Epidemiologic Catchment Area Follow-up Study Research Articles

The association between traumatic life events and insomnia symptoms among men and women: Results from the Baltimore Epidemiologic Catchment Area follow-up study

Study objectivesTrauma exposure likely contributes to poor sleep, but relatively few studies have empirically tested this, instead focusing on posttraumatic stress disorder. Moreover, little is known about sex differences in sleep after trauma. The current study used a cross-sectional and retrospective design to test hypotheses that trauma exposure would be associated with subsequent insomnia symptoms, particularly among women, even after accounting for important covariates. MethodData from Wave 3 (1993-1996) of the Baltimore Epidemiologic Catchment Area Study (N = 1920) were used to examine associations between remote (prior to past year) and recent (past year) trauma and current sleep disturbance (insomnia, hypersomnia symptoms) in the total sample (Mage= 55, 63.2% women, 57.7% white), and separately in men and women. Sensitivity analyses were conducted among individuals with no pretrauma sleep disturbance to examine incident sleep disturbance. ResultsAmong all participants, both remote (odds ratio [OR] = 1.95, 95% confidence interval [CI] [1.34, 2.85]) and recent (OR = 1.94, 95% CI [1.31, 2.87]) trauma exposure were associated with increased odds of insomnia (OR = 2.41, 95% CI [1.54, 3.76]) but not hypersomnia. Associations between trauma and insomnia were particularly strong among women, but null among men. The relationship between trauma exposure and insomnia symptoms persisted among individuals with no pretrauma history of insomnia. ConclusionResults suggest women may be vulnerable to insomnia symptoms as sequelae of trauma. Future research should examine prospective associations between trauma and sleep in larger samples and how assessment and treatment of insomnia among women trauma survivors reduces the public health impact of trauma and poor sleep.

Enduring mental health in the Baltimore epidemiologic catchment area follow-up study.

To estimate the prevalence of enduring mental health (EMH) and examine important correlates of EMH 23years later in the Baltimore Epidemiologic Catchment Area Follow-Up study. We estimated the prevalence of EMH among 964 adults with diagnostic data at all four study waves (1981-2004). Those with EMH were compared to those with any mental or behavioral disorder by demographic, psychosocial, and health characteristics. We used forward selection models to identify the most important predictors of EMH. Twenty-six percent of participants met criteria for enduring mental health across the four waves. Neuroticism, GHQ-20 score, childhood conduct problems, female sex, maternal depression, and poor self-rated health were negatively associated with EMH. We identified several malleable factors associated with a decreased likelihood of enduring mental health. Interventions that target high neuroticism, childhood conduct problems, or maternal depression may increase the likelihood that children achieve EMH later in life. Identifying and treating other factors such as poor self-reported health and greater psychological distress may also keep sub-clinical symptoms from developing into a full mental or behavioral disorder.

Job strain and cognitive change: the Baltimore Epidemiologic Catchment Area follow-up study

ObjectivesTo investigate the association between job strain and subsequent cognitive change over approximately 11 years, using data from the population-based Baltimore Epidemiologic Catchment Area follow-up study.MethodsThe sample ranged from 555...

Longitudinal associations of obesity with affective disorders and suicidality in the Baltimore epidemiologic catchment area follow-up study.

Our aim was to examine the longitudinal associations between obesity and mental health variables (psychiatric diagnoses and suicidal behaviors). Data were from waves 3 and 4 of the Baltimore Epidemiologic Catchment Area study (N = 1071). Participants were aged 30 to 86 years at wave 3 (mean, 47.6 years; SD, 12.8). The prevalence of obesity increased from 27.6% to 39.1% during the follow-up. Logistic regression analyses revealed no associations between baseline obesity and onset of mental disorders or suicidal behaviors between waves 3 and 4 in fully adjusted models; however, baseline obesity predicted new-onset suicide attempts in models adjusted for sociodemographics and mental disorders. Baseline depression predicted weight gain during the 11-year follow-up period (F = 4.014, p < 0.05), even after controlling for important confounders. Overall, most mental health variables were not associated with obesity, suggesting that clinicians and others should be wary of "weight-ism" and avoid making the assumption that higher body weight relates to mental health problems.

Five-Factor Model Personality Traits as Predictors of Incident Coronary Heart Disease in the Community: A 10.5-Year Cohort Study Based on the Baltimore Epidemiologic Catchment Area Follow-Up Study

Certain personality and behavioral traits (e.g., type A and type D) have been reported to be associated with development and progression of coronary heart disease (CHD), but few have examined the relationship using a comprehensive assessment of personality along with a structured assessment of psychiatric disorders. Based on participants (age: 47.3 ± 12.8; female: 62.6%) of the Baltimore Epidemiologic Catchment Area follow-up study, we examined the relationship between the 5 major domains of personality traits (neuroticism, extraversion, openness, agreeableness, and conscientiousness) and incident CHD between Wave III (1993-1996) and Wave IV (2004-2005). Incident CHD developed in 65 participants during the follow-up. Those with incident CHD had lower on openness (44.06 ± 9.29 vs. 47.18 ± 8.80; p = 0.007) and extraversion (45.98 ± 9.25 vs. 49.12 ± 8.92; p = 0.007) scores than those without. Logistic regression models revealed an inverse association (OR = 0.73; 95% CI = 0.54-0.98) between openness factor z-scores and incident CHD after adjusting for putative confounding factors, including DSM III-R Major Depressive Disorder. High openness appears to be an independent protective factor for incident CHD in the community. Future studies should examine behavioral and pathophysiologic mechanisms underlying this association.

Personality and Cognitive Decline in the Baltimore Epidemiologic Catchment Area Follow-up Study

To determine the association between personality domains and 11-year cognitive decline in a sample from a population-based study. Data from Waves 3 (1993-1996) and 4 (2003-2004) of the Baltimore cohort of the Epidemiologic Catchment Area (ECA) study were used for analyses. The sample included 561 adults (mean age ± SD: 45.2 ± 10.78 years) who completed the NEO Personality Inventory-Revised prior to Wave 4. Participants also completed the Mini-Mental State Examination (MMSE) and immediate and delayed word recall tests at Wave 3, and at Wave 4, 10.9 ± 0.6 years later. In models adjusted for baseline cognitive performance, demographic characteristics, medical conditions, depressive symptoms, and psychotropic medication use, each 10-point increase in Neuroticism T-scores was associated with a 0.15-point decrease in MMSE scores (B=-0.15, 95% confidence interval [CI]:-0.30,-0.01), whereas each 10-point increase in Conscientiousness T-scores was associated with a 0.18-point increase on the MMSE (B= 0.18, 95% CI: 0.04, 0.32) and a 0.21-point increase in immediate recall (B= 0.21, 95% CI: 0.003, 0.41) between baseline and follow-up. Findings suggest that greater Neuroticism is associated with decline, and greater Conscientiousness is associated with improvement in performance on measures of general cognitive function and memory in adults. Further studies are needed to determine the extent to which personality traits in midlife are associated with clinically significant cognitive outcomes in older adults, such as mild cognitive impairment and dementia, and to identify potential mediators of the association between personality and cognitive trajectories.

Relationship between personality disorder dimensions and verbal memory functioning in a community population

Based on the Baltimore Epidemiologic Catchment Area (ECA) follow-up survey, we examined relationships between dimensions of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) personality disorders and both subjective and objective memory functioning in a community population. Our study subjects consisted of 736 individuals from the ECA follow-up study of the original Baltimore ECA cohort, conducted between 1993 and 1996 and available for assessment in the Hopkins Epidemiology Study of Personality Disorders from 1997 to 1999. Subjects were assessed for DSM-IV personality disorders using a semi-structured instrument, the International Personality Disorder Examination, and were asked about a subjective appraisal of memory. Verbal memory function, including immediate recall, delayed recall, and recognition, were also evaluated. Multiple linear regression analyses were used to determine associations between personality dimensions of DSM-IV Axis II traits and subjective and objective memory functioning. Scores on schizoid and schizotypal personality dimensions were associated with subjective and objective memory dysfunction, both with and without adjustment for Axis I disorders. Borderline, antisocial, avoidant, and dependent personality disorder scores were associated with subjective memory impairment only, both with and without adjustment for Axis I disorders. This study suggests that subjective feelings of memory impairment and/or objective memory dysfunction are associated with specific personality disorder dimensions.

Personality Disorders and Traits as Predictors of Incident Cardiovascular Disease: Findings From the 23-Year Follow-Up of The Baltimore ECA Study

Over the past several decades, the relationship between personality traits and heart disease has interested clinicians and researchers alike. The authors investigated personality disorders (PDs) and PD dimensional traits as prospective risk factors for incident cardiovascular disease (CVD) in the Baltimore Epidemiologic Catchment Area (ECA) follow-up study. In 1981, 244 community residents were examined for DSM–III PDs, and PD dimensional traits and were followed for incident CVD by 2004. Logistic-regression models with or without adjustment for potential confounders revealed that Cluster B PD and PD dimensional traits at baseline were consistently associated with increased risk of incident CVD by 2004. Post-hoc analysis also revealed that Cluster B PD and traits also predict CVD mortality. Cluster B PDs and dimensional traits may be independent risk factors for incident CVD in the community.

Personality Disorders and Traits as Predictors of Incident Cardiovascular Disease: Findings From the 23-Year Follow-Up of The Baltimore ECA Study

Over the past several decades, the relationship between personality traits and heart disease has interested clinicians and researchers alike. The authors investigated personality disorders (PDs) and PD dimensional traits as prospective risk factors for incident cardiovascular disease (CVD) in the Baltimore Epidemiologic Catchment Area (ECA) follow-up study. In 1981, 244 community residents were examined for DSM-III PDs, and PD dimensional traits and were followed for incident CVD by 2004. Logistic-regression models with or without adjustment for potential confounders revealed that Cluster B PD and PD dimensional traits at baseline were consistently associated with increased risk of incident CVD by 2004. Post-hoc analysis also revealed that Cluster B PD and traits also predict CVD mortality. Cluster B PDs and dimensional traits may be independent risk factors for incident CVD in the community.

History of manic and hypomanic episodes and risk of incident cardiovascular disease: 11.5 year follow-up from the Baltimore Epidemiologic Catchment Area Study

BackgroundWhile several studies have suggested that bipolar disorder may elevate risk of cardiovascular disease, few studies have examined the relationship between mania or hypomania and cardiovascular disease. The purpose of this study is to examine history of manic and hypomanic episodes as an independent risk factor for cardiovascular disease (CVD) during an 11.5year follow-up of the Baltimore Epidemiologic Catchment Area Follow-up Study. MethodsAll participants were psychiatrically assessed face-to-face based on Diagnostic Interview Schedule in 1981 and 1982 and were categorized as having either history of manic or hypomanic episode (MHE; n=58), major depressive episode only (MDE; n=71) or no mood episode (NME; n=1339). Incident cardiovascular disease (CVD; n=67) was determined by self-report of either myocardial infarction (MI) or congestive heart failure (CHF) in 1993–6. ResultsCompared with NME subjects, the odds ratio for incident CVD among MHE subjects was 2.97 (95% confidence interval: 1.40, 6.34) after adjusting for putative risk factors. ConclusionsThese data suggest that a history of MHE increase the risk of incident CVD among community residents. Recognition of manic symptoms and addressing related CVD risk factors could have long term preventative implications in the development of cardiovascular disease in the community.

Anxiety disorders and risk for suicide attempts: findings from the Baltimore Epidemiologic Catchment area follow-up study

Our objective was to determine whether the presence of an anxiety disorder was a risk factor for future suicide attempts. Data were drawn from the 13-year follow-up Baltimore Epidemiological Catchment Area survey (n=1,920). Multiple logistic regression analysis was used to determine the association between baseline anxiety disorders (social phobia, simple phobia, obsessive-compulsive disorder, panic attacks, or agoraphobia) and subsequent onset suicide attempts. The presence of one or more anxiety disorders at baseline was significantly associated with subsequent onset suicide attempts (adjusted odds ratio 2.20, 95% confidence interval 1.04-4.64) after controlling for sociodemographic variables and all baseline mental disorders assessed in the survey. These findings suggest that anxiety disorders are independent risk factors for suicide attempts, and underscore the importance of anxiety disorders as a serious public health problem.

Psychiatrists' Ascertained Treatment Needs for Mental Disorders in a Population-Based Sample

Population-based studies of prevalence have been used to approximate the amount of need for treatment of mental disorders. This study aimed to estimate need for treatment of alcohol dependence, major depression, panic disorder, agoraphobia, and social phobia. Psychiatrists used the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) to assess individuals in a probability sample of the Baltimore Epidemiologic Catchment Area follow-up study for need for and use of mental health services. Population-based estimates were calculated with probability weights. The SCAN sample included 816 participants who were interviewed between 1993 and 1999. Prevalence of need for mental health services in the general population was 28.7%+/-2.7%. Among the disorders studied, the greatest need was for treatment of alcohol dependence; 90% of the SCAN sample who met criteria for this diagnosis, or 13.6%+/-1.9% of the population, needed treatment. In the general population, 10.5%+/-2.1% needed treatment for major depression; 5.2%+/-.9%, for social phobia; 5.2%+/-1.6%, for panic disorder; and 3.2%+/-.9%, for agoraphobia. The highest needs for specific treatment modalities were self-help groups for alcohol dependence, talk therapy for depression, behavior modification for social phobia and agoraphobia, and antidepressant medications for panic disorder. Overall, less than 33% of needs were met. Social phobia and alcohol dependence were the two disorders with the highest proportion of unmet need. Prevalence of mental disorders is only an approximation of the need for treatment. There is a substantial need for mental health services in the general population. Most individuals who would benefit from treatment are not receiving any type of mental health services.

Do We Know Need When We See It?

In day-to-day practice, we view need for treatment much as former Supreme Court Justice Potter Stewart viewed pornography—we know it when we see it. However, defining need for mental health care can be both complex and politically charged. Many of the major health policy debates in the past quarter century have involved battles over how need for care should be defined and who should get to define it. The most common method of defining need is based on prevalence of a mental disorder. However, as is often noted, diagnosis is a crude proxy for need. Some people with diagnoses of mental disorders may not need professional care; others without formal diagnoses may benefit from treatment. So, is it possible to devise a simple definition that more closely approximates the concept? In a study reported in this issue Messias and colleagues sought to address this “need conundrum” by asking psychiatrists to directly assess it. As part of the Baltimore Epidemiologic Catchment Area follow-up study, psychiatrists interviewed each respondent and assessed whether they believed respondents required particular types of treatment. There was a partial, but not complete, concordance between diagnosis and psychiatrist-assessed need. For instance, more than one-quarter of individuals diagnosed as having major depression were not rated by the psychiatrists as having a need for any treatment. Psychiatrist-based assessments may solve some of the problems created by the use of diagnostic-based evaluations of need. Clinicians can factor severity, treatment effectiveness, and other psychosocial factors into their decisions. However, use of clinician-based assessments also creates some new problems. Left to their own devices, psychiatrists vary widely in how they assess need and deliver care, given their training, organizational factors, local practice patterns, and financial incentives. Need for mental health treatment is best represented not as a unitary construct but as a series of overlapping circles. The first circle is the level of disease burden, which can be measured as diagnoses, symptomatology, and functional burden. The second circle is availability of treatments, because need for treatment implies the existence of a therapy. The third is consumers’ perspective on need, which may not agree with the first two measures. Finally, as examined by Messias’ team, a clinician’s judgment can add valuable contextual information. When these four definitions overlap, assessing need is easy. When they diverge, it is important to reconcile them through dialogue that allows balancing of competing priorities. Throughout the process, we must recognize the complexity of defining need in mental health and the reality that we may not always know it even when we think we see it.

Incident hypertension associated with depression in the Baltimore Epidemiologic Catchment area follow-up study

Background This study evaluates the role of depression as a specific risk factor for hypertension. Methods This study analyzed the prospective data in the Baltimore Epidemiologic Catchment Area (ECA) Follow-up Study ( n=1920), a longitudinal population-based study of mental illness in East Baltimore. Incident cases of hypertension as assessed by self-report ( n=148) in 1993 were compared to the remaining cohort without hypertension ( n=901) across three waves of ECA interviews (1981, 1982, 1993). Depression and related symptoms were measured at baseline (1981) by the Diagnostic Interview Schedule (DIS) and categorized as dysphoria, dysthymia, or major depressive episode (MDE) according to Diagnostic and Statistical Manual (DSM) III criteria. Results Individuals with a major depressive episode compared to those who reported never having dysphoria had a marginally significant increased risk for hypertension (Odds Ratio (OR)=2.16; 95% Confidence Interval (CI) (0.94,4.98)) after adjustment for age, gender, race, body mass index, Nam-Powers socioeconomic score, alcohol usage, smoking, exercise, diabetes status, and number of general medical visits. MDE reported to have begun more than a year before the baseline measurement was associated with an increased risk for incident hypertension (Adjusted OR=3.67, 95% CI (1.25,10.79). Limitations Potential misclassification of self-reported hypertension outcome. Conclusions Even though the data are based on self-report of hypertension, these findings suggest that depression may be an independent risk factor for hypertension particularly for those with recurrent episodes or a long term history of the disease.

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

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

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

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

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

The cross-sectional relation between migraine headaches and affective disorders has been demonstrated in studies of clinical and community populations. Few studies have investigated the prospective relation between psychiatric disorders and migraine headaches. A prospective follow-up of the Baltimore, Md, cohort of the Epidemiologic Catchment Area Study assessed psychopathologic features in 1981 and again between 1993 and 1996. Interviews included a history of headaches at baseline and self-reported assessment of migraine headaches at follow-up. Risk estimates for incident migraine headaches by 1981 demographic variables and psychopathologic features were calculated. The cross-sectional association between prevalent migraine and lifetime psychiatric diagnoses was estimated. In the at-risk population of 1343, there were 118 incident cases of migraine headaches. The age- and sex-specific incident rates of migraine headaches followed the expected patterns, with younger age and female sex identified as risk factors. In cross-sectional analyses, major depression (odds ratio, 3.14; 95% confidence interval, 2.03-4. 84) and panic disorder (odds ratio, 5.09; 95% confidence interval, 2. 65-9.79) had the strongest associations, and alcohol and other substance abuse were not associated. In logistic regression models including age, sex, and psychiatric illness in 1981, only phobia was predictive of incident migraines (odds ratio, 1.70; 95% confidence interval, 1.11-2.58). Affective disorders were not predictive of incident migraine headaches. Including a history of tricyclic antidepressant use did not change the results. There is a strong cross-sectional relation between affective disorders and migraine headaches in this cohort. However, there is no association between antecedent affective disorders and incident migraine headaches in this population-based prospective study.

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

Background: There is an ongoing research effort to test if depression is a homogeneous clinical syndrome and to identify valid and useful subtypes based on the number and nature of depressive symptoms. This study summarizes the patterns of depressive symptoms evident in a prospective study of the general population and examines the validity of potential subtypes by studying their course and etiologic heterogeneity. Methods: A general population sample of 1920 adults (aged 18–96) from the Baltimore Epidemiologic Catchment Area (ECA) follow-up study (1981 to 1993/6) were examined. Data on diagnoses, symptoms, course and risk factors were collected using the Diagnostic Interview Schedule (DIS). Latent class analysis was applied to summarize symptom patterns. Course characteristics and risk factor profiles were compared among potential subtypes based on the number of symptom groups or symptom patterns. Logistic regression models were used to examine the etiologic heterogeneity among potential subtypes based on symptoms. Results: The number of symptom groups gave the most efficient insight into differential etiologic processes. Severe depression (7–9 symptom groups) was associated with female gender, family history of depression but not with stressful life events before the onset of the first episode. Moderate (5–6 symptom groups) and mild depression (3–4 symptom groups) were associated with family history of depression, stressful life events before the onset, but not with female gender. The latent class model generated patterns of depressive psychopathology as follows: anhedonia, suicidal, psychomotor, and severely depressed subtypes. The Anhedonia subtype showed a course and risk factor profile distinct from the others. Limitations: The measurement of psychopathology was based on self-reported DIS interviews instead of psychiatric assessments. Recall or report bias cannot be excluded in the ascertainment of family history and stressful life events. Conclusions: Depression is heterogeneous, even below the threshold of syndromal diagnosis. The severity of an episode appears to be more informative than the pattern of symptoms, with the possible exception of a putative anhedonic subtype.

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

To assess the relationship between psychiatric disorders and lack of regular medical care in individuals with chronic medical diseases. Nine hundred sixty-three respondents to the household-based Baltimore Epidemiologic Catchment Area (ECA) Follow-Up Study were interviewed in 1981, 1982, and 1993-1996. The main outcome measures were: 1) not receiving regular care from a health professional for an active chronic medical condition in 1981, 2) persistent lack of regular medical care, and 3) leaving regular medical care. In cross-sectional analyses, having a psychiatric disorder (OR 1.70, 95% CI 1.17-2.48) was associated with not receiving regular medical care. This was mostly due to individuals with phobic disorder (OR 1.57, 95% CI 1.02-2.43). In prospective analyses, depression (RR 2.4, p < 0.04) and alcohol abuse (RR 2.9, p < 0.001) predicted leaving regular medical care one year later. Phobic disorder (RR 2.8, p < 0.001) predicted leaving care thirteen years later. Psychiatric disorders appear to place an individual at risk for irregular medical care. Studies of the quality and continuity of care for patients with chronic medical conditions should include measures of common psychiatric conditions.