Archive for July, 2014

Strong Social Ties Protect Men From Suicide

Being socially connected to others appears to protect men against suicide, according to a new study.

Social integration acts as a safety net to lower the risk of suicide among men.

We speculate that men who are more socially well integrated may have greater access to emotional support and have more opportunities for social engagement and reinforcement of meaningful social roles,” said Alexander Tsai, MD, PhD, Assistant Professor of Psychiatry at Harvard Medical School in Boston.

Suicide is one of the 10 leading causes of death among men in the United States, and suicides among middle-aged men are increasing.

Current trends in research and prevention efforts usually emphasize the psychiatric, psychological, or biological aspects of what drives suicidal thinking and suicidal behavior.

However, research has shown that a substantial proportion of suicides occur in the absence of a formally diagnosed mental disorder, suggesting that a deeper understanding of factors driving suicide is needed, he said.


Dr. Tsai and colleagues analyzed data from the Health Professionals Follow-up Study, an ongoing prospective cohort study of nearly 35,000 men aged 40 to 75 years, to examine the relationship between social integration and suicide mortality over 24 years of follow-up.

They measured social integration with a 7-item index that included marital status, social network size, frequency of contact, religious participation, and participation in other social groups.

Over more than 700,000 person-years of follow-up, there were nearly 150 suicides.

The incidence of suicide decreased with increasing social integration.


Three components — marital status, social network size, and religious service attendance — showed the strongest protective associations.

Social integration also was inversely associated with all-cause and cardiovascular-related mortality, but accounting for competing causes of death did not substantively alter the findings.

“Men who were socially well-integrated had a more than 2-fold reduced risk for suicide over 24 years of follow-up,” Dr. Tsai said.

The study lacked information on participants’ mental well-being.

Some suicides also could have been misclassified as accidental deaths, he noted.

Dr. Tsai added: “The seminal studies about social integration and suicide are based on macro-level data, for example, examining the level of social integration across counties or states and the correlations with suicide rates in those jurisdictions, but these are subject to the well-known ‘ecological fallacy’—just because there is an association at the county or state level does not necessarily imply that an individual with poor social integration is also more likely to commit suicide.”

A fuller understanding of the role of social interaction is important in understanding suicide.

“The bottom line is that we should be approaching suicide as a public health issue relevant to a broad range of medical practitioners and public health specialists, not just a narrow mental health issue relevant only to psychiatrists like myself,” Dr. Tsai said.

“It is important for primary care physicians to recognize that their most socially isolated patients are at elevated risk of committing suicide.”

The researchers published their results in the July 14, 2014, issue of Annals of Internal Medicine.

No Added Heart Attack Risk With Testosterone Therapy in Older Men

Testosterone therapy does not increase the risk of heart attack, or myocardial infarction (MI), among older men, according to a comprehensive new study.

“We believe this is a methodologically rigorous study and should be thoughtfully weighed, critiqued, and discussed alongside the other studies of testosterone therapy and cardiovascular outcomes,” said lead author Jacques Baillargeon, PhD, Director, Epidemiology Division and Associate Professor of Preventive Medicine & Community Health at the University of Texas Medical Branch in Galveston.

“Although recent observational studies have reported an increased risk of cardiovascular disease associated with testosterone use, there is a large body of evidence that is consistent with our finding of no increased risk of MI associated with testosterone use,” Dr. Baillargeon said.

He noted that there are cardiovascular risks associated with untreated hypogonadism (a condition in which the body doesn’t produce enough testosterone) and those should be factored into the risk-benefit assessment about testosterone therapy.


Testosterone prescriptions for older men in the United States have increased more than 3-fold over the past decade.

This trend has been driven by increases in direct-to-consumer marketing; rapid expansion of clinics specializing in the treatment of low testosterone; the development of new drugs and improved delivery mechanisms, particularly dermal gels; and greater diagnostic awareness of hypogonadism, stated Dr. Baillargeon.

The retrospective study used information from 25,000 Medicare beneficiaries aged 66 years and older.

It compared more than 6,300 men treated with testosterone for 8 years with more than 19,000 who were not treated with testosterone.

“We found that use of intramuscular testosterone therapy was not associated with an increased risk of MI,” Dr. Baillargeon said.

In fact, testosterone was associated with a possible protective effect — reduced risk of MI in patients with the highest prognostic risk index.

There were no differences in risk in patients in the lower prognostic risk groups.


There are a number of physiologic pathways whereby testosterone therapy may affect the risk of adverse cardiovascular events.

“Some have reported that testosterone therapy may improve cardiovascular health by way of decreasing fat mass, insulin sensitivity, and lipid profile,” said Dr. Baillargeon.

“Also, testosterone may possess anti-inflammatory and anticoagulant properties.”

He continued, “It is possible that our findings of a protective effect among men in the highest MI prognostic group reflect a process whereby testosterone reduces peripheral vascular resistance, thereby reducing stress on the heart among those who have some degree of coronary artery disease.

It is important to note that there are also postulated mechanisms through which testosterone may increase the risk of cardiovascular disease.

Given the broad range of proposed biologic pathways, it is important to conduct further research on this topic.”


Several recent studies have raised concerns about cardiovascular risks associated with testosterone therapy, in particular for older men.

On June 19, the FDA expanded labeling on testosterone products to include a general warning about the risk of blood clots in veins.

The FDA and European Medicines Agency also are further examining the safety of these products.

The researchers reported their results in the July 2, 2014 issue of the Annals of Pharmacotherapy.

Migraines Worsen During Menopausal Transition

The frequency of migraine attacks is higher in women during perimenopause and postmenopause than in premenopause, according to the first study to demonstrate that the frequency of migraine attacks increases during the menopausal transition.

“Fluctuating estrogen levels play an important role in initiating migraine in women,” said study co-author Richard B. Lipton, MD, Co-Director of the Montefiore Headache Center and Professor and Vice Chair of Neurology and the Edwin S. Lowe Chair in Neurology at the Albert Einstein College of Medicine.

“Migraine onset increases with the beginning of menstruation and is more common around the time of bleeding during the menstrual cycle,” he said.

“The trigger factor is thought to be declining estrogen levels.

As menopause approaches, estrogen levels fluctuate and likely trigger migraine.”

Dr. Lipton noted that estrogen and other sex hormones act on the brain and alter the excitability or sensitivity of the nervous system.


The research was conducted as part of the American Migraine Prevalence and Prevention (AMPP) Study, a longitudinal mailed questionnaire survey of 120,000 households selected to be representative of the US population.

Data from the 2006 AMPP Study survey were used.

Women with migraine aged 35 to 65 years were eligible for the analyses.

Women with migraine were classified based on headache frequency.

A high-frequency group experienced 10 or more headache days per month, and a low- or moderate-frequency group experienced episodic migraines on fewer than 10 days per month.

The women also were classified based on menopausal status.

The premenopausal stage was characterized by regular menstrual cycles.

The perimenopausal stage included women with cycle lengths that varied by at least 7 days or periods of no periods lasting 2 to 11 months.

The postmenopausal stage was defined by no periods persisting for at least 12 months.

The analysis included more than 3600 women, mean age 45 years, with about one-third of them in each of the 3 groups.


Frequent headache (10 or more days per month) was 50% to 60% more common among perimenopausal women (12.2%) and menopausal women (12%) compared with premenopausal women (8%).

Consistent with the clinical impression that migraine worsens during the menopausal transition, these data show that the risk of high-frequency headache is greater during perimenopause and postmenopause as compared with premenopause, Dr. Lipton said.

The researchers concluded that longitudinal studies should examine within-person trajectories of headache frequency and the role of hormonal mechanisms among migraineurs during the menopausal transition.

“In the present report, we compared groups of women who were premenopausal and perimenopausal and postmenopausal in the year of the study,” Dr. Lipton said.

In a longitudinal study, we would follow individual women as they transitioned from premenopausal to perimenopausal to postmenopausal and examine the hormonal changes that underlie changes in headache frequency.”

He added: “Clinicians should know that headaches may get worse as women begin the menopausal transition.

When patients experience migraine worsening, clinicians can explain that hormonal changes may be driving the changes.

Controlling headache is one factor that may contribute to the complex decisions about when to recommend hormone replacement therapy.”

The researchers presented their results on June 20, 2014 at the 56th Annual Scientific Meeting of the American Headache Society in Los Angeles.

Chronic Migraine Burdens Whole Family

Chronic migraine has significant effects on family relationships and activities, according to the results of a new study.

“The effects of chronic migraine can be devastating and far-reaching.

The results of the Chronic Migraine Epidemiology and Outcomes (CaMEO) study highlight the significant impact of chronic migraine not only on the person with migraine but on the entire family,” said Dawn Buse, PhD, Director of Behavioral Medicine, Montefiore Headache Center, and Associate Professor, Clinical Neurology, at Albert Einstein College of Medicine.

Dr. Buse led a study to assess the nature and extent of chronic migraine on family activities and relationships.

“Among 994 women and men who met criteria for chronic migraine, respondents reported missing both routine and special family events on a regular basis and feeling guilty and sad about how this affected their relationships with their spouses and children,” she said.


Almost three-fourths of respondents said they would be better spouses if they did not have chronic migraine.

Almost two-thirds felt guilty about being easily angered or annoyed by their partners because of headache, and at times two-thirds avoided sexual intimacy with their partners because of headache.

The majority of respondents also endorsed that they would be better parents if they did not have chronic migraine.

“About two-thirds of respondents reported that they became easily annoyed with their children due to headache,” Dr. Buse said.

“In addition, slightly more than half of respondents reported that they had reduced participation or enjoyment on a family vacation due to headache in the past year, and 20% cancelled or missed a family vacation altogether.”


The data suggest that women with chronic migraine appear less impaired and burdened by the condition than men.

“However, it is not clear whether there is truly a qualitative difference between the sexes in the nature and severity of attacks or differences in responses and resiliency to migraine attacks,” Dr. Buse said.

“We could hypothesize that males may have a smaller number of family and parenting responsibilities and commitments than females, making their percentage of missed events higher than the percentage for females.

It is also possible that mothers and wives feel that they cannot miss a family event or drop a responsibility.

In this case they may continue their activities despite debilitating pain and associated symptoms.”

The study highlights the point that chronic migraine is a debilitating disease that can affect all aspects of life, including roles, responsibilities, and relationships within the family.

“We hope that these data will help health care professionals further realize the scope of the burden of this condition and be diligent in providing accurate diagnoses and thorough treatment plans,” Dr. Buse said.

Those treatment plans should include both appropriate pharmacologic and nonpharmacologic (cognitive behavioral therapy, biofeedback, and relaxation training) interventions, she noted.

In addition, Dr. Buse advises health care professionals to encourage and facilitate patients in seeking help from mental health care professionals when these feelings become overwhelming.

Dr. Buse presented the results of the study on June 27, 2014 at the 56th Annual Scientific Meeting of the American Headache Society in Los Angeles.

Headaches Associated With Sex Are No Joke

Comedians have long joked about spouses avoiding sex by claiming to have a headache, but headaches associated with sex are no laughing matter, according to a headache specialist.

“Many people who experience headaches during sexual activity are too embarrassed to tell their physicians, and doctors often don’t ask,” said José Biller, MD, Chair of the Department of Neurology with the Loyola University Chicago Stritch School of Medicine and certified in Headache Medicine by the United Council for Neurologic Subspecialties.

Sexual activity is comparable to mild- to moderate-intensity exercise, he noted.

“Headaches associated with sexual activity can be extremely painful and scary,” Dr. Biller said.

“They also can be very frustrating, both to the individual suffering the headache and to the partner.”

About 1% of adults report that they have experienced headaches associated with sexual activity and that such headaches can be severe.

But the actual incidence is certainly higher, Dr. Biller noted.

Headaches usually are caused by disorders such as migraines or tension, and the vast majority of headaches associated with sexual activity are benign.

But headaches also can be secondary to other life-threatening conditions.

In a small percentage of cases, these headaches can result from a serious underlying condition, such as a hemorrhage, brain aneurysm, stroke, cervical artery dissection, or subdural hematoma.

“We recommend that patients undergo a thorough neurological evaluation to rule out secondary causes, which can be life-threatening,” Dr. Biller said.

“This is especially important when the headache is a first occurrence.”


In 2004, the International Headache Society classified headaches associated with sexual activity as a distinct form of primary headache.

The following are the 3 main types of sex-related headaches:

• A dull ache in the head and neck that begins before orgasm and gets worse as sexual arousal increases.

It is similar to a tension headache.

• An intensely painful headache that begins during orgasm and can last for hours.

This so-called thunderclap headache grabs attention because it comes on like a clap of thunder.

Dr. Biller said patients describe this headache as “all of a sudden, there was a terrific pain in the back of my head. It was like someone hit me with a hammer.”

• A headache that occurs after sex and can range from mild to extremely painful.

This headache gets worse when the patient stands and lessens when the patient lies back down.

The cause is an internal leak of spinal fluid, which extends down from the skull into the spine.

When there is a leak in the fluid, the brain sags downward when the patient stands, causing pain, he explained.

Dr. Biller said men are 3 to 4 times more likely to get headaches associated with sexual activity than women.

Depending on the type of headache, medications can help relieve the pain or even prevent the headache, he said.

To reduce the risk of headaches associated with sexual activity, exercise regularly, avoid excessive alcohol intake, maintain a healthy weight and, if necessary, seek counseling, Dr. Biller said.

Just Eating Healthier Trims Diabetes Risk

Improve your overall diet quality and you will lower your risk of type 2 diabetes mellitus, independent of adopting other healthful behaviors, including increased physical activity and body weight loss, according to the results of a new study.

In an analysis of 3 large cohort studies of men and women by researchers at the Harvard School of Public Health, those who improved their diet quality index scores by 10 percent over 4 years reduced their risk for type 2 diabetes by about 20% compared to those who made no changes to their diets.

“We found that diet was indeed associated with diabetes independent of weight loss and increased physical activity,” said lead author Sylvia Ley, PhD, RD, a post-doctoral fellow at the Harvard School of Public Health, at the American Diabetes Association’s 74th Scientific Sessions®.

“If you improve other lifestyle factors you reduce your risk for type 2 diabetes even more, but improving diet quality alone has significant benefits.”

She noted that it is often difficult for people to maintain a calorie-restricted diet for a long time.

“We want them to know that if they can improve the overall quality of what they eat – consume less red meat and sugar-sweetened beverages, and more fruits, vegetables and whole grains – they are going to improve their health and reduce their risk for diabetes,” Dr Ley said.

Lifestyle changes, including individually tailored, macronutrient composition focused, calorie-restricted interventions, can prevent or delay type 2 diabetes among those at high risk, according to randomized controlled trials.

However, it is unclear whether improving overall diet quality by itself is associated with reduced risk of diabetes among healthy adults.


Dr. Ley and colleagues investigated the association between diet quality changes during a 4-year period and subsequent 4-year type 2 diabetes risk, and simultaneous changes in multiple lifestyle factors on that risk (Abstract 74-OR).

They prospectively followed more than 148,000 participants without diabetes at baseline in the Nurses’ Health Study (1986-2006), Nurses’ Health Study II (1991-2011), and Health Professionals Follow-up Study (1986-2010).

The Alternative Healthy Eating Index score was used to assess diet quality.

Associations between changes in diet quality, physical activity, and body weight and diabetes risk were evaluated simultaneously.

The researchers documented more than 9,000 incident cases of type 2 diabetes during the more than 2.3 million person-year follow-up.

Greater than 10% decrease in diet quality scores over 4 years was associated with higher subsequent diabetes risk with multiple adjustments, while at least 10% improvement in dietary scores was associated with lower risk, Dr Ley said during her presentation at the ADA meeting.

When simultaneous relationships among 4-year changes in diet quality, physical activity, and body weight were assessed, improvement in each behavioral factor was independently associated with lower incident diabetes.

“Regardless of where participants started, improving diet quality was beneficial for all,” she noted.