How to Treat Depression in Children

Depression is, by most accounts, on the rise among America’s children. A recent study published in the journal Translational Psychiatry provided the most disturbing news yet. It looked at data on adolescents ages 12 to 17, from the 2009 to 2014 editions of the National Survey of Drug Use and Health, an annual cross-sectional survey conducted in a representative sample of the U.S. population. Researchers concluded that a whopping 36.1 percent of girls had experienced a first bout of depression. Boys were recorded at 13.6 percent – much lower, but still alarmingly high.

Those children also exhibited more behavioral and academic problems than children with no history of depression, prompting the study’s authors to write: “High levels of impairment, suicide attempts, conduct problems and poor academic functioning argue against a ‘wait and see’ approach to clinical treatment of recent first-onset depression.” In other words, getting depressed kids into proper treatment is paramount.

But how do you treat a child with depression? Children, as most health practitioners are quick to say, are not “small adults.” They have their own biochemistry, their own cognitive capabilities and their own tolerances for medications, psychotherapy and other common treatments for depression. They also have more erratic and potentially dangerous reactions to those treatments, particularly medications. That’s why parents should employ the skills of a trained child and adolescent psychiatrist or psychologist for any child with mental illness.


“Most psychiatric symptoms were first described for adults, then later extrapolated to kids,” says Dr. Steven C. Schlozman, assistant professor of psychiatry at Harvard Medical School and associate director of the Clay Center for Young Healthy Minds. “That makes it a bit like fitting a square peg into a round hole.” That fit is made smoother by adding knowledge about childhood development into the geometry, he says. For instance, depression in children may manifest as irritability, rather than sadness or melancholy. “It is important for the physician to recognize this, because you might not think of someone who is irritable as being depressed,” he says.

Likewise, treatments must be adjusted to meet the developmental stage of the child. The treatments are, in broad strokes, the same as those used for adults. The American Academy of Child and Adolescent Psychiatry, or AACAP, says that treatment for childhood depression should include both psychotherapy and medication. “In milder forms of depression, it is reasonable to start with a psychotherapy, but treatment with a medication and psychotherapy should be considered for moderate to severe forms of major depression,” it recommends.

The AACAP says the following therapy styles can be used to help depressed children:

  • Individual therapy. Well-studies therapies include cognitive behavior therapy, or CBT, and interpersonal therapy, or IPT. CBT teaches how to recognize and change unhealthy patterns of thinking that cause feelings and moods that can affect behavior. IPT helps depressed children identify interpersonal events and how these events affect their relationships, their moods and their lives.
  • Family therapy. Here, a therapist helps the entire family – the child or adolescent, parents, siblings and even grandparents – improve communication and support skills to work together in more positive and constructive ways.
  • Group therapy. Multiple patients are led by one or more therapists who teach the group how to better understand and recover from depression.

Why Type 2 Diabetes Is Increasing In Children And Adolescents

With the rise in Type 2 diabetes among adults, you may wonder if there’s also an increase among children and young adults. Turns out, there sure is.

A large study called SEARCH for Diabetes in Youth found that newly diagnosed cases of Type 2 diabetes in children and teens increased by about 4.8 percent in each year of the study’s period between 2002 and 2012.

What’s driving this increase? “Prior to the 1980s, Type 2 diabetes was extremely uncommon in children and adolescents,” says diabetologist and certified diabetes educator Dr. Fran Cogen, interim co-chief of the Division of Endocrinology and Diabetes, director of the Childhood and Adolescent Diabetes Program at Children’s National Health System and professor of pediatrics at George Washington University School of Medicine and Health Sciences in the District of Columbia. “Unfortunately, the rate has increased as our lifestyles have become increasingly sedentary, and we’ve seen an explosion of processed, high-sugar and fast-food options.” Couple that with lower physical activity and more time in front of screens, and that’s a recipe for an increased diabetes risk.

Poor diet choices and lower levels of physical activity increase the risk for obesity, which is the most powerful determinant of Type 2 diabetes in childhood, adolescence and young adulthood, says Dr. Michael Freemark, professor of pediatrics and chief of the Division of Pediatric Endocrinology and Diabetes at Duke University Medical Center in Durham, North Carolina. In fact, several large population studies have found that childhood obesity that continues in the teen years can increase the risk for adult-onset Type 2 diabetes four- to 28-fold, Freemark says. “It’s therefore not surprising that the global rise in the prevalence of childhood Type 2 diabetes has coincided with a dramatic increase in childhood obesity,” he says.

There’s also a genetic role in Type 2 diabetes. In other words, if you have a parent or sibling who has it, there’s a greater chance that you’ll develop the disease as well.

It can be confusing to try and track Type 2 diabetes symptoms, especially in children. Sometimes, there are no symptoms. However, increased thirst, urination, bedwetting and unexplained weight loss could indicate Type 2 diabetes. Another symptom in children is a darkening around the neck and underarms, which is a sign of insulin resistance, says Dr. Robert Rapaport, professor of pediatrics and chief of the Division of Pediatric Endocrinology and Diabetes at the Icahn School of Medicine at Mount Sinai in New York. Insulin resistance is when your body can’t respond correctly to the insulin it produces.

Other possible symptoms of Type 2 diabetes include early puberty, especially in at-risk population groups such as African-Americans and American Islanders, Rapaport says. An increasing number of Staphylococcus skin infections or vaginal yeast infections in girls also can be signs of Type 2 diabetes.

Of course, depending on your child’s age, you may not spot all of the symptoms easily, and your child may not share them or even be aware of them.

Parents may not always have Type 2 diabetes on their minds. “That’s one of the scariest factors of the disease. In many cases, it’s not even on a parent’s radar,” Cogen says.

Even in parents who are aware of diabetes risks, it’s hard to overcome factors like the convenience of fast food, the lack of time to prepare healthier food at home and the higher cost of certain fresh foods. “Parents may also fail to connect the dots between their own family histories of metabolic disease and the child’s risk of obesity and Type 2 diabetes,” Freemark explains.

If you suspect your child has symptoms of Type 2 diabetes, make sure to visit your family doctor or pediatrician. Their office can consider screening for diabetes. When a child is very overweight or has signs of insulin resistance, health professionals are more likely to check blood sugar and possibly hemoglobin A1C level, Freemark says. If there’s a family history of diabetes or signs of polycystic ovary syndrome in teenage girls (including menstrual irregularity and having acne or excess facial hair), there’s a greater chance that they will get their blood sugar tested. A pediatric endocrinologist may need to help care for a child or teen with abnormal results.

Here are some ways to help lower your child’s risk for Type 2 diabetes:

As a family, plan to eat healthier and exercise more. “The key is to make small, incremental changes that the whole family can participate in so no one feels isolated or singled out,” Cogen says. These small changes can help your child lose weight if that’s a problem, and that lowers the chance of developing Type 2 diabetes. Healthier habits are especially important when there’s a long family history of diabetes, but there shouldn’t be the impression that anyone will inevitably develop Type 2 diabetes. “Operating as a team, a family, is much more likely to be successful,” she adds.

Find out about healthier food choices. These include lean meats, vegetables and fruitsand fewer concentrated sweets, sugars, high-density starchy foods, saturated fats and fried and fast foods, Freemark says.

Educate your children as they get older. This creates awareness that will help them when they are adults. For example, research finds that young adult women should have a healthy weight even before they get pregnant to reduce the chances of diabetes both for themselves and their future children, Freemark says. By arming them with information as a teen or young adult, they can make better choices.

Although the increase in Type 2 diabetes in children and teens may seem daunting, there is a silver lining, Freemark says. The risk for Type 2 diabetes in people who were overweight or obese as children but not as adults was no higher than the Type 2 diabetes risk in adults who were never overweight. In other words, you can cut your risk if you lose weight earlier in life. “This encouraging finding suggests that reversal of childhood obesity may prevent subsequent development of Type 2 diabetes,” he says.

Filtered Cigarettes Reduce Lung Cancer Risk

You know that cigarette smoking is the No. 1 risk factor for lung cancer (and a host of other serious diseases). However, if you do choose to smoke, you may wonder if filtered cigarettes are a safer alternative than unfiltered cigarettes. They’re not. In fact, there’s a major effort underway to convince the Food and Drug Administration to ban cigarette filters with holes in them.

In 1964, the Surgeon General’s report stated that smoking caused lung cancer. Tobacco companies were encouraged to make changes in their product to reduce damage to smokers, says Dr. James Davis, medical director at the Duke Center for Smoking Cessation.

The tar in cigarette smoke had known carcinogens (cancer causing agents), so it was a reasonable idea that reducing tar content would lower lung cancer risk. To do this, manufacturers added tiny holes in their filters. When a smoker inhales, these holes bring in outside air along with the smoke. The filters help trap tar, and the highly porous filter paper also allows toxic chemicals to escape. “If you combine air with smoke, you expect to get less smoke and less carcinogens,” Davis says.

Almost all cigarettes sold have these filters with holes, says Dr. Peter Shields, lead investigator and deputy director of The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Institute. “Regular cigarettes have them. Light cigarettes have them, but more. Ultra light cigarettes have them even more. [The filters] made the smoke smoother, so smokers thought [these cigarettes] were healthier.”

When scientists analyzed smoke from filtered cigarettes on a smoking machine – a device that mimics a person smoking – they did show more air and less tar. “It made sense to everyone that [the holes in filters] were helpful,” Davis says.

It turns out, however, that when scientists looked at lung cancer rates by when people were born, they found that despite an overall decrease in lung cancers, the rate of new adenocarcinomas, a certain type of lung cancer, was increasing.

“In the 60s and 70, the most common type of lung cancer was squamous cell carcinomas [which accounted for about two-thirds of cases]. Now, two-thirds of lung cancers in men are adenocarcinomas,” Shields says. Since women really started smoking en masse in the 1970s, after the implementation of filters with holes, they primarily developed adenocarcinomas lung cancers. “The evidence was absolutely clear that adenocarcinomas were going up when they shouldn’t be,” Shields says.

Cigarettes burn differently with ventilation holes, Shields says. You actually get more – not less – bad chemicals. Furthermore, because smokers are addicted to nicotine and get less of it with filtered cigarettes, they compensate by smoking more and taking bigger, deeper puffs, thus inhaling more smoke, more deeply into the far corners of the lungs where adenocarcinomas develop. Smoking machines, researchers learned, do not mimic how real people actually smoke.

According to Davis, it’s difficult to say with certainty if there’s a causal relationship between filter holes and the high rates of adenocarcinomas. “It’s hard to say one thing causes another,” he says, “but by my reading of the evidence, it’s really strong. We don’t wait to see [data showing] bold causality when we see a strong relationship that’s causing real harm. The scientific community should be concerned.”

How to Get Pain Healed

The bright sun, longer days and warm heat of summer seem to effortlessly pluck people outside for an activity-packed couple of months. It’s no surprise that this time of year offers the best weather for outdoor activities, pool parties, traveling and spending as much time out and about as we can. “Summer break” seems to not only apply to our school-aged children, but us as adults, as well. Though these summer months are most definitely an invitation to stay active, the extra physical demands can be tough on the back, especially if you’ve previously dealt with spine issues. In the spirit of staying back pain-free, while still enjoying this sunny time of year, here are some helpful ways to take care of your spine this summer.

For those people with back pain that’s worsened by cold weather, the warm summer months can signal relief, but for others, the change in temperature can be a factor that causes more pain. Increasing heat, humidity and barometric pressure over the summer months can be responsible for back pain “flare-ups,” even in the absence of activity. The easiest way to combat this weather-related pain is to stay indoors in an air-conditioned room to instantly cut out the heat and humidity. Though this option works, it may not be as convenient if you’re someone who likes being active outside. If this is the case and you can’t see yourself hiding from the summer rays, the next best bet is to use ice therapy. Applying ice packs will simultaneously help you cool down, reduce inflammation and soothe your achy muscles. Trade in the heating pad for 20 minutes of icing, remembering that the key is to achieve numbness in the irritated area, and repeat this several times each day (eight to 10 times during a 24-hour period).

Summer is the perfect opportunity for quick weekend trips or long relaxing vacations, but getting to your destination can pose a problem for your back. Long rides in cars, planes or trains with typically uncomfortable and unsupportive seats can do a number on your spine and posture. If you plan to be traveling for an extended period of time, bring a lumbar support pillow with you (or make your own out of a rolled-up blanket) and position it between the seat and your lower back to reduce the stress on your muscles. Traveling always equates to luggage, and handling those heavy suitcases with care can make all the difference. Always bend at the knees when lifting luggage (never at the back), avoid twisting while lifting anything heavy and hold your items as close to your body as possible. Ladies, purses can sometimes be the biggest culprits, so if you’re carrying a shoulder bag, switch sides frequently. And if something is just too heavy to lift, don’t hesitate to ask for help.

Our bodies are designed to move, which circulates the blood and keeps the muscles warm, and sitting in one position for too long starts to stiffen the muscles – making them more prone to pain or injury. If you can, pull over every hour during a road trip to get out of the car for a little walk and stretch out the back and leg muscles. On a plane, get up as often as you can (every 30 minutes to an hour is optimal) to walk back and forth down the aisle and get some stretching in, as well.

Along the same lines of getting up to stretch when you’ve been sitting too long is to sit down when you’ve been standing too long. This may sound like common sense, but you’d be surprised how many of us actually forget to take a break. With all the activity going on – whether that’s spending hours upon hours walking through an amusement park, losing track of time working in the yard or packing up and moving (a summertime chart-topper for many) – sometimes we have to remind ourselves to stop and rest, even for just a few minutes. Sit down, take a few deep breaths, drink some water and stretch. Taking multiple rest breaks combined with some deep stretching will keep the neck, back and leg muscles warmed up and flexible, as well as rejuvenated for the rest of the day.

Perhaps the most refreshing summertime spine health tip is to swim. You’re most likely to be near a pool this summer, so why not hop in and turn it into a workout? Swimming is an ideal exercise for low back pain because of its low-impact nature. It allows the back, leg and core muscles to be strengthened without applying much stress on the spine. Along with muscle strength, you’ll get cardiovascular benefits, as well, and all in a cool and rejuvenating atmosphere. While you’re out at the pool relaxing, supervising kids or getting your workout in, remember to always practice safety first. Never run through the pool deck, as the ground is slippery and one misstep can mean game over for your back. Likewise, avoid a traumatic spine injury by never diving into shallow water. If you’re unsure of the depth, definitely look before you leap.

The warmer months of the year can be chock-full of fun times and adventure, so don’t let spine troubles stand in the way. These tips will surely help you enjoy a happy, healthy and back-pain free summer.

Healthy Foods for Our Eyes

Beyond carrots

You’ve probably heard that carrots and other orange-colored fruits and vegetables promote eye health and protect vision, and it’s true: Beta-carotene, a type of vitamin A that gives these foods their orange hue, helps the retina and other parts of the eye to function smoothly.

But eating your way to good eyesight isn’t only about beta-carotene. Though their connection to vision isn’t as well-known, several other vitamins and minerals are essential for healthy eyes. Make these five foods a staple of your diet to keep your peepers in tip-top shape.

Leafy greens

They’re packed with lutein and zeaxanthin—antioxidants that, studies show, lower the risk of
developing macular degeneration and cataracts.


The yolk is a prime source of lutein and zeaxanthin—plus zinc, which also helps reduce your macular degeneration risk, according to Paul Dougherty, MD, medical director of Dougherty Laser Vision in Los Angeles.

Citrus and berries

These fruits are powerhouses of vitamin C, which has been shown to reduce the risk of developing macular degeneration and cataracts.


They’re filled with vitamin E, which slows macular degeneration, research shows. One handful (an
ounce) provides about half of your daily dose of E.

Fatty fish

Tuna, salmon, mackerel, anchovies and trout are rich in DHA, a fatty acid found in your retina—low levels of which have been linked to dry eye syndrome, says Jimmy Lee, MD, director of refractive surgery at Montefiore Medical Center, in New York City.


The Wrong Foods you Eat

Imagine the following scenario. You’re engaged in conversation at a dinner party with friends that you feel comfortable enough to discuss “hot button” topics with. Politics, religion, and parenting techniques probably come up and most likely, the views vary by person. When I attend dinner parties, however, the issue of food is often the hot topic of the night, and even hotter, the opinions surrounding the right and wrong way to eat. It’s not enough these days that we are eating more kale (thank you trendy farmers markets and Hollywood celebrities!), we have to now dissect the right and wrong way to eat it as well. It was discussions like these that motivated me to write this blog. After all, my career surrounds helping people to simply eat better — to get, what I call, the most bang for their nutritional buck. There are many factors that impact the amount of nutrients that you will derive from a food. Things such as cooking and ripening method, food pairing and even your own gut flora may impact how much benefit you get from plant-based foods. Different varieties of foods affect this as well. Not all nuts, apples or as you’ll read in my first example, potatoes are created equal. If you’re interested in knowing how science views the best way to eat, then read on. Spoiler alert: Raw is not always the right way to go!

Think you’re getting the benefits of the potato vegetable when you consume French fries, mashed or baked potatoes from white potatoes? Think again! One study found that it was purple potatoes that gave the best benefits, like lowering blood pressure and reducing the risk for cancer. Further, a 2014 study found that purple potatoes surpassed their white counterparts when it came to high amounts of polyphenols and decreased effect on overall blood sugar response.

As fall gears up, our love of soup increases as well. Next time you’re making a batch of chicken noodle soup, resist the urge to cut up your carrots. One study found that cutting carrots increased surface size and allowed more nutrients to leach out. That means after washing and peeling, your carrots should hit the water in their whole form. Keep cooking (vs. raw) though. One study found that cooking carrots increased the bioavailability of carotenoids.

If you want high nutrient absorption with your high tea, then forget about doing as the Brits do it! Several studies have shown that adding milk to your tea may actually take away some of the cardiovascular benefits that tea provide. Going with green tea? Add a little juice instead to sweeten. The vitamin C in juice may help to increase the bioavailability of green tea’s nutrients.

Don’t rush your garlic, CRUSH your garlic! Research indicates that crushing your garlic and allowing to sit for at least ten minutes released an enzyme called allicin that has been shown to help reduce the risk of cardiovascular disease by making platelets less sticky or more likely to flow freely through the cardiovascular system.

Salad dressing 
Fat free dressing may seem like a good idea in theory, but when you look at what you give up; it’s no match for the full fat counterpart. Several studies have shown the benefits that fat has when dressing your greens, from keeping you fuller and more satisfied after consumption to getting more nutrient absolution from your salad (specifically from lutein, lycopene, beta-carotene and zeaxanthin).

Apples & Pears 
Let your fruit ripen up a bit! One study found that the ripening process allowed the breakdown of chlorophyll in ripening apples and pears which, in turn, produced more “highly active” antioxidants in the fruit.

Broccoli is, without doubt one of the best foods you can feed your body! Broccoli is part of the brassica family of foods, a family that has shown to be quite effective in terms of prevention of certain cancers from breast cancer to skin cancer , but how you prepare your broccoli makes all the difference in the world. A 2008 study found that steaming was the only cooking method that completely preserved, and even increased, the cancer fighting components of broccoli. Boiling and frying were found to be the worst cooking methods. Still don’t want to ditch the boiled broccoli? Pairing with a spicy food may help! A 2012 study found that adding spicy foods to broccoli increased its cancer fighting power and the spicier the better according to the study authors!

Mustard in any form is a fabulous condiment to add to sauces, salads and sandwiches, but if you’re interested in decreasing overall inflammation as well as reducing your risk for certain cancers then you better keep your mustard choices simple. That’s right! It’s the cheap yellow mustard options that have the best benefits. Why? Because they contain a compound called curcumin (that’s the active ingredient in turmeric) that not only gives cheap yellow mustard its yellow color, but all of its potential health benefits as well!

While the factors discussed in this blog have an impact on the best ways to consume your foods, the truth is, simply adding these foods to your diet is a huge step in the right direction. Once you have mastered a liking for these healthier food options, the next logical step is to prepare in the best way for maximum nutrient density!

Steps Make Your Brain Younger

As our life expectancy continues to increase, one of the biggest fears for our senior citizens is that they may physically live longer than their brain functions.

This thought is being fueled by numerous press reports about the  increase in Alzheimer’s disease and other dementias.

Dementia is generally relates to loss of cognitive function.  Alzheimer’s is a type of dementia, but there are many others like senile (aging) dementia and dementias associated with other neurologic disea

The good news is that the evolving neuroscience shows that there are things we can do to preserve and even enhance our cognitive ability through the life span.

The concept of neuroplasticity shows that our brains can recover after injuries and strokes as well as, in some cases, improve brain function in the face of chronic neurologic disease.

In my book, “30 Days to a Better Brain,” I outline the mind, body and spirit approach to preserving and enhancing cognitive function as practiced at Canyon Ranch.

As we age, we have learned the value of healthy eating and remaining physically active through the life span. Each of these factors is an essential variable in overall health to include brain health and cognitive vitality.

We also know that if we don’t stay physically active, our muscles will atrophy and as we weaken, we lose our ability to actually participate in life activities and we become more vulnerable to falls and injury.

The brain also needs continuing challenges to stay vital as well and to prevent atrophy from minimal activity. So the brain needs a “brain gym”, that is, new information and challenges that give your brain a workout so that brain nerve cells are challenged and preserved and new brain neural networks are made to capture and store the new information.

No matter your age, even centenarians can benefit from learning new things, from a new language to playing a musical instrument or simply staying socially engaged with active stimulating conversation.

Dr. Richard Carmona is the 17th Surgeon General of the United States and president of Canyon Ranch Institute. He is the author of “30 days to a Better Brain.” 

The Main Killer of Drink Is Not Alcohol

Older people who drink heavily don’t necessarily have to fear dying of liver disease, a researcher said.

In a population-based Dutch study, only a handful of heavy drinkers in an older cohort died of liver-related causes, according to Jeoffrey Schouten, MD, of Erasmus Medical Center in Rotterdam, the Netherlands.

The major causes of death were cardiovascular disease and cancer, but not hepatocellular carcinoma, Schouten reported at the annual meeting of the American Association for the Study of Liver Diseases.

On the other hand, the study confirmed previous studies that suggest light and moderate drinking is protective, Schouten said.

He and colleagues followed 3,884 residents of Rotterdam — all 55 or older at the start of the study in 1990 — for a median of 15.2 years, until they died or until Dec. 31, 2008.

The participants were stratified by their drinking level, with the aim of understanding the causes of death for those who drank heavily, as well as the links between all-cause mortality and alcohol consumption.

Every four or five years, participants went through cycle of examinations, including clinical studies and questionnaires on various aspects of their lives, such as alcohol consumption. The clinical exams included blood work, anthropomorphic measurements, and imaging studies.

The study included the following:

  • 1,398 non-drinkers
  • 1,144 light drinkers (less than one gram of alcohol a day)
  • 963 moderate drinkers (between 10 and 30 grams daily)
  • 379 heavy drinkers (more than 30 grams a day)

Over the study period, Schouten reported, there were 1,825 deaths: 556 from cardiovascular disease, 496 from cancers, and 773 from a host of other causes, including three from alcohol-related liver disease.

Among the 188 heavy drinkers who died, 28% died of cardiovascular causes and 34% of cancer, he said. But only three cases of alcohol-related cancers and no cases of liver cancer were reported.

Only two of the heavy drinkers, or 1%, died of alcohol-related liver disease, he said.

A multivariate analysis showed that light and moderate drinkers fared better than both non-drinkers and heavy drinkers in terms of all-cause mortality.

Schouten said previous studies have showed similar patterns, but they were limited because older people were under-represented.

He added that doctors can use the findings to discuss the major risks among older patients who drink heavily, such as cardiovascular disease and cancer, rather than liver disease.

The findings, while not surprising, have some implications for how doctors counsel older patients about their drinking, according to Mack Mitchell, MD, of UT Southwestern Medical Center in Dallas, who was not part of the study, but who was one of the moderators of the session at which it was presented.

“Many people believe they should not drink alcoholic beverages above a certain age for health reasons,” he told MedPage Today, but the study showed that, “the mortality rate for those drinking in moderation was actually lower.”

So the message should not be to stop drinking but to stop drinking to excess, he said.

But for patients who remain heavy drinkers, he said, doctors can tell them that liver damage is the least of their worries — heart disease and cancer are the risks they should be concerned about.

Marijuana Users Highly at Risk for Psychosis

Psychotic illness occurs significantly earlier among marijuana users, results of a meta-analysis suggest.

Data on more than 22,000 patients with psychosis showed an onset of symptoms almost three years earlier among users of cannabis compared with patients who had no history of substance use.

The age of onset also was earlier in cannabis users compared with patients in the more broadly characterized category of substance use, investigators reported online in Archives of General Psychiatry.

“The results of this study provide strong evidence that reducing cannabis use could delay or even prevent some cases of psychosis,” Dr. Matthew Large, of the University of New South Wales in Sydney, Australia, and co-authors wrote in conclusion.

“Reducing the use of cannabis could be one of the few ways of altering the outcome of the illness because earlier onset of schizophrenia is associated with a worse prognosis and because other factors associated with age at onset, such as family history and sex, cannot be changed.”

Psychosis has a strong association with substance use. Patients of mental health facilities have a high prevalence of substance use, which also is more common in patients with schizophrenia compared with the general population, the authors wrote.

Several birth cohort and population studies have suggested a potentially causal association between cannabis use and psychosis, and cannabis use has been linked to earlier onset of schizophrenia. However, researchers in the field remain divided over the issue of a causal association, the authors continued.

Attempts to confirm an earlier onset of psychosis among cannabis users have been complicated by individual studies’ variation in methods used to examine the association. The authors sought to resolve some of the uncertainty by means of meta-analysis.

A systematic search of multiple electronic databases yielded 443 potentially relevant publications. The authors whittled the list down to 83 that met their inclusion criteria: All the studies reported age at onset of psychosis among substance users and nonusers.

The studies comprised 8,167 substance-using patients and 14,352 patients who had no history of substance use. Although the studies had a wide range of definitions of substance use, the use was considered “clinically significant” in all 83 studies. None of the studies included tobacco in the definition of substance use.

The studies included a total of 131 patient samples.

Substance use included alcohol in 22 samples, cannabis in 41, and was simply defined as “substance use” in 68 samples.

Alcohol use was not significantly associated with earlier age at onset of psychosis.

On average, substance users were about 2 years younger than nonusers were. The effect of substance use on age at onset was greater in women than in men, but not significantly so. Heavy use was associated with earlier age at onset compared with light use and former use, but also not significantly different, the authors reported.

Substance users were two years younger at the onset of psychosis compared with nonusers. Age at onset was 2.7 years earlier among cannabis users compared with nonusers.

Acknowledging limitations of the study, the authors cited the lack of information on tobacco use and its association with earlier age at onset of psychosis, and the lack of data on individual patients inherent in all meta-analyses.

Despite the limitations, the authors said the findings have potentially major clinical and policy implications.

“This finding is an important breakthrough in our understanding of the relationship between cannabis use and psychosis,” they wrote in conclusion. “It raises the question of whether those substance users would still have gone on to develop psychosis a few years later.”

“The results of this study confirm the need for a renewed public health warning about the potential for cannabis use to bring on psychotic illness,” they added.

Many Dangerous Bacteria Spread Outside the Hospital

 The dangerous bacteria Clostridium difficile spreads not only in hospitals but also in other health-care settings, causing infections and death rates to hit “historic highs,” U.S. health officials reported Tuesday.

C. difficile is a deadly diarrheal infection that poses a significant threat to U.S. health care patients,” Ileana Arias, principal deputy director at the U.S. Centers for Disease Control and Prevention, said during a morning news conference. “C. difficile is causing many Americans to suffer and die.”

The germ is linked to about 14,000 deaths in the United States every year. People most at risk from C. difficile are those who take antibiotics and also receive care in any medical facility.

“This failure is more difficult to accept because these are treatable, often preventable deaths,” Arias said. “We know what can be done to do a better job of protecting our patients.”

Much of the growth of this bacterial epidemic has been due to the overuse of antibiotics, the CDC noted in its March 6 report. Unlike healthy people, people in poor health are at high risk for C. difficile infection.

Almost 50 percent of infections are among people under 65, but more than 90 percent of deaths are among those aged 65 and older, according to the report.

Previous estimates found that about 337,000 people are hospitalized each year because of C. difficile infections. Those are historically high levels and add at least $1 billion in extra costs to the health care system, the CDC said.

However, these estimates might not completely reflect C. difficile’s overall impact.

According to the new report, 94 percent of C. difficile infections are related to medical care, with 25 percent among hospital patients and 75 percent among nursing home patients or people recently seen in doctors’ offices and clinics.

Although the proportion of infection is lowest in hospitals, they are at the core of prevention because many infected patients are transferred to hospitals for care, raising the risk of spreading the infection there, the CDC said.

Half of those with C. difficile infections were already infected when they were admitted to the hospital, often after getting care at another facility, the agency noted.

The other 50 percent of infections were related to care at the hospital where the infection was diagnosed.

The CDC said that these infections could be reduced if health care workers follow simple infection control precautions, such as prescribing fewer antibiotics, washing their hands more often and isolating infected patients.

These and other measures have reduced C. difficile infections by 20 percent in hospitals in Illinois, Massachusetts and New York, the CDC said.

In England, infections have been cut 50 percent in three years, the agency said.

Patients get C. difficile infections mostly after taking antibiotics, which can diminish the body’s “good” bacteria for several months.

That’s when patients can get sick from C. difficile, which can be picked up from contaminated surfaces or spread by health care providers.

The predominant sign of C. difficile infection is diarrhea, which can cause dehydration. If serious, the infection can become deadly. Other symptoms include fever, nausea and loss of appetite.

The CDC advises that if diarrhea occurs after a patient starts antibiotics, C. difficileshould be suspected and treatment continued with another antibiotic.

Commenting on the report, infectious disease expert Dr. Marc Siegel, an associate professor of medicine at New York University, said, “All these recommendations are fine; the problem is they are not going to work, you can’t stop these practices. This bug exists in a climate of overuse of antibiotics.”

It is hard to eradicate C. difficile because it buries itself in the colon, then recurs and testing isn’t always accurate, Siegel said. “It’s a pervasive problem in hospitals, and even in communities,” he said.