The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication

CONTEXT: Only limited information exists about the epidemiology of DSM-IV panic attacks (PAs) and panic disorder (PD). OBJECTIVE: To present nationally representative data about the epidemiology of PAs and PD with or without agoraphobia (AG) on the basis of the US National Comorbidity Survey Replication findings. DESIGN AND SETTING: Nationally representative face-to-face household survey conducted using the fully structured World Health Organization Composite International Diagnostic Interview. PARTICIPANTS: English-speaking respondents (N=9282) 18 years or older. MAIN OUTCOME MEASURES: Respondents who met DSM-IV lifetime criteria for PAs and PD with and without AG. RESULTS: Lifetime prevalence estimates are 22.7% for isolated panic without AG (PA only), 0.8% for PA with AG without PD (PA-AG), 3.7% for PD without AG (PD only), and 1.1% for PD with AG (PD-AG). Persistence, lifetime number of attacks, and number of years with attacks increase monotonically across these 4 subgroups. All 4 subgroups are significantly comorbid with other lifetime DSM-IV disorders, with the highest odds for PD-AG and the lowest for PA only. Scores on the Panic Disorder Severity Scale are also highest for PD-AG (86.3% moderate or severe) and lowest for PA only (6.7% moderate or severe). Agoraphobia is associated with substantial severity, impairment, and comorbidity. Lifetime treatment is high (from 96.1% for PD-AG to 61.1% for PA only), but 12-month treatment meeting published treatment guidelines is low (from 54.9% for PD-AG to 18.2% for PA only). CONCLUSION: Although the major societal burden of panic is caused by PD and PA-AG, isolated PAs also have high prevalence and meaningful role impairment.     

The symptom structure of posttraumatic stress disorder in the National Comorbidity Replication Survey

Previous research has provided mixed findings for the validity of various three- and four-factor models of posttraumatic stress disorder (PTSD) symptomatology. However, much of this research has been restricted to clinical samples rather than nationally representative community-based samples. The current study employed confirmatory factor analysis to evaluate the validity of three competing models of PTSD symptom structure using the DSM-IV-based National Comorbidity Replication Survey (part II of the NCS-R: N=5692). Individuals with a lifetime diagnosis of PTSD (N=588) were selected and symptom assessment was based on the World Health Organization Composite International Diagnostic Interview. Strong support was found for both the DSM-IV three-factor model and a four-factor model of PTSD symptoms by King et al. [King, D. W., Leskin, G. A., King, L. A., & Weathers, F. W. (1998). Confirmatory factor analysis of the clinician-administered PTSD scale: evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment,10, 90-96], a variation of the DSM-IV model in which avoidance and numbing are viewed as separate factors. There was some evidence, however, that the King et al. [King, D. W., Leskin, G. A., King, L. A., & Weathers, F. W. (1998). Confirmatory factor analysis of the clinician-administered PTSD scale: evidence for the dimensionality of posttraumatic stress disorder. Psychological Assessment,10, 90-96] model demonstrated a significantly superior fit over the DSM-IV three-factor model. Because this study provided support for both the DSM-IV three-factor model and the King et al., four-factor model of PTSD symptoms, further research is still necessary to provide more definitive conclusions in this area.     

The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication

CONTEXT: Little is known about the epidemiology of intermittent explosive disorder (IED). OBJECTIVE: To present nationally representative data on the prevalence and correlates of DSM-IV IED. DESIGN: The World Health Organization Composite International Diagnostic Interview was used to assess DSM-IV anxiety disorders, mood disorders, substance use disorders, and impulse control disorders. SETTING: The National Comorbidity Survey Replication, a face-to-face household survey carried out in 2001-2003. PARTICIPANTS: A nationally representative sample of 9282 people 18 years and older. MAIN OUTCOME MEASURE: Diagnoses of DSM-IV IED. RESULTS: Lifetime and 12-month prevalence estimates of DSM-IV IED were 7.3% and 3.9%, with a mean 43 lifetime attacks resulting in 1359 dollars in property damage. Intermittent explosive disorder-related injuries occurred 180 times per 100 lifetime cases. Mean age at onset was 14 years. Sociodemographic correlates were uniformly weak. Intermittent explosive disorder was significantly comorbid with most DSM-IV mood, anxiety, and substance disorders. Although the majority of people with IED (60.3%) obtained professional treatment for emotional or substance problems at some time in their life, only 28.8% ever received treatment for their anger, while only 11.7% of 12-month cases received treatment for their anger in the 12 months before interview. CONCLUSIONS: Intermittent explosive disorder is a much more common condition than previously recognized. The early age at onset, significant associations with comorbid mental disorders that have later ages at onset, and low proportion of cases in treatment all make IED a promising target for early detection, outreach, and treatment.     

Correlates of mental health service use intensity in the National Comorbidity Survey and National Comorbidity Survey Replication

OBJECTIVE: This study explored sociodemographic and mental health correlates of intensity of mental health care use in two large-scale surveys, aiming to discover the set of correlates with the greatest predictive capacity. METHODS: Data were examined from persons aged 15 to 54 in two nationally representative U.S. household surveys: the National Comorbidity Survey (NCS) (N=5,877), which gathered information from 1990 to 1992, and the NCS Replication (N=4,320), which gathered information from 2001 to 2003. Outcome variables were the number of mental health care visits in the past year to mental health providers, social service providers, and medical providers. This study implemented state-of-the-art statistical methods designed for modeling such outcomes as treatment intensity-that is, visit counts. RESULTS: Across provider types, significant univariate associations were found for intensity of mental health care use based on access variables (for example, employment and health insurance) and two need variables-psychiatric diagnoses and psychiatric disability. Demographic variables and treatment need variables were not consistent service use correlates. Multivariate regression accounting for excessive zero values demonstrated that after the analyses controlled for sociodemographic and access variables, mental disorders (mood, anxiety, and substance use disorders) and psychiatric disability added incrementally to variance in visit counts for mental health care. However, when mental health service use was dichotomized (any use versus no use) demographic and access variables, as well as psychiatric disorders, emerged as correlates. In both sets of analyses, different patterns of psychiatric disorder and disability were associated with provider service use. CONCLUSIONS: These findings extend research on correlates of mental health care use, addressing intensity of use, suggesting that sociodemographic factors and presence of a psychiatric disorder and associated disability drive the initial use of services, whereas presence of a psychiatric disorder and associated disability are associated with continued service use.     

强迫障碍共病强迫型人格障碍的研究

目的:研究强迫型人格障碍(OCPD)在强迫障碍(OCD)中的共病情况,并研究OCD共病OCPD对OCD影响。方法:以69例门诊OCD患者为研究对象,采用DSM-Ⅳ轴Ⅱ障碍用临床定式检查(SCID-Ⅱ)研究强迫障碍患者的共病人格障碍(PD)情况,将研究对象分为2组:OCD共病OCPD组和OCD不共病OCPD组,对比研究2组间临床特征的不同。结果:79.7%强迫障碍患者合并有PD,C类中的OCPD和OCD共病率达43.5%。共病组较不共病组疾病严重程度更重,表现为发病年龄早、病程更长、强迫思维更严重。结论:OCPD和OCD关系密切,OCD共病OCPD是OCD严重程度的一个标志。     

DSM-IV personality disorders in the National Comorbidity Survey Replication.

BACKGROUND: The population prevalence of DSM-IV personality disorders (PDs) remains largely unknown. Data are reported here on the prevalence and correlates of clinician-diagnosed Clusters A, B, and C DSM-IV PDs in the general population of the United States. METHODS: Personality disorder screening questions from the International Personality Disorder Examination (IPDE) were administered in Part II (n = 5692) of the National Comorbidity Survey Replication (NCS-R). A probability sub-sample was then interviewed with the IPDE and used to link screening question responses with IPDE clinical diagnoses. The method of Multiple Imputation (MI) was then implemented to estimate prevalence and correlates of PDs in the full sample. RESULTS: The MI prevalence estimates were 5.7% Cluster A, 1.5% Cluster B, 6.0% Cluster C, and 9.1% any PD. All three PD clusters were significantly comorbid with a wide range of DSM-IV Axis I disorders. Significant associations of PDs with functional impairment were largely accounted for by Axis I comorbidity. CONCLUSIONS: Strong Axis I comorbidity raises questions about the somewhat arbitrary separation of PDs from Axis I disorders in the DSM nomenclature. The impairment findings suggest that the main public health significance of PDs lies in their effects on Axis I disorders rather than in their effects on functioning.     

Sleep problems and suicidality in the National Comorbidity Survey Replication

Objective

Links between sleep problems and suicidality have been frequently described in clinical samples; however, this issue has not been well-studied in the general population. Using data from a nationally representative survey, we examined the association between self-reported sleep difficulties and suicidality in the United States.

Methods

The WHO Composite International Diagnostic Interview was used to assess sleep problems and suicidality in the National Comorbidity Survey Replication (NCS-R). Relationships between three measures of sleep (difficulty initiating sleep, maintaining sleep, early morning awaking), and suicidal thoughts, plans, and attempts were assessed in logistic regression analyses, while controlling for demographic characteristics, 12-month diagnoses of mood, anxiety and substance use disorders, and chronic health conditions.

Results

In multivariate models, the presence of any of these sleep problems was significantly related to each measure of suicidality, including suicidal ideation (OR = 2.1), planning (OR = 2.6), and suicide attempt (OR = 2.5). Early morning awakening was associated with suicidal ideation (OR = 2.0), suicide planning (OR = 2.1), and suicide attempt (OR = 2.7). Difficulty initiating sleep was a significant predictor of suicidal ideation and planning (ORs: 1.9 for ideation; 2.2 for planning), while difficulty maintaining sleep during the night was a significant predictor of suicidal ideation and suicide attempts (ORs: 2.0 for ideation; 3.0 for attempt).

Conclusions

Among community residents, chronic sleep problems are consistently associated with greater risk for suicidality. Efforts to develop comprehensive models of suicidality should consider sleep problems as potentially independent indicators of risk.     

Smoking and suicidal behaviors in the National Comorbidity Survey: Replication

Controversy exists about the role of mental disorders in the consistently documented association between smoking and suicidal behavior. This controversy is addressed here with data from the nationally representative National Comorbidity Survey-Replication (NCS-R). Assessments were made of 12-month smoking, suicidal behaviors (ideation, plans, attempts), and DSM-IV disorders (anxiety, mood, impulse-control, and substance use disorders). Statistically significant odds ratios (2.9-3.1) were found between 12-month smoking and 12-month suicidal behaviors. However, the associations of smoking with the outcomes became insignificant with controls for DSM-IV mental disorders. Although clear adjudication among contending hypotheses about causal mechanisms cannot be made from the cross-sectional NCS-R data, the results make it clear that future research on smoking and suicidal behaviors should focus more centrally than previous research on mental disorders either as common causes, markers, or mediators.     

The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication.

BACKGROUND: Little population-based data exist on the prevalence or correlates of eating disorders. METHODS: Prevalence and correlates of eating disorders from the National Comorbidity Replication, a nationally representative face-to-face household survey (n = 9282), conducted in 2001-2003, were assessed using the WHO Composite International Diagnostic Interview. RESULTS: Lifetime prevalence estimates of DSM-IV anorexia nervosa, bulimia nervosa, and binge eating disorder are .9%, 1.5%, and 3.5% among women, and .3% .5%, and 2.0% among men. Survival analysis based on retrospective age-of-onset reports suggests that risk of bulimia nervosa and binge eating disorder increased with successive birth cohorts. All 3 disorders are significantly comorbid with many other DSM-IV disorders. Lifetime anorexia nervosa is significantly associated with low current weight (body-mass index <18.5), whereas lifetime binge eating disorder is associated with current severe obesity (body-mass index > or =40). Although most respondents with 12-month bulimia nervosa and binge eating disorder report some role impairment (data unavailable for anorexia nervosa since no respondents met criteria for 12-month prevalence), only a minority of cases ever sought treatment. CONCLUSIONS: Eating disorders, although relatively uncommon, represent a public health concern because they are frequently associated with other psychopathology and role impairment, and are frequently under-treated.     

Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication

OBJECTIVE: Despite its inclusion in DSM-IV, little is known about the prevalence or correlates of adult separation anxiety disorder or its relationship to the childhood disorder. Results of the first epidemiological study of adult separation anxiety disorder, to the authors' knowledge, and its relationship to childhood separation anxiety disorder are presented. METHOD: Data were from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of U.S. households. A fully structured, lay-administered diagnostic interview assessed a wide range of DSM-IV disorders, including separation anxiety disorder. No independent clinical validation was obtained of the assessment. RESULTS: Lifetime prevalence estimates of childhood and adult separation anxiety disorders were 4.1% and 6.6%, respectively. Approximately one-third of the respondents who were classified as childhood cases (36.1%) had an illness that persisted into adulthood, although the majority classified as adult cases (77.5%) had first onset in adulthood. The assessment of separation anxiety disorder in the NCS-R was comorbid with other NCS-R or DSM-IV disorders and associated with severe role impairment in roughly half of the comorbid cases and one-fourth of the pure cases. The majority of people with estimated adult separation anxiety disorder are untreated, even though many obtain treatment for comorbid conditions. CONCLUSIONS: Criteria for adult separation anxiety disorder should be refined in future editions of DSM because the disorder is likely to be much more common in adults than previously recognized. Research is needed to develop and evaluate treatments that take into consideration its high comorbidity with other DSM-IV disorders.     

The National Comorbidity Survey Replication (NCS-R): background and aims

The National Comorbidity Survey Replication (NCS-R) is a new nationally representative community household survey of the prevalence and correlates of mental disorders in the US. The NCS-R was carried out a decade after the original NCS. The NCS-R repeats many of the questions from the NCS and also expands the NCS questioning to include assessments based on the more recent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostics system (American Psychiatric Association, 1994). The NCS-R was designed to (1) investigate time trends and their correlates over the decade of the 1990s and (2) expand the assessment of the prevalence and correlates of mental disorders beyond the assessment in the baseline NCS in order to address a number of important substantive and methodological issues that were raised by the NCS. This paper presents a brief review of these aims.     

Risk for psychiatric disorder among immigrants and their US-born descendants: evidence from the National Comorbidity Survey Replication

Although previous research has consistently documented that immigrants to the United States have better mental health than US natives, little is known about why this difference occurs. DSM-IV anxiety, mood, impulse control, and substance use disorders were assessed in a nationally representative survey of the US household population, the National Comorbidity Survey Replication. Differences in risk for disorder between immigrants (N = 299) and 5124 natives (N = 5124) were examined using discrete time survival models. Differences were estimated by generation, age of immigration, and duration of residence in the United States. Immigrants had lower lifetime risk of disorder than natives (OR = 0.7; 95% CI, 0.5-0.9). Risk was equally large for natives who were children of immigrants as for natives of subsequent generations. For mood and impulse control disorders, risk equal to that of natives was also found among immigrants who arrived in the United States as children (12 years of age or younger). Immigrants had lower risk than natives prior to arrival in the United States, but there was a trend toward equalization of risk with longer duration of residence in the United States. Differences in risk for disorder emerge within a single generation following immigration, consistent with a strong effect of environmental factors on changes in risk among immigrant populations. This pattern is consistent with either of two causal processes, one involving early socialization in the United States and the other involving postmigration experiences among immigrants who arrive in the United States as adults.     

Comorbidity of obsessive-compulsive disorder in recovered inpatients with bipolar disorder

Objective: To determine the frequency of obsessive-compulsive disorder (OCD) in inpatient subjects with bipolar disorder (BD) and to examine the clinical characteristics of BD subjects with OCD.

Method: The sample consisted of 143 inpatient subjects with DSM-III-R BD-I and BD-NOS (BD-II), recovered from a current episode of either depression or mania. Demographic and clinical variables were obtained on the day of admission. Current comorbid conditions including OCD were determined by the Structured Clinical Interview for DSM-III-R following recovery from the acute affective episode.

Results: The frequency of current OCD was 7% (N=10). All BD subjects with OCD were BD-II, were male, and had a diagnosis of current dysthymia. They had fewer episodes and a higher incidence of prior suicide attempts than bipolar subjects without OCD. None of the bipolar subjects with OCD fulfilled criteria for cyclothymia.

Conclusions: Our findings suggest that BD-II, OCD, dysthymia, and suicidality cluster together in some subjects with BD. We discuss the clinical implications of our findings.     

Seasonal allergies and suicidality: results from the National Comorbidity Survey Replication

Messias E, Clarke DE, Goodwin RD. Seasonal allergies and suicidality: results from the National Comorbidity Survey Replication. Objective: Studies have shown an association between allergies and suicidality, and a seasonality of suicide has also been described. We hypothesize an association between history of seasonal allergies and suicide ideation and attempt. Method: Data came from the National Comorbidity Survey Replication, a nationally representative sample (n = 5692) of adults living in the US. Logistic regression models were used to calculate adjusted odds ratios (OR) controlling for the following: age, sex, race, smoking, asthma and depression. Results: After weighting and adjustment, a positive and statistically significant association was found between history of seasonal allergies and history of suicidal ideation [adjusted OR = 1.27 (1.01–1.58)]. We found no association between history of seasonal allergies and history of suicide attempts [adjusted OR = 1.17 (0.89–1.52)]. Conclusion: Findings from a population‐based sample support the hypothesized relationship between allergies and suicidal ideation.     

The development and implementation of the National Comorbidity Survey Replication, the National Survey of American Life, and the National Latino and Asian American Survey

This paper provides an overview of the development and implementation of the Collaborative Psychiatric Epidemiology Surveys (CPES): the National Comorbidity Survey Replication (NCS-R), the National Survey of American Life (NSAL), and the National Latino and Asian American Study (NLAAS). It describes the instrument development and testing phases, the development of training and other project materials, interviewer recruitment and training activities, and data collection procedures and outcomes. The last section offers recommendations for other researchers who undertake similar studies and who might benefit from the experiences learned in the development and operation of NCS-R, NSAL and NLAAS.     

The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R).

BACKGROUND: To estimate the prevalence and correlates of clinician-diagnosed DSM-IV nonaffective psychosis (NAP) in a national household survey. METHODS: Data came from the United States National Comorbidity Survey Replication (NCS-R). A screen for NAP was followed by blinded sub-sample clinical reappraisal interviews. Logistic regression was used to impute clinical diagnoses to respondents who were not re-interviewed. The method of Multiple Imputation (MI) was used to estimate prevalence and correlates. RESULTS: Clinician-diagnosed NAP was well predicted by the screen (area under the curve [AUC] = .80). The MI prevalence estimate of NAP (standard error in parentheses) is 5.0 (2.6) per 1000 population lifetime and 3.0 (2.2) per 1000 past 12 months. The vast majority (79.4%) of lifetime and 12-month (63.7%) cases met criteria for other DSM-IV hierarchy-free disorders. Fifty-eight percent of 12-month cases were in treatment, most in the mental health specialty sector. CONCLUSIONS: The screen for NAP in the NCS-R greatly improved on previous epidemiological surveys in reducing false positives, but coding of open-ended screening scale responses was still needed to achieve accurate prediction. The lower prevalence estimate than in total-population incidence studies raises concerns that systematic nonresponse bias causes downward bias in survey prevalence estimates of NAP.     

Comorbidity in obsessive-compulsive disorder: focus on depression

The authors investigated the comorbidity between obsessive-compulsive disorder (OCD) and other psychiatric disorders in a group of 154 outpatients. The influence of an associate major depressive disorder (MDD) on the outcome of treatment with clomipramine was examined in a subgroup of 52 patients. The results showed that MDD was the most frequent disorder associated with OCD (almost 20% of the patients), followed by generalized anxiety and panic disorder. The co-presence of depression delayed the effect of clomipramine.     

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication

CONTEXT: Little is known about lifetime prevalence or age of onset of DSM-IV disorders. OBJECTIVE: To estimate lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the recently completed National Comorbidity Survey Replication. DESIGN AND SETTING: Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using the fully structured World Health Organization World Mental Health Survey version of the Composite International Diagnostic Interview. PARTICIPANTS: Nine thousand two hundred eighty-two English-speaking respondents aged 18 years and older. MAIN OUTCOME MEASURES: Lifetime DSM-IV anxiety, mood, impulse-control, and substance use disorders. RESULTS: Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%. Median age of onset is much earlier for anxiety (11 years) and impulse-control (11 years) disorders than for substance use (20 years) and mood (30 years) disorders. Half of all lifetime cases start by age 14 years and three fourths by age 24 years. Later onsets are mostly of comorbid conditions, with estimated lifetime risk of any disorder at age 75 years (50.8%) only slightly higher than observed lifetime prevalence (46.4%). Lifetime prevalence estimates are higher in recent cohorts than in earlier cohorts and have fairly stable intercohort differences across the life course that vary in substantively plausible ways among sociodemographic subgroups. CONCLUSIONS: About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth.