Parents’ education and the risk of major depression in early adulthood

Background

Early-life low socioeconomic position (SEP) increases the risk of adult major depression; however, associations vary according to the measure of SEP and adults’ life stage. Although maternal education often predicts offspring health better than other SEP indicators, including paternal education, it is unclear how maternal and paternal education differentially influence early-adult depression, and how early-life and adult risk factors may mediate the association.

Methods

Longitudinal data come from the Canadian National Population Health Survey from 1994/1995 to 2006/2007, restricted to a sample (N = 1,267) that was aged 12–24 years in 1994/1995. Past-year major depressive episode (MDE) was assessed in 2004/2005 and 2006/2007 using the Composite International Diagnostic Interview Short Form for Major Depression. Logistic regression models were used to estimate odds ratios (OR) and 95 % confidence intervals (CI) for the association between both maternal and paternal education and MDE, adjusting for respondent’s demographics, early-life adversities, adult SEP, psychosocial factors, and physical health.

Results

Offsprings of mothers with less than secondary school education had higher odds of MDE (adjusted OR 2.04, 95 % CI 1.25–3.32) relative to those whose mothers had more education. Paternal education was not associated with MDE. Although adult income, student status, psychosocial stress, and several early-life adversities remained associated with MDE in the fully adjusted model, the estimate for maternal education was not reduced.

Conclusions

Maternal education was associated with MDE in early adulthood, independent of paternal education and other early-life and early-adult risk factors.     

Parental bonding and suicidality in pregnant teenagers: a population-based study in southern Brazil

Purpose

To assess the associations of the perceived quality of parental bonding with suicidality in a sample of pregnant adolescents.

Methods

A cross-sectional study with a sample size of 828 pregnant teenagers receiving prenatal medical assistance in the national public health system in the urban area of Pelotas, southern Brazil. Suicidality and psychiatric disorders were assessed using the Mini International Neuropsychiatric Interview (MINI), and the Parental Bonding Instrument (PBI) was employed to measure the perceived quality of parental bonding. A self-report questionnaire was used to collect sociodemographic, obstetric and other psychosocial data.

Results

Forty-three (4.94 %) teenagers from a consecutive sample of 871 refused to participate, resulting in 828 participants. Prevalence of suicidality was 13.3 %, lifetime suicide attempts were 7.4 % with 1.3 % reporting attempting suicide within the last month. Significant associations of suicidality with the 18–19-year-old subgroup, low education, prior abortion, physical abuse within the last 12 months were present, and most psychiatric disorders were associated with a higher suicidality prevalence. Additionally, after adjustment in the multivariate analysis, the style of parental bonding was independently associated with suicidality in the pregnant adolescent, with a PR of 2.53 (95 % CI 1.14–5.59) for the maternal ‘affectionless control’ and a PR of 2.91 (95 % CI 1.10–7.70) for the paternal ‘neglectful parenting.’

Conclusions

We found that maternal ‘affectionless control’ and paternal ‘neglectful parenting’ were independent predictors of suicidality in this sample of pregnant teenagers.     

Parenting style and mental disorders in a nationally representative sample of US adolescents

Purpose

We examined associations between parenting style and past-year mental disorders in a nationally representative cross-sectional survey of US adolescents and whether the associations differed by adolescent demographic characteristics.

Methods

The sample included 6483 adolescents aged 13–18 years who were interviewed for a full range of DSM-IV mental disorders. Parenting style was assessed by adolescent-reported maternal and paternal care and control using items from the Parental Bonding Instrument. We controlled for socio-demographics, parental history of mental disorders, stressful life events, sexual violence, inter-parental conflict, and household composition. We also tested for two-way interactions between parental care and control and adolescent age, sex, and race/ethnicity.

Results

In adjusted models, high maternal care was associated with lower odds of depressive, eating, and behavioral disorders, and high maternal control was associated with greater odds of depressive, anxiety, eating, and behavioral disorders. High paternal care was associated with lower odds of social phobia and alcohol abuse/dependence. High paternal control was associated with greater odds of agoraphobia and alcohol abuse/dependence but with lower odds of attention-deficit/hyperactivity disorder. Associations of maternal and paternal control with anxiety disorders and substance abuse/dependence differed by sex. High paternal care was associated with lower odds of anxiety disorders only among Hispanics and non-Hispanic blacks.

Conclusions

Perceived parental care and control were associated with adolescent mental disorders after controlling for multiple potential confounders. Differential patterns of association were found according to adolescent sex and race/ethnicity. Findings have implications for prevention and intervention programs that incorporate familial contextual factors.

     

The impact of parental offending on offspring aggression in early childhood: a population-based record linkage study

Purpose

To examine the impact of parental criminal offending, both paternal and maternal, on offspring aggression at age 5 years, while also considering key risk factors, including parental mental illness, child’s sex, and socioeconomic disadvantage.

Methods

The sample comprised 69,116 children, with linked parental information, from the New South Wales Child Development Study, a population-based multi-agency, multi-generational record linkage study that combines information from a teacher-reported cross-sectional survey of early childhood development at age 5 years (the 2009 Australian Early Development Census; AEDC) with data obtained via administrative records from multiple sources (e.g., health, crime, education, and welfare). Hierarchical logistic regression analyses were conducted to determine the effects of maternal and paternal criminal court appearances (frequency and type of offending), and mental health service contacts, on offspring aggression measured in the AEDC.

Results

Having a parent with a history of offending was significantly associated with high levels of offspring aggression in early childhood. The strength of association was greatest when parents were involved in frequent (≥6 offences: adjusted odds ratio [aOR] range?=?1.55–1.73) and violent (aOR range?=?1.49–1.63) offending. Both maternal and paternal offending remained significant predictors of offspring aggression after accounting for parental mental illness, and associations were similar in magnitude for maternal and paternal offending histories.

Conclusions

Parental history of severe criminal offending increased the risk of high levels of aggression in offspring during early childhood, highlighting the need for intervention with families during this key developmental period.

     

Ante- and perinatal circumstances and risk of attempted suicides and suicides in offspring: the Northern Finland birth cohort 1966 study

Purpose

To investigate those ante- and perinatal circumstances preceding suicide attempts and suicides, which have so far not been studied intensively.

Methods

Examination of the Northern Finland Birth Cohort 1966 (n?=?10,742), originally based on antenatal questionnaire data and now followed up from mid-pregnancy to age 39, to ascertain psychiatric disorders in the parents and offspring and suicides or attempted suicides in the offspring using nationwide registers.

Results

A total of 121 suicide attempts (57 males) and 69 suicides (56 males) had occurred. Previously unstudied antenatal factors (maternal depressed mood and smoking, unwanted pregnancy) were not related to these after adjustment. Psychiatric disorders in the parents and offspring were the risk factors in both genders. When adjusted for these, the statistically significant risk factors among males were a single-parent family for suicide attempts (OR 3.71, 95% CI 1.62–8.50) and grand multiparity for suicides (OR 2.67, 95% CI 1.15–6.18). When a psychiatric disorder in females was included among possible risk factors for suicide attempts, it alone remained significant (OR 15.55, 8.78–27.53).

Conclusions

A single-parent family was a risk factor for attempted suicides and grand multiparity for suicides in male offspring even after adjusting for other ante- and perinatal circumstances and mental disorders in the parents and offspring. Mothers’ antenatal depressed mood and smoking and unwanted pregnancy did not increase the risk of suicide, which is a novel finding.     

The Association Between Prenatal Stress and Externalizing Symptoms in Childhood: Evidence From the Avon Longitudinal Study of Parents and Children

Background

It has been suggested that prenatal maternal stress may increase the risk of childhood externalizing disorders, yet no large cohort study has investigated this association across a large range of acute stressors. Our objective was to estimate the association between prenatal stressful events and risk of offspring conduct disorder and hyperactivity.

The role of parent and offspring sex on risk for externalizing psychopathology in offspring with parental alcohol use disorder: a national Swedish study

Purpose

The substantial literature showing that offspring of parents with alcohol use disorder (AUD) is at increased risk for externalizing psychopathology rarely examines the differential effects of parental and offspring sex. This literature also has other important limitations, such as modest sample sizes and use of unrepresentative samples. Using a large, nationwide Swedish sample, we aim to investigate the roles of parental and offspring sex in externalizing psychopathology among offspring with parental AUD.

Methods

AUD diagnosis and externalizing measures were obtained from national registries. Associations between outcomes and parental AUD were examined using logistic regressions. Parental and offspring sex effects were examined with interaction terms.

Results

Risks for externalizing disorders were increased in sons and daughters with parental AUD, with significant differences between sons and daughters for criminal behavior; maternal AUD had a greater impact than paternal AUD (regardless of offspring sex), but having two parents with AUD increased risk for all outcomes substantially more than having one parent; and maternal AUD increased risk of drug abuse for daughters more than sons, while paternal AUD increased risk of AUD and criminal behavior for sons more than daughters.

Conclusions

Offspring of parents with AUD are at increased risk for externalizing psychopathology. Maternal and paternal AUD differentially affected sons’ vs. daughters’ risks for AUD, drug abuse, and criminal behavior. The transmission of psychopathology within the externalizing spectrum appears to have sex-specific elements.

     

Maternal smoking during pregnancy and neural tube defects in offspring: a meta-analysis

Purpose

This study aims to examine the association between maternal smoking during pregnancy and neural tube defects (NTDs) in offspring.

Methods

We retrieved published studies on the association between maternal smoking during pregnancy and NTDs risk in offspring. Meta-analysis was applied to calculate the overall odds ratios (ORs) and their 95 % confidence intervals (CIs). The publication bias was assessed by the Egger’s regression asymmetry test and Begg’s rank correlation test.

Results

The overall effect of maternal smoking during pregnancy on NTDs was 1.03 (OR?=?1.03, 95 % CI?=?0.80–1.33). When subgroup analysis was conducted by geographic regions, the overall effects were 1.39 (OR?=?1.39, 95 % CI?=?1.18–1.64), 0.88 (OR?=?0.88, 95 % CI?=?0.66–1.17) in Europe and USA; when subgroup analysis was conducted by NTDs types, the overall effect was 1.55 (OR?=?1.55, 95 % CI?=?1.06–2.26) for spina bifida.

Conclusions

Women who smoked during pregnancy had mildly elevated risk of having infants with NTDs.     

The association between depression and parental ethnic affiliation and socioeconomic status: a 27-year longitudinal US community study

Purpose

This study examined the extent to which parental SES and ethnic affiliation during adolescence are associated with Center for Epidemiologic Studies Depression Scale (CES-D) scores compatible with depression during adulthood.

Methods

The data were extracted from the US National Longitudinal Survey of Youth (NLSY79) conducted in 1979 on several ethnic groups (African-Americans, Hispanics and Others). These data included paternal socio-economic status (SES) when respondents (N = 8,331) were on average aged 18. The CES-D was re-administered 27?years later to assess the presence of depression.

Results

Adjusted for age, binary logistic regression modeling showed that parental low SES increased the risk of CES-D of scores compatible with depression across ethnic groups for both genders. A gradient was observed of an increased likelihood of depression scores with lower parental SES levels: among African-American respondents, depression scores were highest at the lowest parental SES levels (OR?=?3.25, 95% CI 2.19–4.84) and the risk dropped at medium (OR?=?3.00, 95% CI 1.96–4.59), and highest SES levels (OR?=?1.85, 95% CI 1.12–3.07). An analogous pattern was generally found for each ethnic group.

Conclusions

Low parental SES during adolescence significantly increases the likelihood of CES-D scores compatible with depression during adulthood across US ethnic groups and in both genders.     

The Effect of Paternal Age on Relapse in First-Episode Schizophrenia

Objective:

Multiple etiological and prognostic factors have been implied in schizophrenia and its outcome. Advanced paternal age has been reported as a risk factor in schizophrenia. Whether this may affect schizophrenia outcome was not previously studied. We hypothesized that advanced paternal age may have a negative effect on the outcome of relapse in schizophrenia.

Method:

We interviewed 191 patients with first-episode schizophrenia and their relatives for parental ages, sociodemographic factors at birth, birth rank, family history of psychotic disorders, and obstetric complications. The outcome measure was the presence of relapse at the end of the first year of treatment.

Results:

In the 1-year follow-up period, 42 (22%) patients experienced 1 or more relapses. The mean paternal age was 34.62 years (SD 7.69). Patients who relapsed had significantly higher paternal age, poorer medication adherence, were female, and were hospitalized at onset, compared with patients who did not relapse. A multivariate regression analysis showed that advanced paternal age (OR 1.05, 95% CI 1.01 to 1.10), medication nonadherence (OR 2.37, 95% CI 1.12 to 4.99), and female sex (OR 2.44, 95% CI 1.14 to 5.24) independently contributed to a higher risk of relapse. Analysis between different paternal age groups found a significantly higher relapse rate with paternal age over 40.

Conclusions:

Advanced paternal age is found to be modestly but significantly related to more relapses, and such an effect is the strongest at a cut-off of paternal age of 40 years or older. The effect is less likely to be mediated through less effective parental supervision or nonadherence to medication. Other possible biological mechanisms need further explorations.     

Self-reported emotional and behavioral symptoms,parent-adolescent bonding and family functioning in clinically referred adolescent offspring of Croatian PTSD war veterans

The presence of posttraumatic stress disorder (PTSD) in male war veterans has been linked with family dysfunction and psychopathology in their children [1, 2]. This study aimed to evaluate self-reported emotional and behavioral symptoms, parent–adolescent bonding and family functioning in clinically referred adolescent offspring of Croatian PTSD war veterans and determine the degree that parent–child bonding and family functioning contributed to adolescent behavior problems. Internalizing and externalizing behavior problems, parent–child bonding and family functioning were assessed in a sample of clinically referred Croatian PTSD veterans adolescent offspring (N = 122) and non-PTSD veteran adolescent offspring (N = 122) matched for age, sex, educational level, family income, parental employment status, ethnicity, and residential area. Youth Self-Report, Parental Bonding Instrument, Family Assessment Device were used. Adolescent offspring of PTSD veterans reported having significantly more internalizing and externalizing problems than non-PTSD veteran offspring, and also more difficulties in their family functioning, lower levels of maternal and paternal care, and more impaired mother–child and father–child bonding than control subjects. Internalizing symptoms were associated with family dysfunction, while externalizing symptoms were associated with paternal overcontrol/overprotection, and low maternal and paternal care. In conclusion, the increase in internalizing and externalizing symptoms as well as family and parental dysfunction among clinically referred adolescent offspring of PTSD veterans compared to their non-PTSD veteran counterparts indicates a need for early detection and interventions targeting both adolescent psychopathology and family relationships.     

Parental socio-economic position during childhood as a determinant of self-harm in adolescence

Purpose

Socio-economic position (SEP) during childhood and parental social mobility have been associated with subsequent health outcomes in adolescence and adulthood. This study investigates whether parental SEP during childhood is associated with subsequent self-harm in adolescence.

Methods

This study uses data from a prospective birth-cohort study (the Avon Longitudinal Study of Parents and Children) which followed 14,610 births in 1991–1992 to age 16–18 years (n = 4,810). The association of parental SEP recorded pre-birth and throughout childhood with self-harm was investigated using logistic regression models, with analyses conducted separately for those reporting self-harm (a) with and (b) without suicidal intent. The impact of missing data was investigated using multiple imputation methods.

Results

Lower parental SEP was associated with increased risk of offspring self-harm with suicidal intent, with less consistent associations evident for self-harm without suicidal intent. Associations were somewhat stronger in relation to measures of SEP in later childhood. Depressive symptoms appeared to partially mediate the associations. Adolescents of parents reporting consistently low income levels during childhood were approximately 1.5 times more likely to engage in SH than those never to report low income.

Conclusions

Lower SEP during childhood is associated with the subsequent risk of self-harm with suicidal intent in adolescence. This association is stronger in those experiencing consistently lower SEP.     

Parental psychopathology and offspring attention-deficit/hyperactivity disorder in a nationwide sample

ObjectiveTo study the associations between a wide range of parental psychiatric disorders and offspring attention-deficit/hyperactivity disorder (ADHD).MethodThis study is based on a nested case–control design. The association between parental registered psychiatric diagnoses and offspring ADHD was examined adjusting for socioeconomic and prenatal factors. Data was linked from Finnish nationwide registers. The cases (n = 10,409) were all the children born between years 1991 and 2005 in Finland and diagnosed with ADHD by the end of 2011. Four controls without ADHD (n = 39,124) were matched for every case by sex, age and place of birth. Main outcomes were adjusted odds ratio (aOR) for parental diagnosis of cases vs controls. Analyses were further stratified by sex. Disorders diagnosed before and after birth were analyzed separately.ResultsThe odds ratio for ADHD increased when only mother (aOR 2.2, 95% CI 2.0–2.3), only father (aOR 1.7, 95% CI 1.6–1.8) and both parents (aOR 3.6, 95% CI 3.3–4.0) were diagnosed. Maternal diagnosis showed stronger association than paternal. The weight of association between several parental disorders and offspring ADHD were similar. Maternal psychopathology overall showed stronger associations with girls than boys with ADHD. The diagnoses registered after birth did not show stronger association than the diagnoses registered before. Conclusions: Maternal psychopathology showing stronger association than paternal implies that environmental factors or their interaction with genetic factors partly mediates the risk of parental psychopathology. Similar associations between several maternal psychiatric disorders and offspring ADHD points towards the need for investigating some common mother-related risk factors.     

School performance and hospital admission due to unipolar depression: a three-generational study of social causation and social selection

Purpose

Both “social causation” and “social selection” offer plausible explanations for an association between education and mental health. We aimed to explore these processes in unipolar depression, with a specific focus on school performance and family tradition of education.

Method

Grandchildren (N?=?28,089, 49% female, aged 13–47?years in 2002) of a cohort born in Uppsala, Sweden, in 1915–1929 were studied in national registers. We obtained data on final grade point average (GPA) in compulsory school, hospitalizations for unipolar depression, grandparental/parental education and other parental social characteristics. Hospitalization in adolescence and adulthood were studied separately, as were hospitalization for depression with or without a lifetime externalizing disorder.

Results

Low compulsory school GPA (1–2 SD or >2 SD below average vs. average GPA) was associated with increased rate of adolescent hospitalization for unipolar depression, both with externalizing comorbidity [hazard ratio (HR) point estimates of 66–80] and without (HR point estimates of 4–6). By contrast, low GPA was only associated with first-time hospitalization in adulthood for the subgroup with externalizing comorbidity (HR point estimates of 4–6). These associations were largely independent of family education and social characteristics. Overall, low parental/grandparental education was not related to increased rates of hospitalization.

Conclusion

The association between school performance and hospitalization for depression depended on adolescent hospitalization or externalizing comorbidity, suggesting that disorders with an early onset are decisive. Contrary to the social patterning of many health outcomes, low grandparental/parental education did not appear to increase the rate of hospitalization for unipolar depression in the offspring.     

Catatonic Schizophrenia: A Cohort Prospective Study

Background:

In the 20th century, catatonia was usually deemed a subtype of schizophrenia. Recently, the nature and classification of catatonia are being reconsidered. This study is the first to describe catatonia using prospectively collected data and to examine how catatonic schizophrenia differs from, or resembles, other types of schizophrenia.

Methods:

Data were analyzed in a cohort of 90 079 offspring followed from birth till ages 29–41 years. Proportional hazards models were used, calculating time to first psychiatric hospital admission, to compare risk factors for catatonic schizophrenia vs “other schizophrenia.”

Results:

Of 568 cases of schizophrenia, 43 (7.6%) had catatonic schizophrenia. The sexes were equally at risk for catatonic schizophrenia in contrast to other schizophrenia, for which the incidence was higher in males (1.70, 1.42–2.03, P < .0001). Advancing paternal age had no influence on the risk of catatonic schizophrenia in contrast to other schizophrenia, in which the risk to offspring of fathers age 35+ was 1.27 (1.03–1.57, P = .03) compared with those of younger fathers. Those with catatonic schizophrenia were somewhat more likely to have older mothers (aged 35+) (relative risk = 2.14, 0.85–5.54) while maternal age was not related to other schizophrenia. Both were equally affected by parental history of schizophrenia. Patients with catatonia were significantly more likely to attempt suicide (P = .006).

Conclusion:

Patients with catatonic schizophrenia show a somewhat different profile of risk factors from those with other types of schizophrenia in this cohort and are more likely to attempt suicide. This lends some support to the hypothesis that catatonic schizophrenia may have a distinct etiology.     

Socioeconomic status and beliefs about depression, schizophrenia and eating disorders

Purpose

The association between socioeconomic status (SES) and knowledge/belief about depression, schizophrenia and eating disorders will be analysed.

Methods

Data stem from a telephone survey in two large German cities (Hamburg and Munich, n = 2,014, response rate 51 %). Written vignettes with typical signs and symptoms suggestive of a depression, schizophrenia and eating disorders were presented to the respondents. Respondents were then asked about knowledge/belief about causes, symptoms, prevalence and treatment using a standardised questionnaire. Education, occupational position and income were used as SES indicators.

Results

Results of mixed hierarchal logistic regression analyses show that individuals with a low SES know less about symptoms and prevalences of depression, schizophrenia and eating disorders. Moreover, people with a high SES are more likely to consider medication as effective in case of depression and schizophrenia, but are less likely to believe that activities such as sports or relaxation are an effective measure to treat the three mental disorders under study. Respondents with a high SES are less likely to believe that a weak will is a possible cause of depression, schizophrenia and eating disorders. We found large similarities in the associations between SES and beliefs across the three mental disorders. Finally, associations of beliefs about mental disorders with education are stronger and more consistent than with income and occupational position.

Conclusions

Results indicate an inequality in mental health literacy and underline that information campaigns on causes, symptoms, prevalence and treatment of mental disorders should consider information needs of people with a low SES.     

Country of birth and hospital treatment for psychosis in New South Wales

Background

Migration has been found to be a risk factor for schizophrenia in several high-income countries.

Aim

To examine whether overseas migrants to New South Wales (NSW) have higher rates of admission to psychiatric hospitals for psychotic disorders, including schizophrenia and mania, compared to people born in Australia.

Methods

The country of birth of people admitted to public mental health units for the treatment of psychotic illness and for non-psychotic disorders between 2001 and 2010 was compared to the country of birth for the NSW population in the 2006 census. Meta-analysis was used to estimate the odds of being admitted for any psychotic disorder, for a schizophrenia-related psychosis and for mania compared to non-psychotic disorder, for those born in Australia, New Zealand and for nine global regions.

Results

Those born in Oceania (including Melanesia, Fiji, Samoa, Tonga and other Polynesian islands, but excluding Hawaii and New Zealand) had the highest odds of admission for the treatment of psychosis compared to a non-psychotic disorder and had the highest odds of being admitted with a diagnosis of schizophrenia or mania.

Conclusions

In the years 2001–2010, those born in Oceania were at an increased risk of admission to NSW psychiatric hospitals for the treatment of psychotic illness.     

Parental Infections Before,During, and After Pregnancy as Risk Factors for Mental Disorders in Childhood and Adolescence: A Nationwide Danish Study

Background

Previous studies have shown associations between maternal infections during pregnancy and increased risks of schizophrenia and autism spectrum disorder in the offspring. However, large-scale studies investigating an association between parental infections both during and outside the pregnancy period and the risk of any mental disorder in the child are lacking.

Physical diseases among persons with obsessive compulsive symptoms and disorder: a general population study

Purpose

This study aimed at evaluating the comorbidity between DSM-IV obsessive compulsive disorder (OCD) and subthreshold forms and physical diseases in the general population as well as disability associated with comorbidity.

Methods

We used data from the 1998 German Mental Health Survey, a representative survey of the German population. Mental disorders and physical diseases of 4181 subjects (aged 18–65) were cross-sectionally assessed. Mental disorders were diagnosed using the M-CIDI/DIA-X interview. Physical diseases were assessed through a self-report questionnaire and a standardized medical interview. We created three groups of obsessive–compulsive symptoms: (1) no obsessive compulsive symptoms (n = 3,571); (2) obsessive compulsive symptoms (OCS, n = 371; endorsement of OCS (either obsession or compulsion) without fulfilling any core DSM-IV criteria); (3) subthreshold OCD/OCD (n = 239; fulfilling either some or all of the core DSM-IV criteria).

Results

In comparison to subjects without OCS, subjects with subthreshold OCD/OCD showed higher prevalence rates of migraine headaches (OR 1.7; 95 % CI 1.1–2.5) and respiratory diseases (OR 1.7; 95 % CI 1.03–2.7); subjects with OCS showed higher prevalence rates of allergies (OR 1.6; 95 % CI 1.1–2.8), migraine headaches (OR 1.9; 95 % CI 1.4–2.7) and thyroid disorders (OR 1.4; 95 % CI 1.01–2.0). Subjects with both OCS and physical disease reported the highest number of days of disability due to physical or psychological problems during the past 30 days compared to subjects with only OCS, only physical disease or neither of them.

Conclusions

OCD and subthreshold forms are associated with higher comorbidity rates with specific physical diseases and higher disability than subjects without OCS. Possible etiological pathways should be evaluated in future studies and clinicians in primary care should be aware of these associations.