The boundary of social phobia. Exploring the threshold

BACKGROUND

Individuals with subthreshold social phobia (SSP) in the community are characterized relative to nonphobic, healthy controls (C), and diagnosed social phobics (SP).

METHODS

Data from 1488 subjects from the Duke University Epidemiological Catchment Area Study were examined. Bivariate and multivariate methods were used to compare the SSP, SP, and C groups on 10 sets of variables.

RESULTS

Compared with C respondents, SSP respondents were more likely to be female and unmarried and to report less income and education. The SSP respondents were also more likely to report work attendance problems, poor grades in school, symptoms of conduct disturbance, impaired subjective social support, lack of self-confidence, lack of a close friend, use of psychotropic drugs in past year, and a greater number of life changes, chronic medical problems, and mental health visits within the past 6 months. In a multivariate logistic regression model with group membership as the dependent variable, compared with C respondents, SSP respondents were more likely to be female, to have less education, and to report more indicators of poor school performance and symptoms of adolescent conduct disturbance. In contrast, in a similar but separate multivariate model, compared with SP respondents, SSP respondents met the criteria for fewer DSM-III psychiatric disorders and were less likely to report impaired instrumental support.

CONCLUSION

Social phobia adversely affects over 10% of the population. Previous epidemiologic catchment area-based prevalence estimates have probably been unrealistically low.

The accuracy of self-report of herpes zoster

The accuracy of self-report of herpes zoster was investigated in the Duke Established Populations for Epidemiological Studies of the Elderly, a longitudinal study of 4162 community-dwelling elderly persons residing in North Carolina, 1986-1993. The authors compared self-reports of zoster with physician diagnosis of zoster and with a zoster verification questionnaire (ZVQ). Compared to physician diagnosis, 3.2% (95% confidence interval 0-61%) of self-reports of zoster (n = 31) were false-positive and no denials of zoster (n = 63) were false-negative. The agreement of self-reports to physician diagnosis was 98.9%, the sensitivity and negative predictive value were 100%, the specificity was 98.4% and the positive predictive value was 96.7%. The ZVQ comparisons were similarly high. These data suggest that the frequency of false-positive and false-negative reports of zoster is low in this elderly population. Zoster self-reports appear to be accurate and suitable for epidemiological investigations.

Mental health care for older adults in the year 2020: a dangerous and avoided topic

Low Medicare reimbursement rates are already causing some mental health professionals to turn away elderly patients, restricting access to care. Where will funds come from to pay for the mental health needs of older adults in the year 2020, when 80 million baby boomers pass age 65? This cohort, in contrast to elders today, have high rates of psychiatric illness, and are also much more likely than older adults to seek mental health services. Seemingly oblivious to these trends, plans are being made to cut, rather than expand, the Medicare budget. We are projecting an increasing gap over the next 25 years between need and availability of geriatric mental health services.

Psychological adjustment of children with sickle cell disease: stability and change over a 10-month period

Rates of poor psychological adjustment of children with sickle cell disease remained relatively constant over initial and follow-up assessment points. However, there was relatively little stability in the classification of the adjustment of individuals, low congruence in specific behavior problem patterns and diagnoses in accordance with the Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; American Psychiatric Association, 1980), and less stability in child adjustment by child report than by mother report. With initial levels of adjustment controlled, children's strategies for coping with pain accounted for a significant increment in child-reported symptoms (19%) and mother-reported internalizing behavior problems (8%) at follow-up beyond the contribution of illness and demographic parameters and follow-up interval. The findings suggest that children's coping strategies are a salient intervention target for enhancing adjustment.

Moderating effects of prior social resources on the hospitalizations of elders who become widowed

In a prospective design, the effects of social resources before widowhood on changes in subsequent hospitalizations were compared for 86 married elders who became widowed over a 2-year period and 86 matched elders who remained married. Subjects were from the Established Populations for Epidemiologic Studies of the Elderly (Duke). Hospitalizations were used as an indicator of a serious health outcome whose report was unlikely to be biased by a widowed person's emotional state. The hypothesis that perceptions of inadequate social support from persons other than the spouse would exacerbate the effects of bereavement on hospitalizations was supported for elders who lacked close friends with whom to talk about private matters while still married; believing that no relative would provide such support and dissatisfaction with support tended to have the same effect. Inadequacies in social embeddedness (few contacts with friends, relatives, or children and being childless) had no significant moderating or main effects on change in hospitalizations.

Religious affiliation and psychiatric disorder among Protestant baby boomers

OBJECTIVE

The authors examined the relationship between religious affiliation and psychiatric disorder among Protestant members of the baby-boom generation (those born between 1945 and 1966) who resided in the Piedmont area of North Carolina.

METHODS

Data were obtained on six-month and lifetime rates of major psychiatric disorders among 853 Protestant baby boomers during wave II of the National Institute of Mental Health's Epidemiologic Catchment Area survey, conducted in 1983-1984. Participants were grouped into three categories based on religious affiliation: mainline Protestants, conservative Protestants, and Pentecostals. Rates of disorder were compared across denominational groups, controlling for sex, race, physical health status, and socioeconomic status and stratifying by frequency of church attendance. The analyses were repeated for 1,826 middle-aged and older Protestants born between 1889 and 1944, and the results were compared with the findings for baby boomers.

RESULTS

Among the baby boomers, Pentecostals had significantly higher six-month and lifetime rates of depressive disorder, anxiety disorder, and any DSM-III disorder. Mainline Protestants had the lowest six-month and lifetime rates of anxiety disorder and the lowest six-month rates of any DSM-III disorder, whereas conservative Protestants had the lowest six-month and lifetime rates of depressive disorder and the lowest lifetime rates of any DSM-III disorder. These relationships among baby boomers were weaker among middle-aged and older Protestants, although a new association with alcohol abuse or dependence emerged among older Pentecostals. When analyses were stratified by frequency of church attendance, associations between psychiatric disorder and Pentecostal affiliation were strongest among infrequent churchgoers, a group also unlikely to seek help from mental health professionals.

CONCLUSIONS

Young adult Pentecostals in the Peidmont area experienced high rates of psychiatric disorder, which was not generally true for Pentecostals who were middle aged or older. Infrequent churchgoers appeared to be at greatest risk, although they seldom sought professional help for their problems.

Change over a 12-month period in the psychological adjustment of children and adolescents with cystic fibrosis

Found that group rates of mother-reported and child-reported adjustment problems remained relatively constant over initial and 12-month follow-up assessment points. However, there was less stability in the classification of the adjustment of individuals, in specific behavior problem patterns and diagnoses, and in child-reported adjustment than in mother-reported adjustment. With initial level of child adjustment controlled, children's perceptions of self-worth accounted for a significant increment in child-reported symptoms and mother-reported adjustment at follow-up. Maternal distress also accounted for a significant increment in child-reported symptoms. These findings add support for the role of maternal adjustment and child self-worth in the adjustment of children with cystic fibrosis.

Stability and change in the psychological adjustment of mothers of children and adolescents with cystic fibrosis and sickle cell disease

Found moderate stability in the classification of maternal adjustment in two longitudinal studies of mothers of children and adolescents with cystic fibrosis and sickle cell disease. In terms of the transactional stress and coping model, stable poor maternal adjustment was associated with higher levels of appraisal of daily stress and palliative coping and low levels of family supportiveness. With initial levels of maternal adjustment, demographic parameters, and follow-up interval controlled, concurrent levels of daily stress accounted for significant portions of variance in maternal adjustment at follow-up for both illness groups. In addition, illness severity, child psychological adjustment, and family conflict added significant increments to maternal adjustment at follow-up in the cystic fibrosis group. Findings are discussed in terms of a basis for subsequent intervention studies to enhance the adjustment of mothers of children with chronic illness.

Religious practices and alcoholism in a southern adult population

OBJECTIVE

The study examined associations between religious variables and alcohol abuse and dependence among 2,969 North Carolina residents aged 18 to 97 who participated in the 1983-1984 National Institute of Mental Health Epidemiologic Catchment Area survey at its Piedmont location.

METHODS

Six-month and lifetime prevalence of alcohol disorders were compared among participants reporting varying levels of religious activity. Data were collected on frequency of Bible reading, prayer, and church attendance; time spent watching or listening to religious programming on television or radio; importance of religion; religious denomination; and identification as "born-again" Christians.

RESULTS

Recent and lifetime alcohol disorders were less common among weekly churchgoers and those who considered themselves born again. Recent, but not lifetime, alcohol disorders were also less common among respondents who frequently read the Bible or prayed privately. Alcohol disorders were more common among those who frequently watched or listened to religious television and radio. Lifetime, but not recent, alcohol disorders were more prevalent among members of Pentecostal denominations.

CONCLUSIONS

Longitudinal study is necessary to further clarify and explain these relationships between religious practices and alcohol disorders.

Predictors of nursing home admission in a biracial population

Racial differences in predictors of institutionalization were studied in a biracial North Carolina cohort (n = 4074). During 3 years of follow-up, 8.5% of Whites and 6.4% of African Americans were admitted to nursing homes. African Americans were one half as likely as Whites to be institutionalized after adjustment for other risk factors. Among Whites, impaired activities of daily living and cognition were the strongest predictors; among African Americans, impaired instrumental activities of daily living and prior history of nursing home use were strongest. Racial differences in nursing home use were not explained by financial and social support or physical and cognitive impairment.

The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area Study

Social phobia was studied in a North Carolina community, using DSM-III criteria. Two kinds of comparison were made: social phobia v. non-social phobia, and comorbid social phobia v. non-comorbid social phobia. Six-month and lifetime prevalence rates were 2.7 and 3.8% respectively. Social phobia had an early onset, lasted a long time and rarely recovered. Predictors of good outcome recovery in a logistic regression analysis were onset of phobia after age 11, absence of psychiatric comorbidity and greater education. The disorder was often missed in medical consultation. Increased rates of psychiatric comorbidity existed, especially for other anxiety disorders and for schizophrenia/schizophreniform disorder. There was increased risk of neurological disorder. Social phobia was also associated with an increased rate of suicide attempts, antisocial behaviour and impaired school performance during adolescence, impaired medical health, increased health-seeking behaviour, poor employment performance, reduced social interaction and impaired social support. Comorbidity accounted for some, but not all observed differences.

Dementia and cancer: a comparison of spouse caregivers

Can prominent themes that have emerged in dementia caregiving research be extrapolated to caregivers of persons with other chronic illnesses such as cancer? To answer this question, the present study compared 272 spouse caregivers of dementia sufferers with 30 spouse caregivers of cancer victims on multiple indicators of well-being. Group contrasts using MANOVA revealed that dementia caregivers were more adversely affected by their role than cancer caregivers. Illness duration and caregivers' employment status did not help to explain this difference, yet caregiver age was a robust covariate. Specifically, younger spouse caregivers were significantly more compromised than older spouse providers.

One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study

The associations between the one-month prevalence rates of mental disorders and sociodemographic characteristics were investigated for 18,571 people interviewed in the first-wave community samples of all 5 sites in the US National Institute of Mental Health (NIMH) Epidemiologic Catchment Area program. Men were found to have a significantly higher rate of cognitive impairment than women after controlling for the effects of age, race or ethnicity, marital status and socioeconomic status. Marital status was one of the most powerful correlates of mental disorder risk: the odds of separated or divorced people having any NIMH Diagnostic Interview Schedule disorder were twice that of married people after controlling for age, gender, race or ethnicity and socioeconomic status. The odds of those in the lowest socioeconomic status group having any Diagnostic Interview Schedule disorder was about 2.5 times that of those in the highest socioeconomic status group, controlling for age, gender, race or ethnicity and marital status. For all disorders except cognitive impairment, race or ethnicity did not remain statistically significant after controlling for age, gender, marital status and socioeconomic status.

Psychiatric disorders in adult children of alcoholics: data from the Epidemiologic Catchment Area project

OBJECTIVE

The authors examined differences in the prevalence of psychiatric disorders in individuals who did or did not have alcoholic parents.

METHOD

They used data from the National Institute of Mental Health Epidemiologic Catchment Area project, specifically from the Piedmont of North Carolina. Prevalence of psychiatric disorders was estimated in 408 ECA participants who reported problem drinking in their mother, their father, or both and in 1,477 age- and sex-matched subjects who did not report having alcoholic parents.

RESULTS

The adult children of alcoholics showed significantly higher current (6-month) prevalence rates of simple phobia and agoraphobia and lifetime rates of dysthymia, generalized anxiety disorder, panic disorder, simple phobia, and agoraphobia. Adult children of alcoholics also had significantly more antisocial symptoms. Male children of alcoholics had higher rates of alcohol and drug abuse and reported more antisocial symptoms than did female children of alcoholics. Male children of alcoholics had a significantly higher rate of lifetime diagnoses of alcohol and drug abuse than men who were not children of alcoholics. More female children of alcoholics had generalized anxiety disorder than women who were not children of alcoholics. Both male and female children of alcoholics had significantly more antisocial symptoms than their matched comparison subjects. Sons of alcoholic fathers had a higher rate of substance abuse and more antisocial symptoms than did daughters of alcoholic fathers. Daughters of alcoholic fathers had a higher rate of generalized anxiety disorder.

CONCLUSIONS

These data on adult children of alcoholics in a large community sample add to a literature based mainly on descriptive material or studies of smaller samples.

Long-term psychosocial effects of childhood exposure to parental problem drinking

OBJECTIVE

The effects of childhood exposure to parental problem drinking remain unclear because of inconsistent findings and methodologic difficulties in previous studies. The authors used a large community sample to examine whether exposure to parental problem drinking in childhood was related to a greater number of psychiatric symptoms and impaired social and occupational functioning in adulthood.

METHOD

The study used self-report data from the Piedmont Health Survey, a project of the Epidemiologic Catchment Area program, which were collected from a stratified random sample of 2,936 adults residing in a five-county catchment area in North Carolina. The National Institute of Mental Health Diagnostic Interview Schedule was used to measure the subjects' lifetime psychiatric symptoms. Social and occupational functioning were assessed with two scales measuring social support, a scale measuring occupational prestige, and an occupational problem index. Regression analyses were used to determine whether exposure to parental problem drinking in childhood was associated with adverse psychosocial outcomes in adulthood.

RESULTS

Adults who had been exposed to parental problem drinking in childhood were more likely to manifest psychiatric symptoms and marital instability, but they showed no difference from the rest of the sample in occupational functioning.

CONCLUSIONS

Exposure to parental problem drinking in childhood is positively associated with specific adverse effects in adulthood even after controlling for other confounding childhood risk factors.

Expenditures in caring for patients with dementia who live at home

OBJECTIVES

Given the national interest in progressive dementia, we estimated expenditures incurred in caring for dementia patients who live at home.

METHODS

Primary caregivers of 264 patients from a university-based memory disorders clinic were interviewed at baseline and asked to keep service use diaries for 6 months; 141 caregivers who returned the diaries are the focus of this report. We examined both formal and informal services (distinguished by whether money was exchanged) and associated expenditures.

RESULTS

Neither caregivers returning diaries nor their patients differed at baseline from those not returning diaries and their patients. Expenditures incurred over 6 months were extensive for both formal ($6986) and informal ($786) services. Out-of-pocket expenditures were high (e.g., in-home companion or sitter, adult day care, visiting nurse). Multivariable analyses indicated that patients with more severe symptoms of dementia and families with higher incomes reported significantly higher expenditures.

CONCLUSIONS

The expense of caring for patients with progressive dementia living at home may be higher than previously estimated and frequently involves expenses paid directly by patients and their families.

Social service interventions for caregivers of patients with dementia: impact on health care utilization and expenditures

OBJECTIVES

An intervention, which had as its primary goal the enhancement of compliance to social work recommendations, was shown to produce extremely high rates of compliance. This report addresses the secondary objective of the study: to evaluate the impact of the intervention on short-term (ie, 6-month) health services utilization and expenditures.

DESIGN

Randomized controlled trial.

SETTING

University-based memory disorders clinic.

PARTICIPANTS

Caregivers of patients with progressive memory disorders.

MAIN OUTCOME MEASURES

Service utilization and expenditures.

RESULTS

The intervention did not have a statistically significant impact on utilization of either health care or community resources. The intervention group had $903 less expenditures during the study period, a difference that did not achieve statistical significance. The results were consistent when controlling for caregiver characteristics that differed at baseline.

CONCLUSIONS

Although the intervention was successful in enhancing compliance with recommendations, more intensive interventions may be required to increase subsequent service utilization. Future investigations may wish to target the appropriateness of services used over a period longer than 6 months.

Black/white differences in hypertension in the elderly: an epidemiologic analysis in central North Carolina

Hypertension in blacks, compared with whites, occurs at higher prevalence rates, is more severe, and carries a worse prognosis for cardiovascular morbidity and mortality. The authors examined the degree to which black/white differences in hypertension in the elderly are explained by demographic variables, income, health behavior (smoking, obesity), health service use, and comorbid diabetes. The study population consisted of subjects participating in the Duke site of the Established Populations for Epidemiologic Studies of the Elderly, initiated in 1984. Cross-sectional data reported here were collected between January 1986 and July 1987. Subjects were aged 65 years or older and were not institutionalized. Blacks were oversampled. Of 5,223 eligible persons, 4,163 (80%) agreed to be interviewed; 16% of the study subjects were white men, 30% white women, 19% black men, and 35% black women. The mean age for all groups was approximately 73 years. Forty-four percent of white men, 52% of white women, 50% of black men, and 66% of black women had hypertension. Eighty percent of hypertensives were receiving pharmacologic therapy. Older age, female sex, lower socioeconomic status, obesity, and diabetes mellitus were associated with hypertension. After adjusting for covariables, black race/ethnicity remained an independent risk factor for high blood pressure in the elderly, with an adjusted odds ratio of 1.30.

Abbreviating the Duke Social Support Index for use in chronically ill elderly individuals

The 35-item Duke Social Support Index (DSSI) measures multiple dimensions of social support and has been used extensively in cross-sectional and longitudinal studies of aging. Epidemiological studies of chronically ill, frail elderly individuals often wish to include a measure of social support. However, most multidimensional measures (including the DSSI) are long and may exhaust the patient, especially when included in an often already congested interview schedule. The authors have developed two abbreviated versions of the DSSI (23-item and 11-item) that capture the essential components of social support related to mental health outcomes and use of health services in treating elderly individuals with nonpsychiatric medical illness.

Religious affiliation and major depression

Data from the Duke Epidemiologic Catchment Area survey were used to examine the relationship between religious affiliation and major depression among 2,850 adults in the community. Religious affiliations were categorized into six groups: mainline Protestant (27 percent), conservative Protestant (59 percent), Pentecostal (4.2 percent), Catholic (2.4 percent), other religions (2.6 percent), and no affiliation (4.4 percent). The six-month prevalence of major depression among Pentecostals was 5.4 percent, compared with 1.7 percent for the entire sample. Even after psychosocial factors such as gender, age, race, socioeconomic status, negative life events, and social support were controlled for, the likelihood of major depression among Pentecostals was three times greater than among persons with other affiliations. Carefully designed studies are needed to understand the complex interactions of religion and mental health.

Drug-use patterns among black and nonblack community-dwelling elderly

OBJECTIVE

To describe and compare drug-use patterns among black and nonblack community-dwelling elderly.

DESIGN

Survey.

SETTING

Five-county urban and rural region in Piedmont, NC.

PARTICIPANTS

Stratified probability household sample of 4164 community residents aged 65 or older from the Piedmont Health Survey of the Elderly (65 percent women, 54 percent black, mean age 73.56 +/- 6.74 y).

MAIN OUTCOME MEASURES

Prevalence of medication use and mean drug use; therapeutic medication category use.

RESULTS

Data were weighted to represent the population in this geographic area. Fewer blacks reported the use of over-the-counter (OTC) medications and total medications than did nonblacks (66 vs. 76 percent and 88 vs. 92 percent, respectively; p less than 0.001). Compared with nonblacks, blacks reported using a lower mean number of prescription (2.02 vs. 2.35; p less than 0.001), OTC (1.12 vs. 1.42; p less than 0.001), and total (3.14 vs. 3.77; p less than 0.001) drugs. The therapeutic medication categories varied by race for prescription cardiovascular, analgesic, and central nervous system (CNS) drugs and OTC nutritional supplements. More nonblacks than blacks reported the use of analgesics (62.5 vs. 55.6 percent, respectively; p less than 0.001), CNS drugs (26.1 vs. 14.2 percent, respectively; p less than 0.001), nutritional supplements (27.5 vs. 16.9 percent, respectively; p less than 0.001), and gastrointestinal agents (29.0 vs. 23.5 percent, respectively; p less than 0.001). Blacks were more likely to report problems in managing their medications than were nonblacks (9.0 vs. 6.1 percent, respectively; p = 0.001).

CONCLUSIONS

Our data suggest that there are distinct racial differences in medication-use patterns among the elderly.

Age and impaired subjective support. Predictors of depressive symptoms at one-year follow-up

We followed a cohort of subjects (predominantly inpatients) suffering a major depressive episode in midlife and late-life for 1 year (N = 118). In this follow-up study, we examined three hypotheses. a) Elder subjects suffering major depression, compared with middle-aged subjects, will more likely report endogenous symptoms and less likely report decreased life satisfaction symptoms at 1-year follow-up. b) Impaired social support during the index episode will predict poor life satisfaction, but not endogenous symptoms at 1-year follow-up, regardless of age. c) Impaired social support during the index episode will be more predictive of decreased life satisfaction symptoms in midlife, compared with late life, at 12-month follow-up. The first two hypotheses were not supported, but the third hypothesis was. Both decreased life satisfaction and endogenous symptoms at outcome were significantly predicted by impaired social support during the index episode. Impaired social support predicted a poor outcome from an episode of major depression in both middle life and late life in controlled analyses. However, the effect of impaired subjective social support was conditional on age. Subjective social support appears to have a decreasing influence on the report of both endogenous and decreased life satisfaction symptoms for older individuals.

Patients with cancer and their spouse caregivers. Perceptions of the illness experience

This study focuses on patterns of response between patients with cancer and their spouse caregivers to examine the reliability of spouse informants in research and clinical settings. Thirty dyads (patient with cancer-spouse caregiver couples; total n = 60) were interviewed concurrently in their homes concerning patient functioning, psychologic distress, physical symptoms, caregiver perceptions of patient functioning, and marriage quality. Couples had been married an average of 32 years. Patients had either the lung or colon as their primary cancer site, and one third had metastasis. Correlations between 14 variable pairs and cross-tabulation of scale scores suggest that spouse caregivers agree with patients on objective measures with observable referents (e.g., ability to dress independently). Partners disagree on subjective aspects of patient functioning (e.g., depression, fear of future, and confidence in treatment) and marriage quality. Almost without exception, caregivers viewed patients' functioning more negatively than patients described themselves. Patients, however, viewed marital quality more negatively than did caregivers. It was concluded that caregivers can serve as proxies for patients with cancer in research and clinical settings when objective data are sought. Data from both spouses are needed, however, to complete the picture of subjective illness experiences in patients with cancer, including perceptions of pain and disease symptoms.

Adult vulnerability for psychiatric disorders: interactive effects of negative childhood experiences and recent stress

The effects of negative childhood experiences on adult psychiatric status remain unclear because of inconsistent findings in previous studies. In this study, we examine the extent to which parental separation/divorce before the age of 10, parental death before the age of 10, and self-reports of parental mental illness during early childhood interact with recent stressful life events to increase the probability of multiple psychiatric disorders and psychiatric symptoms during adulthood. Data are from a stratified random sample of 3801 adults residing in a five-county catchment area in North Carolina. The Diagnostic Interview Schedule was used to measure psychiatric disorders and symptoms during the 6 months prior to the interview. Regression analyses were used to determine whether negative childhood experiences interact with recent stressful life events to increase the probability of psychiatric disorders or symptoms, with other risk factors statistically controlled. Results suggest that: a) parental mental illness increases the likelihood that stressful life events will result in depression, although it is unclear whether this increased vulnerability is due to genetic or environmental factors; b) parental separation/divorce interacts with stressful life events to increase vulnerability to alcohol problems and psychiatric disorders more generally; and c) parental death does not interact with recent events to affect the likelihood of psychiatric problems.