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Recent eLetters

Displaying 11-20 letters out of 368 published

  1. Who is in control? Clinicians' view on their role in self-management approaches: a qualitative metasynthesis

    I enjoyed reading this article on clinician's View on their role in self management approaches. Nowadays a large number of people are living with chronic illnesses. Often, one living with chronic illness needs to be assisted with some skills to take care themselves better, applying the approach of self management. The findings of this study showed that clinicians may find it difficult to shift some tasks to or share control in health care with the patient or family care givers. However there is need for change in position moved from the more traditional approach of provider dominated care to a partnership as innovative approach to patient centered care. The method used to gather the data for this article were clearly explained. Metasynthesis as the methodology to synthesize data from several studies. Complete articles included in the study, on experiences, or views on clinicians' roles on self management approach were recaptured. The approach of synthesizing findings coming from different opinions can be complex, in generating harmonized results. Synthesis could be used as the primary study while qualitative design can used as secondary to explore how they applied the self management approach. Self management approach have many advantages in improving patients' wellbeing in the community, in coping with chronic illness. In low income settings where there is lack of health professionals, primary care teams may have difficulty finding time to provide patient education sessions and to monitor health indicators to ensure safety even when patients and their caretakers have been trained. Thus the needed change cannot be effected by the clinicians alone. It also needs community education, where education depends on the curiosity, educational background and socio economic status of those to included in a programme of education about self management .

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  2. The Lsibon Cohort of Men Who Have Sex With Men

    The Lisbon Cohort of men who have sex with men (MSM) identified gays, bisexuals and MSM aged between 20-29 years as key populations most affected by HIV/AIDS1 and key contributors to the epidemic in Portugal. The study identified the need to establish instruments for monitoring HIV and syphilis incidence, determinants of infection and risk-taking behaviors in MSM. A community-based walk-in centre was used to recruit MSM as participants of a cohort study despite the obvious limitation of recruiting only men that walked into the centre. Chinese and European studies recommended the Internet as an effective avenue for recruiting study subjects, and other authors have used formal health or academic institutions to recruit participants2. The article highlighted several cultural, anthropological and sociological challenges in the conduct of community-based studies with MSM. The use of community-based or Internet strategies for recruiting participants from vulnerable populations such as MSM may be difficult in low-income countries; this is related to the reality that MSM is still not accepted in these countries. Conducting such a study in low-income settings may yield evidence which may not be generalized across populations. However, the Lisbon cohort provides a good foundation for researchers that would like to conduct research around MSM in similar settings.

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  3. A Critical Appraisal of Esposito et al.'s Nomogram for Predicting HbA1c Response to DPP-4 Inhibitors

    Re: A nomogram to estimate the HbA1c response to different DPP-4 inhibitors in type 2 diabetes: a systematic review and meta-analysis of 98 trials with 24 163 patients. Esposito, et al. 5:2 e005892 doi:10.1136/bmjopen-2014-005892

    We read with interest the recent article by Esposito et al. describing their development of a nomogram to predict HbA1c response to different dipeptidyl peptidase (DPP)-4 inhibitors in the treatment of type 2 diabetes (1). We believe that several important factors need to be considered when interpreting the results of this study.

    Firstly, the nomogram was derived from a meta-regression model relating treatment effect to several covariates, including baseline HbA1c level, type of DPP-4 inhibitor and baseline fasting plasma glucose. Other covariates were tested but found to not have additional effects - although background medication was included only as a binary variable, and therefore the treatment effect of different types of medication may not have been captured. Importantly, however, the authors did not further test additional covariates likely to affect treatment response - notably, length of prior drug washout, diabetes duration and race/ethnicity. Regarding the latter, for example, there is evidence that the efficacy of DPP-4 inhibitors is greater in Asians than in Caucasians (2)(3).

    One particularly notable limitation of the model is the use of absolute HbA1c changes rather than the placebo-corrected values that are conventionally used in meta-analyses. The authors acknowledge this limitation without fully justifying it. Unfortunately, the use of absolute HbA1c changes without any adjustments can lead to inaccurate estimates of the treatment effects of individual DPP-4 inhibitors. For example, absolute changes in HbA1c in two of the studies included, both conducted in Asian patients, were -0.24% and -1.05%, suggesting the drug in the latter study (vildagliptin) to be more effective than that in the former (linagliptin). However, the placebo-corrected changes were -0.87% with linagliptin and -0.51% with vildagliptin (4)(5).

    Additionally, the meta-regression model included baseline HbA1c as a covariate. However, most, if not all, of the included studies reported HbA1c changes from baseline derived from ANCOVA models that already contained baseline HbA1c as a covariate.

    As acknowledged by the authors, by far the strongest predictive factor for HbA1c response was baseline HbA1c, with different DPP-4 inhibitors explaining only a small amount of variance between studies. However, there was a significant residual variance in the meta-regression model that could not be explained, and may reflect the potential confounding factors discussed above.

    In light of these limitations, the authors' statement that "[T]he nomogram is not intended to give a comparison of different DPP-4 inhibitors, given the lack of head-to-head RCTs comparing their efficacy in HbA1c reduction from baseline" seems incongruent with their concluding sentence that "[T]he nomogram we developed may help clinicians in predicting the HbA1c response to individual DPP-4 inhibitor [sic] in clinical practice."

    We also note that studies in patients with renal impairment were excluded from the model. Given the high prevalence of chronic kidney disease among patients with T2DM, estimated to be ~40% (6), this exclusion could affect the external validity of the nomogram.

    On the basis of these considerations, we conclude that Esposito et al.'s nomogram - although an interesting and novel approach to predicting HbA1c response to DPP-4 inhibitors - is likely to be confounded, and may not provide an accurate estimate of the true treatment effects of individual medications. Consequently, the nomogram should not be used to compare clinical efficacy or real-world effectiveness between DPP-4 inhibitors, as the authors themselves note.

    1. Esposito K, Chiodini P, Maiorino MI, et al. A nomogram to estimate the HbA1c response to different DPP-4 inhibitors in type 2 diabetes: a systematic review and meta-analysis of 98 trials with 24 163 patients. BMJ Open 2015; 5: e005892. doi:10.1136/bmjopen-2014-005892.

    2. Kim YG, Hahn S, Oh TJ, Kwak SH, Park KS, Cho YM. Differences in the glucose-lowering efficacy of dipeptidyl peptidase-4 inhibitors between Asians and non-Asians: a systematic review and meta-analysis. Diabetologia 2013; 56: 696-708.

    3. Cai X, Han X, Luo Y, Ji L. Efficacy of dipeptidyl-peptidase-4 inhibitors and impact on beta-cell function in Asian and Caucasian type 2 diabetes mellitus patients: A meta-analysis. J Diabetes 2015; 7: 347-59.

    4. Pan C, Xing X, Han P, et al. Efficacy and tolerability of vildagliptin as add-on therapy to metformin in Chinese patients with type 2 diabetes mellitus. Diabetes Obes Metab 2012; 14: 737-744.

    5. Kawamori R, Inagaki N, Araki E, et al. Linagliptin monotherapy provides superior glycaemic control versus placebo or voglibose with comparable safety in Japanese patients with type 2 diabetes: a randomized, placebo and active comparator-controlled, double-blind study. Diabetes Obes Metab 2012; 14: 348-357.

    6. Koro CE, Lee BH, Bowlin SJ. Antidiabetic medication use and prevalence of chronic kidney disease among patients with type 2 diabetes mellitus in the United States. Clin Ther 2009; 31: 2608-2617.

    Acknowledgements: Editorial assistance, supported financially by Boehringer Ingelheim, was provided by Giles Brooke, PhD CMPP, of Envision Scientific Solutions during the preparation of this letter.

    Conflict of Interest:

    All authors are employees of Boehringer Ingelheim Pharma GmbH & Co. KG (Ingelheim, Germany), the manufacturer of a DPP-4 inhibitor (linagliptin).

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  4. Radical austerity and unemployment are associated with increased suicide mortality in Greece.

    Radical austerity and unemployment are associated with increased suicide mortality in Greece. George Rachiotis1, David Stuckler2,3 Martin McKee34, Christos Hadjichristodoulou1. 1.Department of Hygiene and Epidemiology, Medical Faculty, School of Health Science, University of Thessaly, Larissa, Greece 2.Department of Sociology, University of Oxford, Oxford, UK 3.European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK 4.European Observatory on Health Systems and Policies, London, UK We would like to thank researchers and readers of the journal for their interest in our paper [1]. Dr Fountoulakis, in his reply, [2] accused us of selectivity of citation, insisting that the increase in suicides after 2010 has been already reported by him and co-workers [3-6]. Remarkably, three out of 4 references that Dr Fountoulakis mentioned are totally irrelevant to analysis of suicides in Greece after 2010 [3-5]. Surprisingly, in a short communication about suicidality in Greece in the period 2000-2010, the authors stated that:'' The results of the current study suggest no increase in suicidality in Greece during the recent economic crisis...'' [4]. In one of the references mentioned by Dr Fountoulakis [6] there is a statement that the absolute number of suicides in Greece increased in 2011, but data for 2012 were not reported. We did not mention this letter to the editor -which refers to only one year- given that the description of a trend was impossible. Regarding age and gender specific rates, we feel that the use of numerous age groups in the analysis of suicides creates the problems associated with of small numbers of observations. On the contrary our analysis (with 3 large age groups) provides the reader with a clearer picture of the impact of unemployment on suicides, especially among males of working ages. At this point we note that there was a significant correlation between unemployment rates and suicide mortality among males of working age. On the contrary this was not the case for females, despite the observed increase in suicide rates among them. Dr Fountoulakis denied that male suicide rates are common, but the data suggest a 34% increase in male suicide rate in 2011-2012. The increase among females of working age during the same period was lower (25.5%) although considerable. The previous data confirmed a key role for male gender in increased suicide rates in Greece and are consistent with previous published information [7]. Dr Fountoulakis missed the point regarding the significance of 2010 in relation to the radical austerity policies. The fact that, as Dr Fountoulakis stated, the correlation of male suicide rates with unemployment changed, within two years, from 2011 to 2012, from -0.09 to 0.54 is indicative of the strong and independent impact of radical austerity on male suicide rates in Greece. Unfortunately, this documented impact has been consistently ignored by Dr Fountoulakis. Further, we note that Dr Fountoulakis ignored the results by many independent research teams from Greece and abroad regarding a positive correlation between unemployment and suicide rates in Greece [8-10]. In addition he failed to mention that an increase in suicide rates was associated with austerity policies in Greece [11]. Regarding the temporal association between unemployment and suicide rates in Greece, the facts are quite clear. The general trend indicates-at least after 2009 and among males- that unemployment increased and the suicide rates increased afterwards. Dr Fountoulakis failed to explain the nature of the program imposed to Greece by the Troika from 2010. This program refers to a ''shock therapy'' very similar to that implemented in Russian Federation during the 90's. The Greek economy shrank by 25% between 2008-2012 and the unemployment rate doubled from 12.7% in 2010 to 24% in 2012. These figures indicate an unprecedented, at least since World War II, radical experiment in socio-economic destruction and welfare-state retrenchment in Europe. We have pointed out the harmful consequences of continuing delays in publishing mortality data [1]. These delays mean that it will not be possible to bring the story of economic crisis and suicides completely up to date. Indeed, in our analysis we had available data only for the first two years (2011 and 2012) of the implementation of radical austerity in Greece. Nevertheless, these data provide preliminary evidence that radical austerity is associated with increased suicides in Greece, although there are several possible mechanisms by which austerity may act. It is a positive sign that the President of European Commission Jean Claude Juncker recently recognized the ongoing humanitarian crisis in Greece [12]. However, there is an urgent need to undertake a comprehensive health impact assessment of the radical austerity imposed by the Troika, in line with the obligation placed on the European institutions by the European Treaties [13]. References: 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. Reply to Rachiotis et al: Increased unemployment might not be the cause of the world wide rise in suicide rates. BMJ Open, April 23, 2015; e-letter 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. 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]|. 7. Kentikelenis A, Karanikolos M, Reeves A et al. Greece's health crisis: from austerity to denialism. Lancet 2014;383:748-53. 8. Kontaxakis V, Papaslanis T, Havaki-Kontaxaki B et al. Suicide in Greece: 2001-2011. Psychiatrike. 2013;2:170-4. 9. Madianos MG, Alexiou T, Patelakis A et al. Suicide, unemployment and other socioeconomicfactors: evidence from the economic crisis in Greece. Eur J Psychiat 2014;28:39-49. 10. Antonakakis N, Collins A. The impact of fiscal austerity on suicide: on the empirics of a modern Greek tragedy. Soc Sci Med. 2014;112:39-50. doi: 10.1016/j.socscimed.2014.04.019. Epub 2014 Apr 19. 11. Branas CC, Kastanaki AE, Michalodimitrakis M et al. The impact of economic austerity and prosperity events on suicide in Greece: a 30-year interrupted time-series analysis. BMJ Open. 2015;5:e005619. doi: 10.1136/bmjopen-2014-005619. 12. EU's Junker pledges 2bn euros for Greek ''humanitarian crisis''. BBC News. 20 March 2015. 13. McKee M, Karanikolos M, Belcher P et al. Austerity: a failed experiment on the people of Europe. Clinical Medicine 2012;12:346-50.

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  5. Reply to : BMJ Open 2015 5:e007179; doi:10.1136/bmjopen-2014-007179

    Thank you for a well presented article. We would like to highlight a few aspects that we found in the literature related to the subject and subsequently would like to convey our opinions. Alcoholism and other addictions have genetic and environmental causes. Both have serious consequences for children who live in homes where parents are involved. Children of addicted parents are the highest risk group of children to become alcohol and drug abusers due to both genetic and family environment factors1. Biological children of alcohol dependent parents who have been adopted continue to have an increased risk (2-9 fold) of developing alcoholism.2 Adolescent alcohol use, especially heavy use, is associated with many negative outcomes. It has been found that alcohol dependent adolescents have poorer neuropsychological performance and are more sensitive to learning and memory impairments produced by alcohol exposure. Adolescent alcohol use may interfere with the development of social, coping, and related skills needed for effective social functioning in late adolescence and early adulthood. Children who coped effectively with the trauma of growing up in families affected by alcoholism often relied on the support of a non-alcoholic parent, stepparent, grandparent, teachers and others.3 Our opinion apart from those presented in the referenced literature above would be that beyond the socio-cultural and genetic aspects covered in different articles , there is an element of parental responsibility and parental monitoring which needs to be taken into account when it comes to alcohol and substance misuse in the adolescent population . We also feel that there is an argument for parenting styles and parental monitoring as the manner in which boundaries are set and the individual young person's needs met, could be a crucial element in determining the young person's potential subsequent involvement and or reliance on drugs, alcohol and other mind altering substances. Family conflicts , domestic violence , social isolation ,financial problems are only a few other contributing factors which need to be accounted for when one considers the association between parental roles and adolescent drinking behaviour . References: 1. Kumpfer, K.L. (1999). Outcome measures of interventions in the study of children of substance-abusing parents. Paediatrics. Supplement. 103 (5): 1128-1144. 2. Schuckit, M.A., Goodwin, D.A., & Winokur, G. (1972). A study of alcoholism in half siblings. American Journal of Psychiatry, 128: 1132- 1136 3. Brown, S., & Tapert, S. (2004). Adolescence and the trajectory of alcohol use: Basic to clinical studies. Annals of the New York Academy of Sciences, 1021, 234-244.

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  6. Re:PubMed citations in Africa

    Thanks Peter for having interest in our bibliometric analysis1 and for your comments. Wholeheartedly agreed, our bibliometric analysis[1] is not the only citation analysis covering Africa, published in this millennium. We have not overlooked the other citation analysis[2]. There are excellent Africa-focused subject-specific citation analyses from our group and others[3-10]. However, we would like to point that the focus of this citation analysis was not to examine or review existing citation analyses, but rather to describe and examine factors associated with research productivity of first authors based in African institutions using articles indexed in PubMed as a surrogate. The word "quintile" should have been written as 'quartiles', this was a typographical error. The countries were categorised into four groups and not five groups. As stated in the results section [1]: "Eighteen countries occupy the highest quartile with more than 1000 articles each. Ten countries belong to the second quartile (i.e. 500-999 articles) and 13 to the third quartile (100-499 articles). Five countries with less than 100 articles each belong to the lowest quartile." This adds up to 46 countries, which is the number of countries included in the citation analysis. The list of the 46 countries is provided in the online only Supplementary Data [1]. On a final note, this typographical error does not change the results nor does it change the conclusions of our citation analysis[1]. Olalekan A. Uthman 1. Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Cape Town, 7505, South Africa 2. Warwick-Centre for Applied Health Research and Delivery (WCAHRD), University of Warwick, Warwick Medical School, Gibbet Hill Rd, Coventry, CV4 7AL, UK Charles S. Wiysonge 1. Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Cape Town, 7505, South Africa 2. South African Cochrane Centre, South African Medical Research Council, Francie van Zijl Drive, Cape Town, 7505, South Africa References 1. Uthman OA, Wiysonge CS, Ota MO, et al. Increasing the value of health research in the WHO African Region beyond 2015--reflecting on the past, celebrating the present and building the future: a bibliometric analysis. BMJ Open 2015;5(3):e006340. 2. Sankoh O, Byass P. The INDEPTH Network: filling vital gaps in global epidemiology. Int J Epidemiol 2012;41(3):579-88. 3. Uthman OA, Uthman MB. Geography of Africa biomedical publications: an analysis of 1996-2005 PubMed papers. Int J Health Geogr 2007;6:46. 4. Uthman OA. HIV/AIDS in Nigeria: a bibliometric analysis. BMC Infect Dis 2008;8:19. 5. Uthman OA. Pattern and determinants of HIV research productivity in sub-Saharan Africa: bibliometric analysis of 1981 to 2009 PubMed papers. BMC Infect Dis 2010;10:47. 6. Chen JY, Ribaudo HJ, Souda S, et al. Highly active antiretroviral therapy and adverse birth outcomes among HIV-infected women in Botswana. J Infect Dis 2012;206(11):1695-705. 7. Kanoute A, Faye D, Bourgeois D. Current status of oral health research in Africa: an overview. Int Dent J 2012;62(6):301-7. 8. Nachega JB, Uthman OA, Ho YS, et al. Current status and future prospects of epidemiology and public health training and research in the WHO African region. Int J Epidemiol 2012;41(6):1829-46. 9. Wiysonge CS, Uthman OA, Ndumbe PM, et al. A bibliometric analysis of childhood immunization research productivity in Africa since the onset of the Expanded Program on Immunization in 1974. BMC Med 2013;11:66. 10. Bloomfield GS, Baldridge A, Agarwal A, et al. Disparities in cardiovascular research output and citations from 52 african countries: a time-trend, bibliometric analysis (1999-2008). J Am Heart Assoc 2015;4(4).

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  7. Response from the BMJ Open editorial office

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

    Accessible here: http://datadryad.org/resource/doi:10.5061/dryad.8bv8p

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  8. 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. http://www.desastresaereos.net/ft_trag_ten_acidentetenerife3.jpg 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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  9. 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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  10. 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.

    References:

    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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