A population-based study of the risk of schizophrenia and bipolar disorder associated with parent-child separation during development

BACKGROUND

There is growing interest in the role of childhood adversities, including parental death and separation, in the etiology of psychotic disorders. However, few studies have used prospectively collected data to specifically investigate parental separation across development, or assessed the importance of duration of separation, and family characteristics.

METHOD

We measured three types of separation not due to death: maternal, paternal, and from both parents, across the ages of 1-15 years among a cohort of 985 058 individuals born in Denmark 1971-1991 and followed to 2011. Associations with narrowly and broadly defined schizophrenia and bipolar disorder in the psychiatric register were assessed in terms of separation occurrence, age of separation, and number of years separated. Interactions with parental history of mental disorder were assessed.

RESULTS

Each type of separation was associated with all three outcomes, adjusting for age, sex, birth period, calendar year, family history of mental disorder, urbanicity at birth and parental age. Number of years of paternal separation was positively associated with both schizophrenia and bipolar disorder. Associations between separation from both parents and schizophrenia were stronger when separation occurred at later ages, while those with bipolar disorder remained stable across development. The first occurrence of paternal separation appeared to increase risk more when it occurred earlier in childhood. Associations differed according to parental history of mental disorder, although in no situation was separation protective.

CONCLUSIONS

Effects of parental separation may differ by type, developmental timing and family characteristics. These findings highlight the importance of considering such factors in studies of childhood adversity.

Epigenetic and genetic variation at SKA2 predict suicidal behavior and post-traumatic stress disorder

Traumatic stress results in hypothalamic pituitary adrenal (HPA) axis abnormalities and an increased risk to both suicidal behaviors and post-traumatic stress disorder (PTSD). Previous work out of our laboratory identified SKA2 DNA methylation associations with suicidal behavior in the blood and brain of multiple cohorts. Interaction of SKA2 with stress predicted suicidal behavior with ~80% accuracy. SKA2 is hypothesized to reduce the ability to suppress cortisol following stress, which is of potentially high relevance in traumatized populations. Our objective was to investigate the interaction of SKA2 and trauma exposure on HPA axis function, suicide attempt and PTSD. SKA2 DNA methylation at Illumina HM450 probe cg13989295 was assessed for association with suicidal behavior and PTSD metrics in the context of Child Trauma Questionnaire (CTQ) scores in 421 blood and 61 saliva samples from the Grady Trauma Project (GTP) cohort. Dexamethasone suppression test (DST) data were evaluated for a subset of 209 GTP subjects. SKA2 methylation interacted with CTQ scores to predict lifetime suicide attempt in saliva and blood with areas under the receiver operator characteristic curve (AUCs) of 0.76 and 0.73 (95% confidence interval (CI): 0.6-0.92, P = 0.003, and CI: 0.65-0.78, P < 0.0001) and to mediate the suppression of cortisol following DST (β = 0.5 ± 0.19, F = 1.51, degrees of freedom (df) = 12/167, P = 0.0096). Cumulatively, the data suggest that epigenetic variation at SKA2 mediates vulnerability to suicidal behaviors and PTSD through dysregulation of the HPA axis in response to stress.

Concordance between personality disorder assessment methods

BACKGROUND

Studies have criticized the low level of agreement between the various methods of personality disorder (PD) assessment. This is an important issue for research and clinical purposes.

METHOD

Seven hundred and forty-two participants in the Hopkins Epidemiology of Personality Disorders Study (HEPS) were assessed on two occasions using the Personality Disorder Schedule (PDS) and the International Personality Disorder Examination (IPDE). The concordance between the two diagnostic methods for all DSM-IV PDs was assessed using standard methods and also two item response analytic approaches designed to take account of measurement error: a latent trait-based approach and a generalized estimating equations (GEE)-based approach, with post-hoc adjustment.

RESULTS

Raw criteria counts, using the intraclass correlation coefficient (ICC), κ and odds ratio (OR), showed poor concordance. The more refined statistical methods showed a moderate to moderately high level of concordance between the methods for most PDs studied. Overall, the PDS produced lower prevalences of traits but higher precision of measurement than the IPDE. Specific criteria within each PD showed varying endorsement thresholds and precision for ascertaining the disorder.

CONCLUSIONS

Concordance in the raw measurement of the individual PD criteria between the two clinical methods is lacking. However, based on two statistical methods that adjust for differential endorsement thresholds and measurement error in the assessments, we deduce that the PD constructs themselves can be measured with a moderate degree of confidence regardless of the clinical approach used. This may suggest that the individual criteria for each PD are, in and of themselves, less specific for diagnosis, but as a group the criteria for each PD usefully identify specific PD constructs.

The effect of social networks and social support on common mental disorders following specific life events

OBJECTIVE

This study examined the association between life events and common mental disorders while accounting for social networks and social supports.

METHOD

Participants included 1920 adults in the Baltimore Epidemiologic Catchment Area Cohort who were interviewed in 1993-1996, of whom 1071 were re-interviewed in 2004-2005. Generalized estimating equations were used to analyze the data.

RESULTS

Social support from friends, spouse or relatives was associated with significantly reduced odds of panic disorder and psychological distress, after experiencing specific life events. Social networks or social support had no significant stress-buffering effect. Social networks and social support had almost no direct or buffering effect on major depressive disorder, and no effect on generalized anxiety disorder and alcohol abuse or dependence disorder.

CONCLUSION

The significant association between social support and psychological distress, rather than diagnosable mental disorders, highlights the importance of social support, especially when the severity of a mental health related problem is low.

Restless Legs Syndrome and the five-factor model of personality: results from a community sample

OBJECTIVE

To examine personality characteristics as potential mediators of the association between Restless Legs Syndrome (RLS) and psychiatric disorders.

METHOD

Revised NEO Personality Inventory traits are compared in respondents with (n=42) versus without (n=982) a diagnosis of RLS in a general population sample.

RESULTS

RLS was associated with higher neuroticism after adjusting for potential confounders, including current psychopathology. Further analysis showed that the association between RLS and neuroticism contributes to, but does not fully explain, the relationship between RLS and either panic disorder or major depression.

CONCLUSIONS

Neuroticism may mediate part of the relationship between RLS and depression or panic, but the mechanisms of these associations need further exploration.

Depression and osteoporosis: epidemiology and potential mediating pathways

INTRODUCTION

There have been numerous studies examining the association between depression and bone mineral density (BMD), but the underlying nature of this relationship remains unclear. Independent of this association, there is a growing body of evidence that depression impacts the risk for fracture in older adults. This article reviews the current epidemiological evidence regarding comorbidity of depression, low bone mineral density, and fracture.

METHODS

A review of the literature on depression, depressive symptoms, low BMD, osteoporosis, and fracture using electronic databases.

RESULTS

We reviewed 20 studies of the association between depression and BMD and five reports of the relationship between depression and fractures. Potential mediating mechanisms (both physiological and behavioral) are discussed, as well as potential confounding influences (e.g., medication use).

CONCLUSIONS

Most studies support the finding that depression is associated with increased risk for both low BMD and fractures, but variation in study design, sample composition, and exposure measurement make comparisons across studies difficult. Researchers should be aware of potential confounders, such as medication use, that may influence results. Future research should focus on identifying mediating pathways and targets for intervention in the relationships between depression, low BMD, and fracture.

Prevalence and incidence of depressive disorder: the Baltimore ECA follow-up, 1981-2004

OBJECTIVE

To describe trends in prevalence and incidence of depressive disorder in a cohort from Eastern Baltimore.

METHOD

Twenty-three-year-old longitudinal cohort, the Baltimore Epidemiologic Catchment Area Follow-up. Participants were selected probabilistically from the household population in 1981, and interviewed in 1981, 1993, and 2004. Diagnoses were made via the Diagnostic Interview Schedule according to successive editions of the American Psychiatric Association Diagnostic and Statistical Manual.

RESULTS

Older age, lower education, non-White race, and cognitive impairment are independent predictors of attrition due to death and loss of contact, but depressive disorder is not related to attrition. Prevalence rates rise for females between 1981, 1993, and 2004. Incidence rates in the period 1993-2004 are lower than the period 1981-1993, suggesting the rise in prevalence is due to increasing chronicity.

CONCLUSION

There has been a rise in the prevalence of depression in the prior quarter century among middle-aged females.

How migraines impact cognitive function: Findings from the Baltimore ECA

OBJECTIVE

To examine the cross-sectional and longitudinal relationship between migraine headaches and cognitive functioning.

METHODS

The data were from Waves III (1993 through 1996) and IV (2004 through 2005) of the Baltimore Epidemiologic Catchment Area Study. Migraine headaches were diagnosed according to modified criteria of the International Headache Society. Scores on the immediate and delayed recall tests and the Mini-Mental State Examination (MMSE) were compared for migraineurs (n = 204) vs nonmigraineurs (n = 1,244). The longitudinal association between migraine and cognitive changes was assessed by generalized estimating equations.

RESULTS

Migraineurs scored lower on tests of immediate and delayed memory at baseline, but declined by less over time than nonmigraineurs. These associations were specific to migraineurs with aura, who declined by 1.26 (p < 0.01) and 1.47 (p < 0.01) words less on the immediate and delayed recall tests over the 12 years of follow-up. The effects of migraine, specifically with aura, on the MMSE were restricted to those older than 50 years. Among those younger than 50 years, migraineurs with aura declined at the same rate on the MMSE as nonmigraineurs. However, among those older than 50 years, migraineurs with aura declined by 0.99 points (p < 0.01) less over the follow-up.

CONCLUSIONS

Migraineurs, specifically those with aura, exhibited less decline on cognitive tests over time vs nonmigraineurs. For the Mini-Mental State Examination, these effects were only apparent among those who were older than 50 years.

Indicators of fetal growth and bipolar disorder: a Danish national register-based study

BACKGROUND

Several studies have found an association between indicators of fetal growth and/or obstetric complications and schizophrenia but only a few studies have investigated the possible association between these factors and bipolar disorder. Furthermore, the results of these studies have been contradictory. The aim of this study was to investigate whether the risk of bipolar disorder is associated with exposure to indicators of fetal growth.

METHOD

A national population nested case-control study based on Danish longitudinal register databases was carried out. Conditional logistic regression was used, controlling for potential confounding factors such as parental age at birth, socio-economic indicators and psychiatric history. We identified 196 cases, and each case was time-, age- and sex-matched with 25 normal population-based controls. All cases were between the ages of 12 and 26 years at the time of diagnosis, were born between 1973 and 1983 and were admitted and diagnosed between 1987 and 1999.

RESULTS

During the study period 1973-1983, none of the individual variables available for analyses (birthweight, birth length, gestational age and number of previous pregnancies in the mother) was associated with receiving a diagnosis of bipolar disorder.

CONCLUSIONS

None of the indicators of fetal growth under study could be identified as risk factors for bipolar disorder, suggesting that the etiologies of schizophrenia and bipolar disorder, at least in part, are different.

Minor depression as a predictor of the first onset of major depressive disorder over a 15-year follow-up

OBJECTIVE

To study the relationship of minor depression to first onset of major depressive disorder (MDD) among 1634 individuals over a 15-year follow-up using the Baltimore Epidemiologic Catchment Area cohort.

METHOD

Logistic regression analyses were conducted with minor depression alone and also adjusting for anxiety, sociodemographic, and medical variables, with MDD as the outcome variable. Also, among those with minor depression, depressive symptom categories were studied with both logistic regression and population attributable risk (PAR) to determine if they predicted MDD.

RESULTS

Individuals with a history of minor depression had an odds ratio of more than 5 of having a first lifetime episode of MDD (adjusted OR: 5.37, 95% CI: 2.87, 10.06). Suicidal ideation, appetite/weight issues, and sleep difficulty had the highest PARs.

CONCLUSION

Minor depression strongly predicts MDD. Clinical and public health interventions for individuals with minor depression can potentially impact the pathway leading to MDD.

Personal characteristics associated with consistency of recall of depressed or anhedonic mood in the 13-year follow-up of the Baltimore Epidemiologic Catchment Area survey

OBJECTIVE

Our study addressed two primary questions: (1) How reliable is long-term recall of lifetime history of episodes of depressed mood? (2) What characteristics are associated with consistent recall of this history?

METHOD

Psychiatric symptoms were assessed in a population-based longitudinal survey of 1498 persons twice, in 1981 and 1994. Respondents whose reports of history of depressed affect were discordant after a 13-year follow-up interval were compared with those whose reports were concordant.

RESULTS

Absence of a reported history of episode of depressed mood was more consistently recalled than presence of such an episode. The kappa of reported lifetime history of episode of depressed mood was 0.32. Several personal characteristics predicted consistency of recall.

CONCLUSION

If assessment of past episodes of depressed mood is used as guide for identifying cases at risk for depression, account must be taken of the personal factors that might influence recall.

Depressive disorder as a long-term antecedent risk factor for incident back pain: a 13-year follow-up study from the Baltimore Epidemiological Catchment Area sample

BACKGROUND

The co-occurrence of affective distress and back pain is well documented but the relationship between them is less certain. This study examines the relationship between lifetime occurrence of depressive disorder and incident back pain reported over a 13-year period.

METHOD

The Baltimore Epidemiologic Catchment Area Study is a prospective study of a household-residing cohort, selected probabilistically from East Baltimore in 1981. Between 1982-3 (wave 2) and again between 1993-6 (wave 3), a follow-up study of the original cohort was conducted. Questions on depressive disorder and back pain were drawn from the Diagnostic Interview Schedule. Logistic regression analyses were used to evaluate whether depressive disorder acts as a risk factor for incident back pain.

RESULTS

In cross-sectional analyses, lifetime occurrence of depressive disorder was a significant correlate of lifetime prevalence of back pain at wave 1 (OR = 1.6, P = 0.01). During the 13-year follow-up, across three data collection points, there was an increase in the risk for incident back pain when depressive disorder was present at baseline (OR = 1.9, 95% CI 1.03, 3.4). However, during the short-term follow-up period of 1 year, between baseline and wave 2, depressive disorder at baseline was unrelated to first-ever reports of back pain. Lifetime depressive disorder in both waves 1 (baseline) and 2 (1 year later) was associated with a more than three times greater risk for a first-ever report of back pain during the 12 to 13 year follow-up period, in comparison to those who did not have depressive disorder at waves 1 or 2 (OR = 3.4, 95% CI 1.4, 7.8). Back pain at wave 1 was not significantly associated with an increased risk for depression in the longitudinal analysis (OR = 0.8, 95% CI 0.5, 1.4).

CONCLUSIONS

Depressive disorder appears to be a risk factor for incident back pain independent of other characteristics often associated with back pain. Back pain is not a short-term consequence of depressive disorder but emerges over periods longer than 1 year. Moreover, in this study the alternative pathway of back pain as a risk factor for depressive disorder could not be supported.

Adult antisocial personality traits are associated with experiences of low parental care and maternal overprotection

OBJECTIVE

To investigate the role of parenting in the development of adult antisocial personality traits.

METHOD

A total of 742 community-based subjects were assessed for adult DSM-IV antisocial personality disorder traits and for measures of parental behavior experienced as children, including by the Parental Bonding Instrument (PBI).

RESULTS

Three fundamental dimensions of parental behavior - care, behavioral restrictiveness and denial of psychological autonomy - were derived by factor analysis from the PBI. These dimensions significantly correlated with measures of parental behavior considered influential in later antisocial behavior. Adult antisocial traits in males were associated with low maternal care and high maternal behavioral restrictiveness, and in females, antisocial traits were associated with low paternal care and high maternal denial of psychological autonomy. These dimensions did not, however, explain all variance parental behavior has on adult antisocial personality traits.

CONCLUSION

Adult antisocial personality traits are associated with experiences of low parental care and maternal overprotection.

The association of depression and problem drinking: analyses from the Baltimore ECA follow-up study. Epidemiologic Catchment Area

In this study, we hypothesized that there would be an increased risk of greater alcohol consumption among depressed problem drinkers than those without depression in the prior year, and that the strength of this association would be stronger for women. As part of the Epidemiologic Catchment Area (ECA) program, probability samples of area residents were selected and the baseline interview for the Baltimore site was completed in 1981. Between 1993 and 1996, 73% of the survivors (n = 2633) were reinterviewed. For the 334 problem drinkers identified, the occurrence of a depressive episode and level of alcohol consumption for each intervening year between the baseline and follow-up interviews were assessed. Generalized estimating equations (GEE) were used for logistic regression analyses to examine the association between the occurrence of depression in the prior year with transition to higher-level drinking in the subsequent year. The problem drinkers tended to have a bimodal association of transitioning to higher-level drinking; although the strength of the association was greater for men. Future research will need to assess the potential influences on this relationship of other sociodemographic and psychopathologic characteristics, including the effect of treatment for depression or substance use.

Socioeconomic status and depressive syndrome: the role of inter- and intra-generational mobility, government assistance, and work environment

This paper assesses the hypothesis that depressive syndrome is associated with socioeconomic status, using longitudinal data from the Baltimore Epidemiologic Catchment Area Followup. Socioeconomic measures include those used in most studies of status attainment, as well as measures of financial dependence, non-job income, and work environment. Analyses include inter- and intra-generational mobility, and replicate the basic aspects of the status attainment process, as well as psychiatric epidemiologic findings regarding gender, family history of depression, life events, and depressive syndrome. But the involvement of depressive syndrome in the process of status attainment, either as cause or consequence, is small and not statistically significant. There are strong effects of financial dependence and work environment on depressive syndrome. The findings shed doubt on the utility of the causation/selection/drift model for depression, to the extent it is based on linear relationships and socioeconomic rank at the macro level, while lending credibility to social-psychologically oriented theories of work environment, poverty, and depression.

Epidemiology of unexplained fatigue and major depression in the community: the Baltimore ECA follow-up, 1981-1994

BACKGROUND

Fatigue is a common, non-specific, subjective symptom associated with several medical and psychiatric illnesses. The purpose of this investigation was to explore further the epidemiology of unexplained fatigue in the general population and the relationship between fatigue and depression.

METHODS

The design was a prospective population-based study. Subjects included community-dwelling adults who were participants of the Baltimore sample of the Epidemiologic Catchment Area Program in 1981 and who were reinterviewed 13 years later. Lay interviewers using the Diagnostic Interview Schedule interviewed subjects.

RESULTS

Number of somatization symptoms and history of a dysphoric episode at baseline were the two strongest predictors of both new onset of fatigue as well as recurrent/chronic fatigue over the 13-year follow-up interval. In addition, individuals who reported a history of unexplained fatigue at baseline as well as during the follow-up, were at markedly increased risk for new onset major depression as compared to those who never reported such fatigue, (RR = 28.4, 95% CI) (11.7, 68.0). Similarly, respondents who developed new fatigue or had remitted fatigue after 1981 were also at increased risk for developing major depression.

CONCLUSIONS

Somatization was the strongest predictor of both new and chronic fatigue with unknown cause. In addition, fatigue was both predictive and a consequence of the depression syndrome.

Obstetric complications and risk for severe psychopathology in childhood

The purpose of the study was to assess the association of obstetric complications with risk for mental disorders resulting in hospitalization before the age of 15. Records from all births in Denmark from 1973 through 1993 were linked to records of all psychiatric hospitalizations. Diagnoses were grouped into seven broad categories. A reference population of 10% of births in Denmark from 1973 to 1990 was used for comparison. Obstetric complications were associated with the range of mental disorders occurring in childhood. The strongest predictors were a variable indicating the interaction of birth weight with speed of growth and the 5-minute Apgar score. There was no diagnostic group that stood out as different with respect to obstetric complications. These results are consistent with the hypothesis of the continuum of reproductive casualty.

Normal personality traits and comorbidity among phobic, panic and major depressive disorders

High comorbidity among anxiety and depressive conditions is a consistent but not well-understood finding. The current study examines how normal personality traits relate to this comorbidity. In the Baltimore Epidemiologic Catchment Area Follow-up Study, psychiatrists administered the full Schedules for Clinical Assessment in Neuropsychiatry to 320 subjects, all of whom completed the Revised NEO Personality Inventory. The disorders of interest were simple phobia, social phobia, agoraphobia, panic disorder, and major depression. Analyses were carried out with second-order generalized estimating equations. The unadjusted summary odds ratio (SOR - or weighted mean odds ratio) for all five disorders was 1.72 (95% confidence interval=1.21-2.46). Neuroticism, introversion, younger age, and female gender were all significant predictors of prevalence of disorders. After adjustment for the relationships between these personality and demographic predictors and prevalence, the association among disorders was much weaker (SOR=1.11, 95% CI=0.79-1.56). However, subjects with high extraversion had a SOR 213% as high (95% CI=102-444%) as those with low extraversion (1.60 vs. 0.75). Therefore, neuroticism and introversion are associated with increased comorbidity due to relationships in common with the prevalence of the different disorders. In contrast, extraversion is associated with increased comorbidity per se.

Longitudinal study assessing the joint effects of socio-economic status and birth risks on adult emotional and nervous conditions

BACKGROUND

Previous investigations into the impact of birth complications and social environment have generally followed their subjects only at young ages.

AIMS

To assess the long-range impact of socio-economic status (SES) and birth risks on the development of emotional and nervous conditions through adulthood.

METHOD

The Johns Hopkins Pathways Study interviewed 1824 subjects born between 1960 and 1965. The median household income of the children at age 7-8 years was used to divide the cohort into high and low income categories. Differences in life time prevalence of emotional and nervous conditions through adulthood between the two income groups were identified.

RESULTS

Children in the lower income group were 1.86 times more likely to report an emotional or nervous condition as adults. Boys in the lower income group at age 7-8 years were 3.2 times more likely to do so. The risks of difficult birth for adult mental disturbance were accentuated in the low-income group.

CONCLUSIONS

Children who experience birth complications are at increased risk of developing adult mental disturbances; this increase is mitigated by higher SES.

Phobic, panic, and major depressive disorders and the five-factor model of personality

This study investigated five-factor model personality traits in anxiety (simple phobia, social phobia, agoraphobia, and panic disorder) and major depressive disorders in a population-based sample. In the Baltimore Epidemiologic Catchment Area Follow-up Study, psychiatrists administered the Schedules for Clinical Assessment in Neuropsychiatry to 333 adult subjects who also completed the Revised NEO Personality Inventory. All of the disorders except simple phobia were associated with high neuroticism. Social phobia and agoraphobia were associated with low extraversion. In addition, lower-order facets of extraversion, agreeableness, and conscientiousness were associated with certain disorders (i.e., low positive emotions in panic disorder; low trust and compliance in certain phobias; and low competence, achievement striving, and self-discipline in several disorders). This study emphasizes the utility of lower-order personality assessments and underscores the need for further research on personality/psychopathology etiologic relationships.

Psychosocial work environment and depression: epidemiologic assessment of the demand-control model

OBJECTIVES

This study examined the relation between occupational variables and 3 forms of depression (major depressive episode, depressive syndrome, and dysphoria). It was hypothesized that individuals working in occupations with high psychologic strain (high psychologic demands and low decision authority) would have a higher prevalence of depression relative to those working in occupations with the other 3 possible conditions.

METHODS

The analysis was based on data for 905 respondents who were employed full-time in the year before the follow-up interview for the Epidemiologic Catchment Area Program in Baltimore, Md, between 1993 and 1996. Psychosocial work environment, sociodemographic variables, and psychopathology were assessed in a household interview that included the National Institute of Mental Health Diagnostic Interview Schedule. Subscales for the demand-control model for psychosocial work environment were modified slightly after factor analysis.

RESULTS

High job strain was associated with greater prevalence of all 3 forms of depression, especially major depressive episode. The results were stronger for women; for men, being unmarried was the strongest prevalence correlate.

CONCLUSIONS

Major depressive episode, depressive syndrome, and dysphoria are strongly associated with the psychosocial dimensions of the demand-control model.

Mental disorders and the incidence of migraine headaches in a community sample: results from the Baltimore Epidemiologic Catchment area follow-up study

BACKGROUND

The cross-sectional relation between migraine headaches and affective disorders has been demonstrated in studies of clinical and community populations. Few studies have investigated the prospective relation between psychiatric disorders and migraine headaches.

METHODS

A prospective follow-up of the Baltimore, Md, cohort of the Epidemiologic Catchment Area Study assessed psychopathologic features in 1981 and again between 1993 and 1996. Interviews included a history of headaches at baseline and self-reported assessment of migraine headaches at follow-up. Risk estimates for incident migraine headaches by 1981 demographic variables and psychopathologic features were calculated. The cross-sectional association between prevalent migraine and lifetime psychiatric diagnoses was estimated.

RESULTS

In the at-risk population of 1343, there were 118 incident cases of migraine headaches. The age- and sex-specific incident rates of migraine headaches followed the expected patterns, with younger age and female sex identified as risk factors. In cross-sectional analyses, major depression (odds ratio, 3.14; 95% confidence interval, 2.03-4. 84) and panic disorder (odds ratio, 5.09; 95% confidence interval, 2. 65-9.79) had the strongest associations, and alcohol and other substance abuse were not associated. In logistic regression models including age, sex, and psychiatric illness in 1981, only phobia was predictive of incident migraines (odds ratio, 1.70; 95% confidence interval, 1.11-2.58). Affective disorders were not predictive of incident migraine headaches. Including a history of tricyclic antidepressant use did not change the results.

CONCLUSIONS

There is a strong cross-sectional relation between affective disorders and migraine headaches in this cohort. However, there is no association between antecedent affective disorders and incident migraine headaches in this population-based prospective study.

Major depression and cancer: the 13-year follow-up of the Baltimore epidemiologic catchment area sample (United States)

OBJECTIVE

The relationship between depression and development of cancer is not well understood, with some studies finding a significant but small increase in risk for cancer among persons with depression. No studies have employed standardized interviews keyed to the diagnostic criteria for Major Depression. Our objective was to evaluate the relationship between Major Depression at baseline and new onset of cancer at follow-up.

METHOD

The study was based on a population-based 13-year follow-up survey of community-dwelling adults living in East Baltimore in 1981. After excluding 372 persons with a history of cancer or those whom reported their health as poor at the baseline interview, 3109 adults remained. Information on baseline depression status and cancer at follow-up was available for 2017 persons. A diagnosis of cancer was ascertained at follow-up through interview of survivors and from death certificates.

RESULTS

There were 203 new cases of cancer among 2017 persons at risk. Neither Major Depression (relative risk (RR) = 1.0, 95% confidence interval (CI) 0.5-2.1) nor dysphoric episode (RR = 1.3, 95% CI 0.9-1.9) were significantly associated with increased risk of cancer at follow-up. However, among women with Major Depression, the risk of breast cancer was increased (adjusted RR = 3.8, 95% CI 1.0-14.2).

CONCLUSIONS

We found no overall association of depression with cancer. However, among women, Major Depression (but not dysphoric episode alone) was associated with the onset of breast cancer.

Understanding the heterogeneity of depression through the triad of symptoms, course and risk factors: a longitudinal, population-based study

BACKGROUND

There is an ongoing research effort to test if depression is a homogeneous clinical syndrome and to identify valid and useful subtypes based on the number and nature of depressive symptoms. This study summarizes the patterns of depressive symptoms evident in a prospective study of the general population and examines the validity of potential subtypes by studying their course and etiologic heterogeneity.

METHODS

A general population sample of 1920 adults (aged 18-96) from the Baltimore Epidemiologic Catchment Area (ECA) follow-up study (1981 to 1993/6) were examined. Data on diagnoses, symptoms, course and risk factors were collected using the Diagnostic Interview Schedule (DIS). Latent class analysis was applied to summarize symptom patterns. Course characteristics and risk factor profiles were compared among potential subtypes based on the number of symptom groups or symptom patterns. Logistic regression models were used to examine the etiologic heterogeneity among potential subtypes based on symptoms.

RESULTS

The number of symptom groups gave the most efficient insight into differential etiologic processes. Severe depression (7-9 symptom groups) was associated with female gender, family history of depression but not with stressful life events before the onset of the first episode. Moderate (5-6 symptom groups) and mild depression (3-4 symptom groups) were associated with family history of depression, stressful life events before the onset, but not with female gender. The latent class model generated patterns of depressive psychopathology as follows: anhedonia, suicidal, psychomotor, and severely depressed subtypes. The Anhedonia subtype showed a course and risk factor profile distinct from the others.

LIMITATIONS

The measurement of psychopathology was based on self-reported DIS interviews instead of psychiatric assessments. Recall or report bias cannot be excluded in the ascertainment of family history and stressful life events.

CONCLUSIONS

Depression is heterogeneous, even below the threshold of syndromal diagnosis. The severity of an episode appears to be more informative than the pattern of symptoms, with the possible exception of a putative anhedonic subtype.

Psychopathology and the initiation of disability payments

OBJECTIVE

Longitudinal prospective data from the multisite Epidemiologic Catchment Area (ECA) survey were examined to determine relationships between mental disorders, alcohol abuse or dependence, and transfer payments for disability.

METHODS

ECA respondents who were not receiving disability benefits at baseline but who were receiving them at the one-year follow-up were identified. The effects of six psychiatric disorders on the risk of starting payments were examined. They were major depressive disorder, panic disorder, alcohol abuse or dependence, phobic disorder, obsessive-compulsive disorder, and schizophrenia. The odds of starting to receive payments were calculated for persons with these disorders, any mental or addictive disorder, or any two or more disorders, while the analysis controlled for sociodemographic characteristics.

RESULTS

A total of 15,567 people were interviewed at baseline; 7 percent received disability payments. Among the 11, 981 people interviewed at one year, 261 had begun to receive payments that year, for a starting rate of 2.2 percent. Significant predictors of the initiation of payments were little education (odds ratio=3.7) and low household income (OR=2.6). Respondents with panic disorder were 5.2 times more likely to begin receiving benefits than those without this disorder; respondents with schizophrenia were 4.5 times more likely and those with two or more disorders were 2.8 times more likely to start benefits than those without these disorders.

CONCLUSIONS

Differences in social class influenced the initiation of disability payments. However, having a mental or addictive disorder was a more significant predictor, strongly increasing the risk of receiving payments. Given the economic burden to society and potential loss of earnings and opportunity costs for persons with disability and their families, intervening to prevent or alleviate mental disorders should be considered as one alternative to reducing disability payments.

Obstetric factors, urbanization and psychosis

BACKGROUND

Epidemiologic evidence as early as the 1930s has suggested urbanization is linked to schizophrenia, either by place of admission, place of upbringing, or, more recently, place of birth. In the past decade, obstetric complications have been implicated in the etiology of schizophrenia.

METHODS

With appropriate protections for anonymity, the files of the Danish Medical Birth Register were linked with the files of the Danish Psychiatric Case Register. The linkage produced 132 cases of schizophrenia and 69 cases of affective psychosis, who were born in 1973 or later, who entered a Danish psychiatric hospital before 1994. Controls were drawn from a 10% sample of the Medical Birth Register. Analysis was by logistic regression.

RESULTS

The risk of hospitalization for schizophrenia was 4.20 times higher (95% CI=2.4-7.4) for those born in Copenhagen versus those born in rural areas of Denmark, and a linear relationship was demonstrated between urbanization of birthplace and risk. There was no difference in risk of hospitalization for affective psychosis for those born in Copenhagen versus rural areas. Obstetric complications had a moderate sized relationship to schizophrenia, but the relationship of urban birth to schizophrenia was unaffected by adjustment for obstetric complications.

CONCLUSION

Urban birth is a strong risk factor for schizophrenia, not mediated by obstetric complications, which deserves further exploration.

Empirical examination of current depression categories in a population-based study: symptoms, course, and risk factors

OBJECTIVE

Research studies on the validity of current diagnostic and subthreshold categories of depression that use a population-based follow-up design are rare. The authors examined the validity and utility of four current depression categories by examining subject transition between categories and the symptoms, course, and risk factors of each.

METHOD

A general population sample of 1,920 adults from the Baltimore Epidemiologic Catchment Area 13-year follow-up study were examined. Data on diagnoses, symptoms, course, and risk factors were collected by using the National Institute of Mental Health Diagnostic Interview Schedule, the Life Chart Interview, and an office visit. Polychotomous regression was used to examine the heterogeneity of four diagnostic categories: major depressive disorder, depressive syndrome, dysthymia, and a comorbid depression condition (major depressive disorder and dysthymia).

RESULTS

Transitions between the four depression categories occurred over the 13 years. Symptom profiles for the four categories were parallel but differed in severity. Course characteristics among the four categories slightly differed. Risk factor profiles showed significant differences. Family history was associated with both depressive syndrome and major depressive disorder. Stressful life events were most strongly associated with depressive syndrome. Female gender was most strongly associated with the comorbid depression category.

CONCLUSIONS

The evidence suggests that except for dysthymia, the depression categories are genetically homogeneous and environmentally heterogeneous. Stress is associated with mild depression, and gender is associated with severe depression. The apparent familial transmission of the subthreshold entity, depressive syndrome, needs further investigation.

A comparison of self-report and clinical diagnostic interviews for depression: diagnostic interview schedule and schedules for clinical assessment in neuropsychiatry in the Baltimore epidemiologic catchment area follow-up

BACKGROUND

The field of psychiatric epidemiology continues to employ self-report instruments, but the low degree of agreement between diagnoses achieved using these instruments vs. that achieved by psychiatrists in the clinical modality threatens the credibility of the results.

METHODS

In the Baltimore Epidemiologic Catchment Area follow-up, 349 individuals who had a Diagnostic Interview Schedule (DIS) interview were blindly examined by psychiatrists using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Comparisons were made at the level of diagnosis, syndrome, and DSM-IV symptom group. Indexes of agreement were computed and characteristics of discrepant cases were identified.

RESULTS

Agreement on diagnosis of major depressive disorder was only fair (kappa = 0.20), with the DIS missing many cases judged to meet criteria for diagnosis using the SCAN (29% sensitivity). A major source of discrepancy was respondents with false-negative diagnoses who repeatedly failed to report DIS symptoms attributed to life crises or medical conditions. Older age, male sex, and lower impairment were associated with underdetection by the DIS, using logistic regression analysis. In spite of the diagnostic discrepancy, there was substantial correlation in numbers of symptom groups in the 2 modalities (r = 0.49). Agreement was highest (about 55% sensitivity and 90% specificity) when both the SCAN and DIS thresholds were set at the level of depression syndrome instead of diagnosis.

CONCLUSIONS

Weak agreement at the level of diagnosis continues to threaten the credibility of estimates of prevalence of specific disorders. A bias toward underreporting, as well as stronger agreement at the level of the depression syndrome and on ordinal measures of depressive symptoms, suggests that associations with risk factors are conservative.

The psychiatric profile of patients with chronic diseases who do not receive regular medical care

OBJECTIVE

To assess the relationship between psychiatric disorders and lack of regular medical care in individuals with chronic medical diseases.

METHODS

Nine hundred sixty-three respondents to the household-based Baltimore Epidemiologic Catchment Area (ECA) Follow-Up Study were interviewed in 1981, 1982, and 1993-1996. The main outcome measures were: 1) not receiving regular care from a health professional for an active chronic medical condition in 1981, 2) persistent lack of regular medical care, and 3) leaving regular medical care.

RESULTS

In cross-sectional analyses, having a psychiatric disorder (OR 1.70, 95% CI 1.17-2.48) was associated with not receiving regular medical care. This was mostly due to individuals with phobic disorder (OR 1.57, 95% CI 1.02-2.43). In prospective analyses, depression (RR 2.4, p < 0.04) and alcohol abuse (RR 2.9, p < 0.001) predicted leaving regular medical care one year later. Phobic disorder (RR 2.8, p < 0.001) predicted leaving care thirteen years later.

CONCLUSIONS

Psychiatric disorders appear to place an individual at risk for irregular medical care. Studies of the quality and continuity of care for patients with chronic medical conditions should include measures of common psychiatric conditions.

Mental health service utilization by African Americans and Whites: the Baltimore Epidemiologic Catchment Area Follow-Up

OBJECTIVE

To compare mental health service utilization and its associated factors between African Americans and whites in the 1980s and 1990s.

DESIGN

Household-based longitudinal study with baseline interviews in 1981 and follow-up interviews from 1993 to 1996.

SETTING

The Baltimore Epidemiologic Catchment Area (ECA) Follow-Up.

SUBJECTS

Subjects included 1,662 adults (590 African Americans and 1,072 whites).

MAIN OUTCOME VARIABLE

Use of mental health services, defined as talking to any health professional about emotional or nervous problems or alcohol or drug-related problems within the 6 months preceding each interview.

RESULTS

In 1981, crude rates of mental health service use in general medical (GM) settings and specialty mental health settings were similar for African Americans and whites (11.7%). However, after adjustment for predisposing, need, and enabling factors, individuals receiving mental health services were less likely to be African American. Mental health service use increased by 6.5% over follow-up, and African Americans were no longer less likely to report receiving any mental health services in the 1990s. African Americans were more likely than whites to report discussing mental health problems in GM settings without having seen a mental health specialist. They were less likely than whites to report use of specialty mental health services, but this finding was not statistically significant, possibly because of low rates of specialty mental health use by both race groups. Psychiatric distress was the strongest predictor of mental health service use. Attitudes positively associated with use of mental health services were more prevalent among African Americans than whites.

CONCLUSIONS

Mental health service use increased in the past decade, with the greatest increase among African Americans in GM settings. Although it is possible that the racial disparity in use of specialty mental health services remains, the GM setting may offer a safety net for some mental health concerns of African Americans.

The long-term outcomes of mental health treatment in a population-based study

This study examined the long-term outcomes of mental health treatment, specifically individual therapy, group therapy, and pharmacotherapy, in a population-based study. Using a prospective cohort design, the effectiveness of mental health treatment was analyzed on the basis of data from an epidemiological catchment area follow-up study, which assessed health care use and mental health status at 2 times, 15 years apart, in a random sample of Baltimore residents. A cohort of 771 men and women with at least 1 diagnosable Diagnostic and Statistical Manual of Mental Disorders disorder was selected from the 1,920 individuals randomly sampled in 1980 who were followed in 1994-1996. The results are consistent with clinical trials on the efficacy of pharmacotherapy and psychotherapy. After controlling for baseline psychopathology, sociodemographic characteristics, and service providers, participants who received group and individual therapy had lower distress at follow-up than those who either received medication or did not seek or receive any treatment. No concomitant reductions in the number of disorders were found, except for a dose-response association between the number of therapy sessions and the number of disorders at follow-up, as well as distress at follow-up.

Incidence of DIS/DSM-IV social phobia in adults

OBJECTIVE

The aim of the study was to estimate the incidence of social phobia in the general population.

METHOD

The Baltimore cohort of 3481 subjects, sampled during the 1981 Epidemiologic Catchment Area study, was traced. A total of 1920 subjects were re-interviewed from 1993 to 1996 using the Diagnostic Interview Schedule (DIS). A subsample of 349 subjects was interviewed by psychiatrists using the Schedules for Clinical Assessment in Neuropsychiatry.

RESULTS

The estimated incidence of DIS/DSM-IV social phobia is 4-5/1000/year. New cases were found in all age groups, with the highest rates in subjects with baseline depressive and panic disorders. Psychiatric evaluations showed broad diagnostic concordance with DIS diagnoses in incident cases. However, validity indices were highly dependent on diagnostic thresholds. None of the psychiatrist-ascertained social phobics had received treatment for the disorder, although the majority were considered likely to benefit from treatment.

CONCLUSION

New cases of social phobia occur in adults of all age groups, and are often secondary to other psychiatric conditions.

The long-term outcomes of mental health treatment in a population-based study

This study examined the long-term outcomes of mental health treatment, specifically individual therapy, group therapy, and pharmacotherapy, in a population-based study. Using a prospective cohort design, the effectiveness of mental health treatment was analyzed on the basis of data from an epidemiological catchment area follow-up study, which assessed health care use and mental health status at 2 times, 15 years apart, in a random sample of Baltimore residents. A cohort of 771 men and women with at least 1 diagnosable Diagnostic and Statistical Manual of Mental Disorders disorder was selected from the 1,920 individuals randomly sampled in 1980 who were followed in 1994-1996. The results are consistent with clinical trials on the efficacy of pharmacotherapy and psychotherapy. After controlling for baseline psychopathology, sociodemographic characteristics, and service providers, participants who received group and individual therapy had lower distress at follow-up than those who either received medication or did not seek or receive any treatment. No concomitant reductions in the number of disorders were found, except for a dose-response association between the number of therapy sessions and the number of disorders at follow-up, as well as distress at follow-up.

Psychopathology and attrition in the Baltimore ECA 15-year follow-up 1981-1996

Predictors of non-response were investigated in a 15-year follow-up (1981-1996) of 3,481 individuals in a probability sample from the household population of East Baltimore. Demographics (age, sex, race, education, marital status, and unemployment), household factors (living arrangements, household income, household size, and number of children), cultural variables (ancestral ethnicity and foreign language), social variables (social support and networks, committing felony, carrying a weapon, using an alias, and wandering), health factors (physical illness, health insurance, medical assistance, Medicare, receiving disability benefits, social security, and welfare), interviewer's observation, and psychopathologic variables (mental disorders, suicide behavior, comorbidity, and drug use) were collected at baseline in 1981 and in 1982, then linked to follow-up data between 1993 and 1996. A tracing process involving mail, phone, criss-cross directories, motor vehicle administration records, a commercial credit bureau, the state criminal justice system, hospital records, the US National Death Index, and field tracing were used to locate the original sample. A total of 3,066 respondents of the original sample (88.1%) were traced. Non-response was categorized into Sample Mortality (that part of the original sample that died during follow-up), Sample Loss (that part of the original sample that survived but could not be found) and Refusal (that part of the original sample that survived and was found but refused to participate). Stratified analysis and adjusted multiple logistic regression modeling found sample mortality and sample loss were strongly influenced by individual and household variables and by psychopathology. Sample mortality was influenced by specific mental disorders or conditions as mania, drug abuse/dependency, antisocial personality, cognitive impairment, alcohol abuse/dependency, phobia, drug use (except PCP), and comorbidity. Household factors protective against mortality include higher household income, not living as extended members in a married couple family, and living with children in the household. Persons who were unemployed, widowed or single, without high school education, male, and 65 years of age or older were more likely to die. Sample loss was influenced by cognitive impairment, antisocial personality, and cocaine use. Household factors linked to sample loss include living in female-headed families, or non-family households, and living alone. Young nonwhite, divorced/separated, without high school education, and unemployed were also harder to find. Refusal was associated with being white, with incomplete elementary education, living as a spouse in traditional married couple families, or as a child in female-headed families. Psychopathology did not influence refusal.

Social class, assets, organizational control and the prevalence of common groups of psychiatric disorders

This study provides an update on the association between social class and common types of psychiatric disorder in the US. In addition to usual measures of social class, we provide hypotheses for the expectation that assets and organizational control are associated with specific varieties of psychiatric disorders (mood, anxiety, alcohol and drug use disorders). We analyzed two surveys. The National Comorbidity Survey conducted in 1990-1992 yielded 12-month prevalence rates in a probability sample of 8098 respondents in the 48 contiguous states. The Epidemiologic Catchment Area Follow-up conducted in 1993-1996 provided similar rates among 1920 East Baltimore residents. Analyses of the National Comorbidity Survey showed an inverse association between financial and physical assets and mood, anxiety, alcohol, and drug disorders. The Epidemiologic Catchment Area Followup provided additional evidence for the inverse association between financial and physical assets and anxiety, alcohol and drug disorders. Also in the Epidemiologic Catchment Area, lower level supervisors presented higher rates of depression and anxiety disorders than higher level managers. Inequalities in assets and organizational control, as well as typical measures of social class, are associated with specific psychiatric disorders. These constructs can provide additional explanations for why social inequalities in psychiatric disorders occur.

Onset and recovery from panic disorder in the Baltimore Epidemiologic Catchment Area follow-up

BACKGROUND

The objective is to estimate parameters of the natural history of panic disorder, including its prodrome, incidence, recovery and recurrence.

METHOD

In 1981 the Baltimore Epidemiologic Catchment Area Study interviewed 3481 individuals probabilistically selected from the household population. During 1993-1996, 1920 of these individuals (73% of survivors) were interviewed again. Baseline and follow-up interviews included the National Institute of Mental Health Diagnostic Interview Schedule. During the follow-up, a subsample was assessed by psychiatrists using the World Health Organization Schedules for Clinical Assessment in Neuropsychiatry (SCAN).

RESULTS

There were 35 new cases of panic disorder in 24,475 person years of exposure, yielding an annual incidence of 1.43 per 1000 per year. Data from the SCAN assessments suggest the incidence estimate is conservative. Incidence is greater in females and declines with age. About one-third of the new cases arise without agoraphobia, but about half have anxiety of some sort present for many years prior to meeting criteria for diagnosis. People with agoraphobia have less intense onsets but slower recoveries than those without agoraphobia.

CONCLUSIONS

Panic is heterogeneous in its pattern of onset and recovery. Some of the heterogeneity is associated with the presence of other anxiety over a long period of the life.

Absence of social networks, social support and health services utilization

BACKGROUND

This study examines the effects of distress and three types of social relationships (family, friends, and confidantes) on the use of out-patient health services in an adult sample from a community survey of 3481 persons in Baltimore, Maryland.

METHODS

Independent effects of predisposing (age, education, marital status, race and sex), enabling (employment, income and insurance) and need (physical health) factors are adjusted for in estimating the odds of using health care services.

RESULTS

Illness, being female, and having insurance were positively related to use of services, while being aged was inversely related. After adjustment for the above factors, social support interacted with psychological distress to effect the use of medical care: the combination of high distress and low social support by a confidante results in a fourfold increase of medical utilization.

CONCLUSIONS

Our findings support the inclusion of psychological distress and social network variables in addition to physical health status in models attempting to explain the use of health services. Despite an inability to analyse change over time, our data suggest an understanding of the interrelationship between psychosocial factors, distress and health care use would benefit health providers and their patients.

Specific fears and phobias. Epidemiology and classification

BACKGROUND

Data on eight specific fears representing DSM-III-R simple phobia were analysed to evaluate: (a) their prevalence and (b) the validity of subtypes of specific phobia defined by DSM-IV.

METHOD

A modified version of the Composite International Diagnostic Interview was administered to a probability sample of 8098 community respondents. Correlates of responses to questions concerning these fears were analysed.

RESULTS

The most prevalent specific fears were of animals among women, and of heights among men. Slight evidence was found for specific phobia subtypes. Number of fears, independent of type, powerfully predicted impairment, comorbidity, illness course, demographic features, and family psychopathology.

CONCLUSION

Number of specific fears may mark a general predisposition to psychopathology. More detailed information is needed to resolve the question of specific phobia subtypes.

The epidemiology of blood-injection-injury phobia

BACKGROUND

We report the prevalence, clinical characteristics, frequency of mental health treatment, demographic correlates, frequency of co-morbid psychiatric conditions, and general health ramifications of DSM-IV blood-injection-injury phobia in the general population.

METHOD

The Diagnostic Interview Schedule (version III-R), which included questions on blood-injection-injury phobia, was administered to 1920 subjects in the Baltimore ECA Follow-up Study.

RESULTS

The estimated unweighted lifetime prevalence of blood-injection-injury phobia was 3.5%. The median age of onset was 5.5 years; 78% had had symptoms within the last 6 months. Subjects with blood-injection-injury phobia (cases) had higher lifetime histories of fainting and seizures than those without (non-cases). None reported seeking mental health treatment specifically for phobia. Prevalences were lower in the elderly and higher in females and persons with less education. Cases had significantly higher than expected lifetime prevalences of other psychiatric conditions, including marijuana abuse/dependence, major depression, obsessive-compulsive disorder, panic disorder, agoraphobia, social phobia and other simple phobia. Cases and non-cases did not differ with regard to usual health-care settings, regular care for specific medical conditions, numbers of out-patient visits or hospitalizations, or previous general anaesthesia or live births. However, diabetics with blood-injection-injury phobia had higher than expected rates of macrovascular complications.

CONCLUSION

Blood-injection-injury phobia is common, especially in females and those with less education, and it is associated with several co-morbid psychiatric conditions. No strong, broad general health ramifications of this phobia are apparent. However, diabetics with this phobia appear at particular risk for complications; this deserves further study.

Psychopathology as a predictor of disability: a population-based follow-up study in Baltimore, Maryland

To determine whether psychopathology is associated with disability as a result of underlying physical illness or whether such psychopathology antedates disability and is an independent determinant of disability, the authors conducted a nested case-control study within the Epidemiologic Catchment Area Follow-up Study in Baltimore, Maryland. From a 1981 random sample of 3,481 persons from Baltimore interviewed for psychopathology, disability, and other comorbidity, 1,920 who were alive in 1993 were traced and were reinterviewed with a similar instrument. Within the study population, 168 new cases of disability were identified as occurring between 1981 and 1993, as measured by the inability to perform activities of daily living. These cases were compared with 1,715 controls who reported no disability. The sociodemographic factors that were significantly related to incident disability in this analysis were age, female gender, and less than a high school education. These comparisons revealed associations of incident disability in activities of daily living with almost all antecedent chronic physical illnesses. Significant age- and gender-adjusted associations were observed between incident disability in activities of daily living and antecedent (in 1981) alcohol abuse and dependence (odds ratio (OR)=2.5, 95% confidence interval (CI) 1.5-4.2), major depressive disorder (OR=4.2, 95% CI 2.2-8.3), and phobia (OR=1.9, 95% CI 1.3-2.8). The adjusted odds ratio for the joint effect of antecedent depression and chronic physical illness on incident disability in activities of daily living was 17.0 (95% CI 6.9-41.7). There was a significant independent effect of antecedent major depression on activities of daily living disability. The effect of psychopathology on incident disability is nonspecific as to type of baseline chronic physical illness. Such a finding has important implications for defining strategies to prevent disability.

Incidence of obsessive-compulsive disorder in adults

This study addressed the incidence of obsessive-compulsive disorder (OCD) in adults in the general population. The Baltimore cohort of 3481 subjects, originally sampled during the 1981 multisite Epidemiologic Catchment Area Study, was traced. From 1993 to 1996, 1920 people were reinterviewed using the Diagnostic Interview Schedule. The incidence of DSM-III-R obsessive-compulsive disorder in adults was estimated at .55 per 1000 person-years. There was a relatively high rate of new cases in elderly women. It appeared that there were two peaks of onset of OCD over the life span, both of which occur later in female subjects. Subjects with adult incidence OCD often presented for psychiatric treatment, though they did not specify obsessive-compulsive symptoms as the reason. The difference in diagnostic criteria between DSM-III and DSM-III-R substantially influenced the threshold for new case identification.

Remission and relapse in schizophrenia: the Madras Longitudinal Study

This paper uses monthly symptom data on 90 first-onset schizophrenics in Madras, India, to characterize, in a continuous manner, the course of remission and relapse. Remission from the first episode occurs in about 6 months and in about 3 months for later episodes. Syndromes from the Present State Exam, assessed at the first episode, predict differentially to early and later parts of the course. Hypomania and simple depression predict early remission from the first episode; flat affect and grandiose delusions predict longer episodes and shorter remissions later in the course.

Characterizing generalized anxiety: temporal and symptomatic thresholds

We compared demographic and comorbidity profiles of subjects with varying levels of anxiety pathology to test if the clinical characteristics of generalized anxiety disorder (GAD) subjects differed from those of other subjects with generalized anxiety. Using Diagnostic Interview Schedule data from the 1993 follow-up study of the Baltimore cohort of the Epidemiologic Catchment Area Program, we divided subjects into the following five mutually exclusive symptom categories: a) DSM-III-R GAD; b) 6 months of worry or anxiety with six associated symptoms; c) 1 month of anxiety with or d) without six symptoms; and e) no anxiety. The first three groups were homogeneous with regard to demographic and comorbidity profiles, but their profiles differed from those of subjects with no anxiety or fewer than six symptoms. Thus, requiring six symptoms produced a group with a particular epidemiologic profile. Neither the nature of the subjects' worries nor the duration of symptoms influenced this profile. These results are discussed in terms of GAD's construct validity.

Natural history of Diagnostic Interview Schedule/DSM-IV major depression. The Baltimore Epidemiologic Catchment Area follow-up

BACKGROUND

Natural history can be characterized by incidence, recurrence, and duration of episodes. Research on the incidence of major depression is rare; studies of recurrence and duration are limited to clinical samples.

METHODS

The Baltimore, Md, site of the Epidemiologic Catchment Area Program followed up its 1981 baseline cohort of 3481 respondents with an additional assessment in 1993 to 1996. Interviews were obtained from 1920 respondents (73% of the survivors). The Diagnostic Interview Schedule and the same survey procedures as in 1981 were used, augmented with a Life Chart Interview for dating the onset and duration of syndromes.

RESULTS

There were 71 new cases of Diagnostic interview Schedule/DSM-IV major depression and 23,698 person-years of exposure, generating an estimated incidence of 3.0 per 1000 per year. Incidence peaked while subjects were in their 30s, with a smaller peak when they were in their 50s. Prodromal symptoms often occurred many years before the full criteria for diagnosis were met. Women were at higher risk for becoming new cases but had neither higher risk for recurrence nor longer episodes than men. Episodes of depression lasted for 12 weeks. The duration of an episode, and time to an episode-free year, was longer in the first episode than in recurrent episodes.

CONCLUSIONS

The incidence estimated in this study is consistent with that found in the few other similar studies performed. The bimodality of onset suggests the value of further exploring the heterogeneity of depression via its natural history. Reported differences in prevalence between men and women seem to be due to differences in incidence, not chronicity.

Psychopathology and the development of disability

The objective was to determine the effect of preexisting psychopathology on days missed from work or usual activities ("disability days") in a large community sample (N = 3481). Logistic regression analyses were performed with the presence or absence of disability days (wave 2) as the dependent variable. The effects of sociodemographic variables, six psychiatric disorders, a high distress score, and chronic physical conditions (wave 1) were studied. Separate analyses were conducted for the total sample and four subgroups (labor force participants, homemakers, men, and women). The adjusted odds ratios and 95% confidence intervals (95% CI) for subjects with onset of panic disorder were 7.3 (95% CI = 1.8, 28.7); for those with chronic major depressive disorder, 7.2 (95% CI = 0.3, 160.6); and for those with chronic high distress, 5.0 (95% CI = 2.6, 9.9). The relative odds for developing a disability were greater for those with either type of psychiatric disorder or high distress than for those with any prior physical illness or those with a prior disability day. Disability days experienced by persons with psychopathology result in diminished quality of life, economic losses, and increased need for health services. Improved health services and educational and work adjustments for emotionally disabled persons are recommended.

Structural factor analyses for medically unexplained somatic symptoms of somatization disorder in the Epidemiologic Catchment Area study

BACKGROUND

Assess the latent structure of the DSM-III somatization symptoms and the stability of symptom patterns over time.

METHODS

Cross-sectional and longitudinal covariation of symptoms of somatization disorder were investigated using structural equation models in a population-based data set from the Epidemiologic Catchment Area study.

RESULTS

Medically unexplained physical complaints were discovered to cluster into three separate factors, consistent with the DSM-IV definition of somatization disorder, but one dominant general factor was defined, consistent with the DSM-III conceptualization. Individual symptom prevalences and factor structures were different for men and women. The factor structures remained stable at 1 year follow-up. Variations in the threshold of number of somatization symptoms required for diagnosis affected prevalence, sex ratio and temporal stability of the diagnosis.

CONCLUSIONS

These population-based results support dimensional models of somatization. Implications for changing the threshold of the categorical diagnosis of somatization disorder and providing better care for these patients are given.

Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up

BACKGROUND

There is suggestive evidence that depression increases risk of myocardial infarction (MI), but there are no prospective studies in which the measure of depression corresponds to clinical criteria. This study examines prospectively whether a major depressive episode increases the risk of incident MI and evaluates the role of psychotropic medication use in this relationship.

METHODS AND RESULTS

The study is based on a follow-up of the Baltimore cohort of the Epidemiologic Catchment Area Study, a survey of psychiatric disorders in the general population. A history of major depressive episode, dysphoria (2 weeks of sadness), and psychotropic medication use were assessed in 1981, and self-reported MI was assessed in 1994. Sixty-four MIs were reported among 1551 respondents free of heart trouble in 1981. Compared with respondents with no history of dysphoria, the odds ratio for MI associated with a history of dysphoria was 2.07 (95% CI, 1.16 to 3.71), and the odds ratio associated with a history of major depressive episode was 4.54 (95% CI, 1.65 to 12.44), independent of coronary risk factors. In multivariate models, use of barbiturates, meprobamates, phenothiazines, and lithium was associated with an increased risk of MI, whereas use of tricyclic antidepressants and benzodiazepines was not. Among individuals with no history of dysphoria, only lithium use was significantly associated with MI.

CONCLUSIONS

These data suggest that a history of dysphoria and a major depressive episode increase the risk of MI. The association between psychotropic medication use and MI is probably a reflection of the primary relationship between depression and MI.