Prevalence of atypical antipsychotic use in psychiatric outpatients: comparison of women of childbearing age with men

To characterize current treatment practices, we compared the use of atypical antipsychotic drugs among women of childbearing age to men based on electronic medical records of 1073 hospital-based psychiatric outpatients given at least one second-generation antipsychotic drug. One quarter of psychiatric outpatients sampled were prescribed at least one atypical antipsychotic, in more than half of cases for off-label indications. Women were significantly more likely than men to be diagnosed with mood or anxiety disorders than psychotic disorders and to be prescribed quetiapine (60.7 vs. 48.0 %) or aripiprazole (31.2 vs. 23.9 %), but less likely risperidone (15.8 vs. 26.1 %) or ziprasidone (10 vs. 14 %).     

Gender and psychiatric diagnosis: a profile of admissions to mental hospitals in the Western Cape Province, South Africa

Summary Objectives: This retrospective, epidemiological study aimed to identify gender patterns of admission to public mental hospitals, with regard to psychiatric diagnosis and management. Methods: The hospital records of a random, stratified sample of all 7938 patients admitted to the three psychiatric hospitals in the Western Cape Province for a calendar year were studied for gender differences regarding demographic features, admission-related variables, DSM-IV diagnosis, as well as management during hospitalisation and on discharge. Results: Findings were that more women than men were admitted overall. For women the main DSM-IV diagnoses were mood (41%) followed by psychotic disorders (29%); while for men the main diagnoses were psychotic disorders (47%) and substance abuse (23%). Significantly more women than men were labelled with mood, anxiety and adjustment disorders, and with avoidant, dependent, histrionic and borderline personality disorders. Significantly more men were diagnosed as substance abusers, schizophrenic and with cognitive disorders, and also anti-social personality disorder. More women were medicated, both during hospitalisation and on discharge; and more women also received ECT, while more men absconded from hospital. Conclusions: While some results confirm international research, there are areas of variance, as in schizophrenic and bipolar disorders. The findings have psychiatric service implications and indicate the need for further research into the gendered development of psychopathology.     

Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety?

BACKGROUND: Although anxiety disorders are documented in the literature for new mothers (but less so for fathers), rates of postpartum caseness tend to include only those with depression when diagnostic interviews or self-report measures validated on such interviews are used. This methodology therefore underestimates the true percentage of women and men who experience significant psychological difficulties postpartum. This has implications for assessment, treatment and screening for postnatal mood disorders. METHOD: Two studies were conducted on a total of 408 women and 356 men expecting their first child. They were recruited antenatally, and interviewed at 6 weeks postpartum using the Diagnostic Interview Schedule. DSM-IV criteria were applied to determine the presence since birth of depression (major or minor), panic disorder, acute adjustment disorder with anxiety (meeting the criteria for generalised anxiety disorder except for the duration criterion), and phobia. RESULTS: The inclusion of diagnostic assessment for panic disorder and acute adjustment disorder with anxiety increased the rates of caseness by between 57 and 100% for mothers, and 31-130% for fathers, over the rates for major or minor depression. Inclusion of assessment for phobia further increased the rates of disorder in both samples. Couple concordance rates were between 6.6 and 11.1%, with no significant difference between rates for depressive or depressive and anxious caseness. For women, a previous history of an anxiety disorder appears to be a greater risk factor for a postnatal mood disorder (i.e. depression or anxiety) than a history of a depressive disorder. CONCLUSIONS: These results clearly show the need to assess for both depression and anxiety in new and expectant parents, and we believe the term 'postnatal mood disorder' (PMD), rather than postnatal depression, more accurately reflects significant adjustment difficulties in new parents.     

Can gender differences in the prevalence of mental disorders be explained by sociodemographic factors?

Summary Background and aims: Epidemiological studies throughout the world consistently reported higher rates of depression and anxiety disorders in women, whereas men consistently show higher rates of substance and antisocial disorders. The present study examined factors potentially contributing to these gender differences using general population data.Methods: The sample was drawn from population registries (N=4181) and can be regarded as representative for the adult German population aged 18–65. Mental disorders (DSM-IV) were assessed with a diagnostic interview (CIDI) carried out by clinically trained interviewers. A range of sociodemographic variables was analysed within men, within women, and between genders.Results: The prevalence of common mental disorders (mood, anxiety, substance use and somatoform disorders) is higher among females, with the exception of substance use disorders. Young age was related to substance disorders both in women and in men. Not being married and being unemployed were associated with increased rates of mental disorders in both sexes, but in men stronger than in women. Being retired was associated with depression only in women, whereas belonging to a higher social class, working fulltime and having children appeared to be protective factors for men only. Other sociodemographic factors (concerning education, employment and family status) were not associated with increased rates of mental disorders both in women and men.Conclusion: Overall the emotional advantages or disadvantages of marital status, employment status, number of children, parenthood and social class apply equally to men and women. We cannot explain the female preponderance in most mental disorders by detecting specific unfavourable patterns of sociodemographic correlates, suggesting that determinants of gender differences in common mental disorders are still far from being understood.     

Gender differences in cardiovascular and electrodermal responses to public speaking task: the role of anxiety and mood states.

Gender moderates psychophysiological responses to stress. In addition to the hormonal background, different psychological states related to social stressors, such as anxiety and mood, could affect this response. The purpose of this study was to examine the existence of gender differences in the cardiovascular and electrodermal responses to a speech task and their relationship with anxiety and the mood variations experienced. For this, non-specific skin conductance responses (NSRs), heart rate (HR), and finger pulse volume (FPV) were measured at rest, and during preparation, task and recovery periods of an academic career speech in undergraduate men (n=15) and women (n=23), with assessment of changes in the state version of the State-Trait Anxiety Inventory (STAI-S) and in the Profile of Mood States (POMS) questionnaires. Men and women did not differ in trait anxiety, hostility/aggressiveness, or in the appraisal of the task, which were evaluated with the trait version of the State-Trait Anxiety Inventory (STAI-T), the Buss and Durkee Hostility Inventory (BDHI), and a self-report elaborated by ourselves, respectively. Women had higher FPV in all periods except during the task, and were more reactive to the stressor in state anxiety, and in the amplitude of NSRs. No gender differences for HR and for the frequency of NSRs were found. Anxiety and mood states were differently related to cardiovascular and electrodermal measurements in men and women. Further studies should consider the hormonal variations in addition to the psychological dimensions, in order to offer a more integrative perspective of the complex responses to stress.     

The analysis of anxiety and mood in healthy late-reproductive-stage women with regard to hormonal and genetic factors

The purpose of this study was to determine whether anxiety and mood disorders in late-reproductive-stage women are related to the serotonin transporter and monoamine oxidase A gene polymorphisms. Research instrument used in this study were the State-Trait Anxiety Inventory and the UWIST Mood Adjective Checklist. The 44-bp VNTR polymorphism in the 5-HTT (SLC 6A4) promoter region and the 30-bp VNTR polymorphism in the MAO-A promoter region were analyzed. The study included 345 healthy Polish women in the late reproductive stage. The mean age of the participants was 42.3 ± 4.5 years. State anxiety was observed in 16.8 % of the women and trait anxiety in 14.5 %. There were no statistically significant differences in the mood and the mean levels of anxiety depending on the presence of the polymorphisms analyzed in this study. Depressed mood is frequent among healthy women in the late reproductive stage. Anxiety is definitely less common. The study did not demonstrate the relationship between the 5-HTT and MAO-A gene polymorphisms, and the severity of anxiety and mood disorders in healthy late-reproductive-stage women.

     

Does a U-shaped relationship exist between alcohol use and DSM-III-R mood and anxiety disorders?

BACKGROUND: In recent community surveys, abstainers and heavy drinkers of alcohol have reported more mood and anxiety symptoms than moderate drinkers (U-shaped relationship). The present study was aimed at extending this finding by investigating this potential U-shaped relationship using structured diagnostic interviews to assess mood and anxiety disorders. METHODS: Data came from two contemporaneous surveys, the National Comorbidity Survey (NCS; N=6780) and the Mental Health Supplement of the Ontario Health Survey (OHS-MHS; N=7001). The University of Michigan Revision of the Composite International Diagnostic Interview (UM-CIDI) was used to make DSM-III-R psychiatric diagnoses in both surveys. Three mutually exclusive lifetime alcohol use categories were compared: (1) Alcohol abstainers-individuals reporting no alcohol use or less than 12 drinks in any year throughout their life. (2) Moderate drinkers-individuals that did not meet criteria for alcohol abstainers or problem drinkers. (3) Problem drinkers-DSM-III-R lifetime alcohol abuse, dependence or hazardous levels of alcohol use. RESULTS: After controlling for demographic variables, alcohol abstainers were not found to have significantly higher rates of mood and anxiety disorders in comparison with moderate drinkers. However, problem drinking was significantly associated with mood and anxiety disorders. CONCLUSIONS: Across both surveys, there was no evidence of a U-shaped relationship between lifetime alcohol consumption and lifetime mood and anxiety disorders.     

Self-efficacy and mood in cardiac rehabilitation: should gender be considered?

The authors proposed to (a) determine the influence of phase II cardiac rehabilitation (CR) on task and barrier efficacy and mood in men and women, (b) determine the influence of task and barrier efficacy on postphase II CR exercise adherence, and (c) examine the bidirectional relationship between self-efficacy and mood. Fifty-seven men and 24 women completed task and barrier efficacy scales and the anxiety, depression, and vigor subscales 3 to 5 weeks before phase II CR, immediately before and after phase II CR, and 6 to 10 weeks after phase II CR. They found that the women had significantly larger increases in task and barrier efficacy from pre- to postphase II CR than the men did, whereas both men and women had a significant decline at follow-up. Men and women had a similar decrease in anxiety and an increase in vigor during phase II CR. However, vigor significantly declined at follow-up. All changes in mood were significantly related to changes in task and barrier efficacy.     

Obsessional thoughts and compulsive behaviors in a sample of women with postpartum mood symptoms

Postpartum psychiatric disorders are widely recognized by clinicians and researchers, yet while much attention has been paid to perinatal mood disorders, considerably less has been given to anxiety and obsessive–compulsive symptoms in this population. The present study examined anxiety and obsessive–compulsive symptoms among postpartum women with mood complaints, with the aim of delineating the relationship between these symptoms. Sixty postpartum women seeking treatment in a perinatal mood disorders clinic completed measures of depression, anxiety, and obsessive–compulsive symptoms. Obsession-like thoughts and compulsive-like (“neutralizing”) strategies were present among the majority of the sample, yet the severity of these symptoms ranged widely. Depressive and anxiety symptoms were associated with obsessive and neutralizing compulsive symptoms. It may be helpful to consider anxiety and depressive symptoms as part of a broad spectrum of perinatal psychiatric illness. Clinicians should assess for anxiety and obsessive–compulsive symptoms as routinely as they assess for depressive symptoms in the perinatal period.     

Sex differences in subclinical and DSM-IV pathological gambling: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: To examine sex differences in DSM-IV subclinical and pathological gambling in nationally representative data of the US population. METHOD: Data come from a large (n = 43093) representative sample of the adult US population. RESULTS: The lifetime prevalence rate of DSM-IV pathological gambling was 0.64% (95% CI 0.50-0.78) for men and 0.23% (95% CI 0.17-0.29) for women, whereas the lifetime prevalence of subclinical pathological gambling was 6.79% (95% CI 6.32-7.26) for men and 3.26% (95% CI 2.93-3.59) for women. For subclinical pathological gambling, men were significantly (p < 0.01) more likely than women to have smoked more than two packs of cigarettes a day, to be classified as heavy drinkers and to have lifetime diagnoses of alcohol and drug use disorders. Women with subclinical and pathological gambling were significantly more likely than men to have lifetime mood and anxiety disorders. With respect to pathological gambling, women had later ages of onset of the disorder, and were significantly more likely than men to report gambling to relieve depressed mood and to prefer casino gambling. Rates of treatment-seeking for DSM-IV pathological gambling were low for both men and women. CONCLUSIONS: There are important sex differences in the prevalence, symptom pattern, sociodemographic and clinical correlates and course of DSM-IV subclinical and pathological gambling. Results underscore the need to investigate sex differences in the social determinants, neurobiology and treatment response of DSM-IV subclinical and pathological gambling.     

Prevalence of psychiatric disorders in early stages of HIV infection.

As part of a military universal HIV screening program, 442 men were assessed for the presence of DSM-III-R defined psychiatric disorders and symptoms of anxiety and depression after notification of HIV seroconversion. Of them, 84.4% were in the earliest, asymptomatic stages of disease at the time of interview (96% did not have AIDS). The Structured Clinical Interview for DSM-III-R and Structured Interview Guide for the Hamilton Anxiety and Depression Scales were used. Relevant comparisons were made to Epidemiologic Catchment Area prevalence data. HIV seropositive men were more likely than age-matched men in the community to have current diagnoses of major depression (ages 18-44) and anxiety disorders (ages 25-44). Higher lifetime rates of major depression and alcohol use disorder, and high current prevalence of sexual dysfunction (21.7%) were noted. We conclude that men who become HIV seropositive have high rates of mood and substance use disorders prior to knowledge of seroconversion, and that early in the course of HIV infection men are at risk for developing major depression, anxiety disorders, and disorders of sexual desire.     

Lactate infusion induces panic attacks in patients with premenstrual syndrome.

A sodium lactate test was performed during the premenstrual phase in 35 women suffering from prospectively confirmed premenstrual syndrome (PMS) and in 16 controls in order to assess whether these patients were sensitive to this test and whether this sensitivity was accounted for primarily by the presence of concomitant panic disorder. Patients with PMS also underwent the Structured Clinical Interview for the DSM-III-R (SCID) to determine the presence of co-morbid anxiety and/or mood disorders. Only 31% of the PMS patients were free from a depressive/anxiety disorder, while nine patients met criteria for panic disorder, and the remaining 15 subjects were diagnosed as having anxiety and/or mood disorders. Lactate infusion induced panic attacks in 22 subjects (62.9%) and two controls (12.5%). Panickers were equally distributed among PMS patients with or without a concurrent anxiety/mood disorder. Although cardiovascular responses to lactate were similar among PMS patients regardless of the presence of concomitant anxiety/mood disorders, both plasma cortisol levels and panic and mood scores were higher during the test in those patients with concomitant panic disorder. These results suggest that PMS patients display an increased sensitivity to lactate, which is not primarily accounted for by the presence of co-morbid panic disorder.     

Mental disorders among persons with arthritis: results from the World Mental Health Surveys

BACKGROUND: Prior studies in the USA have reported higher rates of mental disorders among persons with arthritis but no cross-national studies have been conducted. In this study the prevalence of specific mental disorders among persons with arthritis was estimated and their association with arthritis across diverse countries assessed. METHOD: The study was a series of cross-sectional population sample surveys. Eighteen population surveys of household-residing adults were carried out in 17 countries in different regions of the world. Most were carried out between 2001 and 2002, but others were completed as late as 2007. Mental disorders were assessed with the World Health Organization (WHO) World Mental Health-Composite International Diagnostic Interview (WMH-CIDI). Arthritis was ascertained by self-report. The association of anxiety disorders, mood disorders and alcohol use disorders with arthritis was assessed, controlling for age and sex. Prevalence rates for specific mental disorders among persons with and without arthritis were calculated and odds ratios (ORs) with 95% confidence intervals were used to estimate the association. RESULTS: After adjusting for age and sex, specific mood and anxiety disorders occurred among persons with arthritis at higher rates than among persons without arthritis. Alcohol abuse/dependence showed a weaker and less consistent association with arthritis. The pooled estimates of the age- and sex-adjusted ORs were about 1.9 for mood disorders and for anxiety disorders and about 1.5 for alcohol abuse/dependence among persons with versus without arthritis. The pattern of association between specific mood and anxiety disorders and arthritis was similar across countries. CONCLUSIONS: Mood and anxiety disorders occur with greater frequency among persons with arthritis than those without arthritis across diverse countries. The strength of association of specific mood and anxiety disorders with arthritis was generally consistent across disorders and across countries.     

Mood variability in anxiety disorders

BACKGROUND: To investigate whether patients with anxiety disorders have more variable mood than control subjects. METHODS: Twenty-eight patients with anxiety disorders and 28 controls were assessed with the State-Trait Anxiety Inventory-Trait form (STAIT), Beck Depression Inventory (BDI), Mood Disorder Questionnaire (MDQ), and TEMPS-A questionnaire for temperament. Participants used Visual Analogue Scales (VAS) to rate low, high and anxious moods, morning and evening, for 7 consecutive days. Mood variability was calculated with the Mean Square Successive Difference (MSSD) and the Standard Error of the Mean (SEM), both derived from the VAS ratings. RESULTS: (1) The MSSD and SEM measures for low mood and anxiety variability were higher in patients than controls. The SEM for high mood was marginally higher in patients. (2) The high mood measures separated into two clusters: (a) the mean of the VAS high mood scale and the TEMPS hyperthymia scale apparently measure an adaptive high mood or hyperthymia that did not correlate or correlated negatively with depression (BDI). (b) The MSSD of the VAS high mood scale, the TEMPS cyclothymia scale, and the MDQ correlated with each other and with the BDI as variable high mood that is distressing. LIMITATIONS: Small sample size. CONCLUSIONS: Patients with anxiety disorders show more mood variability than controls. We also found a difference in the measures of adaptive high mood from variable high mood, the latter associated with depression. Mood variability is an important but neglected aspect of distress in patients with anxiety disorders.     

Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions

BACKGROUND: This study addressed the prevalences, correlates, co-morbidity and disability of DSM-IV generalized anxiety disorder (GAD) and other psychiatric disorders in a large national survey of the general population, the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The study presents nationally representative data, for the first time, on prevalence, correlates, co-morbidity, and comparative disability of DSM-IV GAD.METHOD: Data are taken from a large (n=43093) representative sample of the adult USA population.R: Prevalences of 12-month and lifetime GAD were 2.1% and 4.1%. Being female, middle-aged, widowed/separated/divorced, and low income increased risk, while being Asian, Hispanic, or Black decreased risk. GAD was highly co-morbid with substance use, and other anxiety, mood, and personality disorders. Co-morbidity in GAD was not substantially greater than for most other Axis I and II disorders. Disability and impairment in pure GAD were equivalent to pure mood disorders, but significantly greater than in pure substance use, and other anxiety and personality disorders. Individuals co-morbid for GAD and each mood disorder were more disabled than those with pure forms of GAD or each mood disorder. When co-morbid with GAD, nicotine dependence and other anxiety and personality disorders were not associated with increased disability over that associated with pure GAD, but GAD did show increased disability over that due to each of these disorders in pure form.Conclusions. Associations between GAD and Axis I and II disorders were strong and significant, with variation among specific disorders. Results strongly support GAD as an independent disorder with significant impairment and disability.     

Ethnic differences in allopregnanolone concentrations in women during rest and following mental stress

The neuroactive steroid allopregnanolone (ALLO) is stress sensitive, negatively modulates the HPA axis, and has been implicated in mood disorders. We examined ethnic differences in plasma ALLO at rest and following mental stress in African American (AA) men (n = 21) and women (n = 24) and non-Hispanic White men (n = 24) and women (n = 25). Overall, AA women had lower ALLO concentrations than non-Hispanic White women (p < .05), especially following mental stress (p < .01). Only 20% of AA women showed the expected stress-induced increase in ALLO compared with 59% of non-Hispanic White women (p < .01). No ethnic differences were seen in men. For both ethnic groups, poststress ALLO was negatively correlated with poststress cortisol (p < .05). Results are interpreted to reflect dysregulation in ALLO mechanisms in AA women and may have implications for ethnic differences in mood disorders.     

Common mental disorders in women and men in the first six months after the birth of their first infant: A community study in Victoria,Australia

Introduction

Studies of postpartum mental health have focused predominantly on women and on depression. There is limited evidence regarding men's postpartum mental health and about other common mental disorders, such as anxiety and adjustment disorders, which may also be relevant at this life phase. The main aim of this study was to establish the period prevalence of depression, anxiety, and adjustment disorders in primiparous women and their male partners in the first six months postpartum

Methods

English-speaking couples were recruited in five local government areas in Victoria, Australia. Women and men completed separate telephone interviews which included the Edinburgh Postnatal Depression Scale (EPDS) and selected Depression and Anxiety modules of the Composite International Diagnostic Interview. DSM-IV criteria were used to classify adjustment disorders, based on subclinical symptoms not meeting criteria for diagnoses of major or minor depression or generalised anxiety disorder. The main outcome was any common mental disorder (depression, anxiety or adjustment disorder) in the first six months postpartum

Results

Complete data were available for 172 couples. The 6-month period prevalence of mental health problems was 33% for women and 17% for men. The most common diagnosis in both women and men was adjustment disorder with anxiety symptoms

Limitations

Unpartnered women and men, women whose partners were not willing to participate and those who did not have sufficient English fluency to complete the interviews were excluded from the sample. The results of this study cannot be generalised to these populations.

Conclusion

The most common postnatal mental health problem in both women and men in this community sample was anxiety.     

Psychological predictors of survival in cancer patients undergoing radiation therapy

In a prospective study to identify psychological factors affecting survival in cancer patients receiving radiation therapy, 101 consecutive patients were evaluated for anxiety, depression, and perception of the seriousness of the condition. In 3 years, the survivors were compared to the nonsurvivors. The survivors had significantly higher mean trait anxiety (p less than 0.05) than the nonsurvivors. State anxiety and depression scores also tended to be higher in the survivors (p less than 0.01). Self-assessment of the seriousness of their disease did not differentiate the two groups. The nonsurvivors had significantly more pain (p less than 0.05). Within the nonsurvivor group, survival time was negatively correlated with state anxiety (p less than 0.01), trait anxiety (p less than 0.02), and depression (p less than 0.01). In the nonsurvivors, women rated their condition to be significantly more serious than men (p less than 0.01). Female nonsurvivors tended to rate their condition to be more serious than female survivors (p less than 0.1), while male nonsurvivors rated their condition to be significantly less serious than male survivors (p less than 0.01). Only among female nonsurvivors did the seriousness rating correlate significantly with anxiety (p less than 0.01). The sex differences confirm our previous finding that men may tend to cope with cancer with more massive denial than women. We hypothesize that patients with higher anxiety and depression in the nonsurvivor group had a massive defensive failure, while those who had high anxiety levels in the survivor group had been more realistic about their disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Are gender differences in depression explained by gender differences in co-morbid anxiety?

BACKGROUND: This review tested the hypothesis that gender differences in depression rates are a function of gender differences in co-morbid anxiety disorders. METHOD: We identified studies using diagnostic criteria, and reporting rates of pure depression, pure anxiety and co-morbid depression and anxiety, separately for females and males. The results of these studies were examined to assess the level of support for the co-morbidity hypothesis. RESULTS: Although some studies supported or partially supported the hypothesis, the methodologically superior studies did not. CONCLUSIONS: We conclude that women are more likely than men to be diagnosed with either disorder alone or co-morbidly. Furthermore, the ratio of women to men who experience anxiety alone or anxiety in combination with depression tends to be higher than the ratio of women to men who experience depression alone. Attempts to explain the gender difference in rates of depression would benefit from an understanding that women also are more likely to experience anxiety.     

Alcoholism and anxiety in bipolar illness: differential lifetime anxiety comorbidity in bipolar I women with and without alcoholism

INTRODUCTION: This study was undertaken to evaluate the prevalence rate of anxiety comorbidity in bipolar subjects with and without alcohol use disorders (AUD). METHODS: Bipolar men and women who entered the Stanley Foundation Bipolar Network (SFBN) underwent a Structured Clinical Interview for DSM-IV (SCID-IV) and were divided into those subjects meeting current or lifetime criteria for an alcohol use disorder (AUD=213) vs. those subjects who did not (non-AUD=137). Lifetime rates of comorbid anxiety disorder were evaluated between groups. RESULTS: Of 350 subjects, 163 (46.5%) met criteria for an anxiety disorder. Panic disorder and OCD were the most common anxiety disorders in the AUD and non-AUD groups. OCD and specific phobia were significantly less prevalent in BP I patients with AUD compared to those without. Bipolar women with AUD had a significantly higher rate of PTSD than those without. CONCLUSION: These data highlight the added liability of anxiety comorbidity in BP disorder. Specifically, the greater amount of PTSD and lesser amount of OCD in bipolar women with alcohol comorbidity may have important diagnostic and treatment implications beyond dual diagnosis. Further study in comorbidity patterns is encouraged to not only better understand illness burden, but to maximize pattern-specific treatment outcomes.