US National Comorbidity Survey Research Articles

Rethinking the duration requirement for generalized anxiety disorder: evidence from the National Comorbidity Survey Replication

The proposed revisions of the ICD and DSM diagnostic systems have led to increased interest in evaluation of diagnostic criteria. This report focuses on the DSM-IV requirement that episodes of generalized anxiety disorder (GAD) must persist for at least 6 months. Community epidemiological data are used to study the implications of changing this requirement in the range 1-12 months for estimates of prevalence, onset, course, impairment, co-morbidity, associations with parental GAD, and sociodemographic correlates. Data come from the US National Comorbidity Survey Replication (NCS-R), a US household survey carried out during 2001-2003. Version 3.0 of the WHO Composite International Diagnostic Interview (WMH-CIDI) was used to assess DSM-IV anxiety disorders, mood disorders, substance disorders, and impulse-control disorders. Lifetime, 12-month, and 30-day prevalence estimates of DSM-IV GAD changed from 6.1%, 2.9%, and 1.8% to 4.2-12.7%, 2.2-5.5%, and 1.6-2.6% when the duration requirement was changed from 6 months to 1-12 months. Cases with episodes of 1-5 months did not differ greatly from those with episodes of > or = 6 months in onset, persistence, impairment, co-morbidity, parental GAD, or sociodemographic correlates. A large number of people suffer from a GAD-like syndrome with episodes of < 6 months duration. Little basis for excluding these people from a diagnosis is found in the associations examined here.

The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population

A self-report screening scale of adult attention-deficit/hyperactivity disorder (ADHD), the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) was developed in conjunction with revision of the WHO Composite International Diagnostic Interview (CIDI). The current report presents data on concordance of the ASRS and of a short-form ASRS screener with blind clinical diagnoses in a community sample. The ASRS includes 18 questions about frequency of recent DSM-IV Criterion A symptoms of adult ADHD. The ASRS screener consists of six out of these 18 questions that were selected based on stepwise logistic regression to optimize concordance with the clinical classification. ASRS responses were compared to blind clinical ratings of DSM-IV adult ADHD in a sample of 154 respondents who previously participated in the US National Comorbidity Survey Replication (NCS-R), oversampling those who reported childhood ADHD and adult persistence. Each ASRS symptom measure was significantly related to the comparable clinical symptom rating, but varied substantially in concordance (Cohen's kappa in the range 0.16-0.81). Optimal scoring to predict clinical syndrome classifications was to sum unweighted dichotomous responses across all 18 ASRS questions. However, because of the wide variation in symptom-level concordance, the unweighted six-question ASRS screener outperformed the unweighted 18-question ASRS in sensitivity (68.7% v. 56.3%), specificity (99.5% v. 98.3%), total classification accuracy (97.9% v. 96.2%), and kappa (0.76 v. 0.58). Clinical calibration in larger samples might show that a weighted version of the 18-question ASRS outperforms the six-question ASRS screener. Until that time, however, the unweighted screener should be preferred to the full ASRS, both in community surveys and in clinical outreach and case-finding initiatives.

The US National Comorbidity Survey Replication (NCS-R): design and field procedures.

The National Comorbidity Survey Replication (NCS-R) is a survey of the prevalence and correlates of mental disorders in the US that was carried out between February 2001 and April 2003. Interviews were administered face-to-face in the homes of respondents, who were selected from a nationally representative multi-stage clustered area probability sample of households. A total of 9,282 interviews were completed in the main survey and an additional 554 short non-response interviews were completed with initial non-respondents. This paper describes the main features of the NCS-R design and field procedures, including information on fieldwork organization and procedures, sample design, weighting and considerations in the use of design-based versus model-based estimation. Empirical information is presented on non-response bias, design effect, and the trade-off between bias and efficiency in minimizing total mean-squared error of estimates by trimming weights.

Generalised anxiety disorder

The EBMH Notebook summarises key messages about generalised anxiety disorder, sourced from: Clin Evid Concise2004 (in press); www.clinicalevidence.com. For this review, Clinical Evidence Concise searched and appraised material published until...

Self-criticism and social phobia in the US national comorbidity survey

Background: This study sought to extend findings from a preliminary clinical investigation [J. Affect. Disord. 57 (2000) 223] by examining relations between the personality dimension of self-criticism and diagnostic prevalence of social phobia in a large nationally representative sample. Methods: Participants were from the national comorbidity survey Part II [ n=5877; Arch. Gen. Psychiatry 51 (1994) 8]. Psychiatric diagnoses were made using a modified version of the composite international psychiatric interview. Personality dimensions and distress were assessed using brief self-report measures with strong psychometric properties. Results: Self-criticism was elevated in NCS respondents with a diagnosis of social phobia, even in cases of only past history of social phobia (i.e. >1 year ago), compared to individuals with no psychiatric disorder. The highest levels of self-criticism were reported by people with the complex subtype of social phobia, both with and without comorbid major depression. These levels were significantly greater compared to those observed in another anxiety disorder (panic disorder), the pure speaking subtype of social phobia, and cases of major depression alone. In a regression analysis that controlled for current emotional distress, the broad personality trait of neuroticism, and lifetime histories of mood, anxiety, and substance use disorders, self-criticism remained significantly associated with lifetime prevalence of social phobia. Limitations: The cross-sectional design of the study does not permit causal inferences. Conclusions: Findings from this general population mental health survey demonstrated that self-criticism is robustly associated with social phobia. It may represent an important core psychological process in the complex subtype of this anxiety disorder.

The impairments caused by social phobia in the general population: implications for intervention.

Although social phobia is common, treatment remains low. In order to gauge public health implications of this low treatment, information is needed on the impairments caused by social phobia. A computer literature review searched for the terms 'social anxiety disorder' and 'social phobia' in the MEDLINE and PsycLIT databases. New analyses were carried out in the US National Comorbidity Survey. The literature shows that social phobia has serious effects on role functioning and quality of life. These effects are least severe for pure non-generalized social phobia and most severe for comorbid generalized social phobia with avoidant personality disorder. The most direct impairments involve social interactions and information processing errors in these interactions. Indirect effects are even more important. Three indirect effects are highlighted: effects on secondary mental (e.g. depression), substance (e.g. alcoholism) and physical (e.g. cardiovascular disease) disorders; effects on normative role transitions (e.g. educational attainment); and effects on help-seeking. Given the early age of onset and impacts on secondary disorders and early adult life course transitions, the greatest public health impact of increasing treatment of social phobia is likely to be achieved by developing programs targeted at early identification and treatment through schools.

Depression with atypical features in the National Comorbidity Survey: classification, description, and consequences.

Atypical depression has been found to be distinct from other types of depression in terms of psychiatric symptom profile and treatment response. However, debate continues regarding its specific characteristics, impact, and diagnostic criteria. The current study was conducted to increase understanding of atypical depression diagnosed using only the reversed vegetative symptoms of hypersomnia and hyperphagia. An atypical depression group (n = 304 [36.4% of the depressed sample; 39.0% when weighted to approximate the national population]) was identified within the US National Comorbidity Survey, which assessed psychiatric disorders among a nationally representative sample using the Composite International Diagnostic Interview. The atypical group was identified based on DSM-III-R criteria for a major depressive episode, in addition to atypical features of hypersomnia and hyperphagia. Comparison groups were those with nonatypical depression (n = 532) and individuals without a psychiatric disorder (n = 4071). Compared with nonatypical depression, atypical depression was associated with a greater percentage of women and an earlier age of onset. The atypical group also reported higher rates of most depressive symptoms, suicidal thoughts and attempts, psychiatric comorbidity (panic disorder, social phobia, and drug dependence), disability and restricted activity days, use of some health care services, paternal depression, and childhood neglect and sexual abuse (P<.05). Compared with people without psychiatric disorders, the atypical group reported higher rates of disability and restricted activity days, use of all mental health care services, parental depression, and childhood abuse (P<.001). This analysis of a nationally representative US sample suggests that overeating and oversleeping can be used to identify an atypical depression subgroup that is distinct from other depressed patients in terms of demographics, psychiatric comorbidities, and abuse history. Findings also suggest that atypical depression is associated with increased distress, suicidal ideation, and disability compared with nonatypical depression.

Well-being and life satisfaction in generalized anxiety disorder: comparison to major depressive disorder in a community sample

Background: In most settings, generalized anxiety disorder (GAD) is highly comorbid with major depressive disorder (MDD). This raises uncertainty about the clinical relevance of GAD as a distinct diagnostic entity. The demonstration of functional impairment attached to GAD, independent of that attributable to MDD, would support the importance of GAD as a separate diagnostic category. Methods: The Ontario Health Survey Mental Health Supplement, a survey of more than 8000 residents aged 15–64 of the Canadian province of Ontario, used the University of Michigan Composite International Interview Schedule (also used in the US National Comorbidity Survey) to assign DSM-III-R diagnoses. Several indicators of disability and quality of life were included. Our analytic strategy was to compare these indices in persons with and without GAD, stratified by MDD comorbidity, and adjusting for the effects of relevant sociodemographic factors (e.g., social class, age, gender) and dysthymia. Odds ratios (ORs) are reported; SUDAAN was used to adjust for the sampling framework. Results: GAD was highly comorbid with MDD on both a lifetime and past-year basis. Both past-year and lifetime MDD and GAD were associated with an increased likelihood of low overall perceived well-being. Both lifetime MDD and GAD were associated with dissatisfaction in one’s main activity and with family relationships. Limitations: Other comorbid Axis I or II conditions might be confounders with impairment; a lower rate of GAD than in some prior surveys bears consideration. Conclusions: These observations confirm that GAD is associated with an increased likelihood of poor global well-being and life satisfaction, beyond that associated with MDD. Given the chronicity of GAD relative to the more often episodic course of MDD, the long-term functional benefits of treating GAD may be substantial.

Parental bonding and adult psychopathology: results from the US National Comorbidity Survey.

Research using the parental bonding instrument (PBI) has suggested that lack of parental care and/or overprotection may be important risk factors for adult mental disorders. Much of this research, however, has relied on clinical populations with one or two disorders, or has used highly select community samples. The association between parenting experiences and the occurrence of 13 common mental disorders in adulthood was evaluated in the US National Comorbidity Survey (N = 5877). The effect of sociodemographic variables (age, education, income) was statistically controlled and the effects of six parenting variables (maternal and paternal care, overprotection and authoritarianism) were examined simultaneously. The effects in men and women were examined separately. Lack of care was the parenting variable most consistently associated with adult psychopathology. Parenting experiences with one's mother were more consistently associated with adult mental disorders. In general the impact of parenting was diagnostically non-specific. However, there appeared to be some unique effects for externalizing disorders (substance use disorders and antisocial personality disorder) in males; paternal overprotection and authoritarianism conferred a reduced risk of externalizing disorders in adult males. The overall impact of parenting as assessed by the PBI was modest, accounting for about 1 to 5 % of the variance in the occurrence of adult mental disorders. Parenting experiences, particularly lack of care, are potentially causally related in a non-specific manner to a wide variety of forms of adult psychopathology in both men and women. The overall magnitude of the effect is small but statistically significant in a nationally representative US sample.

Distinguishing generalized anxiety disorder from major depression: prevalence and impairment from current pure and comorbid disorders in the US and Ontario.

Estimation of comparative disease burden in epidemiological surveys is complicated by the fact that high comorbidities exist among many chronic conditions. The easiest way to take comorbidity into consideration is to distinguish between pure and comorbid conditions and to evaluate the incremental effects of comorbid conditions in prediction equations. This approach is illustrated here in an analysis of the effects of pure and comorbid major depression (MD) and generalized anxiety disorder (GAD) on a number of different measures of role impairment in the US National Comorbidity Survey (NCS) and the Mental Health Supplement to the Ontario (Canada) Health Survey (the Supplement). Pure MD and pure GAD were found to have roughly equal independent associations with role impairments. The incremental effects of having comorbid MD and GAD were found to vary depending on the outcome under investigation. The paper closes with a discussion of the methodological complexities associated with generalizing to comorbidities that involve rare conditions or more than two disorders.

Temporal progression of cocaine dependence symptoms in the US National Comorbidity Survey.

Cocaine dependence first appeared as a diagnostic category in 1987 with the publication of DSM-III-R. While the temporal sequencing of alcohol symptoms has a long history, little such attention has been focused on cocaine dependence. This paper examines the retrospective recall of DSM-III-R cocaine dependence symptom progression among a large sample of cocaine users and the relationship of these symptoms to psychiatric comorbidity. Using data from the US National Comorbidity Survey, DSM-III-R criterion 'A' cocaine dependence symptoms were sequenced temporally based on age of symptom onset. Each of these numerical symptom strings was examined to determine its prevalence and association to comorbid psychiatric disorders. Cocaine users represented 16%, of the sample. Although hundreds of symptom sequence permutations are possible, only a few are highly prevalent. Subjects whose early onset symptoms are neuroadaptive (e.g. tolerance and withdrawal) are more likely to develop cocaine dependence than subjects whose early symptoms are characterized by psychosocial consequences. Furthermore, certain temporal patterns were found to increase or decrease the presence or absence of cocaine dependence and psychiatric comorbidity. Finally, psychiatric comorbidity preceded rather than followed cocaine use onset disproportionately. Like alcohol users, cocaine users follow a limited array of symptom sequence pathways from first use to dependence. By better understanding and examining the temporal progression of drug use symptoms, clinicians might improve screening and assessment activities and determine more effectively the extent of risks associated with continued premorbid drug use and enhance treatment-matching. We encourage clinicians to develop evaluation instruments that specifically ask patients to sequence their cocaine use-related symptoms temporally.

The Parental Bonding Instrument: confirmatory evidence for a three-factor model in a psychiatric clinical sample and in the National Comorbidity Survey.

Study of the contribution of retrospective perceptions of dysfunctional parenting in relation to adult psychopathology has been greatly facilitated by the development of the 25-item Parental Bonding Instrument (PBI; Parker et al. 1979). The present study employed confirmatory factor analytic techniques to evaluate competing models of the basic dimensions underlying different versions of the PBI, in a psychiatric sample from a mood disorders program and with a new modification of the PBI employed in the US National Comorbidity Survey. The results indicated that a three-factor model originally identified in a 16-item version of the PBI modified for epidemiological research (Kendler 1996) showed the best fit to the data. The three dimensions of care, overprotection, and authoritarianism also explained the underlying structure of the NCS-modified, eight-item PBI that is now part of the NCS public use dataset available to psychopathology researchers. The replicability of findings across gender, age, and clinical versus community samples attests to the robustness of this three-factor structure of parenting styles.

Lost productivity among full-time workers with mental disorders.

BACKGROUND: Few studies have systematically compared the relationship between lost work productivity (work impairment) and mental disorders using population surveys. AIMS: (1) To identify the importance of individual mental disorders and disorder co-occurrences (comorbidity) as predictors of two measures of work impairment over the past month - work loss (number of days unable to perform usual activities) and work cutback (number of days where usual activities were restricted); (2) to examine whether different types of disorder have a greater impact on work impairment in some occupations than others; (3) to determine whether work impairment in those with a disorder is related to treatment seeking. METHOD: Data were based on full-time workers identified by the Australian National Survey of Mental Health and Well-Being, a household survey of mental disorders modeled on the US National Comorbidity Survey. Diagnoses were of one-month DSM-IV affective, anxiety and substance-related disorders. Screening instruments generated likely cases of ICD-10 personality disorders. The association of disorder types and their co-occurrences with work impairment was examined using multivariate linear regression. Odds ratios determined the significance of mental disorder prevalence across occupations, and planned contrasts were used to test for differences in work impairment across occupations within disorder types. The relationship between work impairment and treatment seeking was determined for each broad diagnostic group with t-tests. RESULTS: Depression, generalized anxiety disorder and personality disorders were predictive of work impairment after controlling for impairment due to physical disorders. Among pure and comorbid disorders, affective and comorbid anxiety-affective disorders respectively were associated with the greatest amount of work impairment. For all disorders, stronger associations were obtained for work cutback than for work loss. No relationship was found between type of occupation and the impact of different types of disorder on work impairment. Only 15% of people with any mental disorder had sought help in the past month. For any mental disorder, significantly greater work loss and work cutback was associated with treatment seeking, but comparisons within specific disorder types were not significant. DISCUSSION: A substantial amount of lost productivity due to mental disorders comes from within the full-time working population. The greater impact of mental disorders on work cutback compared to work loss suggests that work cutback provides a more sensitive measure of work impairment in those with mental disorders. Work impairment was based on self-report only. While there is evidence for the reliability of self-assessed work loss days, no reliability or validity studies have been conducted for work cutback days. The low rates of treatment seeking are a major health issue for the workforce, particularly for affective and anxiety disorders, which are important predictors of lost productivity. IMPLICATIONS FOR HEALTH POLICIES AND FURTHER RESEARCH: Future research should investigate the validity of work cutback, given its importance as a measure of lost productivity in people with mental disorders. Employers need to be aware of the extent to which mental disorders affect their employees so that effective work place interventions can take place. Treatment should be targeted at people with affective and anxiety disorders, particularly where they co-occur.

Associations of substance use, abuse, and dependence with subsequent suicidal behavior.

General population survey data are used to disaggregate the associations of substance use disorders with suicide attempts in order to evaluate a number of hypotheses about the processes leading to these associations. Data are from the US National Comorbidity Survey (1990-1992). Discrete-time survival analysis is used to study the effects of retrospectively reported temporally prior substance use, abuse, and dependence in predicting first onset of suicidal behavior. Alcohol and drug use predict subsequent suicide attempts after controlling for sociodemographics and comorbid mental disorders. Previous use is not a significant predictor among current nonusers. Abuse and dependence are significant predictors among users for three of the 10 substances considered (alcohol, inhalants, and heroin). The number of substances used is more important than the types of substances used in predicting suicidal behavior. Disaggregation shows that the effects of use are largely on suicidal ideation and nonplanned attempts among ideators. In comparison, the effects of use on suicide plans and planned attempts among ideators are not significant. Clinicians need to be aware that current substance use, even in the absence of abuse or dependence, is a significant risk factor for unplanned suicide attempts among ideators.

Comorbidity, disability and the need for treatment for DSM-IV psychiatric disorders in an insured population

Background: This study presents estimates of 12 month and current prevalences of DSM-IV disorders, and the related comor-bidity, disability and service utilization, derived from a national probability sample in Australia. Methods: The DSM-IV psychiatric disorders among persons aged 18 and over in the Australian population were assessed with data collected by lay interviewers using the Composite International Diagnostic Interview, other screening interviews and measures of disability and service utilization. The response rate was 78.1% and the final sample size was 10,641 adults. Results: Close to 20% reported at least one twelve month disorder and 13% a disorder current within the past 30 days. ICD-10 diagnoses were also derived, DSM-IV was the more conservative classification whether or not the new clinical significance criteria was applied. Major depression, any personality disorder, and alcohol dependence were the three most common twelve month disorders, generalized anxiety disorder replaced alcohol dependence as the third most common current disorder. The sexes has similar rates of any disorder, but women had higher rates of affective and anxiety disorders, men higher rates of substance use disorders. Prevalence of most disorders declined with age and education, and were lower among those employed or married. Respondents whose symptoms met criteria for three or more disorders in the past year had greatly increased rates of disability and of mental health consultations. The affective and somatoform disorders were associated with the highest rates of disability. Only 36% of people with a mental disorder this year had consulted for a mental problem, and most had seen a general practitioner. We identified those with a current disorder who were disabled or multiply comorbid - only half had consulted and of those who had not, more than half said they did not need treatment. Conclusions: The 12 month prevalence was lower than reported in the US National Comorbidity Survey but method factors might account for this. The relationships between prevalence and demographic variables, and between comorbidity, disability and service utilization were similar to those found in the US survey. Australia has a national health insurance scheme with total coverage and access to medical help is available to all, commonly at little or no cost. We identify the high rate of not consulting among those with a current disorder, and additional disability or multiple comorbidity, as an important public health problem. Kessler argued for more research on barriers to professional help seeking. This report reinforces his conclusion and shows that economic barriers are not the dominant issue.

Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey.

General population data were used to study co-morbidities between lifetime social phobia and mood disorders. Data come from the US National Comorbidity Survey (NCS). Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2.9), dysthymia (2.7) and bipolar disorder (5.9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10-15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders. Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Improving accuracy of major depression age‐of‐onset reports in the US National Comorbidity Survey

AbstractThis paper describes a series of questions designed to improve the accuracy of age‐of‐onset reports in the US National Comorbidity Survey (NCS) and empirically evaluates the impact of these questions on reports about age of onset of major depressive episodes. The logic underlying the series of question is traced to cognitive psychological research on autobiographical memory. Data are presented showing that the new question series yielded more substantively plausible age‐of‐onset reports than those obtained a decade earlier in the Epidemiologic Catchment Area (ECA) Study. The test–retest consistency of age‐of‐onset reports was also higher in the NCS than the ECA. Despite these improvements, considerable inconsistency in age‐of‐onset reports remains in the NCS test‐retest data. The paper closes with a discussion of potentially promising future directions to improve retrospective age‐of‐onset reports in new psychiatric epidemiological surveys. Copyright © 1999 Whurr Publishers, Ltd.

The World Health Organization Composite International Diagnostic Interview short‐form (CIDI‐SF)

AbstractData are reported on a series of short‐form (SF) screening scales of DSM‐III‐R psychiatric disorders developed from the World Health Organization's Composite International Diagnostic Interview (CIDI). A multi‐step procedure was used to generate CIDI‐SF screening scales for each of eight DSM disorders from the US National Comorbidity Survey (NCS). This procedure began with the subsample of respondents who endorsed the CIDI diagnostic stem question for a given disorder and then used a series of stepwise regression analyses to select a subset of screening questions to maximize reproduction of the full CIDI diagnosis. A small number of screening questions, between three and eight for each disorder, was found to account for the significant associations between symptom ratings and CIDI diagnoses. Summary scales made up of these symptom questions correctly classify between 77% and 100% of CIDI cases and between 94% and 99% of CIDI non‐cases in the NCS depending on the diagnosis. Overall classification accuracy ranged from a low of 93% for major depressive episode to a high of over 99% for generalized anxiety disorder. Pilot testing in a nationally representative telephone survey found that the full set of CIDI‐SF scales can be administered in an average of seven minutes compared to over an hour for the full CIDI. The results are quite encouraging in suggesting that diagnostic classifications made in the full CIDI can be reproduced with excellent accuracy with the CIDI‐SF scales. Independent verification of this reproduction accuracy, however, is needed in a data set other than the one in which the CIDI‐SF was developed. Copyright © 1998 Whurr Publishers Ltd.

Methodological studies of the Composite International Diagnostic Interview (CIDI) in the US national comorbidity survey (NCS)

AbstractThis paper reports the results of methodological studies carried out in conjunction with the US National Comorbidity Survey (NCS) to evaluate Version 1.0 of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). These studies relied on recent survey data collection methodology literature to investigate problems regarding question comprehension, instruction comprehension, respondent motivation to report accurately, and regarding the limits of respondent ability to report accurately. Insights and strategies developed by survey methodologists were used to modify the CIDI in an effort to address these problems. The paper describes these strategies and methodological studies that evaluated their effects, including a clinical reappraisal study and a field experiment that evaluated the impact of question modifications on prevalence estimates. The paper closes with a discussion of remaining methodological problems with the CIDI and potentially useful future studies that might be able to develop solutions to these problems. Copyright © 1998 Whurr Publishers Ltd.

Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey.

Survey data are presented on the associations between retrospectively reported childhood adversities and subsequent onset and persistence of DSM-III-R disorders. Data come from the US National Comorbidity Survey, a large survey of the US household population. Twenty-six adversities were considered, including loss events (e.g. parental divorce), parental psychopathologies (e.g. maternal depression), interpersonal traumas (e.g. rape) and other adversities (e.g. natural disaster). These adversities were consistently associated with onset, but not persistence, of DSM-III-R mood disorders, anxiety disorders, addictive disorders and acting out disorders. Most bivariate associations with onset attenuated in models that controlled for clustering of adversities and for lifetime co-morbidities among psychiatric disorders. Multivariate effects of adversities in logistic models were additive, which means that they have multiplicative effects on probability of disorder onset. Adversities showed little specificity. An analysis of time decay showed that the effects of childhood adversities on disorder onset persist beyond childhood. The existence of strong clustering among childhood adversities and lifetime co-morbidity among adult disorders means that caution is needed in interpreting the results of previous single-adversity single-disorder studies as documenting unique effects of specific childhood adversities on specific adult disorders. Future studies need to assess a broader range of adversities and disorders and to explore the existence and effects of commonly occurring adversity clusters. Replication is needed to verify that the effects of childhood adversities are mostly on first onset rather than on the creation of vulnerabilities that lead to increased risk of persistence.