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1.  Income inequality within urban settings and depressive symptoms among adolescents 
Although recent evidence has shown that area-level income inequality is related to increased risk for depression among adults, few studies have tested this association among adolescents.
We analyzed cross-sectional data from a sample of 1,878 adolescents living in 38 neighborhoods participating in the 2008 Boston Youth Survey. Using multilevel linear regression modeling, we: (1) estimated the association between neighborhood income inequality and depressive symptoms.; (2) tested for cross-level interactions between sex and neighborhood income inequality; and (3) examined neighborhood social cohesion as a mediator of the relationship between income inequality and depressive symptoms.
The association between neighborhood income inequality and depressive symptoms varied significantly by sex, with girls in higher income inequality neighborhood reporting higher depressive symptom scores, but not boys. Among girls, a unit increase in Gini Z-score was associated with more depression symptoms (β=0.38, 95% CI=0.28, 0.47, p=0.01) adjusting for nativity, neighborhood income, social cohesion, crime, and social disorder. There was no evidence that the association between income inequality and depressive symptoms was due to neighborhood-level differences in social cohesion.
The distribution of incomes within an urban area adversely affects adolescent girls’ mental health; future work is needed to understand why, as well as to examine in greater depth the potential consequences of inequality for males, which may have been difficult to detect here.
PMCID: PMC5473150  PMID: 27103664
Income inequality; depression; multilevel analysis; socioeconomic factors; neighborhood characteristics
2.  Comparing alternative effect decomposition methods: the role of literacy in mediating educational effects on mortality 
Epidemiology (Cambridge, Mass.)  2016;27(5):670-676.
Inverse odds ratio weighting, a newly proposed tool to evaluate mediation in exposure-disease associations, may be valuable for a host of research questions but little is known about its performance in real data. We compare this approach to a more conventional Baron and Kenny decomposition on an additive hazards scale to estimate total, direct, and indirect effects using the example of the role of literacy in mediating the effects of education on mortality.
Health and Retirement Study participants born in the U.S. between 1900 and 1947 were interviewed biennially for up to 12 years (N=17,054). Literacy was measured with a brief vocabulary assessment. Decomposition estimates were derived based on Aalen additive hazards models.
A one standard deviation difference in educational attainment (3 years) was associated with 6.7 fewer deaths per 1,000 person-years (β=-6.7, 95% CI: -7.9, -5.4). Of this decrease, 1.3 fewer deaths (β=-1.3, 95% CI: -4.0, 1.2) were attributed to the literacy pathway (natural indirect), representing 19% of the total effect. Baron and Kenny estimates were consistent with inverse odds ratio weighting estimates but were more precise (natural indirect effect: -1.2 (95% CI: -1.7, -0.69, representing 18% of total effect).
In a cohort of older Americans, literacy partially mediated the effect of education on mortality.
PMCID: PMC5051696  PMID: 27280331
3.  Cognitive ability in childhood and the chronicity and suicidality of depression 
The British Journal of Psychiatry  2016;208(2):120-127.
There is inconsistent evidence regarding the influence of general cognitive abilities on the long-term course of depression.
To investigate the association between general childhood cognitive abilities and adult depression outcomes.
We conducted a cohort study using data from 633 participants in the New England Family Study with lifetime depression. Cognitive abilities at age 7 were measured using the Wechsler Intelligence Scale for Children. Depression outcomes were assessed using structured diagnostic interviews administered up to four times in adulthood between ages 17 and 49.
In analyses adjusting for demographic factors and parental psychiatric illness, low general cognitive ability (i.e. IQ<85 v. IQ>115) was associated with recurrent depressive episodes (odds ratio (OR) = 2.19, 95% CI 1.20–4.00), longer episode duration (rate ratio 4.21, 95% CI 2.24–7.94), admission to hospital for depression (OR = 3.65, 95% CI 1.34–9.93) and suicide ideation (OR = 3.79, 95% CI 1.79–8.02) and attempt (OR = 4.94, 95% CI 1.67–14.55).
Variation in cognitive abilities, predominantly within the normal range and established early in childhood, may confer long-term vulnerability for prolonged and severe depression. The mechanisms underlying this vulnerability need to be established to improve the prognosis of depression among individuals with lower cognitive abilities.
PMCID: PMC4738152  PMID: 26585100
4.  Stress across the life course and depression in a rapidly developing population: The Guangzhou Biobank Cohort Study 
To examine the role of stress across the life course in the development of depression among older adults in a non-Western developing setting.
Multivariable linear and multinomial logistic regression were used in cross-sectional analyses of 9729 Chinese participants (mean age 60.2 years) from phase 3 of the Guangzhou Biobank Cohort Study (2006-8) to investigate the association of childhood adversities and adulthood stressors with depression.
Childhood adversities were associated with mild depression (odds ratio (OR) 1.78, 95% CI 1.58–2.02) and moderate-to-severe depression (OR 2.30, 95% CI 1.68–3.15), adjusted for age, sex, education and childhood socio-economic status. Past-year adulthood stressors were also associated with mild depression (OR 1.96, 95% CI 1.54–2.02) and moderate-to-severe depression (OR 3.55, 95% CI 2.21–5.68), adjusting additionally for occupation and income. Adulthood stressors were more strongly associated with depressive symptoms among individuals with a history of childhood adversities.
Childhood adversities and adulthood stressors were independently associated with an increased risk of depression among older ambulatory adults, though adulthood stressors were more strongly associated with depression following exposure to childhood adversities. This is consistent with evidence from Western settings in which the social context of risk and protective factors for depression may differ, and implies that the role of stress in the aetiology of depression is not context-specific.
PMCID: PMC5502762  PMID: 26452069
Depression; childhood adversity; life change events; life stress
5.  Cognitive ability in childhood and the chronicity and suicidality of depression 
There is inconsistent evidence regarding the influence of general cognitive abilities on the long-term course of depression.
To investigate the association between general childhood cognitive abilities and adult depression outcomes.
We conducted a cohort study using data from 633 participants in the New England Family Study with lifetime depression. Cognitive abilities at age 7 were measured using the Wechsler Intelligence Scale for Children. Depression outcomes were assessed using structured diagnostic interviews administered up to 4 times in adulthood between ages 17–49.
In analyses adjusting for demographic factors and parental psychiatric illness, low general cognitive ability (i.e. IQ<85 vs. IQ>115) was associated with recurrent depressive episodes (odds ratio (AOR)=2.19; 95% CI=1.20–4.00), longer episode duration (rate ratio=4.21, CI= 2.24–7.94), hospitalization for depression (OR=3.65; CI=1.34, 9.93) and suicide ideation (OR=3.79, CI=1.79–8.02) and attempt (OR=4.94, CI=1.67–14.55).
Variation in cognitive abilities, predominantly within the normal range and established early in childhood, may confer long-term vulnerability for prolonged and severe depression. The mechanisms underlying this vulnerability need to be established to improve the prognosis of depression among individuals with lower cognitive abilities.
PMCID: PMC4738152  PMID: 26585100
Depression and anxiety  2014;32(1):3-12.
The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self-reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers.
The New Soldier Study (NSS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured self-administered measures to estimate preenlistment histories of suicide ideation, plans, and attempts among new soldiers reporting for Basic Combat Training in 2011–2012. Survival models examined sociodemographic correlates of each suicidal outcome.
Lifetime prevalence estimates of preenlistment suicide ideation, plans, and attempts were 14.1, 2.3, and 1.9%, respectively. Most reported onsets of suicide plans and attempts (73.3–81.5%) occurred within the first year after onset of ideation. Odds of these lifetime suicidal behaviors among new soldiers were positively, but weakly associated with being female, unmarried, religion other than Protestant or Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, or Hispanic.
Lifetime prevalence estimates of suicidal behaviors among new soldiers are consistent with retrospective reports of preenlistment prevalence obtained from soldiers later in their Army careers. Given that prior suicidal behaviors are among the strongest predictors of later suicides, consideration should be given to developing methods of obtaining valid reports of preenlistment suicidality from new soldiers to facilitate targeting of preventive interventions.
PMCID: PMC5113817  PMID: 25338964
military personnel; prevalence; suicide; suicide ideation; suicide attempt
7.  Associations of Dispositional Mindfulness with Obesity and Central Adiposity: the New England Family Study 
To evaluate whether dispositional mindfulness (defined as the ability to attend nonjudgmentally to one’s own physical and mental processes) is associated with obesity and central adiposity.
Study participants (n=394) were from the New England Family Study, a prospective birth cohort, with median age 47 years. Dispositional mindfulness was assessed using the Mindful Attention Awareness Scale (MAAS). Central adiposity was assessed using dual-energy X-ray absorptiometry (DXA) scans with primary outcomes android fat mass and android/gynoid ratio. Obesity was defined as body mass index ≥30 kg/m2.
Multivariable-adjusted regression analyses demonstrated that participants with low vs. high MAAS scores were more likely to be obese (prevalence ratio for obesity= 1.34 (95 % confidence limit (CL): 1.02, 1.77)), adjusted for age, gender, race/ethnicity, birth weight, childhood socioeconomic status, and childhood intelligence. Furthermore, participants with low vs. high MAAS level had a 448 (95 % CL 39, 857) g higher android fat mass and a 0.056 (95 % CL 0.003, 0.110) greater android/gynoid fat mass ratio. Prospective analyses demonstrated that participants who were not obese in childhood and became obese in adulthood (n=154) had −0.21 (95 % CL −0.41, −0.01; p=0.04) lower MAAS scores than participants who were not obese in childhood or adulthood (n=203).
Dispositional mindfulness may be inversely associated with obesity and adiposity. Replication studies are needed to adequately establish whether low dispositional mindfulness is a risk factor for obesity and adiposity.
PMCID: PMC4965799  PMID: 26481650
Mindfulness; Obesity; Adiposity; Epidemiology; Prevention
8.  Invited Commentary: Does the Childhood Environment Influence the Association Between Every X and Every Y in Adulthood? 
American Journal of Epidemiology  2012;176(8):684-688.
The conditions under which children are raised have a long-term impact on health throughout the life course. Because childhood conditions can have such a strong influence on adult risk factors for disease, failure to account for their influences could distort observed associations between adult risk factors and subsequent health outcomes. In other words, childhood conditions could confound the association between every X and Y when X is measured in adulthood. Comparisons of health outcomes between exposed and unexposed siblings have the potential to eliminate confounding effects due to vulnerability factors shared between siblings (i.e., 50% of their genes and aspects of the childhood environment that affect siblings equally). In a large, population-based study of siblings in Denmark, Søndergaard et al. (Am J Epidemiol. 2012;176(8):675–683) found that individuals with higher educational qualifications lived longer than did their siblings with lower educational qualifications. Their results provide evidence for the returns to health resulting from investment in expanded educational opportunities. However, even sibling designs are not conclusive regarding causality; they remain subject to the unmeasured confounding influences of factors that vary within families. Nonetheless, sibling-based approaches should be used more often in studies of adult risk factors to address the long-term influences of the childhood environment on health.
PMCID: PMC3571248  PMID: 23024136
causal inference; education; health; mortality; siblings; social epidemiology
9.  Associations of Mindfulness with Glucose Regulation and Diabetes 
To evaluate whether dispositional mindfulness is associated with glucose regulation and type 2 diabetes.
Study participants (N = 399) were from the New England Family Study, a prospective birth cohort, with median age 47 years. Dispositional mindfulness was assessed using the Mindful Attention Awareness Scale (MAAS). Type 2 diabetes and “normal plasma glucose” were defined using American Diabetes Association criteria.
Multivariable-adjusted regression analyses demonstrated that participants with high versus low MAAS scores were significantly more likely to have normal plasma glucose levels (prevalence ratio = 1.35 (95% confidence interval (CI): 1.08,1.87)), and were not significantly associated with type 2 diabetes (prevalence ratio = 0.83, 95% CI: 0.38,1.79), adjusted for age, sex, race/ethnicity, family history of diabetes and childhood socioeconomic status. Mediation analyses provided evidence of mediation via obesity and sense of control, where indirect effects were prevalence ratios (95% CI) of 1.03 (1.00,1.10) and 1.08 (1.00,1.21), respectively.
Dispositional mindfulness may be associated with better glucose regulation, in part because of a lower likelihood of obesity and greater sense of control among participants with higher levels of mindfulness. These findings need to be replicated by prospective studies to establish causality and to evaluate potential implications for mindfulness-based interventions to reduce risk of type 2 diabetes.
PMCID: PMC4928637  PMID: 26931758
mindfulness; diabetes; type 2 diabetes; glucose regulation; epidemiology
10.  Early childhood social disadvantage is associated with poor health behaviours in adulthood 
Annals of human biology  2016;43(2):144-153.
Individual health behaviours are considered important risk factors for cardiometabolic diseases. These behaviours may be socially patterned by early exposure to social disadvantage, but few studies have prospectively tested this hypothesis empirically.
We investigated whether childhood social disadvantage was associated with likelihood of engaging in less healthy behaviours 40 years later.
Subjects and Methods
Prospective data were analysed from the New England Family Study, a 2005–2007 adult follow-up of a cohort initiated in 1959–1966 (n=565). Childhood social environment (birth-age 7) was assessed using a cumulative index of socioeconomic and family stability factors. Logistic regression models evaluated associations between social disadvantage and each health-related behaviour and obesity in adulthood.
Relative to low disadvantage, higher disadvantage was associated with 3.6-fold greater odds of smoking (95% CI: 1.9, 7.0), 4.8-fold greater odds (in women only) of excess alcohol consumption (95% CI: 1.6, 14.2), and 2.7-fold greater odds of obesity (95% CI: 1.3, 5.5), but was not associated with unhealthy diet or physical inactivity.
These findings suggest childhood social disadvantage may contribute to adult cardiometabolic disease by predisposing children to adopt certain unhealthy behaviours. If replicated, such findings may support intervention strategies that target social environmental factors and behavioural pathways that are established early in life.
PMCID: PMC4977531  PMID: 26727037
Early life adversity; childhood socioeconomic status; body mass index; smoking; alcohol
11.  Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Molecular psychiatry  2016;10.1038/mp.2016.110.
The 2013 U.S. Veterans Administration/Department of Defense Clinical Practice Guidelines (VA/DoD CPG) require comprehensive suicide risk assessments for VA/DoD patients with mental disorders but provide minimal guidance on how to carry out these assessments. Given that clinician-based assessments are known not to be strong predictors of suicide, we investigated whether a precision medicine model using administrative data after outpatient mental health specialty visits could be developed to predict suicides among outpatients. We focused on male non-deployed Regular U.S. Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naïve Bayes, random forests, support vector regression, elastic net penalized regression) were explored. 41.5% of Army suicides in 2004-2009 occurred among the 12.0% of soldiers seen as outpatient by mental health specialists, with risk especially high within 26 weeks of visits. An elastic net classifier with 10-14 predictors optimized sensitivity (45.6% of suicide deaths occurring after the 15% of visits with highest predicted risk). Good model stability was found for a model using 2004-2007 data to predict 2008-2009 suicides, although stability decreased in a model using 2008-2009 data to predict 2010-2012 suicides. The 5% of visits with highest risk included only 0.1% of soldiers (1047.1 suicides/100,000 person-years in the 5 weeks after the visit). This is a high enough concentration of risk to have implications for targeting preventive interventions. An even better model might be developed in the future by including the enriched information on clinician-evaluated suicide risk mandated by the VA/DoD CPG to be recorded.
PMCID: PMC5247428  PMID: 27431294
Army; machine learning; military; predictive modeling; risk assessment; suicide
12.  Adolescent self-injurers: Comparing non-ideators, suicide ideators, and suicide attempters 
Adolescent non-suicidal self-injury (NSSI) and suicidality are serious health concerns; however, factors that contribute to the transition from NSSI to suicide ideation and suicide attempts are unclear. To address this gap, we investigated whether demographic characteristics, child maltreatment, and psychiatric factors are associated with the level suicidality among adolescents with a history of self-injury. Participants were three groups of adolescent inpatient self-injurers (n = 397, 317 female), aged 13–18 years (M = 15.44, SD = 1.36): (a) non-ideators (n = 96; no current suicide ideation and no lifetime suicide attempts), (b) suicide ideators (n = 149; current ideation and no lifetime attempts), and (c) suicide attempters (n = 152; current ideation and at least one lifetime attempt). Participants completed interviews assessing psychiatric diagnoses, suicidality, and NSSI characteristics, as well as questionnaires on childhood trauma, psychiatric symptoms, and risky behavior engagement. Depression severity was associated with greater odds being a suicide ideator (p < 0.001, OR = 1.04) and an attempter (p < 0.001, OR = 1.05) compared to a non-ideator. Suicide attempters used more NSSI methods and reported greater risky behavior engagement than non-ideators (p = 0.03, OR = 1.29 and p = 0.03, OR = 1.06, respectively) and ideators (p = 0.015, OR = 1.25 and p = 0.04, OR = 1.05, respectively); attempters used more severe NSSI methods (e.g., burning). Our results identify a wide range of risk markers for increasing lethality in a sample at high risk for suicide mortality; future research is needed to refine risk assessments for adolescent self-injurers and determine the clinical utility of using risk markers for screening and intervention.
PMCID: PMC5204373  PMID: 27716512
Adolescence; Non-suicidal self-injury; Suicide attempts; Suicide ideation; Risky behavior engagement; Inpatients
13.  Instrumental variable approaches to identifying the causal effect of educational attainment on dementia risk 
Annals of epidemiology  2015;26(1):71-76.e3.
Education is an established correlate of cognitive status in older adulthood, but whether expanding educational opportunities would improve cognitive functioning remains unclear given limitations of prior studies for causal inference. Therefore, we conducted instrumental variable (IV) analyses of the association between education and dementia risk, using for the first time in this area, genetic variants as instruments as well as state-level school policies.
IV analyses in the Health and Retirement Study cohort (1998–2010) used two sets of instruments: 1) a genetic risk score constructed from three single nucleotide polymorphisms (SNPs) (n=8,054); and 2) compulsory schooling laws (CSLs) and state school characteristics (term length, student teacher ratios, and expenditures) (n=13,167).
Employing the genetic risk score as an IV, there was a 1.1% reduction in dementia risk per year of schooling (95% CI: −2.4, 0.02). Leveraging compulsory schooling laws and state school characteristics as IVs, there was a substantially larger protective effect (−9.5%; 95% CI: −14.8, −4.2). Analyses evaluating the plausibility of the IV assumptions indicated estimates derived from analyses relying on CSLs provide the best estimates of the causal effect of education.
IV analyses suggest education is protective against risk of dementia in older adulthood.
PMCID: PMC4688127  PMID: 26633592
causal inference; dementia; education; instrumental variables; unmeasured confounding
14.  Major Depressive Disorder in Long-Term Cancer Survivors: Analysis of the National Comorbidity Survey Replication 
Journal of Clinical Oncology  2009;27(25):4130-4134.
Prior research is mixed as to whether long-term cancer survivors (LCSs) have higher rates of depression than the general population. This is the first study to compare the rates of major depressive disorder (MDD) between LCSs and people without cancer histories in a nationally representative cross-sectional multistage cluster survey sample, the National Comorbidity Survey-Replication (NCS-R).
Between 2001 and 2003, face-to-face interviews were conducted for the NCS-R in a national sample of 9,282 people, of whom 5,692 were assessed for a history of cancer. Participants with cancer diagnoses at least 5 years before the interview were considered LCSs. Survivors of childhood cancers were excluded. Comparing LCSs to those without a cancer history, odds ratios for having a MDD episode in the last 12 months before interview were obtained using multiple logistic regression controlling for demographic and medical variables. Differences in characteristics of those MDD episodes were also compared between groups.
Of participants age 23 years or older, 243 LCSs and 4,890 adults without a cancer history were identified in the sample. Adjusting for demographic variables and medical comorbidities, LCSs did not have increased odds of MDD in the last 12 months, with an odds ratio of (OR) 0.99 (95% CI, 0.55 to 1.79). LCSs reported higher mean levels of impairment from MDD in their home, social, and work life, but these differences were not significant.
LCSs do not appear to have elevated rates of MDD. However, they may experience greater impairment from MDD compared to those without cancer. Longitudinal studies are needed to confirm these findings.
PMCID: PMC2734424  PMID: 19636024
15.  Socioeconomic disadvantage and neural development from infancy through early childhood 
Background: Early social experiences are believed to shape neurodevelopment, with potentially lifelong consequences. Yet minimal evidence exists regarding the role of the social environment on children’s neural functioning, a core domain of neurodevelopment.
Methods: We analysed data from 36 443 participants in the United States Collaborative Perinatal Project, a socioeconomically diverse pregnancy cohort conducted between 1959 and 1974. Study outcomes included: physician (neurologist or paediatrician)-rated neurological abnormality neonatally and thereafter at 4 months and 1 and 7 years; indicators of neurological hard signs and soft signs; and indicators of autonomic nervous system function.
Results: Children born to socioeconomically disadvantaged parents were more likely to exhibit neurological abnormalities at 4 months [odds ratio (OR) = 1.20; 95% confidence interval (CI) = 1.06, 1.37], 1 year (OR = 1.35; CI = 1.17, 1.56), and 7 years (OR = 1.67; CI = 1.48, 1.89), and more likely to exhibit neurological hard signs (OR = 1.39; CI = 1.10, 1.76), soft signs (OR = 1.26; CI = 1.09, 1.45) and autonomic nervous system dysfunctions at 7 years. Pregnancy and delivery complications, themselves associated with socioeconomic disadvantage, did not account for the higher risks of neurological abnormalities among disadvantaged children.
Conclusions: Parental socioeconomic disadvantage was, independently from pregnancy and delivery complications, associated with abnormal child neural development during the first 7 years of life. These findings reinforce the importance of the early environment for neurodevelopment generally, and expand knowledge regarding the domains of neurodevelopment affected by environmental conditions. Further work is needed to determine the mechanisms linking socioeconomic disadvantage with children’s neural functioning, the timing of such mechanisms and their potential reversibility.
PMCID: PMC4715254  PMID: 26675752
Neural development; soft signs; neurological abnormality; socioeconomic status
16.  Lifetime Prevalence of DSM-IV Mental Disorders Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
Depression and anxiety  2014;32(1):13-24.
The prevalence of 30-day mental disorders with retrospectively-reported early onsets is significantly higher in the U.S. Army than among socio-demographically matched civilians. This difference could reflect high prevalence of pre-enlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits.
The New Soldier Study (NSS) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully-structured measures to estimate lifetime prevalence of 10 DSM-IV disorders in new soldiers reporting for Basic Combat Training in 2011-2012 (n=38,507). Prevalence was compared to estimates from a matched civilian sample. Multivariate regression models examined socio-demographic correlates of disorder prevalence and persistence among new soldiers.
Lifetime prevalence of having at least one internalizing, externalizing, or either type of disorder did not differ significantly between new soldiers and civilians, although three specific disorders (generalized anxiety, posttraumatic stress, and conduct disorders) and multi-morbidity were significantly more common among new soldiers than civilians. Although several socio-demographic characteristics were significantly associated with disorder prevalence and persistence, these associations were uniformly weak.
New soldiers differ somewhat, but not consistently, from civilians in lifetime pre-enlistment mental disorders. This suggests that prior findings of higher prevalence of current disorders with pre-enlistment onsets among soldiers than civilians are likely due primarily to a more persistent course of early-onset disorders in the context of the special stresses experienced by Army personnel.
PMCID: PMC5111824  PMID: 25338841
military personnel; mental disorders; prevalence; epidemiology; demographics
17.  Mental Disorders, Comorbidity and Pre-Enlistment Suicidal Behavior among New Soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Service members (Army STARRS) 
Suicide & life-threatening behavior  2015;10.1111/sltb.12153.
We examined the associations between mental disorders and suicidal behavior (ideation, plans, and attempts) among new soldiers using data from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; n=38,507). Most new soldiers with a pre-enlistment history of suicide attempt reported a prior mental disorder (59.0%). Each disorder examined was associated with increased odds of suicidal behavior (ORs=2.6–8.6). Only PTSD and disorders characterized by irritability and impulsive/aggressive behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder) predicted unplanned attempts among ideators. Mental disorders are important predictors of pre-enlistment suicidal behavior among new soldiers and should figure prominently in suicide screening and prevention efforts.
PMCID: PMC4515394  PMID: 25622860
18.  Educational attainment and cigarette smoking: a causal association?† 
Despite abundant evidence that lower education is associated with a higher risk of smoking, whether the association is causal has not been convincingly established.
We investigated the association between education and lifetime smoking patterns in a birth cohort established in 1959 and followed through adulthood (n = 1311). We controlled for a wide range of potential confounders that were measured prior to school entry, and also estimated sibling fixed effects models to control for unmeasured familial vulnerability to smoking.
In the full sample of participants, regression analyses adjusting for multiple childhood factors (including socioeconomic status, IQ, behavioural problems, and medical conditions) indicated that the number of pack-years smoked was higher among individuals with less than high school education [rate ratio (RR) = 1.58, confidence interval (CI) = 1.31, 1.91]. However, in the sibling fixed effects analysis the RR was 1.23 (CI = 0.80, 1.93). Similarly, adjusted models estimated in the full sample showed that individuals with less than high school education had fewer short-term (RR = 0.40; CI = 0.23, 0.69) and long-term (RR = 0.59; CI = 0.42, 0.83) quit attempts, and were less likely to quit smoking (odds ratio = 0.34; CI = 0.19, 0.62). The effects of education on quitting smoking were attenuated in the sibling fixed effects models that controlled for familial vulnerability to smoking.
A substantial portion of the education differential in smoking that has been repeatedly observed is attributable to factors shared by siblings that contribute to shortened educational careers and to lifetime smoking trajectories. Reducing disparities in cigarette smoking, including educational disparities, may therefore require approaches that focus on factors early in life that influence smoking risk over the adult life span.
PMCID: PMC4939617  PMID: 18180240
Education; smoking; causality; disparities
19.  US State-level income inequality and risks of heart attack and coronary risk behaviors: longitudinal findings 
To examine prospectively the association between US state income inequality and incidence of heart attack.
We used data from the National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,445). Respondents completed interviews at baseline (2001–2002) and follow-up (2004–2005). Weighted multilevel modeling was used to determine if US state-level income inequality (measured by the Gini coefficient) at baseline was a predictor of heart attack during follow-up, controlling for individual-level and state-level covariates.
In comparison to residents of US states in the lowest quartile of income inequality, those living in the second [Adjusted Odds Ratio (AOR) =1.71, 95 % CI 1.16–2.53)], third (AOR = 1.81, 95 % CI 1.28–2.57), and fourth (AOR = 2.04, 95 % CI 1.26–3.29) quartiles were more likely to have a heart attack. Similar findings were obtained when we excluded those who had a heart attack prior to baseline.
This study is one of the first to empirically show the longitudinal relationship between income inequality and coronary heart disease. Living in a state with higher income inequality increases the risk for heart attack among US adults.
PMCID: PMC4517572  PMID: 25981210
Income inequality; Coronary heart disease; Social determinants of health; Multilevel modeling; Longitudinal analysis; Population-based study
20.  Predictors of Suicide and Accident Death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
JAMA psychiatry  2014;71(5):493-503.
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality.
To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations.
Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009.
Death by suicide or accident during active Army service.
The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army’s increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides.
Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
PMCID: PMC4124912  PMID: 24590048
21.  Classifying U.S. Army Military Occupational Specialties Using the Occupational Information Network 
Military medicine  2014;179(7):752-761.
To derive job condition scales for future studies of the effects of job conditions on soldier health and job functioning across Army Military Occupation Specialties (MOSs) and Areas of Concentration (AOCs) using Department of Labor (DoL) Occupational Information Network (O*NET) ratings.
A consolidated administrative dataset was created for the “Army Study to Assess Risk and Resilience in Servicemembers” (Army STARRS) containing all soldiers on active duty between 2004 and 2009. A crosswalk between civilian occupations and MOS/AOCs (created by DoL and the Defense Manpower Data Center) was augmented to assign scores on all 246 O*NET dimensions to each soldier in the dataset. Principal components analysis was used to summarize these dimensions.
Three correlated components explained the majority of O*NET dimension variance: “physical demands” (20.9% of variance), “interpersonal complexity” (17.5%), and “substantive complexity” (15.0%). Although broadly consistent with civilian studies, several discrepancies were found with civilian results reflecting potentially important differences in the structure of job conditions in the Army versus the civilian labor force.
Principal components scores for these scales provide a parsimonious characterization of key job conditions that can be used in future studies of the effects of MOS/AOC job conditions on diverse outcomes.
PMCID: PMC4764059  PMID: 25003860
22.  Suicide Among Soldiers: A Review of Psychosocial Risk and Protective Factors 
Psychiatry  2013;76(2):97-125.
Suicide is difficult to predict and prevent and remains a leading cause of death worldwide. Although soldiers historically have had a suicide rate well below that of the general population, the suicide rate among members of the U.S. Army has increased markedly over the past several years and now exceeds that of the general population. This paper reviews psychosocial factors known to be associated with the increased risk of suicidal behavior in general and describes how some of these factors may be especially important in understanding suicide among soldiers. Moving forward, the prevention of suicide requires additional research aimed at: (a) better describing when, where, and among whom suicidal behavior occurs, (b) using exploratory studies to discover new risk and protective factors, (c) developing new methods of predicting suicidal behavior that synthesize information about modifiable risk and protective factors from multiple domains, and (d) understanding the mechanisms and pathways through which suicidal behavior develops. Although the scope and severity of this problem is daunting, the increasing attention and dedication to this issue by the Armed Forces, scientists, and society provide hope for our ability to better predict and prevent these tragic outcomes in the future.
PMCID: PMC4060831  PMID: 23631542
23.  Predicting U.S. Army suicides after hospitalizations with psychiatric diagnoses in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
JAMA psychiatry  2015;72(1):49-57.
The U.S. Army experienced a sharp rise in suicides beginning in 2004. Administrative data show that among those at highest risk are soldiers in the 12 months after inpatient treatment of a psychiatric disorder.
To develop an actuarial risk algorithm predicting suicide in the 12 months after US Army soldier inpatient treatment of a psychiatric disorder to target expanded post-hospital care.
There were 53,769 hospitalizations of active duty soldiers in 2004–2009 with ICD-9-CM psychiatric admission diagnoses. Administrative data available prior to hospital discharge abstracted from a wide range of data systems (socio81 demographic, Army career, criminal justice, medical/pharmacy) were used to predict suicides in the subsequent 12 months using machine learning methods (regression trees, penalized regressions) designed to evaluate cross-validated linear, nonlinear, and interactive predictive associations.
Suicides of soldiers hospitalized with psychiatric disorders in the 12 months after hospital discharge.
68 soldiers died by suicide within 12 months of hospital discharge (12.0% of all Army suicides), equivalent to 263.9 suicides/100,000 person-years compared to 18.5 suicides/100,000 person-years in the total Army. Strongest predictors included socio-demographics (male, late age of enlistment), criminal offenses (verbal violence, weapons possession), prior suicidality, aspects of prior psychiatric inpatient and outpatient treatment, and disorders diagnosed during the focal hospitalizations. 52.9% of post-hospital suicides occurred after the 5% of hospitalizations with highest predicted suicide risk (3,824.1 suicides/100,000 person years). These highest-risk hospitalizations also accounted for significantly elevated proportions of several other adverse post-hospital outcomes (unintentional injury deaths, suicide attempts, re-hospitalizations).
The high concentration of risk of suicides and other adverse outcomes might justify targeting expanded post-hospital interventions to soldiers classified as having highest post-hospital suicide risk, although final determination requires careful consideration of intervention costs, comparative effectiveness, and possible adverse effects.
PMCID: PMC4286426  PMID: 25390793
Army; machine learning; elastic net regression; military; penalized regression; predictive modeling; risk assessment; suicide
24.  Early origins of inflammation: an examination of prenatal and childhood social adversity in a prospective cohort study 
Psychoneuroendocrinology  2014;0:403-413.
Children exposed to social adversity carry a greater risk of poor physical and mental health into adulthood. This increased risk is thought to be due, in part, to inflammatory processes associated with early adversity that contribute to the etiology of many adult illnesses. The current study asks whether aspects of the prenatal social environment are associated with levels of inflammation in adulthood, and whether prenatal and childhood adversity both contribute to adult inflammation.
We examined associations of prenatal and childhood adversity assessed through direct interviews of participants in the Collaborative Perinatal Project between 1959–1974 with blood levels of C-reactive protein in 355 offspring interviewed in adulthood (mean age=42.2 years). Linear and quantile regression models were used to estimate the effects of prenatal adversity and childhood adversity on adult inflammation, adjusting for age, sex, and race and other potential confounders.
In separate linear regression models, high levels of prenatal and childhood adversity were associated with higher CRP in adulthood. When prenatal and childhood adversity were analyzed together, our results support the presence of an effect of prenatal adversity on (log) CRP level in adulthood (β=0.73, 95% CI: 0.26, 1.20) that is independent of childhood adversity and potential confounding factors including maternal health conditions reported during pregnancy. Supplemental analyses revealed similar findings using quantile regression models and logistic regression models that used a clinically-relevant CRP threshold (>3 mg/L). In a fully-adjusted model that included childhood adversity, high prenatal adversity was associated with a 3-fold elevated odds (95% CI: 1.15, 8.02) of having a CRP level in adulthood that indicates high risk of cardiovascular disease.
Social adversity during the prenatal period is a risk factor for elevated inflammation in adulthood independent of adversities during childhood. This evidence is consistent with studies demonstrating that adverse exposures in the maternal environment during gestation have lasting effects on development of the immune system. If these results reflect causal associations, they suggest that interventions to improve the social and environmental conditions of pregnancy would promote health over the life course. It remains necessary to identify the mechanisms that link maternal conditions during pregnancy to the development of fetal immune and other systems involved in adaptation to environmental stressors.
PMCID: PMC4268261  PMID: 25462912
C-reactive protein; inflammation; prenatal exposure; childhood adversity; adult; stress; cohort study; longitudinal
25.  Social Factors, Psychopathology, and Maternal Smoking During Pregnancy 
American journal of public health  2007;98(3):448-453.
We investigated the relative importance of sociodemographic factors and psychiatric disorders for smoking among 453 pregnant women in the National Epidemiological Survey on Alcohol and Related Conditions. Women with less than a high school education and those with current-year nicotine dependence had the highest risk of smoking (90.5%), compared with women with a college degree and without nicotine dependence (3.9%). More effective and accessible interventions for nicotine dependence among pregnant smokers are needed.
PMCID: PMC2253564  PMID: 17600245

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