NHS Choices

Claims that coffee prevents dementia are lukewarm at best

NHS Choices - Behind the Headlines - Wed, 05/10/2016 - 18:30

"Coffee really can help to prevent dementia: Just two cups a day 'cuts the risk of developing it by 36 per cent','' the Mail Online reports. But if you look closely at the research behind this report, the results are of borderline significance, meaning it is likely they were influenced by chance.

Researchers in the US found that postmenopausal women who consume an average of 261mg of caffeine a day (the equivalent of two to three cups of coffee) are at lower risk of cognitive impairment or probable dementia, than those who consume lower levels of caffeine.

The study followed 6,467 women for up to 10 years. Those consuming more caffeine were found to be at lower risk of having problems with cognitive functioning.

However, caffeine consumption was based on self-report and decaffeinated drinks were not specified, it was presumed all coffee, tea and cola drinks were caffeinated.

In addition, the results were modest to say the least. While researchers estimated the preventative effect was 26% (not 36% as widely reported in the media), according to the maths used by the researchers, the actual figure could be as low as 1%.

As the exact cause of dementia and in particular Alzheimer's disease is not known, there is no clear way to prevent the condition. There are things you can do that may reduce your risk, such as stopping smoking and reducing alcohol intake, eating a healthy, balanced diet, and staying physically fit and mentally active.  


Where did the story come from?

The study was carried out by researchers at the University of Wisconsin-Milwaukee, Wake Forest School of Medicine, the Health Partners Institute for Education and Research in Minnesota, and Harvard Medical School, all in the US.

The study was funded by the National Heart, Lung and Blood Institute, at the National Institutes for Health, US. The authors do not report any sources of conflict.

The study was published in the peer-reviewed Journals of Gerontology, Medical Sciences, an open-access journal and is free to read online.

The quality of the UK media's reporting of the study was poor. Firstly, most of the headlines, such as the Mail's "Coffee really can help to prevent dementia," overstated the implications of the study's results.

Secondly, nobody highlighted that the main result in terms of dementia prevention only barely scraped the level required for statistical significance.

Finally, and most importantly, all of the UK media's sources reported a factual inaccuracy. The actual reduction in terms of hazard ratio was 26% not 36%.

The inaccuracy appears to originate with a press release from the EurekAlert! science news service. This suggests no UK media source bothered to read the actual study (which to be fair to EurekAlert! was linked to in its article) and instead just used the press release.


What kind of research was this?

This was a prospective cohort study which aimed to assess the relationship between caffeine intake and overall incidence of probable dementia or cognitive impairment in postmenopausal women. Previous research in animals has suggested a protective effect of caffeine and other components in coffee on brain function.

The researchers used data from a long running randomised controlled trial in the US called the Women's Health Initiative. Women aged 65 to 80 had been randomised to take oestrogen tablets or placebo between 1995 and 1999. They were followed up annually for up to 10 years.

As this was a cohort study using data from the trial, it can only show a link between one factor – in this case caffeine intake – and another – dementia and cognitive impairment. It cannot prove caffeine intake lowered the risk of dementia or cognitive impairment.


What did the research involve?

Researchers looked at data from 6,467 women who had provided self-reported caffeine data within six months of starting the study and had at least one follow-up cognitive assessment.

Global cognitive function was assessed annually by trained, certified technicians and interviewers using the 100-point Modified Mini Mental State (3MS) exam until 2007. Annual assessment after 2007 was done by the 40 point Telephone Interview for Cognitive Status-modified (TICSm).

Both the 3MS and the TICSm are well validated methods of assessing and measuring cognitive abilities.

Caffeine intake was based on self-report at the start of the study using a food frequency questionnaire (FFQ). Caffeine intake was estimated from questions on coffee, tea, and cola beverages, including frequency and serving size. It was presumed that intake of these drinks were of the caffeinated form as there was no specific question asking about decaffeinated forms.

The data was analysed according to caffeine intake and the time until incidence of probable dementia or cognitive impairment. The results were adjusted to take into account risk factors including:

  • age
  • education
  • body mass index
  • hormone therapy
  • race
  • sleep quality
  • depression
  • hypertension
  • prior cardiovascular disease
  • diabetes
  • smoking
  • alcohol consumption


What were the basic results?

In a sample of generally healthy postmenopausal women, during the 10 years of follow-up, 209 women received a classification of probable dementia and 179 of mild cognitive impairment.

Women who drank more than 172mg of caffeine per day (equivalent to just under two cups of coffee) had a 26% lower risk of probable dementia than those who drank less (adjusted hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.56 to 0.99). As mentioned this result is borderline statistically significant.

They were also 26% less likely to have either probable dementia or mild cognitive impairment (HR 0.74, 95% CI 0.60 to 0.91).

The average amount of caffeine consumed in the women above the 172mg cut-off was 261mg, equating to about three cups of coffee or five cups of tea. The average amount consumed below the cut-off was 64mg.


How did the researchers interpret the results?

The researchers concluded that they showed a "lower risk of probable dementia or global cognitive impairment incidence in women with higher caffeine consumption, which are generally consistent with the literature."

Although more studies are needed to verify the consistency of reports, given that caffeine intake is easily modifiable, it is important to quantify its relationship with cognitive health outcomes not only from preventative stand point but also to better understand the underlying mechanisms and their involvement in dementia and cognitive impairment.

They further add "given that Alzheimer's disease prevalence is expected to quadruple by 2050, even a small reduction in age-related cognitive impairment or dementia burden would thereby have significant public health implications."



This study suggests there is a link between self-reported caffeine consumption and risk of developing probable dementia or some kind of cognitive impairment.

The findings could be important in leading to more research to investigate the mechanisms by which caffeine might provide protection against dementia and cognitive impairment. The hope being that such investigation may eventually lead to new forms of drug treatments.

However, there are several limitations of the study, including:

  • The level of caffeine was self-reported and may be inaccurate, particularly as it was presumed the reported intake of coffee, tea and cola were all caffeinated, which may not be the case.
  • As the actual levels of caffeine were not measured in the study, it may have been another component in coffee, tea of cola that was having a positive effect on the cognitive ability of the women.
  • The women in the sample were mostly white and generally highly educated and may not be representative of the general population which may have had an impact on the cognitive functioning scores.
  • Although some confounding factors were adjusted for, some were not, for example other aspects of women's diets and family history of dementia.
  • Breaking down level of caffeine consumed into more than two groups would have been useful to observe if cognitive function improves with caffeine consumed or if there is an optimum level of caffeine consumption somewhere in the middle.

Finally, the measures of cognitive function were not consistent throughout the study and therefore comparing women assessed using different instruments may lead to over- or under-estimation of cognitive impairment or probable dementia, causing inaccuracies in the conclusions.

Overall, it cannot be said that women consuming more caffeine are at a lower risk of developing cognitive impairment or probable dementia. More research is needed to identify whether there are mechanisms by which caffeine may be a protective factor in cognitive functioning.

If you are concerned about dementia then more effective methods of prevention (though not guaranteed) include exercise, healthy diet, quit smoking and moderate your consumption of alcohol. A good general rule is that what is good for heart tends to be good for the brain.

Read more about dementia and Alzheimer's disease prevention

Links To The Headlines

Coffee really CAN help to prevent dementia: Just two cups a day 'cuts the risk of developing it by 36 per cent'. Mail Online, October 4 2016

Drinking coffee every day could 'help prevent dementia'. The Independent, October 4 2016

Drinking two coffees every day could help you ward off dementia. Daily Mirror, October 4 2016

Here's another good reason to swill down loads of coffee, according to science. Metro, October 4 2016

Links To Science

Driscoll I, Shumaker SA, Snively BM, et al. Relationships Between Caffeine Intake and Risk for Probable Dementia or Global Cognitive Impairment: The Women's Health Initiative Memory Study. The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences. Published online September 27 2016

Categories: NHS Choices

Warning over babies sleeping in car seats

NHS Choices - Behind the Headlines - Tue, 04/10/2016 - 16:30

"Long periods sleeping in car seats may be dangerous for young babies," the Daily Mail reports.

The results of a small study suggest spending long periods of time in a car seat may lead to babies having breathing difficulties.

But the researchers pointed out "we cannot be certain of the clinical significance or potential risks".

This novel study used a vehicle simulator to look at the effects of placing a newborn baby in a car seat at the 40⁰ angle required for travelling.

Researchers tested 40 newborns, who were a mix of preterm and full-term.

They found that while sat at this angle for 30 minutes – either stationary or when in motion – the babies' heart and breathing rate increased, and their blood oxygen levels were lower compared with lying flat in a cot.

The difficulty is knowing whether this would put the infants at serious risk – for example, whether their risk of stopping breathing goes up.

We don't know how many harmful effects may occur while a baby is travelling in a car seat, so a larger study is now needed.

Until then, the safety of a baby travelling in a moving vehicle is paramount. It's important to continue to use car seats as instructed for any journeys – and is also required by law.

Francine Bate, chief executive of the Lullaby Trust, the charity who funded the study, advised parents to keep a watchful eye on babies travelling in a car seat, and to also avoid driving long distances without taking a break.

Where did the story come from?

The study was carried out by researchers from Great Western Hospitals NHS Foundation Trust, Swindon, the University of Southampton and the University of Bristol.

It was funded by the Lullaby Trust and published in the peer-reviewed journal, Archives of Disease in Children: Fetal and Neonatal Edition. The article is openly available to access online.

The Mail gives fairly balanced coverage of this study, including making the recommendation that babies should travel in a properly secured child seat during car journeys, as required by law.

What kind of research was this?

This experimental study involved using a simulator designed to reproduce the vibration a baby experiences when placed in a rear-facing car seat in a car travelling at 30mph.

Car seats are used for infants from birth up to 10kg, but may be too big to secure low birthweight or preterm infants who weigh less than 2.5kg.

There are concerns that the prominent back of the head seen in babies may push the head forwards when they sleep in these seats, and possibly obstruct the airway.

There are said to have been isolated reports of deaths while infants have been sleeping in these seats, either while travelling or when being used as an alternative to a cot or pushchair.

A BMJ study from 2006 found that in the 18 months between July 1999 and December 2000, a total of 43 babies who had been travelling in car seats required admission to hospital for serious breathing difficulties. 

There have never been any studies that have actively monitored infants in moving vehicles before, so this moving simulation aimed to better establish how safe car seats are for babies while travelling. 

What did the research involve?

The study aimed to assess the effects of placing healthy full-term and preterm infants in a car seat positioned at an angle of 30⁰ or 40⁰, either while static or moving.

The intention was to replicate the normal routine of parents preparing for and then taking their baby on a car journey.

Mothers of 40 infants – 19 full-term and 21 preterm – were recruited when the babies were ready for hospital discharge.

The babies were monitored continuously for their breathing rate, heart rate, blood oxygen levels and carbon dioxide levels on breathing in and out while spending 30 minutes in three different positions.

Half the infants were randomly allocated to be tested in the following order (protocol A):

  • on a horizontal surface, seated angle of 30⁰ (static)
  • on the simulator, seated angle of 40⁰ (static)
  • on the simulator, seated angle of 40⁰ with movements to simulate being in a car travelling at 30 mph (motion)

The other half received this sequence in a different order (protocol B): static 40⁰, moving 40⁰, then static 30⁰.

The babies' breathing and heart measures when they were lying in a cot (baseline) were compared with those during the tests.

The static 30⁰ positions were tested using the babies' own car seats, as they were ready to go home. The 40⁰ tests used the same seat placed on a motion simulator in the lab.

What were the basic results?

In the full sample of 40 babies, the average pregnancy duration was 36 weeks (range 31 to 39 weeks) and the average birthweight was 2.5kg (range 1.5 to 3.2kg). Babies were tested an average of 13 days after birth.

Looking at the static 30⁰ positions, the only difference compared with baseline was more occasions where the blood oxygen levels were less than optimal.

There were, however, more changes when the babies were angled at 40⁰ and in motion. Babies in these positions had significantly higher heart and breathing rates, and lower blood oxygen levels. Their carbon dioxide levels rose slightly, but not significantly so.

There were also more episodes where blood oxygen levels were notably lower than normal – less than 85% saturation, when normal would be in the high 90s. 

Comparing the preterm babies with the full-term infants, the changes were still in the same direction, but were less so than with the preterm infants.

The order of testing (protocol A or B) made no difference.

How did the researchers interpret the results?

The researchers concluded that: "Term and preterm infants showed significant signs of potentially adverse [heart and breathing] effects in the upright position at 40⁰, particularly with simulated motion."

They went on to say a larger study is required to investigate the significance of these results.


This valuable pilot study is said to be the first to have assessed the effects of a newborn baby sitting in a car seat in the more upright position needed to safely secure them inside a moving vehicle.

The findings suggest spending 30 minutes sat in a car seat while stationary at the lower angle of 30⁰ has minimal effects.

But being placed in a car at the necessary 40⁰ angle, static and in motion, can have significant effects on the newborns' breathing and heart rate.

It's difficult to say whether the findings seen when a baby was positioned at the 40⁰ angle could be harmful and put them at potential risk of stopping breathing, for example. We also have no information on the effects of spending longer than 30 minutes in this position.

And although minimal effects were seen when the babies were placed at a 30⁰ angle, we don't know whether it could start to have an effect if the baby was left in the seat in this position for longer.

Because no studies have been done before in moving cars or simulators, the possible nature, frequency and magnitude of any adverse effects are unknown.

This makes it difficult to know the optimal sample size that would be needed to reliably capture any harmful effects – studies in a larger sample of babies are therefore needed to confirm these results.     

The authors say the American Academy of Pediatrics currently recommends that all preterm infants should undergo monitoring in a car seat before discharge to check for low breathing or heart rate, or low oxygen saturation.

They say many UK neonatal units also follow a "car seat challenge" before discharging preterm babies from hospital. Even so, this doesn't take into account the effects of motion.

Further studies are needed to ensure the safety of newborns travelling in car seats. But for now, car safety remains paramount – parents and carers should continue to use car seats according to their instructions.

Dr Renu Arya, consultant paediatrician at Great Western Hospitals NHS Foundation Trust, who led the research project, said: "Parents should not stop using car safety seats to transport their infants. Infants must be protected in moving vehicles, and UK law requires car seats be used whenever infants travel in cars."

But it may be a good idea to rethink leaving a baby in a car seat for prolonged periods when they're not travelling.

Taking regular breaks when driving long distances is also recommended. As well as giving a baby a chance to move out of their car seat, it will also help keep the driver alert and reduce the risk of accidents.

The Royal Society for the Prevention of Accidents recommends taking at least a 15-minute break every two hours.  

Links To The Headlines

Health fears over letting babies sleep in car seats: Newborns can slump forward blocking out their airways. Daily Mail, October 4 2016

Links To Science

Arya R, Williams G, Kilonback A, et al. Is the infant car seat challenge useful? A pilot study in a simulated moving vehicle. ADC Fetal & Neonatal Edition. Published online September 30 2016

Categories: NHS Choices

Does going on holiday help boost the immune system?

NHS Choices - Behind the Headlines - Mon, 03/10/2016 - 17:30

"Prescribing holidays 'could help fight infections'," BBC News reports, while the Mail Online claims holidays can "turbo-boost" the immune system. But the news isn't quite as conclusive as it sounds.

It comes from a study where two groups of mice were housed for two weeks in two different types of housing: standard housing consisting of a cage with sawdust and nesting material, or an "enhanced environment".

The enhanced environment saw better bedding, wheels, toys and activity tunnels added to the cage. According to the lead researcher, this was akin to "put[ting the mice] in their equivalent of a holiday resort".

The researchers wanted to investigate whether an enhanced environment resulted in changes in mouse behaviour and the composition of white blood cells used to fight off infection.

No differences were seen in the behaviour of the mice – and no major changes were seen in their immune cells.

More in-depth analysis revealed differences in certain inflammatory molecules, suggesting a possible effect on T helper cells, which regulate other immune cells.

But we're not biologically identical to mice – even if the arguably modest effects on immunity were the same in humans, we can't say these changes would result in an improved ability to fight infections.

You're unlikely to get two weeks in the Caribbean on an NHS prescription any time soon.

But you can take steps to enhance your own environment and boost your mood, which could help you cope better with the coming winter months.

Get tips on five ways to stay healthy this winter.

Where did the story come from?

The study was carried out by researchers from the Barts and The London School of Medicine and Dentistry at Queen Mary University of London, and Imperial College of Science, Technology and Medicine at the University of London.

The study did not receive any grant funding.

It was published in the peer-reviewed journal Frontiers in Immunology on an open access basis, so it is freely available to access online.

Both BBC News and the Mail Online provided balanced coverage of the study. However, both talk about the prospect of doctors "prescribing holidays" to help people recover from illness.

This seems a jump too far just based on this research, which is in its early stages and only provides rather inconclusive findings in mice.

What kind of research was this?

This animal study in mice aimed to see whether changes in their housing conditions would alter their T immune cells, a core part of the human immune system.

This builds on recent research, which suggests immune cells alter their form and function in response to environmental changes, such as pollution, geographical location and social status.

Animal research is a useful starting point for understanding biological processes that may be similar in humans.

However, we are not identical to mice, and the experimental scenarios may not be representative of real life in humans.

What did the research involve?

The study involved six-week-old male mice, who were housed for two weeks in groups of five in either standard housing conditions or an enhanced environment.

The enhanced environment was intended to provide an enriched multisensory environment for the animal, rather than just the standard lab cage.

The mice were provided with various nesting materials rather than just sawdust, as well as a nest box and a tunnel, wheel and swing. This equipment was replaced with new toys after one week.

The mice were weighed weekly and had a series of behavioural tests every second day. This included assessing their exploration and anxiety in an open field test, and their repetition and perseverance in a marble-burying test.

Mice that spend much of their time digging for marbles are thought to be displaying obsessive compulsive-type behaviour, which could be caused by underlying anxiety. 

The researchers also obtained samples of immune tissue from the lymph nodes, spleen and thymus gland to assess the composition of T immune cells.

What were the basic results?

The researchers found no significant differences in mouse behaviour on either the open field or marble tests.

Also, despite expectations, they found no major changes in the composition of the T cells. There were no changes in the total number of lymph node or thymus cells.

There was a very minor 5-10% increase in the number of a particular T cell (CD3) in mice in the enhanced environment, but no changes in other T cells.

The researchers then stimulated the T cells in the laboratory by culturing them with antibodies.

They found no differences in any of the inflammatory molecules, with the exception of interferon-gamma.

Levels of this inflammatory molecule were about two times lower in those from the enhanced environment.

This suggested a possible effect on the production of T helper cells, which regulate other immune cells.

Further analysis of T helper cells – again, stimulated with antibodies – confirmed that samples from the enhanced environment produced lower levels of interferon-gamma and higher levels of two other molecules: one possible inflammatory (interleukin 10) and one anti-inflammatory (interleukin 17).

Further genetic analysis showed changes in the gene activity of the different groups of mice, with immune signalling pathways being modified.

How did the researchers interpret the results?

The researchers said their results "provide first evidence for a specific effect of [enhanced environments] on T cell differentiation and its associated changes in gene expression profile.

"In addition, our study sheds new light on the possible mechanisms by which changes in environmental factors can significantly influence the immune response of the host and favour the resolution of the inflammatory response." 


Though an interesting experiment, this mouse study has limited applicability to humans. It certainly doesn't prove that going on holiday will boost your immunity and make you better if you're unwell.

There are a number of points to consider. For one thing, even in mice the results weren't demonstrative. The enhanced environment had no effect on mouse behaviour and there were no major changes to their immune cells.

It was only on further analysis that the researchers found differences in specific inflammatory molecules.

This means we don't know whether this would translate into real differences in the mice – for example, differences in their lifespan or propensity for certain illnesses, inflammatory conditions or cancers.

We also don't know whether these effects would be sustained if the mice stayed in the enhanced environment, or if they would be reversed if they switched back.

Although we have some similarities to mice, human biology is not identical – we can't conclude that exactly the same effects on T helper cells would be seen if we lived in "standard" or "enhanced" stimulatory environments.

And spending time in an enhanced environment with wheels, toys and better bedding doesn't automatically translate into the equivalent of a couple of weeks' holiday for a human being. 

Even if a holiday did temporarily alter specific inflammatory molecules in the same way for us, we don't know if this would make any difference to our ability to fight illness or chronic disease.

The study also only included male mice – do the findings extend to females, whether they're mouse or human?

Nevertheless, most of us know that a break can do us good. It is certainly possible that the effects of relaxation and improved wellbeing could extend to effects on our immune system as well, but this hasn't been proved by this study.

Read more about how to improve your sense of wellbeing

Links To The Headlines

Prescribing holidays 'could help fight infections'. BBC News, September 30 2016

Feeling sick? Going on a holiday may be the best cure: Change of environment could turbo-charge the immune system. Mail Online, September 30 2016

Links To Science

Rattazzi L, Piras G, Brod S, et al. Impact of Enriched Environment on Murine T Cell Differentiation and Gene Expression Profile. Frontiers in Immunology. Published online September 30 2016

Categories: NHS Choices

Women taking the contraceptive pill 'more likely to be depressed'

NHS Choices - Behind the Headlines - Fri, 30/09/2016 - 17:30

"Are you on the Pill? You're more likely to be depressed: Women who use contraception are up to 70% more likely to be on antidepressants," reports the Mail Online.

The news is based on a study by researchers in Denmark to see whether hormonal contraceptive methods were associated with depression. More than 1 million women aged 15 to 34, with no prior history of depression, were included in the study.

The researchers found that, compared to non-users, those who took the pill were 23% more likely to use antidepressants.

However, it's important to note this study is not able to prove that the contraceptive methods are responsible for the depression, only to find possible links to investigate further.

The researchers don't advise that women should stop using their contraception, just that further studies are needed. If this association is found to be true, depression may have to be added as a possible side effect of hormonal contraception. 

Where did the story come from?

The study was carried out by researchers from the University of Copenhagen and was funded by the University of Copenhagen and the Lundbeck Foundation.

The study was published in the peer-reviewed medical journal JAMA Psychiatry.

The study authors revealed that Dr Kessing had consulted for Lundbeck and AstraZeneca and receiving honoraria for this work, while Dr Lidegaard received honoraria for talks within the past three years from Exeltis.

The story was reported accurately in the media, with The Telegraph stating: "The Danish study didn't aim to show that the Pill directly causes depression. But it does point to a worrying association between women taking the contraceptive and those also being prescribed an antidepressant." This is useful to note as this kind of study is not able to prove cause and effect.

What kind of research was this?

This was a large prospective cohort study which aimed to investigate whether the use of hormonal contraception is associated with future use of antidepressants and diagnosis of depression.

This type of study is able to provide possible links between the exposure and outcome, but is not able to prove that one causes the other. It remains possible that other factors, such as concerns over pregnancy, or taking regular medication, might contribute to the outcome.

What did the research involve?

The researchers used data from the National Prescription Register and the Psychiatric Central Research Register in Denmark.

Women and girls aged between 15 and 34 years of age, living in Denmark, were followed up from January 1 2000 to December 2013. They were excluded from the study if they had:

  • a previous diagnosis of depression
  • been prescribed antidepressants
  • another major psychiatric diagnosis
  • cancer
  • venous thrombosis
  • infertility treatment

Contraceptive methods were categorised by oestrogen type and dose, progesterone type and the method of contraception. Data was collected from the National Prescription Register.

Data for the use of antidepressants was collected using two outcome measures:

  • collecting a prescription for antidepressants
  • being diagnosed with depression at any inpatient or outpatient psychiatric department in Denmark

Non-users were defined as those who never used hormonal contraceptives, plus former users.

What were the basic results?

The analysis included 1,061,997 women, with an average age of 24 years. During follow-up, 55.5% of women were current or recent users of hormonal contraception. A total of 133,178 first prescriptions of antidepressants and 23,077 first diagnoses of depression were detected during follow-up.

The researchers compared users of hormonal contraception with non- users and found more users had been prescribed antidepressants or diagnosed with depression.

They calculated the increase in risk of using antidepressants according to contraceptive method as:

Similar figures were found for depression diagnoses.

The researchers also found the risk of depression decreased with age. Adolescents using combined oral contraceptives had an 80% increased risk of antidepressant use (RR 1.8 (95% CI, 1.75 to 1.84)) and those using progesterone-only pills a 120% higher risk (RR 2.2 (95% CI, 1.99 to 2.52)).

How did the researchers interpret the results?

The researchers concluded that the "use of hormonal contraception, especially among adolescents, was associated with subsequent use of antidepressants and a first diagnosis of depression, suggesting depression as a potential adverse effect of hormonal contraceptive use."


This was a large prospective cohort study which aimed to investigate whether using hormonal contraception is associated with the future use of antidepressants and a diagnosis of depression.

The researchers compared users of hormonal contraception with non-users and found users were more likely to be prescribed antidepressants and diagnosed with depression.

However, there are a few important points to consider about the results, such as:

  • this study is not able to prove that the contraceptive methods are responsible for the depression – only to find possible links to investigate further
  • some of the associations are based on a comparatively small number of events
  • the risk of using antidepressants and being diagnosed with depression peaks at approximately two to three months of contraceptive use, but then begins to fall

The researchers tested for a range of other things that might explain the results. For example, they looked at whether doctors were more likely to prescribe hormonal contraception to women who were already low in mood, or whether the initiation of a sexual relationship might influence the risk of depression. They found nothing that could easily explain the link that was shown across all age groups and types of contraception.

Further studies are required to prove this link. If the link is proven in future studies, depression may have to be added as a possible side effect of hormonal contraception.

Links To The Headlines

Women taking pill more likely to be treated for depression, study finds. The Guardian, September 28 2016

Are you on the Pill? You're more likely to be depressed: Women who use contraception are up to 70 per cent more likely to be on antidepressants. Mail Online, September 28 2016

Is the contraceptive Pill making you feel depressed? The Daily Telegraph, September 29 2016

Links To Science

Skovlund CW, Mørch LS, Kessing LV, et al. Association of Hormonal Contraception With Depression. JAMA Psychiatry. Published online September 28 2016

Categories: NHS Choices

Ibuprofen-like painkillers linked to an increased risk of heart failure

NHS Choices - Behind the Headlines - Thu, 29/09/2016 - 17:30

"Ibuprofen could raise the risk of heart failure by up to 83%," claims the Daily Mirror. But this headline massively overstates the danger of this painkiller.

In fact, new research suggests that taking painkillers known as non-steroidal anti-inflammatory drugs (NSAIDs) – which includes ibuprofen – increases the risk of heart failure by less than 20% overall.

NSAIDs are a group of painkilling medicines commonly taken by people with joint problems, backache and arthritis. They are prescribed to relieve pain and reduce inflammation.

The study found that the risk of heart failure varies between NSAIDs and according to dosage.

While a rarely prescribed NSAID called ketorolac almost doubled the risk of heart problems, the more commonly taken ibuprofen increased the chance of heart problems by just 18%.

The risk was also highest for people who took an NSAID on a daily basis and in very high doses.

Some NSAIDs, such as ketoprofen and celecoxib, did not seem to increase the risk at all at usual doses.

This latest study backs up previous evidence that NSAIDs are clearly linked with an increased risk of heart failure. But it's important to bear in mind that the risk is, for most people, still very small.

Heart failure is caused by a wide range of conditions, including high blood pressure, heart attacks and obesity.

Where did the story come from?

This was a large study involving more than 7 million people. It was carried out by researchers from seven European institutions, led by the University of Milan, and was funded by the European Union. The study was published in the peer-reviewed British Medical Journal (BMJ).

Some UK media outlets failed to make it clear the study was carried out among people who were taking prescribed NSAIDs, usually for a long-term condition such as backache or arthritis, rather than people taking the occasional over-the-counter painkiller.

The Daily Express headline wrongly says: "Over-the-counter painkillers raise risk by almost 20%," although at least they used the more credible 20% relative risk figure.

The Daily Mirror's scaremongering headline stating an increased risk of heart failure of 83% was way above that of most of the NSAIDs studied and was wrongly linked to ibuprofen.

BBC News took a more balanced view, and included interviews with experts who discussed exactly who is and isn't at risk from NSAIDs and heart failure.

What kind of research was this?

This was a so-called nested case-control study, which used drug databases to identify people who'd been prescribed NSAIDs during a 10 year period. Of these, those who had been admitted to hospital for heart failure were compared with others in the database of the same age and sex.

This type of study helps researchers identify links between individual drugs and outcomes such as heart disease. They don't directly prove the drug causes the heart disease, but we've already seen randomised controlled trials showing NSAIDs in general do seem to raise the chances of heart failure.

What did the research involve?

Researchers used five drug databases from four European countries to identify adults who'd had at least one NSAID prescription between 2000 and 2010. They then identified anyone from that group who'd later been admitted to hospital with heart failure and matched them with up to 100 "controls" – people the same age and sex, who'd started the study around the same time.

They then looked to see whether a current prescription of an NSAID (within the last 14 days) affected someone's chances of being admitted to hospital with heart failure.

The databases were from the UK, Italy, the Netherlands and Germany. For the UK and the Netherlands, the databases also recorded the daily dose prescribed, so the researchers used this information to calculate the effect of low, normal, high or very high prescribed doses.

The researchers corrected their figures to take account of factors such as previous diagnosis of heart failure or other medical condition and other medicines being taken.

What were the basic results?

The study found 92,163 people who'd been admitted to hospital with heart failure among the 7.6 million people prescribed an NSAID who were included in the study. People admitted with heart failure tended to be older, with an average age of 77, and many of them also had high blood pressure, high cholesterol, cardiovascular disease or diabetes.

Compared to others of about the same age and sex, those who'd been admitted for heart failure were more likely to be currently taking a prescribed NSAID.

In fact, nearly one in five (17.4 %) of heart failure patients and one in seven (14.4 %) of the matched control groups had a current prescription. This meant that having a current prescription for any NSAID raised the risk of heart failure admission by almost 20% (odds ratio (OR) 1.19, 95% confidence interval (CI) 1.17 to 1.22).

However, more interesting was the information about individual drugs. Nine NSAIDs had a raised risk of heart failure: ketorolac, etoricoxib, indomethacin, rofecoxib, piroxicam, diclofenac, nimeluside, ibuprofen and naproxen.

The degree of increased relative risk varied between them, from ketorolac at 83% to naproxen at 16%.

Some of the NSAIDs, including the commonly used ketoprofen and celeocoxib, did not show any increased risk.

The risk was highest for people taking very high daily doses (twice the usual daily dose) of NSAIDs.

How did the researchers interpret the results?

The researchers said their study results showed that the risk of heart failure in people taking NSAIDs "appears to vary between individual NSAIDs, and is dose dependent". 

They say their findings "might apply to NSAIDs obtained over the counter", although they only looked at prescription drugs.

"Although over-the-counter NSAIDs are probably typically used at lower doses, by younger people, and for shorter durations than prescribed NSAIDs, they are sometimes available at the same doses," they observe, adding "they may be inappropriately over-used".

They call for research into the safety of over-the-counter NSAIDs "under the conditions they are typically used".


This useful and well-conducted study isn't the first to say NSAIDs may raise the risk of heart failure. We've known for some time that NSAIDs can have side effects, especially when used at high doses and for long periods.

What this study does help show is the different levels of risk between different NSAIDs, and confirms that the risk depends partly on the dose. It's important to remember that the study only included people who were prescribed NSAIDs and not people who'd bought them over the counter.

The information is most useful to older people taking prescribed NSAIDs long-term for conditions such as gout or arthritis. These are the people most likely to be affected by heart problems linked to NSAIDs.

The study shows that some NSAIDs are less risky than others, and doctors can use this information to discuss with patients which is the most suitable drug if they need long-term anti-inflammatory painkillers.

For people who take NSAIDs over the counter, it's a reminder that these drugs are not risk-free. While an otherwise healtlhy 20-something taking ibuprofen for a day or two to get over backache is highly unlikely to get heart failure as a result, long-term use of NSAIDs at high doses can cause problems.

Sensible advice is to take the lowest dose that works for the shortest period you need it. If you find you need to take NSAIDs very often, or you're taking doses higher than those recommended, you should talk to your doctor about your pain.

Find out more about living with pain.

Links To The Headlines

Ibuprofen link to heart failure: Over-the-counter painkillers raise risk by almost 20%. The Daily Express, September 29 2016

Ibuprofen increases heart risk by a fifth. The Times, September 29 2016

Common painkillers 'increase heart failure risk'. BBC News, September 29 2016

Painkillers like ibuprofen may raise risk of hospital admission for heart failure. The Telegraph, September 29 2016

Links To Science

Corrao G, Arfe A, Scotti L et al. Non-steroidal anti-inflammatory drugs and risk of heart failure in four European countries: nested case control study. The British Medical Journal. Published Online 28 September 2016

Categories: NHS Choices