Mental Health Epidemiologic Catchment Area Research Articles

Drug treatment of chronic insomnia — dawn at the end of a long night?

Insomnia is a hugely prevalent problem, affecting between 7% and 20% of the adult population depending on criteria used, and increasing in prevalence with age. It causes significant impairment in quality of life (see Alford and Wilson, 2008), and the degree of impairment correlates with severity of sleep disturbance and affects employment, physical and social role functioning, and mental health. Sufferers report fatigue, diminished energy and concentration, and memory disturbance. Economic implications include not only the direct costs of diagnosis and treatment (including prescription and non-prescription drugs and self-medication with alcohol) but also costs related to absenteeism, reduced productivity, accidents and increased GP visits that are secondary to the insomnia (Godet-Cayre, et al., 2006; Leger, 1994; Chevalier, et al., 1999). Insomnia is a long-term problem, with many patients reporting duration of more than 20 years (Green, et al., 2005). There is growing evidence from epidemiological studies that insomnia increases the risk of future disorders such as anxiety and depression. The National Institute of Mental Health Epidemiologic Catchment Area study 20 years ago interviewed 7954 adults on two occasions a year apart and found that 14% of those who had insomnia at the first interview had developed new major depression a year later (Ford and Kamerow, 1989). This data has been augmented by several more recent reports of increased risk. A survey of 1200 young adults in Michigan found that the odds ratio of new depression was four times increased in those subjects who had insomnia 3 years earlier (Breslau, et al., 1996) and in a longitudinal population study in Norway those with insomnia were at increased risk of anxiety disorders at the second contact 10 years later (Neckelmann, et al., 2007). As well as being a risk factor for mental illness insomnia is also very prevalent in psychiatric populations with up to 90% of depressed patients having this symptom (Stewart, et al., 2006). It is usually long-lasting – often predating the onset of the psychiatric disorder and if not fully treated is often a risk factor for relapse (Dombrovski, et al., 2007).

Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns

Perpetration of Violence, Violent Victimization, and Severe Mental Illness: Balancing Public Health Concerns

Neuropsychiatric Complications of Traumatic Brain Injury: A Critical Review of the Literature (A Report by the ANPA Committee on Research)

Neuropsychiatric Complications of Traumatic Brain Injury: A Critical Review of the Literature (A Report by the ANPA Committee on Research)

Race Differences in the Mental Health Effects of Divorce

Some research reports that divorce exerts greater negative effects on the mental health of Whites compared with African Americans. However, this literature is limited by inadequate attention to temporal dimensions of marital dissolution, in particular stages of the process and duration in each stage. This study incorporates stage and duration into an examination of race differences in the effects of marital dissolution on symptoms of depression and substance abuse or dependence. Data are drawn from the 1983 Piedmont Health Survey (PHS) of the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Program ( N = 1,941). Results suggest that the mental health effects of marital dissolution are not weaker for African Americans; rather, the nature and timing of the effects vary by race. Furthermore, gender interacts with race to influence the impact of separation and divorce on mental health.

Can a change in the name of depression result in its reduced negativity?

The National Institute of Mental Health Epidemiologic Catchment Area (ECA) study, an extensive community survey, reported that the 6-month prevalence rates for mood disorders were 6% (the lifetime rate was 8.3%) while only 31% of depressed adults sought treatment. The reluctance of patients for treatment of depression can be attributed to some extent to the negativity associated with it at social level. This negativity can be partially assigned to the negative word ‘Depression’ used for this disorder. We therefore propose a change in the name of depression that can help reduce its negativity. A hypothesis explaining the different moods experienced by a normal person and assigning different name to depression has been proposed in the paper.

New Data Reduce One-Year Mental Disorder Prevalence

New Data Reduce One-Year Mental Disorder Prevalence

Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates.

Current US mental disorder prevalence estimates have limited usefulness for service planning and are often discrepant. Data on clinical significance from the National Institute of Mental Health Epidemiologic Catchment Area Program (ECA) and the National Comorbidity Survey (NCS) were used to produce revised estimates, for more accurate projections of treatment need and further explication of rate discrepancies. To ascertain the prevalence of clinically significant mental disorders in each survey, responses to questions on life interference from, telling a professional about, or using medication for symptoms were applied to cases meeting symptom criteria in the ECA (n = 20,861) and NCS (n = 8098). A revised national prevalence estimate was made by selecting the lower estimate of the 2 surveys for each diagnostic category, accounting for comorbidity, and combining categories. Using data on clinical significance lowered the past-year prevalence rates of "any disorder" among 18- to 54-year-olds by 17% in the ECA and 32% in the NCS. For adults older than 18 years, the revised estimate for any disorder was 18.5%. Using the clinical significance criterion reduced disparities between estimates in the 2 surveys. Validity of the criterion was supported by associations with disabilities and suicidal behavior. Establishing the clinical significance of disorders in the community is crucial for estimating treatment need. More work should be done in defining and operationalizing clinical significance, and characterizing the utility of clinically significant symptoms in determining treatment need even when some criteria of the disorder are not met. Discrepancies in ECA and NCS results are largely due to methodologic differences.

Marital Trajectories and Mental Health

This study expands the marital status and mental health literature by examining several dimensions of marital trajectories, including the number and type of prior marital losses and duration in current status. Data are drawn from the Piedmont Health Survey of the National Institute of Mental Health Epidemiologic Catchment Area Study, collected in 1982-83 (n = 2,158). Results indicate that number of prior losses moderates the health-enhancing effect of being currently married; higher order marriages are associated with worse mental health. Although results vary across the mental illnesses examined (depression, anxiety, and substance use), the negative effect of multiple loss also is observed for the currently divorced and widowed. There is less evidence that the type of prior loss (i.e., divorce or widowhood) moderates the effect of current marital status on mental health; however, some support is found among the presently widowed. The analyses of duration in current status suggest that the rate of decline in symptoms of anxiety following one's most recent loss varies by marital history among the currently widowed.

Self-help treatment for combined addiction and mental illness.

New approaches to treating patients with combined mental illness and substance abuse continue to be developed. This rethinking of treatment is particularly important because of the acknowledged organizational barriers to effective management of persons with dual diagnoses and the excessive costs associated with their recidivism. This column describes a model for treatment that combines peer-led self-help from the addiction field with professional treatment from general psychiatry. This approach represents a paradigm shift from the way treatment is applied in the conventional mental health system in that patient peers assume many of the roles that are usually carried out by professionals, and these services are then integrated across levels of care. The model is based on a theoretically grounded perspective on behavioral change. We have evaluated its application in empirical studies in our system of acute inpatient, stepdown, and ambulatory units. This column should help convey how the self-help peer-led approach can be applied to bring about systems-level change in a variety of treatment settings where people with dual diagnoses are encountered, such as large hospital centers, smaller private programs, or multisite health maintenance organizations. The problem Combined substance abuse and mental illness was evident in communitybased populations at the time of the National Institute of Mental Health Epidemiologic Catchment Area survey in 1980‐1985. The survey found that 29 percent of mentally ill persons had substance use disorders. Among psychiatric inpatients, a 1988 New York State survey estimated the prevalence of substance abuse to be 34 percent. In a study the following year at New York City’s Bellevue Hospital Center, our treatment site, we found the remarkably high prevalence of 64 percent of substance use disorders among general psychiatric patients (1). Most notable in terms of likely recidivism was that 38 percent of those admitted to the general psychiatric service were cocaine abusers. Addiction rehabilitation, however, was not integrated into our hospital’s approach to general psychiatric care, and dual diagnosis patients were offered no resources for undertaking recovery from addictive illness. There was no access to peer-led self-help, as in the 12-step programs and drug-free therapeutic communities that were typical of community-based addiction rehabilitation. These circumstances are now widely known to lead to recidivism and a compromised clinical outlook. Furthermore, it is now understood that a material change in the care delivery system is needed to address this population’s needs, and no such adaptation had been made at Bellevue—or at similar institutions.

Mental health service use by Americans with severe mental illnesses.

The aim of this study was to determine the patterns and determinants of service use in severely mentally ill persons drawn from the National Institute of Mental Health Epidemiological Catchment Area (ECA) program, a community-based epidemiologic survey. This information provides a baseline against which to track ongoing changes in the US mental health service system. Severe mental illness (SMI) was defined according to US Senate Appropriations Committee guidelines. Comparisons were made with persons who had a mental disorder that did not meet these criteria (non-SMI). Sociodemographic factors, and 1-year volume and intensity of mental or addictive services use were determined. Differences between those who used services and those who did not were examined using logistic regression. Persons with SMI differed from persons with non-SMI in most sociodemographic characteristics. A higher proportion of persons with SMI used ambulatory services, but the mean number of visits per person did not differ from the non-SMI population. Persons with SMI comprised the bulk of hospital inpatients admitted during a 1-year period. Several significant sociodemographic determinants of service use were found, with different patterns for general medical and specialty service use, pointing out potential barriers to care. As health care reform measures continue to be debated, attention to the service needs of the severely mentally ill is of crucial importance. Pre-managed care (pre-1993) baseline service use benchmarks will be essential to assess the impact of managed care on access to care, particularly for the severely mentally ill. Periodic collection of epidemiologic data on prevalence and service use would thus greatly facilitate service planning and addressing barriers to receiving mental health services in this population.

Prospective study of depression and the risk of heavy alcohol use in women.

The authors' goal was to determine whether depression is associated with a greater risk of heavy alcohol consumption in women. The study was based on a 1-year follow-up of the Baltimore cohort of the National Institute of Mental Health Epidemiologic Catchment Area project. The sample consisted of 1,383 women at risk for heavy alcohol use. History of depression and frequency of lifetime-experienced depressive symptoms were assessed at baseline, and incident cases of heavy drinking were identified 1 year later. After calculating descriptive statistics for the sample, the authors developed a series of logistic regression models to estimate the risk of heavy drinking at follow-up associated with depression status. The initial estimate of the risk for heavy drinking in women with a history of depressive disorder was 2.60 times greater than the risk in women with no history of depressive disorder. This estimate did not change markedly after adjustment for age, history of antisocial personality disorder, or father's history of heavy drinking (relative risk=2.2). A higher frequency of depressive symptoms was also found to be associated with an elevation in the risk for heavy alcohol use (relative risk=1.09). These results add to other evidence that depression must be considered in the assessment of vulnerability for heavy alcohol use in women. Further research is needed to clarify the mechanisms of the observed association and to discover whether detection and effective treatment of depression might reduce risk of later alcohol problems.

Suicidality in Panic Disorder: A Comparison with Schizophrenic, Depressed, and Other Anxiety Disorder Outpatients

Recent findings by Weissman, Klerman, Markowitz, and Ouellette (1989) that subjects with panic disorder, with and without comorbid conditions, may be at increased risk for suicide attempts have been controversial. In an attempt to further investigate this finding, we utilized the original National Institute of Mental Health Epidemiological Catchment Area (ECA) suicide questions in an outpatient psychiatric clinic. We examined patients with panic disorder n = 101 , other anxiety disorders n = 47 , schizophrenia n = 22 , and major depression n = 19 . No significant differences were found among all four groups on any of the ECA suicide ideation questions. Only two (2%) of the panic disorder patients and none of the other groups made a suicide attempt in the past year. While 17% of patients with panic disorder and 9% of patients with other anxiety disorders reported having made a suicide attempt at some other time in their life, the schizophrenic (33%) and depressed groups (40%) reported significantly greater histories of suicide attempts. In a forward stepwise regression analysis for panic disorder patients, a history of substance abuse and comorbid depression predicted suicidality. The actual clinical risk for suicide attempts in panic disorder patients appears to occur when they suffer with comorbid diagnoses. These results highlight the need to aggressively treat panic disorder patients so they do not suffer the all-too-common sequelae of depression and substance abuse.

Self-reported somatization symptoms associated with risk for extreme alcohol use.

The high rates of alcohol use in the population, the increased general health care utilization associated with untreated alcohol problems, and the often diffuse nature of somatization symptoms led us to hypothesize that somatization symptoms might be associated with alcohol use. To determine whether a relationship exists between somatization symptoms and alcohol use. Multivariable logistic regression models were used to analyze existing cross-sectional and 1-year longitudinal survey data from the National Institute of Mental Health Epidemiologic Catchment Area Program. Community households. Probability sample. None. Prevalent and incident heavy or binge drinking ("extreme alcohol use"). These measures are part of the National Institute of Mental Health Epidemiologic Catchment Area Program public core data set that was collected without regard for specific hypotheses. After control for sex, age, and education, 13 self-reported somatization symptoms showed independent cross-sectional associations to prevalent extreme alcohol use. The greater the number of somatization symptoms, the greater the risk, up to a maximum increased odds ratio of 138 to 1, of having comorbid extreme alcohol use when reporting all 13 somatization symptoms in the model. A smaller set of items was associated with the risk for subsequent new onset of extreme alcohol use. Self-reported somatization symptoms could add to the detection of extreme alcohol use. In addition, primary care and other physicians should consider somatic complaints as possible indicators of concurrent and future risk for extreme alcohol use. Potential benefits of better detection of extreme alcohol use include supporting primary and secondary prevention efforts and reduced expenditures for the diagnostic workup of somatic complaints.

Vulnerability of Jews to affective disorders

Psychiatric literature over the past 100 years suggests that Jews are at higher risk for affective disorders than numbers of other religious groups. To examine these claims, the authors analyzed data from the National Institute of Mental Health Epidemiologic Catchment Area (ECA) study. In addition, the relationships among gender, alcoholism, and major depression were investigated. The period prevalence and lifetime rates of DSM-III major depression among Jews, Catholics, Protestants, individuals in other religious groups, and individuals with no religious affiliation were examined in the Los Angeles and New Haven, Conn., ECA data. Logistic regression with covariates for site, gender, marital status, and socioeconomic status was used to estimate odds ratios and 95% confidence intervals. The calculated rates, based on the combined data from ECA study waves 1 and 2 for the white population, were weighted according to the 1980 U.S. population census. Female-to-male rate ratios and rates of alcohol abuse/dependence were also obtained. While no differences were found among females, Jewish males had significantly higher rates of major depression than Catholics, Protestants, and all non-Jews combined. Jews had a 1:1 female-to-male ratio for major depression, in contrast to the other religious groups, which approached the universal 2:1 ratio. Rates of alcohol abuse/dependence were inversely related to rates of major depression. The results support only in part the earlier reports that Jews have higher rates of depression. The equal gender distribution of major depression among Jews may be associated with the lower rate of alcoholism among Jewish males.

Violence and Severe Mental Disorder in Clinical and Community Populations: The Effects of Psychotic Symptoms, Comorbidity, and Lack of Treatment

This paper examines links between violent behavior, type and severity of psychopathology, substance abuse comorbidity, and community mental health treatment, using matched data from two surveys: the National Institute of Mental Health Epidemiologic Catchment Area project and the Triangle Mental Health Survey (a North Carolina study of adults with severe and persistent mental illness). Multivariate logistic regression analysis was used to model the risk of violent acts attributable to three domains of independent variables: sociodemographic characteristics, clinical diagnoses and symptomatology, and mental health services utilization. Findings include: (1) Symptom severity was significantly greater in the clinically-selected sample than in the community survey of respondents with comparable diagnoses who self-reported using mental health services; (2) Violence risk was related to psychoticism/agitation in a curvilinear form; (3) In a multivariable model, violence was significantly associated with substance abuse comorbidity, particular psychotic symptoms (perceived threat and loss of internal cognitive controls), and absence of recent contact with a community mental health provider; (4) The relationship between lack of treatment and higher odds of violence was less pronounced among respondents with substance abuse comorbidity; (5) When clinical and services-use variables were taken into account, sociodemographic predictors were not significantly related to violence.

Activity Limitation and Psychotherapeutic Drug Use Among Community-Residing Elderly Women

This cross-sectional case-comparison study assessed the risk of activity limitation among community-dwelling older women (aged 55 and older) exposed to psychotherapeutic drugs. The data are taken from the National Institute of Mental Health Epidemiologic Catchment Area program. Exposures to short-elimination (≤24 hours) and long-elimination (≥24 hours) half-life psychotherapeutic drugs were assessed, as were the presence of functional disabilities (measured by limitations as defined in the Instrumental Activities of Daily Living and Activities of Daily Living scales). Women who reported the use of long-life sedative hypnotic drugs had a significantly higher risk of having an activity limitation; this relationship remained significant in a multiple regression model that controlled for other factors related to activity limitation, such as age, race, number of chronic health conditions, and presence of psychiatric distress. These results suggest the possibility that psychotherapeutic drug use is implicated in activity limitation. Health care providers should be aware of this possibility when treating older patients and be alert to the autonomic and sedating effects of these and other drugs when prescribing medications to the elderly. There is a need for prospective studies examining the possible trajectories of activity limitation in relation to drug use.

Lifetime co-morbidity of panic attacks and major depression in a population-based study: age of onset.

We used survival analysis to test for a suspected effect of co-morbidity of DIS/DSM-III major depression and panic attack on the age of onset of each of these disorders, in a population-based sample from four sites of the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area Program (N = 12668). The possible effects of gender and presence of a co-morbid disorder on age of onset of the single disorders were analysed using the Cox proportion-hazard-model, with gender as an explanatory variable and the co-morbid disorders as time-dependent covariates. The disorders begin earlier in life when they are co-morbid than when they occur singly. The occurrence of one disorder increases the chance of occurrence of the other. Females have from 1.7 to almost twice the risk for developing panic and/or depression compared with men, even if the co-morbid disorder precedes the index disorder or is lifetime co-morbid. These findings are compatible with a hypothesis of a higher severity in co-morbid cases when compared with a single disorder.

Psychiatric profile and sociodemographic characteristics of adults who report physically abusing or neglecting children.

In this study the authors measured the number of adults in three U.S. communities who reported abusing and neglecting children in their lifetime and assessed the relative impact of sociodemographic characteristics and lifetime diagnosis of mental disorders on both child abuse and child neglect. A total of 9,841 respondents, identified through a household sampling procedure for the National Institute of Mental Health (NIMH) Epidemiologic Catchment Area study, were included in the analysis. Self-reported lifetime histories of abuse and neglect of children were measured in the antisocial personality module of the NIMH Diagnostic Interview Schedule. In the study sample, 147 adults (1.49%) stated that they had abused children, and 140 adults (1.42%) stated that they had neglected children. A total of 58.5% of those who reported abuse of children, and 69.3% of those who reported having neglected a child, had a lifetime diagnosis of a mental disorder. Increased odds of reports of both abuse and neglect were associated with having a greater number of children in the household. Low socioeconomic status was a risk factor for neglecting, but not abusing, children. In multivariate analyses, a lifetime history of alcohol disorder was associated with abuse and neglect, affective disorders with abuse, and anxiety disorders with neglecting children. In light of the associations between mental disorders and mistreatment of children, public health policies designed to prevent child abuse and neglect might be enhanced by an increased focus on interventions targeted at individuals with mental disorders.

Effects of gender and comorbidity on problem drinking in a community sample.

We investigated the influence of gender, comorbidity, drinking history, and age on the clinical manifestations of DSM-III alcohol abuse and/or dependence in men and women. The sample was drawn from the National Institute of Mental Health Epidemiologic Catchment Area study, a large-scale, multicenter survey to investigate psychiatric disorders in the community. The results showed that gender and comorbidity had independent effects on problem drinking after drinking history and age had been taken into account. Gender contributed to the age of onset of problem drinking and the rate of its development. Comorbidity, drinking history, and age contributed independently to its severity. The effects of these variables in this community sample paralleled those reported in treatment samples.

Risk of alcoholism and parental history: gender differences and a possible reporting bias.

Using data from a population-based study, we examined the association of parental history of heavy drinking and depressed mood with the occurrence of alcohol abuse and dependence in the participants, stratified on gender. We hypothesized that a parental history of heavy drinking or depressed mood would have a stronger association with the occurrence of alcohol abuse or dependence among women than among men. In 1981, collaborators in the National Institute of Mental Health Epidemiologic Catchment Area Program recruited 3,481 adult participants after probability sample selection of census tracts and households in Baltimore, Maryland. To assess the occurrence of psychiatric conditions over time, the Diagnostic Interview Schedule was administered soon after sampling and again at follow-up, roughly 1 year later. At the follow-up interview, parental history of psychiatric conditions was assessed. Individuals who did not complete either the baseline or follow-up interview, or who used a proxy informant were excluded from these analyses. These exclusions left 2,588 household residents who comprised the complete study sample, of which 384 had alcohol abuse or dependence. The degree of association of alcoholism with parental history of heavy drinking or depressed mood is greater for women than for men. Men have an increased risk for alcohol abuse and dependence if they report that father has a history of heavy drinking (OR = 1.6, P < .01). For women, an alcohol disorder is associated with heavy drinking in fathers and in mothers (OR = 2.1, P < .01; OR = 2.6, P < .01, respectively). A similar pattern is found for a parental history of depressed mood. In addition, there is evidence of a possible reporting bias: Men and women with alcohol abuse or dependence are less likely to provide family information than participants without alcohol abuse or dependence. Among men, the presence of missing parental history information is significantly associated with alcohol abuse and dependence. The current report shows evidence for a gender difference in the relationship of parental history of heavy drinking and depression with the risk of alcoholism in offspring, and suggests that the effect of missing information should be considered when analyzing family data.