Sildenafil and suicide in Sweden.

Much theory asserts that sexual intimacy sustains mental health. Experimental tests of such theory remain rare and have not provided compelling evidence because ethical, practical, and cultural constraints bias samples and results. An epidemiologic approach would, therefore, seem indicated given the rigor the discipline brings to quasi-experimental research. For reasons that remain unclear, however, epidemiologist have largely ignored such theory despite the plausibility of the processes implicated, which engender, for example, happiness, feelings of belonging and self-worth, and protection against depression. We use an intent-to-treat design, implemented via interrupted time-series methods, to test the hypothesis that the monthly incidence of suicide, a societally important distal measure of mental health in a population, decreased among Swedish men aged 50-59 after July 2013 when patent rights to sildenafil (i.e., Viagra) ceased, prices fell, and its use increased dramatically. The test uses 102 pre, and 18 post, price-drop months. 65 fewer suicides than expected occurred among men aged 50-59 over test months following the lowering of sildenafil prices. Our findings could not arise from shared trends or seasonality, biased samples, or reverse causation. Our results would appear by chance fewer than once in 10,000 experiments. Our findings align with theory indicating that sexual intimacy reinforces mental health. Using suicide as our distal measure of mental health further implies that public health programming intended to address the drivers of self-destructive behavior should reduce barriers to intimacy in the middle-aged populations.

Visiting nearby natural settings supported wellbeing during Sweden's "soft-touch" pandemic restrictions.

The coronavirus pandemic entailed varying restrictions on access, movement and social behavior in populations around the world. Knowledge about how people coped with "soft-touch" restrictions can inform urban spatial planning strategies that enhance resilience against future pandemics. We analyzed data from an online place-based survey on 2845 places across Sweden that respondents abstained from visiting, visited with similar frequency, or visited more frequently in spring 2020 as compared to before the pandemic. In spatial logistic regression models, we relate geographical and sociodemographic properties of places (fields, forests, water, residential population density and daytime population density) to self-perceived changes in wellbeing from visiting the given place less or more often, respectively. Abstaining from visiting places with natural features located in areas of high residential density was associated with a self-perceived negative influence on wellbeing. Yet, fields, forests and water were strongly associated with places people claimed wellbeing benefits from during pandemic restrictions. The further a visited place was from the respondent's home, the more likely it was to have a positive wellbeing influence. As an illustrative case, we map our models onto the landscape of Stockholm, showing that some neighborhoods are likely more resilient than others when coping with pandemic restrictions. Both the most and least resilient neighborhoods span the socio-economic spectrum. Urban planning will do well to enable equitable, easy access to natural settings by foot or bike, to increase pandemic preparedness as well as support climate change mitigation and biodiversity protection.

Analytical approaches to testing pathways linking greenspace to health: A scoping review of the empirical literature.

BACKGROUND: Inadequate translation from theoretical to statistical models of the greenspace - health relationship may lead to incorrect conclusions about the importance of some pathways, which in turn may reduce the effectiveness of public health interventions involving urban greening. In this scoping review we aimed to: (1) summarize the general characteristics of approaches to intervening variable inference (mediation analysis) employed in epidemiological research in the field; (2) identify potential threats to the validity of findings; and (3) propose recommendations for planning, conducting, and reporting mediation analyses. METHODS: We conducted a scoping review, searching PubMed, Scopus, and Web of Science for peer-reviewed epidemiological studies published by December 31, 2019. The list of potential studies was continuously updated through other sources until March 2020. Narrative presentation of the results was coupled with descriptive summary of study characteristics. RESULTS: We found 106 studies, most of which were cross-sectional in design. Most studies only had a spatial measure of greenspace. Mental health/well-being was the most commonly studied outcome, and physical activity and air pollution were the most commonly tested intervening variables. Most studies only conducted single mediation analysis, even when multiple potentially intertwined mediators were measured. The analytical approaches used were causal steps, difference-of-coefficients, product-of-coefficients, counterfactual framework, and structural equation modelling (SEM). Bootstrapping was the most commonly used method to construct the 95% CI of the indirect effect. The product-of-coefficients method and SEM as used to investigate serial mediation components were more likely to yield findings of indirect effect. In some cases, the causal steps approach thwarted tests of indirect effect, even though both links in an indirect effect were supported. In most studies, sensitivity analyses and proper methodological discussion of the modelling approach were missing. CONCLUSIONS: We found a persistent pattern of suboptimal conduct and reporting of mediation analysis in epidemiological studies investigating pathways linking greenspace to health; however, recent years have seen improvements in these respects. Better planning, conduct, and reporting of mediation analyses are warranted.

Collective Optimism and Selection Against Male Twins in Utero.

Scholarly literature claims that health declines in populations when optimism about investing in the future wanes. This claim leads us to describe collective optimism as a predictor of selection in utero. Based on the literature, we argue that the incidence of suicide gauges collective optimism in a population and therefore willingness to invest in the future. Using monthly data from Sweden for the years 1973-2016, we test the hypothesis that the incidence of suicide among women of child-bearing age correlates inversely with male twin births, an indicator of biological investment in high-risk gestations. We find that, as predicted by our theory, the incidence of suicide at month t varies inversely with the ratio of twin to singleton male births at month t + 3. Our results illustrate the likely sensitivity of selection in utero to change in the social environment and so the potential for viewing collective optimism as a component of public health infrastructure.

Residential greenspace is associated with mental health via intertwined capacity-building and capacity-restoring pathways.

BACKGROUND: Experiences afforded by natural settings promote health by helping people to build new adaptive capacities and to restore existing capacities. The aim of this study was to examine relations among restorative experience, mindfulness, rumination and psychological resilience in pathways linking residential greenspace to anxiety and depression symptoms. METHODS: We sampled 529 university students residing in Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI) and tree cover density for different buffer sizes. Symptoms of anxiety and depression were measured with the Generalized Anxiety Disorder scale (7-item) and Patient Health Questionnaire (9-item), respectively. The following mediators were assessed by self-report: perceived greenspace, restorative quality of the neighborhood, dispositional mindfulness, rumination, and psychological resilience. Structural equation modelling techniques were used to test the theoretically-indicated relations among the variables. RESULTS: Across different buffer sizes, higher greenspace was consistently associated with reduced scores on the anxiety and depression scales. This effect was partially mediated via several pathways. Specifically, higher NDVI 500-m was associated with higher perceived greenspace, and in turn, with higher restorative quality, and then with higher mindfulness, lower rumination, and greater resilience to stress, and consequently, with better mental health. CONCLUSIONS: Our findings affirm the potential of greenspace for building psychological resilience and promoting health by offsetting dysfunctional rumination and facilitating mindfulness as components of intertwined capacity-building and capacity-restoring pathways.

Urban residential greenspace and mental health in youth: Different approaches to testing multiple pathways yield different conclusions.

BACKGROUND: Urban greenspace can benefit mental health through multiple mechanisms. They may work together, but previous studies have treated them as independent. OBJECTIVES: We aimed to compare single and parallel mediation models, which estimate the independent contributions of different paths, to several models that posit serial mediation components in the pathway from greenspace to mental health. METHODS: We collected cross-sectional survey data from 399 participants (15-25 years of age) in the city of Plovdiv, Bulgaria. Objective "exposure" to urban residential greenspace was defined by the Normalized Difference Vegetation Index (NDVI), Soil Adjusted Vegetation Index, tree cover density within the 500-m buffer, and Euclidean distance to the nearest urban greenspace. Self-reported measures of availability, access, quality, and usage of greenspace were also used. Mental health was measured with the General Health Questionnaire. The following potential mediators were considered in single and parallel mediation models: restorative quality of the neighborhood, neighborhood social cohesion, commuting and leisure time physical activity, road traffic noise annoyance, and perceived air pollution. Four models were tested with the following serial mediation components: (1) restorative quality → social cohesion; (2) restorative quality → physical activity; (3) perceived traffic pollution → restorative quality; (4) and noise annoyance → physical activity. RESULTS: There was no direct association between objectively-measured greenspace and mental health. For the 500-m buffer, the tests of the single mediator models suggested that restorative quality mediated the relationship between NDVI and mental health. Tests of parallel mediation models did not find any significant indirect effects. In line with theory, tests of the serial mediation models showed that higher restorative quality was associated with more physical activity and more social cohesion, and in turn with better mental health. As for self-reported greenspace measures, single mediation through restorative quality was significant only for time in greenspace, and there was no mediation though restorative quality in the parallel mediation models; however, serial mediation through restorative quality and social cohesion/physical activity was indicated for all self-reported measures except for greenspace quality. CONCLUSIONS: Statistical models should adequately address the theoretically indicated interdependencies between mechanisms underlying association between greenspace and mental health. If such causal relationships hold, testing mediators alone or in parallel may lead to incorrect inferences about the relative contribution of specific paths, and thus to inappropriate intervention strategies.

Multiple pathways link urban green- and bluespace to mental health in young adults.

BACKGROUND: A growing body of scientific literature indicates that urban green- and bluespace support mental health; however, little research has attempted to address the complexities in likely interrelations among the pathways through which benefits plausibly are realized. OBJECTIVES: The present study examines how different plausible pathways between green/bluespace and mental health can work together. Both objective and perceived measures of green- and bluespace are used in these models. METHODS: We sampled 720 students from the city of Plovdiv, Bulgaria. Residential greenspace was measured in terms of the Normalized Difference Vegetation Index (NDVI), tree cover density, percentage of green areas, and Euclidean distance to the nearest green space. Bluespace was measured in terms of its presence in the neighborhood and the Euclidean distance to the nearest bluespace. Mental health was measured with the 12-item form of the General Health Questionnaire (GHQ-12). The following mediators were considered: perceived neighborhood green/bluespace, restorative quality of the neighborhood, social cohesion, physical activity, noise and air pollution, and environmental annoyance. Structural equation modelling techniques were used to analyze the data. RESULTS: Higher NDVI within a 300 m buffer around the residence was associated with better mental health through higher perceived greenspace; through higher perceived greenspace, leading to increased restorative quality, and subsequently to increased physical activity (i.e., serial mediation); through lower noise exposure, which in turn was associated with lower annoyance; and through higher perceived greenspace, which was associated with lower annoyance. Presence of bluespace within a 300 m buffer did not have a straightforward association with mental health owing to competitive indirect paths: one supporting mental health through higher perceived bluespace, restorative quality, and physical activity; and another engendering mental ill-health through higher noise exposure and annoyance. CONCLUSIONS: We found evidence that having more greenspace near the residence supported mental health through several indirect pathways with serial components. Conversely, bluespace was not clearly associated with mental health.

Building mindfulness bottom-up: Meditation in natural settings supports open monitoring and attention restoration.

Mindfulness courses conventionally use effortful, focused meditation to train attention. In contrast, natural settings can effortlessly support state mindfulness and restore depleted attention resources, which could facilitate meditation. We performed two studies that compared conventional training with restoration skills training (ReST) that taught low-effort open monitoring meditation in a garden over five weeks. Assessments before and after meditation on multiple occasions showed that ReST meditation increasingly enhanced attention performance. Conventional meditation enhanced attention initially but increasingly incurred effort, reflected in performance decrements toward the course end. With both courses, attentional improvements generalized in the first weeks of training. Against established accounts, the generalized improvements thus occurred before any effort was incurred by the conventional exercises. We propose that restoration rather than attention training can account for early attentional improvements with meditation. ReST holds promise as an undemanding introduction to mindfulness and as a method to enhance restoration in nature contacts.

Exploring pathways linking greenspace to health: Theoretical and methodological guidance.

BACKGROUND: In a rapidly urbanizing world, many people have little contact with natural environments, which may affect health and well-being. Existing reviews generally conclude that residential greenspace is beneficial to health. However, the processes generating these benefits and how they can be best promoted remain unclear. OBJECTIVES: During an Expert Workshop held in September 2016, the evidence linking greenspace and health was reviewed from a transdisciplinary standpoint, with a particular focus on potential underlying biopsychosocial pathways and how these can be explored and organized to support policy-relevant population health research. DISCUSSIONS: Potential pathways linking greenspace to health are here presented in three domains, which emphasize three general functions of greenspace: reducing harm (e.g. reducing exposure to air pollution, noise and heat), restoring capacities (e.g. attention restoration and physiological stress recovery) and building capacities (e.g. encouraging physical activity and facilitating social cohesion). Interrelations between among the three domains are also noted. Among several recommendations, future studies should: use greenspace and behavioural measures that are relevant to hypothesized pathways; include assessment of presence, access and use of greenspace; use longitudinal, interventional and (quasi)experimental study designs to assess causation; and include low and middle income countries given their absence in the existing literature. Cultural, climatic, geographic and other contextual factors also need further consideration. CONCLUSIONS: While the existing evidence affirms beneficial impacts of greenspace on health, much remains to be learned about the specific pathways and functional form of such relationships, and how these may vary by context, population groups and health outcomes. This Report provides guidance for further epidemiological research with the goal of creating new evidence upon which to develop policy recommendations.

Twinning in Norway Following the Oslo Massacre: Evidence of a 'Bruce Effect' in Humans.

Emerging theory and empirical work suggest that the 'Bruce Effect', or the increase in spontaneous abortion observed in non-human species when environments become threatening to offspring survival, may also appear in humans. We argue that, if it does, the effect would appear in the odds of twins among male and female live births. We test the hypothesis, implied by our argument, that the odds of a twin among male infants in Norway fell below, while those among females rose above, expected levels among birth cohorts in gestation in July 2011 when a deranged man murdered 77 Norwegians, including many youths. Results support the hypothesis and imply that the Bruce Effect operates in women to autonomically raise the standard of fetal fitness necessary to extend the gestation of twins. This circumstance has implications for using twins to estimate the relative contributions of genes and environment to human responses to exogenous stimuli.

Garden greenery and the health of older people in residential care facilities: a multi-level cross-sectional study.

AIMS: To test the relationship between greenery in gardens at residential facilities for older people and the self-perceived health of residents, mediated by experiences of being away and fascination when in the garden and the frequency of visitation there. To examine how these indirect effects vary with the number of physical barriers to visiting the garden. BACKGROUND: Many older people in residential facilities suffer from complex health problems. Access to a green outdoor environment may enable psychological distance, engage effortless attention, encourage more frequent visitation and promote resident health. DESIGN: A multi-level, cross-sectional, correlational design. METHODS: Questionnaires were administered June-August, 2011 to convenience samples of residents at 72 facilities for older people with complex healthcare needs. One to 10 eligible residents were sampled during self-motivated garden visits at each facility (n = 290). They reported on their garden experiences and health. Facility staff reported on objective garden characteristics and barriers to access. A serial mediation model was tested with multiple linear regression analysis. RESULTS: The total indirect effect of greenery on self-perceived health was positive and significant. Garden greenery appears to affect health by enhancing a sense of being away, affording possibilities to experience the outdoor environment as interesting and encouraging visitation. Among residents in homes with multiple barriers, only fascination mediated the relationship between greenery and self-perceived health. CONCLUSION: Ample greenery in outdoor space at residential facilities for older people appears to promote experiences of being away and fascination, more frequent visitation and better health.

Twins less frequent than expected among male births in risk averse populations.

Male twin gestations exhibit higher incidence of fetal morbidity and mortality than singleton gestations. From an evolutionary perspective, the relatively high rates of infant and child mortality among male twins born into threatening environments reduce the fitness of these gestations, making them more vulnerable to fetal loss. Women do not perceive choosing to spontaneously abort gestations although the outcome may result from estimates, made without awareness, of the risks of continuing a pregnancy. Here, we examine whether the non-conscious decisional biology of gestation can be linked to conscious risk aversion. We test this speculation by measuring the association between household surveys in Sweden that gauge financial risk aversion in the population and the frequency of twins among live male births. We used time-series regression methods to estimate our suspected associations and Box-Jenkins modeling to ensure that autocorrelation did not confound the estimation or reduce its efficiency. We found, consistent with theory, that financial risk aversion in the population correlates inversely with the odds of a twin among Swedish males born two months later. The odds of a twin among males fell by approximately 3.5% two months after unexpectedly great risk aversion in the population. This work implies that shocks that affect population risk aversion carry implications for fetal loss in vulnerable twin pregnancies.

Nature and health.

Urbanization, resource exploitation, and lifestyle changes have diminished possibilities for human contact with nature in urbanized societies. Concern about the loss has helped motivate research on the health benefits of contact with nature. Reviewing that research here, we focus on nature as represented by aspects of the physical environment relevant to planning, design, and policy measures that serve broad segments of urbanized societies. We discuss difficulties in defining "nature" and reasons for the current expansion of the research field, and we assess available reviews. We then consider research on pathways between nature and health involving air quality, physical activity, social cohesion, and stress reduction. Finally, we discuss methodological issues and priorities for future research. The extant research does describe an array of benefits of contact with nature, and evidence regarding some benefits is strong; however, some findings indicate caution is needed in applying beliefs about those benefits, and substantial gaps in knowledge remain.

A novel indicator of selection in utero.

Background and objectives: Selection in utero predicts that population stressors raise the standard for how quickly fetuses must grow to avoid spontaneous abortion. Tests of this prediction must use indirect indicators of fetal loss in birth cohorts because vital statistics systems typically register fetal deaths at the 20th week of gestation or later, well after most have occurred. We argue that tests of selection in utero would make greater progress if researchers adopted an indicator of selection against slow-growing fetuses that followed from theory, allowed sex-specific tests and used readily available data. We propose such an indicator and assess its validity as a dependent variable by comparing its values among monthly birth cohorts before, and during, the first 10 months of the COVID-19 pandemic in Sweden. Methodology: We apply Box-Jenkins methods to 50 pre-pandemic birth cohorts (i.e., December 2016 through January 2020) and use the resulting transfer functions to predict counterfactual values in our suggested indicator for selection for ten subsequent birth cohorts beginning in February 2020. We then plot all 60 residual values as well as their 95% detection interval. If birth cohorts in gestation at the onset of the pandemic lost more slow-growing fetuses than expected from history, more than one of the last 10 (i.e. pandemic-exposed) residuals would fall below the detection interval. Results: Four of the last 10 residuals of our indicator for males and for females fell below the 95% detection interval. Conclusions and implications: Consistent with selection in utero, Swedish birth cohorts in gestation at the outset of the COVID-19 pandemic included fewer than expected infants who grew slowly in utero.

Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health.

Nature-based solutions including urban forests and wetlands can help communities cope better with climate change and other environmental stressors by enhancing social-ecological resilience. Natural ecosystems, settings, elements and affordances can also help individuals become more personally resilient to a variety of stressors, although the mechanisms underpinning individual-level nature-based resilience, and their relations to social-ecological resilience, are not well articulated. We propose 'nature-based biopsychosocial resilience theory' (NBRT) to address these gaps. Our framework begins by suggesting that individual-level resilience can refer to both: a) a person's set of adaptive resources; and b) the processes by which these resources are deployed. Drawing on existing nature-health perspectives, we argue that nature contact can support individuals build and maintain biological, psychological, and social (i.e. biopsychosocial) resilience-related resources. Together with nature-based social-ecological resilience, these biopsychosocial resilience resources can: i) reduce the risk of various stressors (preventive resilience); ii) enhance adaptive reactions to stressful circumstances (response resilience), and/or iii) facilitate more rapid and/or complete recovery from stress (recovery resilience). Reference to these three resilience processes supports integration across more familiar pathways involving harm reduction, capacity building, and restoration. Evidence in support of the theory, potential interventions to promote nature-based biopsychosocial resilience, and issues that require further consideration are discussed.

Health benefits of a view of nature through the window: a quasi-experimental study of patients in a residential rehabilitation center.

OBJECTIVE: To examine the health benefits of a bedroom window view to natural surroundings for patients undergoing a residential rehabilitation programme. DESIGN: Longitudinal quasi-experiment. SETTING: A residential rehabilitation centre. SUBJECTS: Two-hundred and seventy-eight coronary and pulmonary patients provided data at all measurement points during the programme. INTERVENTION: Blind, quasi-random allocation to a private bedroom with a panoramic view to natural surroundings or with a view either partially or entirely blocked by buildings. MAIN MEASURES: Self-reported physical and mental health (SF-12), subjective well-being, emotional states, use of the private bedroom and leisure activities. RESULTS: For women, a blocked view appeared to negatively influence change in physical health (time × view × gender interaction, F(4,504) = 2.51, P = 0.04), whereas for men, a blocked view appeared to negatively influence change in mental health (time × view × gender interaction, F(4,504) = 5.67, P < 0.01). Pulmonary patients with a panoramic view showed greater improvement in mental health than coronary patients with such a view (time × view × diagnostic group interaction, F(4,504) = 2.76, P = 0.03). Those with a panoramic view to nature more often chose to stay in their bedroom when they wanted to be alone than those with a blocked view (odds ratio (OR) = 2.32, 95% confidence interval (CI) 1.08-5.01). CONCLUSION: An unobstructed bedroom view to natural surroundings appears to have better supported improvement in self-reported physical and mental health during a residential rehabilitation programme, although the degree of change varied with gender and diagnostic group.

Restoration Skills Training in a Natural Setting Compared to Conventional Mindfulness Training: Sustained Advantages at a 6-Month Follow-Up.

Restoration skills training (ReST) is a mindfulness-based course in which participants draw support from a natural practice setting while they learn to meditate. Well-established conventional mindfulness training (CMT) can improve psychological functioning but many perceive it as demanding and fail to sustain practice habits. Applying non-inferiority logic, previous research indicated that ReST overcomes compliance problems without compromising the benefits gained over 5 weeks' training. This article applies similar logic in a 6-month follow-up. Of 97 contacted ReST and CMT course completers, 68 responded and 29 were included with multiple imputation data. The online survey included questions about their psychological functioning in three domains (dispositional mindfulness, cognitive lapses, and perceived stress) and the forms and frequencies with which they had continued to practice mindfulness after the course. Former ReST participants continued, on average, to show higher dispositional mindfulness and fewer cognitive lapses compared to pre-course ratings. Improved psychological functioning in one or more domains was demonstrated by 35%, as determined by a reliable change index. Again, analyses detected no indications of any substantive disadvantages compared to the more demanding, established CMT approach. Compared to the CMT group, more ReST participants had also continued to practice at least occasionally (92 vs. 67%). Continued practice was linked to sustained improvements for ReST but not clearly so for CMT. ReST participants thus continued to use the skills and sustained the improvements in psychological functioning that they had gained in the course, further supporting the utility of ReST as a health intervention.

More green, less lonely? A longitudinal cohort study.

BACKGROUND: Urban greening may reduce loneliness by offering opportunities for solace, social reconnection and supporting processes such as stress relief. We (i) assessed associations between residential green space and cumulative incidence of, and relief from, loneliness over 4 years; and (ii) explored contingencies by age, sex, disability and cohabitation status. METHODS: Multilevel logistic regressions of change in loneliness status in 8049 city-dwellers between 2013 (baseline) and 2017 (follow-up) in the Household, Income and Labour Dynamics in Australia study. Associations with objectively measured discrete green-space buffers (e.g. parks) (<400, <800 and <1600 m) were adjusted for age, sex, disability, cohabitation status, children and socio-economic variables. Results were translated into absolute risk reductions in loneliness per 10% increase in urban greening. RESULTS: The absolute risk of loneliness rose from 15.9% to 16.9% over the 4 years; however, a 10% increase in urban greening within 1.6 km was associated with lower cumulative incident loneliness [odds ratio (OR) = 0.927, 95% confidence interval (CI) = 0.862 to 0.996; absolute risk reduction = 0.66%]. Stronger association was observed for people living alone (OR = 0.828, 95% CI = 0.725 to 0.944). In comparison to people with <10% green space, the ORs for cumulative incident loneliness were 0.833 (95% CI = 0.695 to 0.997), 0.790 (95% CI = 0.624 to 1.000) and 0.736 (95% CI = 0.549 to 0.986) for 10-20%, 20-30% and >30% green space, respectively. Compared with the <10% green-space reference group with 13.78% incident loneliness over 4 years and conservatively assuming no impact on incident loneliness, associations translated into absolute risk reductions of 1.70%, 2.26% and 2.72% within populations with 10-20%, 20-30% and >30% green space, respectively. These associations were stronger again for people living alone, with 10-20% (OR = 0.608, 95% CI = 0.448 to 0.826), 20-30% (OR = 0.649, 95% CI = 0.436 to 0.966) and >30% (OR = 0.480, 95% CI = 0.278 to 0.829) green space within 1600 m. No age, sex or disability-related contingencies, associations with green space within 400 or 800 m or relief from loneliness reported at baseline were observed. CONCLUSIONS: A lower cumulative incidence of loneliness was observed among people with more green space within 1600 m of home, especially for people living alone. Potential biopsychosocial mechanisms warrant investigation.