Test-retest reliability of the Spanish version of the Diagnostic Interview Schedule for Children (DISC-IV)

The test-retest reliability of the Spanish Diagnostic Interview Schedule for Children (DISC-IV) is presented. This version was developed in Puerto Rico in consultation with an international bilingual committee, sponsored by NIMH. The sample (N = 146) consisted of children recruited from outpatient mental health clinics and a drug residential treatment facility. Two different pairs of nonclinicians administered the DISC twice to the parent and child respondents. Results indicated fair to moderate agreement for parent reports on most diagnoses. Relatively similar agreement levels were observed for last month and last year time frames. Surprisingly, the inclusion of impairment as a criterion for diagnosis did not substantially change the pattern of results for specific disorders. Parents were more reliable when reporting on diagnoses of younger (4-10) than older children. Children 11-17 years old were reliable informants on disruptive and substance abuse/dependence disorders, but unreliable for anxiety and depressive disorders. Hence, parents were more reliable when reporting about anxiety and depressive disorders whereas children were more reliable than their parents when reporting about disruptive and substance disorders.

The effect of lead exposure on behavior problems in preschool children

OBJECTIVES

Interpreting associations between lead exposure and child behavior problems is difficult because studies have not controlled for sociodemographic confounders or have used shed teeth to mark exposure. This study explored associations between blood lead and preschool behavior.

METHODS

Children from a smelter town and a non-lead-exposed town in Yugoslavia were followed up prospectively from pregnancy through age 3. The Child Behavior Checklist was used to assess behavior problems in 379 3-year-olds, controlling for sociodemographic factors and difficult infant temperament.

RESULTS

Multiple regression revealed the expected significant associations between checklist subscales and sociodemographic factors, which explained 7% to 18% of the variance on the subscales. Concurrent blood lead explained a significant 1% to 4% of the variance on the Destructive and Withdrawn subscales. Earlier difficult temperament explained an additional 2% to 5% of the checklist variance. Scores on the Destructive subscale were consistently associated with blood lead. As blood lead increased from 10 to 20 micrograms/dL, subscale scores increased by approximately 0.5 points.

CONCLUSIONS

Lead/behavior associations are significant but small compared with the effects of social factors.

Major depressive disorder in the 6 months after miscarriage

OBJECTIVE

To test a priori hypotheses that miscarrying women are at increased risk for a first or recurrent episode of major depressive disorder in the 6 months following loss and that this increased risk is greater for childless women, women with prior reproductive loss, and women aged 35 years or older; and to evaluate whether risk varies by time of gestation or by attitude toward the pregnancy.

DESIGN

Cohort study.

SETTING

The miscarriage cohort consisted of women attending a medical center for a spontaneous abortion (n=229); the comparison group was a population-based cohort of women drawn from the community (n=230).

PARTICIPANTS

Miscarriage was defined as the involuntary termination of a nonviable intrauterine pregnancy before 28 completed weeks of gestation. Half of all participants were between 25 and 34 years of age; 40% were white and 35% Hispanic; 55% had more than a high school education. Participants constituted 60% of miscarrying women and 72% of community women who completed the first phase of this cohort study.

MAIN OUTCOME MEASURE

Major depressive disorder was measured using the Diagnostic Interview Schedule.

RESULTS

Risk for an episode of major depressive disorder among miscarrying women in the 6 months following loss was compared with the 6-month risk among community women who had not been pregnant in the preceding year. Among miscarrying women, 10.9% experienced an episode of major depressive disorder, compared with 4.3% of community women. The overall relative risk (RR) for an episode of major depressive disorder for miscarrying women was 2.5 (95% confidence interval [CI], 1.2-5.1) and was substantially higher for childless women (RR, 5.0; 95% CI, 1.7-14.4) than for women with children (RR, 1.3; 95% CI, 0.5-3.5) (P<.06). Among miscarrying women, 72% of cases of major depressive disorder began within the first month after loss; only 20% of community cases started during the comparable period. Among miscarrying women with a history of major depressive disorder, 54% experienced a recurrence. However, RR did not vary significantly by history of prior reproductive loss or by maternal age, nor did risk vary by time of gestation or attitude toward the pregnancy.

CONCLUSIONS

Physicians should monitor miscarrying women in the first weeks after reproductive loss, particularly women who are childless or who have a history of major depressive disorder. Where appropriate, supportive counseling or psychopharmacologic treatment should be considered.

Association of stressful life events with chromosomally normal spontaneous abortion

Spontaneous abortion is the most common adverse reproductive outcome. Despite evidence that negative life events increase risk for a number of medical disorders, their role in pregnancy disruption has not been investigated. The present study tested an a priori hypothesis that recent negative life events increase the odds of spontaneous abortion of a chromosomally normal conceptus. Between 1984 and 1986, 192 women aged 18-42 years who visited a medical center after spontaneous abortion were interviewed about positive and negative events that had occurred in the 4-5 months preceding the loss. Subsequently, women with chromosomally normal (n = 111) and chromosomally abnormal (n = 81) losses were identified on the basis of tissue culture after interview. The women with chromosomally abnormal loss provided an estimate of the expected frequency of life events against which to compare the event frequencies of women with chromosomally normal loss. Analyses were adjusted for duration of the recall period, payment status, maternal age, education, and ethnicity. Seventy percent of the women with chromosomally normal losses reported having had one or more negative life events in the months preceding loss, compared with 52% of the women with chromosomally abnormal losses (adjusted odds ratio = 2.6, 95% confidence interval (CI) 1.3-5.2). For private patients (n = 69), the adjusted odds ratio was 4.2 (95% CI 1.3-13.4); for public patients (n = 123), it was 1.9 (95% CI 0.8-4.8). The associations held for postconception events alone and were absent for positive events. Results were unaltered by adjustment for smoking, caffeine intake, and alcohol consumption. With recall bias precluded by the study design, the strength, timing, and specificity of these associations suggest that recent negative life events play a role in chromosomally normal spontaneous abortion. Efforts to replicate these results and to elucidate underlying biologic mechanisms are required.

Psychometric properties of parents and children as informants in child psychiatry epidemiology with the Spanish Diagnostic Interview Schedule for Children (DISC.2)

Parent and child reports were examined to study how epidemiological researchers can best use the information provided to describe childhood psychopathology. As part of a multisite methodologic study of mental disorders in children, a probability sample (N = 248) of children aged 9 to 17 years from the San Juan metropolitan area was selected. This sample was enriched with 74 clinic cases. Both parents and children were administered the DISC.2. Results showed that prevalence estimates were influenced by the informant. The clinicians' diagnosis is more concordant with children's reports of depression and with parents' reports of disruptive disorders. Parents and children provided unique information when interviewed with a structured psychiatric interview about child psychopathology. Their unique perspectives contributed to the observed discordance that emerged when DISC parent and DISC child results are compared. Combining the two perspectives with a simple "OR" rule at the symptom level did not seem to capture the unique perspectives.

Symptom profiles and homelessness in schizophrenia

One hundred homeless schizophrenic men and 100 never homeless schizophrenic men were compared in terms of symptom ratings on the Positive and Negative Syndrome Scale (PANSS), which yields a positive, negative, and general psychopathology scale score, as well as evaluated on a number of other variables. The homeless group obtained significantly higher ratings on the PANSS positive and general psychopathology scales, but the two groups did not differ on the PANSS negative scale score. When symptom patterns for subsets of patients who did not abuse illicit substances or alcohol (N = 23 for homeless, N = 56 for nonhomeless) and who were compliant with medication (N = 63 for homeless, N = 82 for nonhomeless) were examined, the higher ratings on the positive and general psychopathology scales failed to achieve statistical significance, while the absence of between-group differences on the negative scale was maintained. Our results suggest that severity of positive and general psychopathology symptoms, but not of negative symptoms, predicts homelessness in schizophrenia and that illicit substance abuse and neuroleptic noncompliance contributed, at least in part, to our higher positive and general psychopathology symptom ratings in the homeless sample. Our findings underscore the need to undertake prospective longitudinal studies to unravel the multifactorial etiology of homelessness in schizophrenia.

Drug abuse and illicit drug use in Puerto Rico

OBJECTIVES

Based on an epidemiologic field survey of community households in Puerto Rico, this study estimates the frequency of illicit drug use and clinically defined drug abuse and/or dependence syndromes. Results are compared with those from surveys on the United States mainland. Suspected risk factors are studied as well, with a special focus on childhood misbehavior.

METHODS

Trained lay interviewers administered a Spanish Diagnostic Interview Schedule to 912 respondents aged 17 to 68 years who were selected by multistage probability sampling of island households.

RESULTS

An estimated 8.2% of the population had a history of illicit drug use and 1.2% qualified for a standardized lifetime diagnosis of drug abuse, dependence, or both. An estimated 18.4% of the male drug users and 7.7% of the female drug users met criteria for drug abuse and/or dependence. A history of drug use was related to the diagnoses of alcohol abuse and/or dependence and antisocial personality, but few persons who had used illicit drugs at least once in their lifetime reported a history of receiving treatment for alcohol, drug, or mental health problems.

CONCLUSIONS

The data were consistent with a suspected association between level of childhood misbehavior and occurrence of illicit drug use, even after statistical control for potentially confounding variables.

Determinants of depressive symptoms in the early weeks after miscarriage

OBJECTIVES

We tested whether and under what conditions miscarriage increases depressive symptoms in the early weeks following loss.

METHODS

We interviewed 232 women within 4 weeks of miscarriage and 283 pregnant women and 318 community women who had not recently been pregnant. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression (CES-D) Scale.

RESULTS

Among women who had miscarried, the proportion who were highly symptomatic on the CES-D was 3.4 times that of pregnant women and 4.3 times that of community women. Among childless women, the proportion of women who had miscarried who were highly symptomatic was 5.7 times that of pregnant women and 11.0 times that of community women. Women who had miscarried were equally depressed regardless of length of gestation; among pregnant women, depressive symptoms declined with length of gestation. Among women who had miscarried, symptom levels did not vary with attitude toward the pregnancy; among pregnant women, depressive symptoms were elevated in those with unwanted pregnancies. Prior reproductive loss and advanced maternal age (35+ years) were not associated with symptom levels in any cohort.

CONCLUSIONS

Depressive symptoms are markedly increased in the early weeks following miscarriage. This effect is substantially modified by number of living children, length of gestation at loss, and attitude toward pregnancy.

Depressive symptoms in women in the six months after miscarriage

This study, the first systematic investigation of the psychiatric impact of miscarriage, tests whether miscarriage markedly increases depressive symptoms in the 6 months after loss. We interviewed 382 miscarrying women entering the study at 2 weeks, 6 weeks, or 6 months after loss and, for comparison, 283 pregnant women and 318 community women not recently pregnant. Among women interviewed 2 weeks after miscarriage the proportion highly symptomatic on the Center for Epidemiologic Studies-Depression scale was 3.4 times that of pregnant women (95% confidence limits 2.0 and 5.0) and 4.3 times that of community women (95% confidence limits 3.0 and 5.8). Among women first interviewed 6 weeks and 6 months after miscarriage the proportion highly symptomatic was three times that of the community women. Women reinterviewed at 6 weeks and 6 months did not have elevated symptom levels, a result attributed to the unintended therapeutic and test effects of study interviews. Interviews were fully structured, readily administered by telephone by nonmedical personnel. The possibility that such interviews afford miscarrying women substantial psychologic benefits merits future investigation.

A prospective study of birthweight and length of gestation in a population surrounding a lead smelter in Kosovo, Yugoslavia

This paper tests the hypothesis that exposure to lead during pregnancy is associated with reduced intrauterine growth and an increase in preterm delivery. The sample comprises women, recruited at mid-pregnancy, residing in Titova Mitrovica, a lead smelter town, or in Pristina, a non-exposed town 25 miles away. Both towns are in the province of Kosovo, Yugoslavia. Mean blood lead concentrations (BPb's) at mid-pregnancy were 0.92 mumol/L (+/- 0.38, N = 401) in the exposed town and 0.27 mumol/L (+/- 0.09, N = 506) in the comparison town. No differences were found between towns for either birthweight or length of gestation. Mean birthweight was 3308 (+/- 566) grams in Titova Mitrovica and 3361 (+/- 525) grams in Pristina. Mean length of gestation was 274 (+/- 18.8) days in Titova Mitrovica and 275 (+/- 15.6) days in Pristina. After adjustment for the effects of potential confounders, no significant relationships were found between maternal BPb measured at mid-pregnancy, at delivery or in the umbilical cord and either birthweight, length of gestation, or preterm delivery (less than 37 weeks). We conclude that exposure to environmental lead does not impair fetal growth or influence length of gestation.

Determinants of elevated blood lead during pregnancy in a population surrounding a lead smelter in Kosovo, Yugoslavia

We are prospectively examining the relation between environmental lead exposure and pregnancy outcome in cohorts of women exposed to a wide range of air lead concentrations. Titova Mitrovica, Yugoslavia, is the site of a large lead smelter, refinery, and battery factory. At midpregnancy, 602 women in T. Mitrovica and 900 women in Pristina, a non-lead-exposed control town, were interviewed. Blood was obtained for blood lead (PbB), hemoglobin, erythrocyte protoporphyrin, and serum ferritin measurements. Women were seen again at delivery, at which time maternal and umbilical cord blood samples were obtained. While many demographic and social characteristics were similar across the two towns, women in Pristina were more likely to report employment outside the home, cigarette smoking, and alcohol use during pregnancy. As expected, PbB levels were substantially higher in the smelter town. At midpregnancy, PbB geometric means were 17.1 micrograms/dL in T. Mitrovica and 5.1 micrograms/dL in Pristina; 86% of the pregnant women in T. Mitrovica, compared to 3.4% of those in Pristina, had PbB levels greater than 10 micrograms/dL. Within T. Mitrovica, distance between the home and the smelter was the most important predictor of PbB at mid-pregnancy and delivery. Husband's employment in the lead industry was associated with a significant increase in maternal PbB levels independent of place of residence. Higher maternal serum ferritin concentrations were associated with lower PbB levels, suggesting that dietary iron inhibits lead absorption. Overall, the placenta was a poor barrier to lead; the relationship between maternal PbB and umbilical cord PbB was linear across a wide range of PbB levels.

Validity of the 'Ten Questions' for screening serious childhood disability: results from urban Bangladesh

A survey of 2576 children aged two to nine years was carried out in Dhaka, Bangladesh, as part of a collaborative study to test the validity of a questionnaire (the Ten Questions) for screening severe childhood disabilities in community settings. Approximately 7% of the children were positive on the screen and this rate was slightly higher in boys than girls. The sensitivity, specificity and negative predictive value of the Ten Questions were perfect or nearly perfect for severe and moderate (serious) disabilities. The positive predictive value was only 22% for serious disabilities, but 70% of children classified as false positives were found to have mild disabilities or other conditions (such as ear infections) for which early detection and treatment could be beneficial. No major age or gender differences in the validity of the questionnaire were apparent, but this finding needs additional study and confirmation with studies based on larger samples. In general, the results indicate that the Ten Questions is a valid tool for screening serious disabilities in children and can potentially improve the efficiency of health services by reducing the number of children requiring attention from professionals. Future studies using the Ten Questions should foster greater attention to the dimensions of childhood disability as a public health problem in the less developed world.

Past pregnancy outcomes among women living in the vicinity of a lead smelter in Kosovo, Yugoslavia

This analysis compares the rates of spontaneous abortion among women living in the vicinity of a lead smelter with those of women living in a town where blood lead levels were low. Data derive from the obstetric histories of both groups of women obtained while seeking prenatal care for a later pregnancy. A total of 639 women (304 exposed, 335 unexposed) had at least one previous pregnancy and lived at the same address since their first pregnancy. The geometric mean blood lead concentrations in the sample at the time of the interviews were 0.77 mumol/L in the exposed town and 0.25 mumol/L in the unexposed town. The rates of spontaneous abortions in first pregnancies were similar, with 16.4 percent of women in the exposed town and 14.0 percent in the unexposed town reporting loss. The adjusted odds ratio relating town of residence to spontaneous abortion was 1.1 (95% CI = 0.9, 1.4). This analysis represents the first systematic attempt to seek an association between environmental lead exposure and spontaneous abortion. As such, the failure to find a positive association strongly suggests that at the levels of exposure represented in our sample, such an association does not exist.

Use of the Mini-mental State Examination in a probability sample of a Hispanic population

The Spanish DIS was applied to a community probability sample in an island-wide survey of the prevalence of psychiatric disorders in Puerto Rico. The prevalence of "severe cognitive impairment" as measured by the DIS Mini-mental State Examination (DIS/MMSE) is significantly higher than that reported in similar studies in US communities. The total sample (N = 1532) was used to study the impact of demographic variables and other psychiatric diagnoses on DIS/MMSE scores. Educational level was by far the strongest predictor of total scores as well as of scores on individual items. Issues are discussed and recommendations are made related to the use of this test in Hispanic populations of low educational level.

Maternal smoking and trisomy among spontaneously aborted conceptions

In a study of spontaneous abortions, we found an apparently robust association of trisomy with smoking that varies with maternal age. Among women under age 30, smoking either before or at the time of conception is less common in women aborting trisomic conceptions than in controls delivering at 28 weeks or later. Among older women, smoking is more common in women aborting trisomic conceptions than in controls. Our results point to an effect of smoking on the frequency of trisomic abortions that varies with age, and they suggest that the causes of recognized trisomic abortions differ in younger and older women.

The impact of psychiatric intervention on patients with uncontrolled seizures

There is much evidence that emotional stess can trigger both neurogenic and hysterical seizures in susceptible patients. We reviewed out experience with 37 patients whose seizures appeared to be precipitated at times by emotional stress and had not been controlled by anticonvulsant medication alone. Approximately 70 per cent of patients demonstrated substantial improvement in seizure control after psychiatric treatment and maintained this improvement during follow-up. The findings of this study suggest that patient characteristics associated with better prognosis include normal intelligence, partial (as opposed to generalized) neurogenic seizures, a diagnosis of hysterical seizures, a less severely abnormal EEG, and being hypnotizable. After psychiatric treatment, 32 per cent of patients had their anticonvulsant medication reduced and another 16 per cent had it discontinued.