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1.  Psychiatric Disorder Co-morbidity and Correlates in an Ethnically Diverse Sample of Obese Patients with Binge Eating Disorder in Primary Care Settings 
Comprehensive psychiatry  2012;54(3):209-216.
To examine DSM-IV lifetime/current psychiatric disorder co-morbidity and correlates in ethnically-diverse obese patients with binge eating disorder (BED) seeking treatment for obesity and binge eating in primary care.
A consecutive series of 142 participants (43% Caucasian, 37% African-American, 13% Hispanic-American, and 7% “other” ethnicity) were evaluated with semi-structured interviews.
67% of BED patients had at least one additional lifetime psychiatric disorder, with mood (49%), anxiety (41%), and substance-use (22%) disorders most common. In terms of current co-morbidity, 37% had at least one other psychiatric disorder, with anxiety (27%) and mood (17%) most common. Few gender differences were observed but psychiatric co-morbidity rates differed across ethnic/racial groups with larger differences for current diagnoses. African-American and Hispanic groups were more than twice as likely as the Caucasian group to have additional current psychiatric disorders, mood disorders, and anxiety disorders. Psychiatric co-morbidity was associated with greater eating-disorder psychopathology and poorer functioning, but not with binge-eating or BMI.
Our study presents new findings suggesting that among obese BED patients in primary care, ethnic/racial minority groups are more likely than Caucasian groups to present with psychiatric co-morbidity. Within BED, psychiatric co-morbidity shows few gender differences but is associated with greater eating-disorder psychopathology and poorer functioning.
PMCID: PMC3515704  PMID: 22943959
2.  Teaching Evidence-Based Approaches to Suicide Risk Assessment and Prevention that Enhance Psychiatric Training 
Comprehensive psychiatry  2012;54(3):201-208.
This report describes one in a series of National Institute of Health (NIH) supported conferences aimed at enhancing the ability of leaders of psychiatry residency training to teach research literacy and produce both clinician-scholars and physician-scientists in their home programs. Most psychiatry training directors would not consider themselves research scholars or even well-schooled in evidence based practice. Yet they are the front line educators to prepare tomorrow’s psychiatrists to keep up with, critically evaluate, and in some cases actually participate in the discovery of new and emerging psychiatric knowledge. This annual conference is meant to help psychiatry training directors become more enthusiastic, knowledgeable and pedagogically prepared to create research-friendly environments at their home institutions, so that more trainees will, in turn, become research literate, practice evidence-based psychiatry, and enter research fellowships and careers. The overall design of each year’s meeting is a series of plenary sessions introducing participants to new information pertaining to the core theme of that year’s meeting, integrated with highly interactive small group teaching sessions designed to consolidate knowledge and provide pragmatic teaching tools appropriate for residents at various levels of training. The theme of each meeting, selected to be a compelling and contemporary clinical problem, serves as a vehicle to capture training directors’ attention while teaching relevant brain science, research literacy and effective pedagogy. This report describes the content and assessment of the 2011 annual pre-meeting, “Evidence-based Approaches to Suicide Risk Assessment and Prevention: Insights from the Neurosciences and Behavioral Sciences for use in Psychiatry Residency Training.”
PMCID: PMC3529811  PMID: 22995449
3.  Individuals with Single Versus Multiple Suicide Attempts Over 10 Years of Prospective Follow-Up 
Comprehensive psychiatry  2012;54(3):238-242.
The study attempted to identify characteristics that differentiate multiple suicide attempters from single attempters in individuals with personality disorders (PDs) and/or major depression.
Participants were 431 participants enrolled in the Collaborative Longitudinal Study of Personality Disorders from July 1996 to June 2008. Suicide attempts were assessed with the Longitudinal Interval Follow-up Evaluation at 6 and 12 months, then yearly through 10 years. Logistic regression was used to compare single attempters to multiple attempters on Axis I and II psychiatric disorders and personality trait variables.
Twenty-one percent of participants attempted suicide during the 10 years of observation, with 39 (9.0%) reporting a single suicide attempt and 54 (12.5%) reporting multiple suicide attempts. Although no significant differences in were found in baseline Axis I disorders, multiple attempters were significantly more likely to meet criteria for borderline personality disorder and to have higher impulsivity scores than single attempters.
These results underscore the importance of considering both personality disorders and traits in the assessment of suicidality.
PMCID: PMC3541431  PMID: 22995448
suicide; personality; impulsivity; negative affect; longitudinal
4.  Pathological Gambling: Relationship to Obesity, Self-Reported Chronic Medical Conditions, Poor Lifestyle Choices, and Impaired Quality of Life 
Comprehensive psychiatry  2012;54(2):97-104.
Pathological gambling (PG) is an important public health problem that is prevalent, costly to society, and associated with substance misuse, depression, domestic violence, crime, and suicide. Despite these challenges, little is known about the physical health and medical correlates of PG. The goal of this project was to assess self-reported chronic medical conditions, medication usage, lifestyle choices, health care utilization, quality of life variables, and body mass index (BMI) in persons with and without PG.
Subjects with PG and community controls were systematically assessed for their medical health, lifestyle choices, medication usage, and health care utilization. We administered the Medical Outcome Study Short-Form 36 Health Survey to assess perceived health and quality of life. BMI was calculated for all subjects. Obesity was defined as having a BMI ≥ 30 kg/m2.
We compared 95 subjects with DSM-IV PG (South Oaks Gambling Screen [SOGS] score ≥ 5) and 91 control subjects without PG (SOGS ≤ 2) selected through random digit dialing from the general community. PG subjects and controls were similar in age and gender. Persons with PG had more medical and mental health conditions than controls, and were more likely to avoid regular exercise, smoke ≥ 1 pack/day, drink ≥ 5 servings of caffeine daily, and watch television ≥ 20 hours/week. They had more emergency department visits for physical and mental health conditions, were more likely to have been psychiatrically hospitalized in the past year, and were more likely to take psychotropic medication. They were less likely to have had regular dental visits and were more likely to put off medical care due to financial problems. Severity of gambling was positively correlated with number of medical conditions. Persons with PG had poorer self-reported health perceptions on all but one SF-36 subscale. Importantly, persons with PG had a higher BMI than controls and were more likely to be obese.
PG is associated with obesity, chronic medical conditions, poor lifestyle choices, worse quality of life, and the use of costly forms of medical care. Pathological gamblers are less likely to receive regular dental care and are more likely to be unable to pay for medical care. The implications of the findings are discussed.
PMCID: PMC3514656  PMID: 22938650
pathological gambling; health perceptions; obesity; health care utilization; lifestyle
5.  Posttraumatic Stress Disorder as a Moderator of the Association Between Negative Affect and Bulimic Symptoms: An Ecological Momentary Assessment Study 
Comprehensive psychiatry  2012;54(1):61-69.
The purpose of this study was to examine the potential moderating effect of posttraumatic stress disorder (PTSD) on the emotion-behavior relationship in individuals with bulimia nervosa (BN).
A total of 119 women with BN were involved in the study. Participants were divided into two groups: those with BN and PTSD (n = 20), and those with BN only (n = 99). Ecological momentary assessment (EMA) procedures were utilized for the examination of affect, frequency of bulimic behaviors, and the relationship of affect and bulimic behavior over time. The Structured Clinical Interview for DSM-IV Axis I Disorders was conducted for the diagnosis of BN, PTSD, mood disorders, anxiety disorders, and substance use disorders. Mood disorders, anxiety disorders, and substance use disorders functioned as covariates in all analyses.
Statistical models showed that those in the PTSD group reported a greater daily mean level of negative affect and a greater daily frequency of bulimic behaviors than those in the BN only group. Moderation was found for the association between negative affect and time in that the PTSD group showed a faster acceleration in negative affect prior to purging and faster deceleration in negative affect following purging. The association between positive affect and time was also moderated by group, indicating that the PTSD group had a faster acceleration in positive affect after purging than the BN only group.
These findings highlight the importance of recognizing PTSD when interpreting the emotion-behavior relationship in individuals with BN.
PMCID: PMC3473110  PMID: 22789761
Posttraumatic stress disorder; Bulimia nervosa; Palm top computers
6.  Patients’ treatment expectancies in clinical trials of antidepressants versus psychotherapy for depression: a study using hypothetical vignettes 
Comprehensive psychiatry  2012;54(1):28-33.
Previous research on patients’ expectancies for improvement in clinical trials typically has been conducted after patients have already agreed to participate in a study. Depressed patients (n = 55) read 3 vignettes describing hypothetical clinical trials of antidepressant vs pill placebo, antidepressant vs antidepressant, and psychotherapy vs psychotherapy. Patients reported greater overall acceptability for psychotherapy over antidepressants. Patients had significantly greater expectancies for symptom reduction in either active comparator (medication or psychotherapy) compared with the placebo-controlled design. They also reported greater anticipated improvement and willingness to participate in the psychotherapy trial compared with either medication trial design. Patients’ differential expectancies based on study design could lead to different patient populations being selected for these studies and influence clinical improvement.
PMCID: PMC3509270  PMID: 22794942
7.  Prevalence and Correlates of Child Sexual Abuse: A National Study 
Comprehensive psychiatry  2012;54(1):16-27.
This study examines the prevalence, correlates, and psychiatric disorders of adults with history of child sexual abuse (CSA).
Data were derived from a large national sample of the U.S. population. More that 34,000 adults aged 18 years and older residing in households were face-to-face interviewed in a survey conducted during the 2004–2005 period. Diagnoses were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version. Weighted means, frequencies, and odds ratios of sociodemographic correlates and prevalence of psychiatric disorders were computed. Logistic regression models were used to examine the strength of associations between child sexual abuse and psychiatric disorders, adjusted for sociodemographic characteristics, risk factors and other axis I psychiatric disorders.
The prevalence of child sexual abuse was 10.14% (24.8% in men, and 75.2% in women). Child physical abuse, maltreatment, and neglect was more prevalent among individuals with CSA than among those without it. Adults with child sexual abuse history had significantly higher rates of any Axis I disorder and suicide attempts. The frequency, type and number of CSA were significantly correlated with psychopathology.
The high correlation rates of CSA with psychopathology and increased risk for suicide attempts in adulthood suggest the need for a systematic assessment of psychiatric disorders and suicide risk in these individuals. The risk factors for CSA emphasize the need for health care initiatives geared towards increasing recognition and development of treatment approaches for the emotional sequelae CSA as well as early preventive approaches.
PMCID: PMC3518746  PMID: 22854279
Child abuse, sexual; epidemiology; trauma; psychopathology; suicide
8.  Development of criteria for a diagnosis: lessons from the night eating syndrome 
Comprehensive psychiatry  2008;50(5):10.1016/j.comppsych.2008.09.013.
Criteria for inclusion of diagnoses of Axis I disorders in the forthcoming Diagnostic and Statistical Manual (DSM-V) of the American Psychiatric Association are being considered. The 5 criteria that were proposed by Blashfield et al as necessary for inclusion in DSM-IV are reviewed and are met by the night eating syndrome (NES). Seventy-seven publications in refereed journals in the last decade indicate growing recognition of NES. Two core diagnostic criteria have been established: evening hyperphagia (consumption of at least 25% of daily food intake after the evening meal) and/or the presence of nocturnal awakenings with ingestions. These criteria have been validated in studies that used self-reports, structured interviews, and symptom scales. Night eating syndrome can be distinguished from binge eating disorder and sleep-related eating disorder. Four additional features attest to the usefulness of the diagnosis of NES: (1) its prevalence, (2) its association with obesity, (3) its extensive comorbidity, and (4) its biological aspects. In conclusion, research on NES supports the validity of the diagnosis and its inclusion in DSM-V.
PMCID: PMC3835341  PMID: 19683608
9.  Reliability and Validity of the CES-D Scale in Two Special Adult Samples from Rural China 
Comprehensive psychiatry  2012;53(8):1243-1251.
PMCID: PMC3404200  PMID: 22520090
10.  Can patterns of alcohol use disorder in young adulthood help explain gender differences in depression? 
Comprehensive psychiatry  2012;53(8):1071-1077.
To test whether gender differences in the prevalence of major depressive disorder differ by longitudinal patterns of alcohol use disorder symptoms.
Data are from a prospective longitudinal study examining a broad range of mental health and substance use problems. A gender-balanced sample of 808 participants was interviewed at ages 21, 24, 27, and 30. The sample was divided into subgroups corresponding to longitudinal patterns of alcohol use disorder derived from latent class growth analysis.
Four patterns of alcohol use disorder symptoms were identified: A “low disorder symptom” group, a “decreaser” group, an “increaser” group, and a “chronic disorder symptom” group. Rates of depression were significantly higher for females only among those with a pattern of chronic or decreasing alcohol disorder symptoms.
Elevated rates of depression among females in young adulthood may depend on patterns of co-occurring alcohol disorder symptoms. Practitioners should pay particular attention to signs of chronic alcohol use disorders and associated risks for depression among young adult women.
PMCID: PMC3473101  PMID: 22521329
11.  Interpersonal Problems and Developmental Trajectories of Binge Eating Disorder 
Comprehensive psychiatry  2012;53(8):1088-1095.
To explore associations between specific interpersonal constructs and the developmental progression of behaviors leading to binge eating disorder (BED).
Eighty-four consecutively evaluated, treatment-seeking obese (BMI ≥ 30) men and women with BED were assessed with structured diagnostic and clinical interviews and completed a battery of established measures to assess the current and developmental eating- and weight-related variables as well as interpersonal functioning.
Using the interpersonal circumplex structural summary method, amplitude, elevation, the affiliation dimension, and the quadratic coefficient for the dominance dimension were associated with eating and weight-related developmental variables. The amplitude coefficient and more extreme interpersonal problems on the dominance dimension (quadratic)—i.e., problems with being extremely high (domineering) or low in dominance (submissive)—were significantly associated with ayounger age at onset of binge eating, BED, and overweight as well as accounted for significant variance in age at binge eating, BED, and overweight onset. Greater interpersonal problems with having an overly affiliative interpersonal style were significantly associated with, and accounted for significant variance in, ayounger age at diet onset.
Findings provide further support for the importance of interpersonal problems among adults with BED and converge with recent work highlighting the importance of specific types of interpersonal problems for understanding heterogeneity and different developmental trajectories of individuals with BED.
PMCID: PMC3482417  PMID: 22727087
12.  Categorical vs dimensional classifications of psychotic disorders 
Comprehensive psychiatry  2012;53(8):1118-1129.
Both categorical and dimensional methods appear relevant to classifying psychotic disorders; however, there is no clear consensus on the most appropriate categories and dimensions or on the best approach for constructing nosologic criteria that integrate these 2 methods. This review examines the evidence on specific dimensions and categories that would best characterize psychoses.
Entries in the MEDLINE database between 1980 and 2011 were searched for studies of the dimensional and/or categorical structure of psychosis. Studies were included if samples represented a spectrum of psychotic disorders and dimensions/categories were empirically derived using principal components analysis, factor analysis, or latent class analysis.
Most dimensional studies observed 4 or 5 dimensions within psychosis, with positive, negative, disorganization, and affective symptom domains most frequently reported. Substance abuse, anxiety, early onset/developmental, insight, cognition, hostility, and behavioral/social disturbance dimensions appeared in some studies. Categorical studies suggested 3 to 7 major classes within psychosis, including a class similar to Kraepelin’s dementia praecox and one or more classes with significant mood components. Only 2 studies compared the relative fit of empirically derived dimensions and categories within the same data set, and each had significant limitations.
There is relatively consistent evidence on appropriate categories and dimensions for characterizing psychoses. However, the lack of studies directly comparing or combining these approaches provides insufficient evidence for definitive conclusions about their relative merits and integration. The authors provide specific recommendations for designing future studies to identify valid dimensions and/or categories of the psychoses and investigate hybrid approaches to model the structure of the underlying illnesses.
PMCID: PMC3488145  PMID: 22682781
13.  Risk factors for suicidal ideation in a population of community-recruited female cocaine users 
Comprehensive psychiatry  2010;52(3):238-246.
Suicide, as the 11th leading cause of death in America, is a significant public health concern. Previous studies have shown that drug users are a population at especially high risk for suicidal ideation. Although most people who think about killing themselves do not ultimately commit suicide, identifying those at risk for such thoughts is important.
In this analysis, data from a sample of 462 cocaine-using women (87% African-American) recruited using street-outreach methods for a National Institute on Drug Abuse funded study were examined to identify risk factors for lifetime suicidal ideation. Sociodemographic factors, adverse childhood experiences, sexual behaviors, psychiatric comorbidities, and drug abuse and dependence were examined as potential risk factors, using both bivariate and logistic regression analysis.
50% of the sample met at least one criterion for lifetime suicidal ideation and 32% of the sample reported a lifetime suicide attempt. In the final logistic regression model, childhood physical abuse, childhood sexual abuse, rape after the age of 15, post-traumatic stress disorder, and number of DSM-IV depression criteria met emerged as significant independent predictors of lifetime suicidal ideation.
These findings identify important risk factors for suicidal ideation among female substance abusers in community settings.
PMCID: PMC3806049  PMID: 21497216
14.  The effect of dietary and physical activity pattern on metabolic profile in individuals with schizophrenia: A cross-sectional study 
Comprehensive psychiatry  2012;53(7):1028-1033.
With the rate of obesity on the rise worldwide, individuals with schizophrenia represent a particularly vulnerable population. The aim of this study was to assess the metabolic profile of individuals with schizophrenia in relation to dietary and physical activity habits compared to normal controls.
Dietary and physical activity habits of 130 individuals with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnosis of schizophrenia or schizoaffective disorder were compared with 250 BMI, age, gender, and racially matched controls from the 2005-2008 National Health and Nutrition Examination Surveys (NHANES) using a 24-hour diet recall and a self report physical activity questionnaire.
Individuals with schizophrenia had significantly higher levels of glycosylated hemoglobin (HbA1c) and insulin compared to matched controls. Additionally, these individuals had an increased waist circumference and diastolic blood pressure than the comparison group. Daily caloric intake was not different between groups; however, individuals with schizophrenia consumed significantly greater amounts of sugar and fat. Individuals with schizophrenia reported engaging in moderate physical activity less frequently than the NHANES group, but there was no difference in reported vigorous physical activity.
These findings suggest that the dietary and physical activity habits of individuals with schizophrenia contribute to an adverse metabolic profile. Increased opportunities for physical activity and access to healthy foods for individuals with schizophrenia may ease the burden of disease.
PMCID: PMC3380150  PMID: 22425530
obesity; schizophrenia; dietary intake; physical activity; metabolic syndrome
15.  Metabolic Syndrome in Obese Men and Women with Binge Eating Disorder: Developmental Trajectories of Eating and Weight-Related Behaviors 
Comprehensive psychiatry  2012;53(7):1021-1027.
The metabolic syndrome (MetSyn), characterized by vascular symptoms, is strongly correlated with obesity, weight-related medical diseases and mortality, and has increased commensurately with secular increases in obesity in the U.S. Little is known about the distribution of MetSynin obese patients with binge eating disorder (BED) or its associations with different developmental trajectories of dieting, binge eating, and obesity problems. Further, inconsistencies in the limited data necessitate elucidation. This study examined the frequency and correlates of MetSyn in a consecutive series of 148 treatment-seeking obese men and women with BED assessed with structured clinical interviews. Almost half of the participants met criteria for MetSyn. Participants with MetSyn did not differ from those without MetSyn on demographic variables or disordered eating psychopathology. However, our findings suggest that MetSyn is associated with a distinct developmental trajectory, specifically a later age at BED onset and shorter BED duration. Although the findings from this study shed some light on MetSyn and its associations with developmental trajectories of eating and weight-related behaviors, notable inconsistencies characterize the limited literature. Prospective studies are needed to examine causal connections in the development of the MetSyn in relation to disordered eating in addition to excess weight.
PMCID: PMC3394907  PMID: 22483368
16.  Concordance between Chart Review and Structured Interview Assessments of Schizophrenic Symptoms 
Comprehensive psychiatry  2011;53(3):275-279.
It is unclear whether direct structured interviews are able to capture the full range of psychopathology in schizophrenia, as is required in diagnostic assessments or clinical ratings. We examined agreement between symptom ratings derived from direct patient interviews and from review of casenotes.
The study sample comprised 1021 schizophrenic subjects collected as part of the Irish Case-Control Study of Schizophrenia (ICCSS). Diagnostic interviews utilized a modified version of the Structured Clinical Interview for DSM-III-R. Symptoms were rated by the interviewer. In addition, the Casenote Rating Scale was used to rate symptoms based on medical record information. For each negative and positive symptom, we calculated the Pearson correlation between the interview and the casenote rating. Using the mean of the interview and casenote rating for each symptom, exploratory factor analysis using Varimax rotation was performed.
Three factors were extracted in factor analysis: positive, negative, and Schneiderian symptoms. The highest correlations between interview and casenote ratings were for negative symptoms, in which all symptoms were significantly correlated. Positive and Schneiderian symptoms were significantly correlated with the exception of thought insertion, thought withdrawal, voices speaking in sentences, and somatic hallucinations. Significant correlations were generally moderate (0.2–0.55)
Most schizophrenic symptoms, especially negative symptoms, can be assessed by direct interviews as the sole source of information with moderate reliability. However, the presence of some Schneiderian and possibly less prevalent positive symptoms may be difficult to determine without a review of records, which may include longitudinal observations and information from multiple observers.
PMCID: PMC3752589  PMID: 21658694
schizophrenia; clinical features; structured interview; factor analysis
17.  Social Anxiety and Self-consciousness in Binge Eating Disorder: Associations with Eating Disorder Psychopathology 
Comprehensive Psychiatry  2011;53(6):740-745.
Research has consistently shown that anxiety disorders are common among individuals with eating disorders. Although social phobia has been found to be highly associated with eating disorders, less is known about social anxiety in individuals with binge eating disorder (BED). The present study examined associations between social anxiety and self-consciousness with BMI and eating-disorder psychopathology in BED.
Participants were 113 overweight or obese treatment seeking men and women with BED. Participants were administered semi-structural diagnostic clinical interviews and completed a battery of self-report measures.
Social anxiety was positively and significantly correlated with shape- and weight-concerns, and binge eating frequency. After accounting for depressive levels, social anxiety and self-consciousness accounted for significant variance in eating-, shape-, and weight-concerns and overall eating-disorder global severity scores (Eating Disorder Examination). Social anxiety also accounted for significant variance in binge eating frequency after co-varying for depressive levels. Social anxiety and self-consciousness were not significantly associated with BMI or dietary restraint.
Our findings suggest that greater social anxiety and heightened self-consciousness are associated with greater eating disorder psychopathology, most notably with greater shape- and weight-concerns and binge eating frequency in patients with BED. Social anxiety and self-consciousness do not appear to be merely functions of excess weight, and future research should examine whether they contribute to the maintenance of binge eating and associated eating-disorder psychopathology.
PMCID: PMC3306525  PMID: 22152497
18.  Auditory Hallucinations in a Cross-Diagnostic Sample of Psychotic Disorder Patients: A Descriptive, Cross-Sectional Study 
Comprehensive Psychiatry  2011;53(6):718-726.
Auditory hallucinations (AH) are a cardinal feature of schizophrenia spectrum disorders. They are not disease specific, however, and can occur in other conditions, including affective psychoses.
In this descriptive, cross-sectional study, we examined AH in relation to other psychotic symptoms, mood symptoms, illness severity, and functional status in 569 patients with psychosis (n=172 schizophrenia, n=153 schizoaffective disorder, n=244 bipolar disorder with psychotic features).
323 (56.7%) patients reported a lifetime history of AH (75.6% of patients with schizophrenia, 71.9% schizoaffective disorder, and 34.0% bipolar disorder). The mean score for the hallucinations item (P3) of the Positive and Negative Syndrome Scale (PANSS) in the AH group was 3.66 ± 1.79, indicating mild to moderate state hallucinations severity. AH were strongly associated with hallucinations in other sensory modalities and with the first-rank symptoms of delusions of control, thought insertion, and thought broadcasting. Multivariate analysis showed that AH were associated with lower education even after controlling for diagnosis, age, and gender. There was no association between AH and functional status as measured by the Multnomah Community Ability Scale (MCAS).
AH are associated with specific clinical features across the continuum of both schizophrenic and affective psychoses independent of DSM-IV diagnosis.
PMCID: PMC3314103  PMID: 22197213
Hallucinations, auditory; Psychotic disorders; Schizophrenia; Bipolar disorder
19.  Prevalence, Patterns, and Correlates of Co-Occurring Substance Use and Mental Disorders in the US: Variations by Race/Ethnicity 
Comprehensive Psychiatry  2011;53(6):657-665.
This study examines racial/ethnic differences in the prevalence, patterns, and correlates of co-occurring substance use and mental disorders (COD) among Whites, Blacks, Latinos, and Asians using data from the Collaborative Psychiatric Epidemiology Studies.
We first estimated the prevalence of various combinations of different co-occurring depressive and anxiety disorders among respondents with alcohol, drug, and any substance use (alcohol or drug) disorders in each racial/ethnic group. We then estimated the prevalence of different patterns of onset and different psychosocial correlates among individuals with COD of different racial/ethnic groups. We used weighted linear and logistic regression analysis controlling for key demographics to test the effect of race/ethnicity. Tests of differences between specific racial/ethnic subgroups were only conducted if the overall test of race was significant.
Rates of COD varied significantly by race/ethnicity. Approximately 8.2% of Whites, 5.4% of Blacks, 5.8% of Latinos, 2.1% of Asians met criteria for lifetime COD. Whites were more likely than persons in each of the other groups to have lifetime COD. Irrespective of race/ethnicity, the majority of those with COD reported that symptoms of mental disorders occurred before symptoms of substance use disorders. Only rates of unemployment and history of psychiatric hospitalization among individuals with COD were found to vary significantly by racial/ethnic group.
Our findings underscore the need to further examine the factors underlying differences between minority and non-minority individuals with COD as well as how these differences might affect help seeking and utilization of substance abuse and mental health services.
PMCID: PMC3327759  PMID: 22152496
Substance abuse; mental disorders; co-occurring disorders; comorbidity; dual diagnosis; minorities; health disparities; CPES
20.  A Survey of Psychosis-Risk Symptoms in Kenya 
Comprehensive Psychiatry  2011;53(5):516-524.
Defining the pre-psychotic state in an effort to prevent illness progression, and the development of disorders such as schizophrenia, is a rapidly growing area of psychiatry. The presentation of psychotic symptoms can be influenced by culture; however there has not been any previous assessment of psychosis-risk symptoms in the continent of Africa. Our study aimed to measure the prevalence of psychosis-risk in a community sample in Nairobi, Kenya, and to evaluate the effects of key demographic variables.
A culturally modified version of the 12-item PRIME-Screen (mPRIME) was self-administered by 2,758 youth (aged 14–29) recruited through house-to-house visits in Nairobi, Kenya. The prevalence and severity of psychosis-risk items from the mPRIME, and the effects of gender and age on symptoms were evaluated. k-Means cluster analysis was used to identify symptom groups.
Depending on the mPRIME item, 1.8–19.5% of participants reported certainty of having had a psychosis-risk symptom. Overall, 45.5% reported having had any psychosis-risk symptom. Females had a significantly higher mean severity score on items evaluating persecutory ideation and auditory hallucinations. Symptom severity on five items showed a modest (R=0.09–0.13) but significant correlation with age. Cluster analysis identified four groups of participants: normative (55%), high symptom (11%), intermediate symptom (19%), and grandiose symptom (15%).
Psychosis-risk symptoms appear to be highly prevalent in Kenyan youth. Longitudinal studies are needed to determine the correlation of identified symptoms with transition to psychotic illness, as well as the associated functionality and distress, in order to develop appropriate intervention strategies.
PMCID: PMC3265657  PMID: 21945193
Psychosis; Risk; Kenya; Africa; Youth; Prime screen
21.  Cognitive Function in Morbidly Obese Individuals With and Without Binge Eating Disorder 
Comprehensive Psychiatry  2011;53(5):490-495.
Obesity is associated with poorer cognitive function and impulsivity, which may contribute to binge eating disorder (BED). The objective of this study was to compare cognitive function in morbidly obese individuals with and without BED.
A total of 131 morbidly obese individuals (41 with past or present BED, 90 with no BED history) completed a computerized battery of cognitive tests including executive, memory, language, and attention.
Both groups of participants evidenced high rates of cognitive impairment, however, no significant differences emerged between persons with and without BED on cognitive testing. Comparison of persons without BED, current BED, and past BED also yielded no differences.
In the present sample, morbidly obese individuals with and without BED were clinically indistinguishable on tests of cognitive function. Our findings suggest that obesity, rather than binge eating, may be more directly related to cognition. Future studies should further examine this relationship, as it might provide greater insight into the neural mechanisms for this BED.
PMCID: PMC3321396  PMID: 22036317
22.  Longitudinal course of obsessive-compulsive disorder in patients with anxiety disorders: a 15-year prospective follow-up study 
Comprehensive psychiatry  2011;52(6):670-677.
Although obsessive-compulsive disorder (OCD) is typically described as a chronic condition, relatively little is known about the naturalistic, longitudinal course of the disorder. The purpose of the current study was to examine the probability of OCD remission and recurrence as well as to explore demographic and clinical predictors of remission.
This study uses data from the Harvard/Brown Anxiety Disorders Research Program, which is a prospective, naturalistic, longitudinal study of anxiety disorders. Diagnoses were established by means of a clinical interview at study intake. One hundred thirteen Harvard/Brown Anxiety Disorders Research Program participants with OCD were included in the study; all had a history of at least 1 other anxiety disorder. Assessments were conducted at 6-month and/or annual intervals during 15 years of follow-up.
Survival analyses showed that the probability of OCD remission was .16 at year 1, .25 at year 5, .31 at year 10, and .42 at year 15. For those who remitted from OCD, the probability of recurrence was .07 at year 1, .15 by year 3, and by year 5, it reached .25 and remained at .25 through year 15. In predictors of course, those who were married and those without comorbid major depressive disorder (MDD) were more likely to remit from OCD. By year 15, 51% of those without MDD remitted from OCD compared to only 20% of those with MDD.
In the short term, OCD appears to have a chronic course with low rates of remission. However, in the long term, a fair number of people recover from the disorder, and, for those who experience remission from OCD, the probability of recurrence is fairly low.
PMCID: PMC3683832  PMID: 21349511
23.  Characteristics and co-morbidity of ADHD sib pairs in the Central Valley of Costa Rica 
Comprehensive Psychiatry  2011;53(4):379-386.
While genetic epidemiological studies demonstrate a substantial degree of genetic predisposition for Attention-Deficit/Hyperactivity Disorder (ADHD), they also suggest that the genetics are complex and may differ between populations or ethnic groups.
This study describes the phenomenology of siblings with Attention-Deficit/Hyperactivity Disorder (ADHD) from the genetically-isolated population of the Central Valley of Costa Rica.
Rates of DSM-IV defined ADHD subtypes and co-morbid conditions were calculated in a sample of 157 ADHD-affected children (probands and siblings) recruited for genetic studies using standardized approaches. Sib-sib comparisons and logistic regressions were conducted to identify significant patterns of concordance.
Combined type ADHD (69.5%) was the most common subtype among probands, followed by the inattentive (27.4%), and hyperactive-impulsive (3.2%) subtypes. Anxiety disorders were prevalent (55.9%), as were disruptive behavior disorders (30.9%), and Tourette's disorder (17.0%). Probands and siblings showed high sib-sib concordance for anxiety disorders.
ADHD in Costa Rica is similar in clinical and demographic characteristics to ADHD seen in other parts of the world, although the rates of co-occurring psychiatric disorders differ somewhat from those previously reported in Latin American samples. Comorbid anxiety is prevalent, with high rates of sib-sib concordance, and may represent a distinct, homogeneous subgroup suitable for genetic studies.
PMCID: PMC3179797  PMID: 21696714
ADHD; Psychiatric; Genetics; International; Co-morbidity; Sib-pairs
24.  Smoking for weight control and its associations with eating disorder symptomatology 
Comprehensive Psychiatry  2011;53(4):403-407.
This study examined interrelationships between cigarette smoking for weight control and eating disorder symptoms in a community sample of adult female smokers.
Participants were 107 female smokers who completed a battery of questionnaires, including the Eating Disorder Examination – Questionnaire (EDE-Q). Key items measured weight-control smoking, including smoking to prevent overeating, smoking to undo the effects of overeating, and smoking to feel less hungry. Smokers who endorsed smoking in an attempt to control weight were compared to those who denied such behaviors on EDE-Q scores and frequency of binge eating and purging.
A substantial proportion of participants reported weight-control smoking. Participants who endorsed weight-control smoking reported elevations on eating disorder symptoms as measured by the EDE-Q. Compensatory smoking was related to the frequency of binge eating.
The findings have implications for clinicians working with eating disorder patients; for some individuals, cigarette smoking may be used as an attempt to compensate for overeating.
PMCID: PMC3193869  PMID: 21741037
25.  Examination of the structure of psychopathology using latent class analysis 
Comprehensive Psychiatry  2011;53(4):323-332.
A number of recent studies using factor analytic methods find that the structure of psychopathology reflects broad internalizing and externalizing dimensions, with the internalizing dimension being further divided into fear and distress disorders. While these variable-centered studies have provided important insights into the structure of psychopathology, they provide limited information about the classification of individual cases. The present study examines patterns of lifetime internalizing and externalizing psychopathology in participants from the Oregon Adolescent Depression Project using latent class analysis, which classifies individuals rather than variables. A four class solution best fit the data. The largest class (62.5%) included individuals with relatively little psychopathology; one class (16.4%) was largely characterized by internalizing disorders; one class (16.9%) was largely characterized by externalizing disorders; and the final class (4.2%) was characterized by both internalizing and externalizing disorders. The validity of the classes was further examined using data on psychiatric morbidity, temperament, and family aggregation of psychopathology. Classes differed on indices of positive, negative, and disinhibited temperament in ways that were consistent with theoretical predictions. Patterns of familial aggregation of psychopathology demonstrated relative specificity of transmission of different disorders. Overall, the findings support conclusions from studies of dimensional models of internalizing and externalizing disorders, and extend them to person-centered approaches to classification.
PMCID: PMC3196784  PMID: 21757192
psychopathology; structure; personality; latent class analysis

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