Recent eLetters

Displaying 1-10 letters out of 352 published

  1. Response from the BMJ Open editorial office

    The full date set for this article can be found in Dryad.

    Accessible here:

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  2. Re:The volume of complaints against doctors and how they are handled are not necessarily in the best interests of patients and harms doctors. New solutions are needed based on good quality evidence.

    Flying is safe, and health care is dangerous-why? Prior to 1977, the airline industry ran quality improvement and pilot oversight as medicine does now, using the "Captain of the Ship" model, presuming that quality was to be had by making pilots better and better so they were infallible (and blaming 'pilot error' for bad outcomes.) At Tenerife, KLM's head 747 instructor and head of their safety program made an error, along with other errors that day. The airlines changed their approach to safety and designed resilient systems to catch and prevent errors, instead of blaming people for mistakes. (Punishment was moot, as most erring pilots died with their planes.) Doing the wrong things better, (e.g., current physician review) helps no one, so medicine has the equivalent of hundreds of Tenerife events a year. They happen one life at a time, so don't have the shock value of 3/27/77. Designing all our systems to prevent and correct errors would save lives and careers. When will we learn?

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  3. PubMed citations in Africa

    Thank you for this interesting analysis of scientific productivity in Africa.

    There are a couple of things that are not entirely correct, however.

    I don't think this is the only citation analysis covering Africa published in this millennium. For example, you may have overlooked an analysis of epidemiological citations per population published in 2012 (International Journal of Epidemiology 41:579-588).

    Your Figure 1 is also difficult to understand. A "quintile" is a group that contains one-fifth of the observations, ranked by the variable of interest. You only show four quintiles, which is therefore a contradiction in terms, and there is not an equal number of countries in each quintile.

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  4. Reply to Rachiotis et al: Increased unemployment might not be the cause of the world wide rise in suicide rates

    Recently a paper by Rachiotis et al [1] suggested that suicide rates in Greece rose after 2010 and that unemployment is the crucial etiologic factor.

    A number of significant comments are important concerning the above. The selectivity of the literature these authors review is impressive, especially concerning the literature on the suicidal rates of Greece. First of all, these results are by no means new. It has already been reported by our group with the specific conclusion that only after 2010 a rise in suicides is clearly visible [2-5] while, on the contrary, the authors of the paper under discussion have repeatedly suggested it started already after 2007 [6-10]. We are pleased that our conclusions are finally adopted by other research groups although they seem to present them as novel in the literature.

    The second issue is on causality. The detailed inspection of age and gender specific rates suggests that for males the increase in suicidal rates is present in all age groups except <14, 25-29, and >80. For females the increase is also present in all age groups except 40-54 and 65 -69. However, and this is of outmost importance, the greatest increase in the rates from 2003-2010 in comparison to 2011-2 is seen in females aged 15-19 (149.18%), 20-24 (148.65%), 35-39 (86.24%) and 55-59 (60.74%). In comparison the highest rate for males was seen in the age group 55-59 (61%). These results are not in accord with a male gender by unemployment interaction.

    For the years 1981-2012 the correlation of male suicidal rate to unemployment is 0.54 but for 1981-2010 is -0.09, suggesting that there is no linear relationship. The chart of unemployment and male suicidal rates from 1981-2012 (can not be presented here) clearly shows that it is very difficult to decide when suicides started increasing. Three time points are possible and these are the years 2003, 2007 and 2010, depending on the interpretation of the pattern.

    In previous publications of these authors, the assumption that unemployment is responsible for the rise in the suicide rates is strongly supported. However, two recently published papers by a large group of international researchers clearly disputes the assumption that specifically the changes in unemployment have a direct effect on suicidal rates [11 12]. The temporal sequence and correlation of events (suicides rise first, economic recession follows, synchronization of suicidal rate changes across the continent) suggests there is a close relationship between the economic environment and suicidal rates; however this relationship is not that of a direct cause and effect. This seems to be true for US also since in spite of claims that the rise in unemployment caused a rise of the suicide rate in the US [13], a closer look at the data revealed that also in the US suicides raised first and unemployment followed [3]. The Hungarian data present with a similar picture also [14].

    One could argue that those people who are going to lose their jobs are stressed months before this happens, but 'fear' of unemployment is quite different from unemployment per se, especially since such an assumption suggests that employed people do commit suicide before they become unemployed. Since the rise in suicides also affects prospering countries without high unemployment, including Germany and Norway, another possible explanation is that the changes in the socioeconomic environment and especially in the employment conditions (e.g. flexible employment, more rigid rules) which are now in place almost in every country irrespective of its economic status, have overstressed vulnerable populations (e.g. mental patients). If this is so, prosperity in general will not bring a fall in the suicide rates unless it is accompanied by targeted interventions to support these vulnerable groups which are disproportionally stress by recession. Increased suicide rates are probably a consequence of this disproportionate stress.

    Overall, the authors of the paper under discussion here [1] chose to discuss the literature in an impressively ignoring and biased way, which essentially precluded the discussion of an existing and important argument concerning the relationship of unemployment with suicidality. Interpreting data in different ways is legitimate and part of the scientific method and practice; ignoring and hidding parts of the literature is problematic.

    Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


    1. Rachiotis G, Stuckler D, McKee M, et al. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012). BMJ open 2015;5(3):e007295 doi: 10.1136/bmjopen-2014-007295[published Online First: Epub Date]|.

    2. Fountoulakis KN, Koupidis SA, Grammatikopoulos IA, et al. First reliable data suggest a possible increase in suicides in Greece. Bmj 2013;347:f4900 doi: 10.1136/bmj.f4900[published Online First: Epub Date]|.

    3. Fountoulakis KN, Koupidis SA, Siamouli M, et al. Suicide, recession, and unemployment. Lancet 2013;381(9868):721-2 doi: 10.1016/S0140-6736(13)60573-5[published Online First: Epub Date]|.

    4. Fountoulakis KN, Savopoulos C, Siamouli M, et al. Trends in suicidality amid the economic crisis in Greece. European archives of psychiatry and clinical neuroscience 2013;263(5):441-4 doi: 10.1007/s00406 -012-0385-9[published Online First: Epub Date]|.

    5. Fountoulakis KN, Siamouli M, Grammatikopoulos IA, et al. Economic crisis-related increased suicidality in Greece and Italy: a premature overinterpretation. Journal of epidemiology and community health 2013;67(4):379-80 doi: 10.1136/jech-2012-201902[published Online First: Epub Date]|.

    6. Kentikelenis A, Karanikolos M, Reeves A, et al. Greece's health crisis: from austerity to denialism. Lancet 2014;383(9918):748-53 doi: 10.1016/S0140-6736(13)62291-6[published Online First: Epub Date]|.

    7. Chang SS, Stuckler D, Yip P, et al. Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. Bmj 2013;347:f5239 doi: 10.1136/bmj.f5239[published Online First: Epub Date]|.

    8. Karanikolos M, Mladovsky P, Cylus J, et al. Financial crisis, austerity, and health in Europe. Lancet 2013;381(9874):1323-31 doi: 10.1016/S0140-6736(13)60102-6[published Online First: Epub Date]|.

    9. De Vogli R, Marmot M, Stuckler D. Strong evidence that the economic crisis caused a rise in suicides in Europe: the need for social protection. Journal of epidemiology and community health 2013;67(4):298 doi: 10.1136/jech-2012-202112[published Online First: Epub Date]|.

    10. Stuckler D, Basu S, Suhrcke M, et al. Effects of the 2008 recession on health: a first look at European data. Lancet 2011;378(9786):124-5 doi: 10.1016/S0140-6736(11)61079-9[published Online First: Epub Date]|.

    11. Nordt C, Warnke I, Seifritz E, et al. Modelling suicide and unemployment: a longitudinal analysis covering 63 countries, 2000-11. Lancet Psychiatry 2015

    12. Fountoulakis KN, Kawohl W, Theodorakis PN, et al. Relationship of suicide rates to economic variables in Europe: 2000-2011. The British journal of psychiatry : the journal of mental science 2014 doi: 10.1192/bjp.bp.114.147454[published Online First: Epub Date]|.

    13. Reeves A, Stuckler D, McKee M, et al. Increase in state suicide rates in the USA during economic recession. Lancet 2012;380(9856):1813-4 doi: 10.1016/S0140-6736(12)61910-2S0140-6736(12)61910-2 [pii][published Online First: Epub Date]|.

    14. Fountoulakis KN, Gonda X, Dome P, et al. Possible delayed effect of unemployment on suicidal rates: the case of Hungary. Annals of general psychiatry 2014;13:12 doi: 10.1186/1744-859X-13-12[published Online First: Epub Date]|.

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  5. BMJ Open Study on Abortion Mortality in Mexico Is Deeply Flawed

    A recent study in the BMJ Open that looked at the effect of abortion laws on maternal mortality in Mexico is egregiously flawed and biased. It poses an unacceptable risk to public health because it could be used to advocate the criminalization of necessary healthcare for women. This letter exposes the study's biases and flaws in detail.

    The study purports to show that Mexican states with more restrictive abortion laws have lower maternal mortality rates than states with more permissive laws. Although the authors refrain from hypothesizing a causal link between criminalized abortion and better maternal health outcomes, that counter-intuitive implication comes through nonetheless. It's even clearer in the authors' press release about the study.

    BMJ Open is an open access journal that offers easier and quicker publication of studies, but its website also states: "Our aim is to provide a home for all properly conducted medical research to be fully reported, after a rigorous and transparent peer review process."

    So what happened? Why did BMJ Open accept this study without subjecting it to greater scrutiny? Some anti-abortion language even slipped through--on page three of the study, the authors characterize the Mexican states' constitutional amendments protecting the "unborn" from conception as "progressive changes."

    Leading author Elard Koch (and various other co-authors) have published previous studies related to abortion (in Chile, Colombia, and Mexico), but the methodology of those studies has been shown to be seriously flawed and biased, rendering their conclusions invalid. My blog has a compendium of rebuttals ( disgraceful-example-of-bad-science.html) of Koch et al.'s previous work from both professional and lay sources.

    For example, in 2012, Ipas-Mexico published an analysis ( of maternal and abortion-related mortality in Mexico from 1998 to 2008, showing that one in 13 maternal deaths were from abortion. Koch and some co-authors then published a rebuttal to this, and Ipas responded with a statement that referred to the Guttmacher Institute's previous rebuttals to Koch et al.'s work. Guttmacher had explained and defended ( critique.pdf) widely accepted scientific methodologies for estimating numbers of illegal abortions and resulting maternal mortality rates--which Koch et al. had grossly underestimated.


    The BMJ Open study concludes that "maternal and abortion-related mortality ratios were lower in states with less permissive abortion legislation compared with states with more permissive legislation." However, this is based on arbitrarily dividing Mexican states into two categories using a variable with little significance for maternal mortality: those that ban abortion for reasons of "serious genetic or congenital conditions" in the fetus, and those that don't. It's worth quoting the authors in full to expose the nature of their error:

    "In exploratory analyses, segregating states by the number of exemptions provided in criminal codes did not result in detectable differences in sensitivity analyses, with the exception of abortion allowed by genetic or congenital fetal malformations. The remaining seven exemptions were distributed differentially in almost every state or very few states, thus offering no discrimination potential. Therefore, to differentiate between states with more or less permissive abortion legislation in subsequent statistical analyses, states allowing pregnancy termination due to serious genetic or congenital conditions were considered more permissive (14 states) while the remaining states were considered less permissive (18 states)."

    In other words, the authors subjected each legal exemption to a "sensitivity analysis"--which checks all the data to look for patterns among variables--until they found a variable that happened to show a detectable difference in maternal mortality. They then presented this as the primary finding. This error is called "data dredging" because chance associations between just about any two things are easy to find if you crunch enough numbers. To make their random association sound more meaningful, the authors manipulated the definition of "states with less permissive legislation" into something it didn't actually mean at all.

    Twelve Mexican states actually have a more liberal exemption allowing abortion in cases of serious risk to the woman's health, yet nine of those states ended up in the study's category of "less permissive." This demonstrates the arbitrariness of the chosen exemption factor of fetal anomaly, and indicates that the study could well have come to the opposite conclusion if the health exemption had been chosen as the dividing criterion instead. (All Mexican states allow abortion in cases of rape. Otherwise, abortion is mostly or completely illegal in all states except Yucatan, where it is allowed for economic or social reasons, and the Federal District of Mexico City, which allows abortion on request up to 12 weeks.)

    The selected exemption for fetal anomaly cannot possibly by itself show any trends or differences in abortion mortality rates between states. That's because abortions due to fetal abnormality are always a tiny minority of abortions in any country. In Britain for example, only 1 percent of abortions are carried out for reasons of fetal anomaly, and the numbers are similarly tiny for other countries. Further, almost all abortions for fetal abnormality occur later in pregnancy because the anomaly cannot usually be detected until then.

    In settings like Mexico, the numbers of abortions for fetal anomaly will likely be far smaller than 1 percent regardless of legality, because of stigma and other obstacles. Indeed, here's a study ( showing that most Mexican geneticists advise against abortion when the fetus has a genetic or chromosomal disorder. And there's no reason to assume that the average Mexican woman would even know that abortion might be legally available for reasons of fetal abnormality, let alone that she would have the means, resources, or courage to pursue that option. In other words, abortions for reasons of fetal abnormality must be very rare throughout Mexico, and cannot possibly serve as a proxy for tracking trends in maternal mortality due to abortion.

    This fatal flaw renders the study meaningless and the conclusion invalid, because it relies solely on a rarely occurring variable that would not have any noticeable statistical effect on maternal mortality.


    Similarly, the study assumes that because about half of Mexican states tightened their already strict laws against abortion after 2007--by passing a constitutional amendment protecting "the unborn" from conception --this would have a measurable effect on death from unsafe abortion. There is absolutely no basis for this assumption. Criminal laws restricting most abortions were already in effect everywhere outside Mexico City, so women would not be driven to unsafe abortion in any greater discernible numbers.

    This helps expose the second major flaw in the study: the authors' assumption that abortion law accurately predicts abortion practice. In reality, few Mexican women actually obtain abortions under the legal exemptions due to fear and stigma, lack of resources or knowledge, and refusals by anti-abortion doctors.

    One study (in Spanish: criminalization-of-abortion-continues-in-mexico/) by the Mexico City-based Group on Reproductive Choice (GIRE) showed that between 2007 and 2012, only 39 women in Mexico actually got a legal abortion under the country- wide rape exemption, out of a total of 120 who had applied for one. Why would so few apply? First, most states lack sufficient administrative mechanisms for seeking out a legal abortion under any of the exemptions, which means there's simply no way to even apply for an abortion. Second, abortion is highly stigmatized in Mexico, and it takes courage to apply for one--or seek medical attention after an illegal abortion. At least 679 women in Mexico were reported or sentenced for having an illegal abortion between 2009 and 2011. Mexico is one of at least seven countries in the world that imprisons women for having illegal abortions. From 2007 to 2012, 127 women were put on trial for abortion in Mexico, and in one particularly conservative state, Guanajuato, dozens of women have been prosecuted for abortion since 2000, with some of them receiving sentences of up to 30 years in prison.

    Oddly, Koch et al. never mention such shocking facts, nor do they mention the deeply rooted stigma and shame surrounding abortion in Mexico, the judgmental attitudes of many healthcare workers, or indeed any of the social, economic, or logistical difficulties that may inhibit women from even attempting to exercise their legal right to abortion in Mexico. Instead, the study's methodology and conclusion depend on the unspoken assumption that legal exemptions for abortion mean that all or most of those exempted abortions are actually taking place as needed. Nothing could be further from the truth.


    Koch et al. fail to acknowledge that "do-it-yourself" medical abortions have increased substantially over the last decade or more, with pills to end pregnancy now widely available in Mexico and most other Latin American countries. In fact, the words mifepristone and misoprostol never appear once in the BMJ Open study, which is a serious oversight. Clandestine use of the drug misoprostol is generally accepted as being much safer than traditional and more dangerous methods (for example, significantly reducing the rate of infection), even when women misuse it or misinterpret its effects because they don't have instructions on how to use it or what to expect.

    In one of Koch's 2012 rebuttals to the Guttmacher Institute, he asserted that "no study currently exists to date that seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol in Chile." But he ignored several studies from countries such as Brazil and Mexico that showed significant declines in the severity and number of abortion-related complications and sometimes mortality over the same periods in which misoprostol use has grown.

    In the BMJ Open study, Koch and his co-authors follow the same pattern as in a previous Koch-led study on Chile ( Advisory.2012.05.23.pdf): They underestimate the number of abortions and associated maternal mortality by relying only on official statistical sources, while failing to consider that large numbers of illegal abortions are not accounted for in these sources, and that related complications and deaths may often be misclassified. In a criminalized and stigmatized environment, many women will not admit to having an abortion, and many health professionals will not officially report complications or deaths as caused by abortion, either through ignorance of the real cause, or out of compassion for women and their families.

    Koch et al. claim there is no reason for healthcare professionals in Mexico to "misreport deaths from a suspected illegal abortion" due to the existence of separate reporting codes for various types of abortions, including for an unknown cause. This overlooks the fact that issues with miscoding ( have become more common with misoprostol-related complications. For example, it can be challenging for doctors to distinguish medical abortion from miscarriage or other obstetrical complications. Further, Koch et al.'s analysis ignores the effects of fear and abortion stigma on how abortion occurs in illegal settings and whether complications or deaths resulting from them are reported as such.


    It's already well established--practically self-evident--that maternal mortality can be significantly reduced by educating women, upgrading health systems, and improving access to contraception, skilled birth attendants, clean water, sanitation, and so on. Yet, this study and previous Koch-led studies seem to treat such factors like their own new discovery that obviates any need to reform abortion laws.

    Unsafe abortion is just one of many factors that affect maternal mortality rates, though it's among the top five causes. An estimated 13 percent of maternal mortality globally is due to unsafe abortion. It is simply not possible to try to take into account a lot of contributing factors to maternal mortality and conclude that restrictive abortion laws have little or no effect, because the other factors can easily swamp the effect of unsafe abortion on maternal mortality rates. Is it possible that the authors of the BMJ Open study are using such factors as a smokescreen to cover up the effect of unsafe abortion on maternal mortality?

    Mexico still has a relatively high maternal mortality rate compared to other countries--about 45 per 100,000 live births, compared to 28 for the United States, 13 for Canada, and four for Sweden. In Latin America, where abortion is mostly illegal, it's 22 for Chile and 69 for both Brazil and Argentina (2013 data). It's likely that the declines Mexico has been seeing in maternal mortality would be even steeper if abortion was safe, legal, and accessible, and the same goes for Chile.

    Estimating the incidence of illegal, unsafe abortion as well as the resulting deaths and complications is of course a challenging task. Such abortions are unreported and usually never come to the attention of authorities, so vital statistics can only provide a fragment of the evidence-based picture. A variety of methods must be used to carefully piece together a picture that is as reliable as possible. These include, for example, surveys of women, surveys of specific healthcare facilities, and interviews with knowledgeable healthcare workers.

    Such methodologies are embodied in the Abortion Incidence Complications Method (AICM), which was developed about 20 years ago. The AICM has been widely used in studies appearing in peer-reviewed journals, and is recognized by experts around the globe, including the World Health Organization. Despite this, Koch has simply tossed out the AICM on the basis that it uses "imaginary numbers." ( critique.pdf) Not only is this dismissal disingenuous and unwarranted, it amounts to a gratuitous slur against the hundreds of reputable scientists and researchers who spend large amounts of time carefully gathering, comparing, and adjusting abortion-related data under challenging circumstances.


    The BMJ Open study has an important focus on maternal mortality, but unfortunately that focus tends to disguise certain facts that never see the light of day in the study:

    * More than a million (1,026,000) abortions take place in Mexico each year, the large majority of them illegal.

    * About 159,000 women were treated at public hospitals for abortion complications in 2009.

    * An estimated 36 percent of all women who have illegal abortions develop complications that need medical treatment.

    * One-quarter of those do not seek treatment, putting them at risk of lasting negative health consequences.

    The question that Koch et al. need to answer is this: Even if the study did demonstrate that restrictive abortion laws are associated with lower maternal mortality, does that make it acceptable to let a million desperate Mexican women, year after year, suffer the distress and trauma associated with risking their lives, health, and freedom to obtain an illegal abortion?

    Koch et al.'s studies, including the current one in BMJ Open, are promoted widely on the Internet by anti-abortion groups and individuals. Because the studies appear professional and are published in reputable journals, there is a real danger that they can be used to influence policy decisions of governments. For example, they may play a role in decisions to decrease or cut funding for reproductive health programs in developing countries--such as what occurred in Canada in 2010--or to further restrict abortion, despite current laws that still kill 47,000 women a year and injure over eight million.

    By rendering those women invisible, such studies become dangerous weapons that threaten to slow down the global decrease in maternal mortality and continue allowing women to suffer and die unnecessarily. The BMJ Open study is the latest contribution to this ideological battle disguised as science, one that poses a grave public health risk to women.

    AUTHOR'S NOTE: I would like to thank the Guttmacher Institute for its past work, cited in this letter, exposing the serious methodological flaws in Elard Koch's work and debunking his false claims.

    (Further sources for this letter can be found at:

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  6. Demographics and Pulmonary Function Testing

    To the Editor: It was very interesting to read the work established by Wilson et al. entitled " The effects of maintenance schedules following pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a randomised controlled trial" published in the BMJ Open 2015.

    Authors identified that a maintenance programme of three monthly two hour sessions does not improve outcomes in patients with Chronic Obstructive Pulmonary Disease (COPD) after 12 months. To test the effectiveness of their programs, authors randomised subjects to either receive their maintenance program or standard care as a control. The maintenance program consisted of two hours (an hour of individually tailored exercise training and an hour of an education program) every three months for one year.

    The authors explained the PR program thoroughly and provided clear inclusion and exclusion criteria. Nevertheless, only patients who completed at least 60% of the sessions in the initial PR program were included in the study. The authors stated that the intervention group only contains individuals who have complied with the PR program, whereas the control group consists of individuals who would have complied with the intervention as well as individuals who would not have complied. Providing a table that compares the baseline characteristics of subjects who complied and did not comply with the PR program would be beneficial. Sampling bias would be reduced if there was no statistically significant differences in baseline characteristics of both groups, subjects who complied and did not comply to the PR program.

    The authors focused on using questionnaires to assess the benefits of the PR program. They acknowledged that the use of accelerometer or patient independent devices would have provided more accurate data than that obtained from questionnaires. However, one of the key aspects to assess the long term benefits of a PR program is lung function measurements of the subjects, which has not been discussed in this paper1,2. The use of portable spirometers could be beneficial for this type of research because it requires minimal training and is more affordable than standard laboratory pulmonary function tests. Therefore, the effectiveness of these PR intervention programs would be better evaluated if objective lung measurements were examined.

    References: 1-Incorvaia, C., Russo, A., Foresi, A., Berra, D., Elia, R., Passalacqua, G., . . . Ridolo, E. (2014). Effects of pulmonary rehabilitation on lung function in chronic obstructive pulmonary disease: The FIRST study. European Journal of Physical and Rehabilitation Medicine, 50(4), 419-426. 2-Roberts, C. M., Gungor, G., Parker, M., Craig, J., & Mountford, J. (2015). Impact of a patient-specific co-designed COPD care scorecard on COPD care quality: A quasi-experimental study. NPJ Primary Care Respiratory Medicine, 25, 15017. doi:10.1038/npjpcrm.2015.17; 10.1038/npjpcrm.2015.17

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  7. Financial crisis and suicide mortality in Greece: do we need more evidence to be convinced?

    Dimitrios Anyfantakis 1, Adelais Markaki 2, Emmanouil K Symvoulakis 3

    1 Primary Health Care Centre of Kissamos, Chania, Crete, Greece 2 Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece. 3 Private Family Practice Unit in Heraklion, Crete, Greece.

    The study performed by Rachiotis et al. [1] reporting on the impact of financial crisis on suicide rates in Greece was both timely and intriguing. The researchers reported a significant increase of 35% of the mean suicide rate between 2010 and 2012. Remarkably, an increase of suicide mortality rates from 5.75 (2003-2010) to 7.43/100 000 (2011-2012; p<0.01) was recorded among males [1]. A significant positive association was also reported between rise in suicide rate and unemployment in the group of working-age males [1]. The authors concluded that austerity measures in Greece contributed significantly to the increased suicide mortality [1].

    In alignment with the above findings, previous research suggested a positive association between austerity and rise of suicide rate (17% from 2007 to 2009) as well as adverse effects in various health indicators [2]. Remarkably, a reduction of blood and organ donor supply has also been reported as a side-effect of the severe financial and humanitarian constraints placed on the country's national health system [3].

    However, despite growing debate on austerity's negative effects on health [4], governmental and international agencies have been slow to acknowledge this issue. In the past, some of the country's figures on suicides, attempted suicides, use of antidepressants and need for mental health services were met with skepticism, questioning earlier conclusions on the health consequences of the Greek crisis [5].

    The findings by Rachiotis et al.[1] underscore the impact of the Greek financial crisis on health indicators and death by providing the latest pragmatic data. Report of a 35% increase on the incidence of a deadly outcome within a three-year period is reason for not just domestic but global concern.

    References 1. Rachiotis G, Stuckler D, McKee M, Hadjichristodoulou C. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003-2012). BMJ Open. 2015 Mar 25;5(3):e007295. 2. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet. 2011 Oct 22;378(9801):1457-8. 3. Symvoulakis EK, Markaki A, Morgan M, Jones R. Organ donation during economic hardship: an untold end for Prometheus? BMJ 2011; 342:d982 4. Kentikelenis A, Karanikolos M, Reeves A, McKee M, Stuckler D. Greece's health crisis: from austerity to denialism. Lancet. 2014 Feb 22;383(9918):748-53. 5. Liaropoulos L. Greek economic crisis: not a tragedy for health. BMJ. 2012 Nov 27;345:e7988.

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  8. 'False Witnesses' Publish Deeply Flawed Study on Abortion Mortality in Mexico

    This study has been comprehensively refuted, with fatal errors found that invalidate the conclusion:

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  9. Article titles should be factual not rhetorical questions

    It would have been better if the article titled 'What has happened to suicides during the Greek economic crisis?' had been titled 'Suicide rate increases in Greece during economic crisis'. BMJ Open is a scientific journal not a collection of mystery stories.

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  10. Re: Miedema B, Reading SA, Hamilton RA, Morrison KS, Thompson AE. Can certified health professionals treat obesity in a community-based programme? A quasi-experimental study. BMJ Open 2015,5:e006650.

    To the Editor:

    The rapid acceleration of obesity rates worldwide and its contribution as a major risk factor for many chronic and resource-heavy diseases make it paramount for public health and health care research to explore effective ways to manage it. Miedema et al. appropriately utilized a quasi-experimental design to investigate the effectiveness of a community-based exercise and education programme to treat people who are obese in New Brunswick, Canada. (1) The authors acknowledged that the multidimensional factors contributing to the development of obesity require multidimensional treatment strategies to manage it. (1) The described intervention was certainly appropriate based on current literature, particularly the inclusion of group-mediated cognitive- behavioural intervention (GMCBI). (1)

    One of the study's stated hypotheses was "the intervention programme and the GMCBI would improve the health and well-being of the participants". (1) To assess the effectiveness of the multidisciplinary programme, the authors chose the outcomes of blood pressure, resting heart rate, weight and height (BMI), waist circumference and the mental health scale of the SF-36v2 Health Survey. (1) They reported that they also assessed other outcomes "related to physiological abilities, nutrition knowledge and behaviour" which were not reported in the present paper. (1) The programme was designed to assist people who are obese make the behavioural changes necessary to positively manage their health and well- being. Such multimodal approaches are similarly used in chronic disease management (2) and chronic pain management (3) and are shown to be the most effective in the long term.

    Despite delivering an intervention that sought to change health behaviour and improve overall wellness of people with obesity, the authors chose to include outcomes that measure biomedical and psychological constructs. These are insufficient to capture global latent variables as complex as "health" or "well-being". The World Health Organization defines health as "a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity." (4) The ultimate goal of obesity management is not only weight loss, reduction in blood pressure, and lower degrees of depression; it is also empowerment through self-efficacy, control over health and life, and satisfaction in social life. These all lead to overall increased quality of life. To truly demonstrate that their programme made a lasting positive difference in the participants' overall health, the study team should include measures for overall function, quality of life, behavioural change, and self-efficacy. Tackling a health issue as prevalent and complex as obesity requires a population health approach; interventions and their evaluation should reflect this.

    Bibliography 1. Miedema, B, et al., et al. Can certified health professionals treat obesity in a community-based programme? A quasi-experiemental study. BMJ Open. [Online] 02 2015. 2. National standards for diabetes self-management education and support. Haas, L, et al., et al. 2013, Diabetes Care, pp. S100-S108. 3. Interdisciplinary Chronic Pain Management: Past, Present, and Future. Gatchel, Robert J, et al., et al. 2014, American Psychologist, pp. 119- 130. 4. World Health Organization. WHO definition. World Health Organization Definition. [Online] 1948.

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