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      The risk of deliberate self-harm following a diagnosis of rheumatoid arthritis or ankylosing spondylitis: A population-based cohort study

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          Abstract

          Objective

          Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are associated with mental illness. The risk of serious mental illness, including deliberate self-harm (DSH), in these conditions is not well known. We aimed to determine if RA or AS independently increases the risk for DSH.

          Methods

          We conducted retrospective, population-based cohort studies using administrative health data for the province of Ontario, Canada between April 1, 2002 and March 31, 2014. Individuals with incident RA (N = 53,240) or AS (N = 13,964) were separately matched 1:4 by age, sex, and year with comparators without RA or AS. The outcome was a first DSH attempt identified using emergency department data. We estimated hazard ratios (HR) and 95% confidence intervals (95% CI) for risk of DSH in RA and AS versus comparators, adjusting for demographic, clinical and health service utilization variables.

          Results

          Subjects with AS were significantly more likely to self-harm (crude incidence rate [IR] of 0.68/1,000 person years [PY] versus 0.32/1,000 PY in comparators), with an adjusted HR of 1.59 (95% CI 1.15 to 2.21). DSH was increased for RA subjects (IR 0.35/1,000 PY) versus comparators (IR 0.24/1,000 PY) only before (HR 1.43, 95% CI 1.16 to 1.74), but not after covariate adjustment (HR 1.07, 95% CI 0.86 to 1.33).

          Conclusions

          AS carries an increased risk for DSH but no such risk was observed in RA. Further evaluation of at-risk AS subjects is needed, including the longitudinal effects of disease and arthritis therapies on self-harm behaviour. This will inform whether specific risk-reduction strategies for DSH in inflammatory arthritis are needed.

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          Most cited references28

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          Fatal and non-fatal repetition of self-harm. Systematic review.

          Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions. To estimate rates of fatal and non-fatal repetition of self-harm. A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria. Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide. After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.
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            Inflamed moods: a review of the interactions between inflammation and mood disorders.

            Mood disorders have been recognized by the World Health Organization (WHO) as the leading cause of disability worldwide. Notwithstanding the established efficacy of conventional mood agents, many treated individuals continue to remain treatment refractory and/or exhibit clinically significant residual symptoms, cognitive dysfunction, and psychosocial impairment. Therefore, a priority research and clinical agenda is to identify pathophysiological mechanisms subserving mood disorders to improve therapeutic efficacy. During the past decade, inflammation has been revisited as an important etiologic factor of mood disorders. Therefore, the purpose of this synthetic review is threefold: 1) to review the evidence for an association between inflammation and mood disorders, 2) to discuss potential pathophysiologic mechanisms that may explain this association and 3) to present novel therapeutic options currently being investigated that target the inflammatory-mood pathway. Accumulating evidence implicates inflammation as a critical mediator in the pathophysiology of mood disorders. Indeed, elevated levels of pro-inflammatory cytokines have been repeatedly demonstrated in both major depressive disorder (MDD) and bipolar disorder (BD) patients. Further, the induction of a pro-inflammatory state in healthy or medically ill subjects induces 'sickness behavior' resembling depressive symptomatology. Potential mechanisms involved include, but are not limited to, direct effects of pro-inflammatory cytokines on monoamine levels, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, pathologic microglial cell activation, impaired neuroplasticity and structural and functional brain changes. Anti-inflammatory agents, such as acetyl-salicylic acid (ASA), celecoxib, anti-TNF-α agents, minocycline, curcumin and omega-3 fatty acids, are being investigated for use in mood disorders. Current evidence shows improved outcomes in mood disorder patients when anti-inflammatory agents are used as an adjunct to conventional therapy; however, further research is needed to establish the therapeutic benefit and appropriate dosage. Copyright © 2014 Elsevier Inc. All rights reserved.
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              Accuracy of administrative databases in identifying patients with hypertension

              Background Traditionally, the determination of the occurrence of hypertension in patients has relied on costly and time-consuming survey methods that do not allow patients to be followed over time. Objectives To determine the accuracy of using administrative claims data to identify rates of hypertension in a large population living in a single-payer health care system. Methods Various definitions for hypertension using administrative claims databases were compared with 2 other reference standards: (1) data obtained from a random sample of primary care physician offices throughout the province, and (2) self-reported survey data from a national census. Results A case-definition algorithm employing 2 outpatient physician billing claims for hypertension over a 3-year period had a sensitivity of 73% (95% confidence interval [CI] 69%–77%), a specificity of 95% (CI 93%–96%), a positive predictive value of 87% (CI 84%–90%), and a negative predictive value of 88% (CI 86%–90%) for detecting hypertensive adults compared with physician-assigned diagnoses. Compared with self-reported survey data, the algorithm had a sensitivity of 64% (CI 63%–66%), a specificity of 94%(CI 93%–94%), a positive predictive value of 77% (76%–78%), and negative predictive value of 89% (CI 88%–89%). When this algorithm was applied to the entire province of Ontario, the age- and sex-standardized prevalence of hypertension in adults older than 35 years increased from 20% in 1994 to 29% in 2002. Conclusions It is possible to use administrative data to accurately identify from a population sample those patients who have been diagnosed with hypertension. Given that administrative data are already routinely collected, their use is likely to be substantially less expensive compared with serial cross-sectional or cohort studies for surveillance of hypertension occurrence and outcomes over time in a large population.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                21 February 2020
                2020
                : 15
                : 2
                : e0229273
                Affiliations
                [1 ] Sinai Health System, University of Toronto, Toronto, Ontario, Canada
                [2 ] Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
                [3 ] ICES, Toronto, Ontario, Canada
                [4 ] Holland Musculoskeletal Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
                [5 ] Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
                [6 ] Krembil Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
                Universita Campus Bio-Medico di Roma, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0003-3370-0006
                Article
                PONE-D-19-16679
                10.1371/journal.pone.0229273
                7034875
                32084192
                a76e9ceb-3300-4408-843e-12fdeca1058c
                © 2020 Kuriya et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 12 June 2019
                : 3 February 2020
                Page count
                Figures: 4, Tables: 3, Pages: 14
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100011081, Canadian Rheumatology Association;
                Award ID: CCT-015-18
                Award Recipient :
                This work was supported by The Canadian Rheumatology Association / The Arthritis Society Clinician Investigator Award (CCT-015-18 for author BK) and study funding was also provided by the Division of Rheumatology Pfizer Research Chair, University of Toronto and the Sinai Health System Department of Medicine Clinical Research Support Program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This study was also supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). The opinions, results and conclusions are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred.
                Categories
                Research Article
                Medicine and Health Sciences
                Rheumatology
                Arthritis
                Rheumatoid Arthritis
                Medicine and Health Sciences
                Clinical Medicine
                Clinical Immunology
                Autoimmune Diseases
                Rheumatoid Arthritis
                Biology and Life Sciences
                Immunology
                Clinical Immunology
                Autoimmune Diseases
                Rheumatoid Arthritis
                Medicine and Health Sciences
                Immunology
                Clinical Immunology
                Autoimmune Diseases
                Rheumatoid Arthritis
                Medicine and Health Sciences
                Clinical Medicine
                Clinical Immunology
                Autoimmune Diseases
                Ankylosing Spondylitis
                Biology and Life Sciences
                Immunology
                Clinical Immunology
                Autoimmune Diseases
                Ankylosing Spondylitis
                Medicine and Health Sciences
                Immunology
                Clinical Immunology
                Autoimmune Diseases
                Ankylosing Spondylitis
                Engineering and Technology
                Electronics
                Comparators
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Self Harm
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Suicide
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Medical Doctors
                Physicians
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Medical Doctors
                Physicians
                Medicine and Health Sciences
                Pulmonology
                Chronic Obstructive Pulmonary Disease
                Custom metadata
                The data creation plan is included as Supporting Information. The analytic code and macros for data coding are owned by ICES. While data sharing agreements prohibit ICES from making the dataset publicly available, access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS. The authors did not have special access privileges.

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