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1.  Using self-report surveys at the beginning of service to develop multi-outcome risk models for new soldiers in the U.S. Army 
Psychological medicine  2017;47(13):2275-2287.
Background
The U.S. Army uses universal preventives interventions for several negative outcomes (e.g., suicide, violence, sexual assault) with especially high risks in the early years of service. More intensive interventions exist, but would be cost-effective only if targeted at high-risk soldiers. We report results of efforts to develop models for such targeting from self-report surveys administered at the beginning of Army service.
Methods
21,832 new soldiers completed a self-administered questionnaire (SAQ) in 2011–2012 and consented to link administrative data to SAQ responses. Penalized regression models were developed for 12 administratively-recorded outcomes occurring by December 2013: suicide attempt, mental hospitalization, positive drug test, traumatic brain injury (TBI), other severe injury, several types of violence perpetration and victimization, demotion, and attrition.
Results
The best-performing models were for TBI (AUC=0.80), major physical violence perpetration (AUC=0.78), sexual assault perpetration (AUC=0.78), and suicide attempt (AUC=0.74). Although predicted risk scores were significantly correlated across outcomes, prediction was not improved by including risk scores for other outcomes in models. Of particular note: 40.5% of suicide attempts occurred among the 10% of new soldiers with highest predicted risk, 57.2% of male sexual assault perpetrations among the 15% with highest predicted risk, and 35.5% of female sexual assault victimizations among the 10% with highest predicted risk.
Conclusions
Data collected at the beginning of service in self-report surveys could be used to develop risk models that define small proportions of new soldiers accounting for high proportions of negative outcomes over the first few years of service.
doi:10.1017/S003329171700071X
PMCID: PMC5679702  PMID: 28374665
Army; military; predictive modeling; risk assessment; mental health; violence; disciplinary problems
2.  Mental disorders among college students in the WHO World Mental Health Surveys 
Psychological medicine  2016;46(14):2955-2970.
Background
Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years.
Methods
The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1,572) and nonstudents in the same age range (18–22; n = 4,178), including nonstudents who recently left college without graduating (n = 702) based on surveys in 21 countries (4 low/lower-middle income, 5 upper middle-income, 1 lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioural and substance disorders were assessed with the Composite International Diagnostic Interview.
Results
One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders. 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders.
Conclusions
Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.
doi:10.1017/S0033291716001665
PMCID: PMC5129654  PMID: 27484622
Mental Illness; College; Education; College Dropout; College attrition; Epidemiology
3.  PREVALENCE AND CORRELATES OF SUICIDAL BEHAVIOR 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):3-12.
Background
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.
Method
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.
Results
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.
Conclusions
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.
doi:10.1002/da.22317
PMCID: PMC5113817  PMID: 25338964
military personnel; prevalence; suicide; suicide ideation; suicide attempt
4.  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.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1002/da.22316
PMCID: PMC5111824  PMID: 25338841
military personnel; mental disorders; prevalence; epidemiology; demographics
5.  Long-Term Effects of Mental disorders on Employment In the National Comorbidity Survey Ten-Year Follow-up 
Purpose
Although significant negative associations of mental disorders with employment have been documented in epidemiological research, much of this research was based on cross-sectional samples and focused only on severe and persistent mental disorders. The present study examined the longitudinal associations of more common mental disorders with employment.
Methods
Data on the associations of common mental disorders with employment are presented here from 4,501 respondents in the National Comorbidity Survey panel study, a two-wave community epidemiological survey of respondents aged 15-54 at baseline (1990-1992) who were re-interviewed in 2001-2003 and were employed, unemployed in the labor force or student at baseline. Lifetime mental disorders at baseline and disorders with onset after baseline were assessed with the Composite International Diagnostic Interview, a fully-structured interview that assessed lifetime prevalence of internalizing fear disorders (panic, phobias), anxiety/misery disorders (major depression, generalized anxiety disorder, post-traumatic stress disorder), externalizing disorders (conduct disorder, alcohol and illicit drug abuse-dependence), and bipolar disorder.
Results
Both baseline lifetime disorders and disorders with onsets after baseline were associated with significantly reduced odds of subsequent employment among respondents who were either employed or students at baseline. Population projections based on the assumption that these associations represented causal effects suggest that the mental disorders considered here were associated with 1.7-3.2 million adults being unemployed in the US population at follow-up.
Conclusions
Expanded access to treatment among current employees and students with mental disorders might lead to improved employment outcomes in these segments of the population.
doi:10.1007/s00127-015-1097-z
PMCID: PMC4618045  PMID: 26211661
6.  Long-Term Effects of Mental disorders on Educational Attainment In the National Comorbidity Survey Ten-Year Follow-up 
Purpose
The study sought to examine the association of mental disorders with educational attainment in a community sample.
Methods
Data were from 5,001 respondents aged 15–54 in the 1990–1992 National Comorbidity Survey (NCS), re-interviewed in the 2001–2003 NCS follow-up (NCS-2). Discrete-time survival analysis was used to examine the association of disorders present at baseline (NCS) or having first onset after the baseline (assessed in NCS-2) with educational outcomes among 3,954 eligible respondents. Mental disorders were categorized into internalizing fear disorders (simple phobia, social phobia, panic disorder with/without agoraphobia and agoraphobia without panic disorder), internalizing anxiety-misery disorders (major depressive disorder, generalized anxiety disorder and post-traumatic stress disorder), externalizing disorders (alcohol and drug use disorders, conduct disorder) and bipolar disorder. Analyses were conducted separately in students and non-students at baseline.
Results
Among students, baseline bipolar and externalizing disorders, and fear, anxiety-misery and externalizing disorders with onset after baseline were associated with lower odds of high school graduation; baseline anxiety-misery disorders with lower odds of going to college; and baseline externalizing disorders and bipolar disorder with onset after baseline with lower odds of college graduation. Among non-students, baseline fear disorders were associated with lower odds of high school graduation and bipolar disorder with lower odds of going to college. Assuming that the regression coefficients represent causal effects, mental disorders accounted for 5.8–11.0% of high school and 3.2–11.4% of college non-completion.
Conclusions
Expanding access to mental health services for youth might have a net positive societal value by helping to prevent some of these adverse educational outcomes.
doi:10.1007/s00127-015-1083-5
PMCID: PMC4964966  PMID: 26082040
7.  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.
doi:10.1111/sltb.12153
PMCID: PMC4515394  PMID: 25622860
8.  Testing a machine-learning algorithm to predict the persistence and severity of major depressive disorder from baseline self-reports 
Molecular psychiatry  2016;21(10):1366-1371.
Heterogeneity of major depressive disorder (MDD) illness course complicates clinical decision-making. While efforts to use symptom profiles or biomarkers to develop clinically useful prognostic subtypes have had limited success, a recent report showed that machine learning (ML) models developed from self-reports about incident episode characteristics and comorbidities among respondents with lifetime MDD in the World Health Organization World Mental Health (WMH) Surveys predicted MDD persistence, chronicity, and severity with good accuracy. We report results of model validation in an independent prospective national household sample of 1,056 respondents with lifetime MDD at baseline. The WMH ML models were applied to these baseline data to generate predicted outcome scores that were compared to observed scores assessed 10–12 years after baseline. ML model prediction accuracy was also compared to that of conventional logistic regression models. Area under the receiver operating characteristic curve (AUC) based on ML (.63 for high chronicity and .71–.76 for the other prospective outcomes) was consistently higher than for the logistic models (.62–.70) despite the latter models including more predictors. 34.6–38.1% of respondents with subsequent high persistence-chronicity and 40.8–55.8% with the severity indicators were in the top 20% of the baseline ML predicted risk distribution, while only 0.9% of respondents with subsequent hospitalizations and 1.5% with suicide attempts were in the lowest 20% of the ML predicted risk distribution. These results confirm that clinically useful MDD risk stratification models can be generated from baseline patient self-reports and that ML methods improve on conventional methods in developing such models.
doi:10.1038/mp.2015.198
PMCID: PMC4935654  PMID: 26728563
9.  Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army 
JAMA psychiatry  2014;71(5):504-513.
IMPORTANCE
Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment.
OBJECTIVE
To estimate the proportions of 30-day DSM-IV mental disorders among nondeployed US Army personnel with first onsets prior to enlistment and the extent which role impairments associated with 30-day disorders differ depending on whether the disorders had pre-vs post-enlistment onsets.
DESIGN, SETTING, AND PARTICIPANTS
A representative sample of 5428 soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed self-administered questionnaires and consented to linkage of questionnaire responses with administrative records.
MAIN OUTCOMES AND MEASURES
Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/ hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. Role impairment was assessed with a modified Sheehan Disability Scale.
RESULTS
A total of 25.1% of respondents met criteria for any 30-day disorder (15.0% internalizing; 18.4% externalizing) and 11.1% for multiple disorders. A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day disorder (49.6% internalizing; 81.7% externalizing). Also, 12.8% of respondents reported severe role impairment. Controlling for sociodemographic and Army career correlates, which were broadly consistent with other studies, 30-day disorders with pre-enlistment (χ82=131.8, P < .001) and post-enlistment (χ72=123.8, P < .001) ages at onset both significantly predicted severe role impairment, although pre-enlistment disorders were more consistent powerful predictors (7 of 8 disorders significant; odds ratios, 1.6–11.4) than post-enlistment disorders (5 of 7 disorders significant; odds ratios, 1.5–7.7). Population-attributable risk proportions of severe role impairment were 21.7% for pre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all disorders.
CONCLUSIONS AND RELEVANCE
Interventions to limit accession or increase resilience of new soldiers with pre-enlistment mental disorders might reduce prevalence and impairments of mental disorders in the US Army.
doi:10.1001/jamapsychiatry.2014.28
PMCID: PMC4057988  PMID: 24590120
10.  Prevalence and Correlates of Suicidal Behavior Among Soldiers 
JAMA psychiatry  2014;71(5):514-522.
IMPORTANCE
The suicide rate among US Army soldiers has increased substantially in recent years.
OBJECTIVES
To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal behaviors among nondeployed US Army soldiers.
DESIGN, SETTING, AND PARTICIPANTS
A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey.
MAIN OUTCOMES AND MEASURES
Lifetime suicidal ideation, suicide plans, and suicide attempts.
RESULTS
The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%–58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates. Most reported onsets of plans and attempts among ideators (58.3%–63.3%) occur within the year of onset of ideation. Post-enlistment attempts are positively related to being a woman (with an odds ratio [OR] of 3.3 [95% CI, 1.5–7.5]), lower rank (OR = 5.8 [95% CI, 1.8–18.1]), and previously deployed (OR = 2.4–3.7) and are negatively related to being unmarried (OR = 0.1–0.8) and assigned to Special Operations Command (OR = 0.0 [95% CI, 0.0–0.0]). Five mental disorders predict post-enlistment first suicide attempts in multivariate analysis: pre-enlistment panic disorder (OR = 0.1 [95% CI, 0.0–0.8]), pre-enlistment posttraumatic stress disorder (OR = 0.1 [95% CI, 0.0–0.7]), post-enlistment depression (OR = 3.8 [95% CI, 1.2–11.6]), and both pre- and post-enlistment intermittent explosive disorder (OR = 3.7–3.8). Four of these 5 ORs (posttraumatic stress disorder is the exception) predict ideation, whereas only post-enlistment intermittent explosive disorder predicts attempts among ideators. The population-attributable risk proportions of lifetime mental disorders predicting post-enlistment suicide attempts are 31.3% for pre-enlistment onset disorders, 41.2% for post-enlistment onset disorders, and 59.9% for all disorders.
CONCLUSIONS AND RELEVANCE
The fact that approximately one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders suggests that pre-enlistment mental disorders might be targets for early screening and intervention. The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (ie, restricting access to lethal means [such as firearms]) as a suicide prevention strategy.
doi:10.1001/jamapsychiatry.2014.30
PMCID: PMC4100464  PMID: 24590178
11.  Response bias, weighting adjustments, and design effects in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable recommendations to reduce U.S. Army suicides and increase knowledge about determinants of suicidality. Three Army STARRS component studies are large-scale surveys: one of new soldiers prior to beginning Basic Combat Training (BCT; n=50,765 completed self-administered questionnaires); another of other soldiers exclusive of those in BCT (n=35,372); and a third of three Brigade Combat Teams about to deploy to Afghanistan who are being followed multiple times after returning from deployment (n= 9,421). Although the response rates in these surveys are quite good (72.0-90.8%), questions can be raised about sample biases in estimating prevalence of mental disorders and suicidality, the main outcomes of the surveys based on evidence that people in the general population with mental disorders are under-represented in community surveys. This paper presents the results of analyses designed to determine whether such bias exists in the Army STARRS surveys and, if so, to develop weights to correct for these biases. Data are also presented on sample inefficiencies introduced by weighting and sample clustering and on analyses of the trade-off between bias and efficiency in weight trimming.
doi:10.1002/mpr.1399
PMCID: PMC3992816  PMID: 24318218
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling
12.  Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) 
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study of unprecedented size and complexity designed to generate actionable evidence-based recommendations to reduce U.S. Army suicides and increase basic knowledge about determinants of suicidality by carrying out coordinated component studies. A number of major logistical challenges were faced in implementing these studies. The current report presents an overview of the approaches taken to meet these challenges, with a special focus on the field procedures used to implement the component studies. As detailed in the paper, these challenges were addressed at the onset of the initiative by establishing an Executive Committee, a Data Coordination Center (the Survey Research Center [SRC] at the University of Michigan), and study-specific design and analysis teams that worked with staff on instrumentation and field procedures. SRC staff, in turn, worked with the Office of the Deputy Under Secretary of the Army (ODUSA) and local Army Points of Contact (POCs) to address logistical issues and facilitate data collection. These structures, coupled with careful fieldworker training, supervision, and piloting contributed to the major Army STARRS data collection efforts having higher response rates than previous large-scale studies of comparable military samples.
doi:10.1002/mpr.1400
PMCID: PMC3992884  PMID: 24038395
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling
13.  The prevalence and correlates of Intermittent Explosive Disorder in Iraq 
Acta psychiatrica Scandinavica  2012;126(3):219-228.
Objective
Intermittent explosive disorder (IED) is common, begins early in life, and is associated with considerable impairment in the U.S. The epidemiology of IED outside the U.S. is unknown. We examined the prevalence and correlates of IED in Iraq, where exposure to violence has been widespread during the last three decades.
Method
Data were drawn from a national survey of the Iraq population, the Iraq Mental Health Survey (IMHS), conducted in 2006–2007. The WHO Composite International Diagnostic interview was used to assess DSM-IV disorders, including IED. The response rate was 95.2%.
Results
Lifetime and 12-month prevalence estimates of IED were 1.7% and 1.5%. Mean age of onset was 18.5. The mean number of lifetime attacks was 141.6 lifetime attacks, and IED-related injuries occurred 61 times per 100 lifetime cases. IED was significantly comorbid with mood and anxiety, but not substance, disorders.
Conclusion
Although the prevalence of IED is lower in Iraq than in the U.S., the disorder has an early age-of-onset, is highly persistent, and is associated with substantial comorbidity and functional impairment. Iraq lacks national policies or systematic programs to reduce aggression, highlighting the importance of implementing violence prevention programs to reduce the societal burden of violence in Iraq.
doi:10.1111/j.1600-0447.2012.01855.x
PMCID: PMC3992890  PMID: 22443168
Intermittent explosive disorder (IED); mental illness; prevalence; Iraq; World Mental Health Surveys
14.  Prevalence, correlates and treatment of lifetime suicidal behavior among adolescents: Results from the National Comorbidity Survey Replication – Adolescent Supplement (NCS-A) 
JAMA psychiatry  2013;70(3):10.1001/2013.jamapsychiatry.55.
Context
Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (i.e., suicide ideation, plans, and attempts).
Objectives
To estimate lifetime prevalence of suicidal behaviors among US adolescents and associations of retrospectively-reported temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors.
Design
Dual-frame national sample of adolescents from the National Comorbidity Survey-Replication Adolescent Supplement (NCS-A).
Setting
Face-to-face household interviews with adolescents and questionnaires with parents.
Participants
6,483 adolescents (ages 13–18 years) and parents.
Main outcome measures
Lifetime suicide ideation, plans, and attempts.
Results
The estimated lifetime prevalence of suicide ideation, plans, and attempts among NCS-A respondents is 12.1%, 4.0% and 4.1%. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders also predict plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%) treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring.
Conclusions
Suicidal behaviors are commonly occurring among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have pre-existing mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.
doi:10.1001/2013.jamapsychiatry.55
PMCID: PMC3886236  PMID: 23303463
15.  Intermittent Explosive Disorder in the National Comorbidity Survey Replication Adolescent Supplement 
Archives of general psychiatry  2012;69(11):1131-1139.
Context
Epidemiologic studies of adults show that DSM-IV intermittent explosive disorder (IED) is a highly prevalent and seriously impairing disorder. Although retrospective reports in these studies suggest that IED typically begins in childhood, no previous epidemiologic research has directly examined the prevalence or correlates of IED among youth.
Objective
To present epidemiologic data on the prevalence and correlates of IED among US adolescents in the National Comorbidity Survey Replication Adolescent Supplement.
Design
United States survey of adolescent (age, 13–17 years) DSM-IV anxiety, mood, behavior, and substance disorders.
Setting
Dual-frame household-school samples.
Participants
A total of 6483 adolescents (interviews) and parents (questionnaires).
Main Outcome Measures
The DSM-IV disorders were assessed with the World Health Organization Composite International Diagnostic Interview (CIDI).
Results
Nearly two-thirds of adolescents (63.3%) reported lifetime anger attacks that involved destroying property, threatening violence, or engaging in violence. Of these, 7.8% met DSM-IV/CIDI criteria for lifetime IED. Intermittent explosive disorder had an early age at onset (mean age, 12.0 years) and was highly persistent, as indicated by 80.1% of lifetime cases (6.2% of all respondents) meeting 12-month criteria for IED. Injuries related to IED requiring medical attention reportedly occurred 52.5 times per 100 lifetime cases. In addition, IED was significantly comorbid with a wide range of DSM-IV/CIDI mood, anxiety, and substance disorders, with 63.9% of lifetime cases meeting criteria for another such disorder. Although more than one-third (37.8%) of adolescents with 12-month IED received treatment for emotional problems in the year before the interview, only 6.5% of respondents with 12-month IED were treated specifically for anger.
Conclusions
Intermittent explosive disorder is a highly prevalent, persistent, and seriously impairing adolescent mental disorder that is both understudied and undertreated. Research is needed to uncover risk and protective factors for the disorder, develop strategies for screening and early detection, and identify effective treatments.
doi:10.1001/archgenpsychiatry.2012.592
PMCID: PMC3637919  PMID: 22752056
16.  Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys 
The British Journal of Psychiatry  2012;200(4):290-299.
Background
Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity.
Aims
To examine the associations of parent with respondent disorders.
Method
Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews.
Results
Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle- than low-/lower-middle-income countries, and consistently higher for behaviour (11.0-19.9%) than other (7.1-14.0%) disorders.
Conclusions
Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.
doi:10.1192/bjp.bp.111.101253
PMCID: PMC3317036  PMID: 22403085
17.  Treatment of suicidal people around the world † 
Background
Suicide is a leading cause of death worldwide; however, little information is available about the treatment of suicidal people, or about barriers to treatment.
Aims
To examine the receipt of mental health treatment and barriers to care among suicidal people around the world.
Method
Twenty-one nationally representative samples worldwide (n=55 302; age 18 years and over) from the World Health Organization’s World Mental Health Surveys were interviewed regarding past-year suicidal behaviour and past-year healthcare use. Suicidal respondents who had not used services in the past year were asked why they had not sought care.
Results
Two-fifths of the suicidal respondents had received treatment (from 17% in low-income countries to 56% in high-income countries), mostly from a general medical practitioner (22%), psychiatrist (15%) or non-psychiatrist (15%). Those who had actually attempted suicide were more likely to receive care. Low perceived need was the most important reason for not seeking help (58%), followed by attitudinal barriers such as the wish to handle the problem alone (40%) and structural barriers such as financial concerns (15%). Only 7% of respondents endorsed stigma as a reason for not seeking treatment.
Conclusions
Most people with suicide ideation, plans and attempts receive no treatment. This is a consistent and pervasive finding, especially in low-income countries. Improving the receipt of treatment worldwide will have to take into account culture-specific factors that may influence the process of help-seeking.
doi:10.1192/bjp.bp.110.084129
PMCID: PMC3167419  PMID: 21263012
18.  Parental Psychopathology and the Risk of Suicidal Behavior in their Offspring: Results from the World Mental Health Surveys 
Molecular psychiatry  2010;16(12):1221-1233.
Prior research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well-understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive-aggression (e,g., antisocial personality) and anxiety/agitation (e.g., panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55,299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (i.e., time-since-most-recent-episode controlling for age-of-onset and time-since-onset) of subsequent suicidal behavior (suicide ideation, plans, and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental anti-social personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt also was found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of inter-generational transmission of suicidal behavior.
doi:10.1038/mp.2010.111
PMCID: PMC3142278  PMID: 21079606
suicide; parent and family history; intergenerational transmission
19.  Cross-national epidemiology of DSM-IV major depressive episode 
BMC Medicine  2011;9:90.
Background
Major depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative.
Methods
Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults.
Results
The average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed.
Conclusions
MDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.
doi:10.1186/1741-7015-9-90
PMCID: PMC3163615  PMID: 21791035
20.  Age differences in the prevalence and comorbidity of DSM-IV major depressive episodes: Results from the WHO World Mental Health Survey Initiative 
Depression and anxiety  2010;27(4):351-364.
Background
Although depression appears to decrease in late life, this could be due to misattribution of depressive symptoms to physical disorders that increase in late life.
Methods
We investigated this issue by studying age differences in comorbidity of DSM-IV major depressive episodes (MDE) with chronic physical conditions in the WHO World Mental Health (WMH) surveys, a series of community epidemiological surveys carried out in 10 developed countries (n = 51,771) and 8 developing countries (n = 37,265). MDE and other mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). Organic exclusion rules were not used to avoid inappropriate exclusion of cases with physical comorbidity. Physical conditions were assessed with a standard chronic conditions checklist.
Results
Twelve-month DSM-IV/CIDI MDE was significantly less prevalent among respondents ages 65+ than younger respondents in developed but not developing countries. Prevalence of comorbid mental disorders generally either decreased or remained stable with age, while comorbidity of MDE with mental disorders generally increased with age. Prevalence of physical conditions, in comparison, generally increased with age, while comorbidity of MDE with physical conditions generally decreased with age. Depression treatment was lowest among the elderly in developed and developing countries.
Conclusions
The weakening associations between MDE and physical conditions with increasing age argue against the suggestion that the low estimated prevalence of MDE among the elderly is due to increased confounding with physical disorders. Future study is needed to investigate processes that might lead to a decreasing impact of physical illness on depression among the elderly.
doi:10.1002/da.20634
PMCID: PMC3139270  PMID: 20037917
Elderly; Depression; Disability; Comorbidity; Epidemiology
21.  Psychiatric Disorders, Comorbidity, and Suicidality in Mexico 
Journal of affective disorders  2009;124(1-2):98-107.
Background
Prior studies have reported that psychiatric disorders are among the strongest predictors of suicidal behavior (i.e., suicide ideation, plans, and attempts). However, surprisingly little is known about the independent associations between each disorder and each suicidal behavior due to a failure to account for comorbidity.
Methods
This study used data from a representative sample of 5,782 respondents participating in the Mexican National Comorbidity Survey (2001–2002) to examine the unique associations between psychiatric disorders and suicidality.
Results
A prior psychiatric disorder was present in 48.8% of those with a suicide ideation and in 65.2% of those with an attempt. Discrete-time survival models adjusting for comorbidity revealed that conduct disorder and alcohol abuse/dependence were the strongest predictors of a subsequent suicide attempt. Most disorders predicted suicidal ideation but few predicted the transition from ideation to a suicide plan or attempt.
Limitations
M-NCS is a household survey that excluded homeless and institutionalized people, andthe diagnostic instrument used did not include an assessment of all DSM-IV disorders which would increase the comorbidity discussed here.
Conclusions
These results reveal a complex pattern of associations in which diverse psychiatric disorders impact different parts of the pathway to suicide attempts. These findings will help inform clinical and public health efforts aimed at suicide prevention in Mexico and other developing countries.
doi:10.1016/j.jad.2009.10.022
PMCID: PMC2875312  PMID: 19926141
suicide; suicide attempt; risk factors; epidemiology; survey; psychiatric disorder
22.  Childhood adversities as risk factors for onset and persistence of suicidal behaviour 
Background
Suicide is a leading cause of death worldwide, but the precise effect of childhood adversities as risk factors for the onset and persistence of suicidal behaviour (suicide ideation, plans and attempts) are not well understood.
Aims
To examine the associations between childhood adversities as risk factors for the onset and persistence of suicidal behaviour across 21 countries worldwide.
Method
Respondents from nationally representative samples (n = 55 299) were interviewed regarding childhood adversities that occurred before the age of 18 years and lifetime suicidal behaviour.
Results
Childhood adversities were associated with an increased risk of suicide attempt and ideation in both bivariate and multivariate models (odds ratio range 1.2–5.7). The risk increased with the number of adversities experienced, but at a decreasing rate. Sexual and physical abuse were consistently the strongest risk factors for both the onset and persistence of suicidal behaviour, especially during adolescence. Associations remained similar after additional adjustment for respondents’ lifetime mental disorder status.
Conclusions
Childhood adversities (especially intrusive or aggressive adversities) are powerful predictors of the onset and persistence of suicidal behaviours.
doi:10.1192/bjp.bp.109.074716
PMCID: PMC2894980  PMID: 20592429
23.  Twelve Month Prevalence of and Risk Factors for Suicide Attempts in the WHO World Mental Health Surveys 
The Journal of clinical psychiatry  2010;71(12):1617-1628.
Objective
Although suicide is a leading cause of death worldwide, clinicians and researchers lack a data-driven method to assess the risk of suicide attempts. This study reports the results of an analysis of a large cross-national epidemiological survey database that estimates the 12-month prevalence of suicidal behaviors, identifies risk factors for suicide attempts, and combines these factors to create a risk index for 12-month suicide attempts separately for developed and developing countries.
Method
Data come from the WHO World Mental Health (WMH) Surveys (conducted 2001–2007) in which 108,705 adults from 21 countries were interviewed using the WHO Composite International Diagnostic Interview (CIDI). The survey assessed suicidal behaviors and potential risk factors across multiple domains including: socio-demographics, parent psychopathology, childhood adversities, DSM-IV disorders, and history of suicidal behavior.
Results
Twelve-month prevalence estimates of suicide ideation, plans and attempts are 2.0%, 0.6% and 0.3% respectively for developed countries and 2.1%, 0.7% and 0.4% for developing countries. Risk factors for suicidal behaviors in both developed and developing countries include: female sex, younger age, lower education and income, unmarried status, unemployment, parent psychopathology, childhood adversities, and presence of diverse 12-month DSM-IV mental disorders. Combining risk factors from multiple domains produced risk indices that accurately predicted 12-month suicide attempts in both developed and developing countries (AUC=.74–.80).
Conclusion
Suicidal behaviors occur at similar rates in both developed and developing countries. Risk indices assessing multiple domains can predict suicide attempts with fairly good accuracy and may be useful in aiding clinicians in the prediction of these behaviors.
doi:10.4088/JCP.08m04967blu
PMCID: PMC3000886  PMID: 20816034
suicide; risk factors; prediction; assessment; World Mental Health Survey
24.  The Importance of Irritability as a Symptom of Major Depressive Disorder: Results from the National Comorbidity Survey Replication 
Molecular psychiatry  2009;15(8):856-867.
Irritability is a diagnostic symptom of child-adolescent but not adult major depressive disorder (MDD) in both the DSM-IV and ICD-10 systems. We explore the importance of irritability for sub-typing adult DSM-IV MDD in the National Comorbidity Survey Replication (NCS-R), a national US adult household survey. The WHO Composite International Diagnostic Interview (CIDI) was used to assess prevalence of many DSM-IV disorders in the lifetime and in the year before interview (12-month prevalence). MDD was assessed conventionally (i.e., requiring either persistent sadness or loss of interest), but with irritability included as one of the Criterion A symptoms. We also considered the possibility that irritability might be a diagnostic symptom of adult MDD (i.e., detect cases who had neither sad mood nor loss of interest). Twelve-month MDD symptom severity was assessed with the Quick Inventory of Depressive Symptomatology and role impairment with the Sheehan Disability Scale. After excluding bipolar spectrum disorders, irritability during depressive episodes was reported by roughly half of respondents with lifetime DSM-IV MDD. Irritability in the absence of either sad mood or loss of interest, in comparison, was rare. Irritability in MDD was associated with early age-of-onset, lifetime persistence, comorbidity with anxiety and impulse-control disorders, fatigue and self-reproach during episodes, and disability. Irritability was especially common in MDD among respondents in the age range 18–44 and students. Further investigation is warranted of distinct family aggregation, risk factors, and treatment response. Consideration should also be given to including irritability as a non-diagnostic symptom of adult MDD in DSM-V and ICD-11.
doi:10.1038/mp.2009.20
PMCID: PMC3012558  PMID: 19274052
Epidemiology; Irritability; Major Depressive Disorder (MDD); National Comorbidity Survey Replication (NCS-R); adult
25.  Age Differences in Major depression: Results from the National Comorbidity Surveys Replication (NCS-R) 
Psychological medicine  2009;40(2):225.
Background
Although depression appears to decrease in late life, this could be due to misattribution of depressive symptom to physical disorders that increase in late life.
Methods:
We studied age differences in major depressive episodes (MDE) in the National Comorbidity Survey Replication, a national survey of the US household population. DSM-IV MDE was defined without organic exclusions or diagnostic hierarchy rules to facilitate analysis of comorbidity. Physical disorders were assessed with a standard chronic conditions checklist and mental disorders with the WHO Composite International Diagnostic Interview (CIDI) Version 3.0.
Results:
Lifetime and recent DSM-IV/CIDI MDE were significantly less prevalent among respondents ages 65+ than among younger adults. Recent episode severity, but not duration, was also lower among the elderly. Despite prevalence of mental disorders decreasing with age, comorbidity of hierarchy-free MDE with these disorders was either highest among the elderly or unrelated to age. Comorbidity of MDE with physical disorders, in comparison, generally decreased with age despite prevalence of comorbid physical disorders usually increasing. Somewhat more than half of respondents with 12-month MDE received past-year treatment, but the percent in treatment was lowest and most concentrated in the general medical sector among the elderly.
Conclusions:
Given that physical disorders increase with age independent of depression, their lower associations with MDE in old age argue that causal effects of physical disorders on MDE weaken in old age. This result argues against the suggestion that the low estimated prevalence of MDE among the elderly is due to increased confounding with physical disorders.
doi:10.1017/S0033291709990213
PMCID: PMC2813515  PMID: 19531277
Chronic conditions; Comorbidity; Depression; Elderly; Epidemiology

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