Epidemiologic Catchment Area Survey Research Articles

A Case Study of Obsessive-Compulsive Disorder: Some Diagnostic Considerations

Obsessive-Compulsive Disorder (OCD) was considered a rare disorder prior to 1984 when the initial results from the Epidemiologic Catchment Area survey demonstrated a substantial prevalence of the disorder (1). Thus there may be many patients today who entered treatment prior to 1984 with undiagnosed OCD. This paper gives the history of one such patient and reviews the current literature on OCD as it pertains to the diagnostic evidence in this case.

Is there a relationship between "heavy drinking" and HIV high risk sexual behaviors among general population subjects?

The authors investigated the association between "heavy drinking" and sexual behaviors among 2,581 general population subjects from the St. Louis Epidemiologic Catchment Area survey conducted from 1981 to 1983. Lifetime sexual behaviors included promiscuity, infidelity, receiving money for sex, and same gender sex. It was found that sexual behaviors were associated with lifetime heavy drinking. Regardless of gender, race, or age, "heavy drinkers" were significantly more likely to report each of the high risk sexual behaviors, except same gender sex, compared to "nonheavy drinkers." With the multiple logistic regression analyses it was found that "heavy drinking" non-Black females, Black males regardless of drinking history, "heavy drinking" males, and younger subjects regardless of drinking history were at higher risk to report the high risk sexual behaviors. This study confirms that there is a strong association between "heavy drinking" and high risk sexual behaviors in a midwestern population. This is the first study to find an association between alcohol drinking patterns and high risk sexual behaviors in the general population. Implications of these findings for public health education efforts are discussed.

Identifying suicidal ideation in general medical patients

<h3>Objectives.</h3> —To describe characteristics of general medical patients with suicidal ideation and to develop an efficient clinical strategy for identifying these patients. <h3>Design.</h3> —Cross-sectional analysis of data without intervention. <h3>Setting.</h3> —A representative sample of community respondents interviewed as part of the National Institute of Mental Health Epidemiologic Catchment Area surveys. <h3>Subjects.</h3> —A total of 6041 individuals who reported receiving care in general medical settings in the 6 months preceding the baseline interview. <h3>Main Outcome Measure.</h3> —Suicidal ideation within the year preceding the baseline interview. <h3>Results.</h3> —A total of 154 patients (2.6%) had experienced suicidal thoughts within the previous year. In multivariate analyses, the following sociodemographic factors were significantly associated with having suicidal ideation: being white (odds ratio [OR], 2.8;<i>P</i>&lt;.001) relative to African American, separated or divorced (OR, 1.8;<i>P</i>=.03) relative to married, and aged 18 to 30 years (OR, 2.3;<i>P</i>=.02) or aged 31 to 50 years (OR, 2.1;<i>P</i>=.03) relative to those older than 65 years. Gender, educational level, and socioeconomic status were not statistically associated with suicidal ideation. Psychiatric disorders significantly associated with suicidal ideation were major depression (OR, 10.3;<i>P</i>&lt;.001), panic disorder (OR, 5.2;<i>P</i>&lt;.001), alcohol disorder (OR, 2.0;<i>P</i>=.04), and phobic disorder (OR, 1.6;<i>P</i>=.02) within the previous year. However, only 34% of respondents with suicidal ideation met criteria for major depression. With the aid of stepwise logistic regression, a four-item screening questionnaire, the Suicidal Ideation Screening Questionnaire, was developed to predict patients with suicidal ideation. Likelihood ratios for suicidal ideation increased from 0.21 to 32.8 with more positive responses to questions concerning symptoms of hopelessness, guilt, depressed mood, and sleep disturbances. <h3>Conclusions.</h3> —If the results from the four-item screen are reproduced in a clinical setting, general medical patients with a high likelihood for suicidal ideation may be identified with a brief screening questionnaire. This screen would have greater sensitivity than would be achieved by assessing suicidal ideation only in those patients who meet criteria for a distinct psychiatric disorder. (<i>JAMA</i>. 1994;272:1757-1762)

Comparison of alcohol dependence in subjects from clinical, community, and family studies.

This study contrasts the prevalence of alcohol-related symptoms, ages of onset of alcoholism milestones, and lifetime prevalence of other psychiatric disorders in three samples of alcohol-dependent individuals: alcoholics sampled from a variety of clinical settings (not necessarily alcoholism treatment facilities), relatives of alcoholic probands who participated in a Family Study of alcoholism, and alcoholics identified in the St. Louis Epidemiologic Catchment Area survey. Alcohol dependence (with or without abuse) was assessed using DSM-III diagnostic criteria for all samples. Clinical alcoholics had significantly more lifetime alcohol symptoms than Family Study and Community alcoholics and a significant excess of many alcohol symptoms. Onset information indicated that the three groups were similar in terms of appearance of milestones of alcohol dependence. For females aged 45 or younger, lifetime prevalence of major depression was high in both Clinical and Family Study alcoholics compared with Community alcoholics; male alcoholics from the Community Study had an excess of drug dependence. Findings suggest that, although alcoholics identified in clinical settings may have more severe alcohol dependence, certain types of psychiatric comorbidity are present to a greater degree in other samples of untreated alcoholics.

Treated Prevalence Rates of Severe Mental Illness Among HMO Members

The authors examined the extent to which health maintenance organizations (HMOs) enroll and provide services to people with severe mental illness. The automated pharmacy system of a large HMO identified members who had received a prescription for an antipsychotic drug or lithium during the two-year study period (1986 and 1987). These data, combined with data from a 2 percent random sample of HMO members and from medical records, were used to identify members who satisfied DSM-III-R criteria for schizophrenia and bipolar disorder. Treated prevalence rates derived from these data were compared with estimated treated prevalence data obtained in the National Institute of Mental Health's Epidemiologic Catchment Area (ECA) survey. Although methodological complications and small sample sizes precluded a detailed comparison, the study found a significantly lower treated prevalence rate of schizophrenia among HMO members than in the ECA survey. The treated prevalence rate of bipolar disorder was also lower than the ECA rate, but the difference was not significant. The differences in treated prevalence rates seemed to be the result of different study methodologies and factors influencing HMO membership. The results underscore the need for a comprehensive study of the course of severe mental illness among HMO members.

Religious Affiliation and Psychiatric Disorder Among Protestant Baby Boomers

The authors examined the relationship between religious affiliation and psychiatric disorder among Protestant members of the baby-boom generation (those born between 1945 and 1966) who resided in the Piedmont area of North Carolina. Data were obtained on six-month and lifetime rates of major psychiatric disorders among 853 Protestant baby boomers during wave II of the National Institute of Mental Health's Epidemiologic Catchment Area survey, conducted in 1983-1984. Participants were grouped into three categories based on religious affiliation: mainline Protestants, conservative Protestants, and Pentecostals. Rates of disorder were compared across denominational groups, controlling for sex, race, physical health status, and socioeconomic status and stratifying by frequency of church attendance. The analyses were repeated for 1,826 middle-aged and older Protestants born between 1889 and 1944, and the results were compared with the findings for baby boomers. Among the baby boomers, Pentecostals had significantly higher six-month and lifetime rates of depressive disorder, anxiety disorder, and any DSM-III disorder. Mainline Protestants had the lowest six-month and lifetime rates of anxiety disorder and the lowest six-month rates of any DSM-III disorder, whereas conservative Protestants had the lowest six-month and lifetime rates of depressive disorder and the lowest lifetime rates of any DSM-III disorder. These relationships among baby boomers were weaker among middle-aged and older Protestants, although a new association with alcohol abuse or dependence emerged among older Pentecostals. When analyses were stratified by frequency of church attendance, associations between psychiatric disorder and Pentecostal affiliation were strongest among infrequent churchgoers, a group also unlikely to seek help from mental health professionals. Young adult Pentecostals in the Peidmont area experienced high rates of psychiatric disorder, which was not generally true for Pentecostals who were middle aged or older. Infrequent churchgoers appeared to be at greatest risk, although they seldom sought professional help for their problems.

Increased rates of drug abuse and dependence after onset of mood or anxiety disorders in adolescence.

The aim of the study was to examine the relationship of prevalence and age at onset of drug abuse and dependence to mood and anxiety disorders, using epidemiologic data. Life-table analyses using data collected on 20,745 respondents in the National Institute of Mental Health's Epidemiologic Catchment Area surveys were used to calculate the hazard rate for developing drug disorders subsequent to adolescent-onset or adult-onset mood and anxiety disorders. For respondents with onset of a mood disorder during adolescence, the peak age for developing drug abuse and dependence occurs between 15 and 19 years; when the mood disorder begins in adulthood, the peak onset for drug disorders is delayed to between 25 and 29 years of age. Similar but less striking results are found for onset of drug abuse and dependence following either panic or obsessive-compulsive disorder. These findings highlight the need for future prospective studies of children and adolescents to date the onset of mental disorders and substance use disorders. If prospective studies can confirm the apparent pattern of substance use disorders occurring subsequent to mental disorders, prevention and treatment strategies for youth at risk should be developed.

Depressive symptoms among general medical patients: prevalence and one-year outcome.

Using prospective data from the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area surveys, we examined the relationship of depressive symptoms among patients seen by general medical practitioners, with the subsequent development of major depressive disorder. The goals of the analysis were to determine 1) the 1-year psychiatric status of these individuals, and 2) to evaluate factors associated with the risk of major depressive disorder (MDD) or dysthymia. Between 1980 and 1984, collaborators of the NIMH Epidemiologic Catchment Area program recruited 18,571 adult participants after probability sampling of census tracts and households in five metropolitan areas. To assess the occurrence of psychiatric conditions over time, staff administered the Diagnostic Interview Schedule soon after sampling and again at follow-up 1 year later. For this analysis, the study sample was limited to respondents who reported seeing a general medical physician in the previous 6 months and who were free of current depressive disorder at the baseline interview. Overall, 41% of the general medical patients reported experiencing at least one depressive symptom in the past 6 months. Between 3 and 5% of the individuals with depressive symptoms developed MDD or dysthymia at the follow-up interview. Although individuals with depressed mood had a slightly higher estimated relative risk compared with individuals with vegetative, or nonvegetative (cognitive) depressive symptoms, no single classification of symptoms was appreciably more likely to signal MDD or dysthymia 1 year later. However, the risk of depression increased with the number of depressive symptoms reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Religious practices and alcoholism in a southern adult population.

The study examined associations between religious variables and alcohol abuse and dependence among 2,969 North Carolina residents aged 18 to 97 who participated in the 1983-1984 National Institute of Mental Health Epidemiologic Catchment Area survey at its Piedmont location. Six-month and lifetime prevalence of alcohol disorders were compared among participants reporting varying levels of religious activity. Data were collected on frequency of Bible reading, prayer, and church attendance; time spent watching or listening to religious programming on television or radio; importance of religion; religious denomination; and identification as "born-again" Christians. Recent and lifetime alcohol disorders were less common among weekly churchgoers and those who considered themselves born again. Recent, but not lifetime, alcohol disorders were also less common among respondents who frequently read the Bible or prayed privately. Alcohol disorders were more common among those who frequently watched or listened to religious television and radio. Lifetime, but not recent, alcohol disorders were more prevalent among members of Pentecostal denominations. Longitudinal study is necessary to further clarify and explain these relationships between religious practices and alcohol disorders.

Religion and anxiety disorder: An examination and comparison of associations in young, middle-aged, and elderly adults

We examined and compared associations between religious variables and anxiety disorders in 1025 young (ages 18 to 39), 645 middle-aged (ages 40 to 59), and 1299 elderly (ages 60 to 97) community-dwelling adults who participated in Wave II of the Piedmont NIMH Epidemiologic Catchment Area survey. Religious variables included church attendance, prayer and Bible reading, religious TV viewing, importance of religion, religious denomination, and “born again” status. Both six-month (recent) and life-time anxiety disorders were examined. All analyses were controlled for sex, chronic illnesses, recent negative life events, and socioeconomic status using the Cochran-Mantel-Haenszel method. In young adults, rates of anxiety disorder were lower among frequent church attenders, mainline Protestants, and those considering themselves “born again”. On the other hand, anxiety disorder was more frequent among younger adults affiliated with fundamentalist Pentecostal religious groups, those with no religious affiliation, and frequent religious TV viewers or radio listeners. Among middle-age adults, social phobia was less common among frequent church attenders and those considering themselves “born again”, although these differences disappeared when social support was controlled for. As reported elsewhere, there was no relationship between religion and anxiety disorder in older adults. These findings suggest a pattern of both positive and negative relationships between religion and anxiety disorder that is most evident among uoung adults age 18 to 39, and weakens with age as dynamic factors increase the complexity of these relationships.

Using ECA survey data to examine the effect of job layoffs on violent behavior.

The study examined two hypotheses: that being laid off increases the likelihood of violence and that being employed in an industry in which employment is unexpectedly low decreases the likelihood of violence. Logistic regression analyses were used to examine data for more than 4,000 persons who participated in initial and follow-up interviews as part of the Epidemiologic Catchment Area survey. Data for persons who were working and not violent at the time of the initial interview but who were unemployed at reinterview were examined, as were data for persons who remained employed in industries with low employment levels. The risk of violent behavior of those who were laid off was nearly six times higher than that of their employed counterparts. Controlling for concurrent psychiatric disorder did not reveal a lower risk. The risk of violent behavior was reduced among those who remained employed in industries where layoffs were occurring. Economic contraction seems to affect violence in the community in two countervailing processes--one process increases violence and one reduces it. However, the net effect may well be that violence decreases in communities experiencing economic contraction.

Cocaine use and other suspected risk factors for obsessive-compulsive disorder: a prospective study with data from the Epidemiologic Catchment Area surveys

Using prospectively gathered epidemiologic data, we sought to estimate the degree to which the risk of obsessive-compulsive disorder might be elevated among adults actively using cocaine, with and without illicit use of marijuana or other controlled substances. Study subjects were selected in 1980–1984 by taking probability samples of adult household residents at five sites of the Epidemiologic Catchment Area (ECA) Program: New Haven, Connecticut; Baltimore, Maryland; St. Louis, Missouri; Durham-Piedmont, North Carolina; Los Angeles, California. Soon after sampling at baseline, a total of 18 572 participants completed standardized interviews to measure suspected risk factors (including illicit drug use) and to evaluate whether they had met diagnostic criteria for currently or formerly active obsessive-compulsive disorder (OCD), as well as other mental disorders. The interviews were re-administered 1 year later to identify incident cases among 13 306 at-risk participants, 414 being active cocaine users. After sorting these participants into strata defined by age and census tract of household residence and after excluding persons found at baseline to have active or prior OCD, we found 105 incident cases of OCD within 103 of the age-matched and residence-matched strata, which also contained a total of 514 subjects who had not developed OCD. Applying standard epidemiologic strategies presented in prior ECA research reports, we performed conditional multiple logistic regression to estimate the risk of OCD for active cocaine users versus non-users. We also performed unconditional multiple logistic regression to estimate OCD risk for the 414 active cocaine users versus the 12 892 participants not using cocaine. Both of these epidemiologic strategies yielded consistent results: subjects actively using cocaine and also marijuana were found to be at increased risk for OCD. Under the conditional model, the estimated relative risk was 7.2 ( P = 0.03), while the value from unconditional regression was 4.1 ( P = 0.01). Active users of cocaine almost always were active users of marijuana or some other controlled substance, so it was not possible to estimate a relative risk value for subjects using cocaine only. Nonetheless, if replicated, this epidemiologic test of the cocaine-OCD hypothesis warrants attention in laboratory and clinical research, as do other suspected risk factors identified in the study, including sex (being female), employment status (not working for pay) and a prior history of distinct psychiatric disorders such as alcohol dependence, affective disorders and phobic disorders.

Religious affiliation and major depression.

Data from the Duke Epidemiologic Catchment Area survey were used to examine the relationship between religious affiliation and major depression among 2,850 adults in the community. Religious affiliations were categorized into six groups: mainline Protestant (27 percent), conservative Protestant (59 percent), Pentecostal (4.2 percent), Catholic (2.4 percent), other religions (2.6 percent), and no affiliation (4.4 percent). The six-month prevalence of major depression among Pentecostals was 5.4 percent, compared with 1.7 percent for the entire sample. Even after psychosocial factors such as gender, age, race, socioeconomic status, negative life events, and social support were controlled for, the likelihood of major depression among Pentecostals was three times greater than among persons with other affiliations. Carefully designed studies are needed to understand the complex interactions of religion and mental health.

Covariance of personality, neurocognition, and schizophrenia spectrum traits in the community

Clinical researchers have observed in relatives of schizophrenic individuals abnormal personality traits resembling the psychopathology of schizophrenia. Further similarities have been observed in correlations between measures of brain function, including attention and executive abilities, and these personality psychopathologies. However, two methodologic factors might account for the covariation of these ‘schizophrenia spectrum’ personality traits and measures of brain function. Clinical selection bias (Berkson's bias) might result in subjects with overlapping conditions being more likely to be studied, and normal personality attributes could affect performance on neurobehavioral tasks. This study investigated relationships between neurobehavioral correlates of schizophrenia, clinical schizophrenia spectrum personality traits, and normal personality dimensions in the five-factor model of personality. To avoid Berkson's bias, subjects expected to have a high probability of spectrum traits were recruited from the Baltimore Epidemiologic Catchment Area Survey community sample. About 40% of the sample were found to have DSM-IIIR Schizotypal, Schizoid, or Paranoid Personality Traits or Disorders. Schizophrenia Spectrum traits showed significant associations with personality dimensions of the five factor model, particularly Openness to Experience and Neuroticism. In ordinary linear regression models, after adjustment for a number of normal personality characteristics, Schizotypal Personality Traits were still strongly associated with perseverative responses on the Wisconsin Card Sorting Test (WCST). In logistic regression models, subjects with Schizotypal, Schizoid, or Paranoid Traits differed in terms of normal personality profiles and WCST performance.

Reevaluation of secular trends in depression rates.

Results of numerous community surveys of psychiatric illness suggest a striking change in the occurrence of depression, with younger generations experiencing higher lifetime risk and earlier age of onset. Data from the National Institute of Mental Health Epidemiologic Catchment Area Survey (a cross-sectional survey of psychiatric morbidity in five US communities conducted between 1980 and 1984) were reexamined for evidence of methods effects which might contribute to these unexpected findings. A pattern of higher lifetime risk and earlier age of onset among recent birth cohorts was observed for every psychiatric disorder examined, with schizophrenia, major depression, and panic disorder showing equally strong trends. For respondents of all ages, reported first onset of major depression clustered in the 10-year period prior to the study interview, in contrast to the expectation that older respondents would report onset in early adulthood. Examination of individual psychiatric symptoms revealed a nearly universal pattern of decreasing lifetime prevalence among older respondents, a reversal of the expected accumulation of lifetime symptoms with age. These findings suggest that effects of study methods may contribute to the apparent temporal trends in prevalence of depression and that cross-sectional surveys may underestimate lifetime psychiatric morbidity among older respondents. Generational changes in the lifetime risk of depression or other psychiatric disorders may not be reliably assessed by cross-sectional survey data.

Psychopathology and attrition in the epidemiologic catchment area surveys.

This analysis shows the effect of sociodemographic variables and psychopathology on attrition in a 1-year follow-up of 10,167 household-residing respondents, aged 18-64 years, from four sites of the National Institute of Mental Health Epidemiologic Catchment Area Program. Attrition is defined in two ways: failure to locate (n = 1,035) and refusal to participate (n = 1,010). As compared with 8,122 respondents successfully interviewed after 1 year, those who are not located are more likely to be male, Hispanic, young, and unmarried. Refusers are older and more likely to be married and to have lower educational attainment than those successfully reinterviewed. After adjusting for sociodemographic variables, psychopathology had a small to moderate effect on attrition. Panic and depression were associated with failure to locate, but no diagnoses, or selected symptoms, were strongly or significantly associated with refusal to participate in the second wave.

New methods in cross-cultural psychiatry: psychiatric illness in Taiwan and the United States

Cross-cultural psychiatric research has suffered from many methodological shortcomings. To answer some of these shortcomings, the present study compared rates of psychiatric disorders in Taiwan and the United States by combining data from both countries into a single data set. Results from large, community-based surveys in the United States and Taiwan, the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area survey and the Taiwan Psychiatric Epidemiological Project, were combined into a single data set. This integration of the data sets was possible because both surveys used the NIMH Diagnostic Interview Schedule to ascertain cases. The integrated data sets were then analyzed with identical algorithms to generate lifetime prevalence rates of psychiatric disorders according to DSM-III criteria for both the United States and Taiwan. Lifetime prevalence rates of psychiatric illness in Taiwan were generally lower than U.S. rates. The rates of any disorder were 21.56% in Taiwan and 35.55% in the United States (Z = 22.34, p less than 10(-109]. The rates of most specific disorders were lower in Taiwan, and none of the rates was higher in Taiwan. While a culturally determined response bias may have lowered the rates in Taiwan somewhat, the results appear to be valid. Implications for the future use of structured diagnostic interviews in cross-cultural research are discussed.

DSM-III compulsive personality disorder: an epidemiological survey

A two-stage probability sample of community subjects was developed with a full psychiatric examination employing DSM-III criteria in conjunction with the Epidemiological Catchment Area (ECA) survey conducted in Baltimore, MD. This report details the observation on those subjects diagnosed with compulsive personality disorder and compulsive personality traits. The results indicate that this condition has a prevalence of 1.7% in a general population. Male, white, married and employed individuals receive this diagnosis most often. Our data suggest a dimensional rather than categorical character for this disorder. The disorder imparts a vulnerability for the development of anxiety disorders.

Alcohol abuse and the anxiety disorders: Evidence from the epidemiologic catchment area survey

This study examined the prevalence of alcohol abuse and/or dependence in a sample of patients with anxiety disorders gathered from the Epidemiologic Catchment Area Study. Prior research had indicated that anxiety disorders are prevalent among alcoholics and also that alcoholism is prevalent among samples of anxiety disorder patients. The sample included 2471 individuals who met a lifetime diagnosis of agoraphobia, panic disorder, agoraphobia with panic attacks, social phobia, simple phobia, or obsessive-compulsive disorder. About 12% of these individuals met criteria for a lifetime history of alcohol abuse and/or dependence. Relative odds ratios were calculated for the risk of alcohol use disorder, correcting for the effects of site, age, race, and gender. Among those individuals with a history of both anxiety and alcoholism disorders, the highest risk of alcohol use disorder was found in the agoraphobia with panic group. Lowest risk was found among those with a single diagnosis of simple phobia or agoraphobia without panic attacks. Clinical implications of these results are discussed.

Smoking, Smoking Cessation, and Major Depression

A relationship between cigarette smoking and major depressive disorder was suggested in previous work involving nonrandomly selected samples. We conducted a test of this association, employing population-based data (n = 3213) collected between 1980 and 1983 in the St Louis Epidemiologic Catchment Area Survey of the National Institute of Mental Health. A history of regular smoking was observed more frequently among individuals who had experienced major depressive disorder at some time in their lives than among individuals who had never experienced major depression or among individuals with no psychiatric diagnosis. Smokers with major depression were also less successful at their attempts to quit than were either of the comparison groups. Gender differences in rates of smoking and of smoking cessation observed in the larger population were not evident among the depressed group. Furthermore, the association between cigarette smoking and major depression was not ubiquitous across all psychiatric diagnoses. Other data are cited indicating that when individuals with a history of depression stop smoking, depressive symptoms and, in some cases, serious major depression may ensue.