Ellen E. Walters

The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population

BACKGROUND A self-report screening scale of adult attention-deficit/hyperactivity disorder (ADHD), the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) was developed in conjunction with revision of the WHO Composite International Diagnostic Interview (CIDI). The current report presents data on concordance of the ASRS and of a short-form ASRS screener with blind clinical diagnoses in a community sample. METHOD The ASRS includes 18 questions about frequency of recent DSM-IV Criterion A symptoms of adult ADHD. The ASRS screener consists of six out of these 18 questions that were selected based on stepwise logistic regression to optimize concordance with the clinical classification. ASRS responses were compared to blind clinical ratings of DSM-IV adult ADHD in a sample of 154 respondents who previously participated in the US National Comorbidity Survey Replication (NCS-R), oversampling those who reported childhood ADHD and adult persistence. RESULTS Each ASRS symptom measure was significantly related to the comparable clinical symptom rating, but varied substantially in concordance (Cohens kappa in the range 0.16-0.81). Optimal scoring to predict clinical syndrome classifications was to sum unweighted dichotomous responses across all 18 ASRS questions. However, because of the wide variation in symptom-level concordance, the unweighted six-question ASRS screener outperformed the unweighted 18-question ASRS in sensitivity (68.7% v. 56.3%), specificity (99.5% v. 98.3%), total classification accuracy (97.9% v. 96.2%), and kappa (0.76 v. 0.58). CONCLUSIONS Clinical calibration in larger samples might show that a weighted version of the 18-question ASRS outperforms the six-question ASRS screener. Until that time, however, the unweighted screener should be preferred to the full ASRS, both in community surveys and in clinical outreach and case-finding initiatives.

Long-Term Trends in the Use of Complementary and Alternative Medical Therapies in the United States

Community surveys done over the past decade have documented that a substantial proportion of Americans use complementary and alternative medical (CAM) therapies (14), which have been defined as interventions neither taught widely in medical schools nor generally available in U.S. hospitals (1). Many managed care organizations have responded to this evidence by providing insurance coverage for some CAM therapies (5). Furthermore, most U.S. medical schools have begun offering courses on CAM therapies (6). These responses imply that CAM therapies are perceived to be a force to be reckoned with for some time to come. Yet, little is known about the likelihood that this will be the case. The prevailing assumption is that CAM therapies were used by a fairly narrow segment of the population until the 1970s, at which time the ideology associated with the youth counterculture led to a rapid dissemination and use of CAM therapies that has persisted through the present (7). However, lack of rigorous trend data from epidemiologic surveys have precluded evaluating this assumption rigorously or projecting the future growth of CAM therapies on the basis of evidence of past trends. In the current report, we present nationally representative trend data of this sort from a prevalence study. The data came from retrospective self-reports of a nationally representative sample of the U.S. general population in a 19971998 telephone survey (4) about age at first use of 20 representative CAM therapies. In our analysis, we studied trends by examining between-cohort differences in rates of initiation of CAM therapy use (8). In the absence of prospective data, which do not exist, our results represent, to our knowledge, the most accurate information currently available on U.S. trends in CAM therapy use over the past half-century. Methods Sample The telephone survey was conducted between November 1997 and February 1998 in a nationally representative household sample. Random-digit dialing was used to select households, and a random-selection method was used to select one respondent 18 years of age or older for interview in each sample household. Eligibility was limited to English speakers without cognitive or physical impairment that would prevent interview completion. The average administration time was 30 minutes. A

Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey

20 financial incentive for participation was offered. The Beth Israel Deaconess Committee on Clinical Investigations, Boston, Massachusetts, approved the survey methods. Of the initial sample of 9750 telephone numbers, 26% did not work, 17% were not assigned to households, and 9% were unavailable despite six attempted follow-up contacts. Of the remaining households, 481 were ineligible because of language barrier or cognitive or physical incapacity. Of the 4167 total eligible respondents, 1720 (41.3%) completed the interview on initial request. Of a random subsample of 1066 persons who initially declined and were offered an increased stipend (

Comorbidity of substance use disorders with mood and anxiety disorders: Results of the international consortium in psychiatric epidemiology

50), 335 agreed to participate. In all, 2055 interviews were completed. After we extrapolated the conversion rate to all persons who had initially declined and weighted the data for the undersampling of those who participated after initially declining, the weighted overall response rate among eligible respondents was 60%. The data were weighted for three factors: 1) probability of selection within household as well as geographic variation in cooperation (by region of the country and urbanicity [local population density]], 2) nonresponse, and 3) post-stratification for aggregate discrepancies between the sample distributions and Census population distributions on a variety of sociodemographic variables (9, 10). More details on the sample design have been presented elsewhere (4). Age data were missing for 6 respondents; our analyses are limited to the remaining 2049 respondents. Measures The interview was described to respondents as a survey by investigators from Harvard Medical School about the health care practices of Americans. Interviewers made no mention of CAM therapies. The first substantive questions concerned perceived health, functional impairment due to health problems, interactions with physicians, and history of chronic medical conditions. Interviewers then queried respondents about their lifetime and recent use of 20 CAM therapiesacupuncture, aromatherapy, biofeedback, chiropractic care, commercial diet programs, energy healing (for example, laying on of hands), folk remedy, herbal medicine, homeopathy, hypnosis, imagery, lifestyle diet (such as vegetarianism or macrobiotics), massage, megavitamin therapy, naturopathy, osteopathy, relaxation techniques, self-help group, spiritual healing by others, and yoga. Users of each therapy were asked their age at first use as well as details about the conditions for which the therapy was initiated. The final set of questions dealt with sociodemographic issues. Cohorts were aggregated into three subsamples: prebaby boom (respondents 54 years of age at interview, born before 1945); baby boom (34 to 53 years of age at interview, born 19451964); and postbaby boom (18 to 33 years of age at interview, born 19651979). For sociodemographic variables, we used two categories for sex (male or female), four for race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, or other), four for education (less than high school, high school graduate, some college, or college graduate), four for U.S. region (northeast, midwest, south, or west), and four for urbanicity (residence in a large city, small city, suburb, town/rural). Statistical Analysis All analyses were performed with weighted data by using SAS statistical software (11). To assess differences in trends among cohorts, the KaplanMeier (12) method was used to generate a graphic representation of the cumulative lifetime prevalences of CAM therapy use according to cohort. The significance of historical changes in lifetime use was estimated by using discrete-time survival analysis (13), a method of survival analysis appropriate for data in which events are recorded only at discrete time points (for example, in yearly increments). Discrete-time survival analysis was operationalized as a logistic regression with person-year as the unit of analysis and first use of CAM therapy as the outcome variable. The predictors of primary interest were a series of dummy variables for decades of historical time, and covariates included sociodemographic and dummy variables adjusted for the baseline hazard rate of each year of a persons life. This model results in an intercept for each time period, and the odds ratios (ORs) can be interpreted as the relative risk for the annual risk for use of alternative therapy. Subsample models were estimated to study sociodemographic variation in trends. Disaggregated models were estimated to study trends in the use of particular CAM therapies. To adjust for the design effects introduced by weighting of the data, the method of jackknife repeated replications (14) was used to estimate standard errors (SEs). For this method, we used user-written macros in SAS statistical software. For this process, 50 random primary sampling units were created with two random half-samples in each unit for a total of 100 random replicates. Jackknife repeated replication is a method that uses simulations of coefficient distributions in subsamples to generate empirical estimates of SEs and significance tests. The ratios of the coefficients to these adjusted SEs are used to compute the 95% CIs of the ORs. Tests for the significance of sets of predictors taken together were computed by using the Wald chi-square test from coefficient variancecovariance matrices based on the jackknife repeated replications simulations. Results Differences in Aggregate Use Trends among Cohorts At the time of interview, 67.6% of all respondents had used at least one CAM therapy at some time in their lives. The Figure presents KaplanMeier age-of-onset curves showing trends in each cohort in the cumulative probabilities of use according to age. Of note are the dramatic differences in use among cohorts. This is seen most clearly by focusing on cumulative probabilities of use for age 33 years, the oldest age represented in all three cohorts. Approximately 3 of every 10 respondents in the prebaby boom cohort used some type of CAM therapy by the age of 33 years compared with 5 of 10 in the baby boom cohort and 7 of 10 in the postbaby boom cohort. Figure. Weighted KaplanMeier estimates of age of first use of any complementary and alternative medical (CAM) therapy among lifetime users according to cohort. Historical Trends in Aggregate Use The aggregate data in the Figure are presented in a different format in the bottom row of Table 1, where the risk ratios are shown from a discrete-time survival model that estimated the effects of historical time in predicting age at first use of CAM therapy among respondents after adjustment for person-year and sociodemographic variables. The contrast category is first use before 1960. Consistent with the pattern in the Figure, the results of the model for the outcome of any therapy show monotonically increasing risk ratios in each decade from the 1960s through the 1990s. Table 1. Trends in Relative Risk for First Use of 20 Specific Complementary and Alternative Medical Therapies, according to Decade Possible demographic subsample differences in time trends were examined by estimating separate subsample models that were identical to the discrete-time survival model for any therapy and by evaluating the statistical significance of differences in trends across subsamples. No statistically significant (0.05 level in two-sided tests) differences in trends were found for sex, race/ethnicity, education level, region of the country, or urbanicity. Trends in the Use of Specific Therapies Table 1 also shows the risk ratios to estimate first use of each of the 20 CAM therapies assessed. All tre

Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey.

Data on the prevalences, comorbidities, and cohort effects of DSM‐III‐R major depression (MD) and minor depression (mD) are reported for the nationally representative sample of n = 1,769 adolescents and young adults who participated in the National Comorbidity Survey. Lifetime prevalences are 15.3% (MD) and 9.9% (mD), while 30‐day prevalences are 5.8% (MD) and 2.1% (mD). Most cases reported recurrent episodes (73.9% of those with MD and 69.2% with mD) and significant role impairment, including attempted suicide among 21.9% of those with MD. The majority of lifetime cases (76.7% of those with MD and 69.3% with mD) reported other comorbid lifetime NCS/DSM‐III‐R disorders. Depression was temporally secondary in the majority of these cases. Number of prior disorders was more important than type of disorders in predicting subsequent depression, raising the possibility that secondary depression is a nonspecific severity marker for earlier disorders. A cohort effect for both MD and mD was documented that persisted even for episodes lasting a year or longer. Increasing prevalences of prior comorbid disorders were found to play an important part in explaining the cohort effect for depression. Depression and Anxiety 7:3–14, 1998.

Prevalence of ICD-10 mental disorders in a catchment area in the city of São Paulo, Brazil.

This article reports the results of a cross-national investigation of patterns of comorbidity between substance use and psychiatric disorders in six studies participating in the International Consortium in Psychiatric Epidemiology. In general, there was a strong association between mood and anxiety disorders as well as conduct and antisocial personality disorder with substance disorders at all sites. The results also suggest that there is a continuum in the magnitude of comorbidity as a function of the spectrum of substance use category (use, problems, dependence), as well as a direct relationship between the number of comorbid disorders and increasing levels of severity of substance use disorders (which was particularly pronounced for drugs). Finally, whereas there was no specific temporal pattern of onset for mood disorders in relation to substance disorders, the onset of anxiety disorders was more likely to precede that of substance disorders in all countries. These results illustrate the contribution of cross-national data to understanding the patterns and risk factors for psychopathology and substance use disorders.

The Prevalence and Correlates of Nonaffective Psychosis in the National Comorbidity Survey Replication (NCS-R)

BACKGROUND General population data were used to study co-morbidities between lifetime social phobia and mood disorders. METHODS Data come from the US National Comorbidity Survey (NCS). RESULTS Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2.9), dysthymia (2.7) and bipolar disorder (5.9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10-15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders. CONCLUSIONS Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Prevalence and age of onset for drug use in seven international sites: results from the international consortium of psychiatric epidemiology

Background The prevalence (lifetime, 12-month, 1-month) of mental disorders, their relationship with sociodemographic features, and the use of services were investigated in the population aged 18 years or older living in the catchment area of a large hospital complex in the city of São Paulo, Brazil. Methods A community survey was conducted in two boroughs of São Paulo, on 1,464 residents aged 18 years or older. The assessment of psychopathology was made by CIDI 1.1, yielding diagnoses according to ICD-10 for mood disorders, anxiety disorders, non-affective psychosis, substance use disorders, dissociative and somatoform disorders, and cognitive impairment. Results Of the total sample, 45.9 % had at least one lifetime diagnosis of mental disorder, 26.8 % in the year, and 22.2 % in the month prior to interview. The most prevalent disorders (lifetime, 12-month, and 1-month, respectively) were: nicotine dependence (25 %, 11.4 %, 9.3 %), any mood disorder (18.5 %, 7.6 %, 5 %) with depressive episode the most prevalent mood disorder (16.8 %, 7.1 %, 4.5 %), any anxiety disorder (12.5 %, 7.7 %, 6 %), somatoform disorder (6 %, 4.2 %, 3.2 %), and alcohol abuse/dependence (5.5 %, 4.5 %, 4 %). No gender differences were found in overall morbidity. Excluding substance use disorders, women had a higher risk for non-psychotic disorders. The presence of psychiatric diagnosis increased the use of services, with a low proportion of subjects seeking specialty mental care. Conclusion Our results confirm the high prevalence of mental disorders in the community, similar to findings in other countries. A comparison with findings from other studies with similar methodology is made.

A risk index for 12-month suicide attempts in the National Comorbidity Survey Replication (NCS-R)

BACKGROUND To estimate the prevalence and correlates of clinician-diagnosed DSM-IV nonaffective psychosis (NAP) in a national household survey. METHODS Data came from the United States National Comorbidity Survey Replication (NCS-R). A screen for NAP was followed by blinded sub-sample clinical reappraisal interviews. Logistic regression was used to impute clinical diagnoses to respondents who were not re-interviewed. The method of Multiple Imputation (MI) was used to estimate prevalence and correlates. RESULTS Clinician-diagnosed NAP was well predicted by the screen (area under the curve [AUC] = .80). The MI prevalence estimate of NAP (standard error in parentheses) is 5.0 (2.6) per 1000 population lifetime and 3.0 (2.2) per 1000 past 12 months. The vast majority (79.4%) of lifetime and 12-month (63.7%) cases met criteria for other DSM-IV hierarchy-free disorders. Fifty-eight percent of 12-month cases were in treatment, most in the mental health specialty sector. CONCLUSIONS The screen for NAP in the NCS-R greatly improved on previous epidemiological surveys in reducing false positives, but coding of open-ended screening scale responses was still needed to achieve accurate prediction. The lower prevalence estimate than in total-population incidence studies raises concerns that systematic nonresponse bias causes downward bias in survey prevalence estimates of NAP.

The Importance of Irritability as a Symptom of Major Depressive Disorder: Results from the National Comorbidity Survey Replication

This study compares lifetime prevalence and age of first use (onset) for alcohol, cannabis, and other drugs in six international sites. Data from seven epidemiologic field surveys that used compatible instruments and study designs were compiled for cross-site analyses by the International Consortium of Psychiatric Epidemiology (ICPE). The world health organizations composite international diagnostic instrument (WHO-CIDI) and additional items were used to ascertain drug use in each site. Lifetime use rates were estimated for alcohol, cannabis, and other illicit drugs. Survival analyses were used to estimate age of onset. Study settings and main results: use of alcohol twelve or more times ranged in descending order from the Netherlands (86.3%), United States (71.7%), Ontario, Canada (71.6%); São Paulo, Brazil (66.1%), Munich, Germany (64.9%), Fresno, California (USA) (51.9%), to Mexico City (43.2%). Use of cannabis five or more times in a lifetime ranged from 28.8 in the United States to 1.7% in Mexico City, and other drugs ranged from United States (19.4%) to Mexico City (1.7%). Age of first use was similar across study sites. This study demonstrates the fundamental uniformity of onset patterns by age as contrasted with wide variations in lifetime prevalences across sites. Study findings suggest that drug use patterns may change among emigrating populations from low consumption nations as a consequence of international resettlement in nations with higher rates. Methodological limitations of the study along with recommendations for future international comparative research are discussed.