Firearms and hanging top methods for suicide in US as rates continue to rise

Embargoed for release until 5:00 p.m. ET on Monday 18 December 2023  
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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.  
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1. Firearms and hanging top methods for suicide in U.S. as rates continue to rise 

Suicide mortality highest among White, American Indian, and Alaska Native populations 

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2533  

URL goes live when the embargo lifts   

Suicide rates in the United States increased across all racial groups in the United States between 1999 and 2020 but were highest among White people, followed by American Indian and Alaskan Native (AIAN) persons. Firearms and hanging were the top methods used, with a sharp and substantial increase in hangings among women. This finding poses a conundrum for clinicians, as suicide prevention strategies based on means restriction are not effective when the primary means is hanging. The research report is published in Annals of Internal Medicine.  

Researchers from Waseda University, Tokyo, studied data from the Centers for Disease Control and Prevention’s (CDC) WONDER database to assess temporal trends and patterns in method-specific suicide by sex and race in the U.S. from 1999 to 2020. Suicide methods were categorized using International Classification of Diseases, 10^th Edition. The data showed that suicide rates in the United States increased across all racial groups but were highest among White people, followed by AIAN persons. Firearms were the most common method of suicide among men, but suicide by hanging increased rapidly among both men and women. Among AIAN men, firearms and hanging were the major means of suicide, but among AIAN women, hangings increased almost 200% between 1999 and 2020. Substantial increases in rates of hanging were also seen among White women. 

According to the authors, these findings highlight the need for screening to assess suicide risk and to address underlying mental health issues. It is especially important to consider the role of other drivers of suicide, such as economic and social inequality and racism, such has been experienced by AIAN populations. The authors suggest that a combination of comprehensive and focused community-based suicide prevention strategies that are racially relevant need to be implemented at the community and individual levels. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Bibha Dhungel, DrPH, please contact bibha-dhungel@umin.ac.jp.  

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2. Prevalence of transgender-related diagnosis codes increased 9-fold between 2014 and 2021 

Prescriptions for gender affirming hormone therapy and PrEP for HIV prevention also increased during this timeframe 

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2073       

URL goes live when the embargo lifts   

An analysis of trends in HIV testing and preexposure prophylaxis (PrEP) use among transgender men and women found that rates of HIV testing and PrEP prescriptions have increased significantly among these populations between 2014 and 2021. According to the authors, a simultaneous and much larger increase in gender affirming hormone therapy (GAHT) provides an important opportunity for clinicians to engage their transgender patients in HIV prevention care and provide PrEP prescriptions. The analysis is published in Annals of Internal Medicine.  

Transgender persons, particularly transgender women, have a high lifetime risk for acquiring HIV. PrEP is a highly-effective intervention to prevent the acquisition of HIV among persons with sexual or injection drug use risk behaviors. It has been recommended that transgender persons use PrEP preventatively, and it is safe to use with gender-affirming hormone therapy. However, PrEP use has been low among transgender persons. Health care encounters for GAHT can provide opportunities for HIV testing, risk behavior assessment, and PrEP initiation. 

Researchers from the Division of HIV Prevention, Centers for Disease Control and Prevention, analyzed data from the Merative MarketScan commercial databases from 2014 to 2021 to estimate the number of commercially insured transgender women (TGW) and transgender men (TGM) in the United States and their use of HIV prevention services. The authors found that the prevalence of transgender-related diagnosis codes increased by 9-fold between 2014 and 2021. The proportion of these persons receiving GAHT also increased substantially during this same period. They report that in 2021, among 10,613 TGW with a test for or diagnosis of a sexually transmitted infection (STI) within the previous year, 61.1 percent had an HIV test; among those, 20.2 percent were prescribed PrEP. Among 4,184 TGM with STI risk, 48.3 percent had an HIV test and 10.2 percent were prescribed PrEP. The prevalence of both groups receiving a test or diagnosis and were prescribed PrEP also increased substantially from 2014 to 2021. According to the authors, clinical encounters for GAHT may provide additional opportunities for HIV prevention services, such as HIV testing and PrEP. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Ya-Lin A. Huang, PhD, MS, please contact Matt Josey at una3@cdc.gov.

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3. Black adults and children saw a decrease in asthma attacks and related emergency visits during the pandemic 

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2100     
URL goes live when the embargo lifts    
Relative to Whites, asthma attacks and related emergency department (ED) visits trended downward among Black adults and children during the COVID-19 pandemic. Narrowing asthma morbidity disparities through the pandemic suggest opportunities for mitigation, such as improving environmental conditions or developing and equitably delivering vaccines against common respiratory pathogens. Findings from a brief research study are published in Annals of Internal Medicine.  

Researchers from Harvard Medical School/Cambridge Health Alliance analyzed National Health Interview Survey (NHIS) data from 2019 to 2022 to determine whether a decrease in exacerbations of asthma during the COVID-19 pandemic, which has been attributed to a decline in transmission of common respiratory viruses that often provoke asthma attacks, narrowed national disparities in asthma morbidity. The researchers examined three outcomes by racial and ethnic groups: a current asthma diagnosis; and, among those ever diagnosed with asthma, experiencing any asthma episode-attack or an asthma-related ED visit within the past year. The data showed that for adults, asthma prevalence overall increased slightly in 2022, driven by increases among White adults. Hispanic adults had the lowest and Black adults the highest prevalence throughout the study period, with the adjusted difference between Black and White adults decreasing over time. Asthma prevalence among children remained overall stable, and was consistently highest among Black children. Asthma attack rates were stable and comparable among White and Hispanic adults but decreased among Black adults, from 29.3% in 2019 to 22.1% in 2022. During the same timeframe, ED visits decreased among adults and children, with a particularly large drop among Black individuals.  Disparities in ED visit rates between Black (as well as Hispanic) and White children evident in 2019 narrowed sharply during pandemic years.  According to the authors, these findings suggest that policies are needed to address the multitude of factors that drive both asthma pathogenesis and exacerbations. 

 
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Adam Gaffney, MD, MPH, please contact David Cecere at dcecere@challiance.org.

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4. Treatment with thiazide diuretics associated with higher risk for low blood sodium 

Abstract: https://www.acpjournals.org/doi/10.7326/M23-1989    
URL goes live when the embargo lifts    
A cohort study of new users of bendroflumethiazide (BFZ) or hydrochlorothiazide plus a renin–angiotensin system inhibitor (HCTZ–RASi) found that the use of these diuretics was associated with a 2-year cumulative incidence of more than 3 percent for low blood sodium (below 130 mmol/L), also known as hyponatremia. The study is published in Annals of Internal Medicine.  

Thiazide diuretics are commonly used to treat uncomplicated hypertension. Although thiazide diuretics are considered effective, low-cost, and generally well-tolerated, they may cause significant adverse effects. Currently, the frequency of thiazide-induced hyponatremia according to drug labels is unknown or uncommon to very rare, but the exact burden remains unclear. 

Researchers from Statens Serum Institut and the Danish Cancer Institute, Copenhagen, Denmark, conducted a population and register-based cohort study using target trial emulation. One target trial emulation compared new use of BFZ versus a calcium-channel blocker (CCB). They found that the 2-year cumulative incidences for hyponatremia for persons taking BFZ was 3.83 percent. The second target trial emulation compared new use of HCTZ–RASi versus a RASi alone. They found that the two-year cumulative incidence for hyponatremia for persons taking HCTZ-RASi was 3.51 percent. The cumulative incidence for the thiazide diuretics were about 1.4 percentage points higher than for the other antihypertensive comparator drugs. According to the authors, their findings show that new use of thiazide diuretics suggests a substantial excess risk for hyponatremia that is higher than indicated by drug labeling. The risk is particularly pronounced during the first months of treatment and in persons who are older or have comorbidities. 

 
Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Niklas Worm Andersson, MD, please contact Nanna Martensen at presse@ssi.dk

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5. Individual and program-level factors affect flourishing among internal medicine residents  

Abstract: https://www.acpjournals.org/doi/10.7326/M23-2233      
URL goes live when the embargo lifts    
A multi-institutional study provides insight into the individual- and program-level factors that influence flourishing among medical residents. While mean scores on the flourishing index for residents were lower than those of the general population, they were comparable to those in a prior study. The findings are published in Annals of Internal Medicine.  

Studies of physician well-being commonly use narrow measures like happiness, life satisfaction, mental health, or burnout. However, well-being is a complex and multifaceted construct. The flourishing index (FI) measures 5 domains of happiness and life satisfaction while the Secure Flourish Index (SFI) measures adds a domain of financial and material stability.  

Researchers from Washington University School of Medicine and Yale School of Medicine surveyed a convenience sample of residents from 14 residency programs in Connecticut, Illinois, and Pennsylvania from April to August 2021 to describe the FI and SFI and their domains as functions of resident characteristics and measures of well-being. They found that individual-level factors such as resilience, viewing medicine as a calling, and engagement with religion and spirituality as intrinsic contributors to flourishing. While the stability of these factors remains unclear, the research suggests that programs can enhance them through innovative approaches like narrative medicine, advocacy curricula, mindfulness-based stress reduction, and a commitment to celebrating workforce diversity and equity. Additionally, program-level factors such as Residency Program Community Well-being (RCWB) were identified as pivotal targets in fostering a culture of well-being. The findings underscore the importance of high-quality leadership, robust peer support, just program structures, and a clear shared mission in promoting the flourishing of individual residents. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, David Vermette, MD, MBA, MHS, please contact david.v@wustl.edu.  

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