Risk for exposure to alcohol, tobacco, and other drugs on the route to and from school: the role of alcohol outlets.

Despite the national push encouraging children to walk to school, little work has been done to examine what hazards children encounter on the route to school. This study examined the association between the presence of alcohol outlets on children's route to school and perceived safety on the route to school as well as exposure to alcohol, tobacco, and other drugs (ATOD). Data come from a community-based epidemiological study of 394 urban elementary school students. Participants' residential address, school location, and alcohol outlet data were geocoded and the route to school was mapped. The route to school layer and the geocoded alcohol outlet data were joined to determine the number of alcohol outlets children pass on the route to school. Logistic regression models estimated the association between the presence of alcohol outlets on the route to school, alcohol and drug exposure, and self-reported safety. Children with an alcohol outlet on the route to school were more likely to be offered ATOD (OR = 2.20, p = 0.02) as well as be exposed to drug selling (OR = 1.72, p = 0.02) and seeing people using drugs (OR = 1.93, p = 0.02). After adjusting for individual-level variables, the relationship between presence of alcohol outlets and being offered ATOD and seeing people using drugs remained significant. However, after adjusting for individual-level control variables and a proxy for the larger neighborhood context, the association between the presence of alcohol outlets and exposure to ATOD was no longer significant. As national campaigns are encouraging children to walk to school, it is essential to consider what children are exposed to on the route to school.

School environmental conditions and links to academic performance and absenteeism in urban, mid-Atlantic public schools.

School facility conditions, environment, and perceptions of safety and learning have been investigated for their impact on child development. However, it is important to consider how the environment separately influences academic performance and attendance after controlling for school and community factors. Using results from the Maryland School Assessment, we considered outcomes of school-level proficiency in reading and math plus attendance and chronic absences, defined as missing 20 or more days, for grades 3-5 and 6-8 at 158 urban schools. Characteristics of the environment included school facility conditions, density of nearby roads, and an index industrial air pollution. Perceptions of school safety, learning, and institutional environment were acquired from a School Climate Survey. Also considered were neighborhood factors at the community statistical area, including demographics, crime, and poverty based on school location. Poisson regression adjusted for over-dispersion was used to model academic achievement and multiple linear models were used for attendance. Each 10-unit change in facility condition index, denoting worse quality buildings, was associated with a decrease in reading (1.0% (95% CI: 0.1-1.9%) and math scores (0.21% (95% CI: 0.20-0.40), while chronic absences increased by 0.75% (95% CI: 0.30-1.39). Each log increase the EPA's Risk Screening Environmental Indicator (RSEI) value for industrial hazards, resulted in a marginally significant trend of increasing absenteeism (p < 0.06), but no association was observed with academic achievement. All results were robust to school-level measures of racial composition, free and reduced meals eligibility, and community poverty and crime. These findings provide empirical evidence for the importance of the community and school environment, including building conditions and neighborhood toxic substance risk, on academic achievement and attendance.

Poverty and psychiatric status. Longitudinal evidence from the New Haven Epidemiologic Catchment Area study.

We assessed the effect of poverty on psychiatric status using two waves of New Haven (Conn) Epidemiologic Catchment Area data. Poverty was defined using federal poverty guidelines; psychiatric status was assessed by the Diagnostic Interview Schedule (DIS). When examining the course of healthy respondents at the first interview, respondents in poverty had a twofold-increased risk (controlling for demographic factors) for an episode of at least one DIS/DSM-III Axis I psychiatric disorder. Rates of most specific psychiatric disorders were comparably higher for respondents meeting poverty criteria compared with those not in poverty, although these differences were not always statistically significant. The effects of poverty did not differ by sex, age, race, or history of psychiatric episodes.

Training and career activity. The experience of the Yale Advanced Track Program.

The Advanced Track Program of the Yale psychiatric residency is examined by a study of the career patterns of 132 graduates of the program over a 9-year period (1973 to 1982). The findings demonstrate that specific track training sequences are associated with subsequent career activities and that track graduates differ significantly from each other along dimensions of professional activities, work settings, treatment modalities, and patient characteristics. These differences are discussed from the vantage of the relationship between training and professional activity.

Utilization of health and mental health services. Three Epidemiologic Catchment Area sites.

Utilization of health and mental health services by non-institutionalized persons aged 18 years and older is examined based on interviews with probability samples of 3,000 to 3,500 persons in each of three sites of the National Institute of Mental Health Epidemiologic Catchment Area (ECA) program: New Haven, Conn, Baltimore, and St Louis. In all three ECAs, 6% to 7% of the adults made a visit during the prior six months for mental health reasons; proportions were considerably higher among persons with recent DSM-III disorders covered by the Diagnostic Interview Schedule (DIS) or severe cognitive impairment. Between 24% and 38% of all ambulatory visits by persons with DIS disorders were to mental health specialists. In seeking mental health services, men were more likely to turn to the specialty sector than to the generalist; women used both sectors about equally. The aged infrequently received care from mental health specialists. Visits for mental health reasons varied considerably depending on specific types of DIS disorder.

Six-month prevalence of psychiatric disorders in three communities 1980 to 1982.

Six-month prevalence rates for selected DSM-III psychiatric disorders are reported based on community surveys in New Haven, Conn, Baltimore, and St Louis. As part of the Epidemiologic Catchment Area program, data were gathered on more than 9,000 adults, employing the Diagnostic Interview Schedule to collect information to make a diagnosis. The most common disorders found were phobias, alcohol abuse and/or dependence, dysthymia, and major depression. The most common diagnoses for women were phobias and major depression, whereas for men, the most predominant disorder was alcohol abuse and/or dependence. Rates of psychiatric disorders dropped sharply after age 45 years.

Male and female psychiatrists and their patients.

Data from a national survey were used to explore whether the patients of male and female psychiatrists differed substantially in demographic or clinical characteristics and whether there were any differences in psychiatrists' treatment of same-gender versus opposite-gender patients. Women constituted about two-thirds of the female but only one-half of the male psychiatrists' patient loads. Female psychiatrists tended to see all of their patients more frequently, but few other differences were found. Better educated patients of both genders tended to have same-gender therapists; patients experiencing marital disruption tended to be seen by therapists of the opposite gender. Implications of these differences for training and manpower development are discussed.

Applicants' choice of a residency training program.

The authors present results from a survey of senior medical students in the class of 1981 concerning their selection of residency training programs in psychiatry. Generally, students were more influenced by clinical training opportunities and quality of life factors and not much influenced by the philosophy of the program. The implications of the findings are discussed from the perspectives of both advising and recruiting medical students.

The epidemiology of dysthymia in five communities: rates, risks, comorbidity, and treatment.

Data from a survey of five U.S. communities showed that dysthymia affected approximately 3% of the adult population. It was more common in women under age 65, unmarried persons, and young persons with low income and was associated with greater use of general health and psychiatric services and psychotropic drugs. Dysthymia had a high comorbidity with other psychiatric disorders, particularly major depression; only about 25%-30% of cases occur over a lifetime in the absence of other psychiatric disorders. The findings suggest that although the onset and highest risk periods of major depression and bipolar disorder are in young adulthood, a residual state of dysthymia occurs in middle and old age.

Depressive episodes and dysphoria resulting from conjugal bereavement in a prospective community sample.

Using three waves of interviews from the New Haven Epidemiologic Catchment Area Program, the authors contrast the extent and nature of depressive episodes and dysphoria between newly bereaved (N = 39) and married (N = 1,047) respondents age 45 and older. Bereavement greatly increased the risk of both conditions. This observation did not appear to be an artifact because psychosocial risk factors were similar for the bereaved and married groups. Bereavement increased the risk for a depressive episode more among respondents who reported no prior dysphoria than among those who did. Among those meeting criteria for depression, the bereaved reported symptoms similar to those of the married group except for significantly fewer reports of guilt.

Influence of comorbid alcohol and psychiatric disorders on utilization of mental health services in the National Comorbidity Survey.

OBJECTIVE: This study sought to determine how comorbidity of psychiatric and substance abuse disorders affects the likelihood of using mental health services. METHOD: The analysis was based on data on adults aged 18-54 years in the National Comorbidity Survey (N = 5,393). Users and nonusers of mental health and substance abuse services were compared in terms of their demographic characteristics, recent stressful life events, social support, parental history of psychopathology, self-medication, and symptoms of alcohol abuse/dependence. RESULTS: The prevalence of service utilization varied by diagnostic configurations. Comorbid psychiatric or alcohol disorders were stronger predictors of service utilization than a pure psychiatric or alcohol disorder. Factors predicting utilization of services differed for each disorder. CONCLUSIONS: Since comorbidity increases the use of mental health and substance abuse services, research on the relationship of psychiatric and alcohol-related disorders to service utilization needs to consider the coexistence of mental disorders. Attempts to reduce barriers to help seeking for those in need of treatment should be increased.

Trends in psychiatric practice, 1965-1980.

The authors compare the results of a study of the practice activities of psychiatrists conducted in 1979-1980 with one conducted in 1965. Although office-based practice has remained the core activity of the profession, psychiatrists in 1979 had a greater tendency to divide their time among multiple practice sites and activities during the work week. As a consequence, the percentage of practitioners working part-time in a variety of organized care settings has increased substantially. These findings support a view of psychiatry as a profession that is far more diversified than it was 15 years ago. The authors discuss major factors affecting trends in psychiatric practice.

Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study.

OBJECTIVE: This study examined the effects of nine axis I psychiatric disorders, as assessed by the Diagnostic Interview Schedule, on the risk of mortality over a 9-year period among a community sample of 3,560 men and women aged 40 and older. METHOD: The study identified the vital status as of Oct. 1, 1989, of respondents who were first interviewed in 1980 by the New Haven Epidemiologic Catchment Area study. Mortality risk by psychiatric status was estimated by using Cox proportional hazards models. RESULTS: Nine years after the baseline interview, it was confirmed that 1,194 (33.5%) of the respondents were deceased and 2,344 (65.8%) survived; the vital status of 22 (0.6%) remained unknown. When the relative risk of mortality was adjusted for age, several disorders--major depression, alcohol abuse or dependence, and schizophrenia--increased the likelihood of mortality. CONCLUSIONS: These data are further evidence of the negative outcome of some psychiatric problems even when assessed in community samples. The relatively high prevalence of depression and alcohol disorders indicates the far-reaching impact that these problems have on community health in general.

A national study of psychiatrists' professional activities.

OBJECTIVE AND METHOD: A mail survey was conducted in 1988-1989 to study the professional activities of U.S. psychiatrists. Data from the 19,431 active respondents are reported. RESULTS: Nineteen percent of the psychiatrists were women, an increase from the 17% reported in 1982. The median age of the respondents was 50 years. Nearly one-third of the respondents expressed interest in each of the following areas of subspecialization: adolescent psychiatry, substance abuse, geriatrics, and consultation-liaison psychiatry. More than one-fifth reported formal fellowship training in child/adolescent psychiatry. The psychiatrists worked an average of 48 hours per week--two-thirds in direct patient care--in an average of 2.3 different settings. The proportion of psychiatrists reporting private practice as their primary work setting showed a marked decline from 53% in 1982 to 45% in 1988. There was an increase from 4% in 1982 to 11% in 1988 in those whose primary work setting was a private psychiatric hospital. The typical caseload was over 60 patients, with roughly half that number seen each week. For inpatients treated, the two most common diagnoses were affective disorders and schizophrenic disorders. In a typical week psychiatrists treated about one-half of their outpatients with individual psychotherapy; three-fifths of these were also treated with medications. The average net income for psychiatrists working 35 hours or more per week was $99,850 for men and $73,174 for women. CONCLUSIONS: Major trends evident from this study are subspecialization, medicalization, privatization, feminization, and organizational diversification.

Psychological sequelae of medical complications during pregnancy.

To determine whether mothers with complicated pregnancies are at increased risk of postpartum depression and whether their children are at increased risk of being perceived as vulnerable, the investigators conducted an interview survey of mothers of 1095 children aged 4 to 8 in a community-based sample of primary care pediatric practices. The offspring were viewed as vulnerable by 17% of the women with severe pregnancy complications and 9% of the women without pregnancy complications (relative risk = 1.88; 95% confidence interval = 1.11, 2.63). Women with a severe complication of pregnancy were significantly more likely to report postpartum depression than those without a complication (27% vs 11%; relative risk = 2.45; 95% confidence interval = 1.55, 3.01). These relationships persisted after adjustment for prematurity, neonatal hospitalization, and demographic factors. It is concluded that pregnancy complications may place a woman at increased risk of postpartum depression and may have important effects on a mother's long-term perceptions of her child's vulnerability to illness.

Identification and management of psychosocial and developmental problems in community-based, primary care pediatric practices.

The importance of psychological and social issues for children's well-being has long been recognized and their importance in the practice of pediatrics is well documented. However, many of the studies looking at this issue have emphasized psychiatric problems rather than issues commonly referred to as the new morbidity. The goal of this research was to refocus interest on the problems of the new morbidity. This study examined the rates and predictors of psychological problems in 19 of 23 randomly chosen pediatric practices in the greater New Haven area. Families of all 4- to 8-year-old children were invited to participate and to complete the Child Behavior Checklist prior to seeing a clinician. Clinicians completed a 13-category checklist of psychosocial and developmental problems based on a World Health Organization-sponsored primary care, child-oriented classification system. Of the 2006 eligible families, 1886 (94%) participated. Clinicians identified at least one psychosocial or developmental problems in 515 children (27.3%). Thirty-one percent of the children with problems received no active intervention, 40% received intervention by the clinician, and 16% were referred to specialty services. Not surprisingly, children whose problems were rated as moderate or severe were twice as likely to be referred compared with children with mild problems. Recognition of a problem was related to four characteristics: if the visit was for well child rather than acute care; if the clinician felt he or she knew a child well; if the child was male; and if the child had unmarried parents (all P less than or equal to .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Postpartum onset of panic disorder: a coincidental event?

BACKGROUND: This study investigated whether the onset of panic for the first time during the postpartum period represented a coincidental occurrence. METHOD: Sixty-four childbearing women diagnosed with panic disorder who had been treated at the Yale Anxiety Research Clinic were interviewed. Postpartum panic was defined as the first panic occurring within 12 weeks of the woman's first childbirth. RESULTS: Seven women (10.9%) met criteria for postpartum onset, which is significantly greater than the expected age-corrected percentage of 0.92%, Z = 2.29, p < .02. CONCLUSION: The onset of panic in the first postpartum period is not a coincidental event.

Age, period and cohort effects on the risk of major depression: results from five United States communities.

Rates of major depression are presented from the recently completed Epidemiologic Catchment Area (ECA) Study based on probability samples of over 18,000 adults, 18 years of age and older, living in five U.S. communities. These rates were analyzed to describe simultaneously the changes affecting successive birth cohorts and the changes associated with the period in which the onset of the disorder occurred, using age-period-cohort (APC) models. The non-identifiability problem inherent in all APC models was resolved by assuming that the linear period effect and linear cohort effect were non-negative. This assumption is consistent with our a priori substantive knowledge of the disease. Under this assumption, as the linear period effect varies from its minimum to its maximum values, a family of curves representing the possible effects of a factor was generated for each of the time factors--age, period and cohort. The results of the analysis showed a sharp increase in rates of major depression among both men and women in the birth cohort born during the years 1935-1945. The rates among females, however, seemed to have stabilized in the generations born since 1945, while the rates in males continued to rise sharply among the cohorts born in the following decade, after which, in 1955, they also levelled off. In contrast, the rates associated with period of onset of major depression continued to increase between the years 1960-1980 among both men and women of all ages studied. These findings are considered in light of the persistent concentration of depression in women and in biologically related members of families of affected individuals.

Identification of psychosocial problems in pediatric primary care: do family attitudes make a difference?

OBJECTIVE: To evaluate the affect of families' attitudes about the appropriateness of discussing psychosocial concerns on pediatric providers' identification of psychosocial problems. DESIGN: These data were collected as part of the Greater New Haven Child Health Study, New Haven, Conn. The study design was a prospective cohort. SETTING: Families were recruited from a stratified random sample of all primary care practices in the greater New Haven area. Nineteen of 23 invited practices agreed to participate including 2 prepaid practices, 2 neighborhood health centers, and 7 fee-for-service group and 8 fee-for-service solo practices. PARTICIPANTS: All families of children aged 4 to 8 years who attended these practices during 2 separate 3-week periods (1 in fall 1987 and 1 in spring 1988) were invited to participate in the study. Families were invited to participate only once, on the first contact with any eligible child, using approved procedures. Of 2006 eligible families, 1886 (94%) chose to participate. MAIN OUTCOME MEASURE: The outcome variable for these analyses is the identification of any behavioral, emotional, or developmental problem by the pediatrician on the 13-category checklist. Overall, pediatric clinicians identified 27.5% of children with 1 or more psychosocial problems. RESULTS: Our data suggest that there is a great deal of discrepancy between what parents report is appropriate to do when their children have psychosocial problems and what they actually do when they recognize such problems in their children. Most (81.1%) believed it was appropriate to discuss 4 or more of the 6 hypothetical situations with their children's physician, while only 40.9% actually did discuss any of these problems with a physician when a problem occurred. Given the correlates of parents who intended to discuss such problems (higher education, older age, Euro-American ethnicity, higher income, married, availability of medical insurance) the possibility that parents are providing socially acceptable responses to such questions seems likely. Further, our data indicate that parents' actual reports of discussions of psychosocial problems is unrelated to whether physicians identified those problems in children. CONCLUSIONS: Pediatricians'judgments about the presence of psychosocial problems in their young patients seem to be based on their own observations rather than on what parents report. Physician-parent communication about psychosocial problems will be increasingly important as primary care physicians assume their role as gatekeepers to more expensive services such as mental health interventions.

Identification of violence in the home: pediatric and parental reports.

OBJECTIVES: To compare the rates of domestic violence reported by mothers with those identified by physicians, to compare the rates of harsh discipline practices reported by mothers with the rates of abuse identified by physicians, and to examine the relationship between reported domestic violence and harsh discipline practices. DESIGNS: Interviews with parents and pediatricians to compare pediatric detection of domestic violence and child abuse with parental reports of domestic violence and harsh discipline practices. SETTING: Community-based pediatric practices in the 13-town greater New Haven, Conn, area. PARTICIPANTS: Of the 23 practices invited, 19 agreed to participate. Of the 2,006 parents of eligible 4- to 8-year-olds asked to participate, 1,886 (94%) completed the Child Behavior' Checklist. Of those invited into the interview portion, 1,148 (83%) completed the 90-minute in-person interview. MAIN OUTCOME MEASURES: Percentages of cases of domestic violence identified by pediatricians and reported by mothers. Percentages of cases of child abuse detected by pediatricians and percentages of mothers reporting that they have hit their children and left a mark. RESULTS: Pediatricians detected domestic violence in 0.3% of the cases, but parents reported domestic violence in 4.2% kappa= 0.106 [95% confidence interval, -0.007 to 0.219]). Pediatricians identified physical abuse of children in 0.5% of the cases, while mothers reported hitting their children and leaving a mark in 21.6% (kappa = 0.003 [95% confidence interval, -0.018 to 0.024]). Mothers reporting domestic violence were significantly more likely to report hitting hard enough to leave a mark (relative risk, 1.6 ([95% confidence interval, 1.09-2.38]) compared with those not reporting domestic violence. Physicians identifying domestic violence were not significantly more likely to report child abuse than those not identifying domestic violence. CONCLUSIONS: Parents report more cases of violence than pediatricians detect. Pediatricians should ask parents directly about domestic violence and harsh discipline.