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1.  Suicide Among Soldiers: A Review of Psychosocial Risk and Protective Factors 
Psychiatry  2013;76(2):97-125.
Suicide is difficult to predict and prevent and remains a leading cause of death worldwide. Although soldiers historically have had a suicide rate well below that of the general population, the suicide rate among members of the U.S. Army has increased markedly over the past several years and now exceeds that of the general population. This paper reviews psychosocial factors known to be associated with the increased risk of suicidal behavior in general and describes how some of these factors may be especially important in understanding suicide among soldiers. Moving forward, the prevention of suicide requires additional research aimed at: (a) better describing when, where, and among whom suicidal behavior occurs, (b) using exploratory studies to discover new risk and protective factors, (c) developing new methods of predicting suicidal behavior that synthesize information about modifiable risk and protective factors from multiple domains, and (d) understanding the mechanisms and pathways through which suicidal behavior develops. Although the scope and severity of this problem is daunting, the increasing attention and dedication to this issue by the Armed Forces, scientists, and society provide hope for our ability to better predict and prevent these tragic outcomes in the future.
PMCID: PMC4060831  PMID: 23631542
2.  Thought Suppression and Self-Injurious Thoughts and Behaviors 
Behaviour research and therapy  2006;45(8):1957-1965.
This study proposes and tests a theoretical model suggesting that the propensity to suppress unwanted thoughts is associated with an increased presence and frequency of self-injurious thoughts and behaviors (SITB). In the model, propensity to suppress unwanted thoughts is hypothesized to be a cognitive mediator of the relationship between emotional reactivity and SITB, and is expected to be related to the extent to which SITB is initiated to escape from aversive emotions. Results of this cross-sectional study of adolescents (N = 87) revealed that the self-reported propensity to suppress unwanted thoughts is associated with the presence and frequency of non-suicidal self-injury (NSSI), suicidal ideation, and suicide attempts. Furthermore, thought suppression partially mediates the relationship between emotional reactivity and the frequency of NSSI and suicidal ideation. Finally, adolescents with a higher tendency to suppress unwanted thoughts report engaging in NSSI in order to reduce aversive emotions rather than for social communication. Results are discussed within the framework of the negative reinforcement function of SITB.
PMCID: PMC2211522  PMID: 17074302
suicide; non-suicidal self-injury; self-injurious behavior; thought suppression; emotion reactivity
3.  Revealing the form and function of self-injurious thoughts and behaviors: A real-time ecological assessment study among adolescents and young adults 
Journal of abnormal psychology  2009;118(4):816-827.
Self-injurious behaviors are among the leading causes of death worldwide. However, the basic nature of self-injurious thoughts and behaviors (SITBs) is not well-understood because prior studies have relied on long-term, retrospective, aggregate, self-report assessment methods. We used ecological momentary assessment methods to measure suicidal and non-suicidal SITBs as they naturally occur in real-time. Participants were 30 adolescents and young adults with a recent history of self-injury who completed signal- and event-contingent assessments on handheld computers over a 14-day period, resulting in the collection of data on 1262 thought and behavior episodes. Participants reported an average of 5.0 thoughts of nonsuicidal self-injury (NSSI) per week, most often of moderate intensity and short duration (1–30 minutes), and 1.6 episodes of NSSI per week. Suicidal thoughts occurred less frequently (1.1 per week), were of longer duration, and led to self-injurious behavior (i.e., suicide attempts) less often. Details are reported about the contexts in which SITBs most often occur (e.g., what participants were doing, who they were with, and what they were feeling before and after each episode). This study provides a first glimpse of how SITBs are experienced in everyday life and has significant implications for scientific and clinical work on self-injurious behaviors.
PMCID: PMC5258190  PMID: 19899851
4.  Characterizing Implicit Mental Health Associations across Clinical Domains 
Background and objectives
Implicit associations are relatively uncontrollable associations between concepts in memory. The current investigation focuses on implicit associations in four mental health domains (alcohol use, anxiety, depression, and eating disorders) and how these implicit associations: a) relate to explicit associations and b) self-reported clinical symptoms within the same domains, and c) vary based on demographic characteristics (age, gender, race, ethnicity, and education).
Participants (volunteers over age 18 to a research website) completed implicit association (Implicit Association Tests), explicit association (self+psychopathology or attitudes toward food, using semantic differential items), and symptom measures at the Project Implicit Mental Health website tied to: alcohol use (N=12,387), anxiety (N=21,304), depression (N=24,126), or eating disorders (N=10,115).
Within each domain, implicit associations showed small to moderate associations with explicit associations and symptoms, and predicted self-reported symptoms beyond explicit associations. In general, implicit association strength varied little by race and ethnicity, but showed small ties to age, gender, and education.
This research was conducted on a public research and education website, where participants could take more than one of the studies.
Among a large and diverse sample, implicit associations in the four domains are congruent with explicit associations and self-reported symptoms, and also add to our prediction of self-reported symptoms over and above explicit associations, pointing to the potential future clinical utility and validity of using implicit association measures with diverse populations.
PMCID: PMC4871740  PMID: 26962979
implicit associations; alcohol use/abuse; depression; eating disorders; anxiety; Internet research
5.  Measuring the suicidal mind: implicit cognition predicts suicidal behavior 
Psychological science  2010;21(4):511-517.
Suicide is a leading cause of death worldwide, challenging all theories that assume a universal drive for self-preservation. It is difficult to predict and prevent because people who consider killing themselves often are unwilling or incapable of reporting their intention. Advances in the measurement of implicit cognition provide an opportunity to test whether automatic associations of self with death can provide a behavioral marker of suicide risk. We measured implicit associations about death/suicide in 157 people presenting for treatment at a psychiatric emergency department while they awaited medical attention. Results confirmed that suicide attempters hold a significantly stronger implicit association between death/suicide and self than do psychiatrically distressed nonattempters. Moreover, the implicit association of death/suicide with self was associated with an approximately six-fold increase in the odds of making a suicide attempt in the next 6 months, exceeding the predictive validity of known risk factors (e.g., depression or suicide attempt history) and both patients’ and clinicians’ predictions. These results provide the first evidence of a behavioral marker for suicidal behavior and suggest that measures of implicit cognition may be useful for detecting and predicting sensitive clinical behaviors that are unlikely to be reported.
PMCID: PMC5258199  PMID: 20424092
suicide; suicide attempt; prediction; IAT
6.  Mental Disorders, Comorbidity and Pre-Enlistment Suicidal Behavior among New Soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Service members (Army STARRS) 
Suicide & life-threatening behavior  2015;10.1111/sltb.12153.
We examined the associations between mental disorders and suicidal behavior (ideation, plans, and attempts) among new soldiers using data from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; n=38,507). Most new soldiers with a pre-enlistment history of suicide attempt reported a prior mental disorder (59.0%). Each disorder examined was associated with increased odds of suicidal behavior (ORs=2.6–8.6). Only PTSD and disorders characterized by irritability and impulsive/aggressive behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder) predicted unplanned attempts among ideators. Mental disorders are important predictors of pre-enlistment suicidal behavior among new soldiers and should figure prominently in suicide screening and prevention efforts.
PMCID: PMC4515394  PMID: 25622860
7.  Improving the Prediction of Suicidal Behavior in Youth 
Suicidal behaviors increase dramatically during adolescence. In order to effectively intervene and ultimately prevent suicide in youth, the field needs to be able to identify and predict which adolescents are at greatest suicide risk. However, present knowledge of risk factors for suicide and techniques for identifying at-risk youth are insufficient. The purpose of the current manuscript is to highlight some of the key, yet unanswered, questions about the prediction of suicidal behavior in youth, and to suggest the types of research advances needed to move the field forward.
PMCID: PMC4557617  PMID: 23850053
suicide; suicide attempt; suicide risk; adolescence; prediction
8.  Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army 
JAMA psychiatry  2014;71(5):504-513.
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.
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.
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.
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.
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.
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.
PMCID: PMC4057988  PMID: 24590120
9.  Prevalence and Correlates of Suicidal Behavior Among Soldiers 
JAMA psychiatry  2014;71(5):514-522.
The suicide rate among US Army soldiers has increased substantially in recent years.
To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal behaviors among nondeployed US Army soldiers.
A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey.
Lifetime suicidal ideation, suicide plans, and suicide attempts.
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.
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.
PMCID: PMC4100464  PMID: 24590178
10.  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.
PMCID: PMC3992816  PMID: 24318218
Suicide; mental disorders; U.S. Army; epidemiologic research design; design effects; sample bias; sample weights; survey design efficiency; survey sampling
11.  Attentional Bias toward Suicide-Related Stimuli Predicts Suicidal Behavior 
Journal of abnormal psychology  2010;119(3):616-622.
A long-standing challenge for scientific and clinical work on suicidal behavior is that people often are motivated to deny or conceal suicidal thoughts. We proposed that people considering suicide would possess an objectively measurable attentional bias toward suicide-related stimuli, and that this bias would predict future suicidal behavior. Participants were 124 adults presenting to a psychiatric emergency department who were administered a modified emotional Stroop task and followed for six months. Suicide attempters showed an attentional bias toward suicide-related words relative to neutral words, and this bias was strongest among those who had made a more recent attempt. Importantly, this suicide-specific attentional bias predicted which people made a suicide attempt over the next six months, above and beyond other clinical predictors. Attentional bias toward more general negatively-valenced words did not predict any suicide-related outcomes, supporting the specificity of the observed effect. These results suggest that suicide-specific attentional bias can serve as a behavioral marker for suicidal risk, and ultimately improve scientific and clinical work on suicide-related outcomes.
PMCID: PMC2994414  PMID: 20677851
suicide; attentional bias; Stroop task; prediction
12.  Psychiatric Disorders, Comorbidity, and Suicidality in Mexico 
Journal of affective disorders  2009;124(1-2):98-107.
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.
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.
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.
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.
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.
PMCID: PMC2875312  PMID: 19926141
suicide; suicide attempt; risk factors; epidemiology; survey; psychiatric disorder
13.  Are self-injurers impulsive?:Results from two behavioral laboratory studies 
Psychiatry research  2009;169(3):261-267.
Common clinical wisdom suggests that people who engage in self-injury are impulsive. However, virtually all prior work in this area has relied on individuals’ self-report of impulsiveness, despite evidence that people are limited in their ability to accurately report on cognitive processes that occur outside awareness. To address this knowledge gap, we used performance-based measures of several dimensions of impulsiveness to assess whether people engaging in non-suicidal self-injury (NSSI) demonstrate greater impulsiveness than non-injurers. In Study 1, we compared adolescent self-injurers (n=64) to age, sex, and race/ethnicity matched, non-injurious controls (n=30) on self-report impulsiveness (Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version, Kaufman et al., 1997), and on performance-based measures of two dimensions of impulsiveness: behavioral disinhibition (Conners’ Continuous Performance Test, Connors, 1995) and risky decision-making (Iowa Gambling Task, Bechara et al., 1994). In Study 2, we compared adult female self-injurers (n=20) to age and race/ethnicity matched, non-injurious controls (n=20) on self-report impulsiveness (Barratt Impulsiveness Scale-11, Patton et al., 1995), and performance-based measures of behavioral disinhibition, risky decision-making, and two measures of delay discounting (Kirby et al., 1999; Richards et al., 1999). In both studies, self-injurers reported greater impulsiveness; however, performance-based measures of impulsiveness failed to detect any between-group differences. We propose several potential explanations for the discrepancies observed between self-report and performance-based measures of impulsiveness and discuss directions for future research on impulsiveness and self-injury.
PMCID: PMC2766846  PMID: 19758706
self-injury; self-harm; suicide; impulsiveness; impulsivity
14.  Cross-National Prevalence and Risk Factors for Suicidal Ideation, Plans, and Attempts 
Suicide is a leading cause of death world-wide; however, the prevalence and risk factors for the immediate precursors to suicide: suicidal ideation, plans and attempts, are not well-known, especially in developing countries.
To report on the prevalence and risk factors for suicidal behaviors across 17 countries.
84,850 adults were interviewed regarding suicidal behaviors and socio-demographic and psychiatric risk factors.
The cross-national lifetime prevalence (standard error) of suicidal ideation, plans, and attempts is 9.2% (0.1), 3.1% (0.1), and 2.7% (0.1). Across all countries, 60% of transitions from ideation to plan and attempt occur within the first year after ideation onset. Consistent cross-national risk factors included being: female, younger, less educated, unmarried, and having a mental disorder. Interestingly, the strongest diagnostic risk factors were mood disorders in developed countries but impulse-control disorders in developing countries.
Despite cross-national variability in prevalence, there is strong consistency in the characteristics of and risk factors for suicidal behaviors. These findings have significant implications for the prediction and prevention of suicidal behaviors.
PMCID: PMC2259024  PMID: 18245022
15.  Actions speak louder than words: An elaborated theoretical model of the social functions of self-injury and other harmful behaviors 
The question of why some people do things that are intentionally harmful to themselves continues to puzzle scientists, clinicians, and the public. Prior studies have demonstrated that one fairly extreme, direct form of self-harm, non-suicidal self-injury (NSSI), is maintained by both automatic (i.e., intrapersonal) as well as social (i.e., interpersonal) reinforcement. However, the majority of theoretical and empirical papers on this topic focus almost exclusively on the automatic functions. The purpose of this paper is to provide a more comprehensive analysis of the social functions of NSSI. Evidence is presented supporting the notion that NSSI is maintained by social reinforcement in at least a substantial minority of instances. Moreover, an elaborated theoretical model of the social functions of NSSI is outlined that proposes that this behavior represents a high intensity social signal used when less intense communication strategies fail (e.g., speaking, yelling, crying). The model further proposes that NSSI can serve not only as a signal of distress that is reinforced primarily by the caregiving behavior it elicits from others, but that it also can serve as a signal of strength and fitness that is reinforced by warding off potential threats (e.g., peer victimization), and in some cases can strengthen affiliation with others. Support for this theoretical model is drawn from diverse literatures including psychology, evolutionary biology, and cultural anthropology. The paper concludes with specific recommendations for empirical tests of the proposed model of the social functions of NSSI, as well as other harmful behaviors such as alcohol and drug use.
PMCID: PMC2574497  PMID: 19122893
Self-injury; self-harm; self-mutilation; suicide; evolution; animal signals; idioms of distress
16.  Suicide and Suicidal Behavior 
Epidemiologic reviews  2008;30(1):133-154.
Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.
PMCID: PMC2576496  PMID: 18653727
psychiatry; public health; risk factors; self-injurious behavior; suicide; suicide, attempted
17.  Child Maltreatment, Non-Suicidal Self-Injury, and the Mediating Role of Self-Criticism 
Behaviour research and therapy  2007;45(10):2483-2490.
We examined the relation between child maltreatment and non-suicidal self-injury (NSSI). Participants were 86 adolescents who completed measures of child maltreatment, self-criticism, perceived criticism, depression, and NSSI. Analyses revealed significant, small-to-medium associations between specific forms of child maltreatment (physical neglect, emotional abuse, and sexual abuse) and the presence of a recent history of NSSI. Emotional and sexual abuse had the strongest relations with NSSI, and the data supported a theoretical model in which self-criticism mediates the relation between emotional abuse and engagement in NSSI. Specificity for the mediating role of self-criticism was demonstrated by ruling out alternative mediation models. Taken together, these results indicate that several different forms of childhood maltreatment are associated with NSSI and illuminate one mechanism through which maltreatment may be associated with NSSI. Future research is needed to test the temporal relation between maltreatment and NSSI and should aim to identify additional pathways to engagement in NSSI.
PMCID: PMC2034449  PMID: 17531192
self-injury; child abuse; criticism; self-harm; self-mutilation; suicide
18.  Prediction of Suicide Ideation and Attempts Among Adolescents Using a Brief Performance-Based Test 
Suicide is a leading cause of death that is difficult to predict because clinical assessment has relied almost exclusively on individuals' self-report of suicidal thoughts. This is problematic because there often is motivation to conceal such thoughts. The authors tested the ability of the Self-Injury Implicit Association Test (SI-IAT), a reaction-time measure of implicit associations between self-injury and oneself, to detect and predict suicide ideation and attempts. Participants were adolescents who were nonsuicidal (n = 38), suicide ideators (n = 37), or recent suicide attempters (n = 14). Analyses revealed large between-group differences on the SI-IAT, with nonsuicidal adolescents showing large negative associations between self-injury and themselves, suicide ideators showing small positive associations, and suicide attempters showing large positive associations on this performance-based test. The SI-IAT accurately predicted current suicide ideation and attempt status as well as future suicide ideation, and it incrementally improved prediction of these outcomes above and beyond the use of known risk factors. Future research is needed to refine this assessment method and to further develop and examine performance-based assessment of suicide risk in clinical settings.
PMCID: PMC2043087  PMID: 17907852
suicide; self-injury; implicit association test; assessment; prediction
19.  Prevalence, Subtypes, and Correlates of DSM-IV Conduct Disorder in the National Comorbidity Survey Replication 
Psychological medicine  2006;36(5):699-710.
Prior research indicates that conduct disorder (CD) is associated with a range of comorbid mental disorders. However, the actual prevalence, subtypes, and patterns of comorbidity of DSM-IV defined CD in the general U.S. population remains unknown.
Retrospective assessment of CD and other DSM-IV disorders was conducted using fully structured diagnostic interviews among a nationally representative sample of respondents (n = 3,199) in the National Comorbidity Survey Replication.
The estimated lifetime prevalence of CD in the U.S. is 9.5% (males = 12.0%, females = 7.1%), with a median age-of-onset of 11.6 (0.2) years. Latent class analysis identified five CD subtypes characterized by rule violations, deceit/theft, aggression, severe covert behaviors, and pervasive CD symptoms. A dose-response relationship was revealed between CD subtype severity and risk of subsequent disorders. Results also indicated that CD typically precedes mood and substance use disorders, but most often occurs after impulse control and anxiety disorders. Although both active and remitted CD is associated with increased risk of the subsequent first onset of other mental disorders, remitted CD is associated with significantly lower risk of subsequent disorders.
CD is prevalent and heterogeneous in the U.S. population, and more severe subtypes and the presence of active CD are associated with higher risk of comorbid disorders. Future prospective studies using general population samples will further inform the nature and course of this disorder.
PMCID: PMC1925033  PMID: 16438742
20.  Association between parental psychopathology and suicidal behavior among adult offspring: results from the cross-sectional South African Stress and Health survey 
BMC Psychiatry  2014;14:65.
Prior studies have demonstrated a link between parental psychopathology and offspring suicidal behavior. However, it remains unclear what aspects of suicidal behavior among adult offspring are predicted by specific parental mental disorders, especially in Africa. This study set out to investigate the association between parental psychopathology and suicidal behavior among their adult offspring in a South African general population sample.
Parental psychopathology and suicidal behavior in offspring were assessed using structured interviews among 4,315 respondents from across South Africa. The WHO CIDI was used to collect data on suicidal behavior, while the Family History Research Diagnostic Criteria Interview was used to assess prior parental psychopathology. Bivariate and multivariate survival models tested the associations between the type and number parental mental disorders (including suicide) and lifetime suicidal behavior in the offspring. Associations between a range of parental disorders and the onset of subsequent suicidal behavior (suicidal ideation, plans, and attempts) among adult offspring were tested.
The presence of parental psychopathology significantly increased the odds of suicidal behavior among their adult offspring. More specifically, parental panic disorder was associated with offspring suicidal ideation, while parental panic disorder, generalized anxiety disorder and suicide were significantly associated with offspring suicide attempts. Among those with suicidal ideation, none of the tested forms of parental psychopathology was associated with having suicide plans or attempts. There was a dose–response relationship between the number of parental disorders and odds of suicidal ideation.
Parental psychopathology increases the odds of suicidal behavior among their adult offspring in the South African context, replicating results found in other regions. Specific parental disorders predicted the onset and persistence of suicidal ideation or attempts in their offspring. Further research into these associations is recommended in order to determine the mechanisms through which parent psychopathology increases the odds of suicidal behavior among offspring.
PMCID: PMC3944470  PMID: 24592882
Suicide; Parental psychopathology; South Africa
21.  The association between smoking and subsequent suicide-related outcomes in the National Comorbidity Survey panel sample 
Molecular psychiatry  2008;14(12):1132-1142.
Controversy exists about whether the repeatedly-documented associations between smoking and subsequent suicide-related outcomes (SROs; ideation, plans, gestures, and attempts) are due to unmeasured common causes or to causal effects of smoking on SROs. We address this issue by examining associations of smoking with subsequent SROs with and without controls for potential explanatory variables in the National Comorbidity Survey (NCS) panel. The latter consists of 5001 people who participated in both the 199002 NCS and the 2001–03 NCS Follow-up Survey. Explanatory variables include socio-demographics, potential common causes (parental history of mental-substance disorders; other respondent childhood adversities) and potential mediators (respondent history of DSM-III-R mental-substance disorders). Small gross (i.e., without controls) prospective associations are found between history of early-onset nicotine dependence and both subsequent suicide ideation and, among ideators, subsequent suicide plans. None of the baseline smoking measures, though, predicts subsequent suicide gestures or attempts among ideators. The smoking-ideation association largely disappear, but the association of early-onset nicotine dependence with subsequent suicide plans persists (Odds-ratio = 3.0), after adjustment for control variables. However, the latter association is as strong with remitted as active nicotine dependence, arguing against a direct causal effect of nicotine dependence on suicide plans. Decomposition of the control variable effects, furthermore, suggests that these effects are due to common causes more than to mediators. These results refine our understanding of the ways in which smoking is associated with later SROs and for the most part argue against the view that these associations are due to causal effects of smoking.
PMCID: PMC2784156  PMID: 18645572
Epidemiology; longitudinal research; nicotine dependence; prospective study; smoking; suicide; suicide attempts; suicide gestures; suicide ideation; suicide plans; tobacco use
22.  Early onset alcohol use and self-harm: A discordant twin analysis 
Self-harm has considerable societal and economic costs and has been extensively studied in relation to alcohol involvement. Whereas early onset alcohol use (EAU) has been causally linked to maladaptive clinical outcomes, its association with self-harm is less well characterized. The current study aimed to further examine the link between EAU and both non-suicidal self-injury (NSSI) and suicide attempt (SA), and elucidate shared familial and causal/individual-specific pathways that explain this co-occurrence.
Using data from 6,082 Australian same-sex twin pairs (1,732 MZ and 1,309 DZ), ages 23-40, we examined prevalence rates of NSSI and SA among twin pairs concordant and discordant for EAU. Conditional logistic regression, controlling for early clinical covariates and the influence of zygosity on EAU, was used to examine the odds ratio (OR) of self-harm within twin pairs discordant for EAU.
Prevalence rates of both NSSI and SA were highest among twin pairs concordant for EAU and for twins who reported EAU within discordant twin pairs. Results from discordant twin analyses revealed nearly four-fold increased odds of SA for the twin who endorsed EAU, and this OR was equal across monozygotic (MZ) and dizygotic (DZ) twins. EAU also was associated with elevated odds of NSSI (OR=7.62), although this was only the case for DZ twins in discordant pairs.
The equivalent increase in odds of SA for both MZ and DZ twins suggests that causal or individual-specific influences explain the link between EAU and SA. For NSSI, elevated odds for DZ twins and nonsignificant findings for MZ twins implicate correlated genetic factors in the association between EAU and NSSI. Future studies should test mechanisms through which EAU may causally influence SA, as well as examine whether genetic risk for third variables (e.g., negative urgency, stress reactivity) may explain the genetic overlap between EAU and NSSI.
PMCID: PMC4729363  PMID: 26463647
23.  Germline rearrangements in families with strong family history of glioma and malignant melanoma, colon, and breast cancer 
Andersson, Ulrika | Wibom, Carl | Cederquist, Kristina | Aradottir, Steina | Borg, Åke | Armstrong, Georgina N. | Shete, Sanjay | Lau, Ching C. | Bainbridge, Matthew N. | Claus, Elizabeth B. | Barnholtz-Sloan, Jill | Lai, Rose | Il'yasova, Dora | Houlston, Richard S. | Schildkraut, Joellen | Bernstein, Jonine L. | Olson, Sara H. | Jenkins, Robert B. | Lachance, Daniel H. | Wrensch, Margaret | Davis, Faith G. | Merrell, Ryan | Johansen, Christoffer | Sadetzki, Siegal | Bondy, Melissa L. | Melin, Beatrice S. | Adatto, Phyllis | Morice, Fabian | Payen, Sam | McQuinn, Lacey | McGaha, Rebecca | Guerra, Sandra | Paith, Leslie | Roth, Katherine | Zeng, Dong | Zhang, Hui | Yung, Alfred | Aldape, Kenneth | Gilbert, Mark | Weinberger, Jeffrey | Colman, Howard | Conrad, Charles | de Groot, John | Forman, Arthur | Groves, Morris | Levin, Victor | Loghin, Monica | Puduvalli, Vinay | Sawaya, Raymond | Heimberger, Amy | Lang, Frederick | Levine, Nicholas | Tolentino, Lori | Saunders, Kate | Thach, Thu-Trang | Iacono, Donna Dello | Sloan, Andrew | Gerson, Stanton | Selman, Warren | Bambakidis, Nicholas | Hart, David | Miller, Jonathan | Hoffer, Alan | Cohen, Mark | Rogers, Lisa | Nock, Charles J | Wolinsky, Yingli | Devine, Karen | Fulop, Jordonna | Barrett, Wendi | Shimmel, Kristen | Ostrom, Quinn | Barnett, Gene | Rosenfeld, Steven | Vogelbaum, Michael | Weil, Robert | Ahluwalia, Manmeet | Peereboom, David | Staugaitis, Susan | Schilero, Cathy | Brewer, Cathy | Smolenski, Kathy | McGraw, Mary | Naska, Theresa | Rosenfeld, Steven | Ram, Zvi | Blumenthal, Deborah T. | Bokstein, Felix | Umansky, Felix | Zaaroor, Menashe | Cohen, Avi | Tzuk-Shina, Tzeela | Voldby, Bo | Laursen, René | Andersen, Claus | Brennum, Jannick | Henriksen, Matilde Bille | Marzouk, Maya | Davis, Mary Elizabeth | Boland, Eamon | Smith, Marcel | Eze, Ogechukwu | Way, Mahalia | Lada, Pat | Miedzianowski, Nancy | Frechette, Michelle | Paleologos, Nina | Byström, Gudrun | Svedberg, Eva | Huggert, Sara | Kimdal, Mikael | Sandström, Monica | Brännström, Nikolina | Hayat, Amina | Tihan, Tarik | Zheng, Shichun | Berger, Mitchel | Butowski, Nicholas | Chang, Susan | Clarke, Jennifer | Prados, Michael | Rice, Terri | Sison, Jeannette | Kivett, Valerie | Duo, Xiaoqin | Hansen, Helen | Hsuang, George | Lamela, Rosito | Ramos, Christian | Patoka, Joe | Wagenman, Katherine | Zhou, Mi | Klein, Adam | McGee, Nora | Pfefferle, Jon | Wilson, Callie | Morris, Pagan | Hughes, Mary | Britt-Williams, Marlin | Foft, Jessica | Madsen, Julia | Polony, Csaba | McCarthy, Bridget | Zahora, Candice | Villano, John | Engelhard, Herbert | Borg, Ake | Chanock, Stephen K | Collins, Peter | Elston, Robert | Kleihues, Paul | Kruchko, Carol | Petersen, Gloria | Plon, Sharon | Thompson, Patricia | Johansen, C. | Sadetzki, S. | Melin, B. | Bondy, Melissa L. | Lau, Ching C. | Scheurer, Michael E. | Armstrong, Georgina N. | Liu, Yanhong | Shete, Sanjay | Yu, Robert K. | Aldape, Kenneth D. | Gilbert, Mark R. | Weinberg, Jeffrey | Houlston, Richard S. | Hosking, Fay J. | Robertson, Lindsay | Papaemmanuil, Elli | Claus, Elizabeth B. | Claus, Elizabeth B. | Barnholtz-Sloan, Jill | Sloan, Andrew E. | Barnett, Gene | Devine, Karen | Wolinsky, Yingli | Lai, Rose | McKean-Cowdin, Roberta | Il'yasova, Dora | Schildkraut, Joellen | Sadetzki, Siegal | Yechezkel, Galit Hirsh | Bruchim, Revital Bar-Sade | Aslanov, Lili | Sadetzki, Siegal | Johansen, Christoffer | Kosteljanetz, Michael | Broholm, Helle | Bernstein, Jonine L. | Olson, Sara H. | Schubert, Erica | DeAngelis, Lisa | Jenkins, Robert B. | Yang, Ping | Rynearson, Amanda | Andersson, Ulrika | Wibom, Carl | Henriksson, Roger | Melin, Beatrice S. | Cederquist, Kristina | Aradottir, Steina | Borg, Åke | Merrell, Ryan | Lada, Patricia | Wrensch, Margaret | Wiencke, John | Wiemels, Joe | McCoy, Lucie | McCarthy, Bridget J. | Davis, Faith G.
Neuro-Oncology  2014;16(10):1333-1340.
Although familial susceptibility to glioma is known, the genetic basis for this susceptibility remains unidentified in the majority of glioma-specific families. An alternative approach to identifying such genes is to examine cancer pedigrees, which include glioma as one of several cancer phenotypes, to determine whether common chromosomal modifications might account for the familial aggregation of glioma and other cancers.
Germline rearrangements in 146 glioma families (from the Gliogene Consortium; were examined using multiplex ligation-dependent probe amplification. These families all had at least 2 verified glioma cases and a third reported or verified glioma case in the same family or 2 glioma cases in the family with at least one family member affected with melanoma, colon, or breast cancer.The genomic areas covering TP53, CDKN2A, MLH1, and MSH2 were selected because these genes have been previously reported to be associated with cancer pedigrees known to include glioma.
We detected a single structural rearrangement, a deletion of exons 1-6 in MSH2, in the proband of one family with 3 cases with glioma and one relative with colon cancer.
Large deletions and duplications are rare events in familial glioma cases, even in families with a strong family history of cancers that may be involved in known cancer syndromes.
PMCID: PMC4165415  PMID: 24723567
CDKN2A/B; family history; glioma; MLH1; MSH2; TP53
24.  Genome-wide association study of age at menarche in African-American women 
Human Molecular Genetics  2013;22(16):3329-3346.
African-American (AA) women have earlier menarche on average than women of European ancestry (EA), and earlier menarche is a risk factor for obesity and type 2 diabetes among other chronic diseases. Identification of common genetic variants associated with age at menarche has a potential value in pointing to the genetic pathways underlying chronic disease risk, yet comprehensive genome-wide studies of age at menarche are lacking for AA women. In this study, we tested the genome-wide association of self-reported age at menarche with common single-nucleotide polymorphisms (SNPs) in a total of 18 089 AA women in 15 studies using an additive genetic linear regression model, adjusting for year of birth and population stratification, followed by inverse-variance weighted meta-analysis (Stage 1). Top meta-analysis results were then tested in an independent sample of 2850 women (Stage 2). First, while no SNP passed the pre-specified P < 5 × 10−8 threshold for significance in Stage 1, suggestive associations were found for variants near FLRT2 and PIK3R1, and conditional analysis identified two independent SNPs (rs339978 and rs980000) in or near RORA, strengthening the support for this suggestive locus identified in EA women. Secondly, an investigation of SNPs in 42 previously identified menarche loci in EA women demonstrated that 25 (60%) of them contained variants significantly associated with menarche in AA women. The findings provide the first evidence of cross-ethnic generalization of menarche loci identified to date, and suggest a number of novel biological links to menarche timing in AA women.
PMCID: PMC3723312  PMID: 23599027
25.  Cross-Phenotype Polygenic Risk Score Analysis of Persistent Post-Concussive Symptoms in U.S. Army Soldiers with Deployment-Acquired Traumatic Brain Injury 
Journal of Neurotrauma  2017;34(4):781-789.
Traumatic brain injury (TBI) contributes to the increased rates of suicide and post-traumatic stress disorder in military personnel and veterans, and it is also associated with the risk for neurodegenerative and psychiatric disorders. A cross-phenotype high-resolution polygenic risk score (PRS) analysis of persistent post-concussive symptoms (PCS) was conducted in 845 U.S. Army soldiers who sustained TBI during their deployment. We used a prospective longitudinal survey of three brigade combat teams to assess deployment-acquired TBI and persistent physical, cognitive, and emotional PCS. PRS was derived from summary statistics of large genome-wide association studies of Alzheimer's disease, Parkinson's disease, schizophrenia, bipolar disorder, and major depressive disorder (MDD); and for years of schooling, college completion, childhood intelligence, infant head circumference (IHC), and adult intracranial volume. Although our study had more than 95% of statistical power to detect moderate-to-large effect sizes, no association was observed with neurodegenerative and psychiatric disorders, suggesting that persistent PCS does not share genetic components with these traits to a moderate-to-large degree. We observed a significant finding: subjects with high IHC PRS recovered better from cognitive/emotional persistent PCS than the other individuals (R2 = 1.11%; p = 3.37 × 10−3). Enrichment analysis identified two significant Gene Ontology (GO) terms related to this result: GO:0050839∼Cell adhesion molecule binding (p = 8.9 × 10−6) and GO:0050905∼Neuromuscular process (p = 9.8 × 10−5). In summary, our study indicated that the genetic predisposition to persistent PCS after TBI does not have substantial overlap with neurodegenerative and psychiatric diseases, but mechanisms related to early brain growth may be involved.
PMCID: PMC5314978  PMID: 27439997
brain injury; concussion; genetic correlation; military personnel; U.S. Army

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