Religiosity as a protective factor against suicidal behaviour.

OBJECTIVE: Data suggest that adherence to religious beliefs is associated with lower rates of suicide. A number of mediating factors have been hypothesized to explain this association, including enhanced social support, less substance abuse, and lower rates of psychopathology. METHOD: We utilized data from a two-phase population-based, epidemiological study of mental disorders among young Jewish Israel born in a 10-year birth-cohort conducted in the 1980s. This study included data on religiosity and suicidal behaviour. Twenty-five years thereafter, mortality data were obtained from a national vital statistics registry. RESULTS: Rates of suicidal ideation were similar among secular, partially observant, and religious subjects (9.4%, 6.7%, and 6.2%, respectively; adjusted OR for linear trend: 0.80, 95% CI: 0.58-1.09). Rates of suicide attempts were significantly lower among religious subjects (2.4%, 2.5%, and 0.4% for secular, partially observant, and religious, respectively; adjusted OR for linear trend: 0.62, 95% CI: 0.43-0.88). Of the 4914 subjects, eight died by suicide: Seven of them were secular and one was partially observant (χ(2) = 2.52, P = 0.09). There were no differences in social functioning or rates of psychopathology among the study groups. CONCLUSION: Religiosity has a protective effect against suicide attempts, which is independent of social functioning, psychopathology, and substance use.

Toward a Typology of High-Risk Major Stressful Events and Situations in Posttraumatic Stress Disorder and Related Psychopathology.

The diagnosis of posttraumatic stress disorder (PTSD) was introduced in 1980 with the publication of the Diagnostic and Statistical Manual of the American Psychiatric Association, Third Edition (DSM-III). DSM-III put forward a novel syndrome consisting of intrusive, avoidance/numbing, and arousal symptoms as distinctive psychopathology following exposure to traumatic events. The traumatic stressors, although expanded in later editions published in 1987 (DSM-III-R) and 1994 (DSM-IV), focus on life-threatening events and situations. However, at least 12 studies, most of them recent, have found associations between the PTSD symptoms and the PTSD symptom syndrome with stressors, such as unemployment and divorce that would not qualify, even in the broadened DSM-IV diagnosis, as traumatic stressors. These findings challenge the basic assumption on which the PTSD diagnosis is based, the assumption that exposure to life-threatening stressors is the primary cause of a unique set of stress response symptoms. The purpose of this paper is to show how to confront this challenge by developing a typology of stressful situations and events that can be tested systematically for their relation to the PTSD symptom syndrome and other relevant variables. The typology includes but is not limited to the types of situations and events defined as "traumatic" in the DSMs.

The consistency of combat exposure reporting and course of PTSD in Vietnam War veterans.

Self-reports of traumatic events are often used in clinical and epidemiologic studies. Nevertheless, research suggests combat exposure reports may be biased by posttraumatic stress disorder (PTSD) symptom severity, leading to an inflated dose-response relation between combat exposure and PTSD. The authors examined the consistency in combat exposure reports and their relation to PTSD symptoms in Vietnam Veteran American Legionnaires who responded to two mailed surveys (1984, 1998; N = 1,462). Combat exposure reports were highly reliable (test-retest correlation = 0.87). However, changes in exposure reporting were related to changes in PTSD symptoms, specifically reexperiencing symptoms. The effect size of the dose-response relation attributable to changes in reporting was smaller for continuous than categorical measures. Findings are discussed in relation to recent controversies over veterans' combat exposure reports.

Inter-generational longitudinal study of social class and depression: a test of social causation and social selection models.

BACKGROUND: Generations of epidemiologists have documented an association between low socio-economic status (SES) and depression (variously defined), but debate continues as to which is the causative factor. AIMS: To test the extent to which social causation (low SES causing depression) and social selection (depression causing low SES) processes are in evidence in an inter-generational longitudinal study. METHOD: Participants (n = 756) were interviewed up to four times over 17 years using the Schedule for Affective Disorders and Schizophrenia (SADS). RESULTS: Low parental education was associated with increased risk for offspring depression, even after controlling for parental depression, offspring gender and offspring age. Neither parental nor offspring depression predicted later levels of offspring occupation, education or income. CONCLUSION: There is evidence for an effect of parental SES on offspring depression (social causation) but not for an effect of either parental or offspring depression on offspring SES (social selection).

The role of adversity and stress in psychopathology: some evidence and its implications for theory and research.

Three lines of research--studies of extreme situations, epidemiological investigations of relations between socioeconomic status (SES) and psychiatric disorders, and a quasi-experimental test of the social causation-social selection issue raised by the epidemiological findings--provide strong evidence that environmental adversity is important in the occurrence not only of post-traumatic stress disorder (PTSD) but also of other types of psychopathology, including major depression, alcoholism, substance use disorders, antisocial personality disorder, and nonspecific distress. Leads from this triad of studies are developed into a basic proposition about the nature of the role of adversity and stress. The core of this proposition is that the likelihood of onset of the above types of disorder increases with two factors: (1) the proportion of the individual's usual activities in which uncontrollable negative changes take place following a major negative event; and (2) how central the uncontrollable changes are to the individual's important goals and values. The role of environmental adversity in bringing about these uncontrollable changes varies with gender, ethnic/racial status, and SES in our own and other modern, urban societies. The types of psychopathology that develop and their course vary with both the types of adversity (e.g., whether life threat is involved) and with the personal predispositions of the individuals who experience the adversity and stress (e.g., family history of particular types of psychopathology).

A further analysis of race differences in the National Longitudinal Mortality Study.

OBJECTIVES: The purpose of this study was to investigate associations between race and specific causes of mortality among adults 25 years and older in the National Longitudinal Mortality Study. METHODS: Mortality hazard ratios between races during 9 years of follow-up were estimated with Cox proportional hazards models, with control for multiple indicators of socioeconomic status (SES) and SES-relevant variables. RESULTS: Black persons younger than 65 years were at higher risk than others for all-cause and cardiovascular mortality; the strongest effects were observed among persons aged 25 through 44 years. CONCLUSIONS: Race, independent of SES, is related to mortality in American society, but these effects vary by age and disease categories.

The Latino mortality paradox: a test of the "salmon bias" and healthy migrant hypotheses.

OBJECTIVES: Relative to non-Latino Whites, Latinos have a worse socioeconomic profile but a lower mortality rate, a finding that presents an epidemiologic paradox. This study tested the salmon bias hypothesis that Latinos engage in return migration to their country of origin and are thereby rendered "statistically immortal" and the alternative hypothesis that selection of healthier migrants to the United States accounts for the paradox. METHODS: National Longitudinal Mortality Study data were used to examine mortality rates of the following groups for whom the salmon hypothesis is not feasible: Cubans, who face barriers against return migration; Puerto Ricans, whose deaths in Puerto Rico are recorded in US national statistics; and US-born individuals, who are not subject to either salmon or healthy migrant effects. RESULTS: The sample included 301,718 non-Latino Whites and 17,375 Latino Whites 25 years or older. Cubans and Puerto Ricans had lower mortality than non-Latino Whites. Moreover, US-born Latinos had lower mortality than US-born non-Latino Whites. CONCLUSIONS: Neither the salmon nor the healthy migrant hypothesis explains the pattern of findings. Other factors must be operating to produce the lower mortality.

Why is depression comorbid with chronic myofascial face pain? A family study test of alternative hypotheses.

A number of explanations have been proposed to account for findings that rates of depression are elevated in persons with chronic, non-malignant pain disorders (CNPDs); for example, that CNPDs are variants of depression (e.g. 'masked depression'), that the stress of living with CNPDs contribute to the onset of depression ('diathesis-stress'), or that the correlation of CNPDs and depression is a methodological artifact of studying treatment-seeking samples. These alternative hypotheses are tested for one specific CNPD, chronic myofascial face pain, using a family study methodology. The procedure was to conduct direct psychiatric interviews with 106 patients with a history of carefully diagnosed myofascial face pain, 118 acquaintance controls without personal histories of myofascial face pain, and a random sample of adult first degree relatives of these case and control probands. The probands were further subdivided into four roughly equal samples consisting of cases with and without personal histories of major depressive disorder (MDD), and controls with and without personal histories of MDD. Dates of initial onsets of myofascial face pain and MDD in patient probands were obtained from interviews and records. The main results were that, compared to control probands without personal histories of MDD, MDD and depressive spectrum disorders (DSD) were elevated in the first degree relatives of control probands with personal histories of early onset MDD, but not in the first degree relatives of myofascial face pain probands with or without personal histories of early or late onset MDD. This outcome is consistent with the hypothesis that living with chronic myofascial face pain contributes to elevated rates of depression. It is inconsistent with the alternative hypotheses that this CNPD is a variant of depression or that the elevated MDD rates are simply an artifact of selection into treatment. The implications of these results and additional results consistent with them are discussed.

A longitudinal investigation of social causation and social selection processes involved in the association between socioeconomic status and psychiatric disorders.

Social causation theory and social selection theory have been put forth to explain the finding that low socioeconomic status (SES) is associated with risk for psychiatric disorders. The predictions of both theories were investigated using data from a community-based longitudinal study. Psychosocial interviews were administered to 736 families from 2 counties in New York State in 1975, 1983, 1985-1986, and 1991-1993. Results indicated that (a) low family SES was associated with risk for offspring anxiety, depressive, disruptive, and personality disorders after offspring IQ and parental psychopathology were controlled, and (b) offspring disruptive and substance use disorders were associated with risk for poor educational attainment after offspring IQ and parental psychopathology were controlled. These findings indicate that social causation and social selection processes vary in importance among different categories of psychiatric disorders.

Myofascial TMD does not run in families.

This study tests whether facial pain or associated symptoms and disorders aggregates in first degree relatives of those with myofascial temporomandibular disorders (M/TMD). We randomly selected one first degree relative of 106 probands with a lifetime history of M/TMD and one first degree relative of 118 acquaintance control probands with no history of M/TMD. Relatives were directly interviewed about the lifetime occurrence of a broad range of painful and non-painful health conditions and symptoms. Analyses revealed that rates of facial pain, symptoms of TMDs, and a range of other musculoskeletal conditions were not significantly different in first degree relatives of M/TMD probands and first degree relatives of controls. In addition, proband descriptors of facial pain severity or disability did not significantly predict the likelihood of having a first degree relative with one or more TMD-related symptoms. These results indicate that M/TMD is not a familial disorder.

Jews and their intraethnic vulnerability to affective disorders, fact or artifact? II: Evidence from a cohort study.

This paper, which complements a prior review of published studies, reports findings from a community-based survey of 4,914 Israel-born offspring of immigrants from Europe (Ashkenazim) and North Africa. Respondents were examined by psychiatrists using the Schedule for Affective Disorders and Schizophrenia, Israel version, and diagnosed with the Research Diagnostic Criteria. Unlike previous studies, this investigation found that Israelis of North African origin had significantly higher rates of affective disorders, including major depressive and intermittent depressive disorders. The Ashkenazim, however, had higher rates of bipolar I disorder at the definite level of diagnosis. Differential patterns in help-seeking may account for the divergent findings between this community-based study and earlier treatment-based reports. These results suggest the need to further investigate social and genetic etiological factors that may explain the differential rates.

PTSD symptoms and comorbid mental disorders in Israeli war veterans.

BACKGROUND: The purpose of this study was to investigate patterns of mental disorders co-morbid with PTSD symptoms in young Israeli men exposed to combat. METHOD: Six hundred and seventeen subjects were selected via a general population sample and evaluated in a two-phase case-identification procedure, culminating in a modified SADS-L interview, administered by psychiatrists. RESULTS: Major depressive disorder (OR = 3.2), substance use disorders (OR = 1.9) and personality disorders (OR = 3.0) occurred more frequently in men reporting symptoms of PTSD than in men who had been under fire who did not report symptoms. With the possible exception of personality disorders, comorbid disorders did not constitute risk factors for PTSD. Comorbid PTSD and RDC disorders were associated with increased help-seeking. CONCLUSIONS: The results suggest similar rates and types of PTSD comorbidity in Israeli war veterans as in veterans in the US assessed in general population studies, and are consistent with shared risk factors for PTSD and comorbid disorders.

Do premenstrual pain and edema exhibit seasonal variability?

This study tested whether symptoms of pain and edema associated with change during the premenstrual phase of the monthly menstrual cycle exhibit a seasonal pattern. Menstruating chronic myofascial face pain cases (N = 99) and acquaintance controls (N = 100) were questioned about their premenstrual symptoms during the prior month in each of 10 consecutive months. Unlike myofascial face pain and psychological distress, premenstrual symptoms of general discomfort and edema did not show an exacerbation in the dark months for either cases or controls. The positive results for distress and facial pain and the negative results for the premenstrual symptoms occurred whether or not respondents met an algorithmic diagnosis of DSM-IV premenstrual dysphoric syndrome.

The examination of myofascial face pain and its relationship to psychological distress among women.

In this study, 110 female myofascial face pain patients were assessed monthly for 10 months on measures of pain, distress, and stressful life events. D. A. Kenny and A. J. Zautra's (1995) structural equation model for examining the separate trait, state, and error components of the variables was used to analyze the data. Both pain and distress had sizable trait variance, and the trait components were correlated. The 2 variables also showed sizable state variance, and the states of pain covaried with states of distress. A significant time-lagged relationship between the 2 variables was found: Increases in distress led to elevations in pain 1 month later. Stressful life events arising from major social roles were also associated with greater distress, but not pain. Illness events unrelated to the pain syndrome were associated with both pain and distress.

Nongenetic familial transmission of psychiatric disorders? Evidence from children of Holocaust survivors.

There is considerable evidence that psychiatric disorders aggregate in families, a phenomenon for which both genetic and nongenetic explanations have been proposed. However, since genetic and social inheritance usually co-occur, it is difficult to separate out their effects. In this paper, we argue that examining the rates of disorder among children of Holocaust survivors provides a special situation where genetic and nongenetic factors in familial transmission can be separated, and where specific nongenetic mechanisms can be tested. We specify competing hypotheses, and test their viability using data from an epidemiological study of psychiatric disorders conducted in Israel. We find no evidence of higher symptom scale scores or higher rates of current psychiatric disorders for the children of Holocaust survivors. However, they did have higher rates of past disorders.

Minor depression in a cohort of young adults in Israel.

BACKGROUND: A diagnosis of minor depression was considered for DSM-IV. Mild depression is thought to be common in primary care settings and the community, but studies of the validity of minor depression as a separate diagnostic category are few. METHODS: Minor depression as defined by Research Diagnostic Criteria was assessed by psychiatrists using a modified Schedule for Affective Disorders and Schizophrenia-Lifetime version in a cohort of 5200 young adults in Israel. Subjects with year-prevalent minor depression were compared with subjects with major depression or generalized anxiety disorder and with controls on aspects of psychopathologic condition, psychosocial functioning, help-seeking behaviors, and demographic correlates. RESULTS: Symptomatically, minor depression appeared to be a mild version of major depression. Minor depression was associated with good teenage and general social functioning, but also with absence from work, separation or divorce, recent impairment in overall functioning, and help-seeking. CONCLUSIONS: The results lend support for including minor depression or expanding severity modifiers in future classifications to better capture the phenomenon of subthreshold depression.

Psychology, psychologists, and psychiatric epidemiology.

The purpose of this paper is to inquire into what interests psychologists might have in epidemiological approaches to the study of psychopathology, what psychologists have contributed in the past, and what they might be expected to contribute in the future. This inquiry starts with a consideration of epidemiological findings and issues that should command the interests of psychologists: differences between treated rates and untreated rates of psychiatric disorders, relations of psychiatric disorders to gender and socioeconomic status, and problems of case identification and diagnosis. My own experience with these issues and problems is discussed. An argument is made that there are important needs for the expertise of psychologists in psychiatric epidemiology and compelling reasons for them to enter the field in greater numbers than they have in the past.

An epidemiological study of mental disorders in a 10-year cohort of young adults in Israel.

This is an overview of a two-phase epidemiological study of mental disorders among young adults in a ten-year birth cohort (1949-58) conducted in Israel. A sample of 4914 Israel-born offspring of Jewish immigrants was obtained by full probability sampling procedures and screened for caseness using psychometric symptom scales from the Psychiatric Epidemiology Research Interview (PERI). Those screened positive and almost a fifth of the negatives (N = 2741) were interviewed by psychiatrists using the Schedule for Affective Disorders and Schizophrenia, Israel version (SADS-I), in order to determine prevalence rates of specific disorders as defined by the Research Diagnostic Criteria (RDC). The completion rates for each interview phase were 94.5% and 90.7% respectively. Six-month prevalence rates are presented by gender, ethnic origin, and education. Approximately one-fifth of the birth cohort met current RDC criteria for a disorder at the definite level, excluding the RDC category of 'other psychiatric disorder'. Generalized anxiety disorder and major depressive disorder were the most commonly found types. The striking findings centre on alcoholism and drug use disorder which were exceedingly rare, and the unusually similar rates of major depression for males and females. The results from this study are discussed in comparison with those obtained from other epidemiological studies.

Socioeconomic status and psychiatric disorders: the causation-selection issue.

Are inverse relations between psychiatric disorders and socioeconomic status due more to social causation (adversity and stress) or social selection (downward mobility of genetically predisposed)? This classical epidemiological issue is tested by focusing on ethnic status in relation to socioeconomic status. Ethnic status cannot be an effect of disorder because it is present at birth whereas socioeconomic status depends on educational and occupational attainment. A birth cohort sample of 4914 young, Israel-born adults of European and North African background was selected from the country's population register, screened, and diagnosed by psychiatrists. Results indicate that social selection may be more important for schizophrenia and that social causation may be more important for depression in women and for antisocial personality and substance use disorders in men.