In his commentary (Income inequality and health: a new challenge, doi:10.1136/jech-2024-222896), Michael Marmot says that we put the quotes on the cover of our 2009 book The Spirit Level (1). That was the publisher – not us. Contrary to his suggestion, in our 2018 book The Inner Level, we specifically disagreed with the suggestion that The Spirit Level was ‘a theory of everything’ (2). Instead, we emphasised that it is a theory of problems that have negative social gradients – like health, education, violence etc. And, as we have often said, inequality tends, as expected, to have its greatest impact among the poor, but diminishing effects spread further up the hierarchy to the majority of the population. We know of no data which would tell us whether the tiny minority of the very rich are affected.
Marmot’s major original contribution to understanding health inequalities (developed in his 2005 book The Status Syndrome: How your social standing directly affects your health) has been to show that they are rooted in the stresses of status differences (3). The effect of inequality is simply to strengthen the salience of class and status, so increasing their impact. When occasional findings crop up that do not show this effect, it does not mean that the very large number of studies which have shown it are invalid – just as going into the country and not seeing a rabbit does not prove that rabbits don’t exist. Rather than abandoning the theory, a better response would...
In his commentary (Income inequality and health: a new challenge, doi:10.1136/jech-2024-222896), Michael Marmot says that we put the quotes on the cover of our 2009 book The Spirit Level (1). That was the publisher – not us. Contrary to his suggestion, in our 2018 book The Inner Level, we specifically disagreed with the suggestion that The Spirit Level was ‘a theory of everything’ (2). Instead, we emphasised that it is a theory of problems that have negative social gradients – like health, education, violence etc. And, as we have often said, inequality tends, as expected, to have its greatest impact among the poor, but diminishing effects spread further up the hierarchy to the majority of the population. We know of no data which would tell us whether the tiny minority of the very rich are affected.
Marmot’s major original contribution to understanding health inequalities (developed in his 2005 book The Status Syndrome: How your social standing directly affects your health) has been to show that they are rooted in the stresses of status differences (3). The effect of inequality is simply to strengthen the salience of class and status, so increasing their impact. When occasional findings crop up that do not show this effect, it does not mean that the very large number of studies which have shown it are invalid – just as going into the country and not seeing a rabbit does not prove that rabbits don’t exist. Rather than abandoning the theory, a better response would be to ask what sometimes masks the effects. There are many possible reasons why the relationship among US states may sometimes not be evident. Perhaps the social hierarchy of the US has become more of a national phenomenon rather than operating at a state level – the poor health performance of the USA is much as its high inequality would suggest. When inequality is changing, perhaps lagged effects of chronic stress are a problem. As life expectancy is increasingly dominated by deaths at older ages, where socioeconomic health differences appear smaller than at younger ages, might medical care have become a stronger influence? We agree there is further work to do. Meanwhile, confirmations of the link between income inequality and health accumulate, including for excess Covid-19 deaths among low and middle income countries, illicit drug mortality in the USA, so-called ‘deaths of despair’ in US states and Canada, self-rated health in China, and prevalence of tuberculosis across the globe.
In our Spirit Level at 15 analyses it is clear that income inequality in rich countries remains significantly associated with social cohesion (e.g., trust, democracy, racial and gender inequality, homicides and imprisonment) and with children’s life chances (e.g., child wellbeing, educational underachievement and inequalities in attainment, and social mobility), as well as with measures of population health (4,5). Sadly, during the last 15 years, we have seen little diminution of income and wealth inequalities throughout the world. Our recent work has focused on the evidence that income inequality also damages our ability to protect the environment or implement the Sustainable Development Goals (4,6). The global health implications of failing to address this will be devastating. Indeed, Oxfam, the European Union and Thomas Piketty have all said that reducing inequality is a precondition to solving the climate crisis. This is not the time to throw the baby out with the bath water.
1. Wilkinson R, Pickett K. The Spirit Level: why more equal societies almost always do better. London: Penguin, 2009.
2. Wilkinson R, Pickett K. The Inner Level: How more equal societies reduce stress, restore sanity and improve everybody's wellbeing. London: Allen Lane, 2018.
3. Marmot M. Status Syndrome: How your social standing directly affects your health: London: Bloombbury, 2004.
4. Wilkinson RG, Pickett KE. Why the world cannot afford the rich. Nature 2024;627(8003):268-70.
5. Pickett K, Gauhar A, Wilkinson R, et al. The Spirit Level at 15. London: The Equality Trust, 2024.
6. Wilkinson R, Pickett K. From inequality to sustainability. Earth4All: Deep-Dive Paper 01. Winterthur, Switzerland: Club of Rome, 2022.
Alongside the first lethal case of human infection by the A(H5N2) avian influenza virus, which has recently occurred in a Mexican patient with no previous exposure to poultry and/or other animals (https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON520), the marked neurotropism and neuropathogenicity displayed by the highly pathogenic avian influenza (HPAI) virus A(H5N1) in several bird and mammalian hosts - with special reference to the 2.3.4.4b viral clade - are a matter of concern. This appears to be additionally emphasized by the largely and rapidly expanding number of virus-susceptible animals, including several species phylogenetically distant from each other (1-6). Further worrysome issues are represented by the transmission of A(H5N1) virus from wild birds to cattle, with cows from 9 States in USA having tested positive to laboratory investigations (7). Noteworthy, while most infected bovines tend to develop mild clinical signs - with the subsequent risk of getting A(H5N1) avian influenza virus frequently undetected in cattle - consistent amounts of viral infectivity may be also found in raw, unpasteurized cow milk (8). In this respect, a surprisingly high expression of both the avian - sialic acid (SA) alfa-2-3-galactose (gal) - and the human - SA-alfa-2-6-gal - influenza virus receptors has been recently reported within the mammary gland tissue (but not in the uppe...
Alongside the first lethal case of human infection by the A(H5N2) avian influenza virus, which has recently occurred in a Mexican patient with no previous exposure to poultry and/or other animals (https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON520), the marked neurotropism and neuropathogenicity displayed by the highly pathogenic avian influenza (HPAI) virus A(H5N1) in several bird and mammalian hosts - with special reference to the 2.3.4.4b viral clade - are a matter of concern. This appears to be additionally emphasized by the largely and rapidly expanding number of virus-susceptible animals, including several species phylogenetically distant from each other (1-6). Further worrysome issues are represented by the transmission of A(H5N1) virus from wild birds to cattle, with cows from 9 States in USA having tested positive to laboratory investigations (7). Noteworthy, while most infected bovines tend to develop mild clinical signs - with the subsequent risk of getting A(H5N1) avian influenza virus frequently undetected in cattle - consistent amounts of viral infectivity may be also found in raw, unpasteurized cow milk (8). In this respect, a surprisingly high expression of both the avian - sialic acid (SA) alfa-2-3-galactose (gal) - and the human - SA-alfa-2-6-gal - influenza virus receptors has been recently reported within the mammary gland tissue (but not in the upper airways and in the brain) from cattle (9), thus "candidating" the bovine species as a new "mixing vessel" potentially allowing the genetic reassortment/recombination between influenza viruses originating from different animal sources, as it "historically" happens in pigs with avian and human viruses (9). Although there is a paucity of studies aimed at defining how A(H5N1) avian influenza moves between cattle and people, one dairy worker in Texas - where the first case of this viral infection in cows was ascertained in March 2024 - developed a bilateral, virus-induced conjunctivitis (10), followed by a similar ocular disease case ascertained thereafter in another farm worker from Michigan (https://www.nytimes.com/2024/05/22/health/h5n1-bird-flu-dairy.html).
Noteworthy, despite the almost 900 human cases of A(H5N1) viral disease which have been reported from 2003 until now by the World Health Organization (WHO) - 52% of which being characterized by a lethal outcome - an efficient and sustained interhuman infection transmission's chain of such viral pathogen has never been documented, thus far. Nevertheless, based upon the high propensity of influenza viruses to undergo mutations in their genomic make-up through the well-known mechanisms of genetic reassortment/recombination, coupled with the rapidly and consistently expanding viral host range, the possibility the A(H5N1) virus will become easily transmissible between people, thereby acquiring a "pandemic behaviour", appears to be more than plausible (1).
Consequently, an "ad hoc" robust and multidisciplinary "preparedness and readiness effort", strongly relying on the lessons learned from the COVID-19 pandemic and accompanied by a close intersectorial collaboration between human and veterinary medicine, is urgently needed in order to properly counteract this alarming scenario, within a sound One Health perspective's framework.
References
1) Di Guardo, G., Roperto S. (2024). A(H5N1) avian influenza: A new pandemic? Vet. Rec. 194, in press.
3) Puryear, W., et al. (2023). Highly Pathogenic Avian Influenza A(H5N1) Virus Outbreak in New England Seals, United States. Emerg. Infect. Dis. 29:786-791. doi: 10.3201/eid2904.221538.
4) Gamarra-Toledo, V., et al. (2023). Mass Mortality of Sea Lions Caused by Highly Pathogenic Avian Influenza A(H5N1) Virus. Emerg. Infect. Dis. 29:2553-2556. doi: 10.3201/eid2912.230192.
5) Thorsson, E., et al. (2023). Highly Pathogenic Avian Influenza A(H5N1) Virus in a Harbor Porpoise, Sweden. Emerg. Infect. Dis. 29:852-855. doi: 10.3201/eid2904.221426.
6) Murawski, A., et al. (2024). Highly pathogenic avian influenza A(H5N1) virus in a common bottlenose dolphin (Tursiops truncatus) in Florida. Commun. Biol. 7:476. doi: 10.1038/s42003-024-06.
9) Kristensen, C., et al. (2024). The avian and human influenza A virus receptors sialic acid (SA)-α2,3 and SA-α2,6 are widely expressed in the bovine mammary gland. bioRxiv 2024. 05.03.592326.
10) Uyeki, T.M., et al. (2024). Highly pathogenic avian influenza A(H5N1) virus infection in a dairy farm worker. N. Engl. J. Med. doi: 10.1056/NEJMc2405371.
Interested readers should note a relevant Belgian study on this subject was not cited. It repetitively obtained COVID-19 vaccination intentions before and after vaccine introduction in Belgium in 2020 and 2021, and reported results in real time through reports and press releases (see www.corona-study.be), noting the high general vaccination intentions (in closer accordance with the official records of actual coverage than the pre-implementation references cited here) and most of the socioeconomic disparities reported here. These results were also published after peer review in January 2022 for the pre-implementation period in Flanders, the largest region of Belgium (see Valckx et al, Vaccine 2022 at https://www.sciencedirect.com/science/article/pii/S0264410X21014146 ).
Airagnes et al. examined the association between effort–reward imbalance and incident long-term benzodiazepine use (LTBU) (1). The effort–reward imbalance was calculated in quartiles, and the adjusted odds ratios (95% confidence intervals) of the third and fourth quartiles of effort-reward imbalance for incident LTBU over a 2-year follow-up period were 1.74 (1.17 to 2.57) and 2.18 (1.50 to 3.16), respectively. They also clarified a dose-dependent relationship and an
interaction of tobacco smoking on the relationship. I have a comment with special reference to the number of subjects with LTBU during follow-up in each sex.
About two thirds of subjects with LTBU during follow-up were women. The same authors reported that the prevalence of long-term prescribed benzodiazepine use in the French population was 2.8% in men and 3.8% in women in the year 2015 (2). Although the total percentage of subjects with LTBU during follow-up was under 1%, there are differences in the long-term prescription percentage between men and women. As the authors observed the interaction of tobacco smoking on the relationship, I recommend the additional analysis, which should be stratified by sex, according to their previous cross-sectional study (3).
References
1. Airagnes G, Lemogne C, Kab S, et al. Effort-reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort. J Epidemiol Community Health. 2019 Nov;73(11):993-1001.
2. Aira...
Airagnes et al. examined the association between effort–reward imbalance and incident long-term benzodiazepine use (LTBU) (1). The effort–reward imbalance was calculated in quartiles, and the adjusted odds ratios (95% confidence intervals) of the third and fourth quartiles of effort-reward imbalance for incident LTBU over a 2-year follow-up period were 1.74 (1.17 to 2.57) and 2.18 (1.50 to 3.16), respectively. They also clarified a dose-dependent relationship and an
interaction of tobacco smoking on the relationship. I have a comment with special reference to the number of subjects with LTBU during follow-up in each sex.
About two thirds of subjects with LTBU during follow-up were women. The same authors reported that the prevalence of long-term prescribed benzodiazepine use in the French population was 2.8% in men and 3.8% in women in the year 2015 (2). Although the total percentage of subjects with LTBU during follow-up was under 1%, there are differences in the long-term prescription percentage between men and women. As the authors observed the interaction of tobacco smoking on the relationship, I recommend the additional analysis, which should be stratified by sex, according to their previous cross-sectional study (3).
References
1. Airagnes G, Lemogne C, Kab S, et al. Effort-reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort. J Epidemiol Community Health. 2019 Nov;73(11):993-1001.
2. Airagnes G, Lemogne C, Renuy A, et al. Prevalence of prescribed benzodiazepine longterm use in the French general population according to sociodemographic and clinical factors: findings from the CONSTANCES cohort. BMC Public Health 2019;19(1):566.
3. Airagnes G, Lemogne C, Olekhnovitch R, et al. Work-related stressors and increased risk of benzodiazepine long-term use: Findings from the CONSTANCES population-based cohort. Am J Public Health. 2019;109(1):119-125.
The article by Kiely et al., which reported a higher risk of injection site reactions in women than men for both younger and older participants, is interesting. The risk of systemic reactions was also higher following influenza vaccination in women than in men, irrespective of age and vaccine type.1 These findings are a valuable addition to the literature. However, we have two concerning issues for the authors.
First, there is underreporting, which occurs in any adverse events following vaccine or drug studies based on spontaneous reporting.2 Underreporting is a problem in adverse events studies following vaccination using self-reported data. This may lead to a bias away from the null value, and they are susceptible to response bias, social desirability bias, and misclassification.3 Therefore, with underreporting, the conclusions may not be rigorous.
Second concern is the possibility of age and sex differences in adverse events following seasonal influenza vaccination. Previous studies have shown that elderly women have higher humoral responses against influenza than elderly men, but not young women compared with young men.4,5 Some authors have also reported sex and age differences in influenza vaccination. Elderly women typically suffered more frequently from local and systemic side effects because antibody induction is usually higher elderly women than in elderly men after vaccination. Consequently, the sex-related difference observed would not be the true di...
The article by Kiely et al., which reported a higher risk of injection site reactions in women than men for both younger and older participants, is interesting. The risk of systemic reactions was also higher following influenza vaccination in women than in men, irrespective of age and vaccine type.1 These findings are a valuable addition to the literature. However, we have two concerning issues for the authors.
First, there is underreporting, which occurs in any adverse events following vaccine or drug studies based on spontaneous reporting.2 Underreporting is a problem in adverse events studies following vaccination using self-reported data. This may lead to a bias away from the null value, and they are susceptible to response bias, social desirability bias, and misclassification.3 Therefore, with underreporting, the conclusions may not be rigorous.
Second concern is the possibility of age and sex differences in adverse events following seasonal influenza vaccination. Previous studies have shown that elderly women have higher humoral responses against influenza than elderly men, but not young women compared with young men.4,5 Some authors have also reported sex and age differences in influenza vaccination. Elderly women typically suffered more frequently from local and systemic side effects because antibody induction is usually higher elderly women than in elderly men after vaccination. Consequently, the sex-related difference observed would not be the true difference in the adverse events following seasonal influenza vaccination.
Although we have some concerns about the study by Kiely et al.1, we applaud the authors for their commendable work and hope that this study will benefit readers. We look forward to further work on the interaction between sex and age in the occurrence and reporting of adverse events following seasonal influenza vaccination, which will benefit high-risk parents.
Contributors YHL, TYY and GPJ wrote the manuscript. GPJ contributed to the final version of the manuscript. GPJ supervised the project.
Funding None.
Competing interests None declared.
Patient consent for publication Not applicable.
Provenance and peer review: Not commissioned; internally peer reviewed.
ORCID iDs
Gwo-Ping Jong http://orcid.org/0000-0002-7786-5497
References:
1. Kiely M, Tadount F, Lo E, et al. Sex differences in adverse events following seasonal influenza vaccines: a meta-analysis of randomised controlled trials. J Epidemiol Community Health. 2023;77:791-801.
2. Pierfitte C, Bégaud B, Lagnaoui R, Moore ND. Is reporting rate a good predictor of risks associated with drugs? Br J Clin Pharmacol 1999;47:329–31.
3. Escolano S, Hill C, Tubert-Bitter P. A new self-controlled case series method for analyzing spontaneous reports of adverse events after vaccination. Am J Epidemiol 2013;178:1496-504.
4. Engler RJM, Nelson MR, Klote MM, et al. Half- vs full-dose trivalent inactivated influenza vaccine (2004-2005): Age, dose, and sex Effects on immune responses. Arch Intern Med 2008;168:2405–14.
5. Giefing-Kröll C, Berger P, Lepperdinger G, et al. How sex and age affect immune responses, susceptibility to infections, and response to vaccination. Aging Cell 2015;14:309–21.
6. Kini A, Morgan R, Kuo H, et al. Differences and disparities in seasonal influenza vaccine, acceptance, adverse reactions, and coverage by age, sex, gender, and race. Vaccine 2022;40:1643-54.
7. Plant EP, Eick-Cost AA, Ezzeldin H, et al. The effects of birth year, age and sex on hemagglutination inhibition antibody responses to influenza vaccination. Vaccines (Basel) 2018;6:39.
An article by Wei et al. reported the death of a child associated with an increased risk of incident atrial fibrillation (AF). The association was observed when the cause of death was both cardiovascular and non-cardiovascular diseases.1 These findings provide a valuable addition to the literature; however, some issues were not addressed by the authors.
First, several clinical risk factors are associated with incident AF, including concurrent medication, illegal drugs, obesity, sleep apnea, and hyperthyroidism.2-4 For example, we previously reported that insulin users had a higher risk of incident AF than non-users among the elderly patients’ cohort (1.58 odds ratio (OR); 95% confidence interval (CI): 1.37–1.82). Patients with dipeptidyl peptidase 4 inhibitor (OR 0.65; 95% CI: 0.45–0.93) intake had a lower risk of developing AF when compared with non-users.4 However, while associated evaluations were not presented, Wei et al. did not exclude individuals with these risk factors. Consequently, confounding effects may have contributed to the significant effects causing incident AF, thus, omitting these effects may improve study validation outcomes.
Second, the study initially enrolled 2,740,028 participants in the unexposed group and 64,216 participants in the exposed group at baseline, but missing data between groups (50.1% vs. 79.6%) were examined in further analyses. These missing data potentially affected data credibility in mediation analyses.5 Consequent...
An article by Wei et al. reported the death of a child associated with an increased risk of incident atrial fibrillation (AF). The association was observed when the cause of death was both cardiovascular and non-cardiovascular diseases.1 These findings provide a valuable addition to the literature; however, some issues were not addressed by the authors.
First, several clinical risk factors are associated with incident AF, including concurrent medication, illegal drugs, obesity, sleep apnea, and hyperthyroidism.2-4 For example, we previously reported that insulin users had a higher risk of incident AF than non-users among the elderly patients’ cohort (1.58 odds ratio (OR); 95% confidence interval (CI): 1.37–1.82). Patients with dipeptidyl peptidase 4 inhibitor (OR 0.65; 95% CI: 0.45–0.93) intake had a lower risk of developing AF when compared with non-users.4 However, while associated evaluations were not presented, Wei et al. did not exclude individuals with these risk factors. Consequently, confounding effects may have contributed to the significant effects causing incident AF, thus, omitting these effects may improve study validation outcomes.
Second, the study initially enrolled 2,740,028 participants in the unexposed group and 64,216 participants in the exposed group at baseline, but missing data between groups (50.1% vs. 79.6%) were examined in further analyses. These missing data potentially affected data credibility in mediation analyses.5 Consequently, the results should be interpreted with caution and not influence teaching or clinical practice before the findings are comprehensively replicated. We suggest performing sensitivity tests on parents of live-born children in 1991–2016, in the Danish Medical Birth Register, to improve study validation.
In conclusion, although we raised some concerns with Wei et al.1, we applaud the authors for their commendable work and hope this study will benefit readers, clinicians, and patients. We look forward to further work on the early prevention of incident AF and hope that early preventive approaches will benefit bereaved parents.
Contributors TKL, TYY and GPJ wrote the manuscript. GPJ contributed to the final version of the manuscript. TYY and GPJ supervised the project.
Funding None.
Competing interests None declared.
Patient consent for publication Not applicable.
Provenance and peer review: Not commissioned; internally peer reviewed.
References:
1. Wei D, Janszky I, Li J, et al. Loss of a child and the risk of atrial fibrillation: a Danish population-based prospective cohort study. J Epidemiol Community Health 2023;77:322-7.
2. Dai H, Zhang Q, Much AA, et al. Global, regional, and national prevalence, incidence, mortality, and risk factors for atrial fibrillation, 1990–2017: results from the Global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes 2021;7:574–82.
3. Fauchier L, Clementy N, Babuty D. Statin therapy and atrial fibrillation: systematic review and updated meta-analysis of published randomized controlled trials. Curr Opin Cardiol 2013;28:7-18.
4. Chen HY, Yang FY, Jong GP, et al. Antihyperglycemic drugs use and new-onset atrial fibrillation in elderly patients. Eur J Clin Invest 2017;47:388-93.
5. Tsvetanova A, Sperrin M, Peek N, et al. Missing data was handled inconsistently in UK prediction models: a review of method used. J Clin Epidemiol 2021;140:149-58.
While the data that this article studied and the results that were produced show a change in the mental health status and medication behaviors of Portugal, it does not support the change in mental health status captured in much of the literature around the world. When the COVID-19 virus was declared a pandemic, there was global unrest. It is natural for people to feel fear, anxiety, and panic in the face of an unknown pandemic (Usher, Durkin, & Bhullar, 2020). The article addresses some of the discrepancies between the literature coming out that has been showing increases in anxiety and depressive symptoms in the Discussion section. However, these discrepancies do not align with the data presented in the paper. Further explanation and research is needed as to why rates of some prescription medications to manage mental health symptoms are declining when there is evidence showing that mental illnesses have increase as a result of the pandemic.
The article discussed a reduction of prescriptions for anxiolytics, sedatives, and hypnotics in children, adolescents, and elderly women. These medications would address the symptoms of anxiety, stress, and other symptoms that a global pandemic may cause (Javed, Sarwer, Soto, & Mashwani, 2020). The authors suggested that perhaps people have been going to see the doctor less frequently due to quarantines and fear of contracting the virus. However, some of the medications are long-term, so it does not make sense that, duri...
While the data that this article studied and the results that were produced show a change in the mental health status and medication behaviors of Portugal, it does not support the change in mental health status captured in much of the literature around the world. When the COVID-19 virus was declared a pandemic, there was global unrest. It is natural for people to feel fear, anxiety, and panic in the face of an unknown pandemic (Usher, Durkin, & Bhullar, 2020). The article addresses some of the discrepancies between the literature coming out that has been showing increases in anxiety and depressive symptoms in the Discussion section. However, these discrepancies do not align with the data presented in the paper. Further explanation and research is needed as to why rates of some prescription medications to manage mental health symptoms are declining when there is evidence showing that mental illnesses have increase as a result of the pandemic.
The article discussed a reduction of prescriptions for anxiolytics, sedatives, and hypnotics in children, adolescents, and elderly women. These medications would address the symptoms of anxiety, stress, and other symptoms that a global pandemic may cause (Javed, Sarwer, Soto, & Mashwani, 2020). The authors suggested that perhaps people have been going to see the doctor less frequently due to quarantines and fear of contracting the virus. However, some of the medications are long-term, so it does not make sense that, during a particularly stressful event, these medications would decrease. In addition, the authors noted that there was an increase in overall prescription trends throughout the COVID-19 pandemic, especially in older adults and the elderly. This trend though shows that patients have continued to see their doctors and get prescribed medications for other ailments. This demonstrates that it is possible for patients to continue to receive necessary medications for mental illnesses, despite the hurdles of the pandemic.
In addition to the anxiety and stress that the pandemic may cause, it can also increase rates of depression. During the pandemic, especially in the earlier stages of when doctors and researchers were trying to learn more about it, people spent time at home, away from others. This resulted in people feeling isolated and distanced from other people (Usher, Durkin, & Bhullar, 2020). The distancing from other is one of the issues that can cause an increase in depression. The study showed increasing rates of antidepressant prescriptions before the pandemic began, but then they started to decline, which contradicts the increasing depressive symptoms brought on by the pandemic (Gallagher et al., 2020). The authors saw a trend of a drop in antidepressant prescription rates in male and female children, male adolescents, adults, older adults, and the elderly. However, there was no impact on the rate of prescriptions for antidepressants in women during COVID-19. This is interesting because COVID-19 is not something that impacts one gender more than the other. Additional research would be warranted to explain the gap of prescription rates between genders during the pandemic.
Many different factors can explain the conflicting data, including country studied, rate of medication use before COVID-19, etc. As more information continues to come out about COVID-19 and its impacts on mental health, we’ll more fully understand these discrepancies.
References
Gallagher, M. W., Zvolensky, M. J., Long, L. J., Rogers, A. H., & Garey, L. (2020). The impact of covid-19 experiences and associated stress on anxiety, depression, and functional impairment in American adults. Cognitive Therapy and Research, 44(6), 1043–1051. https://doi.org/10.1007/s10608-020-10143-y
Javed, B., Sarwer, A., Soto, E. B., & Mashwani, Z. U. (2020). The coronavirus (COVID-19) pandemic's impact on mental health. The International journal of health planning and management, 35(5), 993–996. https://doi.org/10.1002/hpm.3008
Usher, K., Durkin, J., & Bhullar, N. (2020). The COVID-19 pandemic and mental health impacts. International journal of mental health nursing, 29(3), 315–318. https://doi.org/10.1111/inm.12726
The authors, Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al [1], present an article that, owing to a lack of rigor in the creation and application of ethno-racial categories, ends up employing an analysis method that, although intended to allow proving inequalities, ends up disguising or attenuating them.
Raj Bhopal published a seminal article in this journal in 2004 demonstrating the importance of ethnicity and race variables in epidemiology and public health. Bhopal pointed out that, at a minimum, researchers should explain their understanding of the concepts of race or ethnicity and the classification they use, even more so when we know that they need development in terms of geographic specificity, scope, and precision for different contexts [2]. Similar recommendations are made by Janeth Mosquera in her analysis about the use of the ethnic-racial category in the research published by the three most important scientific journals of Public Health in Colombia [3].
The paper does not present a comprehensive and helpful description of the categories that assist the reader in understanding the ethnic-racial composition of the Colombian population and correctly analyze the regularly available data for public health surveillance. The Colombian surveillance system employs the census ethnic-racial categories. Among these Census categories, the "white-mestizo" used by the authors is not defined and thus is not used for public health surveill...
The authors, Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al [1], present an article that, owing to a lack of rigor in the creation and application of ethno-racial categories, ends up employing an analysis method that, although intended to allow proving inequalities, ends up disguising or attenuating them.
Raj Bhopal published a seminal article in this journal in 2004 demonstrating the importance of ethnicity and race variables in epidemiology and public health. Bhopal pointed out that, at a minimum, researchers should explain their understanding of the concepts of race or ethnicity and the classification they use, even more so when we know that they need development in terms of geographic specificity, scope, and precision for different contexts [2]. Similar recommendations are made by Janeth Mosquera in her analysis about the use of the ethnic-racial category in the research published by the three most important scientific journals of Public Health in Colombia [3].
The paper does not present a comprehensive and helpful description of the categories that assist the reader in understanding the ethnic-racial composition of the Colombian population and correctly analyze the regularly available data for public health surveillance. The Colombian surveillance system employs the census ethnic-racial categories. Among these Census categories, the "white-mestizo" used by the authors is not defined and thus is not used for public health surveillance. Besides, the authors do not define "white-mestizo."
The authors employ an official database published by Colombian national sanitary authorities and provide a link to it. However, as systematic users of the cited source, we must point out that three of the model's explanatory variables are not available on the authors-cited open data platform. Therefore, it is necessary to warn the reader that micro-data on social security affiliation, household's socioeconomic stratum, and area of residence are not available. Consequently, the results are not reproductible with publicly available data. The authors should indicate how they accessed this data and the ethical implications if they exist.
Finally, it is crucial to recognize that the paper implicitly assumes homogeneity in the group's distribution, risk exposure, and events. Authors should discuss whether it is possible, with the available data, to have a syndemic approach, as proposed early on by Bambra and collaborators [4]. This kind of analysis accounts for structural differences within the country and how ethnic groups relate to each other in the territories.
References
1. Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al. Socioeconomic inequalities associated with mortality for COVID-19 in Colombia: a cohort nationwide study. J Epidemiol Community Health 2021;75:610-615; DOI:10.1136/jech-2020-216275
2. Bhopal R. Glossary of terms relating to ethnicity and race: for reflection and debate. Journal of Epidemiology & Community Health 2004;58:441-445; DOI:10.1136/jech.2003.013466
3. Mosquera Becerra J. Unveiling what is said in the colombian public health journals about race and ethnicity. Rev.CS 2015;16:109-2; DOI: https://doi.org/10.18046/recs.i16.1939
4. Bambra C, Riordan R, Ford J, et al. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health 2020;74:964-968; DOI:10.1136/jech-2020-214401
Frank’s essay contains several statements about 5G, its relation to the radiation protection science, and related to this, ICNIRP’s guidance and integrity more generally. ICNIRP considers this to be seriously inaccurate and in need of correction for the sake of both scientific accuracy and development of effective public health policy. However, due to journal word limits we must restrict our response to Frank’s misleading claims about ICNIRP’s integrity (for full response see https://www.icnirp.org/en/activities/news/index.html).
Frank’s essay accuses ICNIRP of unmanaged conflict of interests, and uses this accusation to attempt to throw doubt on ICNIRP’s scientific evaluations. However, ICNIRP has a very rigorous procedure to avoid conflicts of interest (https://www.icnirp.org/en/about-icnirp/commission/index.html), and Frank did not provide any evidence in support of his statement - he merely referred to ‘persistent allegations’ from the Swedish epidemiologist Lennart Hardell. For example, Frank repeats claims made by Hardell that “ICNIRP’s membership includes over-representation of vested interests, especially the giant multinational telecommunications firms who are heavily invested in the roll out of 5G systems internationally”, and no supporting evidence was provided by either author. To be clear, there are no industry r...
Frank’s essay contains several statements about 5G, its relation to the radiation protection science, and related to this, ICNIRP’s guidance and integrity more generally. ICNIRP considers this to be seriously inaccurate and in need of correction for the sake of both scientific accuracy and development of effective public health policy. However, due to journal word limits we must restrict our response to Frank’s misleading claims about ICNIRP’s integrity (for full response see https://www.icnirp.org/en/activities/news/index.html).
Frank’s essay accuses ICNIRP of unmanaged conflict of interests, and uses this accusation to attempt to throw doubt on ICNIRP’s scientific evaluations. However, ICNIRP has a very rigorous procedure to avoid conflicts of interest (https://www.icnirp.org/en/about-icnirp/commission/index.html), and Frank did not provide any evidence in support of his statement - he merely referred to ‘persistent allegations’ from the Swedish epidemiologist Lennart Hardell. For example, Frank repeats claims made by Hardell that “ICNIRP’s membership includes over-representation of vested interests, especially the giant multinational telecommunications firms who are heavily invested in the roll out of 5G systems internationally”, and no supporting evidence was provided by either author. To be clear, there are no industry representations within ICNIRP; people working for industry are not permitted to be ICNIRP members, and ICNIRP does not receive any funding or in-kind contributions from industry. Moving beyond funding, Frank claims that the “the most damning evidence adduced by Hardell is a table of the cross-appointments held by six members of the WHO Monograph Group, across five major international advisory panels on the health effects of non-ionising radiation”. However, this merely reflects the relatively small EMF research community together with the high public interest that has resulted in many national and international advisory boards. Frank does not tell the reader why this would in any way bias ICNIRP’s work. Thus, the essay’s accusations of industry influence are not only incorrect, but also lack appropriate scientific scholarship.
In conclusion, ICNIRP fully supports and contributes to critical debate related to the 5G rollout, but would like to stress the importance of approaching such debate with appropriate scientific scholarship in order to support effective, evidence-based public health measures that provide appropriate protection to the public. For ICNIRP it is imperative to avoid situations whereby personal interests of its members could affect the independence of ICNIRP’s guidance, and so has strong conflict of interest procedures, including transparent reporting of members’ declarations of interest.
Acknowledgements
Rodney Croft (1), Tania Cestari (2), Nigel Cridland (3), Akimasa Hirata (4), Guglielmo d'Inzeo (5), Anke Huss (6), Ken Karipidis (7), Carmela Marino (8), Sharon Miller (9), Gunnhild Oftedal (10), Tsutomu Okuno (11), Eric van Rongen (12), Martin Röösli (13), Soichi Watanabe (14).
Correspondence to: International Commission on Non-Ionizing Radiation Protection, Dr Gunde Ziegelberger, ICNIRP c/o BfS, Ingolstaedter Landstr. 1, 85764 Oberschleissheim, Germany. info@icnirp.org
Affiliations of ICNIRP Collaborators
1. ICNIRP and Australian Centre for Electromagnetic Bioeffects Research, Illawarra Health & Medical Research Institute, University of Wollongong, Australia
2. ICNIRP and Hospital de Clínicas de Porto Alegre, Brazil
3. ICNIRP and Public Health England, United Kingdom
4. ICNIRP and Nagoya Institute of Technology, Japan
5. ICNIRP and La Sapienza University Rome, Italy
6. ICNIRP and Institute for Risk Assessment, Utrecht University, The Netherlands
7. ICNIRP and Australian Radiation Protection and Nuclear Safety Agency (ARPANSA), Australia
8. ICNIRP and Agency for New Technologies, Energy and Sustainable Economic Development (ENEA), Italy
9. ICNIRP
10. ICNIRP and Norwegian University of Science and Technology (NTNU), Norway
11. ICNIRP
12. ICNIRP and Health Council, The Netherlands
13. ICNIRP and Swiss Tropical and Public Health Institute, Basel, Switzerland
14. ICNIRP and National Institute of Information and Communications Technology (NICT), Japan
Hengartner et al. conducted a meta-analysis on suicide risk with selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants in adults (1). Although the pooled relative risks (RRs) of SSRI for suicide risk including suicide and suicide attempt in patients with depression and in patients with all indications did not reach the level of significance, the pooled RR (95% confidence intervals [CIs]) of any new-generation antidepressant for suicide risk in patients with depression and in patients with all indications were 1.29 (1.06-1.57) and 1.45 (1.23-1.70), respectively. The authors presented information on the different suicide risk between SSRI and other new-generation antidepressants , and I present additional information regarding the relationship.
First, Sharma et al. conducted a meta-analysis on the association of SSRI and serotonin-norepinephrine reuptake inhibitors with suicidality and other mental indicators (2). Although the pooled odds ratios (ORs) of antidepressant treatment for suicidality and aggression did not reach the level of significance in adults, the pooed ORs (95% CIs) of antidepressant treatment for suicidality and aggression were 2.39 (1.31-4.33) and 2.79 (1.62-4.81) in children/adolescents. The suicide risk differed in different generations, and suicide risk estimation should be conducted by stratification with generation and type of anti-depressants.
Second, Hengartner and Plöderl reported that odds ratios (OR...
Hengartner et al. conducted a meta-analysis on suicide risk with selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants in adults (1). Although the pooled relative risks (RRs) of SSRI for suicide risk including suicide and suicide attempt in patients with depression and in patients with all indications did not reach the level of significance, the pooled RR (95% confidence intervals [CIs]) of any new-generation antidepressant for suicide risk in patients with depression and in patients with all indications were 1.29 (1.06-1.57) and 1.45 (1.23-1.70), respectively. The authors presented information on the different suicide risk between SSRI and other new-generation antidepressants , and I present additional information regarding the relationship.
First, Sharma et al. conducted a meta-analysis on the association of SSRI and serotonin-norepinephrine reuptake inhibitors with suicidality and other mental indicators (2). Although the pooled odds ratios (ORs) of antidepressant treatment for suicidality and aggression did not reach the level of significance in adults, the pooed ORs (95% CIs) of antidepressant treatment for suicidality and aggression were 2.39 (1.31-4.33) and 2.79 (1.62-4.81) in children/adolescents. The suicide risk differed in different generations, and suicide risk estimation should be conducted by stratification with generation and type of anti-depressants.
Second, Hengartner and Plöderl reported that odds ratios (ORs) (95% confidence intervals [CIs]) of antidepressant treatment for suicides and suicide attempts were 2.83 (1.13-9.67) and 2.38 (1.63-3.61), respectively (3). By using the same database, Kaminski et al. reported that ORs (95% CIs) of antidepressant treatment for suicides and suicide attempts were 1.98 (0.71-5.50) and 1.63 (1.09-2.43), respectively (4). In case of rare events, the level of significance in OR differed by applying different analytical approaches. This means that marginal level of significance should be verified by further studies, and a meta-analysis with high quality of papers is recommended to confirm the association.
References
1. Hengartner MP, Amendola S, Kaminski JA, et al. Suicide risk with selective serotonin reuptake inhibitors and other new-generation antidepressants in adults: a systematic review and meta-analysis of observational studies. J Epidemiol Community Health 2021 Mar 8. doi: 10.1136/jech-2020-214611. [Epub ahead of print]
2. Sharma T, Guski LS, Freund N, et al. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ 2016;352:i65.
3. Hengartner MP, Plöderl M. Newer-generation antidepressants and suicide risk in randomized controlled trials: A re-analysis of the FDA database. Psychother Psychosom 2019;88(4):247-248.
4. Kaminski JA, Bschor T. Antidepressants and suicidality: A re-analysis of the re-analysis. J Affect Disord 2020;266:95-99.
In his commentary (Income inequality and health: a new challenge, doi:10.1136/jech-2024-222896), Michael Marmot says that we put the quotes on the cover of our 2009 book The Spirit Level (1). That was the publisher – not us. Contrary to his suggestion, in our 2018 book The Inner Level, we specifically disagreed with the suggestion that The Spirit Level was ‘a theory of everything’ (2). Instead, we emphasised that it is a theory of problems that have negative social gradients – like health, education, violence etc. And, as we have often said, inequality tends, as expected, to have its greatest impact among the poor, but diminishing effects spread further up the hierarchy to the majority of the population. We know of no data which would tell us whether the tiny minority of the very rich are affected.
Marmot’s major original contribution to understanding health inequalities (developed in his 2005 book The Status Syndrome: How your social standing directly affects your health) has been to show that they are rooted in the stresses of status differences (3). The effect of inequality is simply to strengthen the salience of class and status, so increasing their impact. When occasional findings crop up that do not show this effect, it does not mean that the very large number of studies which have shown it are invalid – just as going into the country and not seeing a rabbit does not prove that rabbits don’t exist. Rather than abandoning the theory, a better response would...
Show MoreAlongside the first lethal case of human infection by the A(H5N2) avian influenza virus, which has recently occurred in a Mexican patient with no previous exposure to poultry and/or other animals (https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON520), the marked neurotropism and neuropathogenicity displayed by the highly pathogenic avian influenza (HPAI) virus A(H5N1) in several bird and mammalian hosts - with special reference to the 2.3.4.4b viral clade - are a matter of concern. This appears to be additionally emphasized by the largely and rapidly expanding number of virus-susceptible animals, including several species phylogenetically distant from each other (1-6). Further worrysome issues are represented by the transmission of A(H5N1) virus from wild birds to cattle, with cows from 9 States in USA having tested positive to laboratory investigations (7). Noteworthy, while most infected bovines tend to develop mild clinical signs - with the subsequent risk of getting A(H5N1) avian influenza virus frequently undetected in cattle - consistent amounts of viral infectivity may be also found in raw, unpasteurized cow milk (8). In this respect, a surprisingly high expression of both the avian - sialic acid (SA) alfa-2-3-galactose (gal) - and the human - SA-alfa-2-6-gal - influenza virus receptors has been recently reported within the mammary gland tissue (but not in the uppe...
Show MoreInterested readers should note a relevant Belgian study on this subject was not cited. It repetitively obtained COVID-19 vaccination intentions before and after vaccine introduction in Belgium in 2020 and 2021, and reported results in real time through reports and press releases (see www.corona-study.be), noting the high general vaccination intentions (in closer accordance with the official records of actual coverage than the pre-implementation references cited here) and most of the socioeconomic disparities reported here. These results were also published after peer review in January 2022 for the pre-implementation period in Flanders, the largest region of Belgium (see Valckx et al, Vaccine 2022 at https://www.sciencedirect.com/science/article/pii/S0264410X21014146 ).
Airagnes et al. examined the association between effort–reward imbalance and incident long-term benzodiazepine use (LTBU) (1). The effort–reward imbalance was calculated in quartiles, and the adjusted odds ratios (95% confidence intervals) of the third and fourth quartiles of effort-reward imbalance for incident LTBU over a 2-year follow-up period were 1.74 (1.17 to 2.57) and 2.18 (1.50 to 3.16), respectively. They also clarified a dose-dependent relationship and an
interaction of tobacco smoking on the relationship. I have a comment with special reference to the number of subjects with LTBU during follow-up in each sex.
About two thirds of subjects with LTBU during follow-up were women. The same authors reported that the prevalence of long-term prescribed benzodiazepine use in the French population was 2.8% in men and 3.8% in women in the year 2015 (2). Although the total percentage of subjects with LTBU during follow-up was under 1%, there are differences in the long-term prescription percentage between men and women. As the authors observed the interaction of tobacco smoking on the relationship, I recommend the additional analysis, which should be stratified by sex, according to their previous cross-sectional study (3).
References
Show More1. Airagnes G, Lemogne C, Kab S, et al. Effort-reward imbalance and long-term benzodiazepine use: longitudinal findings from the CONSTANCES cohort. J Epidemiol Community Health. 2019 Nov;73(11):993-1001.
2. Aira...
The article by Kiely et al., which reported a higher risk of injection site reactions in women than men for both younger and older participants, is interesting. The risk of systemic reactions was also higher following influenza vaccination in women than in men, irrespective of age and vaccine type.1 These findings are a valuable addition to the literature. However, we have two concerning issues for the authors.
Show MoreFirst, there is underreporting, which occurs in any adverse events following vaccine or drug studies based on spontaneous reporting.2 Underreporting is a problem in adverse events studies following vaccination using self-reported data. This may lead to a bias away from the null value, and they are susceptible to response bias, social desirability bias, and misclassification.3 Therefore, with underreporting, the conclusions may not be rigorous.
Second concern is the possibility of age and sex differences in adverse events following seasonal influenza vaccination. Previous studies have shown that elderly women have higher humoral responses against influenza than elderly men, but not young women compared with young men.4,5 Some authors have also reported sex and age differences in influenza vaccination. Elderly women typically suffered more frequently from local and systemic side effects because antibody induction is usually higher elderly women than in elderly men after vaccination. Consequently, the sex-related difference observed would not be the true di...
An article by Wei et al. reported the death of a child associated with an increased risk of incident atrial fibrillation (AF). The association was observed when the cause of death was both cardiovascular and non-cardiovascular diseases.1 These findings provide a valuable addition to the literature; however, some issues were not addressed by the authors.
Show MoreFirst, several clinical risk factors are associated with incident AF, including concurrent medication, illegal drugs, obesity, sleep apnea, and hyperthyroidism.2-4 For example, we previously reported that insulin users had a higher risk of incident AF than non-users among the elderly patients’ cohort (1.58 odds ratio (OR); 95% confidence interval (CI): 1.37–1.82). Patients with dipeptidyl peptidase 4 inhibitor (OR 0.65; 95% CI: 0.45–0.93) intake had a lower risk of developing AF when compared with non-users.4 However, while associated evaluations were not presented, Wei et al. did not exclude individuals with these risk factors. Consequently, confounding effects may have contributed to the significant effects causing incident AF, thus, omitting these effects may improve study validation outcomes.
Second, the study initially enrolled 2,740,028 participants in the unexposed group and 64,216 participants in the exposed group at baseline, but missing data between groups (50.1% vs. 79.6%) were examined in further analyses. These missing data potentially affected data credibility in mediation analyses.5 Consequent...
While the data that this article studied and the results that were produced show a change in the mental health status and medication behaviors of Portugal, it does not support the change in mental health status captured in much of the literature around the world. When the COVID-19 virus was declared a pandemic, there was global unrest. It is natural for people to feel fear, anxiety, and panic in the face of an unknown pandemic (Usher, Durkin, & Bhullar, 2020). The article addresses some of the discrepancies between the literature coming out that has been showing increases in anxiety and depressive symptoms in the Discussion section. However, these discrepancies do not align with the data presented in the paper. Further explanation and research is needed as to why rates of some prescription medications to manage mental health symptoms are declining when there is evidence showing that mental illnesses have increase as a result of the pandemic.
Show MoreThe article discussed a reduction of prescriptions for anxiolytics, sedatives, and hypnotics in children, adolescents, and elderly women. These medications would address the symptoms of anxiety, stress, and other symptoms that a global pandemic may cause (Javed, Sarwer, Soto, & Mashwani, 2020). The authors suggested that perhaps people have been going to see the doctor less frequently due to quarantines and fear of contracting the virus. However, some of the medications are long-term, so it does not make sense that, duri...
The authors, Cifuentes MP, Rodriguez-Villamizar LA, Rojas-Botero ML, et al [1], present an article that, owing to a lack of rigor in the creation and application of ethno-racial categories, ends up employing an analysis method that, although intended to allow proving inequalities, ends up disguising or attenuating them.
Raj Bhopal published a seminal article in this journal in 2004 demonstrating the importance of ethnicity and race variables in epidemiology and public health. Bhopal pointed out that, at a minimum, researchers should explain their understanding of the concepts of race or ethnicity and the classification they use, even more so when we know that they need development in terms of geographic specificity, scope, and precision for different contexts [2]. Similar recommendations are made by Janeth Mosquera in her analysis about the use of the ethnic-racial category in the research published by the three most important scientific journals of Public Health in Colombia [3].
The paper does not present a comprehensive and helpful description of the categories that assist the reader in understanding the ethnic-racial composition of the Colombian population and correctly analyze the regularly available data for public health surveillance. The Colombian surveillance system employs the census ethnic-racial categories. Among these Census categories, the "white-mestizo" used by the authors is not defined and thus is not used for public health surveill...
Show MoreFrank’s essay contains several statements about 5G, its relation to the radiation protection science, and related to this, ICNIRP’s guidance and integrity more generally. ICNIRP considers this to be seriously inaccurate and in need of correction for the sake of both scientific accuracy and development of effective public health policy. However, due to journal word limits we must restrict our response to Frank’s misleading claims about ICNIRP’s integrity (for full response see https://www.icnirp.org/en/activities/news/index.html).
Frank’s essay accuses ICNIRP of unmanaged conflict of interests, and uses this accusation to attempt to throw doubt on ICNIRP’s scientific evaluations. However, ICNIRP has a very rigorous procedure to avoid conflicts of interest (https://www.icnirp.org/en/about-icnirp/commission/index.html), and Frank did not provide any evidence in support of his statement - he merely referred to ‘persistent allegations’ from the Swedish epidemiologist Lennart Hardell. For example, Frank repeats claims made by Hardell that “ICNIRP’s membership includes over-representation of vested interests, especially the giant multinational telecommunications firms who are heavily invested in the roll out of 5G systems internationally”, and no supporting evidence was provided by either author. To be clear, there are no industry r...
Show MoreHengartner et al. conducted a meta-analysis on suicide risk with selective serotonin reuptake inhibitors (SSRI) and other new-generation antidepressants in adults (1). Although the pooled relative risks (RRs) of SSRI for suicide risk including suicide and suicide attempt in patients with depression and in patients with all indications did not reach the level of significance, the pooled RR (95% confidence intervals [CIs]) of any new-generation antidepressant for suicide risk in patients with depression and in patients with all indications were 1.29 (1.06-1.57) and 1.45 (1.23-1.70), respectively. The authors presented information on the different suicide risk between SSRI and other new-generation antidepressants , and I present additional information regarding the relationship.
First, Sharma et al. conducted a meta-analysis on the association of SSRI and serotonin-norepinephrine reuptake inhibitors with suicidality and other mental indicators (2). Although the pooled odds ratios (ORs) of antidepressant treatment for suicidality and aggression did not reach the level of significance in adults, the pooed ORs (95% CIs) of antidepressant treatment for suicidality and aggression were 2.39 (1.31-4.33) and 2.79 (1.62-4.81) in children/adolescents. The suicide risk differed in different generations, and suicide risk estimation should be conducted by stratification with generation and type of anti-depressants.
Second, Hengartner and Plöderl reported that odds ratios (OR...
Show MorePages