Joshua Breslau

Specifying race-ethnic differences in risk for psychiatric disorder in a USA national sample

BACKGROUND Epidemiological studies have found lower than expected prevalence of psychiatric disorders among disadvantaged race-ethnic minority groups in the USA. Recent research shows that this is due entirely to reduced lifetime risk of disorders, as opposed to persistence. Specification of race-ethnic differences with respect to clinical and social characteristics can help identify the protective factors that lead to lower lifetime risk among disadvantaged minority groups. METHOD Data on 5424 Hispanics, non-Hispanic Blacks, and non-Hispanic Whites came from the National Comorbidity Survey Replication, a nationally representative survey conducted with the World Mental Health version of the Composite International Diagnostic Interview. Race-ethnic differences in risk of disorders were compared across specific diagnoses, ages of onset, cohorts and levels of education. RESULTS Both minority groups had lower risk for common internalizing disorders: depression, generalized anxiety disorder, and social phobia. In addition, Hispanics had lower risk for dysthymia, oppositional-defiant disorder and attention deficit hyperactivity disorder; non-Hispanic Blacks had lower risk for panic disorder, substance use disorders and early-onset impulse control disorders. Lower risk among Hispanics, relative to non-Hispanic Whites, was found only among the younger cohort (age<or=43 years). Lower risk among minorities was more pronounced at lower levels of education. CONCLUSION The pattern of race-ethnic differences in risk for psychiatric disorders suggests the presence of protective factors that originate in childhood and have generalized effects on internalizing disorders. For Hispanics, but not for non-Hispanic Blacks, the influence of these protective factors has emerged only recently.

Lifetime risk and persistence of psychiatric disorders across ethnic groups in the United States

BACKGROUND Recent research in the United States has demonstrated striking health disparities across ethnic groups. Despite a longstanding interest in ethnic disadvantage in psychiatric epidemiology, patterns of psychiatric morbidity across ethnic groups have never been examined in a nationally representative sample. METHOD Ethnic differences in psychiatric morbidity are analyzed using data from the National Comorbidity Survey (NCS). The three largest ethnic groups in the United States--Hispanics, Non-Hispanic Blacks and Non-Hispanic Whites were compared with respect to lifetime risk and persistence of three categories of psychiatric disorder: mood disorder, anxiety disorder, and substance use disorder. RESULTS Where differences across ethnic groups were found in lifetime risk, socially disadvantaged groups had lower risk. Relative to Non-Hispanic Whites, Hispanics had lower lifetime risk of substance use disorder and Non-Hispanic Blacks had lower lifetime risk of mood, anxiety and substance use disorders. Where differences were found in persistence of disorders, disadvantaged groups had higher risk. Hispanics with mood disorders were more likely to be persistently ill as were Non-Hispanic Blacks with respect to both mood disorders and anxiety disorders. Closer examination found these differences to be generally consistent across population subgroups. CONCLUSIONS Members of disadvantaged ethnic groups in the United States do not have an increased risk for psychiatric disorders. Members of these groups, however, do tend to have more persistent disorders. Future research should focus on explanations for these findings, including the possibility that these comparisons are biased, and on potential means of reducing the disparity in persistence of disorders across ethnic groups.

Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States

BACKGROUND To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population. METHOD Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed. RESULTS The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%). CONCLUSIONS When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.

Mental Disorders and Subsequent Educational Attainment in a US National Sample

As part of a larger investigation of the adverse effects of mental disorders on role functioning, we examined the associations of early-onset mental disorders with subsequent educational attainment in a large nationally representative survey of the US adult population. Diagnoses and age of onset for each of 17 DSM-IV disorders were assessed through retrospective self-report with the fully structured WHO Composite International Diagnostic Instrument (CIDI). Survival analysis was used to examine the associations between early-onset DSM-IV/CIDI disorders and subsequent termination of schooling with controls for socio-demographic characteristics and childhood adversities (i.e. childhood traumatic events, childhood neglect, parental mental illness, family disruption, and low parental educational attainment). Mental disorders were found to be significantly associated with termination of schooling prior to completion of each of four educational milestones (primary school graduation, high school graduation, college entry, college graduation), with odds ratios in the range of 1.3-7.0. The proportion of school terminations attributable to mental disorders was largest for high school graduation (10.2%) but also meaningful for primary school graduation (3.8%), college entry (4.4%) and college graduation (2.6%). These results add to a growing body of evidence documenting a wide variety of adverse life course effects of mental disorders.

The impact of early behavior disturbances on academic achievement in high school

BACKGROUND. Previous research has indicated that childhood behavioral disturbances predict lower scores on academic tests and curtail educational attainment. It is unknown which types of childhood behavioral problems are most likely to predict these outcomes. METHODS. An ethnically diverse cohort was assessed at 6 years of age for behavioral problems and IQ and at 17 years of age for academic achievement in math and reading. Of the original cohort of 823 children, 693 (84%) had complete data. Multiple regressions were used to estimate associations of attention and internalizing and externalizing problems at age 6 and with math and reading achievement at age 17, adjusting for IQ and indicators of family socioeconomic status. RESULTS. Adjusting for IQ, inner-city community, and maternal education and marital status, teacher ratings of attention, internalizing behavior, and externalizing problems at age 6 significantly predict math and reading achievement at age 17. When types of problems are examined simultaneously, attention problems predict math and reading achievement with little attenuation, whereas the influence of externalizing and internalizing problems is materially reduced and not significant. CONCLUSIONS. Interventions that target attention problems at school entry should be tested as a potential avenue for improving educational achievement.

Risk for Psychiatric Disorder Among Immigrants and Their Us-born Descendants: Evidence From the National Comorbidity Survey Replication

Although previous research has consistently documented that immigrants to the United States have better mental health than US natives, little is known about why this difference occurs. DSM-IV anxiety, mood, impulse control, and substance use disorders were assessed in a nationally representative survey of the US household population, the National Comorbidity Survey Replication. Differences in risk for disorder between immigrants (N = 299) and 5124 natives (N = 5124) were examined using discrete time survival models. Differences were estimated by generation, age of immigration, and duration of residence in the United States. Immigrants had lower lifetime risk of disorder than natives (OR = 0.7; 95% CI, 0.5–0.9). Risk was equally large for natives who were children of immigrants as for natives of subsequent generations. For mood and impulse control disorders, risk equal to that of natives was also found among immigrants who arrived in the United States as children (12 years of age or younger). Immigrants had lower risk than natives prior to arrival in the United States, but there was a trend toward equalization of risk with longer duration of residence in the United States. Differences in risk for disorder emerge within a single generation following immigration, consistent with a strong effect of environmental factors on changes in risk among immigrant populations. This pattern is consistent with either of two causal processes, one involving early socialization in the United States and the other involving postmigration experiences among immigrants who arrive in the United States as adults.

Childhood socio-economic status and the onset, persistence, and severity of DSM-IV mental disorders in a US national sample

Although significant associations between childhood socio-economic status (SES) and adult mental disorders have been widely documented, SES has been defined using several different indicators often considered alone. Little research has examined the relative importance of these different indicators in accounting for the overall associations of childhood SES with adult outcomes. Nor has previous research distinguished associations of childhood SES with first onsets of mental disorders in childhood, adolescence, and adulthood from those with persistence of these disorders into adulthood in accounting for the overall associations between childhood SES and adult mental disorders. Disaggregated data of this sort are presented here for the associations of childhood SES with a wide range of adult DSM-IV mental disorders in the US National Comorbidity Survey Replication (NCS-R), a nationally-representative sample of 5692 adults. Childhood SES was assessed retrospectively with information about parental education and occupation and childhood family financial adversity. Associations of these indicators with first onset of 20 DSM-IV disorders that included anxiety, mood, behavioral, and substance disorders at different life-course stages (childhood, adolescence, early adulthood, and mid-later adulthood) and the persistence/severity of these disorders were examined using discrete-time survival analysis. Lifetime disorders and their ages-of-onset were assessed retrospectively with the WHO Composite International Diagnostic Interview. Different aspects of childhood SES predicted onset, persistence, and severity of mental disorders. Childhood financial hardship predicted onset of all classes of disorders at every life-course stage with odds-ratios (ORs) of 1.7-2.3. Childhood financial hardship was unrelated, in comparison, to disorder persistence or severity. Low parental education, although unrelated to disorder onset, significantly predicted disorder persistence and severity, whereas parental occupation was unrelated to onset, persistence, or severity. Some, but not all, of these associations were explained by other co-occurring childhood adversities. These specifications have important implications for mental health interventions targeting low-SES children.

Immigration to the USA and risk for mood and anxiety disorders: Variation by origin and age at immigration

BACKGROUND Risk for mood and anxiety disorders associated with US-nativity may vary across immigrant groups. METHOD Using data from the National Epidemiological Study of Alcohol and Related Conditions (NESARC), we examined the association of lifetime risk for mood and anxiety disorders with US-nativity and age at immigration across seven subgroups of the US population defined by country or region of ancestral origin: Mexico, Puerto-Rico, Cuba, Central and South America, Western Europe, Eastern Europe, and Africa and the Caribbean. Discrete time survival models were used to compare lifetime risk between the US-born, immigrants who arrived in the USA prior to the age of 13 years and immigrants who arrived in the USA at the age of 13 years or older. RESULTS The association of risk for mood and anxiety disorders with US-nativity varies significantly across ancestral origin groups (p<0.001). Among people from Mexico, Eastern Europe, and Africa or the Caribbean, risk for disorders is lower relative to the US-born among immigrants who arrived at the age of 13 years or higher (odds ratios in the range 0.34-0.49) but not among immigrants who arrived prior to the age of 13 years. There is no association between US-nativity and risk for disorder among people from Western Europe and Puerto Rico. CONCLUSIONS Low risk among immigrants relative to the US-born is limited to groups among whom risk for mood and anxiety disorder is low in immigrants who spent their pre-adolescent years outside of the USA.

Mental disorders and termination of education in high-income and low- and middle-income countries : epidemiological study

BACKGROUND Studies of the impact of mental disorders on educational attainment are rare in both high-income and low- and middle-income (LAMI) countries. AIMS To examine the association between early-onset mental disorder and subsequent termination of education. METHOD Sixteen countries taking part in the World Health Organization World Mental Health Survey Initiative were surveyed with the Composite International Diagnostic Interview (n=41 688). Survival models were used to estimate associations between DSM-IV mental disorders and subsequent non-attainment of educational milestones. RESULTS In high-income countries, prior substance use disorders were associated with non-completion at all stages of education (OR 1.4-15.2). Anxiety disorders (OR=1.3), mood disorders (OR=1.4) and impulse control disorders (OR=2.2) were associated with early termination of secondary education. In LAMI countries, impulse control disorders (OR=1.3) and substance use disorders (OR=1.5) were associated with early termination of secondary education. CONCLUSIONS Onset of mental disorder and subsequent non-completion of education are consistently associated in both high-income and LAMI countries.

Childhood and adolescent onset psychiatric disorders, substance use, and failure to graduate high school on time

We examined the joint predictive effects of childhood and adolescent onset psychiatric and substance use disorders on failure to graduate high school (HS) on time. Structured diagnostic interviews were conducted with a US national sample of adults (18 and over). The analysis sample included respondents with at least 8 years of education who were born in the US or arrived in the US prior to age 13 (N = 29,662). Psychiatric disorders, substance use and substance use disorders were examined as predictors of termination or interruption of educational progress prior to HS graduation, with statistical adjustment for demographic characteristics and childhood adversities. Failure to graduate HS on time was more common among respondents with any of the psychiatric and substance use disorders examined, ranging from 18.1% (specific phobia) to 33.2% (ADHD-combined type), compared with respondents with no disorder (15.2%). After adjustment for co-occurring disorders, significant associations with failure to graduate on time remained only for conduct disorder (OR = 1.89, 95% CI 1.57-2.26) and the three ADHD subtypes (Inattentive OR = 1.78, 95% CI 1.44-2.20, Hyperactive-Impulsive OR = 1.38, 95% CI 1.14-1.67, and Combined OR = 2.06, 95% CI 1.66-2.56). Adjusting for prior disorders, tobacco use was associated with failure to graduate on time (OR = 1.97, 95% CI 1.80-2.16). Among substance users, substance use disorders were not associated with on-time graduation. The findings suggest that the adverse impact of childhood and adolescent onset psychiatric disorders on HS graduation is largely accounted for by problems of conduct and inattention. Adjusting for these disorders, smoking remains strongly associated with failure to graduate HS on time.