Joel Swendsen

Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication- Adolescent Supplement (NCS-A)

OBJECTIVE To present estimates of the lifetime prevalence of DSM-IV mental disorders with and without severe impairment, their comorbidity across broad classes of disorder, and their sociodemographic correlates. METHOD The National Comorbidity Survey-Adolescent Supplement NCS-A is a nationally representative face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview. RESULTS Anxiety disorders were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%), with approximately 40% of participants with one class of disorder also meeting criteria for another class of lifetime disorder. The overall prevalence of disorders with severe impairment and/or distress was 22.2% (11.2% with mood disorders, 8.3% with anxiety disorders, and 9.6% behavior disorders). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavior, 13 years for mood, and 15 years for substance use disorders. CONCLUSIONS These findings provide the first prevalence data on a broad range of mental disorders in a nationally representative sample of U.S. adolescents. Approximately one in every four to five youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. The likelihood that common mental disorders in adults first emerge in childhood and adolescence highlights the need for a transition from the common focus on treatment of U.S. youth to that of prevention and early intervention.

New researchLifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A)

OBJECTIVE To present estimates of the lifetime prevalence of DSM-IV mental disorders with and without severe impairment, their comorbidity across broad classes of disorder, and their sociodemographic correlates. METHOD The National Comorbidity Survey-Adolescent Supplement NCS-A is a nationally representative face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States. DSM-IV mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview. RESULTS Anxiety disorders were the most common condition (31.9%), followed by behavior disorders (19.1%), mood disorders (14.3%), and substance use disorders (11.4%), with approximately 40% of participants with one class of disorder also meeting criteria for another class of lifetime disorder. The overall prevalence of disorders with severe impairment and/or distress was 22.2% (11.2% with mood disorders, 8.3% with anxiety disorders, and 9.6% behavior disorders). The median age of onset for disorder classes was earliest for anxiety (6 years), followed by 11 years for behavior, 13 years for mood, and 15 years for substance use disorders. CONCLUSIONS These findings provide the first prevalence data on a broad range of mental disorders in a nationally representative sample of U.S. adolescents. Approximately one in every four to five youth in the U.S. meets criteria for a mental disorder with severe impairment across their lifetime. The likelihood that common mental disorders in adults first emerge in childhood and adolescence highlights the need for a transition from the common focus on treatment of U.S. youth to that of prevention and early intervention.

Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A)

OBJECTIVE Mental health policy for youth has been constrained by a paucity of nationally representative data concerning patterns and correlates of mental health service utilization in this segment of the population. The objectives of this investigation were to examine the rates and sociodemographic correlates of lifetime mental health service use by severity, type, and number of DSM-IV disorders in the National Comorbidity Survey-Adolescent Supplement. METHOD Face-to-face survey of mental disorders from 2002 to 2004 using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Total and sector-specific mental health service use was also assessed. RESULTS Approximately one third of adolescents with mental disorders received services for their illness (36.2%). Although disorder severity was significantly associated with an increased likelihood of receiving treatment, half of adolescents with severely impairing mental disorders had never received mental health treatment for their symptoms. Service rates were highest in those with attention-deficit/hyperactivity disorder (59.8%) and behavior disorders (45.4%), but fewer than one in five affected adolescents received services for anxiety, eating, or substance use disorders. Comorbidity and severe impairment were strongly associated with service utilization, particularly in youth with behavior disorders. Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment. CONCLUSIONS Despite advances in public awareness of mental disorders in youth, a substantial proportion of young people with severe mental disorders have never received specialty mental health care. Marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions.

The comorbidity of depression and substance use disorders

Depression and substance use disorders are highly prevalent in the general population and often co-occur within the same individual. This association is most commonly explained either by a causal relationship or a shared etiologic factor underlying both disorders. In light of these mechanisms of association, this article summarizes evidence from clinical, epidemiologic, and genetic epidemiologic studies. Details of a large family study designed to addresses key methodological and conceptual issues identified in the review are also presented. The association of alcoholism with depression is likely to be attributable to causal factors rather than a shared etiology, but the scarcity of information for other classes of substance use disorders precludes similar conclusions regarding their association with depression. The lack of unidirectional and consistent patterns of association for depression and substance use disorders indicates that multiple mechanisms of comorbidity are likely to be simultaneously active in this population.

Mental Disorders as Risk factors for Substance Use, Abuse and Dependence: Results from the 10-year Follow-up of the National Comorbidity Survey

AIMS The comorbidity of mental disorders and substance dependence is well documented, but prospective investigations in community samples are rare. This investigation examines the role of primary mental disorders as risk factors for the later onset of nicotine, alcohol and illicit drug use, abuse and dependence with abuse. DESIGN The National Comorbidity Survey (NCS) was a nationally representative survey of mental and substance disorders in the United States carried out in 1990-92. The NCS-2 re-interviewed a probability subsample of NCS respondents in 2001-03, a decade after the baseline survey. PARTICIPANTS A total of 5001 NCS respondents were re-interviewed in the NCS-2 (87.6% of baseline sample). RESULTS Aggregate analyses demonstrated significant prospective risks posed by baseline mental disorders for the onset of nicotine, alcohol and illicit drug dependence with abuse over the follow-up period. Particularly strong and consistent associations were observed for behavioral disorders and previous substance use conditions, as well as for certain mood and anxiety disorders. Conditional analyses demonstrated that many observed associations were limited to specific categories of use, abuse or dependence, including several mental disorders that were non-significant predictors in the aggregate analyses. CONCLUSIONS Many mental disorders are associated with an increased risk of later substance use conditions, but important differences in these associations are observed across the categories of use, abuse and dependence with abuse. These prospective findings have implications for the precision of prevention and treatment strategies targeting substance use disorders.

The Comorbidity of Alcoholism With Anxiety and Depressive Disorders in Four Geographic Communities

The comorbidity of alcoholism with anxiety and depressive disorders was examined in four epidemiologic investigations from diverse geographic sites. Despite variability in lifetime prevalence rates for these disorders, there was strong cross-site consistency in the magnitude and specific patterns of comorbidity. Individuals with alcohol abuse or dependence generally experienced a twofold to threefold increased risk of anxiety and depressive disorders. Phobic conditions typically preceded the onset of alcoholism, but no systematic pattern was observed for panic or depressive disorders. Considerable heterogeneity was also observed concerning the impact of comorbid conditions on symptoms of the index disorder. While the presence of comorbid anxiety or depressive disorders was consistently associated with moderate increases in the symptoms of alcohol abuse or dependence, alcoholism was associated with large increases in the number of depressive symptoms and little or no increase in phobic symptoms. The findings are discussed in terms of the self-medication hypothesis and the etiologic heterogeneity of these forms of comorbidity in the general population.

Major Depressive Disorder With Subthreshold Bipolarity in the National Comorbidity Survey Replication

OBJECTIVE There is growing clinical and epidemiologic evidence that major mood disorders form a spectrum from major depressive disorder to pure mania. The authors examined the prevalence and clinical correlates of major depressive disorder with subthreshold bipolarity compared with pure major depressive disorder in the National Comorbidity Survey Replication (NCS-R). METHOD The NCS-R is a nationally representative face-to-face household survey of the U.S. population conducted between February 2001, and April 2003. Lifetime history of mood disorders, symptoms, and clinical indicators of severity were collected using version 3.0 of the World Health Organizations Composite International Diagnostic Interview. RESULTS Nearly 40% of study participants with a history of major depressive disorder had a history of subthreshold hypo-mania. This subgroup had a younger age at onset, more episodes of depression, and higher rates of comorbidity than those without a history of hypomania and lower levels of clinical severity than those with bipolar II disorder. CONCLUSIONS These findings demonstrate heterogeneity in major depressive disorder and support the validity of inclusion of subthreshold mania in the diagnostic classification. The broadening of criteria for bipolar disorder would have important implications for research and clinical practice.

Psychiatric comorbidity in migraine: a review

Investigations of migraine comorbidity have confirmed its association with diverse psychiatric conditions. This association appears to be strongest for major depression and anxiety disorders (particularly panic and phobia), but increased comorbidity has also been reported with substance abuse and certain mood disorders. This literature also indicates that greater psychiatric comorbidity exists for migraine sufferers with aura than without. Some support is found for the notion that psychiatric comorbidity is higher in transformed migraine than in simple migraine (particularly in the case of chronic substance abuse). However, research into the possible mechanisms underlying these associations remains limited. Studies examining the order of onset and the cross-transmission of migraine and psychiatric disorders in families have been unable to distinguish fully between causal and common aetiological models of association. The conclusions are discussed in light of both methodological and conceptual issues relevant to understanding migraine comorbidity.

Major Depression in the National Comorbidity Survey–Adolescent Supplement: Prevalence, Correlates, and Treatment

OBJECTIVE To present the 12-month prevalence of DSM-IV major depressive disorder (MDD) and severe MDD; to examine sociodemographic correlates and comorbidity; and to describe impairment and service use. METHOD Data are from the National Comorbidity Survey-Adolescent Supplement (NCS-A), a nationally representative survey of 10,123 adolescents aged 13 to 18 years that assesses DSM-IV disorders using the Composite International Diagnostic Interview (CIDI) Version 3.0. One parent or surrogate of each participating adolescent was also asked to complete a self-administered questionnaire. RESULTS Lifetime and 12-month prevalence of MDD were 11.0% and 7.5%, respectively. The corresponding rates of severe MDD were 3.0% and 2.3%. The prevalence of MDD increased significantly across adolescence, with markedly greater increases among females than among males. Most cases of MDD were associated with psychiatric comorbidity and severe role impairment, and a substantial minority reported suicidality. The prevalence of severe MDD was about one-fourth of that of all MDD cases; estimates of impairment and clinical correlates were of 2- to 5-fold greater magnitude for severe versus mild/moderate depression, with markedly higher rates for suicidal thoughts and behaviors. Treatment in any form was received by the majority of adolescents with 12-month DSM-IV MDD (60.4%), but only a minority received treatment that was disorder-specific or from the mental health sector. CONCLUSION Findings underscore the important public health significance of depression among US adolescents and the urgent need to improve screening and treatment access in this population.

Risk and Protective Factors Associated with Trajectories of Depressed Mood from Adolescence to Early Adulthood

This study used semi-parametric group-based modeling to explore unconditional and conditional trajectories of self-reported depressed mood from ages 12 to 25 years. Drawing on data from the National Longitudinal Study of Adolescent Health (N = 11,559), 4 distinct trajectories were identified: no depressed mood, stable low depressed mood, early high declining depressed mood, and late escalating depressed mood. Baseline risk factors associated with greater likelihood of membership in depressed mood trajectory groups compared with the no depressed mood group included being female, Black or African American, Hispanic or Latino American, or Pacific Islander or Asian American; having lower socioeconomic status; using alcohol, tobacco, or other drugs on a weekly basis; and engaging in delinquent behavior. Baseline protective factors associated with greater likelihood of membership in the no depressed mood group compared with the depressed mood trajectory groups included 2-parent family structure; feeling connected to parents, peers, or school; and self-esteem. With the exception of delinquent behavior, risk and protective factors also distinguished the likelihood of membership among several of the 3 depressed mood groups. The results add to basic etiologic research regarding developmental pathways of depressed mood in adolescence and young adulthood.