Childhood Factors Associated With Unnatural Death Through Midadulthood.

Importance: Life expectancy is decreasing in the US. Without national efforts to address factors that support policies and programs directed at children living in areas of concentrated poverty, life expectancy will likely continue to decline while costs and suffering associated with unnatural deaths will increase. Objective: To identify which childhood factors are associated with death from unnatural causes through midadulthood. Design, Setting, and Participants: For this cohort study, longitudinal data on childhood characteristics came from a group-randomized intervention trial implemented in Baltimore City Public Schools, Baltimore, Maryland (baseline 1985-1986; all students entering first grade were selected to participate at age 6 years). Participants were followed up to midadulthood with a National Death Index search through December 31, 2020. Data analysis was performed from February to May 2023. Exposures: Exposures included individual factors (ie, sociodemographic characteristics, teacher-reported aggressive behavior, self-reported depression, anxiety, early alcohol and cannabis use, and assaultive violence exposure), family and peer factors (ie, household structure and education level, deviant peer affiliation, and parental monitoring), and neighborhood factors (ie, rates of neighborhood assault and public assistance). Main Outcomes and Measures: The main outcome was unnatural death, defined as death due to unintentional injury, suicide, and homicide. A National Death Index search ascertained participants who died by age 41 to 42 years and cause of death. Multivariable Cox proportional hazards models were used to identify whether the exposures were independently associated with future mortality by unnatural causes. Results: The initial trial included 2311 children, and longitudinal data were available for 2180 participants (median [IQR] age in first grade, 6.3 [6.0-6.5] years; 1090 female [50.0%]; 1461 Black [67.0%]; 1168 received free or reduced lunch in first grade [53.6%]). A total of 111 male participants (10.2%) and 29 female participants (2.7%) died; among those who died, 96 male participants (86.5%) and 14 female participants (48.3%) died of unnatural causes. Two factors remained significantly associated with mortality from unnatural causes: female sex was associated with reduced risk (hazard ratio, 0.13; 95% CI, 0.08-0.22), and neighborhood public assistance was associated with increased risk (hazard ratio, 1.89; 95% CI, 1.09-3.30). Conclusions and Relevance: In this urban population-based cohort study, no modifiable risk factors of mortality at the level of the individual (eg, depression or anxiety and substance use) or the family (eg, household education level) were identified. However, the degree of neighborhood poverty in early childhood was significantly associated with death by unnatural causes in early adulthood, suggesting that economic policies are needed to advance health equity in relation to premature mortality.

Spirituality moderates the relationship between cancer caregiver burden and depression.

OBJECTIVES: Cancer has become a chronic disease that requires a considerable amount of informal caregiving, often quite burdensome to family caregivers. However, the influence of spirituality on the caregivers' burden and mental health outcomes has been understudied. This study was to examine how caregiver burden, spirituality, and depression change during cancer treatment and investigate the moderating role of spirituality in the relationship between caregiver burden and depression for a sample of caregivers of persons with cancer. METHODS: This secondary analysis used a longitudinal design employing 3 waves of data collection (at baseline, 3 months, and 6 months). Family caregivers completed the Caregiver Reaction Assessment, Spiritual Perspective Scale, and the PROMIS® depression measure. Linear mixed model analyses were used, controlling for pertinent covariates. RESULTS: Spirituality, total caregiver burden, and depression remained stable over 6 months. More than 30% of the caregivers had mild to severe depressive symptoms at 3 time points. There was evidence of overall burden influencing depression. Of note was a protective effect of caregivers' spirituality on the relationship between depression and caregiver burden over time (b = -1.35, p = .015). The lower the spirituality, the stronger the relationship between depression and burden, especially regarding subscales of schedule burden, financial burden, and lack of family support. SIGNIFICANCE OF RESULTS: Spirituality was a significant resource for coping with caregiving challenges. This study suggests that comprehensive screening and spiritual care for cancer caregivers may improve their cancer caregiving experience and possibly influence the care recipients' health.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia.

OBJECTIVES: The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia. DESIGN: A mixed-methods study was performed. SETTING AND PARTICIPANTS: During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica. METHODS: Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ2 tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. RESULTS: Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001). CONCLUSIONS AND IMPLICATIONS: This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Nurse staffing and deficiency of care for inappropriate psychotropic medication use in nursing home residents with dementia.

PURPOSE: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. DESIGN: This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018. METHODS: Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. RESULTS: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26). CONCLUSION: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use. CLINICAL RELEVANCE: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

Variation Across U.S. Assisted Living Facilities: Admissions, Resident Care Needs, and Staffing.

PURPOSE: Though more people in the United States currently reside in assisted living facilities (ALFs) than nursing homes, little is known about ALF admission policies, resident care needs, and staffing characteristics. We therefore conducted this study using a nationwide sample of ALFs to examine these factors, along with comparison of ALFs by size. DESIGN: Cross-sectional secondary data analysis using data from the 2010 National Survey of Residential Care Facilities. METHODS: Measures included nine admission policy items, seven items on the proportion of residents with selected conditions or care needs, and six items on staffing characteristics (e.g., access to licensed nurse, aide training). Facilities (n = 2,301) were divided into three categories by size: small, 4 to 10 beds; medium, 11 to 25 beds; and large, 26 or more beds. Analyses took complex sampling design effects into account to project national U.S. estimates. FINDINGS: More than half of ALFs admitted residents with considerable healthcare needs and served populations that required nursing care, such as for transfers, medications, and eating or dressing. Staffing was largely composed of patient care aides, and fewer than half of ALFs had licensed care provider (registered nurse, licensed practical nurse) hours. Smaller facilities tended to have more inclusive admission policies and residents with more complex care needs (more mobility, eating and medication assistance required, short-term memory issues, p < .01) and less access to licensed nurses than larger ALFs (p < .01). CONCLUSIONS: This study suggests ALFs are caring for and admitting residents with considerable care needs, indicating potential overlap with nursing home populations. Despite this finding, ALF regulations lag far behind those in effect for nursing homes. In addition, measurement of care outcomes is critically needed to ensure appropriate ALF care quality. CLINICAL RELEVANCE: As more people choose ALFs, outcome measures for ALFs, which are now unavailable, should be developed to allow for oversight and monitoring of care quality.

Gambling Disorder and Minority Populations: Prevalence and Risk Factors.

PURPOSE OF REVIEW: Previous studies demonstrate disparities in health and health services including gambling disorders (GD) among ethnic and racial minority groups. In this review, we summarize studies examining the prevalence of GD across different ethnic and racial minorities. RECENT FINDINGS: We describe the sociodemographic subgroup variations at heightened risk for GD and factors associated with GD in racial and ethnic minority groups including gambling availability, comorbid substance use, psychiatric conditions, stress, acculturation, and differences in cultural values and cognitions. We found that research of GD among minority groups is scant, and the prevalence of GD among these groups is at a magnitude of concern. SUMMARY: Racial and ethnic minority status in it of itself is not a risk factor for GD but may be a proxy for underlying potential risk factors. The need for prevention and treatment programs for different cultural group remains unmet.

Transitions in gambling participation during late adolescence and young adulthood.

PURPOSE: The purpose of this study was to examine transitions in gambling participation from late adolescence into emerging adulthood and to identify factors (i.e., gender, race, intervention status, lunch status, conduct disorder, parental monitoring, neighborhood environment, and substance use) that might influence these transitions. METHODS: Markov modeling was used to describe the movement between past-year gambling states (i.e., nongambling and gambling) across 5 years. Annual data on the past-year gambling behavior and substance use were collected from 515 young men and women starting at the age of 17 years. RESULTS: Past-year gambling declined from 51% prevalence at the age of 17 years to 21% prevalence at the age of 22 years. Participants who reported no past-year gambling at a particular annual assessment had more than an 80% probability of also reporting no past-year gambling at the following assessment. Men were 1.07-2.82 times more likely than women to transition from past-year nongambling to gambling year to year, and women were 1.27-5.26 times more likely than men to transition from past-year gambling to nongambling year to year. In addition, gender and past-year tobacco use interacted such that men who used tobacco were most likely (and men who did not use tobacco least likely) to gamble at baseline. CONCLUSIONS: Transition rates between gambling states appear to be relatively stable over time from late adolescence into emerging adulthood; however, men and those who engage in substance use may be at an increased risk of gambling participation.

Association of comorbid generalized anxiety disorder and alcohol use disorder symptoms with health-related quality of life: results from the National Epidemiological Survey on Alcohol and Related Conditions.

BACKGROUND: Although prior studies have documented the co-occurrence of generalized anxiety disorder (GAD) and alcohol use disorder (AUD) disorder, there is a paucity of research assessing the patterns of alcohol involvement among individuals with GAD symptoms. This study investigated subtypes, or classes, of comorbid AUD and GAD symptoms, and assessed the association of class membership with health-related quality of life. METHODS: Using data from the Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions, a latent class analysis was performed on the subset of individuals who were current drinkers and had reported ever experiencing a 6-month episode of feeling tense, nervous, or worried most of the time. We examined the association of these latent classes with physical and mental health-related quality of life measured by the Short Form-12, version 2. RESULTS: Latent class analysis identified a 5-class model of AUD and GAD symptoms. A significant graded relationship was observed between the ordered classes and severity of impairment on the mental health scale of the Short Form-12, version 2, but no significant relationship was found with the physical health scale. CONCLUSIONS: Mental, but not physical, health-related quality of life in this population is associated with both the number and pattern of comorbid GAD and AUD symptoms.

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.

An updated global picture of cigarette smoking persistence among adults.

BACKGROUND: Cross-national variance in smoking prevalence is relatively well documented. The aim of this study is to estimate levels of smoking persistence across 21 countries with a hypothesized inverse relationship between country income level and smoking persistence. METHODS: Data from the World Health Organization World Mental Health Survey Initiative were used to estimate cross-national differences in smoking persistence--the proportion of adults who started to smoke and persisted in smoking by the date of the survey. RESULTS: There is large variation in smoking persistence from 25% (Nigeria) to 85% (China), with a random-effects meta-analytic summary estimate of 55% with considerable cross-national variation. (Cochran's heterogeneity Q statistic = 6845; p < 0.001). Meta-regressions indicated that observed differences are not attributable to differences in country's income level, age distribution of smokers, or how recent the onset of smoking began within each country. CONCLUSION: While smoking should remain an important public health issue in any country where smokers are present, this report identifies several countries with higher levels of smoking persistence (namely, China and India).

Smoking estimates from around the world: data from the first 17 participating countries in the World Mental Health Survey Consortium.

OBJECTIVE: To contribute new multinational findings on basic descriptive features of smoking and cessation, based upon standardised community surveys of adults residing in seven low-income and middle-income countries and 10 higher-income countries from all regions of the world. METHODS: Data were collected using standardised interviews and community probability sample survey methods conducted as part of the WHO World Mental Health Surveys Initiative. Demographic and socioeconomic correlates of smoking are studied using cross-tabulation and logistic regression approaches. Within-country sample weights were applied with variance estimation appropriate for complex sample survey designs. RESULTS: Estimated prevalence of smoking experience (history of ever smoking) and current smoking varied across the countries under study. In all but four countries, one out of every four adults currently smoked. In higher-income countries, estimated proportions of former smokers (those who had quit) were roughly double the corresponding estimates for most low-income and middle-income countries. Characteristics of smokers varied within individual countries, and in relation to the World Bank's low-medium-high gradient of economic development. In stark contrast to a sturdy male-female difference in the uptake of smoking seen in each country, there is no consistent sex-associated pattern in the odds of remaining a smoker (versus quitting). CONCLUSION: The World Mental Health Surveys estimates complement existing global tobacco monitoring efforts. The observed global diversity of associations with smoking and smoking cessation underscore reasons for implementation of the Framework Convention on Tobacco Control provisions and prompt local adaptation of prevention and control interventions.

Is depressed mood in childhood associated with an increased risk for initiation of alcohol use during early adolescence?

OBJECTIVE: Using prospective data, we tested the hypothesis that early depressed mood was associated with an increased risk for initiation of alcohol use. In addition, we examined whether these associations varied according to the youths' report that alcohol consumption occurred with or without parental permission. METHODS: The participants for these analyses were students, ages 9 to 13 years old, participating in a longitudinal study in an urban sample of public schools (n=2311). As part of the prospective annual assessments of the students, in 1990 through 1994, data on depressive mood and alcohol use were gathered. Logistic regression models were used to assess the association between the level of baseline depressed mood in 1990 and initiation of alcohol use between 1991 through 1994 in the sample of youth at risk for new onset drinking (n=1526). Other characteristics assessed in the analyses included age, sex, race-ethnicity, alcohol use by peers, neighborhood environment, and receipt of subsidized lunch. RESULTS: Higher level of early depressed mood was associated with an earlier and increased estimated risk of initiating alcohol use without parental permission for boys but not for girls. Depressed mood was not associated with alcohol use initiation that occurred with parental sanctions. CONCLUSIONS: Findings from the current study support the hypothesis that among urban youth, early depressed mood influences the initiation of alcohol consumption without parental permission for boys.

Adult smokers in Colombia: who isn't giving it up?

Without ongoing surveillance systems to assess tobacco product demand and exposure levels, many low and middle income countries monitor smoking via periodic cross-sectional surveys. In this article, we seek to update estimates for the prevalence of adult smoking in Colombia and contribute additional information useful for tobacco control initiatives. Data are from the 2003 Colombian National Study of Mental Health (NSMH). A national probability sample of 4426 adults (age 18-65) was assessed via a computer-assisted interview. An estimated 49% of the adult population had smoked at least once in their lifetimes; one in three adults (31%) had smoked regularly. Nearly half of regular smokers had been able to quit (44%; 95% CI=40-48). Several personal and smoking-related characteristics were associated with failing to quit: being a younger age, employed as compared to being a homemaker, and a history of daily use. Quitters and non-quitters were equivalent with respect to sex, educational status, and age of smoking onset. In conclusion, our findings describe the characteristics of regular smokers in Colombia and identify subgroups of non-quitters that may help guide tobacco control activities.

Gender and the tobacco-depression relationship: a sample of African American college students at a Historically Black College or University (HBCU).

This study examined the relationship between tobacco use and depression and its possible variation by gender among African American young adults. A paper-and-pencil survey was administered to African American college students graduating in 2003 from a Historically Black College or University (HBCU). Tobacco use measures included lifetime involvement. Depression symptoms were assessed using a revised version of the CES-D. Male smokers were found to be four times more likely to be depressed than male non-smokers (OR=4.4; 95% CI, 1.4, 14.3; p=0.012). However, female smokers were not more likely to be depressed than female non-smokers (OR=1.0; 95% CI, 0.5, 2.1). Findings from this study suggest the need of gender-specific tobacco or depression interventions among HBCU students.