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Suicide rates in the United States have been increasing, necessitating an understanding of demographic variations by ethnicity, age, sex and method to inform effective prevention strategies.
Objective
To dissect suicide rates in the US population from 2001 to 2023 by age, sex, ethnicity, and method.
Methods
This retrospective observational study utilized suicide data and population statistics from the CDC’s WISQARS database for the years 2001 (n = 30,418), 2018 (n = 48,132), 2020 (n = 45,721) and 2023 (n = 49,014). Cases were stratified by age, sex, ethnicity, and suicide method to assess trends and demographic differences.
Results
From 2001 to 2023, the overall US suicide rate rose from 10.7 to 14.6 per 100,000, with a temporary decrease in 2019 and 2020 (14.4 and 13.8, respectively). The primary driver of the increase was firearm-related suicides among White males, contributing 25.8% of the rise from 2001 to 2018 and 51.6% from 2020 to 2023. Decline between 2018 and 2020 was mainly due to reductions in firearm and drug-related suicides among White males, but firearm suicides surged again from 2020 to 2023. Additionally, firearm suicides among ethnic minorities, especially Black/African-American males, accounted for 14.0% of the increase during 2020–2023. Drug-related suicides also increased by 8.6% among White females aged 45 and older in the same period.
Conclusions
Firearm suicides are the leading factor in the changing suicide rates in the United States from 2001 to 2023, alongside rising drug-related suicides among White females. These trends highlight the necessity for targeted prevention efforts that consider demographic-specific factors and method accessibility.
Background: Despite guidelines recommending shorter durations of therapy and empiric coverage of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) only for patients with certain risk factors, optimizing therapy for community-acquired pneumonia (CAP) remains a challenge for antimicrobial stewardship (AMS) teams. We investigated the impact of a multimodal AMS initiative on the rate of guideline-discordant empiric antibiotic selection and total duration of therapy for CAP. Methods: A quality improvement initiative was implemented at 9 community hospitals in 2022 to optimize CAP therapy. Education was provided to pharmacists and providers. Alerts were implemented within the electronic medical record to prompt the AMS team to review fluoroquinolones, antipseudomonal β-lactams, and anti-MRSA agents ordered for CAP. Clinical pharmacists reviewed antibiotic orders for CAP at hospital discharge and encouraged providers to prescribe a total antibiotic duration of 5–7 days. For the preintervention period (July– September 2021) and the postintervention period (July to September 2022), a random sample of 320 patients with an antibiotic order for CAP were evaluated retrospectively via chart review. Patients treated for an indication other than CAP were excluded. The primary outcome was the proportion of patients with a total duration of therapy >7 days. Secondary outcomes included average duration of therapy, rate of guideline-discordant empiric therapy, and type of guideline discordance. Results: In total, 317 patients were included. The proportion of patients with a total duration of therapy >7 days decreased from 29% to 14% (P < .01). Average duration of therapy and guideline-discordant empiric therapy also decreased significantly (Table 1). Conclusions: This multifaceted AMS initiative was associated with decreased guideline-discordant empiric therapy and decreased total duration of therapy for CAP.
Cognitive impairments are well-established features of psychotic disorders and are present when individuals are at ultra-high risk for psychosis. However, few interventions target cognitive functioning in this population.
Aims
To investigate whether omega-3 polyunsaturated fatty acid (n−3 PUFA) supplementation improves cognitive functioning among individuals at ultra-high risk for psychosis.
Method
Data (N = 225) from an international, multi-site, randomised controlled trial (NEURAPRO) were analysed. Participants were given omega-3 supplementation (eicosapentaenoic acid and docosahexaenoic acid) or placebo over 6 months. Cognitive functioning was assessed with the Brief Assessment of Cognition in Schizophrenia (BACS). Mixed two-way analyses of variance were computed to compare the change in cognitive performance between omega-3 supplementation and placebo over 6 months. An additional biomarker analysis explored whether change in erythrocyte n−3 PUFA levels predicted change in cognitive performance.
Results
The placebo group showed a modest greater improvement over time than the omega-3 supplementation group for motor speed (ηp2 = 0.09) and BACS composite score (ηp2 = 0.21). After repeating the analyses without individuals who transitioned, motor speed was no longer significant (ηp2 = 0.02), but the composite score remained significant (ηp2 = 0.02). Change in erythrocyte n-3 PUFA levels did not predict change in cognitive performance over 6 months.
Conclusions
We found no evidence to support the use of omega-3 supplementation to improve cognitive functioning in ultra-high risk individuals. The biomarker analysis suggests that this finding is unlikely to be attributed to poor adherence or consumption of non-trial n−3 PUFAs.
Chapter 5 lays the groundwork for the discussions of role-based constitutional fellowship in Chapters 6–9. In addition to arguing that fellowship is a self-initiating brand of liberal democratic trust, this chapter shows that fellowship assumes different complexions in different contexts. First, when trust exists in the formal political sphere, political actors compete as adversaries with a sense of self-restraint. Such trust involves counteracting “the institutionalized enmity problem,” the tendency for political actors to compete as enemies. Second, when trust exists in the general citizenry, citizens treat one another in manners befitting their equal citizenship, despite their differences. Such trust involves counteracting “the social domination problem”: enough citizens must demonstrate that they take the persistence of undue social hierarchies seriously. Third, when trust exists between the political sphere and the general citizenry, citizens believe that political actors largely do try to further the public good. Such trust involves counteracting “the representative cynicism problem,” the tendency for citizens to believe that political actors are in it for themselves.
Chapter 6 discusses how trust can emerge in the formal political sphere. Engaging with arguments for “political friendship” and “salutary hypocrisy,” this chapter shows that a division of labour between “principled pragmatists” and “principled purists” can counteract the institutionalized enmity problem. Principled pragmatists can develop a sense of reciprocity by engaging in some forms of hypocrisy and by striking compromises; this reciprocity can counteract the tendency for political actors to compete as enemies. Meanwhile, principled purists can more stubbornly refuse to compromise in order to keep principled pragmatists honest. There are times, however, when the distribution of principled pragmatists across mainstream parties is unbalanced, just as there are times when some (former) mainstream liberal democrats have forged enduring alliances with autocratic political actors. Accordingly, the chapter argues that in these circumstances, those who stand outside of these “unholy alliances” must embrace contestation and show that participation in these alliances is politically disadvantageous.
Chapter 2 critiques two prominent approaches to the question of difference and disagreement. Engaging with John Rawls and Jürgen Habermas’s accounts of “deliberative democracy,” the chapter first argues that discursive approaches to democracy “aim too high.” They overestimate the degree to which a basic “liberal public culture” is secure, and do not provide convincing accounts of how citizens can become (and continue to be) steadfast liberal democrats who will do what it takes to sustain liberal democracy. The chapter then probes “realist” approaches to democracy. Focusing on William Connolly and Chantal Mouffe’s accounts of “democratic agonism,” the chapter argues that realist approaches “aim too low.” They overestimate the ability of sound institutions to channel difference and disagreement, and do not adequately acknowledge the need for a sense of unity to prevent difference and disagreement from spiralling out of control. This chapter concludes that liberal democracy must be supported by a sense of unity that is oriented toward the preservation of liberal democracy and that does not unduly suppress difference and disagreement.
Chapter 7 discusses how trust can emerge in the general citizenry. Engaging with Danielle Allen’s iteration of “political friendship” and its critics, this chapter argues that a division of labour between the practices of “talking” and “shouting back” among the underprivileged, the oppressed, and their allies can counteract the social domination problem. Shouting back (aggressive civic disruption) makes it harder for the privileged and the dominant to claim ignorance about the persistence of injustices, while talking can promote trust between the underprivileged, the oppressed, and their allies on the one hand and “unwitting oppressors” and “softer complicit oppressors” on the other hand. Distinguishing among forms of talking, this chapter shows that the practice and revision of good manners should be the primary vehicle to cultivate trust. In addition, this chapter argues that allies should strive to “listen well” – to afford the underprivileged and the oppressed a sense of recognition when such recognition is all too rare, and to discourage unwitting oppressors and softer complicit oppressors from aligning politically with “harder complicit oppressors” and “proud oppressors.”
Chapter 1 introduces the motivating problem and the central contribution of the book. The chapter begins by observing that even though difference and disagreement can be valuable for liberal democracy, their expression can “overheat,” strain liberal democratic institutions, and leave the polity vulnerable to the growing influence of autocratic political forces. The chapter posits that the more citizens share in “role-based constitutional fellowship,” the more a liberal democracy can harness the benefits of difference and disagreement while sidestepping the potential perils of difference and disagreement. Under role-based constitutional fellowship, citizens share in a culture of trust where they feel united in the general effort to preserve liberal democracy. This culture of trust can emerge because citizens (perhaps unwittingly at first) observe a division of labour; they behave in different ways, according to which spheres of activity they find themselves in and according to what normative roles they find themselves occupying within those spheres. This chapter characterizes fellowship as a “negative idealistic” perspective that lies between “deliberative” and “realist” or “agonist” conceptions of democracy.
Chapter 8 discusses how trust can emerge between the formal political sphere and the general citizenry. Returning to the discussion of salutary hypocrisy, the chapter notes that people generally distrust hypocrisy. So, even though salutary hypocrisy can facilitate compromise and trust among political actors, that hypocrisy can simultaneously aggravate distrust between political actors and citizens at large. Accordingly, this chapter argues that political actors (principled pragmatists in particular) must justify their apparent hypocrisy and take steps to avoid needlessly aggravating citizens’ cynicism. The chapter suggests that political actors should refrain from excessively demonizing one another, explain why they struck compromises (but only after the fact and with care), and avoid encouraging citizens to develop fantastical understandings of politics.
Chapter 9 proposes concrete measures to promote role-based constitutional fellowship. First, the chapter acknowledges that bounded solidarity can support fellowship. Accordingly, the chapter identifies ways of imagining the nation to ensure that that solidarity is inclusive, and urges liberal democrats to promote inclusion cautiously. Second, the chapter discusses trust among political actors. The chapter acknowledges that some institutional arrangements – namely Westminster systems – seem relatively effective at channelling competition and alleviating the need for fellowship. Most democratic systems, however, are non-Westminster systems. Accordingly, the chapter suggests reforms that can make it easier for political competitors to act like fellows. Third, the chapter discusses trust among citizens at large. In addition to certain democratic education arrangements, the chapter argues that the integrated workplace and less-voluntary associations are more promising than voluntary civil societal associations as forums to promote trust. Fourth, the chapter demonstrates the need for some material redistribution to ensure that citizens feel that they are all in it together.
Chapter 4 considers a perspective that encourages citizens to develop a preliminary culture of trust on top of something other than a shared commitment to liberal democracy. According to “liberal nationalists” like David Miller and Yael Tamir, citizens should develop a sense of “bounded solidarity” on the basis of their shared nationality. Although nationality can assume exclusivist, illiberal, and anti-democratic forms, liberal nationalists maintain that it can evolve in inclusive and liberal democratic directions. This chapter shows that liberal nationalism is an incomplete perspective. Although liberal nationalism can help overcome the problem of initiation, it cannot adequately ensure that nationality will shed itself of exclusivist racial or ethnic components. Moreover, liberal nationalism does not provide citizens with the resources and capacities necessary to deepen any preliminary sense of trust which might have emerged; liberal nationalism only helps citizens better tolerate their differences and disagreements. So, this chapter paves the way for the rest of the book’s discussion of role-based constitutional fellowship. The chapter also considers constitutional patriotism.
Chapter 2 concluded that liberal democracy must be supported by a sense of unity that is oriented toward the preservation of liberal democracy and that does not suppress difference and disagreement. Chapter 3 explores what this unity ought to look like by engaging with Aristotle’s notion of political friendship. For Aristotle, citizens who belong to different factions are political friends when they share a commitment to preserve the regime, provided that the regime is “correct” or not excessively “deviant.” The chapter determines that the unity we seek should assume the form of a culture of trust where citizens believe that their fellow citizens probably value the continuation of their civic relationship, where citizens share a commitment to liberal democracy, and where they can nonetheless debate the meaning of equality and justice. Such trust, however, faces an initiation problem by virtue of presupposing a broad commitment to liberal democracy. This chapter concludes that citizens must either first develop a preliminary sense of trust on top of something other than a commitment to liberal democracy or be able to contribute to liberal democratic trust without realizing it.
Chapter 10 concludes the book by suggesting two potential lines of inquiry that emerge from the discussion of role-based constitutional fellowship. First, the chapter suggests that future research should consider how non-citizens should be treated in a liberal democracy. Second, the chapter suggests that future research should consider how liberal democrats should respond to liberal democracy’s enemies.
Difference and disagreement can be valuable, yet they can also spiral out of control and damage liberal democracy. Advancing a metaphor of citizenship that the author terms 'role-based constitutional fellowship,' this book offers a solution to this challenge. Cheng argues that a series of 'divisions of labor' among citizens, differently situated, can help cultivate the foundational trust required to harness the benefits of disagreement and difference while preventing them from 'overheating' and, in turn, from leaving liberal democracy vulnerable to the growing influence of autocratic political forces. The book recognizes, however, that it is not always appropriate to attempt to cultivate trust, and acknowledges the important role that some forms of confrontation might play in identifying and rectifying undue social hierarchies, such as racial-ethnic hierarchies. Hanging Together thereby works to pave a middle way between deliberative and realist conceptions of democracy.
Glutamatergic dysfunction has been implicated in sensory integration deficits in schizophrenia, yet how glutamatergic function contributes to behavioural impairments and neural activities of sensory integration remains unknown.
Methods
Fifty schizophrenia patients and 43 healthy controls completed behavioural assessments for sensory integration and underwent magnetic resonance spectroscopy (MRS) for measuring the anterior cingulate cortex (ACC) glutamate levels. The correlation between glutamate levels and behavioural sensory integration deficits was examined in each group. A subsample of 20 pairs of patients and controls further completed an audiovisual sensory integration functional magnetic resonance imaging (fMRI) task. Blood Oxygenation Level Dependent (BOLD) activation and task-dependent functional connectivity (FC) were assessed based on fMRI data. Full factorial analyses were performed to examine the Group-by-Glutamate Level interaction effects on fMRI measurements (group differences in correlation between glutamate levels and fMRI measurements) and the correlation between glutamate levels and fMRI measurements within each group.
Results
We found that schizophrenia patients exhibited impaired sensory integration which was positively correlated with ACC glutamate levels. Multimodal analyses showed significantly Group-by-Glutamate Level interaction effects on BOLD activation as well as task-dependent FC in a ‘cortico-subcortical-cortical’ network (including medial frontal gyrus, precuneus, ACC, middle cingulate gyrus, thalamus and caudate) with positive correlations in patients and negative in controls.
Conclusions
Our findings indicate that ACC glutamate influences neural activities in a large-scale network during sensory integration, but the effects have opposite directionality between schizophrenia patients and healthy people. This implicates the crucial role of glutamatergic system in sensory integration processing in schizophrenia.