Heterogeneity of treatment dropout: PTSD,depression, and alcohol use disorder reductions in PTSD and AUD/SUD treatment noncompleters

Treatment dropout is often assumed to be due to worsening or lack of symptom improvement, despite minimal research examining symptom change among treatment dropouts. Thus, the present study examined symptom change in veterans who discontinued evidence‐based treatment for comorbid posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD). Participants were veterans who completed at least one session of a 12‐session Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure (COPE) for comorbid PTSD/AUD. The study analyses investigated the 43% of the sample (n = 22) that did not complete the full 12‐session protocol and were therefore considered treatment dropouts. Symptom changes in PTSD, AUD, and depression were examined among dropouts using two methods: (a) clinically significant change criteria and (b) good end‐state criteria. Results indicated that a significant proportion of treatment dropouts displayed clinically significant improvement and/or met good end‐state criteria for PTSD (40–59%), AUD (66%), and depression (45–68%) prior to dropping out. The results revealed that participants who displayed symptom improvement attended more treatment sessions and completed more imaginal exposures than participants who did not experience significant improvement. Together, the findings add to a growing body of literature suggesting that a large proportion of treatment dropouts may actually improve. Although preliminary, the findings challenge the notion that treatment dropout is always associated with negative outcomes.     

新疆克拉玛依地区酒精滥用者焦虑、抑郁症状及自杀风险调查

目的:调查新疆克拉玛依地区酒精滥用者的抑郁、焦虑症状及其自杀风险,为此类精神卫生问题的预防和早期干预提供参考依据。方法:采用PPS抽样调查对1992例社区居民进行调查和统计分析,用酒精使用障碍筛查量表(AUDIT)筛查酒精滥用,初级保健精神障碍患者健康问卷中的抑郁分量表(PHQ-9)和焦虑分量表(PHQ GAD-7)筛查抑郁症状和焦虑症状,简明国际神经精神访谈(MINI)自杀筛选问卷筛查自杀风险。结果:筛查出酒精滥用阳性者298例,酒精滥用比为15.1%。酒精滥用者抑郁症状阳性比53.4%、焦虑阳症状性比35.9%、自杀风险比5.7%,均高于非滥用者(阳性比分别是42.3%、27%、3.2%,均P0.05)。结论:本研究提示,在酒精滥用筛查时要注意对相关精神卫生问题的评估和诊断,以便采取及时、有效的干预措施。     

The relationship of prenatal alcohol exposure and the postnatal environment to child depressive symptoms

OBJECTIVE: This study examined the association between prenatal alcohol exposure and child depressive symptoms, and the mediating effects of maternal and child characteristics. METHODS: Participants were 42 children aged 4-5 years and their biological mothers. Prenatal alcohol consumption was assessed by self-report of maximum drinks per drinking occasion. The Pictorial Depression Scale (PDS) measured child depressive symptoms. Mother-child interactions were assessed using the family interaction puzzle task. RESULTS: Structural equation modeling indicated that prenatal alcohol exposure was associated with more negative child affect. In turn, mothers of more negative children were less emotionally connected to their children, and those children had higher levels of depressive symptomatology. Results could not be explained by current maternal drinking patterns or maternal depression. CONCLUSIONS: Study findings highlight the importance of examining prenatal alcohol exposure as a risk factor in the prediction of childhood-onset depression and the environmental mechanisms that may mediate that relationship.     

Construction and evaluation of an alcohol vapor chamber system

An increasing number of studies demonstrated that alcohol vapor chamber is an effective way to model physical signs of alcohol use disorders. Although researchers are developing different vapor chambers to study chronic alcohol exposure model worldwide, few studies build and modify their own vapor chambers in China. Here, we designed and established an alcohol vapor chamber system for small animals. We described a paradigm showing how to control and monitor alcohol concentration in whole system. The vapor chamber system with several advantages including accommodating up to ten standard mouse cages. Furthermore, the system was tested by evaluating the blood alcohol concentration and neuron injury in mice. Importantly, the alcohol withdrawal after vapor exposure caused motor coordination impairment, anxiolytic- and depression-like behavior. Finally, the N-methyl-D-aspartate receptor (NMDAR)-mediated glutamatergic transmissions in the medial prefrontal cortex was changed after alcohol vapor exposure-induced behaviors. The frequency and amplitude of spontaneous excitatory postsynaptic currents between control and alcohol groups were not different, suggesting that alcohol exposure-induced behaviors are associated with the change in NMDAR response. Taken together, the new alcohol vapor chamber system was constructed, which would help to research the relationship between the stable alcohol exposure and withdrawal behaviors and to study chronic alcohol exposure-induced disorders in China.     

Obstetric care provider engagement in a perinatal depression screening program

To investigate obstetric care provider attitudes toward perinatal depression screening and factors associated with variable screening rates. Provider attitudes about depression screening were investigated via structured interviews (open-ended and rating scale questions) and analyzed using qualitative content analysis. Most providers (86%) found screening effective at identifying women at risk for perinatal depression (average rating of 8.7 on 10-point analog scale). However, 95% overestimated their own screening rates and 67% inaccurately thought they achieved universal screening. Providers not directly involved in their office-based screening process demonstrated lower average screening rates (37%) than those who maintained active involvement (59%; p = 0.07). Obstetric care providers support perinatal depression screening in the context of a program that assumes responsibility for processing screens, conducts assessments of at-risk women and provides referrals to mental health professionals. Provider participation in screening and tying screening to routine obstetric outpatient activities such as glucose tolerance testing are associated with higher screening rates. Presented in part at the annual meeting of the American College of Obstetrics & Gynecology, San Diego, CA, May 2007.     

Summarizing recommendations to eliminate weight stigma in prenatal health care settings: A scoping review

ObjectiveAs the prevalence of obesity increases, more women are at risk of potentially experiencing weight stigma in prenatal health care settings. The objective of this scoping review was to summarize the primary literature assessing potential causes of weight stigma in prenatal health care settings and synthesize recommendations for health care providers to improve clinical practice.MethodsA search strategy was developed combining the terms pregnancy, weight stigma, obesity, and prenatal care. A systematic search was completed in the following databases: Medline, EMBASE, PsycInfo, CINAHL, Opengrey, and Proquest.ResultsEighteen resources were included in this review, of which 17 were qualitative, and one was a mixed-methods study design. Weight stigma occurred in prenatal health care settings when providers: avoided weight-related discussions, assumed lifestyle behaviors, and had poor communication when discussing risks associated with obesity. Recommendations to prevent weight stigma included: offering sensitivity training to discuss obesity during pregnancy, implementing a patient-centred approach, including evaluating individual health behaviors, and providing educational resources to patients explaining potential risks and referrals.ConclusionThis review summarizes recommendations to eliminate weight stigma in prenatal health care settings.Practice implicationsThese recommendations can be implemented in clinical practice and can improve the delivery of prenatal care.     

Tailoring screening protocols for perinatal depression: prevalence of high risk across obstetric services in Western Australia

Given what appears to be an ever-increasing list of concerning consequences of perinatal depression, longitudinal studies have much to offer when considering the timing and efficacy of prevention and intervention strategies. The course of depressive symptomatology across the perinatal period at four obstetric services was investigated utilising Western Australian data collected as part of the beyondblue National Postnatal Depression Program. Pregnant women completed one or two Edinburgh Postnatal Depression Scale (EPDS) assessments during pregnancy and a demographic and psychosocial risk factors questionnaire. One or two EPDS assessments were administered within 12 months postpartum. Prevalence of high risk scores across gestational ages ranged from 14% to 5% during pregnancy and 6% to 9% in the postnatal period. For women who were screened twice, the prevalence of high risk scores appeared earlier and decreased with advancing gestation (p = 0.026). The prevalence of postnatal high risk increased after 12 weeks postpartum (p = 0.029). Screening protocols for depressive symptomatology during pregnancy may need to be fine-tuned across individual hospitals, and take into account gestational ages, in order to be most effective. As depressive symptomatology persists postnatally, screening protocols may need to extend beyond 12 weeks postpartum.     

A history of personal violence and postpartum depression: is there a link?

Summary Background: A link between violence and depression has been shown, but not a link between violence and postpartum depression. This study sought to determine if there is an association between a history of abuse (physical, sexual, emotional as a child or adult) and postpartum depression (PPD). Method: 200 postpartum women were recruited from 6 hospitals. At 8–10 weeks postpartum, a telephone interviewer asked women about physical, emotional or sexual abuse as an adult or child and sociodemographic, obstetrical and personal medical history. PPD was assessed using the Edinburgh Postnatal Depression Scale (EPDS, score of ≥12). Abuse was determined by the Conflict Tactics Scale or the Abuse Assessment Screen. Chi-square and logistic regression were used to determine the relationship between violence and PPD. Results: 11% of women had EPDS scores of ≥12. Rates of childhood (6.5%), or adult (6.5%) physical abuse; and childhood (13%) or adult (14%) sexual abuse were reported by respondents. Emotional abuse in the current relationship (29.6%) exceeded that of childhood abuse (3.5%). Overall 43.2% of respondents had at least one form of abuse. Having a history of depression (OR = 3.3 (95% CI, 1.3–8.7)), panic attack during pregnancy (OR = 5.4 (1.6–19.0)), maternal complications (OR = 5.0 (1.7–15.1)), low social support (OR = 3.3 (1.3–8.7)) and emotional abuse (OR = 2.8 (1.1–7.4) were associated with PPD. Conclusion: Emotional abuse but not physical or sexual abuse was found to be associated with PPD. A possible explanation for this relationship may be that being in an abusive situation puts one at risk for depression and in turn, postpartum depression.     

Diagnosing depression in primary care using self-completed instruments: UK validation of PHQ-9 and CORE-OM.

There is increased emphasis on routine assessment of depression in primary care. This report is the first UK validation of two self-completed measures: the Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM). Optimum cut-off points were established against a diagnostic gold standard in 93 patients. PHQ-9 sensitivity = 91.7% (95% confidence interval [CI] = 77.5 to 98.3%) and specificity 78.3% (95% CI = 65.8 to 87.9%). CORE-OM sensitivity = 91.7% (95% CI = 77.5 to 98.2%) and specificity = 76.7% (95% CI = 64.0 to 86.6%). Brief self-rated questionnaires are as good as clinician-administered instruments in detecting depression in UK primary care.     

History of depression, race, and cardiovascular risk in cardia

Though previous data indicate a positive association between depression and coronary heart disease, the mechanisms mediating these associations remain unclear. These prospective analyses assessed the association between history of Center for Epidemiologic Studies Depression Scale depression and possible mediators of cardiovascular risk at Year 15 of follow-up in African Americans (AA) and Caucasians (C) in the Coronary Artery Risk Development in Young Adults Study. Physiological assessments included plasma levels of low-density-lipoprotein cholestrol (LDL), high-density-lipoprotein cholestrol (HDL), total cholesterol, triglycerides and fasting glucose, diabetes and blood pressure. Behavioral risk factors included alcohol consumption, smoking, physical activity, and body mass index (BMI). AA’s showed significant associations between history of depression and diabetes that did not exist in Cs and AA women had significantly more episodes of depression than any other group. However, associations of depression with smoking, BMI, and physical activity were consistent across groups in the expected direction. HDL-cholesterol was positively and LDL-cholesterol inversely associated with depression in Cs, which was unexpected. These data indicate that in this still healthy cohort, there are already associations between depression and factors that predispose to cardiovascular risk.     

Strengths of associations between depressive symptoms and loneliness,perfectionistic concerns,risky alcohol use and physical activity across levels of sleep quality in Swedish university students: A cross-sectional study

Previous research shows that sleep quality may interact with some other predictors of depression, such that poor sleep could strengthen the association between these factors and depression. We aimed to determine the presence of statistical interactions between sleep quality and loneliness, risky alcohol use, perfectionistic concerns and/or physical inactivity in relation to depressive symptoms. Further, we aimed to describe the functional form of the statistical interactions and associations. We used a cross-sectional design and included 4262 Swedish university students. All measures were self-reported, sleep quality was measured with the Pittsburgh Sleep Quality Index, and depressive symptoms with the short-form Depression, Anxiety and Stress Scale. Regression models of increasing complexity (linear and non-linear, with and without interactions) were compared to determine the presence of associations and statistical interactions, and to explore the best functional form for these associations and interactions. Out-of-sample R² from repeated cross-validation was used to select the final models. We found that sleep quality was associated with depressive symptoms in all final models. Sleep quality showed a linear interaction with perfectionistic concerns in relation to depressive symptoms, such that perfectionistic concerns were more strongly associated with depressive symptoms when sleep quality was poor. Loneliness, risky alcohol use and physical inactivity were non-linearly associated with depressive symptoms but did not interact with sleep quality. We concluded that out of the four examined variables, only perfectionistic concerns interacted with sleep quality in relation to depressive symptoms. This interaction was weak and explained little of the overall variance in depressive symptoms.     

The impact of depression and fluoxetine treatment on obstetrical outcome

Summary Introduction: This study prospectively followed women over the course of pregnancy to assess the impact of depression and/or antidepressant treatment on obstetrical outcome.Method: Sixty-four outpatient women with an Axis I diagnosis of major depressive disorder or no psychiatric history were followed in each trimester of pregnancy with administration of the CES-D. A subset of the women with depression received treatment with fluoxetine during pregnancy. Subjects with a CES-D score greater than 16 at any time point were further assessed for the presence of an active major or minor depressive episode. Primary outcome variables included infant gestational age, birth weight, Apgar score, and admission to the neonatal intensive care unit.Results: Analyzable data were available for 62 women. No significant differences were found in outcome variables between those women with exposure to medication and/or prenatal depressed mood and those women without a history of depression.Conclusions: In contrast to other studies, our study did not demonstrate an adverse effect of fluoxetine exposure per se on obstetrical outcome. In addition, we did not find a significant impact of depression during pregnancy on obstetrical outcome.     

Screening for maternal depression in a low education population using a two item questionnaire

Summary Objective: To assess a two-question screening tool, the Patient Health Questionnaire-2 (PHQ-2), for identifying depressive symptomatology in economically disadvantaged mothers of children in pediatric settings and to explore risk factors associated with a positive depression screen. Methods: A convenience sample of mothers was enrolled at an inner city well-child clinic with children age 3 days to 5 years. The PHQ-2 and Edinburgh Postnatal Depression Scale (EPDS) (as reference scale) were completed. Results: Ninety-four mothers participated. Agreement of the PHQ-2 and EPDS was moderate. The sensitivity of the PHQ-2 for identifying a positive screen on the EPDS was 43.5%; the specificity was 97.2%. The sensitivity of the PHQ-2 was higher for mothers with education beyond high school compared to those with less education. Perceived lack of support with child care and having two or more children were associated with a positive screen. The rate of positive screen was similar for mothers with infants and with older children. Conclusion: Given the low sensitivity of the PHQ-2 in lower educated mothers, additional research in populations with varying sociodemographic characteristics is indicated. Similar rates of symptoms for mothers within and beyond the postpartum period and mothers previously screened support the need for periodic screening. Correspondence: Cynthia Cutler, MD, Department of Pediatrics, New York University Medical Center, NBV 8S-4-11, 462 1^st Avenue, New York, NY 10016, U.S.A.     

International comparison of clinicians' ability to identify depression in primary care: meta-analysis and meta-regression of predictors

Background

There are international differences in the epidemiology of depression and the performance of primary care physicians but the factors underlying these national differences are uncertain.

Aim

To examine the international variability in diagnostic performance of primary care physicians when diagnosing depression in primary care.

Design of study

A meta-analysis of unassisted clinical diagnoses against semi-structured interviews.

Method

A systematic literature search, critical appraisal, and pooled analysis were conducted and 25 international studies were identified involving 8917 individuals. A minimum of three independent studies per country were required to aid extrapolation.

Results

Clinicians in the Netherlands performed best at case finding (the ability to rule in cases of depression with minimal false positives) (AUC+ 0.735) and this was statistically significantly better than the ability of clinicians in Australia (AUC+ 0.622) and the US (AUC+ 0.653), who were the worst performers. Clinicians from Italy had intermediate case-finding abilities. Regarding screening (the ability to rule out cases of no depression with minimal false negatives) there were no strong differences. Looking at overall accuracy, primary care physicians in Italy and the Netherlands were most successful in their diagnoses and physicians from the US and Australia least successful (83.5%, 81.9%, 74.3%, and 67.0%, respectively). GPs in the UK appeared to have the lowest ability to detect depression, as a proportion of all cases of depression (45.6%; 95% CI = 27.7% to 64.2%). Several factors influenced detection accuracy including: collecting data on clinical outcomes; routinely comparing the clinical performance of staff; working in small practices; and having long waits to see a specialist.

Conclusion

Assuming these differences are representative, there appear to be international variations in the ability of primary care physicians to diagnose depression, but little differences in screening success. These might be explained by organisational factors.     

Health risk appraisal in older people 2: the implications for clinicians and commissioners of social isolation risk in older people

BACKGROUND: Social isolation is associated with poorer health, and is seen by the World Health Organisation (WHO) as one of the major issues facing the industrialised world. AIM: To explore the significance of social isolation in the older population for GPs and for service commissioners. DESIGN OF STUDY: Secondary analysis of baseline data from a randomised controlled trial of health risk appraisal. SETTING: A total of 2641 community-dwelling, non-disabled people aged 65 years and over in suburban London. METHOD: Demographic details, social network and risk for social isolation based on the 6-item Lubben Social Network Scale, measures of depressed mood, memory problems, numbers of chronic conditions, medication use, functional ability, self-reported use of medical services. RESULTS: More than 15% of the older age group were at risk of social isolation, and this risk increased with advancing age. In bivariate analyses risk of social isolation was associated with older age, education up to 16 years only, depressed mood and impaired memory, perceived fair or poor health, perceived difficulty with both basic and instrumental activities of daily living, diminishing functional ability, and fear of falling. Despite poorer health status, those at risk of social isolation did not appear to make greater use of medical services, nor were they at greater risk of hospital admission. Half of those who scored as at risk of social isolation lived with others. Multivariate analysis showed significant independent associations between risk of social isolation and depressed mood and living alone, and weak associations with male sex, impaired memory and perceived poor health. CONCLUSION: The risk of social isolation is elevated in older men, older persons who live alone, persons with mood or cognitive problems, but is not associated with greater use of services. These findings would not support population screening for individuals at risk of social isolation with a view to averting service use by timely intervention. Awareness of social isolation should trigger further assessment, and consideration of interventions to alleviate social isolation, treat depression or ameliorate cognitive impairment.     

Late-life depression in the primary care setting: Challenges,collaborative care,and prevention

Late-life depression is highly prevalent worldwide. In addition to being a debilitating illness, it is a risk factor for excess morbidity and mortality. Older adults with depression are at risk for dementia, coronary heart disease, stroke, cancer and suicide. Individuals with late-life depression often have significant medical comorbidity and, poor treatment adherence. Furthermore, psychosocial considerations such as gender, ethnicity, stigma and bereavement are necessary to understand the full context of late-life depression.     

Maternal-foetal bonding: the impact of domestic violence on the bonding process between a mother and child

Summary Objectives: To test the hypothesis that domestic violence has an impact on the maternal-foetal bond and the maternal-infant bond, and to investigate any relationship between the two bonding states (taking into account post-natal depression). Design: Case-control, unmatched, study with random cluster sampling. Setting: Refuge shelters in Central Birmingham and Greater London (cases). City hospital (Dudley Road), Bartley Green and Longbridge General Practices (controls). Subjects: Women who gave birth in the year preceding the study: 11 who experienced physical or mental abuse whilst pregnant, 27 who reported no abuse. Measures: Severity of abuse in the cases (ASS). Degree of maternal-foetal (ADS) and maternal-infant bonding (BPNB) achieved in cases and controls. Level of Post-Natal Depression in the cases (EPND). Results: Mothers who were abused during pregnancy are less likely to bond well with their foetus and subsequently their child. In non-abused mothers there is a prominent strengthening in maternal-child bonding after birth, this change is minimal in abused women. Within the index sample significantly positive correlations were found between MFB and MIB; MFB and ASS; and MIB and ASS scores. No such correlations were found in the control group. Abused women were more likely to suffer from post-natal depression as compared to their non-abused counterparts, the degree of depression was not related to the severity of the abuse experienced. Conclusions: Our findings suggest that exposure to abuse weakens the maternal-foetal bond, possibly making it not amenable to the normal strengthening post partum, thus diminishing the strength of the maternal-infant bond in abused mothers.     

The impact of receiving polygenic risk scores for alcohol use disorder on psychological distress,risk perception,and intentions to reduce drinking

For the return of polygenic risk scores to become an acceptable clinical practice in psychiatry, receipt of polygenic risk scores must be associated with minimal harm and changes in behavior that decrease one's risk for developing a psychiatric outcome. Data from a randomized controlled trial was used to assess the impact of different levels of hypothetical polygenic risk scores for alcohol use disorder on psychological distress, risk perception, and intentions to change drinking behaviors. The analytic sample consisted of 325 participants recruited from an urban, public university. Results demonstrated that there were significant increases in psychological distress as the level of genetic risk for alcohol use disorder increased. In addition, the perceived chance of developing alcohol use disorder significantly increased as the level of genetic risk increased. Promisingly, a greater proportion of participants indicated that they would intend to engage in follow-up behaviors, such as seeking additional information, talking to a healthcare provider about risk, and reducing drinking behaviors, as the level of genetic risk increased. Returning polygenic risk scores for alcohol use disorder in a clinical setting has the potential to promote risk-reducing behavior change, especially with increasing levels of genetic risk. The study was registered on ClinicalTrials.gov (Identifier: NCT05143073).     

Relapse of depression during pregnancy following antidepressant discontinuation: a preliminary prospective study

Summary. Objective: Pregnancy has frequently been referred to as a time of emotional well-being for patients. However, systematic data about the risk for relapse of depression during pregnancy are sparse.Method: We completed a longitudinal cohort study of thirty-two (N=32) women with histories of depression who were euthymic at conception and who either discontinued or attempted to discontinue antidepressant therapy proximate to conception. Subjects were prospectively followed across pregnancy once per trimester using structured clinical interviews. Rates of relapse and time to relapse were examined. Factors distinguishing the population with respect to risk for relapse including demographic characteristics and illness history were also examined.Results: Seventy-five percent (N=24) of patients relapsed during pregnancy. The majority of relapses (79%, N=19) occurred in the first trimester, and relapse was more prevalent in women with histories of more chronic depression.Conclusions: Pregnancy is not protective with respect to risk for relapse of depression. Careful treatment planning is necessary for those women on antidepressants who plan to conceive or who become pregnant.     

Prevalence of anxiety and depression during pregnancy in a private setting sample

Summary Objectives: To estimate the prevalence and risk factors for antenatal anxiety (AA) and antenatal depression (AD). Methods: We performed a cross sectional study of 432 women attending a private clinic in the city of Osasco, S?o Paulo, from 5/27/1998 to 5/13/2002. The following instruments were used: Spielberger state-trait anxiety inventory (STAI), Beck depression inventory (BDI), and a questionnaire for socio-demographic and obstetric data. Inclusion criteria were: pregnant women with no past or present history of depression, psychiatric treatment, alcohol or drug abuse and no clinical and obstetric complications. The prevalence of AA, according to STAI, and AD, according to Beck Inventory, were estimated with 95% confidence intervals (95% CI). Odds ratios and 95% CI were used to examine the association between AA and AD and exposures variables. Results: The prevalence of AA, state and trait were 59.5 (95 CI%: 54.8:64.1%) and 45.3% (95% CI: 40.6:50.0), respectively. The prevalence of AD was 19.6 (95% CI:15.9:23.4). In the multivariate analysis, AA-trait (OR: 5.26; 95% CI 2.17:12.5, p < 0.001), AA-state (OR: 2.27; 95% CI 1.08:4.76, p = 0.02) and AD (OR: 2.43; 95% CI 1.40:4.34, p = 0.002) were associated with lower women’s educational level. AA-trait (OR: 3.43; 95% CI 1.68:7.00, p = 0.001), AA-state (OR: 2.22; CI 95% 1.09:4.53, p = 0.02) and AD (OR: 2.82; CI 95% 1.35:5.97, p = 0.005) were also associated with not being married. AA-trait was associated with lower women’s income (OR: 2.22; 95% CI 0.98:5.26, p = 0.05) and not being white (OR: 1.7; 95% CI 1.00:2.91, p = 0.04), while AD was associated with lower couple’s income (OR: 2.43; 95% CI 1.40:4.34, p = 0.001) and greater number of previous abortions (OR: 2.21; 95% CI 1.23:3.97, p = 0.009). Conclusions: Prevalence of AA and AD were high in this sample of women attending a private care setting, particularly AA state and trace. AA and AD were associated with similar socio-demographic and socio-economic risk factors, suggesting some common environmental stressors may be involved.