- Email: [email protected]
Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions
Affective, Substance Use, and Anxiety Disorders in Persons with Arthritis, Diabetes, Heart Disease, High Blood Pressure, or Chronic Lung Conditions Kenneth B. Wells, M.D., M.P.H., M. Audrey Burnam, Ph.D.
Jacqueline M. Golding, Ph.D.,
Abstract: The authors estimated the sex- and age-adjusted prevalence of affective, substance use, and anxiety disorders in persons in a general population sample who identified themselves as having arthritis, diabetes, heart disease, high blood pressure, chronic lung disease, or no chronic medical conditions. Persons who reported ever having arthritis, heart disease, chronic iung disease, or high blood pressure had a significantly increased adjusted prevalence of each of the three groups of lifetime psychiatric disorders, relative to a no-chronic conditions comparison group (each p < 0.05). Persons who ever had diabetes had an increased adjusted prevalence of lifetime affective and anxiety but not substance use disorder. Persons with current (i.e., active) arthritis, heart disease, or high blood pressure had a significantly increased adjusted prevalence of recent (6-month) anxiety disorder, whereas those with current chronic lung disease had an increased adjusted prevalence of recent affective and substance use but not anxiety disorder.
Introduction Patients with chronic medical conditions often have serious limitations in daily functioning [l-3] and require ongoing medical care. Such care may include identification of concurrent psychiatric disorders, which can exacerbate the functional limitations and complicate the assessment and treatment of the medically ill [4]. Moreover, conFrom the Universitv of California, Los Angeles, Neuropsychiatric Institute ani Hospital, School of Medycine, Los Aneeles. California (K.B.W.). The RAND Corporation, Santa Mon:a, California (K.B.W.;. M.A.B.), and ‘the Department of Psychiatry, University of Arkansas for Medical Sciences (1.M.G.). ” Add;ess reprint requests to: Kenneth B. Wells, M.D., M.P.H., The RAND Corporation, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138.
320 ISSN 0163~8343/89/$3.W
and
current psychiatric disorders themselves require definitive treatment. Several studies suggest, however, that primary care physicians tend to underdetect psychiatric disorder in persons with medical illness [5,6]. Estimates of the prevalence of psychiatric disorders in persons with specific chronic medical conditions would be useful to clinicians, by indicating which psychiatric disorders they most need to assess and treat. In addition, such estimates would be useful in furthering our understanding of the relationship between psychiatric and medical conditions. For example, many theories have been proposed about the causal nature of the relationship between anxiety and hypertension [6-s]. To date, however, there have been no generalizable estimates of prevalence of anxiety disorder in persons with and without hypertension. Thus, theories about the relationship between these disorders have developed in the absence of the necessary descriptive data. A similar problem applies to theories about the relationships between other specific medical and psychiatric disorders. In this article, we provide estimates of the prevalence of three groupings of psychiatric disorders (affective, substance use, and anxiety disorders) in persons who report that they have arthritis, diabetes, high blood pressure, heart disease, or chronic lung disease. These conditions are among the most prevalent conditions in a general population and in the offices of medical clinicians [9,10]. The estimates in this article are designed as a follow-up to an earlier publication in which we found, after adjusting for sex and age, that persons with General Hospital Psychiatry 11, 320-327, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Medical-Psychiatric
arthritis, lung disease, or heart disease had an increased prevalence of any psychiatric disorder, but that persons with diabetes or hypertension did not [9]. We have not previously reported which specific types of psychiatric disorders accounted for the increased prevalence of any psychiatric disorder for persons in the former group, nor whether there were some psychiatric disorders of increased prevalence for persons in the latter group. Existing studies of the prevalence of psychiatric disorders in persons with the five medical conditions listed above have one or more design flaws that limit their conclusions. In particular, most estimates are based on convenience samples of patients treated in particular clinical settings. Such estimates may not be generalizable to other patient or community samples. Estimates based on general populations are needed to determine the relationship among psychiatric and medical illnesses unconfounded by factors, such as severity of illness and access to services, that affect the decision to obtain health care. Second, only a few studies identified psychiatric disorders according to DSM-III criteria. Third, most studies focused on prevalence of current psychiatric disorders; lifetime psychiatric disorders, which include past but not current disorders, are also of interest. For example, past psychiatric disorders may have contributed to the development of a chronic medical condition, and such disorders may be likely to recur. Fourth, few previous studies compared persons with chronic medical conditions to a comparison group of persons without medical disorders. The current article was designed to avoid some of these flaws. We provide estimates based on a identify groups of DSM-III general population, psychiatric disorders, examine both recent and lifetime prevalence intervals, and make use of a nochronic conditions comparison group. Previous studies do provide some basis for speculation about the prevalence of specific psychiatric disorders in persons with the five medical conditions studied here. They suggest, for example, that the prevalence of anxiety and affective disorders is increased in persons with heart disease and arthritis [ll-151. We were unable to locate previous studies of the prevalence of specific psychiatric disorders in persons with chronic lung disease. Several authors have reported a high prevalence of depressive symptoms or depressive disorder in patients with hypertension and some found that anxiety can induce hypertensive episodes [7,8,16,17]. Lustman and colleagues [18], in a review of the
Comorbidity
literature, indicate that the evidence is inconclusive for an increased prevalence of depression in diabetics; little has been published, however, on the prevalence of anxiety disorder in diabetics. Although substance abuse may occur as a response to chronic illness, and also may cause or exacerbate many medical disorders, including hypertension and diabetes [19], there are few available estimates of the prevalence of substance abuse in persons with specific chronic medical conditions.
Methods The NIMH Epidemiologic Catchment Area (ECA) Program is a multisite general population survey of the epidemiology of psychiatric disorders and use of health services [20]. In the Los Angeles ECA site, staged probability samples of household residents from two mental health catchment areas (East Los Angeles and Venice/Culver City) were drawn. Approximately 50% of respondents are of Hispanic origin (mostly Mexican American) 1211. For each household, one adult was randomly selected to participate in a series of face-to-face interviews. The first wave of interviews was completed in 1982-1983. The response rate was 68% (N = 3132). Respondents were somewhat more likely than the corresponding household population to be young and Hispanic [22]. This article reports data on all Mexican Americans and non-Hispanic whites in the sample (N = 2554). Data on psychiatric disorders were obtained with the NIMH Diagnostic Interview Schedule (DIS) [23-251. For lifetime and 6-month prevalence intervals, we determined the presence of any DSMIII affective disorder (major depression, dysthymia, or mania), any substance use disorder (alcohol or drug abuse or dependence), and any anxiety disorder (generalized anxiety, panic disorder, phobia, or obsessive-compulsive disorder). Our measure of chronic medical disease is a 15item battery that elicits data on whether or not the respondent ever had or currently has certain medical conditions and whether the respondent is currently under medical care for each condition. Each condition was referred to in the battery either by a phrase in nontechnical language (i.e., “high blood pressure”) or by a list of alternative names asthma, or for the condition (i.e., “emphysema, other chronic lung disease”). In this article, we focus on the following conditions: (1) arthritis, (2) 321
K. B. Wells et al.
diabetes, (3) heart disease, (4) high blood pressure, and (5) chronic lung disease. We developed indicators of each lifetime and current chronic medical condition, the latter defined as a condition reported as currently present or for which the respondent reported being currently under care. For each prevalence interval, we identified persons who had none of the five chronic conditions listed above nor three other conditions assessed by the battery (cancer, neurologic disorder, physical handicap). We refer to such persons as the no-chronic-conditions comparison group. The interview also elicits data on age, job status (scored by the Nam-Powers job status scale) [26], sex, marital status, and ethnicity (categorized as Mexican American or non-Hispanic white). We used cross-tabulations to examine the lifetime and 6-month prevalence of each of the three groups of psychiatric disorders in persons with each of the five lifetime chronic medical conditions noted above and for persons with no lifetime chronic medical conditions. We conducted a parallel analysis for persons with current medical conditions. Prevalence estimates were adjusted for sex and age using a direct method [27]. For persons with lifetime and recent chronic medical conditions, we compared the prevalence of each group of psychiatric disorders for persons with that condition to prevalence for persons in the no-chronic-conditions group. There were thus 12 comparisons for each condition. Because there are many significant all in a consistent direction, we comparisons, thought a strict correction for multiple comparisons was too conservative. Therefore, we report significance of these comparisons at the 0.05, 0.01, 0.005, and 0.001 significance levels and discuss findings significant at the 0.05 level or better. With a strict correction for multiple comparisons, one would use about the 0.005 level for these comparisons. Data were weighted to adjust for differential probability of selection within households and across the two catchment areas. The prevalences (percentages) reported here are weighted, but the sample sizes are the actual sample sizes. For the cross-tabulations, standard errors and significance are corrected for the staged sampling design (i.e., they approximate exact variance using Taylor series linearization estimates), [28,29]. Our conclusions were not affected by 322
Table 1. Prevalence of current and lifetime chronic medical conditions Lifetime (standard % error)
Condition Arthritis Diabetes Heart disease High blood pressure Chronic lung disease
18.6 5.7
(0.8) (0.5)
1;:: 10.2
19:; (0.6)
the presence factor.
absence
or
of
Current (standard error) % 14.8 4.2 4.9 10.4 4.8
this
(0.7) (0.4) (0.5) (0.6) (0.4)
correction
Results The sample consists of 2554 persons, of whom 51.5% are Mexican Americans and 50.4% are women. The mean age of respondents is 39.5 years, 55.4% are married, and 63.6% are employed. Table 1 presents the percentage of the respondents having each lifetime and current chronic medical condition. Each of these conditions is relatively common in this population. Nearly 18% of the sample have ever had high blood pressure and nearly 18% have ever had arthritis, for example. Table 2 presents the sex- and age-adjusted prevalence of each of the three groups of lifetime and recent psychiatric disorders in persons with each lifetime chronic medical condition and those with no lifetime medical condition. Persons with a history of ever having arthritis have an increased adjusted prevalence of lifetime affective, substance use, and anxiety disorders, relative to the no-chronic-conditions group (ts range from 2.39, p < 0.05, to 4.69, p < 0.001); and of recent affective and anxiety disorders (ts are 2.30 and 1.97, respectively, each p < 0.05). Those with lifetime diabetes have an increased adjusted prevalence of lifetime affective and anxiety disorder and recent anxiety disorder (ts are 2.03, p < 0.05; 3.46, p < 0.001; and 2.76, p < 0.01, respectively). Persons with lifetime heart disease have an increased adjusted prevalence of each lifetime psychiatric disorder (ts range from 2.36, p < 0.05, to 3.34, p < 0.001) and recent affective and anxiety disorders (fs are 2.84, p < 0.005, and 2.65, p < 0.01, respectively). Those who have ever had high blood pressure
Medical-Psychiatric
have an increased adjusted prevalence of each lifetime and recent psychiatric disorder (fs range from 2.11, p < 0.01 to 4.26, p < O.OOl), whereas those with lifetime chronic lung disease have an increased adjusted prevalence of each lifetime psychiatric disorder (lowest f = 3.03, p < 0.005) and recent affective and anxiety disorders (fs are 3.66, p < 0.001, and 1.96, p = 0.05, respectively). Table 3 presents the comparable findings for current chronic medical conditions-those that are reported as currently present, or for which the respondent is currently under care. Persons with current arthritis have an increased adjusted prevalence of lifetime substance use and anxiety disorders (lowest f = 2.41, p < 0.05) and recent anxiety disorder (f = 2.21, p < 0.05). Those with current diabetes have an increased adjusted prevalence of lifetime anxiety disorder (f = 2.08, p < 0.05). Persons with current heart disease have an increased adjusted prevalence of lifetime and recent anxiety disorders (fs are 2.69 and 2.62, respectively, each p < 0.01). The sample with current hypertension has an increased adjusted prevalence of recent anxiety disorder (f = 1.99, p < 0.05). Those with current chronic lung disease have an increased adjusted prevalence of each group of lifetime psychiatric disorders (fs range from 2.05, p < 0.05, to 4.00, p < 0.001) and of recent affective and substance use disorders (fs are 2.76, p < 0.01, and 1.97, p < 0.05, respectively).
Comorbidity
Discussion This article presents the first available estimates, based on a general household, of the prevalence of specific psychiatric disorders in persons with specific chronic medical conditions. The results indicate that, when identifying both types of health problems (medical and psychiatric) using the broadest possible prevalence interval (lifetime), there is an increased prevalence of affective, substance use, and anxiety disorders in persons with four of the medical conditions (arthritis, heart disease, high blood pressure, chronic lung disease), relative to persons with none of the eight chronic medical conditions assessed in the Los Angeles ECA project. In addition, persons with lifetime diabetes had an increased prevalence of lifetime affective and anxiety, but not substance abuse disorder. These results support the conclusion that persons with major chronic medical illnesses have, generally, an increased prevalence of the most common major psychiatric disorders. For persons with each of the five lifetime medical conditions, we reached the same general conclusion of an increased prevalence of affective and anxiety disorders, regardless of the prevalence interval for identifying the psychiatric disorder (recent versus lifetime), with one exception: although persons with lifetime diabetes had a significantly increased prevalence of lifetime affective disorder relative to the no-chronic-conditions group, the large increase
Table 2. Sex- and age-adjusted prevalence of lifetime and recent psychiatric disorders with lifetime chronic medical conditions and no chronic conditions”
in 2552 persons
Medical condition
Arthritis (N=518) % SE
Diabetes (N = 154) % SE
Heart
High blood
Chronic lung
disease (N = 214) % SE
pressure (N=487) % SE
disease (N = 269) % SE
Psychiatric disorder
None (N = 1353) % SE
Lifetime Affective Substance use Anxiety
6.9 17.3 10.5
0.8 1.2 1.1
14.3b 30.5” 20.W
3.0 2.6 2.5
14.4b 21.6 26.2=
3.6 4.2 4.4
18.6’ 30.2’ 20.3*
3.4 4.9 4.0
16.4d 300 21.7’
3.0 3.3 2.6
17.Y 33.5’ 19.6d
2.5 2.9 2.8
Recent Affective Substance use Anxiety
4.4 6.0 5.3
0.6 0.7 0.7
11.3b 7.8 9.1b
2.9 2.0 1.8
9.6 5.7 15.T
3.2 3.4 3.7
14.2d 13.8 15.3’
3.4 4.2 3.7
11.3’ 12.7b 15.1’
2.5 3.1 2.2
13.8’ 9.2 8.7b
2.5 1.8 1.6
“Persons with no chronic conditions have none of the five conditions or cancer, neurologic disease, physical handicap. Note: Comparison of prevalence of psychiatric disorder is significantly different for those with the chronic medical condition and those with no conditions at: bp<0.05; ‘p
323
K. B. Wells et al.
Table 3. Sex- and age-adjusted prevalence of lifetime and recent psychiatric five current chronic medical conditions and no chronic conditions”
disorders
in persons
with
Medical condition
Arthritis (N=417) % SE
Diabetes (N= 114) % SE
Heart
High blood
Chronic lung
Disease (N = 140) % SE
pressure (N=291) % SE
disease (N= 127) SE %
Psychiatric disorder
None (N= 1711) SE %
Lifetime Affective Substance use Anxiety
8.4 19.6 12.4
0.8 1.1 1.0
12.4 33.4’ 20.7b
2.7 3.8 3.3
12.3 13.6 27.1b
4.1 4.7 7.0
15.6 28.4 28.3’
4.1 6.6 5.8
8.1 21.9 16.1
2.8 3.8 2.9
19.4 36.W 21.0b
3.9 4.0 4.1
Recent Affective Substance use Anxiety
5.8 6.8 6.0
0.6 0.8 0.6
10.0 7.5 11.9b
2.6 2.1 2.6
9.6 6.2 15.8
3.6 4.4 6.1
9.1 11.9 21.F
3.4 5.3 5.7
6.6 9.3 12.1b
2.7 3.5 3.0
15.6 12.5 10.0
3.5 2.8 2.5
“Persons with no chronic conditions have none of the five conditions or cancer, neurologic disease, physical handicap. Note: Comparison of prevalence of psychiatric disorder is significantly different for those with the chronic medical condition and those with no conditions at: ‘p
in prevalence of recent affective disorder for those with lifetime diabetes was not significant. Thus, we had poor precision for this particular comparison. The pattern of results for lifetime chronic medical conditions and substance use disorders is comwith lifetime high blood plex. For persons pressure, we conclude that there is an increased prevalence of both lifetime and recent substance use disorders. For lifetime diabetes, we conclude that there is no evidence of an association between this condition and either lifetime or recent substance use disorder. For the three remaining medical conditions, we reach different conclusions about the prevalence of substance use disorder for different prevalence intervals. Specifically, persons with lifetime heart disease had an increased prevalence of lifetime substance use disorder. Although the prevalence of recent substance use disorder in this group was twice as high as in the no-chronicconditions group, the difference was not significant, indicating poor precision for the comparison. For lifetime chronic lung disease and arthritis, there was an increased prevalence of lifetime but not recent substance use disorder; the latter result was not due to poor precision, however, as the confidence intervals for the comparison were small. One possible explanation for the pattern of results for these two conditions is that the relationship is much stronger for those with relatively earlier onset of their substance use, either because 324
the relationship takes time to develop or because early onset is a marker of severity of substance use disorder. Persons with early onset of substance use would be expected to constitute a higher percentage of persons with lifetime, compared to recent, substance use disorder. Another possible explanation is that persons with lifetime arthritis and heart disease may include persons with a relatively long course of medical illness; they may have developed substance abuse early in the course of the medical illness (or vice versa) and then stopped the substance use because it interfered too much with their functioning as the medical condition progressed. Our findings about the prevalence of psychiatric conditions in persons with current medical conditions should be interpreted with some caution, because of the generally lower precision for these analyses. We think these findings can be used to identify psychiatric disorders that are especially strongly associated with current chronic medical conditions, but not those that are unrelated to current chronic medical conditions. We conclude that the prevalence of lifetime and/or recent anxiety disorder tends to be high for each of the five current chronic medical conditions, and that lifetime and/ or recent substance use disorders are of increased prevalence in persons with current arthritis and chronic lung disease. Persons with current chronic lung disease also had an increased prevalence of lifetime and current affective disorder.
Medical-Psychiatric
The most striking difference between the findings for current and lifetime medical conditions is for high blood pressure. Although persons with lifetime high blood pressure have an increased prevalence of each group of lifetime and recent psychiatric disorder, the only psychiatric disorder group of increased prevalence for those with current high blood pressure was recent anxiety disorder. This pattern of results is not due only to the relatively lower precision of analyses of current high blood pressure, but also to the much lower prevalence of psychiatric disorders in persons with current, as opposed to lifetime, high blood pressure. This is consistent with the conclusion of Wells and colleagues [9] of no association between recent high blood pressure and presence or absence of any lifetime or recent psychiatric disorder. One possible explanation for these findings is that those with current high blood pressure include many persons with relatively short-lived disease, that is, they have few complications, and thus a low prevalence of secondary psychiatric disorder. What are the clinical implications of these major conclusions? First, because the associations of both affective and anxiety disorders with each chronic medical condition studied are strong, it is clear that clinicians who treat patients with these chronic medical illnesses should be well-trained in the assessment and management of these specific psychiatric disorders. Because we found strong associations for both recent and lifetime psychiatric disorders, it may be reasonable for that training to include an emphasis on both current and past psychiatric disorder. Past, but not active, psychiatric disorder may recur, and for some types of disorder, for example, recurrent major depression, prophylactic treatment may be indicated. Second, it is clear that some chronic medical conditions, especially hypertension, arthritis, and chronic lung disease, are associated with substance use disorder. Yet assessment and management of substance use disorders typically receives little emphasis in medical training programs. Particularly because substance use disorders would be expected to further limit the functioning of chronically medically ill persons, this may be an especially high-priority area for both development of training programs and further research. Our conclusions are based on a general household sample and are thus more generalizable than conclusions based on convenience (i.e., treated) samples. However, because the findings reported
Comorbidity
here do not include data from an institutionalized (hospital or jail) sample, the results may not gen eralize to these settings. Those hospitalized could have more severe chronic medical conditions or psychiatric disorders, and thus stronger associations between the two types of health problems. The sample studied here was designed to include an approximately equal number of Mexican Americans and non-Hispanic whites in Los Angeles and thus differs considerably from the general U.S. population. In an earlier paper [9] we reported that there were no significant interactions between ethnicity and chronic medical conditions in predicting the likelihood of any lifetime or recent psychiatric disorder. The conclusions of this study should be tested in other geographic sites and for other ethnic groups. The measure of psychiatric disorders in this study was the Diagnostic Interview Schedule (DIS). A number of previous studies have examined the validity of the diagnoses derived from administration of the DIS. A fundamental problem in interpreting the results of such studies is that no “gold standard’ diagnostic assessment tool is available against which to evaluate the performance of the DIS. Clinical assessments are also vulnerable to error, partly because of too little standardization [30]. The measure of chronic medical conditions was a simple set of self-report items, similar to that used in household health interviews such as the Hispanic Health and Nutrition Survey (H-HANES) [31]. The measure could be subject to response biases such as poor understanding by respondents of descriptors such as “high blood pressure.” Our results raise many interesting questions about the nature of relationships among medical conditions and psychiatric disorders. Why are certain conditions, such as chronic lung conditions, so strongly associated with psychiatric disorders? Are there particular chronic medical conditions within these broad groupings, for example, emphysema within chronic lung conditions, that largely account for the associations reported here? How is prevalence of psychiatric disorder affected by the presence of more than one chronic medical condition, and by particular combinations of chronic medical conditions? How does course of psychiatric disorder over time covary with course of chronic medical conditions? Data on questions such as these would help to unravel the complicated causal relationships among medical and psychiatric disorders. 325
B. Wells et al.
This research was supported by the Epidemiologic Catchment Area Program (ECA). The ECA is a series offive epidemiologic research studies performed by independent research teams in collaboration with staff of the Division of Biometry and Epidemiology @BE) of the National institute of Mental Health (NIMHJ. The NIMH Principal Collaborators are Darrel A. Regier, Ben Z. Locke, and jack D. Burke, jr.; the NIMH Project Officer is William j. Huber. The Principal lnvestigators and Co-Investigators from the five sites are: Yale University, UOl MH 3422PJerome K. Myers, Myrna M. Weissman, and Gay L. Tischler; the Johns Hopkins University, UOl MH 33870-Morton Kramer and Sam Shapiro; Washington University, St. Louis, UOl MH 33883-Lee N. Robins and John E. Helzer; Duke University, UOI MH 35386-Dan Blazer and Linda George; University of California, Los Angeles, UOZ MH 35865-Marvin Karno, Richard L. Hough, Iavier 1. Escobar, M. Audrey Burnam, and Dianne M. Timbers. The work reported here was supported in part by NIMH Research Scientist Development Award MH 00351 and NIMH Research Training Grant MH 14664.
References 1. Haynes RB, Sackett DL, Taylor DW, et al: Increased absenteeism from work after detection and labeling of hypertensive patients. N Engl J Med 299:741-744, 1978 the social psychological 2. Given CW: Measuring health states of ambulatory chronically ill patients: Hypertension and diabetes as tracer conditions. J Community Health 9:179-195, 1984 3. Croog SH, Levine S: Life After a Heart Attack: Social and Psychological Factors Eight Years Later. New York, Human Sciences Press, 1982 4. Wells KB, Golding J, Burnam MA: Psychiatric disorder and limitations in physical functioning in a general population. Am J Psychiatry 145:712-717, 1988 5. Goldberg D, Steele JJ, Johnson A, et al: Ability of primary care physicians to make accurate ratings of psychiatric symptoms. Arch Gen Psychiatry 39:829833, 1982 6. Kessler LG, Cleary I’D, Burke JD Jr: Psychiatric disorders in primary care: Results of a follow-up study. Arch Gen Psychiatry 42:583-587, 1985 7. Foster GD, Bell ST: Relation of state and trait anxiety to essential hypertension. Psycho1 Rep 52:355-358, 1983 8. White WB, Baker LH: Episodic hypertension secondary to panic disorder. Arch Intern Med 146:11291130, 1986 9. Wells KB, Gelding JM, Bumam MA: Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry 145:976-981, 1988 10. Rosenblatt RA, Cherkin DC, Schneeweiss R, et al: The content of ambulatory medical care in the United States-and interspecialty comparison. N Engl J Med 309:892-897, 1983 11. Rodin G, Voshart K: Depression in the medically ill: An overview. Am J Psychiatry 143:696-705, 1986 12. Stern M, Pascale L, Ackerman A: Life adjustment postmyocardial infarction: Determining predictive variables. Arch Intern Med 137:1680-1685, 1977
326
13. Cassem N, Hackett T: Psychological aspects of myocardial infarction. Med Clin No Am 612:711-721, 1977 14. Samet CM, Geller RD: Anxiety associated with cardiovascular disorders: A study using lorazepam. Psychosomatics 20:709-713, 1979 15. Wilkinson VA: Juvenile chronic arthritis in adolescence: Facing the reality. Int Rehabil Med 3:11-17, 1981 16. Huapaya L, Ananth J: Depression associated with hypertension: A review. Psychiatr J Univ Ottawa 5:58-62, 1980 17. Logue J, Hansen H: A case-control study of hypertensive women in a post-disaster community: Wyoming Valley, Pennsylvania. J Hum Stress 6:28-34, 1980 18. Lustman P, Amado H, Wetzel R: Depression in diabetics: A critical appraisal. Compr Psychiatry 24:6574, 1983 19. Selzer ML: Alcoholism and alcoholic psychoses. In Kaplan HI, Freedman AM, Sadock BJ (eds), Comprehensive Textbook of Psychiatry, III, Baltimore, Williams, and Wilkins, 1980, pp 16291644 20. Regier DA, Myers JK, Kramer M, et al: The NIMH Epidemiologic Catchment Area Program: Historical major and study popucontext, objectives, lation characteristics. Arch Gen Psychiatry 41:934-941, 1984 21. Hough RL, Kamo M, Burnam MA, et al: The Los Angeles Epidemiologic Catchment Area research program and the epidemiology of psychiatric disorders among Mexican-Americans. J Operational Psychiatry 1442-51, 1983 22. Burnam MA, Hough RL, Escobar JI, et al: Sixmonth prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles. Arch Gen Psychiatry 44687-694, 1987 23. Robins LN, Helzer JE, Croughan J, et al: National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Arch Gen Psychiatry 38:381-389, 1981 24. Kamo M, Bumam MA, Escobar JI, et al: Development of the Spanish-language version of the National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry 40~118%1188,1983 25. Bumam MA, Karno M, Hough RL, et al: The Spanish Diagnostic Interview Schedule: Reliability and comparison with clinical diagnoses. Arch Gen Psychiatry 40:1189-1196, 1983 26. Nam CB, Powers M: Variations in socioeconomic structure by race, residence and the life cycle. Am Social Rev 30:97-103, 1965 27. Shah BV: SESUDAAN: Standard Errors Program for Computing of Standardized Rates From Sample Survey Data. Research Triangle Park, NC, Research Triangle Institute, 1981 28. Lee ES, Forthofer RN, Lorimor RJ: Analysis of complex sample survey data-Problem and strategy. Sociol Meth Res 15:69-100, 1986 29. Holt M: SURREGR: Standard Errors of Regression Coefficients From Sample Survey Data. Research Tri-
Medical-Psychiatric
angle Park, NC, Research Triangle Institute, 1981 30. Burke JD: Diagnostic categorization by The Diagnostic Interview Schedule (DIS): A comparison with other methods of assessment. In Barrett JE, Rose RM
Comorbidity
(eds), Mental Disorders in the Community, New York, Guilford, 1986, pp 255-285 31. Data Collection Forms of the Hispanic HANES: Adult Sample Person Questionnaire Form PHS 6206. Washington, DC, US Department of Health and Human Services, 1982
327
Jacqueline M. Golding, Ph.D.,
Abstract: The authors estimated the sex- and age-adjusted prevalence of affective, substance use, and anxiety disorders in persons in a general population sample who identified themselves as having arthritis, diabetes, heart disease, high blood pressure, chronic lung disease, or no chronic medical conditions. Persons who reported ever having arthritis, heart disease, chronic iung disease, or high blood pressure had a significantly increased adjusted prevalence of each of the three groups of lifetime psychiatric disorders, relative to a no-chronic conditions comparison group (each p < 0.05). Persons who ever had diabetes had an increased adjusted prevalence of lifetime affective and anxiety but not substance use disorder. Persons with current (i.e., active) arthritis, heart disease, or high blood pressure had a significantly increased adjusted prevalence of recent (6-month) anxiety disorder, whereas those with current chronic lung disease had an increased adjusted prevalence of recent affective and substance use but not anxiety disorder.
Introduction Patients with chronic medical conditions often have serious limitations in daily functioning [l-3] and require ongoing medical care. Such care may include identification of concurrent psychiatric disorders, which can exacerbate the functional limitations and complicate the assessment and treatment of the medically ill [4]. Moreover, conFrom the Universitv of California, Los Angeles, Neuropsychiatric Institute ani Hospital, School of Medycine, Los Aneeles. California (K.B.W.). The RAND Corporation, Santa Mon:a, California (K.B.W.;. M.A.B.), and ‘the Department of Psychiatry, University of Arkansas for Medical Sciences (1.M.G.). ” Add;ess reprint requests to: Kenneth B. Wells, M.D., M.P.H., The RAND Corporation, 1700 Main Street, P.O. Box 2138, Santa Monica, CA 90406-2138.
320 ISSN 0163~8343/89/$3.W
and
current psychiatric disorders themselves require definitive treatment. Several studies suggest, however, that primary care physicians tend to underdetect psychiatric disorder in persons with medical illness [5,6]. Estimates of the prevalence of psychiatric disorders in persons with specific chronic medical conditions would be useful to clinicians, by indicating which psychiatric disorders they most need to assess and treat. In addition, such estimates would be useful in furthering our understanding of the relationship between psychiatric and medical conditions. For example, many theories have been proposed about the causal nature of the relationship between anxiety and hypertension [6-s]. To date, however, there have been no generalizable estimates of prevalence of anxiety disorder in persons with and without hypertension. Thus, theories about the relationship between these disorders have developed in the absence of the necessary descriptive data. A similar problem applies to theories about the relationships between other specific medical and psychiatric disorders. In this article, we provide estimates of the prevalence of three groupings of psychiatric disorders (affective, substance use, and anxiety disorders) in persons who report that they have arthritis, diabetes, high blood pressure, heart disease, or chronic lung disease. These conditions are among the most prevalent conditions in a general population and in the offices of medical clinicians [9,10]. The estimates in this article are designed as a follow-up to an earlier publication in which we found, after adjusting for sex and age, that persons with General Hospital Psychiatry 11, 320-327, 1989 0 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
Medical-Psychiatric
arthritis, lung disease, or heart disease had an increased prevalence of any psychiatric disorder, but that persons with diabetes or hypertension did not [9]. We have not previously reported which specific types of psychiatric disorders accounted for the increased prevalence of any psychiatric disorder for persons in the former group, nor whether there were some psychiatric disorders of increased prevalence for persons in the latter group. Existing studies of the prevalence of psychiatric disorders in persons with the five medical conditions listed above have one or more design flaws that limit their conclusions. In particular, most estimates are based on convenience samples of patients treated in particular clinical settings. Such estimates may not be generalizable to other patient or community samples. Estimates based on general populations are needed to determine the relationship among psychiatric and medical illnesses unconfounded by factors, such as severity of illness and access to services, that affect the decision to obtain health care. Second, only a few studies identified psychiatric disorders according to DSM-III criteria. Third, most studies focused on prevalence of current psychiatric disorders; lifetime psychiatric disorders, which include past but not current disorders, are also of interest. For example, past psychiatric disorders may have contributed to the development of a chronic medical condition, and such disorders may be likely to recur. Fourth, few previous studies compared persons with chronic medical conditions to a comparison group of persons without medical disorders. The current article was designed to avoid some of these flaws. We provide estimates based on a identify groups of DSM-III general population, psychiatric disorders, examine both recent and lifetime prevalence intervals, and make use of a nochronic conditions comparison group. Previous studies do provide some basis for speculation about the prevalence of specific psychiatric disorders in persons with the five medical conditions studied here. They suggest, for example, that the prevalence of anxiety and affective disorders is increased in persons with heart disease and arthritis [ll-151. We were unable to locate previous studies of the prevalence of specific psychiatric disorders in persons with chronic lung disease. Several authors have reported a high prevalence of depressive symptoms or depressive disorder in patients with hypertension and some found that anxiety can induce hypertensive episodes [7,8,16,17]. Lustman and colleagues [18], in a review of the
Comorbidity
literature, indicate that the evidence is inconclusive for an increased prevalence of depression in diabetics; little has been published, however, on the prevalence of anxiety disorder in diabetics. Although substance abuse may occur as a response to chronic illness, and also may cause or exacerbate many medical disorders, including hypertension and diabetes [19], there are few available estimates of the prevalence of substance abuse in persons with specific chronic medical conditions.
Methods The NIMH Epidemiologic Catchment Area (ECA) Program is a multisite general population survey of the epidemiology of psychiatric disorders and use of health services [20]. In the Los Angeles ECA site, staged probability samples of household residents from two mental health catchment areas (East Los Angeles and Venice/Culver City) were drawn. Approximately 50% of respondents are of Hispanic origin (mostly Mexican American) 1211. For each household, one adult was randomly selected to participate in a series of face-to-face interviews. The first wave of interviews was completed in 1982-1983. The response rate was 68% (N = 3132). Respondents were somewhat more likely than the corresponding household population to be young and Hispanic [22]. This article reports data on all Mexican Americans and non-Hispanic whites in the sample (N = 2554). Data on psychiatric disorders were obtained with the NIMH Diagnostic Interview Schedule (DIS) [23-251. For lifetime and 6-month prevalence intervals, we determined the presence of any DSMIII affective disorder (major depression, dysthymia, or mania), any substance use disorder (alcohol or drug abuse or dependence), and any anxiety disorder (generalized anxiety, panic disorder, phobia, or obsessive-compulsive disorder). Our measure of chronic medical disease is a 15item battery that elicits data on whether or not the respondent ever had or currently has certain medical conditions and whether the respondent is currently under medical care for each condition. Each condition was referred to in the battery either by a phrase in nontechnical language (i.e., “high blood pressure”) or by a list of alternative names asthma, or for the condition (i.e., “emphysema, other chronic lung disease”). In this article, we focus on the following conditions: (1) arthritis, (2) 321
K. B. Wells et al.
diabetes, (3) heart disease, (4) high blood pressure, and (5) chronic lung disease. We developed indicators of each lifetime and current chronic medical condition, the latter defined as a condition reported as currently present or for which the respondent reported being currently under care. For each prevalence interval, we identified persons who had none of the five chronic conditions listed above nor three other conditions assessed by the battery (cancer, neurologic disorder, physical handicap). We refer to such persons as the no-chronic-conditions comparison group. The interview also elicits data on age, job status (scored by the Nam-Powers job status scale) [26], sex, marital status, and ethnicity (categorized as Mexican American or non-Hispanic white). We used cross-tabulations to examine the lifetime and 6-month prevalence of each of the three groups of psychiatric disorders in persons with each of the five lifetime chronic medical conditions noted above and for persons with no lifetime chronic medical conditions. We conducted a parallel analysis for persons with current medical conditions. Prevalence estimates were adjusted for sex and age using a direct method [27]. For persons with lifetime and recent chronic medical conditions, we compared the prevalence of each group of psychiatric disorders for persons with that condition to prevalence for persons in the no-chronic-conditions group. There were thus 12 comparisons for each condition. Because there are many significant all in a consistent direction, we comparisons, thought a strict correction for multiple comparisons was too conservative. Therefore, we report significance of these comparisons at the 0.05, 0.01, 0.005, and 0.001 significance levels and discuss findings significant at the 0.05 level or better. With a strict correction for multiple comparisons, one would use about the 0.005 level for these comparisons. Data were weighted to adjust for differential probability of selection within households and across the two catchment areas. The prevalences (percentages) reported here are weighted, but the sample sizes are the actual sample sizes. For the cross-tabulations, standard errors and significance are corrected for the staged sampling design (i.e., they approximate exact variance using Taylor series linearization estimates), [28,29]. Our conclusions were not affected by 322
Table 1. Prevalence of current and lifetime chronic medical conditions Lifetime (standard % error)
Condition Arthritis Diabetes Heart disease High blood pressure Chronic lung disease
18.6 5.7
(0.8) (0.5)
1;:: 10.2
19:; (0.6)
the presence factor.
absence
or
of
Current (standard error) % 14.8 4.2 4.9 10.4 4.8
this
(0.7) (0.4) (0.5) (0.6) (0.4)
correction
Results The sample consists of 2554 persons, of whom 51.5% are Mexican Americans and 50.4% are women. The mean age of respondents is 39.5 years, 55.4% are married, and 63.6% are employed. Table 1 presents the percentage of the respondents having each lifetime and current chronic medical condition. Each of these conditions is relatively common in this population. Nearly 18% of the sample have ever had high blood pressure and nearly 18% have ever had arthritis, for example. Table 2 presents the sex- and age-adjusted prevalence of each of the three groups of lifetime and recent psychiatric disorders in persons with each lifetime chronic medical condition and those with no lifetime medical condition. Persons with a history of ever having arthritis have an increased adjusted prevalence of lifetime affective, substance use, and anxiety disorders, relative to the no-chronic-conditions group (ts range from 2.39, p < 0.05, to 4.69, p < 0.001); and of recent affective and anxiety disorders (ts are 2.30 and 1.97, respectively, each p < 0.05). Those with lifetime diabetes have an increased adjusted prevalence of lifetime affective and anxiety disorder and recent anxiety disorder (ts are 2.03, p < 0.05; 3.46, p < 0.001; and 2.76, p < 0.01, respectively). Persons with lifetime heart disease have an increased adjusted prevalence of each lifetime psychiatric disorder (ts range from 2.36, p < 0.05, to 3.34, p < 0.001) and recent affective and anxiety disorders (fs are 2.84, p < 0.005, and 2.65, p < 0.01, respectively). Those who have ever had high blood pressure
Medical-Psychiatric
have an increased adjusted prevalence of each lifetime and recent psychiatric disorder (fs range from 2.11, p < 0.01 to 4.26, p < O.OOl), whereas those with lifetime chronic lung disease have an increased adjusted prevalence of each lifetime psychiatric disorder (lowest f = 3.03, p < 0.005) and recent affective and anxiety disorders (fs are 3.66, p < 0.001, and 1.96, p = 0.05, respectively). Table 3 presents the comparable findings for current chronic medical conditions-those that are reported as currently present, or for which the respondent is currently under care. Persons with current arthritis have an increased adjusted prevalence of lifetime substance use and anxiety disorders (lowest f = 2.41, p < 0.05) and recent anxiety disorder (f = 2.21, p < 0.05). Those with current diabetes have an increased adjusted prevalence of lifetime anxiety disorder (f = 2.08, p < 0.05). Persons with current heart disease have an increased adjusted prevalence of lifetime and recent anxiety disorders (fs are 2.69 and 2.62, respectively, each p < 0.01). The sample with current hypertension has an increased adjusted prevalence of recent anxiety disorder (f = 1.99, p < 0.05). Those with current chronic lung disease have an increased adjusted prevalence of each group of lifetime psychiatric disorders (fs range from 2.05, p < 0.05, to 4.00, p < 0.001) and of recent affective and substance use disorders (fs are 2.76, p < 0.01, and 1.97, p < 0.05, respectively).
Comorbidity
Discussion This article presents the first available estimates, based on a general household, of the prevalence of specific psychiatric disorders in persons with specific chronic medical conditions. The results indicate that, when identifying both types of health problems (medical and psychiatric) using the broadest possible prevalence interval (lifetime), there is an increased prevalence of affective, substance use, and anxiety disorders in persons with four of the medical conditions (arthritis, heart disease, high blood pressure, chronic lung disease), relative to persons with none of the eight chronic medical conditions assessed in the Los Angeles ECA project. In addition, persons with lifetime diabetes had an increased prevalence of lifetime affective and anxiety, but not substance abuse disorder. These results support the conclusion that persons with major chronic medical illnesses have, generally, an increased prevalence of the most common major psychiatric disorders. For persons with each of the five lifetime medical conditions, we reached the same general conclusion of an increased prevalence of affective and anxiety disorders, regardless of the prevalence interval for identifying the psychiatric disorder (recent versus lifetime), with one exception: although persons with lifetime diabetes had a significantly increased prevalence of lifetime affective disorder relative to the no-chronic-conditions group, the large increase
Table 2. Sex- and age-adjusted prevalence of lifetime and recent psychiatric disorders with lifetime chronic medical conditions and no chronic conditions”
in 2552 persons
Medical condition
Arthritis (N=518) % SE
Diabetes (N = 154) % SE
Heart
High blood
Chronic lung
disease (N = 214) % SE
pressure (N=487) % SE
disease (N = 269) % SE
Psychiatric disorder
None (N = 1353) % SE
Lifetime Affective Substance use Anxiety
6.9 17.3 10.5
0.8 1.2 1.1
14.3b 30.5” 20.W
3.0 2.6 2.5
14.4b 21.6 26.2=
3.6 4.2 4.4
18.6’ 30.2’ 20.3*
3.4 4.9 4.0
16.4d 300 21.7’
3.0 3.3 2.6
17.Y 33.5’ 19.6d
2.5 2.9 2.8
Recent Affective Substance use Anxiety
4.4 6.0 5.3
0.6 0.7 0.7
11.3b 7.8 9.1b
2.9 2.0 1.8
9.6 5.7 15.T
3.2 3.4 3.7
14.2d 13.8 15.3’
3.4 4.2 3.7
11.3’ 12.7b 15.1’
2.5 3.1 2.2
13.8’ 9.2 8.7b
2.5 1.8 1.6
“Persons with no chronic conditions have none of the five conditions or cancer, neurologic disease, physical handicap. Note: Comparison of prevalence of psychiatric disorder is significantly different for those with the chronic medical condition and those with no conditions at: bp<0.05; ‘p
323
K. B. Wells et al.
Table 3. Sex- and age-adjusted prevalence of lifetime and recent psychiatric five current chronic medical conditions and no chronic conditions”
disorders
in persons
with
Medical condition
Arthritis (N=417) % SE
Diabetes (N= 114) % SE
Heart
High blood
Chronic lung
Disease (N = 140) % SE
pressure (N=291) % SE
disease (N= 127) SE %
Psychiatric disorder
None (N= 1711) SE %
Lifetime Affective Substance use Anxiety
8.4 19.6 12.4
0.8 1.1 1.0
12.4 33.4’ 20.7b
2.7 3.8 3.3
12.3 13.6 27.1b
4.1 4.7 7.0
15.6 28.4 28.3’
4.1 6.6 5.8
8.1 21.9 16.1
2.8 3.8 2.9
19.4 36.W 21.0b
3.9 4.0 4.1
Recent Affective Substance use Anxiety
5.8 6.8 6.0
0.6 0.8 0.6
10.0 7.5 11.9b
2.6 2.1 2.6
9.6 6.2 15.8
3.6 4.4 6.1
9.1 11.9 21.F
3.4 5.3 5.7
6.6 9.3 12.1b
2.7 3.5 3.0
15.6 12.5 10.0
3.5 2.8 2.5
“Persons with no chronic conditions have none of the five conditions or cancer, neurologic disease, physical handicap. Note: Comparison of prevalence of psychiatric disorder is significantly different for those with the chronic medical condition and those with no conditions at: ‘p
in prevalence of recent affective disorder for those with lifetime diabetes was not significant. Thus, we had poor precision for this particular comparison. The pattern of results for lifetime chronic medical conditions and substance use disorders is comwith lifetime high blood plex. For persons pressure, we conclude that there is an increased prevalence of both lifetime and recent substance use disorders. For lifetime diabetes, we conclude that there is no evidence of an association between this condition and either lifetime or recent substance use disorder. For the three remaining medical conditions, we reach different conclusions about the prevalence of substance use disorder for different prevalence intervals. Specifically, persons with lifetime heart disease had an increased prevalence of lifetime substance use disorder. Although the prevalence of recent substance use disorder in this group was twice as high as in the no-chronicconditions group, the difference was not significant, indicating poor precision for the comparison. For lifetime chronic lung disease and arthritis, there was an increased prevalence of lifetime but not recent substance use disorder; the latter result was not due to poor precision, however, as the confidence intervals for the comparison were small. One possible explanation for the pattern of results for these two conditions is that the relationship is much stronger for those with relatively earlier onset of their substance use, either because 324
the relationship takes time to develop or because early onset is a marker of severity of substance use disorder. Persons with early onset of substance use would be expected to constitute a higher percentage of persons with lifetime, compared to recent, substance use disorder. Another possible explanation is that persons with lifetime arthritis and heart disease may include persons with a relatively long course of medical illness; they may have developed substance abuse early in the course of the medical illness (or vice versa) and then stopped the substance use because it interfered too much with their functioning as the medical condition progressed. Our findings about the prevalence of psychiatric conditions in persons with current medical conditions should be interpreted with some caution, because of the generally lower precision for these analyses. We think these findings can be used to identify psychiatric disorders that are especially strongly associated with current chronic medical conditions, but not those that are unrelated to current chronic medical conditions. We conclude that the prevalence of lifetime and/or recent anxiety disorder tends to be high for each of the five current chronic medical conditions, and that lifetime and/ or recent substance use disorders are of increased prevalence in persons with current arthritis and chronic lung disease. Persons with current chronic lung disease also had an increased prevalence of lifetime and current affective disorder.
Medical-Psychiatric
The most striking difference between the findings for current and lifetime medical conditions is for high blood pressure. Although persons with lifetime high blood pressure have an increased prevalence of each group of lifetime and recent psychiatric disorder, the only psychiatric disorder group of increased prevalence for those with current high blood pressure was recent anxiety disorder. This pattern of results is not due only to the relatively lower precision of analyses of current high blood pressure, but also to the much lower prevalence of psychiatric disorders in persons with current, as opposed to lifetime, high blood pressure. This is consistent with the conclusion of Wells and colleagues [9] of no association between recent high blood pressure and presence or absence of any lifetime or recent psychiatric disorder. One possible explanation for these findings is that those with current high blood pressure include many persons with relatively short-lived disease, that is, they have few complications, and thus a low prevalence of secondary psychiatric disorder. What are the clinical implications of these major conclusions? First, because the associations of both affective and anxiety disorders with each chronic medical condition studied are strong, it is clear that clinicians who treat patients with these chronic medical illnesses should be well-trained in the assessment and management of these specific psychiatric disorders. Because we found strong associations for both recent and lifetime psychiatric disorders, it may be reasonable for that training to include an emphasis on both current and past psychiatric disorder. Past, but not active, psychiatric disorder may recur, and for some types of disorder, for example, recurrent major depression, prophylactic treatment may be indicated. Second, it is clear that some chronic medical conditions, especially hypertension, arthritis, and chronic lung disease, are associated with substance use disorder. Yet assessment and management of substance use disorders typically receives little emphasis in medical training programs. Particularly because substance use disorders would be expected to further limit the functioning of chronically medically ill persons, this may be an especially high-priority area for both development of training programs and further research. Our conclusions are based on a general household sample and are thus more generalizable than conclusions based on convenience (i.e., treated) samples. However, because the findings reported
Comorbidity
here do not include data from an institutionalized (hospital or jail) sample, the results may not gen eralize to these settings. Those hospitalized could have more severe chronic medical conditions or psychiatric disorders, and thus stronger associations between the two types of health problems. The sample studied here was designed to include an approximately equal number of Mexican Americans and non-Hispanic whites in Los Angeles and thus differs considerably from the general U.S. population. In an earlier paper [9] we reported that there were no significant interactions between ethnicity and chronic medical conditions in predicting the likelihood of any lifetime or recent psychiatric disorder. The conclusions of this study should be tested in other geographic sites and for other ethnic groups. The measure of psychiatric disorders in this study was the Diagnostic Interview Schedule (DIS). A number of previous studies have examined the validity of the diagnoses derived from administration of the DIS. A fundamental problem in interpreting the results of such studies is that no “gold standard’ diagnostic assessment tool is available against which to evaluate the performance of the DIS. Clinical assessments are also vulnerable to error, partly because of too little standardization [30]. The measure of chronic medical conditions was a simple set of self-report items, similar to that used in household health interviews such as the Hispanic Health and Nutrition Survey (H-HANES) [31]. The measure could be subject to response biases such as poor understanding by respondents of descriptors such as “high blood pressure.” Our results raise many interesting questions about the nature of relationships among medical conditions and psychiatric disorders. Why are certain conditions, such as chronic lung conditions, so strongly associated with psychiatric disorders? Are there particular chronic medical conditions within these broad groupings, for example, emphysema within chronic lung conditions, that largely account for the associations reported here? How is prevalence of psychiatric disorder affected by the presence of more than one chronic medical condition, and by particular combinations of chronic medical conditions? How does course of psychiatric disorder over time covary with course of chronic medical conditions? Data on questions such as these would help to unravel the complicated causal relationships among medical and psychiatric disorders. 325
B. Wells et al.
This research was supported by the Epidemiologic Catchment Area Program (ECA). The ECA is a series offive epidemiologic research studies performed by independent research teams in collaboration with staff of the Division of Biometry and Epidemiology @BE) of the National institute of Mental Health (NIMHJ. The NIMH Principal Collaborators are Darrel A. Regier, Ben Z. Locke, and jack D. Burke, jr.; the NIMH Project Officer is William j. Huber. The Principal lnvestigators and Co-Investigators from the five sites are: Yale University, UOl MH 3422PJerome K. Myers, Myrna M. Weissman, and Gay L. Tischler; the Johns Hopkins University, UOl MH 33870-Morton Kramer and Sam Shapiro; Washington University, St. Louis, UOl MH 33883-Lee N. Robins and John E. Helzer; Duke University, UOI MH 35386-Dan Blazer and Linda George; University of California, Los Angeles, UOZ MH 35865-Marvin Karno, Richard L. Hough, Iavier 1. Escobar, M. Audrey Burnam, and Dianne M. Timbers. The work reported here was supported in part by NIMH Research Scientist Development Award MH 00351 and NIMH Research Training Grant MH 14664.
References 1. Haynes RB, Sackett DL, Taylor DW, et al: Increased absenteeism from work after detection and labeling of hypertensive patients. N Engl J Med 299:741-744, 1978 the social psychological 2. Given CW: Measuring health states of ambulatory chronically ill patients: Hypertension and diabetes as tracer conditions. J Community Health 9:179-195, 1984 3. Croog SH, Levine S: Life After a Heart Attack: Social and Psychological Factors Eight Years Later. New York, Human Sciences Press, 1982 4. Wells KB, Golding J, Burnam MA: Psychiatric disorder and limitations in physical functioning in a general population. Am J Psychiatry 145:712-717, 1988 5. Goldberg D, Steele JJ, Johnson A, et al: Ability of primary care physicians to make accurate ratings of psychiatric symptoms. Arch Gen Psychiatry 39:829833, 1982 6. Kessler LG, Cleary I’D, Burke JD Jr: Psychiatric disorders in primary care: Results of a follow-up study. Arch Gen Psychiatry 42:583-587, 1985 7. Foster GD, Bell ST: Relation of state and trait anxiety to essential hypertension. Psycho1 Rep 52:355-358, 1983 8. White WB, Baker LH: Episodic hypertension secondary to panic disorder. Arch Intern Med 146:11291130, 1986 9. Wells KB, Gelding JM, Bumam MA: Psychiatric disorder in a sample of the general population with and without chronic medical conditions. Am J Psychiatry 145:976-981, 1988 10. Rosenblatt RA, Cherkin DC, Schneeweiss R, et al: The content of ambulatory medical care in the United States-and interspecialty comparison. N Engl J Med 309:892-897, 1983 11. Rodin G, Voshart K: Depression in the medically ill: An overview. Am J Psychiatry 143:696-705, 1986 12. Stern M, Pascale L, Ackerman A: Life adjustment postmyocardial infarction: Determining predictive variables. Arch Intern Med 137:1680-1685, 1977
326
13. Cassem N, Hackett T: Psychological aspects of myocardial infarction. Med Clin No Am 612:711-721, 1977 14. Samet CM, Geller RD: Anxiety associated with cardiovascular disorders: A study using lorazepam. Psychosomatics 20:709-713, 1979 15. Wilkinson VA: Juvenile chronic arthritis in adolescence: Facing the reality. Int Rehabil Med 3:11-17, 1981 16. Huapaya L, Ananth J: Depression associated with hypertension: A review. Psychiatr J Univ Ottawa 5:58-62, 1980 17. Logue J, Hansen H: A case-control study of hypertensive women in a post-disaster community: Wyoming Valley, Pennsylvania. J Hum Stress 6:28-34, 1980 18. Lustman P, Amado H, Wetzel R: Depression in diabetics: A critical appraisal. Compr Psychiatry 24:6574, 1983 19. Selzer ML: Alcoholism and alcoholic psychoses. In Kaplan HI, Freedman AM, Sadock BJ (eds), Comprehensive Textbook of Psychiatry, III, Baltimore, Williams, and Wilkins, 1980, pp 16291644 20. Regier DA, Myers JK, Kramer M, et al: The NIMH Epidemiologic Catchment Area Program: Historical major and study popucontext, objectives, lation characteristics. Arch Gen Psychiatry 41:934-941, 1984 21. Hough RL, Kamo M, Burnam MA, et al: The Los Angeles Epidemiologic Catchment Area research program and the epidemiology of psychiatric disorders among Mexican-Americans. J Operational Psychiatry 1442-51, 1983 22. Burnam MA, Hough RL, Escobar JI, et al: Sixmonth prevalence of specific psychiatric disorders among Mexican Americans and non-Hispanic whites in Los Angeles. Arch Gen Psychiatry 44687-694, 1987 23. Robins LN, Helzer JE, Croughan J, et al: National Institute of Mental Health Diagnostic Interview Schedule: Its history, characteristics, and validity. Arch Gen Psychiatry 38:381-389, 1981 24. Kamo M, Bumam MA, Escobar JI, et al: Development of the Spanish-language version of the National Institute of Mental Health Diagnostic Interview Schedule. Arch Gen Psychiatry 40~118%1188,1983 25. Bumam MA, Karno M, Hough RL, et al: The Spanish Diagnostic Interview Schedule: Reliability and comparison with clinical diagnoses. Arch Gen Psychiatry 40:1189-1196, 1983 26. Nam CB, Powers M: Variations in socioeconomic structure by race, residence and the life cycle. Am Social Rev 30:97-103, 1965 27. Shah BV: SESUDAAN: Standard Errors Program for Computing of Standardized Rates From Sample Survey Data. Research Triangle Park, NC, Research Triangle Institute, 1981 28. Lee ES, Forthofer RN, Lorimor RJ: Analysis of complex sample survey data-Problem and strategy. Sociol Meth Res 15:69-100, 1986 29. Holt M: SURREGR: Standard Errors of Regression Coefficients From Sample Survey Data. Research Tri-
Medical-Psychiatric
angle Park, NC, Research Triangle Institute, 1981 30. Burke JD: Diagnostic categorization by The Diagnostic Interview Schedule (DIS): A comparison with other methods of assessment. In Barrett JE, Rose RM
Comorbidity
(eds), Mental Disorders in the Community, New York, Guilford, 1986, pp 255-285 31. Data Collection Forms of the Hispanic HANES: Adult Sample Person Questionnaire Form PHS 6206. Washington, DC, US Department of Health and Human Services, 1982
327