Katherine M. Keyes

Psychiatric Disorders in Pregnant and Postpartum Women in the United States

CONTEXT Psychiatric disorders and substance use during pregnancy are associated with adverse outcomes for mothers and their offspring. Information about the epidemiology of these conditions in this population is lacking. OBJECTIVE To examine sociodemographic correlates, rates of DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking among past-year pregnant and postpartum women in the United States. DESIGN National survey. SETTING Face-to-face interviews conducted in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions. PARTICIPANTS A total of 43 093 respondents were interviewed, of whom 14 549 were women 18 to 50 years old with known past-year pregnancy status. MAIN OUTCOME MEASURES Prevalence of 12-month DSM-IV Axis I psychiatric disorders, substance use, and treatment seeking. RESULTS Past-year pregnant and postpartum women had significantly lower rates of alcohol use disorders and any substance use, except illicit drug use, than nonpregnant women. In addition, currently pregnant women had a lower risk of having any mood disorder than nonpregnant women. The only exception was the significantly higher prevalence of major depressive disorder in postpartum than in nonpregnant women. Age, marital status, health status, stressful life events, and history of traumatic experiences were all significantly associated with higher risk of psychiatric disorders in pregnant and postpartum women. Lifetime and past-year treatment-seeking rates for any psychiatric disorder were significantly lower among past-year pregnant than nonpregnant women with psychiatric disorders. Most women with a current psychiatric disorder did not receive any mental health care in the 12 months prior to the survey regardless of pregnancy status. CONCLUSIONS Pregnancy per se is not associated with increased risk of the most prevalent mental disorders, although the risk of major depressive disorder may be increased during the postpartum period. Groups of pregnant women with particularly high prevalence of psychiatric disorders were identified. Low rates of maternal mental health care underscore the need to improve recognition and delivery of treatment for mental disorders occurring during pregnancy and the postpartum period.

The Impact of Institutional Discrimination on Psychiatric Disorders in Lesbian, Gay, and Bisexual Populations: A Prospective Study

OBJECTIVES We examined the relation between living in states that instituted bans on same-sex marriage during the 2004 and 2005 elections and the prevalence of psychiatric morbidity among lesbian, gay, and bisexual (LGB) populations. METHODS We used data from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653), a longitudinal, nationally representative study of noninstitutionalized US adults. RESULTS Psychiatric disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, increased significantly between waves 1 and 2 among LGB respondents living in states that banned gay marriage for the following outcomes: any mood disorder (36.6% increase), generalized anxiety disorder (248.2% increase), any alcohol use disorder (41.9% increase), and psychiatric comorbidity (36.3% increase). These psychiatric disorders did not increase significantly among LGB respondents living in states without constitutional amendments. Additionally, we found no evidence for increases of the same magnitude among heterosexuals living in states with constitutional amendments. CONCLUSIONS Living in states with discriminatory policies may have pernicious consequences for the mental health of LGB populations. These findings lend scientific support to recent efforts to overturn these policies.

National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM‐IV and DSM‐5 Criteria

Prevalence of posttraumatic stress disorder (PTSD) defined according to the American Psychiatric Associations Diagnostic and Statistical Manual fifth edition (DSM-5; 2013) and fourth edition (DSM-IV; 1994) was compared in a national sample of U.S. adults (N = 2,953) recruited from an online panel. Exposure to traumatic events, PTSD symptoms, and functional impairment were assessed online using a highly structured, self-administered survey. Traumatic event exposure using DSM-5 criteria was high (89.7%), and exposure to multiple traumatic event types was the norm. PTSD caseness was determined using Same Event (i.e., all symptom criteria met to the same event type) and Composite Event (i.e., symptom criteria met to a combination of event types) definitions. Lifetime, past-12-month, and past 6-month PTSD prevalence using the Same Event definition for DSM-5 was 8.3%, 4.7%, and 3.8% respectively. All 6 DSM-5 prevalence estimates were slightly lower than their DSM-IV counterparts, although only 2 of these differences were statistically significant. DSM-5 PTSD prevalence was higher among women than among men, and prevalence increased with greater traumatic event exposure. Major reasons individuals met DSM-IV criteria, but not DSM-5 criteria were the exclusion of nonaccidental, nonviolent deaths from Criterion A, and the new requirement of at least 1 active avoidance symptom.

State-Level Policies and Psychiatric Morbidity In Lesbian, Gay, and Bisexual Populations

OBJECTIVES We investigated the modifying effect of state-level policies on the association between lesbian, gay, or bisexual status and the prevalence of psychiatric disorders. METHODS Data were from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative study of noninstitutionalized US adults (N=34,653). States were coded for policies extending protections against hate crimes and employment discrimination based on sexual orientation. RESULTS Compared with living in states with policies extending protections, living in states without these policies predicted a significantly stronger association between lesbian, gay, or bisexual status and psychiatric disorders in the past 12 months, including generalized anxiety disorder (F=3.87; df=2; P=.02), post-traumatic stress disorder (F=3.42; df=2; P=.04), and dysthymia (F=5.20; df=2; P=.02). Living in states with policies that did not extend protections also predicted a stronger relation between lesbian, gay, or bisexual status and psychiatric comorbidity (F=2.47; df=2; P=.04). CONCLUSIONS State-level protective policies modify the effect of lesbian, gay, or bisexual status on psychiatric disorders. Policies that reduce discrimination against gays and lesbians are urgently needed to protect the health and well-being of this population.

Medical marijuana laws in 50 states: Investigating the relationship between state legalization of medical marijuana and marijuana use, abuse and dependence

BACKGROUND Marijuana is the most frequently used illicit substance in the United States. Little is known of the role that macro-level factors, including community norms and laws related to substance use, play in determining marijuana use, abuse and dependence. We tested the relationship between state-level legalization of medical marijuana and marijuana use, abuse, and dependence. METHODS We used the second wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a national survey of adults aged 18+ (n=34,653). Selected analyses were replicated using the National Survey on Drug Use and Health (NSDUH), a yearly survey of ∼68,000 individuals aged 12+. We measured past-year cannabis use and DSM-IV abuse/dependence. RESULTS In NESARC, residents of states with medical marijuana laws had higher odds of marijuana use (OR: 1.92; 95% CI: 1.49-2.47) and marijuana abuse/dependence (OR: 1.81; 95% CI: 1.22-2.67) than residents of states without such laws. Marijuana abuse/dependence was not more prevalent among marijuana users in these states (OR: 1.03; 95% CI: 0.67-1.60), suggesting that the higher risk for marijuana abuse/dependence in these states was accounted for by higher rates of use. In NSDUH, states that legalized medical marijuana also had higher rates of marijuana use. CONCLUSIONS States that legalized medical marijuana had higher rates of marijuana use. Future research needs to examine whether the association is causal, or is due to an underlying common cause, such as community norms supportive of the legalization of medical marijuana and of marijuana use.

An invariant dimensional liability model of gender differences in mental disorder prevalence: evidence from a national sample.

Epidemiological studies of categorical mental disorders consistently report that gender differences exist in many disorder prevalence rates and that disorders are often comorbid. Can a dimensional multivariate liability model be developed to clarify how gender impacts diverse, comorbid mental disorders? We pursued this possibility in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N = 43,093). Gender differences in prevalence were systematic such that women showed higher rates of mood and anxiety disorders, and men showed higher rates of antisocial personality and substance use disorders. We next investigated patterns of disorder comorbidity and found that a dimensional internalizing-externalizing liability model fit the data well, where internalizing is characterized by mood and anxiety disorders, and externalizing is characterized by antisocial personality and substance use disorders. This model was gender invariant, indicating that observed gender differences in prevalence rates originate from women and mens different average standings on latent internalizing and externalizing liability dimensions. As hypothesized, women showed a higher mean level of internalizing, while men showed a higher mean level of externalizing. We discuss implications of these findings for understanding gender differences in psychopathology and for classification and intervention.

Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis.

Objective To estimate the contributions of biological aging, historical trends, and birth cohort effects on trends in pre-eclampsia in the United States. Design Population based retrospective study. Setting National hospital discharge survey datasets, 1980-2010, United States. Participants 120 million women admitted to hospital for delivery. Main outcome measures Temporal changes in rates of mild and severe pre-eclampsia in relation to maternal age, year of delivery, and birth cohorts. Poisson regression as well as multilevel age-period-cohort models with adjustment for obesity and smoking were incorporated. Results The rate of pre-eclampsia was 3.4%. The age-period-cohort analysis showed a strong age effect, with women at the extremes of maternal age having the greatest risk of pre-eclampsia. In comparison with women delivering in 1980, those delivering in 2003 were at 6.7-fold (95% confidence interval 5.6-fold to 8.0-fold) increased risk of severe pre-eclampsia. Period effects declined after 2003. Trends for severe pre-eclampsia also showed a modest birth cohort effect, with women born in the 1970s at increased risk. Compared with women born in 1955, the risk ratio for women born in 1970 was 1.2 (95% confidence interval 1.1 to 1.3). Similar patterns were also evident for mild pre-eclampsia, although attenuated. Changes in the population prevalence of obesity and smoking were associated with period and cohort trends in pre-eclampsia but did not explain the trends. Conclusions Rates of severe pre-eclampsia have been increasing in the United States and age-period-cohort effects all contribute to these trends. Although smoking and obesity have driven these trends, changes in the diagnostic criteria may have also contributed to the age-period-cohort effects. Health consequences of rising obesity rates in the United States underscore that efforts to reduce obesity may be beneficial to maternal and perinatal health.

Stressful life experiences, alcohol consumption, and alcohol use disorders: the epidemiologic evidence for four main types of stressors.

BackgroundExposure to stress is potentially important in the pathway to alcohol use and alcohol use disorders. Stressors occur at multiple time points across the life course, with varying degrees of chronicity and severity.MethodWe review evidence from epidemiologic studies on the relationship between four different stressors (fateful/catastrophic events, child maltreatment, common adult stressful life events in interpersonal, occupational, financial, and legal domains, and minority stress) and alcohol consumption and alcohol use disorders.ResultsStudies generally demonstrate an increase in alcohol consumption in response to exposure to terrorism or other disasters. Research has demonstrated little increase in incident alcohol use disorders, but individuals with a history of alcohol use disorders are more likely to report drinking to cope with the traumatic event. Childhood maltreatment is a consistent risk factor for early onset of drinking in adolescence and adult alcohol use disorders, and accumulating evidence suggests that specific polymorphisms may interact with child maltreatment to increase risk for alcohol consumption and disorder. Stressful life events such as divorce and job loss increase the risk of alcohol disorders, but epidemiologic consensus on the specificity of these associations across gender has not been reached. Finally, both perceptions of discrimination and objective indicators of discrimination are associated with alcohol use and alcohol use disorders among racial/ethnic and sexual minorities.ConclusionTaken together, these literatures demonstrate that exposure to stress is an important component in individual differences in risk for alcohol consumption and alcohol use disorders. However, many areas of this research remain to be studied, including greater attention to the role of various stressors in the course of alcohol use disorders and potential risk moderators when individuals are exposed to stressors.

Stigma and Treatment for Alcohol Disorders in the United States

Among a nationally representative sample of adults with an alcohol use disorder, the authors tested whether perceived stigmatization of alcoholism was associated with a lower likelihood of receiving alcohol-related services. Data were drawn from a face-to-face epidemiologic survey of 34,653 adults interviewed in 2004-2005 who were aged 20 years or older and residing in households and group quarters in the United States. Alcohol abuse/dependence was diagnosed by using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, version (AUDADIS-IV). The stigma measure used was the Perceived Devaluation-Discrimination Scale. The main outcome was lifetime intervention including professional services and 12-step groups for alcohol disorders. Individuals with a lifetime diagnosis of an alcohol use disorder were less likely to utilize alcohol services if they perceived higher stigma toward individuals with alcohol disorders (odds ratio = 0.37, 95% confidence interval: 0.18, 0.76). Higher perceived stigma was associated with male gender (β = -0.75; P < 0.01), nonwhite compared with non-Hispanic white race/ethnicity, lower income (β = 1.0; P < 0.01), education (β = 1.48; P < 0.01), and being previously married (β = 0.47; P = 0.02). Individuals reporting close contact with an alcohol-disordered individual (e.g., relative with an alcohol problem) reported lower perceived stigma (β = -1.70; P < 0.01). A link between highly stigmatized views of alcoholism and lack of services suggests that stigma reduction should be integrated into public health efforts to promote alcohol treatment.

Adolescent Marijuana Use from 2002 to 2008: Higher in States with Medical Marijuana Laws, Cause Still Unclear

PURPOSE Since 1996, 16 states have legalized marijuana use for medical purposes. The current study provides a scientific assessment of the association of medical marijuana laws (MML) and adolescent marijuana use using national data. METHOD State representative survey data on approximately 23,000 12-17 year olds were collected by the National Survey on Drug Use and Health annually from 2002-2008. Yearly state-specific estimates of prevalence of past-month marijuana use and perception of its riskiness were statistically tested for differences between states with and without MML by year and across years. RESULTS States with MML had higher average adolescent marijuana use, 8.68% (95% CI: 7.95-9.42) and lower perception of riskiness, during the period 2002-2008 compared to states without MML, 6.94% (95% CI: 6.60-7.28%). In the eight states that passed MML since 2004, in the years prior to MML passage, there was already a higher prevalence of use and lower perceptions of risk in those states compared to states that have not passed MML. CONCLUSIONS While the most likely of several possible explanations for higher adolescent marijuana use and lower perceptions of risk in MML states cannot be determined from the current study, results clearly suggest the need for more empirically-based research on this topic.