death, but it also acts as a pro-oxidant, promoting reactive oxygen species independent apoptosis. Although there is plausible preclinical evidence for the use of NAC in the treatment of psychiatric disorders, deleterious side effects are still of concern. Microglia, key innate immune cells in the brain, play an important role in inflammation in psychiatric disorders. This study aimed to investigate the beneficial and deleterious effects of NAC on microglia and stress-induced behavior abnormalities in mice, and its association with microglial TNF-α and nitric oxide (NO) production. The microglial cell line MG6 was stimulated by Escherichia coli lipopolysaccharide (LPS) using NAC at varying concentrations for 24 h. NAC inhibited LPS-induced TNF-α and NO synthesis, whereas high concentrations (≥30 mM) caused MG6 mortality. Intraperitoneal injections of NAC did not ameliorate stress-induced behavioral abnormalities in mice, but high-doses induced microglial mortality. Furthermore, NAC-induced mortality was alleviated in microglial TNF-α-deficient mice and human primary M2 microglia. Our findings provide ample evidence for the use of NAC as a modulating agent of inflammation in the brain. The risk of side effects from NAC on TNF-α remains unclear and merits further mechanistic investigations.

An online intervention to promote mental health literacy for psychosis amongst parents of adolescents: A pilot randomized controlled trial.

AIM: This study evaluated an online mental health literacy intervention to improve help-seeking for psychosis amongst parents of adolescents. METHODS: A total of 2496 parents of first-grade junior high school students, recruited from a Japan-based survey company, participated in a randomized controlled trial in July 2016; participants were randomly allocated to the intervention (n = 1248) or control group (n = 1248). They were assessed at baseline and one-week post intervention. The intervention group received a 30-minute online educational programme that included a narrative of the mother of an adolescent with psychosis. RESULTS: There were no between-group differences in changes in the rate of 'no help-seeking' in any hypothetical situations of a child's psychosis and prodromal symptoms. CONCLUSIONS: The intervention might have been suboptimal to improve mental health literacy for psychosis amongst parents of adolescents. A narrative message from a service user may be helpful to encourage parents in help-seeking.