Food Insecurity, Adolescent Suicidal Thoughts and Behaviors, and Country-Level Context: A Multi-Country Cross-Sectional Analysis.

PURPOSE: Preventing adolescent suicide is a global priority. Inequalities in adolescent suicide and attempt rates are reported across countries, including a greater risk in adolescents experiencing food insecurity. Little is known about the extent to which country-level contextual factors moderate the magnitude of socio-economic inequalities in suicidal thoughts and behavior. We aimed to examine the cross-country variability and national moderators of the association between food insecurity and suicidal thoughts and behavior in school-attending adolescents. METHODS: We analysed data on 309,340 school-attending adolescents from 83 countries that participated in the Global School-based Student Health Survey between 2003 and 2018. We used Poisson regression to identify whether suicidal thoughts and behavior were more prevalent in adolescents experiencing food insecurity compared to food-secure adolescents. Meta-regression and mixed-effects regression were used to determine whether country-level indicators moderated the magnitude of inequality. RESULTS: Suicidal ideation, suicide planning, and suicide attempts were more prevalent in food-insecure adolescents compared to food-secure adolescents in 72%, 78%, and 90% of countries respectively; however, the magnitude of these associations varied between countries. We observed wider inequalities in countries with greater levels of national wealth and universal health coverage and lower prevalence of adolescent food insecurity. Economic inequality had no moderating role. DISCUSSION: Food insecurity could contribute to the development of adolescent suicidal thoughts and behavior, and this association is likely to be moderated by country-level context. Food insecurity may be a modifiable target to help prevent adolescent suicide, especially in countries where food insecurity is less common.

Antidepressant medication to prevent depression relapse in primary care: the ANTLER RCT.

BACKGROUND: There has been a steady increase in the number of primary care patients receiving long-term maintenance antidepressant treatment, despite limited evidence of a benefit of this treatment beyond 8 months. OBJECTIVE: The ANTidepressants to prevent reLapse in dEpRession (ANTLER) trial investigated the clinical effectiveness and cost-effectiveness of antidepressant medication in preventing relapse in UK primary care. DESIGN: This was a Phase IV, double-blind, pragmatic, multisite, individually randomised parallel-group controlled trial, with follow-up at 6, 12, 26, 39 and 52 weeks. Participants were randomised using minimisation on centre, type of antidepressant and baseline depressive symptom score above or below the median using Clinical Interview Schedule - Revised (two categories). Statisticians were blind to allocation for the outcome analyses. SETTING: General practices in London, Bristol, Southampton and York. PARTICIPANTS: Individuals aged 18-74 years who had experienced at least two episodes of depression and had been taking antidepressants for ≥ 9 months but felt well enough to consider stopping their medication. Those who met an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of depression or with other psychiatric conditions were excluded. INTERVENTION: At baseline, participants were taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg. They were randomised to either remain on their current medication or discontinue medication after a tapering period. MAIN OUTCOME MEASURES: The primary outcome was the time, in weeks, to the beginning of the first depressive episode after randomisation. This was measured by a retrospective Clinical Interview Schedule - Revised that assessed the onset of a depressive episode in the previous 12 weeks, and was conducted at 12, 26, 39 and 52 weeks. The depression-related resource use was collected over 12 months from medical records and patient-completed questionnaires. Quality-adjusted life-years were calculated using the EuroQol-5 Dimensions, five-level version. RESULTS: Between 9 March 2017 and 1 March 2019, we randomised 238 participants to antidepressant continuation (the maintenance group) and 240 participants to antidepressant discontinuation (the discontinuation group). The time to relapse of depression was shorter in the discontinuation group, with a hazard ratio of 2.06 (95% confidence interval 1.56 to 2.70; p < 0.0001). By 52 weeks, relapse was experienced by 39% of those who continued antidepressants and 56% of those who discontinued antidepressants. The secondary analysis revealed that people who discontinued experienced more withdrawal symptoms than those who remained on medication, with the largest difference at 12 weeks. In the discontinuation group, 37% (95% confidence interval 28% to 45%) of participants remained on their randomised medication until the end of the trial. In total, 39% (95% confidence interval 32% to 45%) of participants in the discontinuation group returned to their original antidepressant compared with 20% (95% confidence interval 15% to 25%) of participants in maintenance group. The health economic evaluation demonstrated that participants randomised to discontinuation had worse utility scores at 3 months (-0.037, 95% confidence interval -0.059 to -0.015) and fewer quality-adjusted life-years over 12 months (-0.019, 95% confidence interval -0.035 to -0.003) than those randomised to continuation. The discontinuation pathway, besides giving worse outcomes, also cost more [extra £2.71 per patient over 12 months (95% confidence interval -£36.10 to £37.07)] than the continuation pathway, although the cost difference was not significant. CONCLUSIONS: Patients who discontinue long-term maintenance antidepressants in primary care are at increased risk of relapse and withdrawal symptoms. However, a substantial proportion of patients can discontinue antidepressants without relapse. Our findings will give patients and clinicians an estimate of the likely benefits and harms of stopping long-term maintenance antidepressants and improve shared decision-making. The participants may not have been representative of all people on long-term maintenance treatment and we could study only a restricted range of antidepressants and doses. Identifying patients who will not relapse if they discontinued antidepressants would be clinically important. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15969819 and EudraCT 2015-004210-26. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 69. See the NIHR Journals Library website for further project information.

Antidepressants are used to treat depression when someone is unwell, but are also used as maintenance treatment to prevent the reoccurrence of depression. There has been a large increase in the use of long-term maintenance antidepressant treatment, but the evidence for the benefits of maintenance beyond 8 months is very poor. The ANTidepressants to prevent reLapse in dEpRession (ANTLER) trial was a randomised controlled trial that examined the effectiveness of long-term maintenance treatment with antidepressants. The participants were well enough to consider stopping antidepressant medication, were recruited from primary care and had taken antidepressants for ≥ 9 months. In total, 238 participants were randomised to continue taking antidepressants and 240 were randomised to receive a visually identical tablet that contained no active ingredients after a period when the antidepressants were gradually reduced. Neither the participants nor those interviewing them knew which group they had been placed in, and they were followed up for 1 year. Participants who discontinued antidepressants were more likely to experience relapse than those who continued antidepressants. By 52 weeks, 39% of those who continued antidepressants had experienced a relapse, compared with 56% in the group that discontinued antidepressants. In other words, over a 52-week period, one in every six patients who stopped antidepressants would experience a relapse that may not have occurred if they had remained on their antidepressants. Patients in the discontinuation group reported more symptoms of anxiety and depression and experienced more withdrawal symptoms than those in the maintenance group, mostly in the first 3­4 months after stopping the antidepressants. Participants in the discontinuation group also reported lower quality of life than those in the maintenance group but both groups used similar amounts of health-care and social care resources over the 12-month period. About one-third of participants who were allocated to the discontinuation group in the ANTLER trial decided to restart their antidepressants. However, another one-third of participants in that group remained on trial medication for 12 months and managed without antidepressants. Long-term maintenance treatment with antidepressants is effective in reducing the rate of relapses. For those who are considering stopping their antidepressant, our findings will provide estimates of the likely benefits and harms, to improve shared decision-making and support the regular review of long-term antidepressant prescription.

The mental health of lesbian, gay, and bisexual adults compared with heterosexual adults: results of two nationally representative English household probability samples.

BACKGROUND: Evidence on inequalities in mental health in lesbian, gay, and bisexual people arises primarily from non-random samples. AIMS: To use a probability sample to study change in mental health inequalities between two survey points, 7 years apart; the contribution of minority stress; and whether associations vary by age, gender, childhood sexual abuse, and religious identification. METHODS: We analysed data from 10 443 people, in two English population-based surveys (2007 and 2014), on common mental disorder (CMD), hazardous alcohol use, and illicit drug use. Multivariable models were adjusted for age, gender, and economic factors, adding interaction terms for survey year, age, gender, childhood sexual abuse, and religious identification. We explored bullying and discrimination as mediators. RESULTS: Inequalities in risks of CMD or substance misuse were unchanged between 2007 and 2014. Compared to heterosexuals, bisexual, and lesbian/gay people were more likely to have CMD, particularly bisexual people [adjusted odds ratio (AOR) = 2.86; 95% CI 1.83-4.46], and to report alcohol misuse and illicit drug use. When adjusted for bullying, odds of CMD remained elevated only for bisexual people (AOR = 3.21; 95% CI 1.64-6.30), whilst odds of alcohol and drug misuse were unchanged. When adjusted for discrimination, odds of CMD and alcohol misuse remained elevated only for bisexual people (AOR = 2.91; 95% CI 1.80-4.72; and AOR = 1.63; 95% CI 1.03-2.57 respectively), whilst odds of illicit drug use remained unchanged. There were no interactions with age, gender, childhood sexual abuse, or religious identification. CONCLUSIONS: Mental health inequalities in non-heterosexuals have not narrowed, despite increasing societal acceptance. Bullying and discrimination may help explain the elevated rate of CMD in lesbian women and gay men but not in bisexual people.

Social relationships and depression during the COVID-19 lockdown: longitudinal analysis of the COVID-19 Social Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic led to measures that reduced social contact and support. We explored whether UK residents with more frequent or supportive social contact had fewer depressive symptoms during March-August 2020, and potential factors moderating the relationship. METHODS: A convenience sample of UK dwelling participants aged ⩾18 in the internet-based longitudinal COVID-19 Social Study completed up to 22 weekly questionnaires about face-to-face and phone/video social contact frequency, perceived social support, and depressive symptoms using the PHQ-9. Mixed linear models examined associations between social contact and support, and depressive symptoms. We examined for interaction by empathic concern, perspective taking and pre-COVID social contact frequency. RESULTS: In 71 117 people with mean age 49 years (standard deviation 15), those with high perceived social support scored 1.836 (1.801-1.871) points lower on PHQ-9 than those with low support. Daily face-to-face or phone/video contact was associated with lower depressive symptoms (0.258 (95% confidence interval 0.225-0.290) and 0.117 (0.080-0.154), respectively) compared to no contact. The negative association between social relationships and depressive symptoms was stronger for those with high empathic concern, perspective taking and usual sociability. CONCLUSIONS: We found during lockdown that those with higher quality or more face-to-face or phone/video contact had fewer depressive symptoms. Contact quality was more strongly associated than quantity. People who were usually more sociable or had higher empathy had more depressive symptoms during enforced reduced contact. The results have implications for COVID-19 and potential future pandemic management, and for understanding the relationship between social factors and mental health.

Assessment of the Role of IQ in Associations Between Population Density and Deprivation and Nonaffective Psychosis.

Importance: Being born or raised in more densely populated or deprived areas is associated with increased risk of nonaffective psychosis in adulthood, but few studies to date have examined the role of general cognitive ability in these associations. Objective: To investigate whether lower IQ contributed to the association between population density or deprivation and nonaffective psychosis (mediation) and whether these associations were stronger in people with lower IQ (effect modification). Design, Setting, and Participants: This prospective cohort study evaluated a population-based sample of men born in Sweden from January 1, 1982, to December 31, 1988, and conscripted into military service at 18 years of age. Data were collected from January 1, 1982, to December 31, 2016, and analyzed from May 1 to December 31, 2018. Exposures: Continuous measures of small area-level population density (persons per square kilometer) and socioeconomic deprivation at birth. Deprivation was based on area-level social, criminal, and unemployment data. IQ was assessed during conscription at 18 years of age (mean [SD] IQ, 100 [15]). Main Outcomes and Measures: First diagnosis of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, nonaffective psychosis from 18 years of age until December 31, 2016, recorded in the National Patient Register. Results: The study sample included a total of 227 429 men who were classified as at risk of psychosis from 18 years of age until the end of follow-up. Of these, 1596 men (0.7%) were diagnosed with nonaffective psychosis. After adjustments for confounders, odds of nonaffective psychosis increased per 1-SD increase in population density (odds ratio [OR], 1.07; 95% CI, 1.04-1.14) and deprivation (OR, 1.09; 95% CI, 1.02-1.13) at birth. IQ was negatively associated with deprivation after adjustments (effect estimate per 1-SD increase in deprivation: -0.70 points; 95% CI, -0.78 to -0.62 points) but not with population density. In mediation analyses, based on the potential outcome framework, 23% (95% CI, 17%-49%) of the total effect of deprivation on nonaffective psychosis was mediated by IQ. IQ did not modify associations between deprivation or population density and nonaffective psychosis. Conclusions and Relevance: These findings suggest that being born in more deprived neighborhoods may partly increase risk of nonaffective psychosis through subsequent effects on cognitive development, consistent with the wider literature on neurodevelopmental delays associated with psychotic disorder. Identifying factors in deprived environments that give rise to this process could inform public health strategies to prevent nonaffective psychosis.

A randomised controlled trial assessing the use of citalopram, sertraline, fluoxetine and mirtazapine in preventing relapse in primary care patients who are taking long-term maintenance antidepressants (ANTLER: ANTidepressants to prevent reLapse in dEpRession): study protocol for a randomised controlled trial.

BACKGROUND: Antidepressants are used both for treating acute episodes and for prophylaxis to prevent future episodes of depression, also called maintenance treatment. This article describes the protocol for a randomised controlled trial (ANTLER: ANTidepressants to prevent reLapse in dEpRession) to investigate the clinical effectiveness and cost-effectiveness in UK primary care of continuing on long-term maintenance antidepressants compared with a placebo in preventing relapse of depression in those who have taken antidepressants for more than 9 months and who are currently well enough to consider stopping maintenance treatment. METHODS/DESIGN: The ANTLER trial is an individually randomised, double-blind, placebo-controlled trial in which participants are randomised to remain on active medication or to take an identical placebo after a tapering period of 2 months. Eligible participants are those who: are between the ages of 18 and 74 years; have had at least two episodes of depression; and have been taking antidepressants for 9 months or more and are currently taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg but are well enough to consider stopping their medication. The participants will be followed up at 6, 12, 26, 39 and 52 weeks. The primary outcome will be the time in weeks to the beginning of the first episode of depression after randomisation. This will be measured using a retrospective version of the Clinical Interview Schedule-Revised administered at 12, 26, 39 and 52 weeks. Secondary outcomes will include depressive and anxiety symptoms, adverse effects, withdrawal symptoms, emotional processing tasks, quality of life and the resources and costs used. We will also perform a cost-effectiveness analysis based on results of the trial. DISCUSSION: The ANTLER trial findings will inform primary care prescribing practice by providing a valid and generalisable estimate of the clinical effectiveness and cost-effectiveness of long-term maintenance treatment with antidepressants in UK primary care. TRIAL REGISTRATION: Controlled Trials ISRCTN Registry, ISRCTN15969819. Registered on 21 September 2015.