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Press releases Saturday 16 February 2008

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(1) Suicide rates in young men at lowest levels since 1970s
(2) Should doctors advocate alternative sources of nicotine?
(3) One in four stroke patients die within a month
(4) Infertility will become more common in generations to come, say experts
(5) Group education for diabetes patients can change behaviour and improve health

(1) Suicide rates in young men at lowest levels since 1970s
(Suicide rates in young men in England and Wales in the 21st century: time trend study)
http://www.bmj.com/cgi/content/short/bmj.39475.603935.25v1
(The population impact on incidence of suicide and non-fatal self harm of regulatory action against the use of selective serotonin reuptake inhibitors in under 18s in the United Kingdom: ecological study)
http://www.bmj.com/cgi/content/short/bmj.39462.375613.BEv1
(Editorial: Antidepressants and suicide)
http://www.bmj.com/cgi/content/short/bmj.39482.666366.80v1

The reasons for the steady decline in suicides among young people in the UK are explored in two studies by researchers from the University of Bristol published on bmj.com today.

The studies were carried out in collaboration with the Office for National Statistics and IMS Health.

The first shows that fewer young men in England and Wales are dying by suicide than at any time in the last 30 years. Contributory factors probably include less unemployment and laws that have reduced the risks from car exhaust fumes.

The researchers carried out a time trend analysis among men and women aged 15-24 and 25-34 between 1968 and 2005 using data on suicide mortality, population statistics and surveys, prescribing information and data on unemployment and divorce.

They found that for 15-24 year-old men, the overall suicide rate dropped from 16.6 per 100,000 people in 1990 to 8.5 per 100,000 in 2005. Amongst 25-34 year old men, overall suicide rates declined from 22.2 per 100,000 in 1990 to 15.7 per 100,000 in 2005.

Various factors have played a part in this reduction to the suicide rate.

Car exhaust emission legislation in 1993 has contributed to falling suicide rates, say the authors, because it has led to a marked reduction in car exhaust gas poisoning due to the increased number of cars with catalytic converters.

This, however, is one of several factors at play including the impact of the suicide prevention policy initiatives in England and Wales.

For women, suicide rates in the 21st century are at their lowest levels since 1968, but the proportion of women aged 15-34 committing suicide by hanging has increased massively from 5.7 per cent of all suicides to 47.3 per cent by 2005.

Professor David Gunnell, co-author of the papers, said: "Favourable changes in several different factors - levels of employment, substance misuse and antidepressant prescribing as well as policy focus on suicide and vehicle exhaust gas legislation - may have contributed to the recent reductions."

The second study finds no effect on suicide of the recent restrictions on antidepressant prescribing to children and adolescents in the UK.

They analysed three separate sets of data between 1993 and 2006 (SSRI antidepressant prescriptions to 12-19 year olds in the UK, annual deaths from suicide in 12-17 year olds in England and Wales, and hospital admissions for self-harm in 12-17 year olds in England).

But they found no evidence of a temporal association between trends in antidepressant prescribing and deaths from suicide or hospital admissions for self harm despite a halving in levels of prescribing following regulatory action in 2003.

The authors say: "These findings are important because they suggest that reduced access to antidepressants in young people appears not to have had an adverse impact on suicide deaths."

An accompanying editorial suggests that sustained use of antidepressants is probably too rare to have much overall effect on risk of suicide in people living with depression.

Contacts:
David Gunnell, Professor of Epidemiology, Department of Social Medicine, University of Bristol, UK
Email: d.j.gunnell@bristol.ac.uk
Richard Martin, Reader in Clinical Epidemiology, Department of Social Medicine, University of Bristol, UK
Email: richard.martin@bristol.ac.uk
Benedict Wheeler, Research Fellow, Department of Social Medicine, University of Bristol, UK
Email: ben.wheeler@bristol.ac.uk

(2) Should doctors advocate alternative sources of nicotine?
(Head to Head: Should doctors advocate snus and other nicotine replacements?)
Yes:
http://www.bmj.com/cgi/content/short/336/7640/358
No:
http://www.bmj.com/cgi/content/short/336/7640/359

Should doctors suggest alternative sources of nicotine to people who are unable to give up cigarettes, asks this week's BMJ?

Smoking currently kills over 100,000 UK citizens each year, predominantly from lung cancer, heart disease, and chronic obstructive pulmonary disease, writes John Britton, Professor of Epidemiology at City Hospital, Nottingham. Currently 77% of UK smokers want to quit, and 78% have tried and failed, mainly because of nicotine addiction.

He argues that health professionals should strongly advise smokers to quit all nicotine use, and do all they can to support this. However, for those who try repeatedly and fail, or for those who are not ready to stop using nicotine, switching to a medicinal nicotine product is the logical best option.

By far the safest alternative is the current range of nicotine replacement products, he says. But, if all else fails, there is a case for individual smokers trying smokeless tobacco, or snus, which is substantially less hazardous than smoking.

Recent data from Sweden, where snus has been available for years, suggests that smokeless tobacco is an acceptable smoking substitute for some smokers. Yet, in the UK, it is illegal for a doctor or anyone else to supply snus.

Britton believes that, as a measure of last resort in smokers who have tried all other cessation and substitution options, doctors would be justified in suggesting an individual trial of snus. Whether this approach will prove effective remains to be seen and desperately needs to be tested in clinical trials, he concludes.

But Alexander Macara, President of the National Heart Forum, argues that this could result in increased use of tobacco.

He points to evidence that smokeless tobacco is carcinogenic to humans. Studies have also shown increases in the risk of oral and pancreatic cancers and heart attacks related to the use of various smokeless tobacco products.

He acknowledges that smokeless tobacco is less addictive than smoked tobacco, but warns that at least 60% of people who use snus to quit smoking become chronic snus users.

Both Action on Smoking and Health and the Royal College of Physicians of London have considered providing safer sources of nicotine as a harm reduction option, but Macara fears that, if legalised, snus might be taken up by people, especially the young, who might never have smoked tobacco but who may then progress to doing so.

The tobacco industry's constant defence is that tobacco is a legal product, he says. But if we had known before tobacco was ever used, how disastrous it would prove to be, would it not have been banned in all its forms?

Contacts:
Yes: John Britton, Professor of Epidemiology, City Hospital, Nottingham, UK
Email: j.britton@virgin.net
No: Alexander Macara, President, National Heart Forum, Bristol, UK
Email: alexandermacara@yahoo.co.uk

(3) One in four stroke patients die within a month
(Editorial: Functional status and long term outcome of stroke)
http://www.bmj.com/cgi/content/short/336/7637/337

Despite advances in prevention, acute care, and rehabilitation, 20-30% of stroke patients in the UK die within a month and 13% of survivors are discharged to institutional care, according to experts in this week's BMJ.

Their views follow a study published on bmj.com last month which found the more independent patients are six months after a stroke, the better their chances of long term survival.

Despite undoubted progress, we still have much to do, argue Richard Thomson and Helen Rodgers from Newcastle University's Medical Faculty.

For example, most acute trusts in the UK now have a stroke unit, but in 2006 only 62% of patients in the UK were admitted to a stroke unit and only 54% spent more than half of their inpatient stay on one, they say.

Thrombolysis (giving anti-clotting drugs within three hours of an acute stroke) reduces death and disability, yet in 2006 only 30 trusts in the UK provide this service, and even fewer provide it at all hours of the day, they add.

And, although up to 20% of stroke patients may be eligible for thrombolytic treatment, in 2006 only 218 patients - less than 0.5% of patients with acute ischaemic stroke in England, Wales, and Northern Ireland - received it.

Early supported discharge by a specialist stroke team can also improve outcome, yet provision of this service is limited.

Research has largely focused on prevention and care soon after stroke, and less upon interventions to improve care for survivors and on how to minimise the long term effects of stroke.

Patients and their carers often report feeling abandoned after discharge and that they are badly informed and supported, both practically and emotionally.

The national stroke strategy, published in December 2007, emphasises the importance of service development and implementing evidence based practice as well as involving patients, carers, health professionals, social services, and charities in shaping local stroke services.

Let us hope that these admirable aims will become the template for both commissioners and providers of care to seize the opportunity to enhance the health and wellbeing of a substantial and, to date, underserved group of patients, they conclude.

Contactss:
Richard Thomson, Professor of Epidemiology and Public Health, Institute of Health and Society, Newcastle University Medical School, UK
Email: richard.thomson@newcastle.ac.uk
Helen Rodgers, Reader in Stroke Medicine, Newcastle University Medical School, UK
Email: helen.rodgers@newcastle.ac.uk

(4) Infertility will become more common in generations to come, say experts
(Editorial: Interpreting trends in fecundity over time)
http://www.bmj.com/cgi/content/short/336/7640/339

Infertility will become more prevalent in generations to come, but interpreting these trends is complicated, say researchers in this week's BMJ.

Infertility is a common problem in affluent societies, write experts from Aarhus University Hospital Denmark and the University of California in an editorial. It affects around 15% of couples trying to conceive, although not all seek medical help.

In some countries, up to 6% of children are conceived through assisted reproductive techniques.

But examining changes in fecundity over time is difficult, say the authors, because fertility is determined by social, behavioural, and biological factors that cannot be reliably ascertained in studies based on retrospectively collected data.

These cultural and social norms may mask more subtle biological changes in the population.

More direct markers of fecundity are urgently needed, they say, and the time has probably come to include fecundity in ongoing representative health surveys.

They predict that fecundity is expected to decline over time, even if no environmental causes are identified. This is because, with the advent of assisted conception, subfertile couples may have as many children as fertile couples, so genetic factors linked to infertility will become more prevalent in the generations to come.

The best way to counteract infertility and help couples to have children naturally is to deal with the avoidable causes of subfecundity, say the authors, and there are good grounds for promoting further research and for trying to make up for the many years during which research into infertility has been neglected.

The endocrine disruption hypothesis - which states that environmental chemicals may cause adverse development of sexual organs by interference with hormonal regulation - is just one of many hypotheses that deserve attention from funding agencies, they conclude.

Contacts:
Jens Peter Ellekilde Bonde, Professor of Occupational Medicine, Department of Occupational Medicine, Aarhus University Hospital, Aarhus, Denmark
Email: jpbon@as.aaa.dk
Jørn Olsen, Professor of Epidemiology, University of California, Los Angeles, USA
Email: jo@ucla.edu

(5) Group education for diabetes patients can change behaviour and improve health
(Effectiveness of the diabetes education for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial)
http://www.bmj.com/cgi/content/short/bmj.39474.922025.BEv1
(Editorial: Structured education in people with type 2 diabetes)
http://www.bmj.com/cgi/content/short/bmj.39478.693715.80v1

A structured group education programme for people with newly diagnosed type 2 diabetes can successfully change patients' attitudes and behaviour towards their condition and improve their health, according to a study published on bmj.com today.

Type 2 diabetes affects around 4-5% of European populations and consumes a disproportionate amount of health service resource. In the long-term, it can lead to serious complications such as blindness, kidney failure, and amputation. It is also associated with increased illness and premature death from heart disease.

Although the Diabetes National Service Framework in the UK promotes group structured education, until now, there has been no scientific evaluation and no programmes meeting all the quality criteria identified by the National Institute for Health and Clinical Excellence.

So researchers set out to test whether the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) structured education programme could fill this evidence gap.

Their study involved 824 patients with newly diagnosed type 2 diabetes at 207 general practices in England and Scotland. The average age of participants was 59.5 years.

Participants were divided into two groups. The intervention group received a six-hour structured group education programme delivered in the community by two trained health care professional educators. The control group received usual care. All patients were monitored over 12 months.

The intervention group showed a modest but significant weight loss (1.1kg) at 12 months. The proportion giving up smoking was also significantly higher in the intervention group.

However, there was no difference in blood glucose levels (HbA1c) between the groups.

Self-reported physical activity was greater in the intervention group at 4 months, but this difference was not present at 8 and 12 months. But there was a greater improvement in risk for coronary heart disease at 12 months.

The intervention group showed greater understanding of their illness and its seriousness. They showed a better perception of the duration of their diabetes and of their ability to affect the course of their diabetes through lifestyle changes.

They also experienced less depression, which is often linked to poor blood sugar control and increased mortality in patients with diabetes.

In summary, this programme encapsulates a patient centred approach to diabetes care, say the authors.

This trial has filled an existing gap in the evidence base and has shown that group structured education focused on behaviour change can successfully engage patients in starting additional effective lifestyle changes sustainable over 12 months from diagnosis, they conclude.

An accompanying editorial points out that the challenge is to maintain the patient centred emphasis beyond the initial delivery of the education programme.

Contacts:
Marian Carey, National Director, DESMOND Programme, University Hospitals of Leicester NHS Trust, UK
Tel: +44 (0)7971 105 165
Helen Dallosso, Research Associate, DESMOND Programme, University Hospitals of Leicester NHS Trust, UK
Tel: +44 (0)116 258 7290

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