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Wu Q, Xing X, Yang M, Bai Z, He Q, Cheng Q, Hu J, Wang H, Fan Y, Su H, Liu Z, Cheng J. Increased Suicide Mortality and Reduced Life Expectancy Associated With Ambient Heat Exposure. Am J Prev Med 2024; 66:780-788. [PMID: 38311191 DOI: 10.1016/j.amepre.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Ambient heat exposure is a risk factor for suicide in many regions of the world. However, little is known about the extent to which life expectancy has been shortened by heat-related suicide deaths. This study aimed to evaluate the short-term effects of heat on suicide mortality and quantify the reduced life expectancy associated with heat in China. METHODS A time-stratified, case-crossover analysis in 2023 was performed during the warm season (May to September) from 2016 to 2020 to assess the short-term association between extreme heat (the 95th percentile of mean temperature) and suicide mortality in Anhui Province, China. A subgroup analysis was performed according to sex, age, marital status, suicide type, and region. The attributable fraction and years of life lost due to heat were calculated, and the heat-related life expectancy loss was estimated. RESULTS This study included 9,642 suicide deaths, with an average age of 62.4 years and 58.8% of suicides in males. Suicide risk was associated with an 80.7% increase (95% confidence interval [CI]: 21.4%-68.9%) after exposure to extreme heat (30.6°C) in comparison to daily minimum temperature (7.9°C). Subgroup analysis revealed that heat-related suicide risk was more prominent in the married population than in the unmarried population. Heat was estimated to be associated with 31.7% (95% CI: 18.0%-43.2%) of the suicides, corresponding to 7.0 years of loss in life expectancy for each decedent. CONCLUSIONS Heat exposure was associated with an increased risk of suicide and reduced life expectancy. However, further prospective studies are required to confirm this relationship.
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Affiliation(s)
- Qiyue Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Major Autoimmune Disease, Hefei, China
| | - Xiuya Xing
- Anhui Provincial Center for Disease Control and Prevention, Hefei, China; Public Health Research Institute of Anhui Province, Hefei, China
| | - Min Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Major Autoimmune Disease, Hefei, China
| | - Zhongliang Bai
- Department of Health Services Management, School of Health Services Management, Anhui Medical University, Hefei, China
| | - Qin He
- Anhui Provincial Center for Disease Control and Prevention, Hefei, China; Public Health Research Institute of Anhui Province, Hefei, China
| | - Qianyao Cheng
- Anhui Provincial Center for Disease Control and Prevention, Hefei, China; Public Health Research Institute of Anhui Province, Hefei, China
| | - Jingyao Hu
- Anhui Provincial Center for Disease Control and Prevention, Hefei, China; Public Health Research Institute of Anhui Province, Hefei, China
| | - Huadong Wang
- Anhui Provincial Center for Disease Control and Prevention, Hefei, China; Public Health Research Institute of Anhui Province, Hefei, China
| | - Yinguang Fan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Major Autoimmune Disease, Hefei, China
| | - Hong Su
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Major Autoimmune Disease, Hefei, China
| | - Zhirong Liu
- Anhui Provincial Center for Disease Control and Prevention, Hefei, China; Public Health Research Institute of Anhui Province, Hefei, China.
| | - Jian Cheng
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China; Anhui Province Key Laboratory of Major Autoimmune Disease, Hefei, China.
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Shoib S, Hussaini SS, Armiya’u AY, Saeed F, Őri D, Roza TH, Gürcan A, Agrawal A, Solerdelcoll M, Lucero-Prisno III DE, Nahidi M, Swed S, Ahmed S, Chandradasa M. Prevention of suicides associated with global warming: perspectives from early career psychiatrists. Front Psychiatry 2023; 14:1251630. [PMID: 38045615 PMCID: PMC10693336 DOI: 10.3389/fpsyt.2023.1251630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 10/30/2023] [Indexed: 12/05/2023] Open
Abstract
Climate change poses significant challenges to global mental health, with potential consequences including increased rates of suicide and mental health disorders. Early Career Psychiatrists (ECPs) play a crucial role in addressing these challenges. The Climate Psychiatry Alliance, a group of psychiatrists dedicated to improving mental health amidst climate change, recognizes the importance of cultivating climate-aware ECPs. Training ECPs to become confident climate-aware clinicians enables them to effectively treat patients experiencing anxiety, depression, and PTSD in the context of climate-related distress. Together with other mental health professionals, ECPs can contribute to efforts by implementing strategies for monitoring and treating mental health problems arising from climate events. Additionally, they can raise awareness about the psychological consequences and risks of suicide associated with climate change. Collaboration among ECPs from various regions is essential in developing community-based approaches and reducing vulnerabilities. ECPs must prioritize supporting vulnerable populations by advocating for increased funding for mental health support and research in affected areas. Long-term solutions to address the mental health impacts of climate change and global warming should be pursued to mitigate future suicidality. Integrating climate considerations into local mental health programs and expanding psychological support services is crucial. By promoting emotional resilience and self-awareness, ECPs can contribute to building a more climate-resilient and mentally healthy society.
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Affiliation(s)
- Sheikh Shoib
- Department of Health Services, Srinagar, India
- Sharda University, Greater Noida, India
- Psychosis Research Centre, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
- Healing Mind and Wellness Initiative, Nawab Bzar, Srinagar, India
| | | | - Aishatu Yusha’u Armiya’u
- Department of Psychiatry, College of Medical Sciences, Abubakar Tafawa Balewa University, Bauchi, Nigeria
| | | | - Dorottya Őri
- Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
- Department of Mental Health, Heim Pal National Paediatric Institute, Budapest, Hungary
| | - Thiago Henrique Roza
- Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ahmet Gürcan
- Department of Psychiatry, Başkent University Medical Faculty, Ankara, Türkiye
| | - Aditi Agrawal
- St Elizabeth Medical Centre, Boston University Affiliate, Boston, MA, United States
| | - Mireia Solerdelcoll
- Department of Child and Adolescent Psychiatry, Institute of Psychology, Psychiatry and Neuroscience, King’s College London, London, United Kingdom
- Department of Child and Adolescent Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Don Eliseo Lucero-Prisno III
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mahsa Nahidi
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sarya Swed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | - Saeed Ahmed
- Institute of Behavioural Sciences, Semmelweis University, Budapest, Hungary
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Sarlon J, Partonen T, Lang UE. Potential links between brown adipose tissue, circadian dysregulation, and suicide risk. Front Neurosci 2023; 17:1196029. [PMID: 37360180 PMCID: PMC10288144 DOI: 10.3389/fnins.2023.1196029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/12/2023] [Indexed: 06/28/2023] Open
Abstract
Circadian desynchronizations are associated with psychiatric disorders as well as with higher suicidal risk. Brown adipose tissue (BAT) is important in the regulation of body temperature and contributes to the homeostasis of the metabolic, cardiovascular, skeletal muscle or central nervous system. BAT is under neuronal, hormonal and immune control and secrets batokines: i.e., autocrine, paracrine and endocrine active substances. Moreover, BAT is involved in circadian system. Light, ambient temperature as well as exogen substances interact with BAT. Thus, a dysregulation of BAT can indirectly worsen psychiatric conditions and the risk of suicide, as one of previously suggested explanations for the seasonality of suicide rate. Furthermore, overactivation of BAT is associated with lower body weight and lower level of blood lipids. Reduced body mass index (BMI) or decrease in BMI respectively, as well as lower triglyceride concentrations were found to correlate with higher risk of suicide, however the findings are inconclusive. Hyperactivation or dysregulation of BAT in relation to the circadian system as a possible common factor is discussed. Interestingly, substances with proven efficacy in reducing suicidal risk, like clozapine or lithium, interact with BAT. The effects of clozapine on fat tissue are stronger and might differ qualitatively from other antipsychotics; however, the significance remains unclear. We suggest that BAT is involved in the brain/environment homeostasis and deserves attention from a psychiatric point of view. Better understanding of circadian disruptions and its mechanisms can contribute to personalized diagnostic and therapy as well as better assessment of suicide risk.
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Affiliation(s)
- Jan Sarlon
- University Psychiatric Clinics (UPK), University of Basel, Basel, Switzerland
| | - Timo Partonen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Undine E. Lang
- University Psychiatric Clinics (UPK), University of Basel, Basel, Switzerland
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Frangione B, Rodríguez Villamizar LA, Lang JJ, Colman I, Lavigne E, Peters C, Anisman H, Villeneuve PJ. Short-term changes in meteorological conditions and suicide: A systematic review and meta-analysis. ENVIRONMENTAL RESEARCH 2022; 207:112230. [PMID: 34688638 DOI: 10.1016/j.envres.2021.112230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/08/2021] [Accepted: 10/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Suicide is a leading cause of death, particularly for young adults. Suicidal behaviours are influenced by a wide-range of personal, social, and cultural factors. Emerging evidence suggests that daily changes in meteorological conditions, including temperature, increases the risk of suicide. METHODS We conducted a systematic review and meta-analysis of studies that examined associations between either daily, or weekly, variations for eight meteorological variables and suicide outcomes (attempts, or deaths). Meta-analytic methods were applied to derive summary measures of association using random effect models. We assessed the heterogeneity in these associations by region and biological sex. RESULTS We identified 29 studies of suicide. Of these, 26 reported associations between temperature, while fewer studies reported on rain (n = 4), solar radiation (n = 4), humidity (n = 3), sunshine (n = 3), atmospheric pressure (n = 2), wind (n = 2) and cloud cover (n = 2). The overall relative risk for suicide deaths/attempts per 1 °C increase in ambient temperature was 1.016 (95% CI: 1.013-1.019). Subgroup analysis of temperature found stronger associations with suicide when using the maximum rather than the mean daily temperature, among men, and for completed suicides relative to attempts. Regionally, the strongest associations were found in the East Asia and Pacific region. While associations were found for solar radiation and cloud coverage and suicide, we did not undertake a meta-analysis for these exposures as it was not possible to standardize measures of association across studies. Statistically significant associations were not observed for other identified meteorological variables. CONCLUSIONS Our findings suggest that daily increases in temperature increase the risk of suicide, particularly, among men and in the East Asia and Pacific region.
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Affiliation(s)
- Brianna Frangione
- Faculty of Science, Department of Health Sciences, Carleton University, K1S 5B6, Ottawa, Canada
| | | | - Justin J Lang
- Public Health Agency of Canada, Centre for Surveillance and Applied Research, K1S 5H4, Ottawa, Canada; Faculty of Science, Department of Neuroscience, Carleton University, K1S 5B6, Ottawa, Canada
| | - Ian Colman
- School of Mathematics and Statistics, Carleton University, K1S 5B6, Ottawa, Canada
| | - Eric Lavigne
- Faculty of Medicine, Department of Epidemiology and Public Health, University of Ottawa/université d'Ottawa, K1N 6N5, Ottawa, Canada; Health Canada/Santé Canada, K1A 0K9, Ottawa, Canada
| | - Cheryl Peters
- School of Epidemiology and Public Health, University of Ottawa, K1N 6N5, Ottawa, Canada; Cancer Epidemiology and Prevention Research, Alberta Health Services, T2S 3C3, Calgary, Canada
| | - Hymie Anisman
- Cumming School of Medicine, University of Calgary, T2N 4N1, Calgary, Canada
| | - Paul J Villeneuve
- Faculty of Science, Department of Neuroscience, Carleton University, K1S 5B6, Ottawa, Canada; CHAIM Research Centre, Carleton University, K1S 5B6, Ottawa, Canada.
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Casas L, Cox B, Nemery B, Deboosere P, Nawrot TS. High temperatures trigger suicide mortality in Brussels, Belgium: A case-crossover study (2002-2011). ENVIRONMENTAL RESEARCH 2022; 207:112159. [PMID: 34606845 DOI: 10.1016/j.envres.2021.112159] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 09/28/2021] [Accepted: 09/28/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Temperature may trigger the risk of suicide, however, the extent and shape of the associations show geographical variation. Here, we investigate the short-term effects of temperature on suicide deaths occurring in Brussels between January 1st, 2002 and December 31st, 2011. METHODS We conducted a bidirectional time-stratified case-crossover study with cases being suicide deaths occurring among Brussels residents aged 5 years or older. Cases were matched by day of the week with control days from the same month and year. The exposure was the daily average temperature measured at the Uccle station (Brussels) and obtained from the Belgian Royal Meteorological Institute. We combined conditional logistic regression with distributed lag non-linear models (DLNM) to obtain one week (lag 0-6) cumulative risk ratios (RR) and their 95% confidence intervals (CI) for the effects of moderate and extreme cold (5th and 1st percentiles of temperature, respectively) and moderate and extreme heat (95th and 99th percentiles of temperature, respectively), relative to the median temperature. RESULTS In total, 1891 suicide deaths were included. The median temperature was 11.6 °C, moderate and extreme cold temperatures were 0 and -3.1 °C, respectively, and moderate and extreme high temperatures were 20.9 and 24.4 °C, respectively. The cumulative risk of suicide mortality was almost twice higher among lags 0 to 6 for both moderate and extreme heat, relative to the period median temperature (e.g. moderate heat RR = 1.80 CI:1.27-2.54). No statistically significant associations were observed for cold temperatures. CONCLUSIONS In Brussels, a western European city with temperate climate, high temperatures may trigger suicide deaths up to one week later. In the context of climate change, adaptation strategies must take into consideration the effects of temperature on mental health.
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Affiliation(s)
- Lidia Casas
- Social Epidemiology and Health Policy, Department Family Medicine and Population Health, University of Antwerp, Doornstraat 331, 2610, Wilrijk, Belgium; Institute for Environment and Sustainable Development (IMDO), University of Antwerp, Belgium.
| | - Bianca Cox
- Centre for Environmental Sciences, Hasselt University, Agoralaan Gebouw, D 3590, Diepenbeek, Belgium
| | - Benoit Nemery
- Centre for Environment and Health - Department of Public Health and Primary Care, KU Leuven, Herestraat 49, Leuven, Belgium
| | - Patrick Deboosere
- Interface Demography, Sociology Department, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium
| | - Tim S Nawrot
- Centre for Environmental Sciences, Hasselt University, Agoralaan Gebouw, D 3590, Diepenbeek, Belgium; Centre for Environment and Health - Department of Public Health and Primary Care, KU Leuven, Herestraat 49, Leuven, Belgium
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Liu J, Varghese BM, Hansen A, Xiang J, Zhang Y, Dear K, Gourley M, Driscoll T, Morgan G, Capon A, Bi P. Is there an association between hot weather and poor mental health outcomes? A systematic review and meta-analysis. ENVIRONMENT INTERNATIONAL 2021; 153:106533. [PMID: 33799230 DOI: 10.1016/j.envint.2021.106533] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Mental health is an important public health issue globally. A potential link between heat exposure and mental health outcomes has been recognised in the scientific literature; however, the associations between heat exposure (both high ambient temperatures and heatwaves) and mental health-related mortality and morbidity vary between studies and locations. OBJECTIVE To fill gaps in knowledge, this systematic review aims to summarize the epidemiological evidence and investigate the quantitative effects of high ambient temperatures and heatwaves on mental health-related mortality and morbidity outcomes, while exploring sources of heterogeneity. METHODS A systematic search of peer-reviewed epidemiological studies on heat exposure and mental health outcomes published between January 1990 and November 2020 was conducted using five databases (PubMed, Embase, Scopus, Web of Science and PsycINFO). We included studies that examined the association between high ambient temperatures and/or heatwaves and mental health-related mortality and morbidity (e.g. hospital admissions and emergency department visits) in the general population. A range of mental health conditions were defined using ICD-10 classifications. We performed random effects meta-analysis to summarize the relative risks (RRs) in mental health outcomes per 1 °C increase in temperature, and under different heatwaves definitions. We further evaluated whether variables such as age, sex, socioeconomic status, and climate zone may explain the observed heterogeneity. RESULTS The keyword search yielded 4560 citations from which we identified 53 high temperatures/heatwaves studies that comprised over 1.7 million mental health-related mortality and 1.9 million morbidity cases in total. Our findings suggest associations between heat exposures and a range of mental health-related outcomes. Regarding high temperatures, our meta-analysis of study findings showed that for each 1 °C increase in temperature, the mental health-related mortality and morbidity increased with a RR of 1.022 (95%CI: 1.015-1.029) and 1.009 (95%CI: 1.007-1.015), respectively. The greatest mortality risk was attributed to substance-related mental disorders (RR, 1.046; 95%CI: 0.991-1.101), followed by organic mental disorders (RR, 1.033; 95%CI: 1.020-1.046). A 1 °C temperature rise was also associated with a significant increase in morbidity such as mood disorders, organic mental disorders, schizophrenia, neurotic and anxiety disorders. Findings suggest evidence of vulnerability for populations living in tropical and subtropical climate zones, and for people aged more than 65 years. There were significant moderate and high heterogeneities between effect estimates in overall mortality and morbidity categories, respectively. Lower heterogeneity was noted in some subgroups. The magnitude of the effect estimates for heatwaves varied depending on definitions used. The highest effect estimates for mental health-related morbidity was observed when heatwaves were defined as "mean temperature ≥90th percentile for ≥3 days" (RR, 1.753; 95%CI: 0.567-5.421), and a significant effect was also observed when the definition was "mean temperature ≥95th percentile for ≥3 days", with a RR of 1.064 (95%CI: 1.006-1.123). CONCLUSIONS Our findings support the hypothesis of a positive association between elevated ambient temperatures and/or heatwaves and adverse mental health outcomes. This problem will likely increase with a warming climate, especially in the context of climate change. Further high-quality studies are needed to identify modifying factors of heat impacts.
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Affiliation(s)
- Jingwen Liu
- School of Public Health, The University of Adelaide, Australia
| | | | - Alana Hansen
- School of Public Health, The University of Adelaide, Australia
| | - Jianjun Xiang
- School of Public Health, The University of Adelaide, Australia; School of Public Health, Fujian Medical University, China
| | - Ying Zhang
- Sydney School of Public Health, The University of Sydney, Australia
| | - Keith Dear
- School of Public Health, The University of Adelaide, Australia
| | - Michelle Gourley
- Burden of Disease and Mortality Unit, Australian Institute of Health and Welfare, Australia
| | - Timothy Driscoll
- Sydney School of Public Health, The University of Sydney, Australia
| | - Geoffrey Morgan
- Sydney School of Public Health, The University of Sydney, Australia
| | - Anthony Capon
- Monash Sustainable Development Institute, Monash University, Australia
| | - Peng Bi
- School of Public Health, The University of Adelaide, Australia.
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Cornelius SL, Berry T, Goodrich AJ, Shiner B, Riblet NB. The Effect of Meteorological, Pollution, and Geographic Exposures on Death by Suicide: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18157809. [PMID: 34360101 PMCID: PMC8345465 DOI: 10.3390/ijerph18157809] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/07/2021] [Accepted: 07/20/2021] [Indexed: 12/07/2022]
Abstract
Suicide is a significant public health concern worldwide and in the United States. Despite the far-reaching impact of suicide, risk factors are still not well understood and efforts to accurately assess risk have fallen short. Current research has highlighted how potentially modifiable environmental exposures (i.e., meteorological, pollution, and geographic exposures) can affect suicide risk. A scoping review was conducted to evaluate the strength of the historical and current literature on the environment’s effect on suicide and suicide risk. Three databases (i.e., Medline, Embase, and PsychInfo) were reviewed to identify relevant studies and two authors independently reviewed studies considering pre-determined inclusion criteria. A total of 46 meteorological studies were included as well as 23 pollution studies and 12 geographic studies. Descriptive statistics, including counts, percentages, review of studies’ sample size (minimum, maximum, median, and interquartile range), were calculated using Excel and SAS 9.4. Overall, strong evidence supports that exposure to sunlight, temperature, air pollution, pesticides, and high altitude increases suicide risk, although effect sizes range from very small to small.
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Affiliation(s)
- Sarah L. Cornelius
- VA Medical Center, White River Junction, VT 05009, USA; (T.B.); (B.S.); (N.B.R.)
- Correspondence: ; Tel.: +1-(802)-295-9363
| | - Tara Berry
- VA Medical Center, White River Junction, VT 05009, USA; (T.B.); (B.S.); (N.B.R.)
| | - Amanda J. Goodrich
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA 90033, USA;
| | - Brian Shiner
- VA Medical Center, White River Junction, VT 05009, USA; (T.B.); (B.S.); (N.B.R.)
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
| | - Natalie B. Riblet
- VA Medical Center, White River Junction, VT 05009, USA; (T.B.); (B.S.); (N.B.R.)
- Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, USA
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Suicide and Associations with Air Pollution and Ambient Temperature: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147699. [PMID: 34300149 PMCID: PMC8303705 DOI: 10.3390/ijerph18147699] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/17/2021] [Accepted: 07/19/2021] [Indexed: 12/22/2022]
Abstract
Given health threats of climate change, a comprehensive review of the impacts of ambient temperature and ar pollution on suicide is needed. We performed systematic literature review and meta-analysis of suicide risks associated with short-term exposure to ambient temperature and air pollution. Pubmed, Scopus, and Web of Science were searched for English-language publications using relevant keywords. Observational studies assessing risks of daily suicide and suicide attempts associated with temperature, particulate matter with aerodynamic diameter ≤10 μm (PM10) and ≤2.5 mm (PM2.5), ozone (O3), sulfur dioxide (SO2), nitrogen dioxide (NO2), and carbon monoxide (CO) were included. Data extraction was independently performed in duplicate. Random-effect meta-analysis was applied to pool risk ratios (RRs) for increases in daily suicide per interquartile range (IQR) increase in exposure. Meta-regression analysis was applied to examine effect modification by income level based on gross national income (GNI) per capita, national suicide rates, and average level of exposure factors. In total 2274 articles were screened, with 18 studies meeting inclusion criteria for air pollution and 32 studies for temperature. RRs of suicide per 7.1 °C temperature was 1.09 (95% CI: 1.06, 1.13). RRs of suicide per IQR increase in PM2.5, PM10, and NO2 were 1.02 (95% CI: 1.00, 1.05), 1.01 (95% CI: 1.00, 1.03), and 1.03 (95% CI: 1.00, 1.07). O3, SO2, and CO were not associated with suicide. RR of suicide was significantly higher in higher-income than lower-income countries (1.09, 95% CI: 1.07, 1.11 and 1.20, 95% CI: 1.14, 1.26 per 7.1 °C increased temperature, respectively). Suicide risks associated with air pollution did not significantly differ by income level, national suicide rates, or average exposure levels. Research gaps were found for interactions between air pollution and temperature on suicide risks.
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Kubo R, Ueda K, Seposo X, Honda A, Takano H. Association between ambient temperature and intentional injuries: A case-crossover analysis using ambulance transport records in Japan. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 774:145511. [PMID: 33609821 DOI: 10.1016/j.scitotenv.2021.145511] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Epidemiological studies based on mortality and crime data have indicated that short-term exposure to higher temperature increases the risk of suicide and violent crimes. However, there are few studies on non-fatal intentional injury, especially on non-fatal self-harm which is much more common than suicide. OBJECTIVES We aimed to clarify how short-term exposure to temperature is associated with emergency ambulance transport caused by intentional injuries including acts of self-harm and assault. METHOD We applied a time-stratified case-crossover design using a conditional quasi-Poisson regression model for each of the 46 prefectures. All temperatures were converted to percentile value for each prefecture, to account for the varied climate across Japan. A Distributed Lag Non-Linear Model was used to explore the temperature percentile and lag pattern. The prefecture-specific results were combined using a meta-analysis with the random effects model. RESULT Between 2012 and 2015, the number of acts of self-harm and assault across all 46 prefectures totaled 151,801 and 95,861, respectively. We found that as the temperature increased, the relative risk (RRs) for both self-harm and assault behaviors increased in a nearly linear manner. The pooled relative risk at the 99th percentile temperature for self-harm behavior was 1.11 (95% CI: 1.07, 1.15) compared with the risk at the 1st percentile temperature, and that for assault was 1.12 (95% CI: 1.08, 1.16) at lag 0. The RRs were highest at lag0 and less than 1 at lag7-20. CONCLUSION The present study found that short-term exposure to higher temperature promotes the risk of emergency ambulance transport due to acts of self-harm and assault. The lag pattern indicates a possible "displacement" effect. These results suggest that exposure to high temperatures may potentially function as a trigger for intentional injuries.
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Affiliation(s)
- Ryusei Kubo
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Kyoto, Japan
| | - Kayo Ueda
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Kyoto, Japan; Graduate School of Global Environmental Studies, Kyoto University, Kyoto, Japan.
| | - Xerxes Seposo
- School of Tropical Medicine and Global Health, Nagasaki University, Japan
| | - Akiko Honda
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Kyoto, Japan; Graduate School of Global Environmental Studies, Kyoto University, Kyoto, Japan
| | - Hirohisa Takano
- Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Kyoto, Japan; Graduate School of Global Environmental Studies, Kyoto University, Kyoto, Japan
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Bruno RR, Wernly B, Masyuk M, Muessig JM, Schiffner R, Bäz L, Schulze C, Franz M, Kelm M, Jung C. No impact of weather conditions on the outcome of intensive care unit patients. Wien Med Wochenschr 2021; 172:40-51. [PMID: 33738633 PMCID: PMC8837525 DOI: 10.1007/s10354-021-00830-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/10/2021] [Indexed: 11/30/2022]
Abstract
Global warming leads to increased exposure of humankind to meteorological variation, including short-term weather changes. Weather conditions involve changes in temperature, heat and cold, in air pressure and in air humidity. Every single condition influences the incidence and mortality of different diseases such as myocardial infarction and stroke. This study investigated the impact of weather conditions on short- and long-term mortality of 4321 critically ill patients (66 ± 14 years, 2638 men) admitted to an intensive care unit (ICU) over a period of 5 years. Meteorological information (air temperature, air pressure and humidity) for the same period was retrieved. The influence of absolute weather parameters, different seasons, sudden weather changes including "warm" and "cold" spells on ICU and long-term mortality was analyzed. After correction for Simplified Acute Physiology Score (SAPS-2), no impact of meteorological conditions on mortality was found. Different seasons, sudden weather changes, "warm spells" or "cold spells" did not affect the outcome of critically ill patients.
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Affiliation(s)
- Raphael Romano Bruno
- Division of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Bernhard Wernly
- Clinic of Internal Medicine II, Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria.,Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Maryna Masyuk
- Division of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Johanna M Muessig
- Division of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Rene Schiffner
- Department of Neurology, Jena University Hospital, Friedrich Schiller University, Jena, Germany.,Orthopedic Department, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Laura Bäz
- Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology, and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology, and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Division of Cardiology, Angiology, Pneumology, and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf (CARID), Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonary Diseases, and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
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11
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Temporal patterns of suicide and circulatory system disease-related mortality are inversely correlated in several countries. BMC Psychiatry 2021; 21:153. [PMID: 33726707 PMCID: PMC7962271 DOI: 10.1186/s12888-021-03159-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/08/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Nearly 800,000 suicides occur worldwide annually and suicide rates are increasing faster than population growth. Unfortunately, the pathophysiology of suicide remains poorly understood, which has hindered suicide prevention efforts. However, mechanistic clues may be found by studying effects of seasonality on suicide and other mortality causes. Suicides tend to peak in spring-summer periods and nadir in fall-winter periods while circulatory system disease-related mortality tends to exhibit the opposite temporal trends. This study aimed to determine for the first time whether monthly temporal cross-correlations exist between suicide and circulatory system disease-related mortality at the population level. If so and if common biological factors moderate risks for both mortality types, such factors may be discoverable and utilized to improve suicide prevention. METHODS We conducted time series analyses of monthly mortality data from northern (England and Wales, South Korea, United States) and southern (Australia, Brazil) hemisphere countries during the period 2009-2018 (N = 41.8 million all-cause mortality cases). We used a Poisson regression variant of the standard cosinor model to determine peak months of mortality. We also estimated cross-correlations between monthly mortality counts from suicide and from circulatory system diseases. RESULTS Suicide and circulatory disease-related mortality temporal patterns were negatively correlated in Australia (- 0.32), Brazil (- 0.57), South Korea (- 0.32), and in the United States (- 0.66), but no temporal correlation was discernable in England and Wales. CONCLUSIONS The negative temporal cross-correlations between these mortality types we found in 4 of 5 countries studied suggest that seasonal factors broadly and inversely moderate risks for circulatory disease-related mortality and suicide, but not in all regions, indicating that the effect is not uniform. Since the seasonal factors of temperature and light exert opposite effects on suicide and circulatory disease-related mortality in several countries, we propose that physiologically-adaptive circulatory system responses to heat and light may increase risk for suicide and should be studied to determine whether they affect suicide risk. For example, heat and light increase production and release of the bioactive gas nitric oxide and reduce circulatory system disease by relaxing blood vessel tone, while elevated nitric oxide levels are associated with suicidal behavior, inverse effects that parallel the inverse temporal mortality patterns we detected.
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12
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Aguglia A, Giacomini G, Montagna E, Amerio A, Escelsior A, Capello M, Cutroneo L, Ferretti G, Scafidi D, Costanza A, Serafini G, Amore M. Meteorological Variables and Suicidal Behavior: Air Pollution and Apparent Temperature Are Associated With High-Lethality Suicide Attempts and Male Gender. Front Psychiatry 2021; 12:653390. [PMID: 33746805 PMCID: PMC7973231 DOI: 10.3389/fpsyt.2021.653390] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 01/17/2023] Open
Abstract
This study analyzed the impact of meteorological variables and high-lethality suicide attempts (HLSA) to assess a potential time shift of HLSA affected by climate evolution to predict the suicide attempt cases over different periods of the year. After attempting suicide, 225 subjects were admitted to the emergency ward of the IRCCS Ospedale Policlinico San Martino and later to the psychiatric unit from March 2016 to July 2018. Socio-demographic and clinical characteristics as well as the meteorological variables were collected. The Mann-Kendall test as well as redundancy and cross-correlation analyses were performed to analyze the trends, statistically correlations, and correspondence of the trends, respectively between suicidal behaviors and climatic factors. Sixty-seven (29.8%) committed a HLSA. Our findings indicate a significant association between HLSA and male gender and apparent temperature with a strong correlation of 75% with a phase shift of -1 month. Solar radiation and air pollution (PM2.5) have a positive correlation of 65 and 32%, respectively, with a zero-time lag. Limitations include that the data are limited to a single hospital; psychological factors, or other clinical variables that could be ruled out as a trigger have not been considered. Meteorological variables may not mirror the temperature that the patient is exposed to due to the air conditioning systems. Exploring those environmental factors associated with HLSA in a more detailed manner could lead to early intervention and prevention strategies for such distressing admissions.
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Affiliation(s)
- Andrea Aguglia
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Gabriele Giacomini
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Montagna
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Amerio
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy.,Department of Psychiatry, Tufts University, Boston, MA, United States
| | - Andrea Escelsior
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Capello
- Department of Earth, Environment, and Life Sciences, University of Genoa, Genoa, Italy
| | - Laura Cutroneo
- Department of Earth, Environment, and Life Sciences, University of Genoa, Genoa, Italy
| | - Gabriele Ferretti
- Department of Earth, Environment, and Life Sciences, University of Genoa, Genoa, Italy
| | - Davide Scafidi
- Department of Earth, Environment, and Life Sciences, University of Genoa, Genoa, Italy
| | - Alessandra Costanza
- Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), Geneva, Switzerland.,Department of Psychiatry, Azienda Ospedaliera Nazionale Santi Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Gianluca Serafini
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal, and Child Health, University of Genoa, Genoa, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino, Genoa, Italy
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13
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Richardson RA, Harper S, Weichenthal S, Nandi A, Mishra V, Jha P. Extremes in water availability and suicide: Evidence from a nationally representative sample of rural Indian adults. ENVIRONMENTAL RESEARCH 2020; 190:109969. [PMID: 32739270 PMCID: PMC7530027 DOI: 10.1016/j.envres.2020.109969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Extremes in water availability, either exceptionally wet or dry conditions, can damage crops and may detrimentally affect the livelihood and well-being of people engaged in agriculture. We estimated the effect of water availability on suicide in rural India, a context where the majority of households are dependent upon agriculture. METHODS We used data from a nationally representative sample of 8.5 million people who were monitored for causes of death from 2001 to 2013. Water availability was measured with high-resolution precipitation and temperature data (i.e., the Standardized Precipitation Evapotranspiration Index). We used a fixed effects approach that modeled changes in water availability within districts (n = 569) over time (n = 13 years) to estimate the impact on suicide deaths. We restricted our analysis to rural areas and to deaths occurring during the growing season (June-March) among adults aged 15 or older, and controlled for sex, age, region, and year. We used Poisson regression with standard errors clustered at the district level and total deaths as the offset. RESULTS There were 9456 suicides and 249,786 total deaths in our study population between 2001 and 2013. Compared to normal growing seasons, the percent of deaths due to suicide increased by 18.7% during extremely wet growing seasons (95% CI: 6.2, 31.2) and by 3.6% during extremely dry growing seasons (95% CI: -17.9, 25.0). We found that effects varied by age. CONCLUSIONS We found extremes is water availability associated with an increase in suicide. Abnormally wet growing conditions may play an important, yet overlooked, role in suicide among rural Indian adults.
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Affiliation(s)
- Robin A Richardson
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
| | - Sam Harper
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada; Institute for Health and Social Policy, McGill University, Montreal, QC, Canada
| | - Scott Weichenthal
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Arijit Nandi
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada; Institute for Health and Social Policy, McGill University, Montreal, QC, Canada
| | - Vimal Mishra
- Indian Institute of Technology (IIT), Gandhinagar, GJ, India
| | - Prabhat Jha
- Centre for Global Health Research, St. Michael's Hospital and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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14
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Ma Y, Zhou L, Chen K. Burden of cause-specific mortality attributable to heat and cold: A multicity time-series study in Jiangsu Province, China. ENVIRONMENT INTERNATIONAL 2020; 144:105994. [PMID: 32745780 DOI: 10.1016/j.envint.2020.105994] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/12/2020] [Accepted: 07/16/2020] [Indexed: 06/11/2023]
Abstract
Previous epidemiological studies primarily examined the temperature-related mortality burden of all-cause or cardiovascular diseases (CVD) and respiratory diseases. However, evidence on the heat- and cold-attributable mortality burden from other specific causes is limited. This paper aimed to systematically examine the association of heat and cold with a comprehensive spectrum of plausible temperature-related diseases, and to estimate the mortality burdens attributable to heat and cold. In the time-series study of 11 cities in Jiangsu, China, distributed lag non-linear models were applied to estimate city-specific temperature-mortality associations, and then meta-analysis was conducted to pool the estimates. A total of 1,368,648 cases of death were included in this study. Both extreme heat and cold were associated with increased mortality risks from all-cause, CVD, respiratory diseases, nervous diseases, and external causes. Short-term exposures to heat and cold were associated with excess burden of mortality for several specific diseases, accounting for 16.38% (95% eCI, 7.27-22.31%) for myocardial infarction (MI), 12.41% (95% eCI, 8.81-15.07%) for stroke, 27.97% (95% eCI, 18.42-33.35%) for hypertensive heart disease, 25.18% (95% eCI, 18.42-29.63%) for chronic obstructive pulmonary disease, and 28.46% (95% eCI: 4.93-33.57%) for Alzheimer's and dementia. Diabetes was only associated with extreme heat, with 4.61% (95% eCI, 0.13-7.13%) of diabetes mortality attributable to heat. In total, 11.98% (95% eCI, 10.46-13.08%) of mortality was attributable to heat and cold, with 3.49% (95% eCI, 2.87-4.00%) attributable to heat and 8.48% (95% eCI, 7.31-9.49%) attributable to cold, and about 64% of this overall temperature-related mortality burden was found in 6 aforementioned specific causes and about 10% of mortality burden in external causes. Extreme heat and/or cold are associated with increased risks of mortality from a wide range of causes, including previously identified causes in cardiorespiratory diseases and under-studied causes such as diabetes and Alzheimer's and dementia. Future research is needed to confirm the substantial mortality burden of heat and cold.
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Affiliation(s)
- Yiqun Ma
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA; Yale Center on Climate Change and Health, Yale School of Public Health, New Haven, CT, USA.
| | - Lian Zhou
- College of Applied Meteorology, Nanjing University of Information Science and Technology, Nanjing, China; Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China.
| | - Kai Chen
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA; Yale Center on Climate Change and Health, Yale School of Public Health, New Haven, CT, USA
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15
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Kayipmaz S, San I, Usul E, Korkut S. The effect of meteorological variables on suicide. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2020; 64:1593-1598. [PMID: 32440830 DOI: 10.1007/s00484-020-01940-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 06/11/2023]
Abstract
We aimed to reveal the relationship between the meteorological variables and suicide rates (completed suicides and suicide attempts) independently of the seasonal cycle and holiday effects. This is an observational retrospective study. We collected the data on age, gender, and suicide method of all suicide cases transferred to hospitals from the scene by emergency medical services as well as those cases in which the victim died on the scene between January 1, 2017 and June 30, 2019. We also collected data on maximum, minimum, and average temperatures (°C), average humidity (%), and average actual pressure (hPa) measured daily in Ankara. The total number of cases due to suicide between the given dates was 6777. The suicide method in 60.1% of the cases was drug poisoning, which was the most common suicide method. Investigating the effect of meteorological variables on suicide cases (suicide attempts and completed suicides), the present study found that after smoothing the effect of the day of the week and seasonality, an increase in the minimum temperature on the day of the application by 1 unit (1°C degree) leads to an increase in the number of suicides by 0.01 point (0.01 ± 0.005, p = 0.046). There was no significant change in the variables other than the minimum temperature. We believe that the results of the present study will contribute to growing body literature about the epidemiology of suicide. We also believe that there is a need for large-scale studies that include individual data to reveal causality.
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Affiliation(s)
- Selvi Kayipmaz
- Baskent University Faculty of Medicine, Department of Psychiatry, Ankara, Turkey.
| | - Ishak San
- Provincial Health Directorate of Ankara, Director of Emergency Medical Services, Ankara, Turkey
| | - Eren Usul
- Provincial Health Directorate of Ankara, Deputy Director of Emergency Medical Services, Ankara, Turkey
| | - Semih Korkut
- Ministry of Health of Turkey, General Director of Emergency Medical Services, Ankara, Turkey
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