Assessment of differential item functioning of the PHQ-9, HADS-D and PROMIS-depression scales in persons with and without multiple sclerosis.

OBJECTIVE: We tested for the presence of differential item functioning (DIF) in commonly used measures of depressive symptoms, in people with multiple sclerosis (MS) versus people with a psychiatric disorder without MS. METHODS: Participants included individuals with MS, or with a lifetime history of a depressive or anxiety disorder (Dep/Anx) but no immune-mediated inflammatory disease. Participants completed the Patient Health Questionnaire (PHQ-9), Hospital Anxiety and Depression Scale (HADS), and the Patient Reported Outcome Measurement Information System (PROMIS)-Depression. We assessed unidimensionality of the measures using factor analysis. We evaluated DIF using logistic regression, with and without adjustment for age, gender and body mass index (BMI). RESULTS: We included 555 participants (MS: 252, Dep/Anx: 303). Factor analysis showed that each depression symptom measure had acceptable evidence of unidimensionality. In unadjusted analyses comparing the MS versus Dep/Anx groups we identified multiple items with evidence of DIF, but few items showed DIF effects that were large enough to be clinically meaningful. We observed non-uniform DIF for one PHQ-9 item, and three HADS-D items. We also observed DIF with respect to gender (one HADS-D item), and BMI (one PHQ-9 item). For the MS versus Dep/Anx groups, we no longer observed DIF post-adjustment for age, gender and BMI. On unadjusted and adjusted analyses, we did not observe DIF for any PROMIS-D item. CONCLUSION: Our findings suggest that DIF exists for the PHQ-9 and HADS-D with respect to gender and BMI in clinical samples that include people with MS whereas DIF was not observed for the PROMIS-Depression scale.

Virtual Acute Psychiatric Ward: Evaluation of Outcomes and Cost Savings.

OBJECTIVE: The COVID-19 pandemic motivated rapid expansion of virtual care. In Winnipeg, Canada, the authors launched a virtual psychiatric acute care ward (vWARD) to divert patients from hospitalization through daily remote treatment by a psychiatry team using telephone or videoconferencing. This study examined vWARD patient characteristics, predictors of transfer to a hospital, use of acute care postdischarge, and costs of the vWARD compared with in-person hospitalization. METHODS: Data for all vWARD admissions from March 23, 2020, to April 30, 2021, were retrieved from program documents and electronic records. Emergency department visits and hospitalizations in the 6 months before admission and the 30 days after discharge were documented. Logistic regression identified factors associated with transfer to a hospital. Thirty-day acute care use after discharge was modeled with Kaplan-Meier curves. A break-even cost analysis was generated with data for usual hospital-based care. RESULTS: The 132 vWARD admissions represented a diverse demographic and clinical population. Overall, 57% involved suicidal behavior, and 29% involved psychosis or mania. Seventeen admissions (13%) were transferred to a hospital. Only presence of psychosis or mania significantly predicted transfer (OR=34.2, 95% CI=3.3-354.6). Eight individuals were hospitalized in the 30 days postdischarge (cumulative survival=0.93). vWARD costs were lower than usual care across several scenarios. CONCLUSIONS: A virtual ward is a feasible, effective, and potentially cost-saving intervention to manage acute psychiatric crises in the community and avoid hospitalization. It has benefits for both the health system and the individual who prefers to receive care at home.

Needs Assessment of Clients Accessing a Community Mental Health Crisis Stabilization Unit.

This study aimed to examine the needs of clients accessing a community mental health crisis stabilization unit (CSU) in Winnipeg, Canada. Sociodemographics, service connections, and need were assessed among CSU clients. The Camberwell Assessment of Need Short Appraisal Schedule - Patient (CANSAS-P) was administered to differentiate need domains that were met and unmet. An ordinal regression examined sociodemographics and level of total unmet need; client characteristics were correlated with unmet need. In total, 271 questionnaires were analyzed. On average, respondents had 6.2 areas of unmet need, with "psychosocial distress" (n = 186, 68.6%), "safety to self" (n = 140, 51.7%), "company" (n = 139, 51.3%), and "physical health" (n = 124, 45.8%) being reported most often. Higher level of unmet need was predicted by disability income and absence of income. Overall, CSU clients had high rates of unmet need reflecting important determinants of health. This information can inform community mental health crisis service delivery to positively impact mental health recovery.

Characterising methamphetamine use to inform health and social policies in Manitoba, Canada: a protocol for a retrospective cohort study using linked administrative data.

INTRODUCTION: Rising use of methamphetamine is causing significant public health concern in Canada. The biological and behavioural effects of methamphetamine range from wakefulness, vigour and euphoria to adverse physical health outcomes like myocardial infarction, haemorrhagic stroke, arrhythmia and seizure. It can also cause severe psychological complications such as psychosis. National survey data point to increasing rates of methamphetamine use, as well as increasing ease of access and serious methamphetamine-related harms. There is an urgent need for evidence to address knowledge gaps, provide direction to harm reduction and treatment efforts and inform health and social policies for people using methamphetamine. This protocol describes a study that aims to address this need for evidence. METHODS: The study will use linked, whole population, de-identified administrative data from the Manitoba Population Research Data Repository. The cohort will include individuals in the city of Winnipeg, Manitoba, who came into contact with the health system for reasons related to methamphetamine use from 2013 to 2021 and a comparison group matched on age, sex and geography. We will describe the cohort's sociodemographic characteristics, calculate incidence and prevalence of mental disorders associated with methamphetamine use and examine rates of health and social service use. We will evaluate the use of olanzapine pharmacotherapy in reducing adverse emergency department outcomes. In partnership with Indigenous co-investigators, outcomes will be stratified by First Nations and Métis identity. ETHICS AND DISSEMINATION: The study was approved by the University of Manitoba Health Research Ethics Board, and access datasets have been granted by all data providers. We also received approval from the First Nations Health and Social Secretariat of Manitoba's Health Information Research Governance Committee and the Manitoba Métis Federation. Dissemination will be guided by an 'Evidence 2 Action' group of public rightsholders, service providers and knowledge users who will ensure that the analyses address the critical issues.

The effects of early pregnancy loss on health outcomes and health care utilization and costs.

OBJECTIVE: To evaluate the effects of early pregnancy loss on subsequent health care use and costs. DATA SOURCES: Linked administrative health databases from Manitoba, Canada. STUDY DESIGN: This was a population-based cohort study. The exposure of interest was first recorded ectopic pregnancy or miscarriage (EPM). Outcomes included visits to all ambulatory care providers, family physicians (FPs), specialists, and hospitals, as well as the costs associated with these visits. We also assessed the impact of EPM on a global measure of health service utilization and the incidence and costs of psychotropic medications. DATA COLLECTION/EXTRACTION METHODS: We identified women who experienced their first recorded loss (EPM) from 2003-2012 and created a propensity score model to match these women to women who experienced a live birth, with outcome measures available through 31 December 2014. We used a difference in differences approach with multivariable negative binomial models and generalized estimating equations (GEE) to assess the impact of EPM on the aforementioned health care utilization indicators. PRINCIPAL FINDINGS: EPM was associated with a short-term increase in visits to, and costs associated with, certain ambulatory care providers. These findings were driven in large part by increased visits/costs to FPs (rate difference [RD]: $19.92 [95% CI: $16.33, $23.51]) and obstetrician-gynecologists (OB-GYNs) (RD $9.41 [95% CI: $8.42, $10.40]) in the year immediately following the loss, excluding care associated with the loss itself. We also detected an increase in hospital stays and costs and a decrease in the use of psychotropic medications relative to matched controls. CONCLUSION: Pregnancy loss may lead to subsequent increases in certain types of health care utilization. While the absolute costs associated with post-EPM care are relatively small, the observed patterns of service utilization are informative for providers and policy makers seeking to support women following a loss.

Assessment of mismatch repair deficiency in ovarian cancer.

BACKGROUND: Hereditary causes of ovarian cancer include Lynch syndrome, which is due to inherited pathogenic variants affecting one of the four mismatch repair genes involved in DNA repair. The aim of this study was to evaluate tumour mismatch repair deficiency and prevalence of Lynch syndrome in high-risk women referred to the Manchester Centre for Genomic Medicine with ovarian cancer over the past 20 years. METHODS: Women with ovarian cancer diagnosed before the age of 35 years and/or with a suggestive personal or family history of Lynch syndrome cancers underwent tumour testing with immunohistochemistry for mismatch repair deficiency and, where indicated, MLH1 promoter methylation testing followed by constitutional testing for Lynch syndrome. RESULTS: In total, 261 ovarian cancers were tested and 27 (10.3%; 95% CI 6.9% to 14.7%) showed mismatch repair deficiency by immunohistochemistry. Three of 7 with MLH1 loss showed MLH1 promoter hypermethylation, and 18 of the remaining 24 underwent constitutional testing for Lynch syndrome. A further 15 women with mismatch repair proficient tumours underwent constitutional testing because of a strong family history of Lynch syndrome cancers. Pathogenic variants were identified in 9/33 (27%) women who underwent constitutional testing, aged 33-59 years (median 48 years), including one whose tumour was mismatch repair proficient. Most Lynch syndrome tumours were of endometrioid histological subtype. CONCLUSIONS: Tumour mismatch repair deficiency identified by immunohistochemistry is a useful prescreen for constitutional testing in women with ovarian cancer with personal or family histories suggestive of Lynch syndrome.

A Novel Emergency Telepsychiatry Program in a Canadian Urban Setting: Identifying and Addressing Perceived Barriers for Successful Implementation: Un nouveau programme de télépsychiatrie d'urgence en milieu urbain canadien: Identifier et aborder les obstacles perçus d'une mise en œuvre réussie.

OBJECTIVES: To report on the perceived barriers surrounding the use of telepsychiatry for emergency assessments and our approach to overcoming those barriers to achieve successful implementation of a program to increase access to emergency psychiatric assessment in a Canadian urban setting. METHODS: We conducted a survey of emergency care staff to inform the implementation of an emergency telepsychiatry program in the urban setting of Winnipeg, Manitoba, where hospitals have variable on-site emergency psychiatric coverage. We analyzed survey responses for perceived barriers we would need to address in implementation. We employed implementation strategies for each barrier and scaled the program to three sites over the first year. Data from the first year were collected including number of telepsychiatry assessments, reasons for referral, wait time, and percentage of patient transfers avoided. RESULTS: Survey respondents (N = 111) had little prior exposure to telepsychiatry, but the majority were open to its use for emergency psychiatric assessments in the region. We identified three categories of perceived barriers: clinical, logistical/technical, and readiness barriers. Implementation planning addressed each barrier, and a hub-and-spoke program was launched. After the first year, the program had one hub serving three spokes, and 243 emergency telepsychiatry assessments had been completed. After 12 months, we were avoiding 65% of patient transfers. CONCLUSIONS: By conducting a user survey to identify perceived barriers, and addressing these during implementation, we successfully scaled our emergency telepsychiatry program across our region. Our report of this experience may benefit others attempting to implement a similar program.

Evaluation of a Suicide Risk Assessment Tool in a Large Sample of Detained Youth.

OBJECTIVES: We evaluated the six-item Inmate Security Assessment (ISA) tool used among detained youth in Manitoba, Canada. METHOD: Two hundred and forty-one recorded self-harm incidents among all incarcerated youth occurred between January 1, 2005 and December 31, 2010 (N=5102). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) for three categories of suicide risk (high, medium, and low) as well as each of the six suicide risk evaluation indicators were determined. Receiver operating characteristic (ROC) curves and area under the curve (AUC) calculations for the three suicide risk levels and the six indicators were created. RESULTS: Having at least a low suicide risk level (93.8%) or at least one suicide risk factor (94.6%) provided high sensitivity. Specificity was high if an individual had at least a medium suicide risk level (94.2%) or at least three suicide risk indicators (96.7%). The PPV was low (8.9-16.2%) and the NPV was high (94.9-99.3%) for all suicide risk levels. The most sensitive risk factor for self-harm was a prior history of suicidal behavior or a family history of suicide (94.6%). All risk indicators had a low PPV (7.4-23.1%) and a high NPV (95.4-99.5%). A very low NLR was found for those without prior suicidal behavior or a family history of suicide (0.107). The AUC was 0.719 (95%CI = 0.692-0.746), indicating a fair test. CONCLUSION: The ISA is a moderately accurate tool for identifying risk for self-harm in detained youth.

OBJECTIFS: Nous avons évalué l'instrument en 6 items évaluant la sécurité des détenus (ESD) en usage chez les adolescents détenus au Manitoba, Canada. MÉTHODE: Deux cent quarante et un incidents d'automutilation enregistrés parmi les adolescents incarcérés ont eu lieu entre le 1er janvier 2005 et le 31 décembre 2010 (N = 5102). La sensibilité, la spécificité, la valeur prédictive positive (VPP), la valeur prédictive négative (VPN), le rapport de vraisemblance positif (RVP) et le rapport de vraisemblance négatif (RVN) pour trois catégories de risque de suicide (élevé, moyen et faible) de même que chacun des six indicateurs de l'évaluation du risque de suicide ont été déterminés. Les calculs des courbes caractéristiques du fonctionnement du receveur (ROC) et de la zone située sous la courbe (ZSC) ont été créés pour les trois niveaux de risque de suicide et les six indicateurs. RÉSULTATS: Avoir au moins un faible niveau de risque de suicide (93,8 %) ou au moins un facteur de risque de suicide (94,6 %) procurait une sensibilité élevée. La spécificité était élevée si une personne avait au moins un niveau moyen de risque de suicide (94,2 %) ou au moins trois indicateurs de risque de suicide (96,7 %). La VPP était faible (8,9­16,2 %) et la VPN était élevée (94,9­99,3 %) pour tous les niveaux de risque de suicide. Le facteur de risque le plus sensible pour l'automutilation était des antécédents de comportement suicidaire ou des antécédents de suicide familiaux (94,6 %). Tous les indicateurs de risque avaient une faible VPP (7,4­23,1 %) et une VPN élevée (95,4­99,5 %). Un RVN très faible a été constaté chez ceux n'ayant pas de comportement suicidaire antérieur ni des antécédents de suicide familiaux (0,107). La ZSC était de 0,719 (IC à 95 % 0,692 à 0,746), indiquant un bon test. CONCLUSION: L'ISA est un instrument modérément exact pour identifier le risque d'automutilation chez les adolescents détenus.

Predicting Future Suicide: Clinician Opinion versus a Standardized Assessment Tool.

OBJECTIVE: To compare the effectiveness of clinician prediction of risk to a standardized assessment of presentation status. METHODS: All adult psychiatry emergency department consults in the two main hospitals in Winnipeg, Canada, were assessed using a standardized form (n = 5,376). This form includes two risk scales for a gestalt physician assessment of risk (Suicide Likelihood scale, suicide Attempt Likelihood scale) and the Columbia Classification Algorithm of Suicide Assessment (C-CASA). Regression determined whether assessments predicted future suicide attempts and deaths. The area under the curve (AUC) determined the prediction accuracy of these methods. RESULTS: Although the regression results were significant, the AUCs were either moderate or poor. Clinician assessment was not effective at predicting deaths (AUC = .546, .36-.73), but moderately accurate at predicting future attempts (AUC = .728, .66-.79). C-CASA assessment was moderately accurate at predicting both attempts and deaths (AUC = .666 and .678). CONCLUSIONS: Clinician assessment does not significantly outperform a simple assessment of the occurrence of suicidal thoughts and behaviors during presentation to the emergency department. Behavior-based standardized assessments should be further researched in this field. Assessment of suicidality at presentation using C-CASA or similar assessment should be standard for psychiatric patients assessed in the emergency department.

Increased Burden of Psychiatric Disorders in Rheumatoid Arthritis.

OBJECTIVE: We estimated the incidence and prevalence of depression, anxiety disorder, bipolar disorder, and schizophrenia in a population-based cohort with rheumatoid arthritis (RA) as compared to an age-, sex-, and geographically matched cohort without RA. METHODS: Using population-based administrative health data from Manitoba, Canada, we identified persons with incident RA between 1989 and 2012, and a cohort from the general population matched 5:1 on year of birth, sex, and region of residence. We applied validated algorithms for depression, anxiety disorder, bipolar disorder, and schizophrenia to determine the annual incidence of these conditions after the diagnosis of RA, and their lifetime and annual period prevalence. We compared findings between cohorts using negative binomial regression models. RESULTS: We identified 10,206 incident cases of RA and 50,960 matched individuals. After adjustment for age, sex, socioeconomic status, region of residence, number of physician visits, and year, the incidence of depression was higher in the RA cohort over the study period (incidence rate ratio [IRR] 1.46 [95% confidence interval (95% CI) 1.35-1.58]), as was the incidence of anxiety disorder (IRR 1.24 [95% CI 1.15-1.34]) and bipolar disorder (IRR 1.21 [95% CI 1.00-1.47]). The incidence of schizophrenia did not differ between groups (IRR 0.96 [95% CI 0.61-1.50]). Incidence rates of psychiatric disorders declined minimally over time. The lifetime and annual period prevalence of depression and anxiety disorder were also higher in the RA than in the matched cohort over the study period. CONCLUSION: The incidence and prevalence of depression, anxiety disorder, and bipolar disorder are elevated in the RA population as compared to a matched population.

Experimental Assessment of Photon Fluence Rate Distributions in a Medium-Pressure UV Photoreactor.

The performance of a medium-pressure (MP) mercury lamp photoreactor is strongly influenced by the spatial photon fluence rate (PFR) distributions which are wavelength-dependent. To address this issue, PFR distributions in an MP lamp photoreactor were measured using a 360-degree response microfluorescent silica detector (MFSD). To accurately express the optical behavior in an MP photoreactor, PFR, MFSD response PFR (PFRMFSD), and effective germicidal PFR (PFRGER) were defined and compared. The measured axial and radial PFRMFSD values agreed well with the corresponding results from a simulation model (UVCalc). The PFR and PFRGER were obtained from the measured PFRMFSD by using correction factors calculated by the UVCalc. Under identical UV transmittance (254 nm) conditions (75% and 85%), the weighted average PFRGER values were 13.3-18.7% lower than the corresponding PFR values, indicating that PFRGER, rather than PFR should be used in MP photoreactor design to meet disinfection standards. Based on measured lamp output, medium absorption spectrum, MFSD response, and microbial DNA response spectrum, the detailed relationships between the PFR, PFRMFSD, and PFRGER were elucidated. This work proposes a new method for the accurate description of wavelength-dependent PFR distributions in MP photoreactors, thus providing an important tool for the optimal design of these systems.

Emergency department and inpatient coding for self-harm and suicide attempts: Validation using clinician assessment data.

Administrative data have been used to determine the occurrence of suicide attempts and deliberate self-harm, but research about the accuracy of these sources is limited. This study used a clinical sample (n = 5719) containing psychiatry consultations from the emergency departments and inpatient units of the two major tertiary hospitals in Winnipeg, Canada to validate the accuracy of inpatient hospital diagnosis codes at identifying presentations for self-harm and suicide attempts. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) was used as the gold standard. International Classification of Diseases version 10 Canadian Enhancement codes for intentional self-harm, undetermined intent self-harm, and accidental poisoning were assessed. Measures of validity included Kappa (κ), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Sensitivity of hospitalized attempts was low using intentional intent codes (36.9%, 95% confidence interval [CI]: 32.4-41.4%) but improved using unknown intent and accidental poisoning codes (44.8%, 95% CI: 40.2-49.4%). Agreement for suicide attempts did not increase with the addition of unknown intent and accidental poisoning codes (κ = 0.465-0.481), but were better for any self-harm (κ = 0.395-0.478). Hospital diagnosis codes undercount attempts and self-harm admissions. Including more data sources might improve the detection of events.

VUV/UV/Chlorine as an Enhanced Advanced Oxidation Process for Organic Pollutant Removal from Water: Assessment with a Novel Mini-Fluidic VUV/UV Photoreaction System (MVPS).

Vacuum ultraviolet (VUV) and ultraviolet (UV)/chlorine processes are regarded as two of many advanced oxidation processes (AOPs). Because of the similar cost of VUV/UV and UV lamps, a combination of VUV and UV/chlorine (i.e., VUV/UV/chlorine) may enhance the removal of organic pollutants in water but without any additional power input. In this paper, a mini-fluidic VUV/UV photoreaction system (MVPS) was developed for bench-scale experiments, which could emit both VUV (185 nm) and UV (254 nm) or solely UV beams with a nearly identical UV photon fluence. The photon fluence rates of UV and VUV output by the MVPS were determined to be 8.88 × 10(-4) and 4.93 × 10(-5) einstein m(-2) s(-1), respectively. The VUV/UV/chlorine process exhibited a strong enhancement concerning the degradation of methylene blue (MB, a model organic pollutant) as compared to the total performance of the VUV/UV and UV/chlorine processes, although the photon fluence of the VUV only accounted for 5.6% of that of the UV. An acidic pH favored MB degradation by the VUV/UV/chlorine process. The synergistic mechanism of the VUV/UV/chlorine process was mainly ascribed to the effective use of (•)OH for pollutant removal through formation of longer-lived secondary radicals (e.g., (•)OCl). This study demonstrates that the new VUV/UV/chlorine process, as an enhanced AOP, can be applied as a highly effective and energy-saving technology for small-scale water and wastewater treatment.

Baseline Insurance Status and Risk of Common Mental Disorders: A Propensity-Based Analysis of a Longitudinal U.S. Sample.

OBJECTIVE: Because of pervasive poor general medical and mental health status among patients receiving Medicaid, there has been substantial debate about whether Medicaid, as currently financed and delivered, is better than no insurance. The study aimed to address whether insurance status is associated with the subsequent incidence and persistence of common mental disorders. METHODS: Data came from a nationally representative U.S. population-based longitudinal survey that assessed mental disorders at two time points three years apart. Propensity score methods were used to adjust for potential confounding and to assess the association between three mutually exclusive insurance status groups (no insurance, private insurance only, and Medicaid only) and the subsequent incidence and persistence of mood, anxiety, and substance use disorders for persons ages 18-65 (N=26,410). RESULTS: Compared with private insurance, lack of insurance was associated with higher odds of both the incidence and persistence of substance use disorders and with higher odds of persistence of any mood or anxiety disorder. Compared with having private insurance, having Medicaid insurance was associated with increased odds of persistent mood and anxiety disorders during follow-up. Overall, findings did not significantly differ between the uninsured and Medicaid groups. CONCLUSIONS: The findings do not support prior reports that U.S. adults with Medicaid have worse mental health outcomes than uninsured adults. Lacking insurance may put individuals at higher risk of developing substance use disorders, and uninsured individuals with preexisting mental conditions were more likely to have mood, anxiety, and substance use problems that persist over time.

Suicide risk assessment and intervention in people with mental illness.

Suicide is the 15th most common cause of death worldwide. Although relatively uncommon in the general population, suicide rates are much higher in people with mental health problems. Clinicians often have to assess and manage suicide risk. Risk assessment is challenging for several reasons, not least because conventional approaches to risk assessment rely on patient self reporting and suicidal patients may wish to conceal their plans. Accurate methods of predicting suicide therefore remain elusive and are actively being studied. Novel approaches to risk assessment have shown promise, including empirically derived tools and implicit association tests. Service provision for suicidal patients is often substandard, particularly at times of highest need, such as after discharge from hospital or the emergency department. Although several drug based and psychotherapy based treatments exist, the best approaches to reducing the risk of suicide are still unclear. Some of the most compelling evidence supports long established treatments such as lithium and cognitive behavioral therapy. Emerging options include ketamine and internet based psychotherapies. This review summarizes the current science in suicide risk assessment and provides an overview of the interventions shown to reduce the risk of suicide, with a focus on the clinical management of people with mental disorders.

The effect of neighborhood socioeconomic status on education and health outcomes for children living in social housing.

OBJECTIVES: We explored differences in health and education outcomes between children living in social housing and not, and effects of social housing's neighborhood socioeconomic status. METHODS: In this cohort study, we used the population-based repository of administrative data at the Manitoba Centre for Health Policy. We included children aged 0 to 19 years in Winnipeg, Manitoba, in fiscal years 2006-2007 to 2008-2009 (n = 13,238 social housing; n = 174,017 others). We examined 5 outcomes: age-2 complete immunization, a school-readiness measure, adolescent pregnancy (ages 15-19 years), grade-9 completion, and high-school completion. Logistic regression and generalized estimating equation modeling generated rates. We derived neighborhood income quintiles (Q1 lowest, Q5 highest) from average household income census data. RESULTS: Children in social housing fared worse than comparative children within each neighborhood income quintile. When we compared children in social housing by quintile, preschool indicators (immunization and school readiness) were similar, but adolescent outcomes (grade-9 and high-school completion, adolescent pregnancy) were better in Q3 to Q5. CONCLUSIONS: Children in social housing had poorer health and education outcomes than all others, but living in social housing in wealthier areas was associated with better adolescent outcomes.

The SAD PERSONS scale for suicide risk assessment: a systematic review.

The SAD PERSONS scale (SPS) is widely used for suicide risk assessment in clinical and educational settings. The study objective was to systematically review the SPS performance in clinical situations. A systematic search of electronic databases was conducted. Relevant descriptive, quality, and outcome data were reviewed. In the search, 149 studies were identified and 9 met inclusion criteria. Included studies were highly variable across outcome measures, populations, and assessment methods. Only 3 studies examined SPS performance in predicting suicide outcomes; none showed the scale accurately predicted suicidal behavior. Available literature is of limited quality and quantity. Insufficient evidence exists to support SPS use in assessment or prediction of suicidal behavior. Well-designed studies that address the observed limitations are required.

A prospective assessment of reports of drinking to self-medicate mood symptoms with the incidence and persistence of alcohol dependence.

IMPORTANCE: Mood disorders and alcohol dependence frequently co-occur. Etiologic theories concerning the comorbidity often focus on drinking to self-medicate or cope with affective symptoms. However, there have been few, if any, prospective studies in population-based samples of alcohol self-medication of mood symptoms with the occurrence of alcohol dependence. Furthermore, it is not known whether these associations are affected by treatment or symptom severity. OBJECTIVE: To evaluate the hypothesis that alcohol self-medication of mood symptoms increases the probability of subsequent onset and the persistence or chronicity of alcohol dependence. DESIGN: Prospective study using face-to-face interviews-the National Epidemiologic Survey on Alcohol and Related Conditions. SETTING: Nationally representative survey of the US population. PARTICIPANTS: Drinkers at risk for alcohol dependence among the 43 093 adults surveyed in 2001 and 2002 (wave 1); 34 653 of whom were reinterviewed in 2004 and 2005 (wave 2). MAIN OUTCOMES AND MEASURES: Association of alcohol self-medication of mood symptoms with incident and persistent DSM-IV alcohol dependence using logistic regression and the propensity score method of inverse probability of treatment weighting. RESULTS: The report of alcohol self-medication of mood symptoms was associated with an increased odds of incident alcohol dependence at follow-up (adjusted odds ratio [AOR], 3.10; 95% CI, 1.55-6.19; P = .002) and persistence of dependence (AOR, 3.45; 95% CI, 2.35-5.08; P < .001). The population-attributable fraction was 11.9% (95% CI, 6.7%-16.9%) for incident dependence and 30.6% (95% CI, 24.8%-36.0%) for persistent dependence. Stratified analyses were conducted by age, sex, race/ethnicity, mood symptom severity, and treatment history for mood symptoms. CONCLUSIONS AND RELEVANCE: Drinking to alleviate mood symptoms is associated with the development of alcohol dependence and its persistence once dependence develops. These associations occur among individuals with subthreshold mood symptoms, with DSM-IV affective disorders, and for those who have received treatment. Drinking to self-medicate mood symptoms may be a potential target for prevention and early intervention efforts aimed at reducing the occurrence of alcohol dependence.

Reports of drinking to self-medicate anxiety symptoms: longitudinal assessment for subgroups of individuals with alcohol dependence.

BACKGROUND: Self-medication with alcohol is frequently hypothesized to explain anxiety and alcohol dependence comorbidity. Yet, there is relatively little assessment of drinking to self-medicate anxiety and its association with the occurrence or persistence of alcohol dependence in population-based longitudinal samples, or associations within demographic and clinical subgroups. METHODS: Hypothesizing that self-medication of anxiety with alcohol is associated with the subsequent occurrence and persistence of alcohol dependence, we assessed these associations using data from the National Epidemiologic Survey on Alcohol and Related Conditions, and examined these associations within population subgroups. This nationally representative survey of the US population included 43,093 adults surveyed in 2001-2002, and 34,653 reinterviewed in 2004-2005. Logistic regression incorporating propensity score methods was used. RESULTS: Reports of drinking to self-medicate anxiety was associated with the subsequent occurrence (adjusted odds ratio (AOR) = 5.71, 95% confidence interval (CI) = 3.56-9.18, P < .001) and persistence (AOR = 6.25, CI = 3.24-12.05, P < .001) of alcohol dependence. The estimated proportions of the dependence cases attributable to self-medication drinking were 12.7 and 33.4% for incident and persistent dependence, respectively. Stratified analyses by age, sex, race-ethnicity, anxiety disorders and subthreshold anxiety symptoms, quantity of alcohol consumption, history of treatment, and family history of alcoholism showed few subgroup differences. CONCLUSIONS: Individuals who report drinking to self-medicate anxiety are more likely to develop alcohol dependence, and the dependence is more likely to persist. There is little evidence for interaction by the population subgroups assessed. Self-medication drinking may be a useful target for prevention and intervention efforts aimed at reducing the occurrence of alcohol dependence.