Alan M. Zaslavsky

Short screening scales to monitor population prevalences and trends in non-specific psychological distress

BACKGROUND A 10-question screening scale of psychological distress and a six-question short-form scale embedded within the 10-question scale were developed for the redesigned US National Health Interview Survey (NHIS). METHODS Initial pilot questions were administered in a US national mail survey (N = 1401). A reduced set of questions was subsequently administered in a US national telephone survey (N = 1574). The 10-question and six-question scales, which we refer to as the K10 and K6, were constructed from the reduced set of questions based on Item Response Theory models. The scales were subsequently validated in a two-stage clinical reappraisal survey (N = 1000 telephone screening interviews in the first stage followed by N = 153 face-to-face clinical interviews in the second stage that oversampled first-stage respondents who screened positive for emotional problems) in a local convenience sample. The second-stage sample was administered the screening scales along with the Structured Clinical Interview for DSM-IV (SCID). The K6 was subsequently included in the 1997 (N = 36116) and 1998 (N = 32440) US National Health Interview Survey, while the K10 was included in the 1997 (N = 10641) Australian National Survey of Mental Health and Well-Being. RESULTS Both the K10 and K6 have good precision in the 90th-99th percentile range of the population distribution (standard errors of standardized scores in the range 0.20-0.25) as well as consistent psychometric properties across major sociodemographic subsamples. The scales strongly discriminate between community cases and non-cases of DSM-IV/SCID disorders, with areas under the Receiver Operating Characteristic (ROC) curve of 0.87-0.88 for disorders having Global Assessment of Functioning (GAF) scores of 0-70 and 0.95-0.96 for disorders having GAF scores of 0-50. CONCLUSIONS The brevity, strong psychometric properties, and ability to discriminate DSM-IV cases from non-cases make the K10 and K6 attractive for use in general-purpose health surveys. The scales are already being used in annual government health surveys in the US and Canada as well as in the WHO World Mental Health Surveys. Routine inclusion of either the K10 or K6 in clinical studies would create an important, and heretofore missing, crosswalk between community and clinical epidemiology.

Childhood adversities and adult psychiatric disorders in the National Comorbidity Survey Replication I: Associations with first onset of DSM-IV disorders.

CONTEXT Although significant associations of childhood adversities (CAs) with adult mental disorders have been documented consistently in epidemiological surveys, these studies generally have examined only 1 CA per study. Because CAs are highly clustered, this approach results in overestimating the importance of individual CAs. Multivariate CA studies have been based on insufficiently complex models. OBJECTIVE To examine the joint associations of 12 retrospectively reported CAs with the first onset of DSM-IV disorders in the National Comorbidity Survey Replication using substantively complex multivariate models. DESIGN Cross-sectional community survey with retrospective reports of CAs and lifetime DSM-IV disorders. SETTING Household population in the United States. PARTICIPANTS Nationally representative sample of 9282 adults. MAIN OUTCOME MEASURES Lifetime prevalences of 20 DSM-IV anxiety, mood, disruptive behavior, and substance use disorders assessed using the Composite International Diagnostic Interview. RESULTS The CAs studied were highly prevalent and intercorrelated. The CAs in a maladaptive family functioning (MFF) cluster (parental mental illness, substance abuse disorder, and criminality; family violence; physical abuse; sexual abuse; and neglect) were the strongest correlates of disorder onset. The best-fitting model included terms for each type of CA, number of MFF CAs, and number of other CAs. Multiple MFF CAs had significant subadditive associations with disorder onset. Little specificity was found for particular CAs with particular disorders. Associations declined in magnitude with life course stage and number of previous lifetime disorders but increased with length of recall. Simulations suggest that CAs are associated with 44.6% of all childhood-onset disorders and with 25.9% to 32.0% of later-onset disorders. CONCLUSIONS The fact that associations increased with length of recall raises the possibility of recall bias inflating estimates. Even considering this, the results suggest that CAs have powerful and often subadditive associations with the onset of many types of largely primary mental disorders throughout the life course.

Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States

Estimates of 12‐month and lifetime prevalence and of lifetime morbid risk (LMR) of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM‐IV‐TR) anxiety and mood disorders are presented based on US epidemiological surveys among people aged 13+. The presentation is designed for use in the upcoming DSM‐5 manual to provide more coherent estimates than would otherwise be available. Prevalence estimates are presented for the age groups proposed by DSM‐5 workgroups as the most useful to consider for policy planning purposes. The LMR/12‐month prevalence estimates ranked by frequency are as follows: major depressive episode: 29.9%/8.6%; specific phobia: 18.4/12.1%; social phobia: 13.0/7.4%; post‐traumatic stress disorder: 10.1/3.7%; generalized anxiety disorder: 9.0/2.0%; separation anxiety disorder: 8.7/1.2%; panic disorder: 6.8%/2.4%; bipolar disorder: 4.1/1.8%; agoraphobia: 3.7/1.7%; obsessive‐compulsive disorder: 2.7/1.2. Four broad patterns of results are most noteworthy: first, that the most common (lifetime prevalence/morbid risk) lifetime anxiety‐mood disorders in the United States are major depression (16.6/29.9%), specific phobia (15.6/18.4%), and social phobia (10.7/13.0%) and the least common are agoraphobia (2.5/3.7%) and obsessive‐compulsive disorder (2.3/2.7%); second, that the anxiety‐mood disorders with the earlier median ages‐of‐onset are phobias and separation anxiety disorder (ages 15–17) and those with the latest are panic disorder, major depression, and generalized anxiety disorder (ages 23–30); third, that LMR is considerably higher than lifetime prevalence for most anxiety‐mood disorders, although the magnitude of this difference is much higher for disorders with later than earlier ages‐of‐onset; and fourth, that the ratio of 12‐month to lifetime prevalence, roughly characterizing persistence, varies meaningfully in ways consistent with independent evidence about differential persistence of these disorders. Copyright

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys

BACKGROUND Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders. AIMS To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries. METHOD Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI). RESULTS Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries. CONCLUSIONS Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

INHALED NITRIC OXIDE AND PERSISTENT PULMONARY HYPERTENSION OF THE NEWBORN

Background Persistent pulmonary hypertension of the newborn causes systemic arterial hypoxemia because of increased pulmonary vascular resistance and right-to-left shunting of deoxygenated blood. Inhaled nitric oxide decreases pulmonary vascular resistance in newborns. We studied whether inhaled nitric oxide decreases severe hypoxemia in infants with persistent pulmonary hypertension. Methods In a prospective, multicenter study, 58 full-term infants with severe hypoxemia and persistent pulmonary hypertension were randomly assigned to breathe either a control gas (nitrogen) or nitric oxide (80 parts per million), mixed with oxygen from a ventilator. If oxygenation increased after 20 minutes and systemic blood pressure did not decrease, the treatment was considered successful and was continued at lower concentrations. Otherwise, it was discontinued and alternative therapies, including extracorporeal membrane oxygenation, were used. Results Inhaled nitric oxide successfully doubled systemic oxygenation in 16 of 30 infants (53 percent), whereas conventional therapy without inhaled nitric oxide increased oxygenation in only 2 of 28 infants (7 percent). Long-term therapy with inhaled nitric oxide sustained systemic oxygenation in 75 percent of the infants who had initial improvement. Extracorporeal membrane oxygenation was required in 71 percent of the control group and 40 percent of the nitric oxide group (P=0.02). The number of deaths was similar in the two groups. Inhaled nitric oxide did not cause systemic hypotension or increase methemoglobin levels. Conclusions Inhaled nitric oxide improves systemic oxygenation in infants with persistent pulmonary hypertension and may reduce the need for more invasive treatments.

Patterns and predictors of attention-deficit/ hyperactivity disorder persistence into adulthood : Results from the national comorbidity survey replication

BACKGROUND Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood. METHODS A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders). RESULTS Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD. CONCLUSIONS No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.

Prevalence, Persistence, and Sociodemographic Correlates of DSM-IV Disorders in the National Comorbidity Survey Replication Adolescent Supplement

CONTEXT Community epidemiological data on the prevalence and correlates of adolescent mental disorders are needed for policy planning purposes. Only limited data of this sort are available. OBJECTIVE To present estimates of 12-month and 30-day prevalence, persistence (12-month prevalence among lifetime cases and 30-day prevalence among 12-month cases), and sociodemographic correlates of commonly occurring DSM-IV disorders among adolescents in the National Comorbidity Survey Replication Adolescent Supplement. DESIGN The National Comorbidity Survey Replication Adolescent Supplement is a US national survey of DSM-IV anxiety, mood, behavior, and substance disorders among US adolescents based on face-to-face interviews in the homes of respondents with supplemental parent questionnaires. SETTING Dual-frame household and school samples of US adolescents. PARTICIPANTS A total of 10,148 adolescents aged 13 to 17 years (interviews) and 1 parent of each adolescent (questionnaires). MAIN OUTCOME MEASURES The DSM-IV disorders assessed with the World Health Organization Composite International Diagnostic Interview and validated with blinded clinical interviews based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Good concordance (area under the receiver operating characteristic curve ≥0.80) was found between Composite International Diagnostic Interview and Schedule for Affective Disorders and Schizophrenia for School-Age Children diagnoses. RESULTS The prevalence estimates of any DSM-IV disorder are 40.3% at 12 months (79.5% of lifetime cases) and 23.4% at 30 days (57.9% of 12-month cases). Anxiety disorders are the most common class of disorders, followed by behavior, mood, and substance disorders. Although relative disorder prevalence is quite stable over time, 30-day to 12-month prevalence ratios are higher for anxiety and behavior disorders than mood or substance disorders, suggesting that the former are more chronic than the latter. The 30-day to 12-month prevalence ratios are generally lower than the 12-month to lifetime ratios, suggesting that disorder persistence is due more to episode recurrence than to chronicity. Sociodemographic correlates are largely consistent with previous studies. CONCLUSIONS Among US adolescents, DSM-IV disorders are highly prevalent and persistent. Persistence is higher for adolescents than among adults and appears to be due more to recurrence than chronicity of child-adolescent onset disorders.

Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents: Results From the National Comorbidity Survey Replication Adolescent Supplement

CONTEXT Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (ie, suicide ideation, plans, and attempts). OBJECTIVES To estimate the lifetime prevalence of suicidal behaviors among US adolescents and the associations of retrospectively reported, temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors. DESIGN Dual-frame national sample of adolescents from the National Comorbidity Survey Replication Adolescent Supplement. SETTING Face-to-face household interviews with adolescents and questionnaires for parents. PARTICIPANTS A total of 6483 adolescents 13 to 18 years of age and their parents. MAIN OUTCOME MEASURES Lifetime suicide ideation, plans, and attempts. RESULTS The estimated lifetime prevalences of suicide ideation, plans, and attempts among the respondents are 12.1%, 4.0%, and 4.1%, respectively. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders are also predictors of plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%), treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring. CONCLUSIONS Suicidal behaviors are common among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have preexisting mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.

Screening for Serious Mental Illness in the General Population with the K6 screening scale: Results from the WHO World Mental Health (WMH) Survey Initiative

Data are reported on the background and performance of the K6 screening scale for serious mental illness (SMI) in the World Health Organization (WHO) World Mental Health (WMH) surveys. The K6 is a six‐item scale developed to provide a brief valid screen for Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM‐IV) SMI based on the criteria in the US ADAMHA Reorganization Act. Although methodological studies have documented good K6 validity in a number of countries, optimal scoring rules have never been proposed. Such rules are presented here based on analysis of K6 data in nationally or regionally representative WMH surveys in 14 countries (combined N = 41,770 respondents). Twelve‐month prevalence of DSM‐IV SMI was assessed with the fully‐structured WHO Composite International Diagnostic Interview. Nested logistic regression analysis was used to generate estimates of the predicted probability of SMI for each respondent from K6 scores, taking into consideration the possibility of variable concordance as a function of respondent age, gender, education, and country. Concordance, assessed by calculating the area under the receiver operating characteristic curve, was generally substantial (median 0.83; range 0.76–0.89; inter‐quartile range 0.81–0.85). Based on this result, optimal scaling rules are presented for use by investigators working with the K6 scale in the countries studied. Copyright

Use of Hormone Replacement Therapy by Postmenopausal Women in the United States

Postmenopausal hormone replacement therapy (HRT) is a subject of major interest in the field of womens health. Although HRT has a clear role in the treatment of menopausal symptoms (1), uncertainty exists about its long-term use to prevent disease and prolong life (2). In randomized, controlled trials, HRT has been shown to improve lipid profiles (3) and increase bone density in postmenopausal women (4) but not to decrease the rate of subsequent coronary events in women with established coronary artery disease (5). Observational studies have shown that women who use HRT have a substantially decreased risk for coronary artery disease (6-8), osteoporosis and fractures (8-10), and death (12), but they may also have an increased risk for breast cancer (13). In 1992, guidelines from the American College of Physicians advised that postmenopausal women who have had hysterectomy and women at risk for coronary heart disease are likely to benefit from preventive HRT (14, 15). A more recent decision analysis suggested that almost all postmenopausal women will benefit from HRT, especially those with risk factors for coronary heart disease (16). Despite these recommendations, the benefits and risks of HRT are not fully defined. The decision to use preventive HRT is usually not simple and is probably influenced by the personal characteristics and beliefs of women and their physicians. Previous studies have sought to characterize women who use postmenopausal HRT (17-27), but most of these studies examined local or highly selected cohorts of patients. A recent report on HRT use in a national sample of women in the United States analyzed past and current use together and last collected data in 1992 (26). To our knowledge, only one study has assessed psychological factors that may influence the decision to use HRT (27). Therefore, we examined patterns of HRT use in a national sample of postmenopausal women during 1995 to understand how sociodemographic, clinical, and psychological characteristics were associated with current use of this treatment. We also assessed patterns of use in women at risk for cardiovascular disease who may benefit most from this therapy. Finally, we sought to identify potential selection effects that may be present in observational studies while randomized clinical trials of this therapy are in progress (28). Methods Study Sample In 1995, the John D. and Catherine T. MacArthur Foundation Research Network on Successful Midlife Development conducted a random-digit telephone survey of a probability sample of adults in the United States from 25 to 74 years of age to identify physical, psychological, and social factors that promote good health, psychological well-being, and social responsibility. The study protocol was approved by the human subjects committee of Harvard Medical School. The survey was conducted by using a multistage sampling design. For the first stage, an equal probability sample of telephone numbers, stratified by county in proportion to population, was selected from more than 70 million directory-listed residential numbers. After determining household eligibility, respondents were selected on the basis of age and sex and were offered a stipend for participation. The response rate for this telephone survey was 70%. United States Census data from 1990 for each telephone exchange were used to assess for response bias, and no statistically significant differences were found between eligible households for which the telephone interview was completed and other households by age, education, income, Hispanic ethnicity, other ethnicity, and residence in a Metropolitan Statistical Area. Participants who completed the telephone interview were also mailed a self-administered questionnaire. We limited our cohort to women 50 to 74 years of age; 93% of these women also completed the self-administered questionnaire and were eligible for our sample, yielding an estimated response rate of 65% for the combined telephone survey and questionnaire. Compared with women who responded to the telephone interview only, these women were younger (mean age, 60.1 compared with 62.7 years; P=0.02), more likely to be married (56% compared with 35%; P=0.004), and more likely to have completed at least 12 years of education (84% compared with 61%; P=0.001). From this cohort (n=668), we identified all postmenopausal women with no personal history of breast cancer (n=495). A woman was considered postmenopausal if she reported that her menses had stopped permanently. Because by 50 years of age, most women with a uterus in our sample had undergone natural menopause, women who had undergone hysterectomy were considered postmenopausal whether or not they had undergone bilateral salpingo-oophorectomy. Data Collection Current users of HRT were women who reported use of hormone replacement, such as estrogen, in the past 30 days. Women were also asked about sociodemographic, clinical, and psychological factors that had previously been associated with use of HRT in other studies or that we postulated might influence its use. Sociodemographic variables included age (denoted by indicator variables for 5-year increments), ethnicity (white or nonwhite), education (<12 years, high school graduate or general education diploma, or college graduate), household income (in quartiles), marital status (currently married), children (one or more), employment status (full-time job), rural residence (not living in a Metropolitan Statistical Area), and geographic region (Northeast, Midwest, South, and West) as defined by the U.S. Census. Clinical variables included a history of hysterectomy, having a regular physician, use of supplemental calcium, physical activity (vigorous activity one or more times per week), and a waist-to-hip ratio of 0.85 or less as a measure of body habitus; all of these factors were previously associated with use of HRT. We also examined self-report of diabetes, cigarette smoking (current, former, or never smoker), family history of myocardial infarction, hypertension, high cholesterol level, personal history of myocardial infarction or angina (based on the Rose criteria [29]), sexual activity, alcohol use, multivitamin use, and use of alternative therapies. Psychological variables included perceived risk for heart disease and cancer (above average compared with average or below), self-perceived physical and mental health (excellent, very good, or good compared with fair or poor), depression (based on the Composite International Diagnostic Interview [30]), self-report of depression or anxiety, perceived control over health, and thought and effort put into health. Women were also asked whether they worry about becoming less attractive or developing illness as they age. Measures of six major personality characteristicsagency (self-confident, forceful, assertive, outspoken, and dominant), agreeableness (helpful, warm, caring, softhearted, and sympathetic), openness (creative, imaginative, intelligent, curious, sophisticated, and adventurous), neuroticism (moody, worrying, nervous, and not calm), extroversion (outgoing, friendly, lively, active, and talkative), and conscientiousness (organized, responsible, hardworking, and not careless)were adapted from standard scales (31-34). Finally, we used the Somatic Amplification Scale (35) to assess somatosensory amplification (experiencing somatic sensation as intense, noxious, and disturbing). Statistical Analysis Data were weighted to adjust for differing probabilities of contacting households, sampling persons within each household, and obtaining completed surveys from designated participants (36) and to approximate the U.S. population on the basis of the Current Population Survey (October 1995). First, we adjusted for differing probabilities of successfully contacting households in geographic areas by mapping 1990 U.S. Census data on age, ethnicity, income, education, and urban location to telephone exchanges. Second, we adjusted for the higher probability of sampling persons in smaller households when their household was contacted. Third, we adjusted for differing probabilities of obtaining self-administered questionnaires from persons who completed the telephone interview by using numerous variables from the telephone interview. Finally, we created post-stratification weights so that the sample more closely approximated the U.S. population on the basis of 1995 Current Population Survey data. Thus, the weighted sample resembles the U.S. population by geographic region, ethnicity, age, education, marital status, and residence in a Metropolitan Statistical Area. We used the Pearson chi-square test to compare rates of HRT use by categorical variables and the Mantel-Haenszel chi-square test for the same comparison after stratifying by hysterectomy status (37). We converted values of each continuous psychological variable to ranks and compared users and nonusers of HRT by using two-way analysis of variance to control for hysterectomy status. We conducted multivariable logistic regression analyses in two stages. Because we had large numbers of sociodemographic, clinical, and psychological variables, we first created three separate models for each of these types of variables. Each model included all variables of a particular type with a P value of 0.2 or less in bivariable analyses. Finally, all variables with P values of 0.2 or less in the intermediate models were included in a final composite main-effects model. Because we also wished to ensure that the final model controlled for key demographic and clinical variables that might confound the effect of statistically significant variables, we also forced the following select variables to enter the final model: ethnicity, marital status, waist-to-hip ratio, income, hypertension, high cholesterol, family history of myocardial infarction, smoking, and personal history of coronary artery disease . Only this final composite multivariable logi