Katie A. McLaughlin

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.

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.

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.

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.

Development of Lifetime Comorbidity in the World Health Organization World Mental Health Surveys

CONTEXT Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity. OBJECTIVE To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the World Health Organization World Mental Health Surveys. DESIGN Nationally or regionally representative community surveys. SETTING Fourteen countries. PARTICIPANTS A total of 21 229 survey respondents. MAIN OUTCOME MEASURES First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the World Health Organization Composite International Diagnostic Interview. RESULTS Separate internalizing (anxiety and mood disorders) and externalizing (behavior and substance disorders) factors were found in exploratory factor analysis of lifetime disorders. Consistently significant positive time-lagged associations were found in survival analyses for virtually all temporally primary lifetime disorders predicting subsequent onset of other disorders. Within-domain (ie, internalizing or externalizing) associations were generally stronger than between-domain associations. Most time-lagged associations were explained by a model that assumed the existence of mediating latent internalizing and externalizing variables. Specific phobia and obsessive-compulsive disorder (internalizing) and hyperactivity and oppositional defiant disorders (externalizing) were the most important predictors. A small number of residual associations remained significant after controlling the latent variables. CONCLUSIONS The good fit of the latent variable model suggests that common causal pathways account for most of the comorbidity among the disorders considered herein. These common pathways should be the focus of future research on the development of comorbidity, although several important pairwise associations that cannot be accounted for by latent variables also exist that warrant further focused study.

Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication (NCS-R) II: Associations with persistence of DSM-IV disorders

CONTEXT Although significant associations of childhood adversities (CAs) with adult mental disorders have been widely documented, associations of CAs with onset and persistence of disorders have not been distinguished. This distinction is important for conceptual and practical purposes. OBJECTIVE To examine the multivariate associations of 12 retrospectively reported CAs with persistence of adult DSM-IV disorders in the National Comorbidity Survey Replication. DESIGN Cross-sectional community survey. SETTING Household population in the United States. PARTICIPANTS Nationally representative sample of 5692 adults. MAIN OUTCOME MEASURES Recency of episodes was assessed separately for each of 20 lifetime DSM-IV mood, anxiety, disruptive behavior, and substance use disorders in respondents with a lifetime history of these disorders using the Composite International Diagnostic Interview. Predictors of persistence were examined using backward recurrence survival models to predict time since most recent episode controlling for age at onset and time since onset. RESULTS The CAs involving maladaptive family functioning (parental mental illness, substance use disorder, criminality, family violence, physical and sexual abuse, and neglect) but not other CAs were significantly but modestly related to persistence of mood, substance abuse, and anxiety disorders. Number of maladaptive family functioning CAs had statistically significant, but again substantively modest, subadditive associations with the same outcomes. Exposure to multiple other CAs was significantly associated with persistence of mood and anxiety disorders. Associations remained statistically significant throughout the life course, although the substantive size of associations indicated by simulations showing time to most recent episode would increase by only 1.6% (from a mean of 8.3 years to a mean of 8.4 years) in the absence of CAs. CONCLUSIONS The overall statistically significant associations of CAs with adult DSM-IV/Composite International Diagnostic Interview disorders are due largely to component associations with onsets rather than with persistence, indirectly suggesting that the greatest focus of public health attention on CAs should be aimed at primary rather than secondary prevention.

Rumination as a transdiagnostic factor in depression and anxiety.

The high rate of comorbidity among mental disorders has driven a search for factors associated with the development of multiple types of psychopathology, referred to as transdiagnostic factors. Rumination is involved in the etiology and maintenance of major depression, and recent evidence implicates rumination in the development of anxiety. The extent to which rumination is a transdiagnostic factor that accounts for the co-occurrence of symptoms of depression and anxiety, however, has not previously been examined. We investigated whether rumination explained the concurrent and prospective associations between symptoms of depression and anxiety in two longitudinal studies: one of adolescents (N=1065) and one of adults (N=1317). Rumination was a full mediator of the concurrent association between symptoms of depression and anxiety in adolescents (z=6.7, p< .001) and was a partial mediator of this association in adults (z=5.6, p< .001). In prospective analyses in the adolescent sample, baseline depressive symptoms predicted increases in anxiety, and rumination fully mediated this association (z=5.26, p< .001). In adults, baseline depression predicted increases in anxiety and baseline anxiety predicted increases in depression; rumination fully mediated both of these associations (z=2.35, p= .019 and z=5.10, p< .001, respectively). These findings highlight the importance of targeting rumination in transdiagnostic treatment approaches for emotional disorders.

Childhood Adversities and First Onset of Psychiatric Disorders in a National Sample of US Adolescents

CONTEXT Although childhood adversities (CAs) are known to be highly co-occurring, most research examines their associations with psychiatric disorders one at a time. However, recent evidence from adult studies suggests that the associations of multiple CAs with psychiatric disorders are nonadditive, arguing for the importance of multivariate analysis of multiple CAs. To our knowledge, no attempt has been made to perform a similar kind of analysis among children or adolescents. OBJECTIVE To examine the multivariate associations of 12 CAs with first onset of psychiatric disorders in a national sample of US adolescents. DESIGN A US national survey of adolescents (age range, 13-17 years) assessing DSM-IV anxiety, mood, behavior, and substance use disorders and CAs. The CAs include parental loss (death, divorce, and other separations), maltreatment (neglect and physical, sexual, and emotional abuse), and parental maladjustment (violence, criminality, substance abuse, and psychopathology), as well as economic adversity. SETTING Dual-frame household-school samples. PARTICIPANTS In total, 6483 adolescent-parent pairs. MAIN OUTCOME MEASURES Lifetime DSM-IV disorders assessed using the World Health Organization Composite International Diagnostic Interview. RESULTS Overall, exposure to at least 1 CA was reported by 58.3% of adolescents, among whom 59.7% reported multiple CAs. The CAs reflecting maladaptive family functioning were more strongly associated than other CAs with the onset of psychiatric disorders. The best-fitting model included terms for the type and number of CAs and distinguished between maladaptive family functioning and other CAs. The CAs predicted behavior disorders most strongly and fear disorders least strongly. The joint associations of multiple CAs were subadditive. The population-attributable risk proportions across DSM-IV disorder classes ranged from 15.7% for fear disorders to 40.7% for behavior disorders. The CAs were associated with 28.2% of all onsets of psychiatric disorders. CONCLUSIONS Childhood adversities are common, highly co-occurring, and strongly associated with the onset of psychiatric disorders among US adolescents. The subadditive multivariate associations of CAs with the onset of psychiatric disorders have implications for targeting interventions to reduce exposure to CAs and to mitigate the harmful effects of CAs to improve population mental health.

AGE DIFFERENCES IN THE PREVALENCE AND CO-MORBIDITY OF DSM-IV MAJOR DEPRESSIVE EPISODES : RESULTS FROM THE WHO WORLD MENTAL HEALTH SURVEY INITIATIVE

Background: Although depression appears to decrease in late life, this could be due to misattribution of depressive symptoms to physical disorders that increase in late life. Methods: We investigated this issue by studying age differences in co‐morbidity of DSM‐IV major depressive episodes (MDE) with chronic physical conditions in the WHO World Mental Health (WMH) surveys, a series of community epidemiological surveys of respondents in 10 developed countries (n=52,485) and 8 developing countries (n=37,265). MDE and other mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). Organic exclusion rules were not used to avoid inappropriate exclusion of cases with physical co‐morbidity. Physical conditions were assessed with a standard chronic conditions checklist. Results: Twelve‐month DSM‐IV/CIDI MDE was significantly less prevalent among respondents ages 65+ than younger respondents in developed but not developing countries. Prevalence of co‐morbid mental disorders generally either decreased or remained stable with age, while co‐morbidity of MDE with mental disorders generally increased with age. Prevalence of physical conditions, in comparison, generally increased with age, while co‐morbidity of MDE with physical conditions generally decreased with age. Depression treatment was lowest among the elderly in developed and developing countries. Conclusions: The weakening associations between MDE and physical conditions with increasing age argue against the suggestion that the low estimated prevalence of MDE among the elderly is due to increased confounding with physical disorders. Future study is needed to investigate processes that might lead to a decreasing impact of physical illness on depression among the elderly. Depression and Anxiety, 2010.