Antidepressant Dose, Age, and the Risk of Deliberate Self-harm

IMPORTANCE A comprehensive meta-analysis of randomized trial data suggests that suicidal behavior is twice as likely when children and young adults are randomized to antidepressants compared with when they are randomized to placebo. Drug-related risk was not elevated for adults older than 24 years. To our knowledge, no study to date has examined whether the risk of suicidal behavior is related to antidepressant dose, and if so, whether risk depends on a patient's age. OBJECTIVE To assess the risk of deliberate self-harm by antidepressant dose, by age group. DESIGN, SETTING, AND PARTICIPANTS This was a propensity score-matched cohort study using population-based health care utilization data from 162 625 US residents with depression ages 10 to 64 years who initiated antidepressant therapy with selective serotonin reuptake inhibitors at modal or at higher than modal doses from January 1,1998, through December 31.2010. MAIN OUTCOMES AND MEASURES International Classification of Diseases, Ninth Revision (ICD-9) external cause of injury codes E950.x-E958.x (deliberate self-harm). RESULTS The rate of deliberate self-harm among children and adults 24 years of age or younger who initiated high-dose therapy was approximately twice as high as among matched patients initiating modal-dose therapy (hazard ratio [HR], 2.2 [95% Cl, 1.6-3.0]), corresponding to approximately 1 additional event for every 150 such patients treated with high-dose (instead of modal-dose) therapy. For adults 25 to 64 years of age, the absolute risk of suicidal behavior was far lower and the effective risk difference null (HR, 1.2 [95% CI, 0.8-1.9]). CONCLUSIONS AND RELEVANCE Children and young adults initiating therapy with antidepressants at high-therapeutic (rather than modal-therapeutic) doses seem to be at heightened risk of deliberate self-harm. Considered in light of recent meta-analyses concluding that the efficacy of antidepressant therapy for youth seems to be modest, and separate evidence that antidepressant dose is generally unrelated to therapeutic efficacy, our findings offer clinicians an additional incentive to avoid initiating pharmacotherapy at high-therapeutic doses and to closely monitor patients starting antidepressants, especially youth, for several months

Objectively Measured Physical Activity in Sixth-Grade Girls

Objectives - To describe the objectively-measured physical activity (PA) characteristics of a diverse sample of 6th grade girls to examine influences on PA, and to report compliance with PA guidelines. Design - Cross-sectional study. Setting - Six locations across the United States. Participants - 1578 6th grade girls. Actigraph accelerometers were worn for 7 days, and data for 6 days were included in the analyses. Main exposure - Race/ethnicity, free-or-reduced price lunch (FRPL), and geographic region. Main outcome measure - Six operational definitions of adequate activity (60 min or 30 min of daily MVPA at or above 4.6, 3.8 or 3.0 METS (metabolic equivalents)) were applied to examine whether girls met physical activity guidelines. Results - Average time spent in sedentary, light, moderate, and vigorous activities was 460, 342, 18, and 6 min/day, respectively. White girls were more active than girls in other race/ethnic groups, and girls who did not receive FRPL were more active than girls who did. Girls in western states were most active. Percentages of girls in compliance with the 6 thresholds for adequate activity varied widely, and ranged from 0.6% to 99.8%. Conclusions - When physical activity is measured objectively and a 4.6 MET cupoint for MVPA is applied, most 6th grade girls fall below guidelines for adequate physical activity. One notable finding was the impact of different accelerometer scoring protocols on estimates of compliance. Conceptual and empirical work is needed to define appropriate physical activity for youth using objective physical activity measures

Correlates of Physical Activity in Black, Hispanic, and White Middle School Girls

Background: A need exists to better understand multilevel influences on physical activity among diverse samples of girls. This study examined correlates of moderate-to-vigorous physical activity (MVPA) among adolescent girls from different racial/ethnic backgrounds. Methods: 1,180 6th grade girls (24.5% black, 15.7% Hispanic, and 59.8% white) completed a supervised self-administered questionnaire that measured hypothesized correlates of PA. MVPA data were collected for 6 days using the ActiGraph accelerometer. Hierarchical regression analysis was used to examine correlates of PA in each racial/ethnic group. Results: Hispanic girls (n=185) engaged in 21.7 minutes of MVPA per day, black girls (n=289) engaged in 19.5 minutes of MVPA per day, and white girls (n=706) engaged in 22.8 minutes of MVPA per day. Perceived transportation barriers (+; P=.010) were significantly and positively related to MVPA for Hispanic girls. For black girls, Body Mass Index (BMI) (-; P\u3c.005) and social support from friends (+; P=.006) were significant correlates of MVPA. For white girls, BMI (-; P\u3c.001), barriers (-; P=.012), social support from friends (+; P=.010), participation in school sports (+; P=.009), and community sports (+; P=.025) were significant correlates of MVPA. Explained variance ranged from 30% to 35%. Conclusions: Correlates of MVPA varied by racial/ethnic groups. Effective interventions in ethnically diverse populations may require culturally tailored strategies

Promoting Physical Activity in Middle School Girls: Trial of Activity for Adolescent Girls

Background - Physical activity is important for weight control and good health; however, activity levels decline in the adolescent years, particularly in girls. Design - Group randomized controlled trial. Setting/participants - Middle school girls with English-speaking skills and no conditions to prevent participation in physical activity in 36 schools in six geographically diverse areas of the United States. Random, cross-sectional samples were drawn within schools: 6th graders in 2003 (n=1721) and 8th graders in 2005 (n=3504) and 2006 (n=3502). Intervention - A 2-year study-directed intervention (fall 2003 to spring 2005) targeted schools, community agencies, and girls to increase opportunities, support, and incentives for increased physical activity. Components included programs linking schools and community agencies, physical education, health education, and social marketing. A third-year intervention used school and community personnel to direct intervention activities. Main outcome measures - The primary outcome, daily MET-weighted minutes of moderate-to-vigorous physical activity (MET-weighted MVPA), was assessed using accelerometry. Percent body fat was assessed using anthropometry. Results - After the staff-directed intervention (pre-stated primary outcome), there were no differences (mean=-0.4, 95% CI=-8.2 to 7.4) in adjusted MET-weighted MVPA between 8th-grade girls in schools assigned to intervention or control. Following the Program Champion-directed intervention, girls in intervention schools were more physically active than girls in control schools (mean difference 10.9 MET-weighted minutes of MVPA, 95% CI=0.52-21.2). This difference is about 1.6 minutes of daily MVPA or 80 kcal per week. There were no differences in fitness or percent body fat at either 8th-grade timepoint. Conclusion - A school-based, community-linked intervention modestly improved physical activity in girls

Objectively Assessed Associations between Physical Activity and Body Composition in Middle-School Girls: The Trial of Activity for Adolescent Girls

Declining levels of physical activity probably contribute to the increasing prevalence of overweight in US youth. In this study, the authors examined cross-sectional and longitudinal associations between physical activity and body composition in sixth- and eighth-grade girls. In 2003, girls were recruited from six US states as part of the Trial of Activity for Adolescent Girls. Physical activity was measured using 6 days of accelerometry, and percentage of body fat was calculated using an age- and ethnicity-specific prediction equation. Sixth-grade girls with an average of 12.8 minutes of moderate-to-vigorous physical activity (MVPA) per day (15th percentile) were 2.3 times (95% confidence interval: 1.52, 3.44) more likely to be overweight than girls with 34.7 minutes of MVPA per day (85th percentile), and their percent body fat was 2.64 percentage points greater (95% confidence interval: 1.79, 3.50). Longitudinal analyses showed that percent body fat increased 0.28 percentage points less in girls with a 6.2-minute increase in MVPA than in girls with 4.5-minute decrease (85th and 15th percentiles of change). Associations between MVPA in sixth grade and incidence of overweight in eighth grade were not detected. More population-based research using objective physical activity and body composition measurements is needed to make evidence-based physical activity recommendations for US youth

Age-Related Change in Physical Activity in Adolescent Girls

Purpose - To determine the annual rate at which physical activity changes in girls during middle school using both objective and self-report measures of physical activity. Methods - Participants were 6th and 8th grade girls from the control schools in the Trial of Activity for Adolescent Girls (TAAG). Random cross-sectional samples initially were drawn from 6th grade girls (n=786) and two years later from 8th grade girls (n=1545). A cohort of 501 girls was in both the 6th and 8th grade samples. The girls wore an accelerometer for six days and completed the 3-Day Physical Activity Recall (3DPAR). Data were summarized using 3.0-4.6- and 6.5-MET cutpoints for accelerometry and self-reported physical activity. Analyses were performed using repeated measures ANOVA in PROC MIXED. Results - More than 40% of the girls were White, approximately 20% were African-American, and 20% were Hispanic. The annual percent decrease in physical activity in the cross-sectional sample was approximately 4% (-1.76 min MVPA/day), using accelerometer data. The percent decrease in physical activity based on self-report data was higher, 6-13%, depending on the physical activity variable. Declines tended to be larger in African-American girls, but the ethnic differences were not statistically significant. Conclusions - Based on comparisons of cross-sectional samples of 6th and 8th grade girls, objectively-measured physical activity declined at a rate of 4% per year

Comparison of Two Approaches to Structured Physical Activity Surveys of Adolescents

Purpose - To compare the test-retest reliability, convergent validity, and overall feasibility/usability of activity-based (AB) and time-based (TB) approaches for obtaining self-reported moderate-to-vigorous physical activity (MVPA) from adolescents. Methods - Adolescents (206 females and 114 males) completed two 3-d physical activity recalls using the AB and TB surveys, which contained identical lists of physical activities. The participants wore an MTI Actigraph® accelerometer for the same period. Results - The TB instrument took about 3 min longer to complete (P=0.022). Overall 2-d test-retest correlations for MVPA were similar for the two surveys (r=0.676 and 0.667), but the girls had higher reliability on the AB survey than the boys (girls: r=0.713; boys: r=0.568). The overall 3-d correlations for MVPA surveys and Actigraph counts varied by gender (girls: AB=0.265 vs TB=0.314; boys: AB=0.340 vs TB=0.277). Correlations for vigorous physical activity and Actigraph counts were higher for the AB than for the TB (r=0.281 vs 0.162). As the interval between completing the surveys and the days being recalled increased, reliability and validity were lower, especially for the AB survey. Conclusion - For both genders, either approach is acceptable for obtaining MVPA information on a single day, but the TB approach appears to be slightly favored over the AB approach for obtaining multiple days of MVPA. A 3-d recall period appears to be too long for accurate recall of MVPA information from either instrument. For both genders, the surveys overestimate activity levels; thus, self-reports should be supplemented with objective data

Future Directions for Transforming Kinesiology Implementation Science Into Society

Physical activity policy can play a crucial role in ensuring that individuals, communities, and societies can obtain the wide range of health benefits associated with regular physical activity participation. Policies such as Title IX, the Americans With Disabilities Act, and state physical education laws have all increased opportunities for millions of Americans to participate in physical activity. With that said, how policies are developed and implemented vary considerably. The purpose of this manuscript is to contrast an academic conceptual framework with a pragmatic approach for policy implementation. In an ideal world, polices would be developed from foundational knowledge, scaled up to community-level interventions, and implemented in a sequential fashion. However, policy implementation is a disorderly process that requires a practical methodology. The National Physical Activity Plan encompasses strategies and tactics across 10 key societal sectors—and highlights the disorderly process of policy implementation across the various sectors

Correlates of Physical Activity in Black, Hispanic, and White Middle School Girls

Background: A need exists to better understand multilevel influences on physical activity among diverse samples of girls. This study examined correlates of moderate-to-vigorous physical activity (MVPA) among adolescent girls from different racial/ethnic backgrounds. Methods: 1,180 6th grade girls (24.5% black, 15.7% Hispanic, and 59.8% white) completed a supervised self-administered questionnaire that measured hypothesized correlates of PA. MVPA data were collected for 6 days using the ActiGraph accelerometer. Hierarchical regression analysis was used to examine correlates of PA in each racial/ethnic group. Results: Hispanic girls (n=185) engaged in 21.7 minutes of MVPA per day, black girls (n=289) engaged in 19.5 minutes of MVPA per day, and white girls (n=706) engaged in 22.8 minutes of MVPA per day. Perceived transportation barriers (+; P=.010) were significantly and positively related to MVPA for Hispanic girls. For black girls, Body Mass Index (BMI) (-; P\u3c.005) and social support from friends (+; P=.006) were significant correlates of MVPA. For white girls, BMI (-; P\u3c.001), barriers (-; P=.012), social support from friends (+; P=.010), participation in school sports (+; P=.009), and community sports (+; P=.025) were significant correlates of MVPA. Explained variance ranged from 30% to 35%. Conclusions: Correlates of MVPA varied by racial/ethnic groups. Effective interventions in ethnically diverse populations may require culturally tailored strategies

Age-Related Changes in Types and Contexts of Physical Activity in Middle School Girls

Background - Because girls are less physically active than boys, it is important to understand the types of activities preferred by girls, and changes in those preferences over time, in order to design effective physical activity interventions. Purpose - To describe developmental trends in participation in specific forms of physical activity in 6th- and 8th-grade girls. Methods - Data for this study are from the Trial of Activity for Adolescent Girls. Self-reported physical activity, anthropometric, and demographic data were collected from random cross sections of 6th-grade girls in 36 middle schools in six U.S. communities. The same data were collected 2 years later from random cross sections of 8th-grade girls, as well as in previously measured 6th-grade girls who remained in the schools. Analyses were conducted with SAS using mixed model ANOVAs to determine differences between 6th- and 8th-grade girls. Data were collected in 2002-2003 and 2004-2005 and analyzed in 2008-2009. Results - The top physical activities reported by 6th- and 8th-grade girls were similar. Of the top 13 activities reported by 6th- or 8th-grade girls, 8th-grade girls reported participating in more 30-minute blocks for 10 of the activities and were more likely to report participating as part of an organized program. Conclusions - The activities reported by 6th- and 8th-grade girls were similar, but the way they participated in them changed from 6th to 8th grade. Eighth-grade girls were more likely to participate in activities that are often part of school-based team sports, and the time of participation in these activities was greater. Interventions to increase physical activity in adolescent girls should be informed by the factors that influence their participation in organized school sports programs and community-based activities that promote physical activity