1
|
McGrath JJ, Saha S, Al-Hamzawi A, Alonso J, Bromet EJ, Bruffaerts R, Caldas-de-Almeida JM, Chiu WT, de Jonge P, Fayyad J, Florescu S, Gureje O, Haro JM, Hu C, Kovess-Masfety V, Lepine JP, Lim CW, Mora MEM, Navarro-Mateu F, Ochoa S, Sampson N, Scott K, Viana MC, Kessler RC. Psychotic Experiences in the General Population: A Cross-National Analysis Based on 31,261 Respondents From 18 Countries. JAMA Psychiatry 2015; 72:697-705. [PMID: 26018466 PMCID: PMC5120396 DOI: 10.1001/jamapsychiatry.2015.0575] [Citation(s) in RCA: 318] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Community-based surveys find that many otherwise healthy individuals report histories of hallucinations and delusions. To date, most studies have focused on the overall lifetime prevalence of any of these psychotic experiences (PEs), which might mask important features related to the types and frequencies of PEs. OBJECTIVE To explore detailed epidemiologic information about PEs in a large multinational sample. DESIGN, SETTING, AND PARTICIPANTS We obtained data from the World Health Organization World Mental Health Surveys, a coordinated set of community epidemiologic surveys of the prevalence and correlates of mental disorders in representative household samples from 18 countries throughout the world, from 2001 through 2009. Respondents included 31,261 adults (18 years and older) who were asked about lifetime and 12-month prevalence and frequency of 6 types of PEs (2 hallucinatory experiences and 4 delusional experiences). We analyzed the data from March 2014 through January 2015. MAIN OUTCOMES AND MEASURES Prevalence, frequency, and correlates of PEs. RESULTS Mean lifetime prevalence (SE) of ever having a PE was 5.8% (0.2%), with hallucinatory experiences (5.2% [0.2%]) much more common than delusional experiences (1.3% [0.1%]). More than two-thirds (72.0%) of respondents with lifetime PEs reported experiencing only 1 type. Psychotic experiences were typically infrequent, with 32.2% of respondents with lifetime PEs reporting only 1 occurrence and 31.8% reporting only 2 to 5 occurrences. We found a significant relationship between having more than 1 type of PE and having more frequent PE episodes (Cochran-Armitage z = -10.0; P < .001). Lifetime prevalence estimates (SEs) were significantly higher among respondents in middle- and high-income countries than among those in low-income countries (7.2% [0.4%], 6.8% [0.3%], and 3.2% [0.3%], respectively; χ²₂ range, 7.1-58.2; P < .001 for each) and among women than among men (6.6% [0.2%] vs 5.0% [0.3%]; χ²₁ = 16.0; P < .001). We found significant associations with lifetime prevalence of PEs in the multivariate model among nonmarried compared with married respondents (χ²₂ = 23.2; P < .001) and among respondents who were not employed (χ²₄= 10.6; P < .001) and who had low family incomes (χ²₃ = 16.9; P < .001). CONCLUSIONS AND RELEVANCE The epidemiologic features of PEs are more nuanced than previously thought. Research is needed that focuses on similarities and differences in the predictors of the onset, course, and consequences of distinct PEs.
Collapse
Affiliation(s)
- John J. McGrath
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4076, Australia,Discipline of Psychiatry, University of Queensland, St Lucia, QLD 4072, Australia,Queensland Brain Institute, University of Queensland, St Lucia, QLD 4072, Australia,Corresponding author: Professor John McGrath, Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Queensland, 4076, Australia. , Phone: +61 7 3271 8694, Fax: +61 7 3271 8698
| | - Sukanta Saha
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD 4076, Australia,Discipline of Psychiatry, University of Queensland, St Lucia, QLD 4072, Australia,Queensland Brain Institute, University of Queensland, St Lucia, QLD 4072, Australia
| | - Ali Al-Hamzawi
- College of Medicine, Al-Qadisiya University, Diwania governorate, Iraq
| | - Jordi Alonso
- Health Services Research Unit, IMIM-Institut de Recerca Hospital del Mar, Barcelona, Spain,CIBER en EpidemiologÕïa y Salud Puïblica (CIBERESP), Barcelona, Spain
| | - Evelyn J. Bromet
- Department of Psychiatry, Stony Brook University School of Medicine
| | - Ronny Bruffaerts
- Universitair Psychiatrisch Centrum - Katholieke Universiteit Leuven (UPC-KUL), Campus Gasthuisberg, Belgium
| | - José Miguel Caldas-de-Almeida
- Chronic Diseases Research Center (CEDOC) and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
| | - Wai Tat Chiu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter de Jonge
- University of Groningen, University Medical Center, Groningen Department of Psychiatry, Interdisciplinary Center, Psychopathology and Emotion regulation (ICPE), Groningen, The Netherlands
| | - John Fayyad
- Institute for Development, Research, Advocacy, and Applied Care (IDRAAC), Beirut, Lebanon
| | - Silvia Florescu
- National School of Public Health, Management and Professional Development, Bucharest, Romania
| | - Oye Gureje
- Department of Psychiatry, University College Hospital, Ibadan, Nigeria
| | - Josep Maria Haro
- Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona, Spain
| | - Chiyi Hu
- Shenzhen Insitute of Mental Health & Shenzhen Kanging Hospital, China
| | - Viviane Kovess-Masfety
- Ecole des Hautes Etudes en Santé Publique (EHESP), EA 4057 Paris Descartes University, Paris, France
| | - Jean Pierre Lepine
- Hôpital Lariboisière Fernand Widal, Assistance Publique Hôpitaux de Paris INSERM UMR-S 1144, University Paris Diderot and Paris Descartes Paris, France
| | - Carmen W. Lim
- Department of Psychological Medicine, Dunedin School of Medecine, University of Otago, New Zealand
| | | | - Fernando Navarro-Mateu
- Subdirección General de Salud Mental y Asistencia Psiquiátrica. Servicio Murciano de Salud, El Palmar (Murcia), Spain
| | - Susana Ochoa
- Parc Sanitari Sant Joan de Déu, CIBERSAM, Universitat de Barcelona
| | - Nancy Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| | - Kate Scott
- Department of Psychological Medicine, Dunedin School of Medecine, University of Otago, New Zealand
| | - Maria Carmen Viana
- Department of Social Medicine, Federal University of Espírito Santo, Brazil
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Bruffaerts R, Demyttenaere K, Kessler RC, Tachimori H, Bunting B, Hu C, Florescu S, Haro JM, Lim CCW, Kovess-Masfety V, Levinson D, Medina Mora ME, Piazza M, Piotrowski P, Posada-Villa J, Salih Khalaf M, ten Have M, Xavier M, Scott KM. The associations between preexisting mental disorders and subsequent onset of chronic headaches: a worldwide epidemiologic perspective. J Pain 2014; 16:42-52. [PMID: 25451620 DOI: 10.1016/j.jpain.2014.10.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 09/17/2014] [Accepted: 10/14/2014] [Indexed: 01/01/2023]
Abstract
UNLABELLED Although there is a significant association between preexisting depression and later onset of chronic headache, the extent to which other preexisting mental disorders are associated with subsequent onset of headache in the general population is not known. Also unknown is the extent to which these associations vary by gender or by life course. We report global data from the WHO's World Mental Health surveys (n = 52,095), in which, by means of the Composite International Diagnostic Interview-3.0, 16 mental disorders from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, were retrospectively assessed in terms of lifetime prevalence and age of onset. Frequent or severe headaches were assessed using self-reports. After adjustment for covariates, survival models showed a moderate but consistent association between preexisting mood (odds ratios [ORs] = 1.3-1.4), anxiety (ORs = 1.2-1.7), and impulse-control disorders (ORs = 1.7-1.9) and the subsequent onset of headache. We also found a dose-response relationship between the number of preexisting mental disorders and subsequent headache onset (OR ranging from 1.9 for 1 preexisting mental disorder to 3.4 for ≥5 preexisting mental disorders). Our findings suggest a consistent and pervasive relationship between a wide range of preexisting mental disorders and the subsequent onset of headaches. This highlights the importance of assessing a broad range of mental disorders, not just depression, as specific risk factors for the subsequent onset of frequent or severe headaches. PERSPECTIVE This study shows that there is a temporal association between a broad range of preexisting mental disorders and the subsequent onset of severe or frequent headaches in general population samples across the world.
Collapse
Affiliation(s)
- Ronny Bruffaerts
- Universitair Psychiatrisch Centrum-Katholieke Universiteit Leuven (UPC-KUL), Leuven, Belgium.
| | - Koen Demyttenaere
- Universitair Psychiatrisch Centrum-Katholieke Universiteit Leuven (UPC-KUL), Leuven, Belgium
| | - Ronald C Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Hisateru Tachimori
- National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Brendan Bunting
- Psychology Research Institute, University of Ulster, Londonderry, Northern Ireland
| | - Chiyi Hu
- Shenzhen Institute of Mental Health and Shenzhen Kangning Hospital, Guangdong Province, PR China
| | - Silvia Florescu
- National School of Public Health, Management and Professional Development, Romania
| | | | - Carmen C W Lim
- Department of Psychological Medicine, Otago University, Dunedin, New Zealand
| | - Viviane Kovess-Masfety
- Université Paris Descartes & EHESP School for Public Health Department of Epidemiology, Paris, France
| | - Daphna Levinson
- Mental Health Services, Ministry of Health, Jerusalem, Israel
| | | | - Marina Piazza
- Mental Health, Alcohol and Drugs Research Unit, School of Public Health, Universidad Peruana Cayetano, Heredia, Peru
| | | | | | | | - Margreet ten Have
- Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Miguel Xavier
- Chronic Diseases Research Center (CEDOC) and Department of Mental Health, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Kate M Scott
- Department of Psychological Medicine, Otago University, Dunedin, New Zealand
| |
Collapse
|
3
|
Guerrero EG, Villatoro JA, Kong Y, Gamiño MB, Vega WA, Mora MEM. Mexicans' use of illicit drugs in an era of drug reform: national comparative analysis by migrant status. Int J Drug Policy 2014; 25:451-7. [PMID: 24816376 DOI: 10.1016/j.drugpo.2014.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 03/11/2014] [Accepted: 04/08/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although rates of illicit drug use are considerably lower in Mexico than in the United States, rates in Mexico have risen significantly. This increase has particular implications for Mexican women and US migrants, who are considered at increased risk of drug use. Due to drug reforms enacted in Mexico in 2008, it is critical to evaluate patterns of drug use among migrants who reside in both regions. METHODS We analysed a sample of Mexicans (N=16,249) surveyed during a national household survey in 2011, the Encuesta Nacional de Adicciones (National Survey of Addictions). Comparative analyses based on Mexicans' migrant status - (1) never in the United States, (2) visited the United States, or (3) lived in the United States (transnationals) - featured analysis of variance and Chi-square global tests. Two multilevel regressions were conducted to determine the relationships among migrant status, women, and illicit drug use. RESULTS Comparative findings showed significant differences in type and number of drugs used among Mexicans by migrant status. The regression models showed that compared with Mexicans who had never visited the United States, Mexican transnationals were more likely to report having used drugs (OR=2.453, 95% CI=1.933, 3.113) and using more illicit drugs (IRR=2.061, 95% CI=1.626, 2.613). Women were less likely than men to report having used drugs (OR=0.187, 95% CI=0.146, 0.239) and using more illicit drugs (IRR=0.153, 95% CI=0.116, 0.202). CONCLUSIONS Overall, the findings support further exploration of risk factors for illicit drug use among Mexican transnationals, who exhibit greater drug use behaviours than Mexicans never in the United States. Because drug reform mandates referrals to treatment for those with recurrent issues of drug use, it is critical for the Mexican government and civic society to develop the capacity to offer evidence-based substance abuse treatment for returning migrants with high-risk drug behaviours.
Collapse
Affiliation(s)
- Erick G Guerrero
- School of Social Work, University of Southern California, 655 West 34th Street, Los Angeles, CA 90089, United States.
| | - Jorge Ameth Villatoro
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Calzada México Xochimilco 101, San Lorenzo Huipulco, 14370 Cuidad de México, Distrito Federal, Mexico.
| | - Yinfei Kong
- School of Social Work, University of Southern California, 655 West 34th Street, Los Angeles, CA 90089, United States.
| | - Marycarmen Bustos Gamiño
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Calzada México Xochimilco 101, San Lorenzo Huipulco, 14370 Cuidad de México, Distrito Federal, Mexico.
| | - William A Vega
- School of Social Work, University of Southern California, 655 West 34th Street, Los Angeles, CA 90089, United States.
| | - Maria Elena Medina Mora
- Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Calzada México Xochimilco 101, San Lorenzo Huipulco, 14370 Cuidad de México, Distrito Federal, Mexico.
| |
Collapse
|
4
|
Degenhardt L, Bucello C, Calabria B, Nelson P, Roberts A, Hall W, Lynskey M, Wiessing L, Mora MEM, Clark N, Thomas J, Briegleb C, McLaren J. What data are available on the extent of illicit drug use and dependence globally? Results of four systematic reviews. Drug Alcohol Depend 2011; 117:85-101. [PMID: 21377813 DOI: 10.1016/j.drugalcdep.2010.11.032] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Revised: 11/10/2010] [Accepted: 11/11/2010] [Indexed: 11/27/2022]
Abstract
BACKGROUND We systematically reviewed availability and quality of data on the prevalence of use and dependence on meth/amphetamine, cannabis, cocaine and opioids. METHODS Multiple search strategies: (a) peer-reviewed literature searches (1990-2008) using methods recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; (b) systematic searches of online databases; (c) Internet searches to find other published evidence of drug use; (d) repeated consultation and feedback from experts around the globe; (e) a viral email sent to lists of researchers in the illicit drug and HIV fields. Data were extracted and graded according to predefined variables reflecting quality of data source. RESULTS Qualitative evidence of illicit drug use and dependence was found for most countries, which hold over 98% of the world's population aged 15-64 years. Countries where use was identified but prevalence estimates had not been made (evidence of drug supply, trafficking, reports of use, treatment data) were mainly from Asia, Africa, the Middle East, and Oceania. Estimates of the prevalence of use were located in 77 countries for meth/amphetamine, 95 for cannabis, 86 for cocaine and 89 for opioids. Dependence prevalence estimates existed in very few countries; 9 meth/amphetamine dependence estimates, 7 cannabis dependence estimates, 5 cocaine dependence estimates, and 25 opioid dependence estimates were located. CONCLUSIONS Data on the extent of meth/amphetamine, cannabis, cocaine and opioid use and dependence must be improved in quality and coverage. Dependence estimates are lacking even in high income countries that have required resources. Responses to illicit drug dependence require better estimates of its scale.
Collapse
Affiliation(s)
- Louisa Degenhardt
- Burnet Research Institute, GPO Box 2284, Melbourne, Victoria 3001, Australia.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Bromet E, Andrade LH, Hwang I, Sampson NA, Alonso J, de Girolamo G, de Graaf R, Demyttenaere K, Hu C, Iwata N, Karam AN, Kaur J, Kostyuchenko S, Lépine JP, Levinson D, Matschinger H, Mora MEM, Browne MO, Posada-Villa J, Viana MC, Williams DR, Kessler RC. Cross-national epidemiology of DSM-IV major depressive episode. BMC Med 2011; 9:90. [PMID: 21791035 PMCID: PMC3163615 DOI: 10.1186/1741-7015-9-90] [Citation(s) in RCA: 1222] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 07/26/2011] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Major depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative. METHODS Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults. RESULTS The average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed. CONCLUSIONS MDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.
Collapse
Affiliation(s)
- Evelyn Bromet
- Department of Psychiatry, State University of New York at Stony Brook, South Campus, Stony Brook, NY 11794-8790, NY, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Alonso J, Vilagut G, Chatterji S, Heeringa S, Schoenbaum M, Üstün TB, Rojas-Farreras S, Angermeyer M, Bromet E, Bruffaerts R, de Girolamo G, Gureje O, Haro JM, Karam AN, Kovess V, Levinson D, Liu Z, Mora MEM, Ormel J, Posada-Villa J, Uda H, Kessler RC. Including information about co-morbidity in estimates of disease burden: results from the World Health Organization World Mental Health Surveys. Psychol Med 2011; 41:873-886. [PMID: 20553636 PMCID: PMC3045479 DOI: 10.1017/s0033291710001212] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The methodology commonly used to estimate disease burden, featuring ratings of severity of individual conditions, has been criticized for ignoring co-morbidity. A methodology that addresses this problem is proposed and illustrated here with data from the World Health Organization World Mental Health Surveys. Although the analysis is based on self-reports about one's own conditions in a community survey, the logic applies equally well to analysis of hypothetical vignettes describing co-morbid condition profiles. METHOD Face-to-face interviews in 13 countries (six developing, nine developed; n=31 067; response rate=69.6%) assessed 10 classes of chronic physical and nine of mental conditions. A visual analog scale (VAS) was used to assess overall perceived health. Multiple regression analysis with interactions for co-morbidity was used to estimate associations of conditions with VAS. Simulation was used to estimate condition-specific effects. RESULTS The best-fitting model included condition main effects and interactions of types by numbers of conditions. Neurological conditions, insomnia and major depression were rated most severe. Adjustment for co-morbidity reduced condition-specific estimates with substantial between-condition variation (0.24-0.70 ratios of condition-specific estimates with and without adjustment for co-morbidity). The societal-level burden rankings were quite different from the individual-level rankings, with the highest societal-level rankings associated with conditions having high prevalence rather than high individual-level severity. CONCLUSIONS Plausible estimates of disorder-specific effects on VAS can be obtained using methods that adjust for co-morbidity. These adjustments substantially influence condition-specific ratings.
Collapse
Affiliation(s)
- Jordi Alonso
- Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM-Hospital del Mar), Barcelona, Spain
- CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Gemma Vilagut
- Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM-Hospital del Mar), Barcelona, Spain
- CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | | | - Steven Heeringa
- University of Michigan, Institute for Social Research, Ann Arbor, MI USA
| | | | | | - Sonia Rojas-Farreras
- Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM-Hospital del Mar), Barcelona, Spain
| | | | - Evelyn Bromet
- State University of New York, Stony Brook, New York, USA
| | | | | | - Oye Gureje
- University College Hospital, Ibadan, Nigeria
| | | | - Aimee N. Karam
- Department of Psychiatry and Clinical Psychology, Saint George Hospital University Medical Center, Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University Medical School, and the Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
| | | | - Daphna Levinson
- Research & Planning, Mental Health Services Ministry of Health, Jerusalem, Israel
| | - Zhaorui Liu
- Institute of Mental Health, Peking University, Beijing, China
| | | | - J. Ormel
- Interdisciplinary Center for Psychiatric Epidemiology, University Medical Center Groningen, The Netherlands
| | | | - Hidenori Uda
- Health, Social Welfare, and Environmental Department, Osumi Regional Promotion Bureau, Kagoshima Prefecture, Japan
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| |
Collapse
|
7
|
Karam EG, Andrews G, Bromet E, Petukhova M, Ruscio AM, Salamoun M, Sampson N, Stein DJ, Alonso J, Andrade LH, Angermeyer M, Demyttenaere K, de Girolamo G, de Graaf R, Florescu S, Gureje O, Kaminer D, Kotov R, Lee S, Lepine JP, Mora MEM, Browne MAO, Posada-Villa J, Sagar R, Shalev AY, Takeshima T, Tomov T, Kessler RC. The role of criterion A2 in the DSM-IV diagnosis of posttraumatic stress disorder. Biol Psychiatry 2010; 68:465-73. [PMID: 20599189 PMCID: PMC3228599 DOI: 10.1016/j.biopsych.2010.04.032] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 04/30/2010] [Accepted: 04/30/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Controversy exists about the utility of DSM-IV posttraumatic stress disorder (PTSD) criterion A2 (A2): that exposure to a potentially traumatic experience (PTE; PTSD criterion A1) is accompanied by intense fear, helplessness, or horror. METHODS Lifetime DSM-IV PTSD was assessed with the Composite International Diagnostic Interview in community surveys of 52,826 respondents across 21 countries in the World Mental Health Surveys. RESULTS Of 28,490 representative PTEs reported by respondents, 37.6% met criterion A2, a proportion higher than the proportions meeting other criteria (B-F; 5.4%-9.6%). Conditional prevalence of meeting all other criteria for a diagnosis of PTSD given a PTE was significantly higher in the presence (9.7%) than absence (.1%) of A2. However, as only 1.4% of respondents who met all other criteria failed A2, the estimated prevalence of PTSD increased only slightly (from 3.64% to 3.69%) when A2 was not required for diagnosis. Posttraumatic stress disorder with or without criterion A2 did not differ in persistence or predicted consequences (subsequent suicidal ideation or secondary disorders) depending on presence-absence of A2. Furthermore, as A2 was by far the most commonly reported symptom of PTSD, initial assessment of A2 would be much less efficient than screening other criteria in quickly ruling out a large proportion of noncases. CONCLUSIONS Removal of A2 from the DSM-IV criterion set would reduce the complexity of diagnosing PTSD, while not substantially increasing the number of people who qualify for diagnosis. Criterion A2 should consequently be reconceptualized as a risk factor for PTSD rather than as a diagnostic requirement.
Collapse
Affiliation(s)
- Elie George Karam
- Department of Psychiatry and Clinical Psychology, Saint George Hospital University Medical Center, Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University Medical School, and the Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
| | - Gavin Andrews
- Department of Psychiatry, University of New South Wales, Sydney, Australia
| | | | - Maria Petukhova
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| | | | - Mariana Salamoun
- Department of Psychiatry and Clinical Psychology, Saint George Hospital University Medical Center, Department of Psychiatry and Clinical Psychology, Faculty of Medicine, Balamand University Medical School, and the Institute for Development, Research, Advocacy and Applied Care (IDRAAC), Beirut, Lebanon
| | - Nancy Sampson
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| | - Dan J. Stein
- Department of Psychiatry, Groote Schuur Hospital, Cape Town, South Africa
| | - Jordi Alonso
- Health Services Research Unit, Institut Municipal d’Investigació Mèdica (IMIM-Hospital del Mar), CIBER en Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Laura Helena Andrade
- Section of Psychiatric Epidemiology- LIM 23 Department and Institute of Psychiatry School of Medicine University of São Paulo São Paulo, Brazil
| | | | - Koen Demyttenaere
- Department of Psychiatry, University Hospital Gasthuisberg, Leuven, Belgium
| | | | - Ron de Graaf
- Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Silvia Florescu
- Public Health Research and Evidence Based Medicine Department, National School of Public Health and Health Services Management, Bucharest, Romania
| | - Oye Gureje
- University College Hospital, Prince of Wales Ibadan, Nigeria
| | - Debra Kaminer
- Department of Psychology, University of Cape Town, South Africa
| | - Roman Kotov
- Department of Psychiatry, Stony Brook University, New York, USA
| | - Sing Lee
- Department of Psychiatry, The Chinese University of Hong Kong, Hong Kong, China
| | - Jean Pierre Lepine
- INSERM U 705, CNRS UMR 7157, University Paris Diderot, Hôpital Lariboisière Fernand Widal, Assistance Publique Hôpitaux de Paris, Paris France
| | | | | | | | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Arieh Y. Shalev
- Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel
| | - Tadashi Takeshima
- National Institute of Mental Health, National Center of Neurology and Psychiatry, Japan
| | - Toma Tomov
- Department of Psychiatry, New Bulgarian University, Sofia, Bulgaria
| | - Ronald C. Kessler
- Department of Health Care Policy, Harvard Medical School, Boston, MA USA
| |
Collapse
|
8
|
de Graaf R, Radovanovic M, van Laar M, Fairman B, Degenhardt L, Aguilar-Gaxiola S, Bruffaerts R, de Girolamo G, Fayyad J, Gureje O, Haro JM, Huang Y, Kostychenko S, Lépine JP, Matschinger H, Mora MEM, Neumark Y, Ormel J, Posada-Villa J, Stein DJ, Tachimori H, Wells JE, Anthony JC. Early cannabis use and estimated risk of later onset of depression spells: Epidemiologic evidence from the population-based World Health Organization World Mental Health Survey Initiative. Am J Epidemiol 2010; 172:149-59. [PMID: 20534820 DOI: 10.1093/aje/kwq096] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Early-onset cannabis use is widespread in many countries and might cause later onset of depression. Sound epidemiologic data across countries are missing. The authors estimated the suspected causal association that links early-onset (age <17 years) cannabis use with later-onset (age > or =17 years) risk of a depression spell, using data on 85,088 subjects from 17 countries participating in the population-based World Health Organization World Mental Health Survey Initiative (2001-2005). In all surveys, multistage household probability samples were evaluated with a fully structured diagnostic interview for assessment of psychiatric conditions. The association between early-onset cannabis use and later risk of a depression spell was studied using conditional logistic regression with local area matching of cases and controls, controlling for sex, age, tobacco use, and other mental health problems. The overall association was modest (controlled for sex and age, risk ratio = 1.5, 95% confidence interval: 1.4, 1.7), was statistically robust in 5 countries, and showed no sex difference. The association did not change appreciably with statistical adjustment for mental health problems, except for childhood conduct problems, which reduced the association to nonsignificance. This study did not allow differentiation of levels of cannabis use; this issue deserves consideration in future research.
Collapse
Affiliation(s)
- Ron de Graaf
- Department of Epidemiology, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Lee S, Tsang A, Kessler RC, Jin R, Sampson N, Andrade L, Karam EG, Mora MEM, Merikangas K, Nakane Y, Popovici DG, Posada-Villa J, Sagar R, Wells JE, Zarkov Z, Petukhova M. Rapid-cycling bipolar disorder: cross-national community study. Br J Psychiatry 2010; 196:217-25. [PMID: 20194545 PMCID: PMC2830056 DOI: 10.1192/bjp.bp.109.067843] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The epidemiology of rapid-cycling bipolar disorder in the community is largely unknown. AIMS To investigate the epidemiological characteristics of rapid-cycling and non-rapid-cycling bipolar disorder in a large cross-national community sample. METHOD The Composite International Diagnostic Interview (CIDI version 3.0) was used to examine the prevalence, severity, comorbidity, impairment, suicidality, sociodemographics, childhood adversity and treatment of rapid-cycling and non-rapid-cycling bipolar disorder in ten countries (n = 54 257). RESULTS The 12-month prevalence of rapid-cycling bipolar disorder was 0.3%. Roughly a third and two-fifths of participants with lifetime and 12-month bipolar disorder respectively met criteria for rapid cycling. Compared with the non-rapid-cycling, rapid-cycling bipolar disorder was associated with younger age at onset, higher persistence, more severe depressive symptoms, greater impairment from depressive symptoms, more out-of-role days from mania/hypomania, more anxiety disorders and an increased likelihood of using health services. Associations regarding childhood, family and other sociodemographic correlates were less clear cut. CONCLUSIONS The community epidemiological profile of rapid-cycling bipolar disorder confirms most but not all current clinically based knowledge about the illness.
Collapse
Affiliation(s)
- Sing Lee
- Hong Kong Mood Disorders Center, Prince of Wales Hospital, Shatin, NT, Hong Kong.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Storr CL, Cheng H, Alonso J, Angermeyer M, Bruffaerts R, de Girolamo G, de Graaf R, Gureje O, Karam EG, Kostyuchenko S, Lee S, Lepine JP, Medina Mora ME, Myer L, Neumark Y, Posada-Villa J, Watanabe M, Wells JE, Kessler RC, Anthony JC. Smoking estimates from around the world: data from the first 17 participating countries in the World Mental Health Survey Consortium. Tob Control 2009; 19:65-74. [PMID: 19965796 DOI: 10.1136/tc.2009.032474] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To contribute new multinational findings on basic descriptive features of smoking and cessation, based upon standardised community surveys of adults residing in seven low-income and middle-income countries and 10 higher-income countries from all regions of the world. METHODS Data were collected using standardised interviews and community probability sample survey methods conducted as part of the WHO World Mental Health Surveys Initiative. Demographic and socioeconomic correlates of smoking are studied using cross-tabulation and logistic regression approaches. Within-country sample weights were applied with variance estimation appropriate for complex sample survey designs. RESULTS Estimated prevalence of smoking experience (history of ever smoking) and current smoking varied across the countries under study. In all but four countries, one out of every four adults currently smoked. In higher-income countries, estimated proportions of former smokers (those who had quit) were roughly double the corresponding estimates for most low-income and middle-income countries. Characteristics of smokers varied within individual countries, and in relation to the World Bank's low-medium-high gradient of economic development. In stark contrast to a sturdy male-female difference in the uptake of smoking seen in each country, there is no consistent sex-associated pattern in the odds of remaining a smoker (versus quitting). CONCLUSION The World Mental Health Surveys estimates complement existing global tobacco monitoring efforts. The observed global diversity of associations with smoking and smoking cessation underscore reasons for implementation of the Framework Convention on Tobacco Control provisions and prompt local adaptation of prevention and control interventions.
Collapse
Affiliation(s)
- Carla L Storr
- Department of Family and Community Health, University of Maryland, Baltimore, School of Nursing, Baltimore, Maryland, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Seedat S, Scott KM, Angermeyer MC, Berglund P, Bromet EJ, Brugha TS, Demyttenaere K, de Girolamo G, Haro JM, Jin R, Karam EG, Kovess-Masfety V, Levinson D, Medina Mora ME, Ono Y, Ormel J, Pennell BE, Posada-Villa J, Sampson NA, Williams D, Kessler RC. Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. ACTA ACUST UNITED AC 2009; 66:785-95. [PMID: 19581570 DOI: 10.1001/archgenpsychiatry.2009.36] [Citation(s) in RCA: 742] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT Gender differences in mental disorders, including more anxiety and mood disorders among women and more externalizing disorders among men, are found consistently in epidemiological surveys. The gender roles hypothesis suggests that these differences narrow as the roles of women and men become more equal. OBJECTIVES To study time-space (cohort-country) variation in gender differences in lifetime DSM-IV mental disorders across cohorts in 15 countries in the World Health Organization World Mental Health Survey Initiative and to determine if this variation is significantly related to time-space variation in female gender role traditionality as measured by aggregate patterns of female education, employment, marital timing, and use of birth control. DESIGN Face-to-face household surveys. SETTING Africa, the Americas, Asia, Europe, the Middle East, and the Pacific. PARTICIPANTS Community-dwelling adults (N = 72,933). MAIN OUTCOME MEASURES The World Health Organization Composite International Diagnostic Interview assessed lifetime prevalence and age at onset of 18 DSM-IV anxiety, mood, externalizing, and substance disorders. Survival analyses estimated time-space variation in female to male odds ratios of these disorders across cohorts defined by the following age ranges: 18 to 34, 35 to 49, 50 to 64, and 65 years and older. Structural equation analysis examined predictive effects of variation in gender role traditionality on these odds ratios. RESULTS In all cohorts and countries, women had more anxiety and mood disorders than men, and men had more externalizing and substance disorders than women. Although gender differences were generally consistent across cohorts, significant narrowing was found in recent cohorts for major depressive disorder and substance disorders. This narrowing was significantly related to temporal (major depressive disorder) and spatial (substance disorders) variation in gender role traditionality. CONCLUSIONS While gender differences in most lifetime mental disorders were fairly stable over the time-space units studied, substantial intercohort narrowing of differences in major depression was found to be related to changes in the traditionality of female gender roles. Additional research is needed to understand why this temporal narrowing was confined to major depression.
Collapse
Affiliation(s)
- Soraya Seedat
- Medical Research Council Research Unit on Anxiety and Stress Disorder, Cape Town, South Africa
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Lara C, Fayyad J, de Graaf R, Kessler RC, Aguilar-Gaxiola S, Angermeyer M, Demytteneare K, de Girolamo G, Haro JM, Jin R, Karam EG, Lépine JP, Mora MEM, Ormel J, Posada-Villa J, Sampson N. Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative. Biol Psychiatry 2009; 65:46-54. [PMID: 19006789 PMCID: PMC2629074 DOI: 10.1016/j.biopsych.2008.10.005] [Citation(s) in RCA: 270] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 09/23/2008] [Accepted: 10/02/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although it is known that childhood attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood, childhood predictors of this persistence have not been widely studied. METHODS Childhood history of ADHD and adult ADHD were assessed in 10 countries in the World Health Organization World Mental Health Surveys. Logistic regression analysis was used to study associations of retrospectively reported childhood risk factors with adult persistence among the 629 adult respondents with childhood ADHD. Risk factors included age; sex; childhood ADHD symptom profiles, severity, and treatment; comorbid child/adolescent DSM-IV disorders; childhood family adversities; and child/adolescent exposure to traumatic events. RESULTS An average of 50% of children with ADHD (range: 32.8%-84.1% across countries) continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to childhood ADHD symptom profile (highest persistence associated with the attentional plus impulsive-hyperactive type, odds ratio [OR]=12.4, compared with the lowest associated with the impulsive-hyperactive type), symptom severity (OR=2.0), comorbid major depressive disorder (MDD; OR=2.2), high comorbidity (>or=3 child/adolescent disorders in addition to ADHD; OR=1.7), paternal (but not maternal) anxiety mood disorder (OR=2.4), and parental antisocial personality disorder (OR=2.2). A multivariate risk profile of these variables significantly predicts persistence of ADHD into adulthood (area under the receiving operator characteristic curve=.76). CONCLUSIONS A substantial proportion of children with ADHD continue to meet full criteria for ADHD as adults. A multivariate risk index comprising variables that can be assessed in adolescence predicts persistence with good accuracy.
Collapse
Affiliation(s)
- Carmen Lara
- Autonomous University of Puebla, Puebla, Mexico
| | - John Fayyad
- Institute for Development, Research, Advocacy, and Applied Care (IDRAAC), St. George Hospital University Medical Center, Beirut, Lebanon
| | - Ron de Graaf
- Netherlands Institute of Mental Health and Addiction, Utrecht, Netherlands
| | - Ronald C. Kessler
- Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States
| | - Sergio Aguilar-Gaxiola
- Center for reducing Health Disparities, University of California, Sacramento, California, United States
| | | | | | | | | | - Robert Jin
- Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States
| | - Elie G. Karam
- Institute for Development, Research, Advocacy, and Applied Care (IDRAAC), St. George Hospital University Medical Center, Beirut, Lebanon
| | | | - Maria Elena Medina Mora
- Division of Epidemiological and Social Research, Mexican Institute of Psychiatry, Mexico City, Mexico
| | - Johan Ormel
- Department of Psychiatry & Department of Epidemiology and Bioinformatics, University Medical Center Groningen; Graduate School of Behavioural and Cognitive Neurosciences & Graduate School for Experimental Psychopathology, University of Groningen, the Netherlands
| | - José Posada-Villa
- Ministry of Social Protection, Colegio Mayor de Cundinamarca University, Bogota, Colombia
| | - Nancy Sampson
- Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States
| |
Collapse
|
13
|
Degenhardt L, Chiu WT, Sampson N, Kessler RC, Anthony JC, Angermeyer M, Bruffaerts R, de Girolamo G, Gureje O, Huang Y, Karam A, Kostyuchenko S, Lepine JP, Mora MEM, Neumark Y, Ormel JH, Pinto-Meza A, Posada-Villa J, Stein DJ, Takeshima T, Wells JE. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: findings from the WHO World Mental Health Surveys. PLoS Med 2008; 5:e141. [PMID: 18597549 PMCID: PMC2443200 DOI: 10.1371/journal.pmed.0050141] [Citation(s) in RCA: 540] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 05/14/2008] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Alcohol, tobacco, and illegal drug use cause considerable morbidity and mortality, but good cross-national epidemiological data are limited. This paper describes such data from the first 17 countries participating in the World Health Organization's (WHO's) World Mental Health (WMH) Survey Initiative. METHODS AND FINDINGS Household surveys with a combined sample size of 85,052 were carried out in the Americas (Colombia, Mexico, United States), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), Middle East and Africa (Israel, Lebanon, Nigeria, South Africa), Asia (Japan, People's Republic of China), and Oceania (New Zealand). The WHO Composite International Diagnostic Interview (CIDI) was used to assess the prevalence and correlates of a wide variety of mental and substance disorders. This paper focuses on lifetime use and age of initiation of tobacco, alcohol, cannabis, and cocaine. Alcohol had been used by most in the Americas, Europe, Japan, and New Zealand, with smaller proportions in the Middle East, Africa, and China. Cannabis use in the US and New Zealand (both 42%) was far higher than in any other country. The US was also an outlier in cocaine use (16%). Males were more likely than females to have used drugs; and a sex-cohort interaction was observed, whereby not only were younger cohorts more likely to use all drugs, but the male-female gap was closing in more recent cohorts. The period of risk for drug initiation also appears to be lengthening longer into adulthood among more recent cohorts. Associations with sociodemographic variables were consistent across countries, as were the curves of incidence of lifetime use. CONCLUSIONS Globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones. Sex differences were consistently documented, but are decreasing in more recent cohorts, who also have higher levels of illegal drug use and extensions in the period of risk for initiation.
Collapse
Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Montano Loza AJ, Ramirez Iglesias MT, Perez Diaz I, Cruz Castellanos S, Garcia Andrade C, Medina Mora ME, Robles Díaz G, Kershenobich D, Gutierrez Reyes G. Association of alcohol-metabolizing genes with alcoholism in a Mexican Indian (Otomi) population. Alcohol 2006; 39:73-9. [PMID: 17134659 DOI: 10.1016/j.alcohol.2006.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 07/07/2006] [Accepted: 07/07/2006] [Indexed: 12/11/2022]
Abstract
Association studies provide a powerful approach to link DNA variants and genetic predisposition to complex diseases. In this study, we determined the genotype and allelic frequencies of genes encoding enzymes involved in alcohol metabolism in alcoholic and nonalcoholic subjects of related ethnicity. A total of 118 individuals of Otomi Mexican Indian ancestry were included. Fifty-nine were chronic alcoholics according to WHO criteria and alcohol dependents according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) criteria. They were compared to 59 teetotalers or alcohol consumers of <10 g per day. The restriction fragment length polymorphisms analyzed were ADH1B/MaeIII, ALDH2/MboII, CYP2E1/DraI, CYP2E1/RsaI, and CYP2E1/TaqI. Of the studied polymorphisms, a significant difference between alcoholic and nonalcoholic Otomies was observed only in the CYP2E1/TaqI. The common genotype in alcoholics was A1/A2 (54%), and in nonalcoholics the homozygous A2/A2 (63%) (odds ratio [OR]: 0.28; 95% confidence interval [CI]: 0.13-0.60; P=.002). The frequency of the mutant allele A1 was significantly higher in alcoholics than in nonalcoholics (41 vs. 21%; OR: 2.4; 95% CI: 1.3-4.3; P=.003). This documents the presence of a polymorphism of CYP2E1 that is overexpressed in alcoholic Otomies, in which the variant allele (A1 of CYP2E1/TaqI) is associated with increased susceptibility to alcoholism. The appreciation that this finding may be an additional factor contributing to the high frequency of liver cirrhosis in Otomies requires further investigation.
Collapse
|