Joint hypermobility in functional neurological disorder: A cross-sectional study.

BACKGROUND: Functional Neurological Disorder (FND) is associated with anxiety and depression, and perhaps with joint hypermobility, which is itself associated with anxiety and depression. We conducted a survey to explore the relationship between these. METHODS: An online survey of people with FND was conducted, with participants asked to nominate healthy controls from their social group to join. Participants were asked about their anxiety (measured with GAD7), depression (measured with PHQ9) and joint hypermobility (measured with 5PQ). A regression analysis was conducted using a general linear model. RESULTS: 215 people with FND and 22 people without FND were included in the analysis. GAD7, PHQ9 and hypermobility scores were all higher in the group with FND, with 74% of people with FND meeting the common cut-off for a diagnosis of joint hypermobility syndrome, as compared with 45% of those without FND. Anxiety, depression and joint hypermobility scores all predicted FND status, with joint hypermobility the strongest. Hypermobility moderated the effect of anxiety, with the effect being stronger at lower levels of anxiety. CONCLUSION: While anxiety, depression and hypermobility symptoms each appear to contribute to FND, the role of anxiety is moderated by hypermobility, particularly when anxiety is lower.

Using Instrumental Variables to Measure Causation over Time in Cross-Lagged Panel Models.

Cross-lagged panel models (CLPMs) are commonly used to estimate causal influences between two variables with repeated assessments. The lagged effects in a CLPM depend on the time interval between assessments, eventually becoming undetectable at longer intervals. To address this limitation, we incorporate instrumental variables (IVs) into the CLPM with two study waves and two variables. Doing so enables estimation of both the lagged (i.e., "distal") effects and the bidirectional cross-sectional (i.e., "proximal") effects at each wave. The distal effects reflect Granger-causal influences across time, which decay with increasing time intervals. The proximal effects capture causal influences that accrue over time and can help infer causality when the distal effects become undetectable at longer intervals. Significant proximal effects, with a negligible distal effect, would imply that the time interval is too long to estimate a lagged effect at that time interval using the standard CLPM. Through simulations and an empirical application, we demonstrate the impact of time intervals on causal inference in the CLPM and present modeling strategies to detect causal influences regardless of the time interval in a study. Furthermore, to motivate empirical applications of the proposed model, we highlight the utility and limitations of using genetic variables as IVs in large-scale panel studies.

MR-DoC2: Bidirectional Causal Modeling with Instrumental Variables and Data from Relatives.

Establishing causality is an essential step towards developing interventions for psychiatric disorders, substance use and many other conditions. While randomized controlled trials (RCTs) are considered the gold standard for causal inference, they are unethical in many scenarios. Mendelian randomization (MR) can be used in such cases, but importantly both RCTs and MR assume unidirectional causality. In this paper, we developed a new model, MRDoC2, that can be used to identify bidirectional causation in the presence of confounding due to both familial and non-familial sources. Our model extends the MRDoC model (Minica et al. in Behav Genet 48:337-349,  https://doi.org/10.1007/s10519-018-9904-4 , 2018), by simultaneously including risk scores for each trait. Furthermore, the power to detect causal effects in MRDoC2 does not require the phenotypes to have different additive genetic or shared environmental sources of variance, as is the case in the direction of causation twin model (Heath et al. in Behav Genet 23:29-50,  https://doi.org/10.1007/BF01067552 , 1993).

Relationship between the Bolsa Família national cash transfer programme and suicide incidence in Brazil: A quasi-experimental study.

BACKGROUND: Socioeconomic factors have been consistently associated with suicide, and economic recessions are linked to rising suicide rates. However, evidence on the impact of socioeconomic interventions to reduce suicide rates is limited. This study investigates the association of the world's largest conditional cash transfer programme with suicide rates in a cohort of half of the Brazilian population. METHODS AND FINDINGS: We used data from the 100 Million Brazilian Cohort, covering a 12-year period (2004 to 2015). It comprises socioeconomic and demographic information on 114,008,317 individuals, linked to the "Bolsa Família" programme (BFP) payroll database, and nationwide death registration data. BFP was implemented by the Brazilian government in 2004. We estimated the association of BFP using inverse probability of treatment weighting, estimating the weights for BFP beneficiaries (weight = 1) and nonbeneficiaries by the inverse probability of receiving treatment (weight = E(ps)/(1-E(ps))). We used an average treatment effect on the treated (ATT) estimator and fitted Poisson models to estimate the incidence rate ratios (IRRs) for suicide associated with BFP experience. At the cohort baseline, BFP beneficiaries were younger (median age 27.4 versus 35.4), had higher unemployment rates (56% versus 32%), a lower level of education, resided in rural areas, and experienced worse household conditions. There were 36,742 suicide cases among the 76,532,158 individuals aged 10 years, or older, followed for 489,500,000 person-years at risk. Suicide rates among beneficiaries and nonbeneficiaries were 5.4 (95% CI = 5.32, 5.47, p < 0.001) and 10.7 (95% CI = 10.51, 10.87, p < 0.001) per 100,000 individuals, respectively. BFP beneficiaries had a lower suicide rate than nonbeneficiaries (IRR = 0.44, 95% CI = 0.42, 0.45, p < 0.001). This association was stronger among women (IRR = 0.36, 95% CI = 0.33, 0.38, p < 0.001), and individuals aged between 25 and 59 (IRR = 0.41, 95% CI = 0.40, 0.43, p < 0.001). Study limitations include a lack of control for previous mental disorders and access to means of suicide, and the possible under-registration of suicide cases due to stigma. CONCLUSIONS: We observed that BFP was associated with lower suicide rates, with similar results in all sensitivity analyses. These findings should help to inform policymakers and health authorities to better design suicide prevention strategies. Targeting social determinants using cash transfer programmes could be important in limiting suicide, which is predicted to rise with the economic recession, consequent to the Coronavirus Disease 2019 (COVID-19) pandemic.

Hyperventilation in functional seizures: Evidence for subtypes.

PURPOSE: Functional seizures (FS) are heterogenous, with no agreed way to subdivide them. One FS subtype frequently observed during EEG is those whose seizures are provoked by hyperventilation. We wished to see whether this subtype might reflect a different seizure mechanism. METHODS: We analysed the video-EEG/ECGs of all patients with FS from two hospitals in Melbourne from 2010-6. RESULTS: We identified 120 patients during the study period, 107 of whom had usable recordings. Examining those 11 (10%) whose seizures had been induced by hyperventilation, we compared the heart rates of those where the seizure occurred during the hyperventilation, and those where they occurred afterwards. The during-hyperventilation group had a higher baseline heart rate which increased prior to their seizure; the after-hyperventilation group had a lower baseline heart rate and no pre-ictal increase. In those patients whose seizures were not hyperventilation-induced, the same two heart rate patterns could be found: those with a higher baseline heart rate showed increasing heart rate prior to seizure onset, while those with a lower baseline heart rate did not. Cluster analysis showed the sample was optimally divided into these two groups based on their pre-onset heart rate alone. CONCLUSION: Patients with FS show two distinct patterns of pre-ictal heart rate, which may reflect two distinct seizure mechanisms.

Trends in method-specific suicide in Brazil from 2000 to 2017.

PURPOSE: Understanding long-term patterns of suicide methods can inform public health policy and prevention strategies. In Brazil, firearm-related policies may be one salient target for suicide prevention. This study describes trends in method-specific suicide at the national and state-levels in Brazil, with a particular focus on firearm-related suicides. METHODS: Brazilian mortality data for suicide and undetermined intent among people aged 10 years and older between 2000 and 2017 were obtained from the National Mortality Information System. We examined national and state-level trends in age-standardised suicide rates for hanging, self-poisoning, firearms, jumping from a high place, other, and unspecified methods. We also compared total rates of mortality from suicide and undetermined intent over the period. Applying Joinpoint regression, we tested changes in trends of firearm-specific suicide rates. RESULTS: The total suicide rate increased between 2000 and 2017. Rates of hanging, self-poisoning by drugs or alcohol and jumping from a high place showed the largest increases, while firearm-specific suicide rates decreased over the study period. Trends in methods of suicide varied by sex and state. CONCLUSION: It is of public health concern that suicide rates in Brazil have risen this millennium. Restricting access to firearms might be an effective approach for reducing firearm-specific suicides, especially in states where firearm availability remains particularly high. Treatment and management of substance misuse may also be an important target for suicide prevention policies. More work is needed to understand the causes of rising suicide rates in Brazil and to improve the mental health of the population.

Migration of Junior Doctors: The Case of Psychiatric Trainees in Portugal.

INTRODUCTION: In the last few decades, the rates of international medical migration have continuously risen. In Psychiatry, there is great disparity in the workforce between high and low-income countries. Yet, little is known about the 'push' and 'pull' factors and the migratory intentions of trainees. This study aims to assess the factors impacting the decisions of psychiatric trainees in Portugal towards migration. MATERIAL AND METHODS: A questionnaire was developed in the Brain Drain study and was distributed to psychiatric trainees in Portugal. RESULTS: The sample consists of 104 psychiatric trainees (60.6% female). Overall, 40.4% of the trainees had prior experience of living abroad and the majority (96.9%) felt that this experience influenced their attitude towards migration in a positive way. About 75% of trainees had 'ever' considered leaving the country, but the majority (70.0%) had not taken any 'practical steps' towards migration. The main reasons to stay in Portugal were personal, while the main reason to leave was financial. The majority of the trainees (55.7%) were dissatisfied or very dissatisfied with their income, working conditions and academic opportunities. DISCUSSION: Working conditions, salaries and academic opportunities are the main triggers for the migration of psychiatric trainees from Portugal. CONCLUSION: These results may inform the decisions of stakeholders in the health and education sectors and point out the necessary investments required and the impact it may have on the workforce.

Introdução: Nas últimas décadas, a migração médica internacional tem aumentado continuamente. Na Psiquiatria, existe uma grande disparidade de recursos humanos entre países desenvolvidos e com baixo desenvolvimento económico. No entanto, pouco se sabe sobre os fatores que atraem (push) ou afastam (pull) a mobilidade e quais as intenções migratórias dos internos de psiquiatria. O objetivo deste estudo é avaliar os fatores que influenciam o processo de tomada de decisão dos internos de Psiquiatria em Portugal relativamente à migração. Material e Métodos: Um questionário foi desenvolvido no âmbito do estudo Brain Drain, e foi enviado aos internos de Psiquiatria em Portugal. Resultados: A amostra é constituída por 104 internos de Psiquiatria (60,6% do sexo feminino). No geral, 40,4% dos internos tiveram uma experiência de mobilidade e a maioria (96,9%) sentiu que esta os influenciou positivamente na sua atitude em relação à migração. Cerca de 75% dos internos já considerou emigrar, mas a maioria (70,0%) não deu nenhum passo nessa direção. A principal razão para permanecer no país prende-se com factores pessoais, enquanto o principal motivo para emigrar é financeiro. A maioria (55,7%) dos internos estava insatisfeito ou muito insatisfeito com o seu salário, condições de trabalho e oportunidades académicas. Discussão: Condições de trabalho, salários e oportunidades académicas são os principais estímulos para a emigração nos internos de Psiquiatria em Portugal. Conclusão: Estes resultados poderão apoiar a tomada de decisão dos decisores em saúde e educação médica sobre os investimentos necessários e a sua influência na força laboral futura.

Care-seeking as a proxy indicator of the mental health of elderly Brazilians

Objective: To assess a large set of metadata made public by the Brazilian Ministry of Health on older subjects who visited outpatient mental health services in Brazil from 2008 to 2012. Methods: We extracted data from the Brazilian Unified Health System Information Technology Department (Departamento de Informática do Sistema Único de Saúde, DATASUS), then calculated rates of visits per population in each of the five regions of Brazil, using census data for each year. Finally, logistic regressions were performed with depressive disorders or dementias as dependent variables, controlled by age and year of visit, stratified by region. Results: Mood disorders were the leading reason for visits to outpatient mental health services by older adults, followed by delusional disorders. The calculated rates were lower than the known prevalence of depressive disorders and dementias, but the regressions revealed typical patterns. Males were less likely to present with a depressive disorder, while older subjects were more likely to present with depression and dementia. Conclusions: Publicly available data from DATASUS may not enable inferences about the prevalence of mental disorders in elders, but inferential analyses match what is known about these conditions. This approach is supplemental to other more common ones and is of special importance for policymakers and health system managers.

Association between homicide rates and suicide rates: a countrywide longitudinal analysis of 5507 Brazilian municipalities.

OBJECTIVE: To estimate the association between homicide and suicide rates in Brazilian municipalities over a period of 7 years. DESIGN: We conducted a longitudinal ecological study using annual mortality data from 5507 Brazilian municipalities between 2008 and 2014. Multivariable negative binomial regression models were used to examine the relationship between homicide and suicide rates. Robustness of results was explored using sensitivity analyses to examine the influence of data quality, population size, age and sex on the relationship between homicide and suicide rates. SETTING: A nationwide study of municipality-level data. PARTICIPANTS: Mortality data and corresponding population estimates for municipal populations aged 10 years and older. PRIMARY AND SECONDARY OUTCOME MEASURES: Age-standardised suicide rates per 100 000. RESULTS: Municipal suicide rates were positively associated with municipal homicide rates; after adjusting for socioeconomic and demographic factors, a doubling of the homicide rate was associated with 22% increase in suicide rate (rate ratio=1.22, 95% CI: 1.13 to 1.33). A dose-response effect was observed with 4% increase in suicide rates at the third quintile, 9% at the fourth quintile and 12% at the highest quintile of homicide rates compared with the lowest quintile. The observed effect estimates were robust to sensitivity analyses. CONCLUSIONS: Municipalities with higher homicide rates have higher suicide rates and the relationship between homicide and suicide rates in Brazil exists independently of many sociodemographic and socioeconomic factors. Our results are in line with the hypothesis that changes in homicide rates lead to changes in suicide rates, although a causal association cannot be established from this study. Suicide and homicide rates have increased in Brazil despite increased community mental health support and incarceration, respectively; therefore, new avenues for intervention are needed. The identification of a positive relationship between homicide and suicide rates suggests that population-based interventions to reduce homicide rates may also reduce suicide rates in Brazil.

Care-seeking as a proxy indicator of the mental health of elderly Brazilians.

OBJECTIVE: To assess a large set of metadata made public by the Brazilian Ministry of Health on older subjects who visited outpatient mental health services in Brazil from 2008 to 2012. METHODS: We extracted data from the Brazilian Unified Health System Information Technology Department (Departamento de Informática do Sistema Único de Saúde, DATASUS), then calculated rates of visits per population in each of the five regions of Brazil, using census data for each year. Finally, logistic regressions were performed with depressive disorders or dementias as dependent variables, controlled by age and year of visit, stratified by region. RESULTS: Mood disorders were the leading reason for visits to outpatient mental health services by older adults, followed by delusional disorders. The calculated rates were lower than the known prevalence of depressive disorders and dementias, but the regressions revealed typical patterns. Males were less likely to present with a depressive disorder, while older subjects were more likely to present with depression and dementia. CONCLUSIONS: Publicly available data from DATASUS may not enable inferences about the prevalence of mental disorders in elders, but inferential analyses match what is known about these conditions. This approach is supplemental to other more common ones and is of special importance for policymakers and health system managers.

Schizophrenia moderates the relationship between white matter integrity and cognition.

Cognitive impairment is a primary feature of schizophrenia, with alterations in several cognitive domains appearing in the pre-morbid phase of the disorder. White matter microstructure is also affected in schizophrenia and considered to be related to cognition, but the relationship of the two is unclear. As interaction between cognition and white matter structure involves the interplay of several brain structures and cognitive abilities, investigative methods which can examine the interaction of multiple variables are preferred. A multiple-groups structural equation model (SEM) was used to assess the relationship between diffusion tension imaging data (fractional anisotropy of selected white matter tracts) and cognitive abilities of 196 subjects - 135 healthy subjects and 61 patients with schizophrenia. It was found that multiple-indicators, multiple-causes model best fitted the data analysed. Schizophrenia moderated the relation of white matter function on cognition with a large effect size. This paper extends previous work on modelling intelligence within a SEM framework by incorporating neurological elements into the model, and shows that white matter microstructure in patients with schizophrenia interacts with cognitive abilities.

First episode psychosis moderates the effect of gray matter volume on cognition.

Patients with first episode psychosis (FEP) present with cognitive deficits and volume differences in certain brain areas. Brain volumetric information further correlates with cognitive testing, and multiple brain areas shows different strengths of correlation with the cognitive functions being tested. Traditionally, these cognitive functions are independently related to volumetric differences, but these functions share variance. Failing to account for this aspect of cognition hinders the proper representation of cognition in neuroimaging studies. We used modeling methods which account for this shared variance to investigate the differences of correlations between cognitive abilities and brain areas. A multiple-groups structured equation model (SEM) approach was used to design and test a model representing the relation between gray matter volumetric data and neuropsychological test scores in a sample of 100 Brazilian FEP patients and 94 controls. Models with a latent variable formed by neurological measures and reflecting cognitive measures performed better on fit tests. FEP moderated the relation between gray matter volumes and cognition by altering the profile of correlations between groups. This moderation had a large effect size. SEM provides a fine grained picture of the interdependence of structural brain changes and cognition.