Multi-ancestry genome-wide association study of major depression aids locus discovery, fine mapping, gene prioritization and causal inference

Most genome-wide association studies (GWAS) of major depression (MD) have been conducted in samples of European ancestry. Here we report a multi-ancestry GWAS of MD, adding data from 21 cohorts with 88,316 MD cases and 902,757 controls to previously reported data. This analysis used a range of measures to define MD and included samples of African (36% of effective sample size), East Asian (26%) and South Asian (6%) ancestry and Hispanic/Latin American participants (32%). The multi-ancestry GWAS identified 53 significantly associated novel loci. For loci from GWAS in European ancestry samples, fewer than expected were transferable to other ancestry groups. Fine mapping benefited from additional sample diversity. A transcriptome-wide association study identified 205 significantly associated novel genes. These findings suggest that, for MD, increasing ancestral and global diversity in genetic studies may be particularly important to ensure discovery of core genes and inform about transferability of findings.

Psychiatric comorbidity in the Baltimore ECA follow-up study: the matrix approach

BACKGROUND

Psychiatric comorbidity is defined as the joint occurrence of two or more mental or substance use disorders. Widespread psychiatric comorbidity has been reported in treatment and population-based studies. The aim of this study was to measure the extent and impact of psychiatric comorbidity in a cohort of the Baltimore Epidemiologic Catchment Area study.

METHODS

We examined the comorbidity burden of 16 mental disorders in a cohort of 847 participants using both established and novel analytical approaches The Comorbidity to Diagnosis Inflation Ratio (CDIR), is a statistical instrument that quantifies impact of pairwise comorbid associations, both on the whole sample, as well as on each specific disorder.

RESULTS

Most anxiety disorders had substantial co-occurrence with each other, as well as with Major Depressive Disorder (MDD). In addition, mood disorders had a high degree of comorbidity with Alcohol Dependence (AD). The CDIR for the whole sample was 1.32, indicating a ratio of 132 comorbidities per 100 diagnoses. The conditions with high sample prevalence were relatively less comorbid than the low prevalence conditions. Obsessive Compulsive Disorder had a comorbidity burden that was 89% greater than the overall sample.

CONCLUSION

Anxiety disorders are highly interrelated, as well as highly comorbid with depression. The comorbidity phenomenon is linked to the differential prevalence of the analyzed conditions. Comorbidity frequency (most prevalent comorbid condition) appears mutually exclusive to comorbidity burden (most widely interrelated condition). While AD and MDD were the most frequently diagnosed disorders; low prevalence conditions as OCD and GAD were the most widely interrelated.

Genetic propensity for risky behavior and depression and risk of lifetime suicide attempt among urban African Americans in adolescence and young adulthood

Suicide attempts (SA) among African Americans have increased at a greater rate than any other racial/ethnic group. Research in European ancestry populations has indicated that SA are genetically influenced; however, less is known about the genetic contributors that underpin SA among African Americans. We examined whether genetic propensity for depression and risky behaviors (assessed via polygenic risk scores; PRS) independently and jointly are associated with SA among urban, African Americans and whether sex differences exist in these relations. Participants (N = 1,157, 45.0% male) were originally recruited as part of two first grade universal school-based prevention trials. Participants reported in adolescence and young adulthood on whether they ever attempted suicide in their life. Depression and risky behaviors PRS were created based on large-scale genome-wide association studies conducted by Howard et al. (2019) and Karlson Línner et al. (2019), respectively. There was a significant interaction between the risky behavior PRS and depression PRS such that the combination of high risky behavior polygenic risk and low/moderate polygenic risk for depression was associated with greater risk for lifetime SA among the whole sample and African American males specifically. In addition, the risky behavior PRS was significantly positively associated with lifetime SA among African American males. These findings provide preliminary evidence regarding the importance of examining risky behavior and depression polygenic risk in relation to SA among African Americans, though replication of our findings in other African American samples is needed.

Prescription opioid use among individuals with serious mental illness

Prevalence and correlates of prescription opioid use were explored in individuals with serious mental illness (SMI) by examining a sample of adults from two inner city community psychiatry clinics. Of 271 participants, 12.9% (n = 35) were on a prescribed opioid. Being on an opioid was significantly associated with history of heroin use and active prescription sedative-hypnotic use, including benzodiazepine use. Concurrent use of opioids with sedative-hypnotics was significantly associated with suicidal ideation. The results highlight risks of prescription opioid use in those with SMI, particularly in combination with prescription sedative-hypnotics.

Delays in Seeking General Medical Services and Measurable Abnormalities Among Individuals With Serious Mental Illness

OBJECTIVE

The study explored the association of delays in seeking general medical care with elevated blood pressure and metabolic abnormalities among individuals with serious mental illness.

METHODS

Association of delays in medical care with blood pressure, serum hemoglobin A1c (HbA1C), and lipids was assessed among patients at two inner-city community mental health centers.

RESULTS

Of 271 participants, 62% reported delays in seeking general medical care due to attitudinal and financial barriers. Care delay was associated with abnormalities in measured blood pressure (adjusted odds ratio [AOR]=2.14, p=.029) and HbA1c (AOR=3.18, p=.026). Care delay was not associated with abnormalities in lipid profiles.

CONCLUSIONS

This study found that delays in seeking general medical care are common and are associated with clinical markers linked with common medical conditions. The results may help to explain the elevated morbidity and mortality associated with serious mental illness.

Reduction of plasma glutathione in psychosis associated with schizophrenia and bipolar disorder in translational psychiatry

The establishment of mechanism-driven peripheral markers is important for translational psychiatry. Many groups, including ours, have addressed molecular alterations in peripheral tissues in association with symptomatic changes in major illnesses. Oxidative stress is implicated in the pathophysiology of schizophrenia (SZ) and bipolar disorder (BP) through studies of patient peripheral tissues and animal models. Although the relationship between peripheral changes and brain pathology remain elusive, oxidative stress may bridge such translational efforts. Nonetheless, the molecular substrates of oxidative stress are not well defined in mental conditions. Glutathione (GSH) is a non-enzymatic antioxidant that eliminates free radicals, and has been suggested to have a role in SZ. We performed a cross-sectional study of 48 healthy controls (CON), 52 SZ patients and 62 BP patients to compare the levels of peripheral GSH by a biochemical enzyme assay. We show a significant reduction of plasma GSH in both SZ and BP patients compared with CON. We evaluated possible influences of clinical characteristics on the level of GSH in SZ and BP. A decrease in GSH level correlated with Positive and Negative Syndrome Scale (PANSS) total and positive scores for SZ and correlated with the PANSS general for BP. Taken together, we provide evidence that SZ and BP display a common molecular signature in the reduction of peripheral GSH in the psychosis dimension.

Occupations and the prevalence of major depressive episode in the National Survey on Drug Use and Health

OBJECTIVE

This study explores the relationship of occupations to major depressive episode (MDE).

METHOD

National Survey on Drug Use and Health (NSDUH) data from the civilian noninstitutionalized United States population are analyzed regarding mental illnesses, employment, and specific occupations and industries. This analysis uses combined 2005 to 2014 NSDUH data, comprising a sample of 433,000 adults aged 18 to 64 years old, of whom 22,700 were both employed and had experienced an MDE in the past year.

RESULTS

The findings focus on 30 occupations with the highest prevalence of MDE (greater than 9.0%). There is no simple overarching concept that describes these occupations, although common factors suggest hypotheses about the relationship of occupation to depression.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

The findings suggest the possibility of prioritizing available preventive and treatment interventions to occupational settings with the highest prevalence of MDE. (PsycINFO Database Record

Vascular Disease and Trajectories of Late-life Major Depressive Disorder in Secondary Psychiatric Care

Objectives

To examine 5 years trajectories of secondary-treated late-life major depressive disorder (MDD), and evaluate whether pre-existing cerebrovascular disease and related risk factors are associated with more severe trajectories of late-life MDD.

Methods

Data were obtained from Danish registers. The sample included 11,184 adults ≥ 60 at index MDD diagnosis. Trajectories of in or outpatient contact at psychiatric hospitals for MDD over the 5 years period following index MDD diagnosis were modeled using latent class growth analysis. Risk factors included cerebrovascular disease, cardiovascular disease, hypertension, diabetes, and vascular dementia defined based on hospital diagnoses and prescription medications, demographic characteristics and characteristics of the index MDD diagnosis.

Results

The final model included classes with consistently low (66%), high decreasing (19%), consistently high (9%) and moderate fluctuating (6%) probabilities of contact at a psychiatric hospital for MDD during the 5 year period following the index MDD diagnosis (Fig. 1). Older age, greater severity, inpatient treatment and > 12 antidepressant prescriptions within 5 years of the index MDD diagnosis predicted membership in more severe trajectory classes. Cerebrovascular disease and related risk factors were not associated with trajectory class membership.

Conclusions

A substantial proportion (34%) of individuals diagnosed with MDD in late-life require specialized psychiatric treatment for extended periods of time. We found no evidence that cerebrovascular disease or related risk factors predicted course trajectories in secondary-treated late-life MDD.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Mental health and psychosocial support in humanitarian settings: a public mental health perspective

AIMS

To discuss the potential usefulness of a public health approach for 'mental health and psychosocial support' (MHPSS) interventions in humanitarian settings.

METHODS

Building on public mental health terminology in accordance with recent literature on this topic and considering existing international consensus guidelines on MHPSS interventions in humanitarian settings, this paper reflects on the relevance of the language of promotion and prevention for supporting the rationale, design and evaluation of interventions, with a particular focus on populations affected by disasters and conflicts in low- and middle-income countries.

RESULTS

A public mental health approach and associated terminology can form a useful framework in the design and evaluation of MHPSS interventions, and may contribute to reducing a divisive split between 'mental health' and 'psychosocial' practice in the humanitarian field. Many of the most commonly implemented MHPSS interventions in humanitarian settings can be described in terms of promotion and prevention terminology.

CONCLUSIONS

The use of a common terminology across health, protection, education, nutrition and other relevant sectors providing humanitarian interventions has the potential to allow for integration of MHPSS activities in one overall framework, with diverse humanitarian practitioners working to achieve a common goal.

Gluten sensitivity and relationship to psychiatric symptoms in people with schizophrenia

The relationship between gluten sensitivity and schizophrenia has been of increasing interest and novel mechanisms explaining this relationship continue to be described. Our study in 100 people with schizophrenia compared to 100 matched controls replicates a higher prevalence of gluten sensitivity and higher mean antigliadin IgG antibody levels schizophrenia (2.9 ± 7.7 vs. 1.3 ± 1.3, p = 0.046, controlled for age). Additionally, we examined symptoms within the schizophrenia group and found that while positive symptoms are significantly lower in people who have elevated antigliadin antibodies (AGA; 4.11 ± 1.36 vs. 6.39 ± 2.99, p = 0.020), no robust clinical profile differentiates between positive and negative antibody groups. Thus, identifying people in schizophrenia who may benefit from a gluten-free diet remains possible by blood test only.

Turning points and lessons learned: stressful life events and personality trait development across middle adulthood

The present research examined stressful life events and personality development across middle adulthood. Participants (N = 533) related the most stressful event they had experienced within the last 10 years, indicated whether they considered the event to be a turning point and/or lesson learned, and twice completed a comprehensive measure of traits defined by the five-factor model of personality; the stressful event occurred between these two assessments. Descriptions were coded to classify events into broad content domains based on the nature of the event. Prospectively, individuals high in Neuroticism perceived the event as a turning point; extraverts learned a lesson from it. Longitudinally, perceiving the event as a negative turning point was associated with increases in Neuroticism, whereas learning a lesson from the event was associated with increases in Extraversion and Conscientiousness. Characteristics of the events themselves were primarily unrelated to trait change. Across middle adulthood, personality trait change may be more strongly related to how individuals understand the stressful events in their lives rather than simply the occurrence of such events.

Perceptions of stressful life events as turning points are associated with self-rated health and psychological distress

We test the hypothesis that changes in physical and psychological health are associated with construals of stressful life events. At two points in time, approximately 10 years apart, participants (n=1038) rated their physical health and psychological distress. At the second assessment, participants also reported their most stressful life event since the first assessment and indicated whether they considered the event a turning point and/or lesson learned. Lower self-ratings of health and higher ratings of psychological distress, controlling for baseline health and distress, and relevant demographic factors, were associated with perceiving the stressful life event as a turning point, particularly a negative turning point. The two health measures were primarily unrelated to lessons learned. How individuals construe the most stressful events in their lives are associated with changes in self-rated health and distress.

Maternal thyroid autoantibodies during the third trimester and hearing deficits in children: an epidemiologic assessment

Elevated maternal thyroid autoantibodies during pregnancy are linked to infertility, miscarriage, and neurodevelopmental deficits such as in cognitive function. It has not been established whether autoantibodies to thyroid peroxidase are associated with sensorineural hearing loss (SNHL). The authors tested stored third-trimester maternal serum specimens of 1,736 children for thyroid peroxidase autoantibodies (TPOaAb) by using an enzyme-linked immunosorbent assay technique. The children participated at the Baltimore, Maryland, site of the Collaborative Perinatal Project, which enrolled pregnant women in 1959-1965. An audiology examination was administered to the children at 8 years of age and was used to identify cases of SNHL. Compared with 4.3% of the other children, 22.7% of the children whose mothers had elevated TPOaAb (> or =62.5 IU/ml) had SNHL. The difference was significant after controlling for maternal race, age, and hypothyroidism (exact prevalence odds ratio = 7.5, 95% confidence interval: 2.4, 23.3). When a lower cutoff of TPOaAb > or =31.25 IU/ml was used, there continued to be an association with SNHL (exact prevalence odds ratio = 5.7, 95% confidence interval: 2.1, 15.6). The direction and magnitude of the association were similar when an alternative case definition of SNHL was used. These data suggest that antenatal exposure to maternal TPOaAb during the third trimester of pregnancy is associated with impaired auditory development.

Migraine headaches are not associated with a unique depressive symptom profile: results from the Baltimore Epidemiologic Catchment Area Study

OBJECTIVE

There is a well-established link between migraine headaches and depression. However, it is unclear whether individuals with migraine experience a unique profile of depressive symptoms in comparison to individuals without migraine.

METHODS

This question was addressed using data from the Baltimore cohort of the Epidemiologic Catchment Area Study. The cross-sectional association between migraine headaches and each depressive symptom was calculated using logistic regression, and symptom profiles among those with migraine headaches (n=249) and those without (n=1480) were compared using generalized estimating equations.

RESULTS

Migraine headaches were associated with increased odds of reporting seven of nine depressive symptom groups by a factor of roughly 2. However, when the symptom profiles were compared, individuals with migraine headaches did not differ in their profile of symptoms.

CONCLUSION

These results suggest that individuals with migraine headaches are more likely to report depressive symptoms but do not display a unique profile of symptoms.

Psychiatrists' ascertained treatment needs for mental disorders in a population-based sample

OBJECTIVE

Population-based studies of prevalence have been used to approximate the amount of need for treatment of mental disorders. This study aimed to estimate need for treatment of alcohol dependence, major depression, panic disorder, agoraphobia, and social phobia.

METHODS

Psychiatrists used the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) to assess individuals in a probability sample of the Baltimore Epidemiologic Catchment Area follow-up study for need for and use of mental health services. Population-based estimates were calculated with probability weights.

RESULTS

The SCAN sample included 816 participants who were interviewed between 1993 and 1999. Prevalence of need for mental health services in the general population was 28.7%+/-2.7%. Among the disorders studied, the greatest need was for treatment of alcohol dependence; 90% of the SCAN sample who met criteria for this diagnosis, or 13.6%+/-1.9% of the population, needed treatment. In the general population, 10.5%+/-2.1% needed treatment for major depression; 5.2%+/-.9%, for social phobia; 5.2%+/-1.6%, for panic disorder; and 3.2%+/-.9%, for agoraphobia. The highest needs for specific treatment modalities were self-help groups for alcohol dependence, talk therapy for depression, behavior modification for social phobia and agoraphobia, and antidepressant medications for panic disorder. Overall, less than 33% of needs were met. Social phobia and alcohol dependence were the two disorders with the highest proportion of unmet need.

CONCLUSIONS

Prevalence of mental disorders is only an approximation of the need for treatment. There is a substantial need for mental health services in the general population. Most individuals who would benefit from treatment are not receiving any type of mental health services.

The gluten connection: the association between schizophrenia and celiac disease

OBJECTIVE

Schizophrenia affects roughly 1% of the population and is considered one of the top 10 causes of disability worldwide. Given the immense cost to society, successful treatment options are imperative. Based on initial findings, gluten withdrawal may serve as a safe and economical alternative for the reduction of symptoms in a subset of patients.

METHOD

A review of the literature relevant to the association between schizophrenia and celiac disease (gluten intolerance) was conducted.

RESULTS

A drastic reduction, if not full remission, of schizophrenic symptoms after initiation of gluten withdrawal has been noted in a variety of studies. However, this occurs only in a subset of schizophrenic patients.

CONCLUSION

Large-scale epidemiological studies and clinical trials are needed to confirm the association between gluten and schizophrenia, and address the underlying mechanisms by which this association occurs.

Socioeconomic inequalities in depression: a meta-analysis

Low socioeconomic status (SES) is generally associated with high psychiatric morbidity, more disability, and poorer access to health care. Among psychiatric disorders, depression exhibits a more controversial association with SES. The authors carried out a meta-analysis to evaluate the magnitude, shape, and modifiers of such an association. The search found 51 prevalence studies, five incidence studies, and four persistence studies meeting the criteria. A random effects model was applied to the odds ratio of the lowest SES group compared with the highest, and meta-regression was used to assess the dose-response relation and the influence of covariates. Results indicated that low-SES individuals had higher odds of being depressed (odds ratio = 1.81, p < 0.001), but the odds of a new episode (odds ratio = 1.24, p = 0.004) were lower than the odds of persisting depression (odds ratio = 2.06, p < 0.001). A dose-response relation was observed for education and income. Socioeconomic inequality in depression is heterogeneous and varies according to the way psychiatric disorder is measured, to the definition and measurement of SES, and to contextual features such as region and time. Nonetheless, the authors found compelling evidence for socioeconomic inequality in depression. Strategies for tackling inequality in depression are needed, especially in relation to the course of the disorder.

The logic for a conception-to-death cohort study

This article proposes that the nation undertake a study of a cohort which will be followed from pregnancy to death- a research project that will require more than 100 years. The project would take advantage of the recent completion of the human genome study, the accelerating development of new non-invasive measurement technologies, as well as new information about the complexity and long duration of the causal period for diseases. This complexity involves increasing awareness of long developmental processes which do not fit the typical picture of disease and that do not always have an obvious demarcation of disease onset. Appreciation for the complexity of the web of causation has expanded as the human genome project has unfolded, because it has become increasingly apparent how intimately the action of genetic material depends on contingencies of the individual interacting with the environment; and that the chances of discovering the action of genes, singly or in clusters, will be greatly enhanced by the ability to characterize the environment during distinct developmental periods. Likewise, the ability to understand environmental influences will depend on knowledge of genes. Additionally, there is new evidence for here-to-fore unsuspected comorbidities, the understanding of which would be greatly benefitted by a conception-to-death cohort study with a broad range of health outcomes. In many cases these developmental processes, contingencies, and comorbidities involve long causal periods, approaching that of the entire human lifespan. A conception-to-death cohort study would provide information on disease, human development, environmental risk and protective factors, and public health that will not be achievable by any other research design.

A transcriptional profile of multicellular development inDictyostelium discoideum

A distinct feature of development in the simple eukaryote Dictyostelium discoideum is an aggregative transition from a unicellular to a multicellular phase. Using genome-wide transcriptional analysis we show that this transition is accompanied by a dramatic change in the expression of more than 25% of the genes in the genome. We also show that the transcription patterns of these genes are not sensitive to the strain or the nutritional history, indicating that Dictyostelium development is a robust physiological process that is accompanied by stereotypical transcriptional events. Analysis of the two differentiated cell types, spores and stalk cells, and their precursors revealed a large number of differentially expressed genes as well as unexpected patterns of gene expression, which shed new light on the timing and possible mechanisms of cell-type divergence. Our findings provide new perspectives on the complexity of the developmental program and the fraction of the genome that is regulated during development.

Supplemental data available on-line

The quadratic cumulative odds regression model for scored ordinal outcomes: application to alcohol dependence

In this paper, we develop new regression models for the analysis of scored ordinal data (i.e. ordinal outcomes where the categories are assigned numeric values). The novel feature of these models is that they enable one to capture and identify nonlinear aspects of the relationship between an ordinal clinical measurement (used for disease diagnosis) and risk factors. These nonlinearities may be useful in generating hypotheses about the risk factor's role in the etiologic process as well as suggesting how to design future studies of the risk factor. We apply our model to study the effects of race, gender, and family history on alcohol dependence among a cohort of lifetime drinkers from the 1992 National Longitudinal Alcohol Epidemiologic Survey.

Depressive disorder, dysthymia, and risk of stroke: thirteen-year follow-up from the Baltimore epidemiologic catchment area study

BACKGROUND AND PURPOSE

This study examined depressive disorder as a risk factor for incident stroke in a prospective, population-based design.

METHODS

The Baltimore Epidemiologic Catchment Area Study is a prospective 13-year follow-up of a probability sample of household residents from Baltimore, Md. Depressive disorder was measured with the diagnostic interview schedule, and stroke was assessed by questions from the health interview survey or by documentation on a death certificate.

RESULTS

During the 13-year follow-up of 1703 individuals, 66 strokes were reported and 29 strokes were identified by death certificate search. Individuals with a history of depressive disorder were 2.6 times more likely to report stroke than those without this disorder after controlling for heart disease, hypertension, diabetes, and current and previous use of tobacco. Medications used in the treatment of depressive disorder at baseline did not alter this finding. A history of dysthymia demonstrated a similar relationship to stroke, although the estimate was not statistically significant.

CONCLUSIONS

Depressive disorder is a risk factor for stroke that appears to be independent of traditional cardiovascular risk factors. Further research on mechanisms for the association and the impact of treatment for depressive disorder on subsequent stroke is needed.

Ethnic disadvantage and schizophrenia

OBJECTIVE

To review and interpret epidemiologic research on ethnic disadvantage and schizophrenia.

METHOD

A search of the research literature was conducted.

RESULTS

Seventeen population-based studies were reported in the United Kingdom and the Netherlands from 1967 to 1997. The studies report high incidence rates for immigrants whose position in society is disadvantaged, than majority-group native-born, with a range of relative incidence from 1.7 to 13.2. It is proposed that the developmental task for formulating the life plan challenges the young adult's executive function abilities, which may be weaker in individuals vulnerable to schizophrenia. Formulating the life plan may be made more difficult by the position in society of disadvantaged ethnic minorities, raising the risk for schizophrenia.

CONCLUSION

Further research on executive function, and the developmental challenge of formulating the life plan, might provide insights into the etiology of schizophrenia, as well as suggest avenues for prevention.

Types of panic attacks and their association with psychiatric disorder and physical illness

The differentiation of three types of panic attacks is proposed to be significant for understanding the course and etiology of panic and other psychiatric disorders and physical illnesses. The present investigation is based on longitudinal data from the Epidemiologic Catchment Area (ECA) Study of 1980 to 1981 and its 1994 to 1996 follow-up. Multidimensional scaling (MDS) of panic symptoms identified three types of panic which were consistent over time and for which reliable scales were constructed to measure derealization, cardiac panic, and respiratory panic. Unlike panic disorder, none of the three types of panic attacks predicted the incidence of depression. Derealization was associated with a broader variety of psychiatric disorders than the other two types of panic, including simple phobias, but was not associated with physical diseases. Cardiac panic attacks were associated with a history of heart disease and predicted the incidence of agoraphobia but were not comorbid with depression, unlike the other two forms of panic. Respiratory panic attacks were consistently symptomatic of dysthymia and predicted a higher risk of hospitalization for breast cancer and myocardial infarction (MI).

Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force

Associations between affective disorders, anxiety disorders, and substance use disorders were examined in epidemiological studies conducted in Germany, Switzerland, Puerto Rico, and the mainland US. There was a remarkable degree of similarity across studies in the magnitude and type of specific disorders associated with the affective disorders. Comorbidity with affective disorders was greater for the anxiety disorders than for substance misuse. Panic disorder was the subtype of anxiety that was most highly comorbid with depression. Social phobia was the specific phobic type with the strongest association with the affective disorders. The magnitude of associations between substance misuse and affective disorders generally was quite low and less consistent across sites. No major differences were found in the patterns of comorbidity by gender or age group, affective subtype or prevalence period. The onset of anxiety disorders generally preceded that of depression, whereas alcohol misuse was equally likely to pre-or post-date the onset of affective disorders. Finally, comorbidity was associated with an elevation in treatment rates across all sites, confirming Berkson's paradox on an international level.

Use of mental health services by households in the United States

OBJECTIVE

The study examined differences in the use of mental health services by persons living in different types of households.

METHODS

Data were obtained from the Epidemiologic Catchment Area (ECA) survey, a multistage probability sampling procedure of households in five U.S cities conducted in 1981-1984. Data from 12,417 persons living in four of the five ECA sites (Baltimore, St. Louis, Durham, North Carolina, and Los Angeles) were classified according to household categories used by the U.S. Bureau of the Census. Logistic regression analysis was used to examine the relationship of mental health service use to household type, relationship of survey respondent to head of household, household income and size, number of children in the household, ECA site, presence of mental disorders, and sociodemographic factors.

RESULTS

Use of mental health services varied by type of household but not by individual within the same household. Persons in female-headed families and persons living alone had the highest use of mental health services, even after other variables were controlled.

CONCLUSIONS

The findings highlight the need for outreach efforts to determine needs and preferences for health, mental health, and social services by persons in various households, especially persons in female-headed families and persons living alone.

A feasibility study of extended chemotherapy for locally advanced non-small cell lung cancer: a phase II trial of cancer and leukemia group B

The purpose of this study was to determine the feasibility of additional chemotherapy beyond 5 weeks of vinblastine-cisplatin followed by radiation therapy for patients with stage III non-small cell lung cancer. In this randomized phase II trial, the goal was to determine, in a similar population of patients, the toxicity of either of two additional chemotherapy programs. Ninety-one patients with stage III non-small cell lung cancer received the same induction regime of vinblastine/cisplatin/radiotherapy. In patients randomized to regime 1, an additional four cycles of vinblastine/cisplatin were given after the radiotherapy. In regimen 2, six weekly doses of carboplatin were given concurrent with the radiotherapy. The additional four cycles of vinblastine and cisplatin were completed by 34% of patients; the concurrent carboplatin program was completed by 70% of patients. Grade 3 or 4 granulocytopenia occurred in 53% of patients on regime 1 versus 17% on regime 2 (p < 0.003); grade 3 or 4 nausea/vomiting occurred in 20% of those on regime 1 versus 7% on regimen 2 (p = 0.175). Response rates and survival were similar for the two regimens, with approximately 30% of patients surviving at 2 years. Given the reduced toxicity and the improved capacity to complete the planned therapy with the concurrent carboplatin treatment, this regimen will be further examined in a phase III trial.

Prognostic factors in small-cell carcinoma of the lung: an analysis of 1,521 patients

Cancer and Leukemia Group B (CALGB) accrued 1,745 patients with limited (LD) or extensive (ED) small-cell lung cancer (SCCL) to five separate trials between 1972 and 1986. We reviewed these data to evaluate the impact of pretreatment prognostic factors on outcome. In multivariate analysis, female gender was predictive of improved response (LD, P = .01; ED, P = .04) and survival (LD, P = .01; ED, P = .02). A performance status of 0 or 1 was associated with improved response rates in both subsets, but was statistically significant (P = .04) only for overall objective response in LD patients. Performance status was a highly significant predictor of survival in both LD and ED groups (P less than .001). Supraclavicular lymph node involvement, while still LD, had a borderline unfavorable impact on survival (P = .06) compared with a lesser extent of LD involvement. In ED patients, a decrease in survival rates was associated with an increased number of metastatic sites (P = .01). Changes in the patient population were noted with time: the percentage of women increased from 21% to greater than 35%; an increased number of metastatic sites was identified among ED patients; mean performance status improved for both LD and ED subsets. These trends reflect the changing demographics of lung cancer, improved lung cancer staging, and probably lead-time bias. Response rates, overall survival, and long-term (greater than 2-year) survival varied significantly among the five protocols, both before and after multivariate correction for identified prognostic variables. However, the changing character of the study population limits the ability to determine retrospectively how much improvements in therapy contributed to the positive changes in failure-free survival, overall survival, and long-term survival observed in our sequentially studied population.

Melphalan and prednisone plus total bone marrow irradiation as initial treatment for multiple myeloma

Patients who have received radiation to localized areas of marrow eventually regenerate marrow in the irradiated area, if the dose is 2,400 centigrays (cGy) or less. This trial was designed to deliver a radiation dose of 1500 cGy to all marrow containing sites in patients with multiple myeloma, a technique we refer to as total bone marrow irradiation, or TBMI. Patients with previously untreated myeloma received 12 weeks of melphalan (L-PAM) and prednisone (pred) therapy. Four weeks later, sequential irradiation was administered using the 3-2 technique with rest periods to permit recovery from radiation-induced cytopenia. This was followed by electron beam irradiation of the rib and skull fields. Following completion of TBMI, patients were untreated until relapse. Twenty patients were entered. At entry 5, 8, and 7 patients had low, intermediate and high tumor cell loads, respectively. Two patients had a serum Ca in excess of 12 mg/dl; 3 had an increased creatinine. The median performance (ECOG) was 1. At week 16, immediately prior to TBMI, 5 of the 20 patients fulfilled the Myeloma Task Force criteria for response and 5 others had improved. Six patients did not begin the radiation therapy portion of the protocol. Three had rapidly progressive disease, one persistent leukopenia, one refused radiation therapy and one was withdrawn by his physician. Only 6 of the fourteen patients receiving the radiation treatment phase of the protocol were able to tolerate the intended course of 1500 cGy to all areas. Eight other patients received lower doses. Patients completing the radiation phase of the protocol failed to have further reductions in M-protein or improvement in other parameters beyond those obtained on the chemotherapy phase of the protocol. The median duration of response and survival was 12.0 and 42 months, respectively. We suggest possible reasons for the disappointing results of this trial and conclude that this approach to the primary treatment of myeloma holds little promise.

Accelerated radiotherapy followed by chemotherapy for locally recurrent small-cell carcinoma of the lung. A phase II study of Cancer and Leukemia Group B

Recurrent or persistent small-cell carcinoma of the lung (SCCL) after chemotherapy (CT) alone has shown a poor response to conventional salvage radiotherapy (RT). Accelerated RT is judged more effective than conventional RT for rapidly growing tumors such as SCCL. The objectives of this study were: to determine the tolerability of accelerated RT; and to test the ability of accelerated RT plus CT to achieve local tumor control (LTC) of SCCL recurrent after CT. Patients whose localized tumor was not controlled were selected from Arm III of the Cancer and Leukemia Group B (CALGB) protocol 8083 (Proc. ASCO 2:230, 1984) as eligible for this study. The program of accelerated RT consisted of the delivery of 50.1 Gray (Gy) in 30 fractions over a period of 21 days to the chest. New chemotherapy different from the first began 2 weeks after the completion of RT and was repeated every 3 weeks for 18 months (M). Of 29 potentially eligible patients with locally recurrent SCCL after the first line CT alone from Arm III of the CALBG protocol 8083, 12 were enrolled initially in this study. The analysis of LTC included 11 patients excluding one patient who died 4 weeks after the start of RT from liver metastases. The LTC achieved was as follow: complete remission in 8/11 (72%) and partial remission in 3/11 patients. None of the patients was converted to CR by subsequent chemotherapy. Survival ranged from 2 to 20 M, with a median survival time of 6 M. Tolerance to the subsequent CT, normal tissue reaction to accelerated RT, and the theoretical advantage of accelerated RT over conventional RT for SCCL were evaluated.

Prevalence of treated and untreated DSM-III schizophrenia. Results of a two-stage community survey

Psychiatrists, using a standardized clinical method, examined a probability sample of 810 subjects in eastern Baltimore and made diagnoses of mental disorders among those subjects according to DSM-III criteria. The authors estimated that there were 4.6 active cases of schizophrenia per 1000 adult noninstitutionalized population, and 6.4 cases per 1000 population, including both active and remitted cases. Among the 17 active and remitted schizophrenics identified in the survey, one half were not receiving any form of mental health services at the time of the survey; these data yield a prevalence rate of untreated cases of 3.1 per 1000 population. All of the untreated schizophrenics were deemed by the examining psychiatrist to be in need of services.

Combined modality therapy with radiotherapy, chemotherapy, and immunotherapy in limited small-cell carcinoma of the lung: a Phase III cancer and Leukemia Group B Study

Patients with limited-stage small-cell carcinoma of the lung (SCCL) were randomly assigned to a four-drug chemotherapy program consisting of methotrexate, doxorubicin, cyclophosphamide, and CCNU (MACC) or to a regimen consisting of cyclophosphamide, CCNU, and vincristine alternated with Adriamycin (Adria Laboratories, Columbus, Ohio) and vincristine (CCV/AV). All patients received 4,500 cGy, in a split course, to the primary tumor, mediastinum, and supraclavicular lymph node drainage areas and 3,000 cGy to the whole brain. After four cycles of chemotherapy, patients were randomly assigned to chemotherapy plus methanol extractable residue of BCG (MER-BCG) or no MER-BCG. The complete response frequencies were similar for the two regimens (54% and 48%) as were the median survivals (12.0 and 11.5 months) and the two-year survival rates (15% and 17%). Immunotherapy with MER-BCG did not prolong the time to disease progression or improve survival. Women had a greater chance of achieving a complete remission independent of performance status. There was a complex interaction between sex and the chemotherapy regimens that may have important implications for the design and stratification of future trials in SCCL.

Portal film quality: a multiple institutional study

The variation in quality of the several thousand portal films submitted to the Quality Assurance Review Center (QARC) has been substantial. To ascertain the nature and severity of this problem, a detailed study of "whole brain" portal films which were taken at 23 different radiotherapy departments for patients entered on three national leukemia studies was performed. Each film was analyzed in two ways: (a) independent subjective evaluation by four experienced radiotherapists and (b) measurement of objective parameters. Scores from 416 evaluations together with measured parameters were stored in a data base system for easy statistical manipulation. The dependence of perceived film quality on these objective parameters has been correlated and is the subject of this report.