Age,period, and cohort patterns in the epidemiology of suicide attempts among sexual minorities in the United States and Canada: detection of a second peak in middle adulthood

Purpose

Sexual minority adults experience fivefold greater risk of suicide attempt, as compared with heterosexuals. Establishing age-specific epidemiological patterns of suicide is a prerequisite to planning interventions to redress the sexual orientation suicide inequity, and such patterns must be carefully interpreted in light of correlated period and cohort effects. We, therefore, combined US and Canadian data (1985–2017) from primary (two pooled multi-year national surveys, N = 15,477 and N = 126,463) and secondary (published, meta-analytic, N = 122,966) sources to separately estimate age, period, and cohort trends in self-reported suicide attempts among sexual minorities.

Methods

Age- and gender-stratified cross-sectional data were used to infer age and cohort effects. Age-collapsed meta-analyzed data were used to infer period effects among sexual minorities of all genders.

Results

We identified a bimodal age distribution in recent suicide attempts for sexual minorities across genders, though more pronounced among sexual minority men: one peak in adolescence (18–20 years of age for both genders) and one peak nearing mid-life (30–35 years of age for men; 35–40 years of age for women). This pattern was also apparent using recall data within birth cohorts of sexual minority men, suggesting it is not an artifact of birth cohort effects. Finally, we observed decreasing trends in lifetime suicide attempt prevalence estimates for both sexual minorities and heterosexuals, though these decreases did not affect the magnitude of the sexual orientation disparity.

Conclusion

In the context of exclusively adolescent-focused suicide prevention interventions for sexual minorities, tailored suicide prevention for sexual minority adults should be pursued throughout the life course.

     

Spanish Medical Interpreters’ Management of Challenges in End of Life Discussions

ObjectiveProfessional medical interpreters facilitate patient understanding of illness, prognosis, and treatment options. Facilitating end of life discussions can be challenging. Our objective was to better understand the challenges professional medical interpreters face and how they affect the accuracy of provider-patient communication during discussions of end of life.MethodsWe conducted semi-structured interviews with professional Spanish medical interpreters. We asked about their experiences interpreting end of life discussions, including questions about values, professional and emotional challenges interpreting these conversations, and how those challenges might impact accuracy. We used a grounded theory, constant comparative method to analyze the data. Participants completed a short demographic questionnaire.ResultsSeventeen Spanish language interpreters participated. Participants described intensive attention to communication accuracy during end of life discussions, even when discussions caused emotional or professional distress. Professional strains such as rapid discussion tempo contributed to unintentional alterations in discussion content. Perceived non-empathic behaviors of providers contributed to rare, intentional alterations in discussion flow and content.ConclusionWe found that despite challenges, Spanish language interpreters focus intensively on accurate interpretation in discussions of end of life.Practice ImplicationsProvider training on how to best work with interpreters in these important conversations could support accurate and empathetic interpretation.     

Fear learning circuitry is biased toward generalization of fear associations in posttraumatic stress disorder

Fear conditioning is an established model for investigating posttraumatic stress disorder (PTSD). However, symptom triggers may vaguely resemble the initial traumatic event, differing on a variety of sensory and affective dimensions. We extended the fear-conditioning model to assess generalization of conditioned fear on fear processing neurocircuitry in PTSD. Military veterans (n=67) consisting of PTSD (n=32) and trauma-exposed comparison (n=35) groups underwent functional magnetic resonance imaging during fear conditioning to a low fear-expressing face while a neutral face was explicitly unreinforced. Stimuli that varied along a neutral-to-fearful continuum were presented before conditioning to assess baseline responses, and after conditioning to assess experience-dependent changes in neural activity. Compared with trauma-exposed controls, PTSD patients exhibited greater post-study memory distortion of the fear-conditioned stimulus toward the stimulus expressing the highest fear intensity. PTSD patients exhibited biased neural activation toward high-intensity stimuli in fusiform gyrus (P<0.02), insula (P<0.001), primary visual cortex (P<0.05), locus coeruleus (P<0.04), thalamus (P<0.01), and at the trend level in inferior frontal gyrus (P=0.07). All regions except fusiform were moderated by childhood trauma. Amygdala–calcarine (P=0.01) and amygdala–thalamus (P=0.06) functional connectivity selectively increased in PTSD patients for high-intensity stimuli after conditioning. In contrast, amygdala–ventromedial prefrontal cortex (P=0.04) connectivity selectively increased in trauma-exposed controls compared with PTSD patients for low-intensity stimuli after conditioning, representing safety learning. In summary, fear generalization in PTSD is biased toward stimuli with higher emotional intensity than the original conditioned-fear stimulus. Functional brain differences provide a putative neurobiological model for fear generalization whereby PTSD symptoms are triggered by threat cues that merely resemble the index trauma.     

PTSD in Latino Patients: Illness Beliefs, Treatment Preferences, and Implications for Care

Background  Little is known about how Latinos with post-traumatic stress disorder (PTSD) understand their illness and their preferences for mental health treatment. Objective  To understand the illness beliefs and treatment preferences of Latino immigrants with PTSD. Design  Semi-structured, face-to-face interviews. Participants  Sixty foreign-born, Latino adults recruited from five primary care centers in New York and New Jersey and screened for PTSD. Approach  Content analytic methods identified common themes, their range, and most frequent or typical responses. Results  Participants identified their primary feelings as sadness, anxiety, nervousness, and fear. The most common feeling was “sad” (triste). Other words frequently volunteered were “angry” (enojada), “nervous” (nerviosa), and “scared” (miedo). Participants viewed their PTSD as impairing health and functioning. They ascribed their somatic symptoms and their general medical problems to the “stress” from the trauma and its consequences on their lives. The most common reason participants volunteered for their work and school functioning being impaired was their poor concentration, often due to intrusive thoughts. Most expressed their desire to receive mental health treatment, to receive it within their primary care center, and preferred psychotherapy over psychotropic medications. Among participants who did not report wanting treatment, most said it was because the trauma was “in the past.” Conclusions  Clinicians may consider enquiring about PTSD in Latino patients who report feeling sad, anxious, nervous, or fearful. Our study suggests topics clinicians may include in the psychoeducation of patients with PTSD.     

An unusual cause of acute renal failure in systemic sclerosis

BACKGROUND: Scleroderma renal crisis is one of the most life threatening complications of scleroderma. Enteric hyperoxaluria complicates extensive disease or resection of the small intestine in the presence of an intact colon, and is associated with calcium oxalate nephrolithiasis. This cause of renal failure may be underestimated and should be considered in all patients with malabsorption and renal failure. CASE REPORT: A 78 year old woman with systemic sclerosis affecting the bowel developed acute renal failure caused by oxalate nephropathy. RESULTS: The patient's renal failure improved on an oxalate free diet.