US National Comorbidity Survey Replication Research Articles

Body image and paranoia

Paranoia builds upon feelings of vulnerability. Our clinical experience indicates that negative body image, including concerns regarding weight, may be one source of feeling vulnerable and hence raise the risk of paranoia. There has been no empirical test of an association between body image and paranoia. Our aim was to provide the first test of this issue by examining in epidemiologically representative cohorts the cross-sectional associations between paranoia and a proxy measure of body image. This was an initial exploration of a potentially important but overlooked issue. Data were used from 5515 participants in the US National Comorbidity Survey-Replication (NCS-R). To validate the findings, the analyses were replicated with 10,113 participants in the US National Comorbidity Survey–Adolescents (NCS-A). Concerns about weight were associated with paranoia in the NCS-R (OR = 1.48, p = 0.006, CI = 1.123, 1.955) and NCS-A (OR = 1.67, p < 0.001, CI = 1.490, 1.873). The associations remained significant after controlling for gender and body mass index. The results show that negative body image and paranoia are associated in the general population, consistent with the idea that paranoia may build upon feelings of vulnerability arising from body image concerns. Studies are needed to examine whether there is a causal relationship.

Associations between adult attachment style and mental health care utilization: Findings from a large-scale national survey

This study investigated the association between attachment style and the use of a range of mental health services controlling socio-demographic, physical and psychological risk factors. Using a large nationally representative sample from the US National Comorbidity Survey Replication (NCS-R), a total of 5645 participants (18+) were included. The majority of participants reported their attachment as secure (63.5%), followed by avoidant (22.2%), unclassified (8.8%), and anxious (5.5%). The percentages using different health services studied varied widely (1.1–31.1%). People with insecure (anxious and avoidant) attachment were more likely to report accessing a hotline, having had a session of psychological counselling or therapy, getting a prescription or medicine for mental and behavioural problems. Individuals with anxious attachment only were also more likely to report the use of internet support groups or chat rooms. This is a first analysis to explore relationships between self-reported adult attachment style and a wide range of health care services. Insecurely attached individuals were more likely to use a wide range of health care services even after controlling for socio-demographic factors, psychiatric disorders and chronic health conditions. These findings suggest that adult attachment plays an important role in the use of mental health care services.

The effects of temporally secondary co-morbid mental disorders on the associations of DSM-IV ADHD with adverse outcomes in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Although DSM-IV attention deficit hyperactivity disorder (ADHD) is known to be associated with numerous adverse outcomes, uncertainties exist about how much these associations are mediated temporally by secondary co-morbid disorders. The US National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a national survey of adolescents aged 13-17 years (n = 6483 adolescent-parent pairs), assessed DSM-IV disorders with the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Statistical decomposition was used to compare direct effects of ADHD with indirect effects of ADHD through temporally secondary mental disorders (anxiety, mood, disruptive behavior, substance disorders) in predicting poor educational performance (suspension, repeating a grade, below-average grades), suicidality (ideation, plans, attempts) and parent perceptions of adolescent functioning (physical and mental health, interference with role functioning and distress due to emotional problems). ADHD had significant gross associations with all outcomes. Direct effects of ADHD explained most (51.9-67.6%) of these associations with repeating a grade in school, perceived physical and mental health (only girls), interference with role functioning and distress, and significant components (34.5-44.6%) of the associations with school suspension and perceived mental health (only boys). Indirect effects of ADHD on educational outcomes were predominantly through disruptive behavior disorders (26.9-52.5%) whereas indirect effects on suicidality were predominantly through mood disorders (42.8-59.1%). Indirect effects on most other outcomes were through both mood (19.8-31.2%) and disruptive behavior (20.1-24.5%) disorders, with anxiety and substance disorders less consistently important. Most associations were comparable for girls and boys. Interventions aimed at reducing the adverse effects of ADHD might profitably target prevention or treatment of temporally secondary co-morbid disorders.

Lifetime co-morbidity of DSM-IV disorders in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Research on the structure of co-morbidity among common mental disorders has largely focused on current prevalence rather than on the development of co-morbidity. This report presents preliminary results of the latter type of analysis based on the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). A national survey was carried out of adolescent mental disorders. DSM-IV diagnoses were based on the Composite International Diagnostic Interview (CIDI) administered to adolescents and questionnaires self-administered to parents. Factor analysis examined co-morbidity among 15 lifetime DSM-IV disorders. Discrete-time survival analysis was used to predict first onset of each disorder from information about prior history of the other 14 disorders. Factor analysis found four factors representing fear, distress, behavior and substance disorders. Associations of temporally primary disorders with the subsequent onset of other disorders, dated using retrospective age-of-onset (AOO) reports, were almost entirely positive. Within-class associations (e.g. distress disorders predicting subsequent onset of other distress disorders) were more consistently significant (63.2%) than between-class associations (33.0%). Strength of associations decreased as co-morbidity among disorders increased. The percentage of lifetime disorders explained (in a predictive rather than a causal sense) by temporally prior disorders was in the range 3.7-6.9% for earliest-onset disorders [specific phobia and attention deficit hyperactivity disorder (ADHD)] and much higher (23.1-64.3%) for later-onset disorders. Fear disorders were the strongest predictors of most other subsequent disorders. Adolescent mental disorders are highly co-morbid. The strong associations of temporally primary fear disorders with many other later-onset disorders suggest that fear disorders might be promising targets for early interventions.

Occupational Trauma and Mental Illness—Combat, Peacekeeping, or Relief Work and the National Co-Morbidity Survey Replication

Peacekeepers, relief workers, and military members experience multiple traumas, and trauma is believed to increase risk for psychiatric distress. We examined whether combat and/or peacekeeping or relief work was associated with subsequent mental illness. Using data from the US National Co-morbidity Survey Replication (n = 2383), we estimated whether combat, peacekeeping, or relief work was associated with increased prevalence of mental illness through bivariate cross-tabulations and multivariate logistic regression. Combat was associated with increased subsequent posttraumatic stress disorder (PTSD) and alcohol or drug issues more than peacekeeping or relief work. Combat, alone or combined with peacekeeping/relief work, appears to be a risk factor for subsequent PTSD and issues with drugs and alcohol. Peacekeeping/relief work without combat does not appear to be associated with these diagnoses. We found an association between combat and subsequent PTSD and drug and alcohol issues. Absent combat, peacekeeping, or relief work were not associated with mental illness. Previous diagnoses and trauma exposure may increase potential for subsequent mental health problems.

Validation of diagnoses of distress disorders in the US National Comorbidity Survey Replication Adolescent Supplement (NCS‐A)

Research diagnostic interviews need to discriminate between closely related disorders in order to allow comorbidity among mental disorders to be studied reliably. Yet conventional studies of diagnostic validity generally focus on single disorders and do not examine discriminant validity. The current study examines the validity of fully-structured diagnoses of closely-related distress disorders (generalized anxiety disorder, post-traumatic stress disorder, major depressive episode, and dysthymic disorder) in the lay-administered Composite International Diagnostic Interview Version 3.0 (CIDI) with independent clinical diagnoses based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). The NCS-A is a national survey of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) among 10,148 adolescents. A probability sub-sample of 347 of these adolescents and their parents were administered blinded follow-up K-SADS interviews. Good concordance [area under the receiver operating characteristic curve (AUC)] was found between diagnoses based on the CIDI and the K-SADS for generalized anxiety disorder (AUC = 0.78), post-traumatic stress disorder (AUC = 0.79), and major depressive episode/dysthymic disorder (AUC = 0.86). Further, the CIDI was able to effectively discriminate among different types of distress disorders in the sub-sample of respondents with any distress disorder.

Childhood socio-economic status and the onset, persistence, and severity of DSM-IV mental disorders in a US national sample

Although significant associations between childhood socio-economic status (SES) and adult mental disorders have been widely documented, SES has been defined using several different indicators often considered alone. Little research has examined the relative importance of these different indicators in accounting for the overall associations of childhood SES with adult outcomes. Nor has previous research distinguished associations of childhood SES with first onsets of mental disorders in childhood, adolescence, and adulthood from those with persistence of these disorders into adulthood in accounting for the overall associations between childhood SES and adult mental disorders. Disaggregated data of this sort are presented here for the associations of childhood SES with a wide range of adult DSM-IV mental disorders in the US National Comorbidity Survey Replication (NCS-R), a nationally-representative sample of 5692 adults. Childhood SES was assessed retrospectively with information about parental education and occupation and childhood family financial adversity. Associations of these indicators with first onset of 20 DSM-IV disorders that included anxiety, mood, behavioral, and substance disorders at different life-course stages (childhood, adolescence, early adulthood, and mid-later adulthood) and the persistence/severity of these disorders were examined using discrete-time survival analysis. Lifetime disorders and their ages-of-onset were assessed retrospectively with the WHO Composite International Diagnostic Interview. Different aspects of childhood SES predicted onset, persistence, and severity of mental disorders. Childhood financial hardship predicted onset of all classes of disorders at every life-course stage with odds-ratios (ORs) of 1.7–2.3. Childhood financial hardship was unrelated, in comparison, to disorder persistence or severity. Low parental education, although unrelated to disorder onset, significantly predicted disorder persistence and severity, whereas parental occupation was unrelated to onset, persistence, or severity. Some, but not all, of these associations were explained by other co-occurring childhood adversities. These specifications have important implications for mental health interventions targeting low-SES children.

Validation of the diagnoses of panic disorder and phobic disorders in the US National Comorbidity Survey Replication Adolescent (NCS-A) supplement

Validity of the adolescent version of the World Health Organization Composite International Diagnostic Interview (CIDI) Version 3.0, a fully-structured research diagnostic interview designed to be used by trained lay interviewers, is assessed in comparison to independent clinical diagnoses based on the Schedule for Affective Disorders and Schizophrenia for School-age Children (K-SADS). This assessment is carried out in the clinical reappraisal sub-sample (n = 347) of the US National Comorbidity Survey Adolescent (NCS-A) supplement, a large (n = 10,148) community epidemiological survey of the prevalence and correlates of adolescent mental disorders in the United States. The diagnoses considered are panic disorder and phobic disorders (social phobia, specific phobia, agoraphobia). CIDI diagnoses are found to have good concordance with K-SADS diagnoses [area under the receiver operating characteristic curve (AUC) = 0.81-0.94], although the CIDI diagnoses are consistency somewhat higher than the K-SADS diagnoses. Data are also presented on criterion-level concordance in an effort to pinpoint CIDI question series that might be improved in future modifications of the instrument. Finally, data are presented on the factor structure of the fears associated with social phobia, the only disorder in this series where substantial controversy exists about disorder subtypes.

Comorbidity and treatment of mental disorders and sleep problems in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Comorbidity and treatment of mental disorders and sleep problems in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Prevalence, overlap, and correlates of anxiety disorders in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Prevalence, overlap, and correlates of anxiety disorders in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A)

Do gender differences in mental health contribute to gender differences in physical health?

Previous research has demonstrated that women and men tend to have different types of mental and physical health problems. Using data from the US National Comorbidity Survey Replication (NCS-R) of 2001-2003, we consider whether the female excess in internalizing disorders contributes to the female excess in chronic debilitating conditions and whether the male excess in externalizing disorders contributes to the male excess in life threatening conditions. We find that women have significantly higher odds of meeting the DSM-IV criteria for one or more lifetime internalizing disorders and significantly lower odds of meeting the DSM-IV criteria for one or more lifetime externalizing disorders. We also find that women have higher odds of reporting four of the ten chronic debilitating conditions examined, including arthritis, frequent or severe headaches, seasonal allergies, and gallbladder removal, and lower odds of reporting three of the six life threatening conditions examined, including stroke, heart disease, and high blood pressure. We conclude that the female excess in internalizing disorders partially mediates, or explains, the female excess in arthritis, headaches, and gallbladder removal, while the male excess in externalizing disorders partially accounts for the male excess in heart disease and high blood pressure.

Childhood adversities and adult psychopathology in the National Comorbidity Survey Replication (NCS-R) III: Associations with functional impairment related to DSM-IV disorders

Despite evidence that childhood adversities (CAs) are associated with increased risk of mental disorders, little is known about their associations with disorder-related impairment. We report the associations between CAs and functional impairment associated with 12-month DSM-IV disorders in a national sample. We used data from the US National Comorbidity Survey Replication (NCS-R). Respondents completed diagnostic interviews that assessed 12-month DSM-IV disorder prevalence and impairment. Associations of 12 retrospectively reported CAs with impairment among cases (n=2242) were assessed using multiple regression analysis. Impairment measures included a dichotomous measure of classification in the severe range of impairment on the Sheehan Disability Scale (SDS) and a measure of self-reported number of days out of role due to emotional problems in the past 12 months. CAs were positively and significantly associated with impairment. Predictive effects of CAs on the SDS were particularly pronounced for anxiety disorders and were significant in predicting increased days out of role associated with mood, anxiety and disruptive behavior disorders. Predictive effects persisted throughout the life course and were not accounted for by disorder co-morbidity. CAs associated with maladaptive family functioning (MFF; parental mental illness, substance disorder, criminality, family violence, abuse, neglect) were more consistently associated with impairment than other CAs. The joint effects of co-morbid MFF CAs were significantly subadditive. Simulations suggest that CAs account for 19.6% of severely impairing disorders and 17.4% of days out of role. CAs predict greater disorder-related impairment, highlighting the ongoing clinical significance of CAs at every stage of the life course.

The relationship of gambling to intimate partner violence and child maltreatment in a nationally representative sample

It has been suggested that family violence is associated with gambling problems. However, to date, this relationship has not been thoroughly investigated using representative data. The purpose of the current study was to analyze the relationship between gambling problems and the perpetration and victimization of intimate partner violence (including dating and marital violence) and child maltreatment (including minor child assault and severe child abuse) using nationally representative data. Data were drawn from the US National Comorbidity Survey Replication ( n = 3334; 18 years and older). Multiple logistic and multinomial logistic regression models were used to examine the relationships between gambling and the perpetration and victimization of dating violence, marital violence, and child maltreatment. The results indicated that problem gambling was associated with increased odds of the perpetration of dating violence (Adjusted Odds Ratios (AORs) ranged from 2.2 to 4.2), while pathological gambling was associated with increased odds of the perpetration of dating violence (AORs ranged from 5.7 to 11.9), severe marital violence (AOR = 20.4), and severe child abuse (AOR = 13.2). Additionally, dating violence, marital violence, and severe child abuse victimization were associated with increased odds of gambling problems. The results were attenuated when adjusted for lifetime mental disorders. These findings can be used as evidence-based research to inform healthy public gambling polices and inform prevention and intervention efforts.

Smoking and mental illness: results from population surveys in Australia and the United States.

BackgroundSmoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders and depression. People with mental illness have high rates of morbidity and mortality from smoking related illnesses such as cardiovascular disease, respiratory diseases and cancer. As many people who meet diagnostic criteria for mental disorders do not seek treatment for these conditions, we sought to investigate the relationship between mental illness and smoking in recent population-wide surveys.MethodsSurvey data from the US National Comorbidity Survey-Replication conducted in 2001–2003, the 2007 Australian Survey of Mental Health and Wellbeing, and the 2007 US National Health Interview Survey were used to investigate the relationship between current smoking, ICD-10 mental disorders and non-specific psychological distress. Population weighted estimates of smoking rates by disorder, and mental disorder rates by smoking status were calculated.ResultsIn both the US and Australia, adults who met ICD-10 criteria for mental disorders in the 12 months prior to the survey smoked at almost twice the rate of adults without mental disorders. While approximately 20% of the adult population had 12-month mental disorders, among adult smokers approximately one-third had a 12-month mental disorder – 31.7% in the US (95% CI: 29.5%–33.8%) and 32.4% in Australia (95% CI: 29.5%–35.3%). Female smokers had higher rates of mental disorders than male smokers, and younger smokers had considerably higher rates than older smokers. The majority of mentally ill smokers were not in contact with mental health services, but their rate of smoking was not different from that of mentally ill smokers who had accessed services for their mental health problem. Smokers with high levels of psychological distress smoked a higher average number of cigarettes per day.ConclusionMental illness is associated with both higher rates of smoking and higher levels of smoking among smokers. Further, a significant proportion of smokers have mental illness. Strategies that address smoking in mental illness, and mental illness among smokers would seem to be important directions for tobacco control. As the majority of smokers with mental illness are not in contact with mental health services for their condition, strategies to address mental illness should be included as part of population health-based mental health and tobacco control efforts.

Design and field procedures in the US National Comorbidity Survey Replication Adolescent Supplement (NCS‐A)

An overview is presented of the design and field procedures of the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a US face-to-face household survey of the prevalence and correlates of DSM-IV mental disorders. The survey was based on a dual-frame design that included 904 adolescent residents of the households that participated in the US National Comorbidity Survey Replication (85.9% response rate) and 9244 adolescent students selected from a nationally representative sample of 320 schools (74.7% response rate). After expositing the logic of dual-frame designs, comparisons are presented of sample and population distributions on Census socio-demographic variables and, in the school sample, school characteristics. These document only minor differences between the samples and the population. The results of statistical analysis of the bias-efficiency trade-off in weight trimming are then presented. These show that modest trimming meaningfully reduces mean squared error. Analysis of comparative sample efficiency shows that the household sample is more efficient than the school sample, leading to the household sample getting a higher weight relative to its size in the consolidated sample relative to the school sample. Taken together, these results show that the NCS-A is an efficient sample of the target population with good representativeness on a range of socio-demographic and geographic variables.

Does the ‘gateway’ matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication

The 'gateway' pattern of drug initiation describes a normative sequence, beginning with alcohol and tobacco use, followed by cannabis, then other illicit drugs. Previous work has suggested that 'violations' of this sequence may be predictors of later problems but other determinants were not considered. We have examined the role of pre-existing mental disorders and sociodemographics in explaining the predictive effects of violations using data from the US National Comorbidity Survey Replication (NCS-R). The NCS-R is a nationally representative face-to-face household survey of 9282 English-speaking respondents aged 18 years and older that used the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to assess DSM-IV mental and substance disorders. Drug initiation was estimated using retrospective age-of-onset reports and 'violations' defined as inconsistent with the normative initiation order. Predictors of violations were examined using multivariable logistic regressions. Discrete-time survival analysis was used to see whether violations predicted progression to dependence. Gateway violations were largely unrelated to later dependence risk, with the exception of small increases in risk of alcohol and other illicit drug dependence for those who initiated use of other illicit drugs before cannabis. Early-onset internalizing disorders were predictors of gateway violations, and both internalizing and externalizing disorders increased the risks of dependence among users of all drugs. Drug use initiation follows a strong normative pattern, deviations from which are not strongly predictive of later problems. By contrast, adolescents who have already developed mental health problems are at risk for deviations from the normative sequence of drug initiation and for the development of dependence.

Asthma and suicidal ideation with and without suicide attempts among adults in the United States: what is the role of cigarette smoking and mental disorders?

Evidence of a respiratory diseases and suicidal ideation and suicide attempts link exists. To improve our understanding of the mechanism underlying these links, there is a need for examination of the relationship between specific respiratory disease, such as asthma, and suicidal ideation and behavior. In addition, studies need to examine many common risk factors that may play a role in the association between asthma and suicidal ideation and suicide behavior. To examine the association between asthma and suicidal ideation with and without attempts among adults in the United States, specifically investigating the role of cigarette smoking, nicotine dependence, depression, anxiety, and alcohol abuse. Data on 5,692 individuals 18 years and older were drawn from the US National Comorbidity Survey Replication. Descriptive and multivariate logistic regression analyses were conducted to examine the study objectives. The estimates of lifetime prevalence for suicidal ideation without and with attempts and asthma were 8.7%, 4.2%, and 12.0%, respectively. Being a woman, a current smoker, depressed, anxious, an alcohol abuser, or nicotine dependent increased the likelihood of suicidal ideation with attempts and asthma. Asthma was significantly (P < .001) associated with suicidal ideation with but not without attempts. Adjustment for smoking, nicotine dependence, age, sex, and race/ethnicity decreased the association between asthma and suicidal ideation with attempts by 16%. Similarly, adjustment for depression, panic disorder, and alcohol abuse led to a 12.4% decrease in this relationship. Despite these adjustments, independently or combined, a statistically significant (P = .02) association remained between asthma and suicidal ideation with attempts. Cigarette smoking and concurrent mental health conditions may independently account for significant proportions of the association between asthma and suicidal ideation with attempts. More research is needed to further elucidate the mechanism of the remaining association between asthma and suicide attempts. Modification of smoking behaviors and effective treatment of depression, anxiety, alcohol abuse, and possibly asthma are important suicide prevention strategies.

Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences.

We sought to determine the fractions of psychiatric disorders and suicide ideation and attempts in a general population sample attributable to childhood physical abuse, sexual abuse, and witnessing domestic violence. Data were obtained from the US National Comorbidity Survey Replication. Population attributable fractions were calculated to determine the proportion of psychiatric disorders and suicide ideation and attempts attributable to adverse childhood experiences. The analysis was stratified by gender. The estimated attributable fractions for psychiatric disorders attributable to having experienced any adverse childhood event ranged from 22% to 32% among women and 20% to 24% among men. Having experienced any adverse event accounted for a substantial proportion of suicide ideation and attempts among women (16% and 50%, respectively) and men (21% and 33%, respectively). Substantial proportions of poor mental health outcomes were also attributable to increasing number of adverse events. The estimated proportions of poor mental health outcomes attributed to childhood adversity were medium to large for men and women. Prevention efforts that reduce exposure to adverse childhood events could substantially reduce the prevalence of psychopathology and suicidal behavior in the general population.

Evaluating symptom expression as a function of a posttraumatic stress disorder severity

Little is known about the relative severity or typical sequence of Diagnostic and Statistical Manual (DSM-IV) symptoms of posttraumatic stress disorder (PTSD). Using data from the National Comorbidity Study-Replication (NCS-R) [Kessler, R. C., Berglund, P., Chiu, W. T., Demler, O., Heeringa, S., & Hiripi, E., et al. (2004). The US National Comorbidity Survey-Replication (NCS-R): design and field procedures. International Journal of Methods in Psychiatric Research, 13(2), 69–92], the current study used a logistic item response model to assess the degree to which DSM-IV symptoms combine to define a primary construct underlying PTSD, to identify which symptoms are associated with greater severity of PTSD, and to determine whether the symptoms and symptom patterns are influenced by gender. Results suggested that PTSD symptoms can be combined to assess a single dimension of PTSD severity, providing support for a continuum of symptom severity. However, several DSM-IV symptoms provided overlapping information, potentially reducing the effectiveness of these symptoms in describing a broad range of PTSD. More precise assessment of PTSD severity may help improve the descriptive value of PTSD measures relationship to continuous measures of treatment outcomes, and ultimately inform more effective treatments.

DSM-IV pathological gambling in the National Comorbidity Survey Replication

Little is known about the prevalence or correlates of DSM-IV pathological gambling (PG). Data from the US National Comorbidity Survey Replication (NCS-R), a nationally representative US household survey, were used to assess lifetime gambling symptoms and PG along with other DSM-IV disorders. Age of onset (AOO) of each lifetime disorder was assessed retrospectively. AOO reports were used to study associations between temporally primary disorders and the subsequent risk of secondary disorders. Most respondents (78.4%) reported lifetime gambling. Lifetime problem gambling (at least one Criterion A symptom of PG) (2.3%) and PG (0.6%) were much less common. PG was significantly associated with being young, male, and Non-Hispanic Black. People with PG reported first gambling significantly earlier than non-problem gamblers (mean age 16.7 v. 23.9 years, z=12.7, p<0.001), with gambling problems typically beginning during the mid-20s and persisting for an average of 9.4 years. During this time the largest annual gambling losses averaged US$4800. Onset and persistence of PG were predicted by a variety of prior DSM-IV anxiety, mood, impulse-control and substance use disorders. PG also predicted the subsequent onset of generalized anxiety disorder, post-traumatic stress disorder (PTSD) and substance dependence. Although none of the NCS-R respondents with PG ever received treatment for gambling problems, 49.0% were treated at some time for other mental disorders. DSM-IV PG is a comparatively rare, seriously impairing, and undertreated disorder whose symptoms typically start during early adulthood and is frequently secondary to other mental or substance disorders that are associated with both PG onset and persistence.