The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey Replication.

Irritability is a diagnostic symptom of major depressive disorder (MDD) in children and adolescents but not in adults in both the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and International Classification of Diseases (ICD-10) systems. We explore the importance of irritability for subtyping adult DSM-IV MDD in the National Comorbidity Survey Replication (NCS-R), a national US adult household survey. The WHO Composite International Diagnostic Interview (CIDI) was used to assess prevalence of many DSM-IV disorders in the lifetime and in the year before interview (12-month prevalence). MDD was assessed conventionally (that is, requiring either persistent sadness or loss of interest), but with irritability included as one of the Criterion A symptoms. We also considered the possibility that irritability might be a diagnostic symptom of adult MDD (that is, detect cases who had neither sad mood nor loss of interest). Twelve-month MDD symptom severity was assessed with the Quick Inventory of Depressive Symptomatology and role impairment with the Sheehan Disability Scale. After excluding bipolar spectrum disorders, irritability during depressive episodes was reported by roughly half of respondents with lifetime DSM-IV MDD. Irritability in the absence of either sad mood or loss of interest, in comparison, was rare. Irritability in MDD was associated with early age of onset, lifetime persistence, comorbidity with anxiety and impulse-control disorders, fatigue and self-reproach during episodes, and disability. Irritability was especially common in MDD among respondents in the age range 18-44 and students. Further investigation is warranted of distinct family aggregation, risk factors and treatment response. Consideration should also be given to including irritability as a nondiagnostic symptom of adult MDD in DSM-V and ICD-11.

Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey.

BACKGROUND: General population survey data are presented on the lifetime prevalence of suicide attempts as well as transition probabilities to onset of ideation, plans among ideators, and attempts among ideators either with or without a plan. Risk factors for these transitions are also studied. METHODS: Data are from part II of the National Comorbidity Survey, a nationally representative survey carried out from 1990 to 1992 in a sample of 5877 respondents aged 15 to 54 years to study prevalences and correlates of DSM-III-R disorders. Transitions are estimated using life-table analysis. Risk factors are examined using survival analysis. RESULTS: Of the respondents, 13.5% reported lifetime ideation, 3.9% a plan, and 4.6% an attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72% from a plan to an attempt, and 26% from ideation to an unplanned attempt. About 90% of unplanned and 60% of planned first attempts occurred within 1 year of the onset of ideation. All significant risk factors (female, previously married, age less than 25 years, in a recent cohort, poorly educated, and having 1 or more of the DSM-III-R disorders assessed in the survey) were more strongly related to ideation than to progression from ideation to a plan or an attempt. CONCLUSIONS: Prevention efforts should focus on planned attempts because of the rapid onset and unpredictability of unplanned attempts. More research is needed on the determinants of unplanned attempts.

Income differences in persons seeking outpatient treatment for mental disorders: a comparison of the United States with Ontario and The Netherlands.

BACKGROUND: Variations in the relationships among income, use of mental health services, and sector of care are examined by comparing data from 3 countries that differ in the organization and financing of mental health services. METHODS: Data come from the 1990-1992 National Comorbidity Survey (n = 5,384), the 1990-1991 Mental Health Supplement to the Ontario Health Survey (n = 6,321), and the 1996 Netherlands Mental Health Survey and Incidence Study (n = 6031). Analysis of the association between income and use of mental health services was carried out for the population that was between ages 18 and 54 years. Differential use of mental health treatment was examined in 3 sectors: the general medical sector, the specialty sector, and the human services sector. RESULTS: No significant association between income and probability of any mental health treatment was observed for persons with psychiatric disorders in any of the 3 countries. However, there were significant differences among countries in the association between income and sector of mental health care treatment. In the United States, income is positively related to treatment being received in the specialty sector and negatively related to treatment being received in the human services sector. In the Netherlands, patients in the middle-income bracket are less likely to receive specialty care, while those in the high-income bracket are less likely to be seen in the human service sector. Income is unrelated to the sector of care for patients in Ontario. CONCLUSIONS: Future research should examine whether differential access to the specialty sector for low-income people in the United States is associated with worse mental health outcomes.

Lifetime panic-depression comorbidity in the National Comorbidity Survey.

BACKGROUND: The National Comorbidity Survey is a nationally representative survey of the prevalences and correlates of DSM-III-R disorders in the US household population. METHODS: Retrospective age-at-onset reports were used to study predictive relationships between lifetime panic and depression. RESULTS: Strong associations were found between the lifetime prevalences of panic and major depressive episodes (odds ratios: for panic attacks with depression, 6.2; for panic disorder with depression, 6.8). These associations were not significantly influenced by the inclusion or exclusion of respondents with mania. Temporally primary depression predicted a first onset of subsequent panic attacks but not of panic disorder. Temporally primary panic attacks, with or without panic disorder and whether or not the panic was persistent, predicted a first onset of subsequent major depression. The associations between panic attack and depression were attenuated in models that controlled for prior traumatic life experiences and histories of other DSM-III-R disorders. CONCLUSIONS: Lifetime panic-depression comorbidity characterizes most community respondents with panic disorder and a substantial few of those with major depression. The absence of a dose-response relationship suggests that primary panic attack is a marker, rather than a causal risk factor, of subsequent depression. Primary depression, in comparison, appears to be a genuine risk factor for secondary panic attacks. That primary depression predicts panic attacks but not panic disorder suggests that secondary panic is a severity marker of depression rather than a comorbid condition. These results are far from definitive because they are based on retrospective reports, lay-administered diagnostic interviews, and only 1 survey. However, they raise important questions that could lead to a fundamental rethinking of panic-depression comorbidity if they are replicated in future epidemiological and clinical studies.

The structure of the genetic and environmental risk factors for six major psychiatric disorders in women. Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and alcoholism.

BACKGROUND: Although prior family and twin studies have examined the relationship between the genetic and environmental risk factors for pairs of psychiatric disorders, the interrelationship between these classes of risk factors for a broad range of psychiatric disorders remains largely unknown. METHODS: An epidemiologic sample of 1030 female-female twin pairs with known zygosity, ascertained from the Virginia Twin Registry, were evaluated by a personal interview conducted by mental health professionals, assessing lifetime history of phobia, generalized anxiety disorder, panic disorder, bulimia nervosa, major depression, and alcoholism. RESULTS: A multivariate twin analysis suggested the following. First, genetic, familial-environmental, and individual-specific environmental risk factors each cause a unique pattern of comorbidity among the six disorders. Second, genetic influences on these disorders are best explained by two factors, the first of which loads heavily on phobia, panic disorder, and bulimia nervosa and the second, on major depression and generalized anxiety disorder. Third, unlike other disorders, genetic influences on alcoholism are largely disorder specific. Fourth, familial-environmental influences on these disorders are best explained by a single factor that substantially influenced liability to bulimia nervosa only. Fifth, individual-specific environmental influences on the risk for these psychiatric disorders are best explained by a single factor, with highest loadings on generalized anxiety disorder and major depression and with large-disorder-specific loadings, especially on phobias, panic disorder, and alcoholism. CONCLUSIONS: These results support the following hypotheses: First, each major risk factor domain (genes, family environment, and individual-specific environment) influences comorbidity between these disorders in a distinct manner. Second, genetic influences on these six disorders are neither highly specific nor highly nonspecific. Neither a model that contains a discrete set of genetic factors for each disorder nor a model in which all six disorders results from a single set of genes is well supported. Third, the anxiety disorders are not, from a genetic perspective, etiologically homogeneous. Fourth, most of the genetic factors that influence vulnerability to alcoholism in women do not alter the risk for development of other common psychiatric disorders. These results should be interpreted in the context of both the strengths and limitations of multivariate twin analysis.

The identification and validation of distinct depressive syndromes in a population-based sample of female twins.

BACKGROUND: Depression, a clinically heterogeneous syndrome, may also be etiologically heterogeneous. Using a prospective, epidemiologic, and genetically informative sample of adult female twins, we identify and validate a typology of depressive syndromes. METHODS: Latent class analysis was applied to 14 disaggregated DSM-III-R symptoms for major depression reported over the last year by members of 1029 female-female twin pairs. RESULTS: Seven classes were identified, of which 3 represented clinically significant depressive syndromes: (1) mild typical depression, (2) atypical depression, and (3) severe typical depression. Severe typical depression was characterized by comorbid anxiety and panic, long episodes, impairment, and help seeking. Atypical depression was similar in severity to mild typical depression, but was characterized by increased eating, hypersomnia, frequent, relatively short episodes, and a proclivity to obesity. Individuals with recurrent episodes tended to have the same syndrome on each occasion. The members of twin pairs concordant for depression had the same depressive syndrome more often than expected by chance and this resemblance was greater in monozygotic than in dizygotic pairs. CONCLUSION: In an epidemiologic sample of female twins, depression is not etiologically homogeneous, but is instead made up of several syndromes that are at least partially distinct from a clinical, longitudinal, and familial/genetic perspective.

Anorexia nervosa and anorexic-like syndromes in a population-based female twin sample.

OBJECTIVE: The authors explored the epidemiologic characteristics and risk factors of anorexia nervosa and examined the relationship between narrowly defined anorexia nervosa and anorexia-like syndromes. METHOD: Structured interviews were administered to a population-based sample of 2,163 female twins. Anorexia nervosa was diagnosed by computer algorithm ("computer narrow") and by narrow and broad clinical definitions. RESULTS: Lifetime prevalence estimates of 0.51%, 1.62%, and 3.70% were obtained for the computer narrow, clinical narrow, and clinical broad diagnoses, respectively. Dieting status, greater number of years of parental education, low self-esteem, high levels of neuroticism, and maternal overprotectiveness were significantly associated with anorexia nervosa. Both the pattern of comorbidity and the relationship to epidemiologic risk factors suggested an etiologic continuity between narrowly and broadly defined anorexic syndromes. Co-twins of twins with anorexia nervosa were at significantly higher risk for lifetime anorexia nervosa, bulimia nervosa, major depression, and current low body mass index. Significant comorbidity was found between anorexia nervosa and major depression, bulimia nervosa, generalized anxiety disorder, alcoholism, phobias, and panic disorder. CONCLUSIONS: The authors' analyses support the hypothesis of a spectrum of anorexic-like syndromes in women. These syndromes are familial and share familial etiologic factors with major depression and bulimia nervosa.

The social consequences of psychiatric disorders, III: probability of marital stability.

OBJECTIVE: The associations of prior DSM-III-R disorders with probability and timing of subsequent divorce were examined. METHOD: The data came from the part II subsample (N=5,877) of the National Comorbidity Survey. The respondents completed a structured diagnostic interview that retrospectively dated age at onset of each of 14 lifetime DSM-III-R disorders and recorded ages at first marriage and divorce. These data were used to estimate survival models describing the relationships between prior disorders and subsequent divorce. In addition, simulations were used to estimate the number of years spent out of marriage because of these causal relationships in the total U.S. population. RESULTS: Prior psychiatric disorders were associated with a substantially higher risk of divorce. The simulations suggested that the effects of these associations in the U.S. population in the survey's age range are approximately 23 million lost years of marriage among men and 48 million lost years of marriage among women. CONCLUSIONS: Psychiatric disorders have a number of adverse consequences for those who suffer from them and for their families and communities. The results reported here suggest that an increase in the number of people who divorce and a decrease in the number of years of marriage in the population may be among them. The debate over whether society can afford to provide universal treatment for psychiatric disorders needs to take these costs into consideration.

Social consequences of psychiatric disorders, II: Teenage parenthood.

OBJECTIVE: The subject of this study was the relation between retrospectively reported early-onset psychiatric disorders and subsequent teenage parenthood in the general population. METHOD: The data were from 5,877 respondents aged 15-54 years in the National Comorbidity Survey, a nationally representative household survey. Information on respondents' DSM-III-R anxiety disorders, mood disorders, substance abuse disorders, and conduct disorder, age at the birth of the first child, and teenage sexual activity was collected in face-to-face interviews. RESULTS: Early-onset psychiatric disorders were associated with subsequent teenage parenthood among both females and males, with significant odds ratios of 2.0-12.0 and population attributable risk proportions of 6.2%-33.7%. Disaggregation analyses showed that disorders were associated with increased probability of sexual activity but not with decreased probability of using contraception. CONCLUSIONS: These results add to a growing body of evidence that psychiatric disorders are associated with a variety of adverse life consequences. The current policy debate concerning universal insurance coverage needs to take this into consideration. Planners of interventions aimed at preventing teenage pregnancy should consider including a mental health treatment component in their intervention packages. Mental health professionals treating adolescents need to be sensitized to their higher risk of pregnancy, while family doctors and specialists treating teenage mothers or their children need to be sensitized to the mothers' higher risk of psychiatric disorder.

PIP: Data from the US National Comorbidity Survey on 5877 respondents 15-54 years of age were used to assess the relationship between retrospectively identified early-onset psychiatric disorders and subsequent adolescent parenthood. Between 21-24% of the sample's male and female age cohorts reported having their first child at ages 15-19 years. The cumulative and conditional probability curves for adolescent parenthood were consistently higher among men and women with prior psychiatric diagnoses of anxiety, affective, addictive, and conduct disorders than among those without psychiatric diagnoses. The diagnosis most predictive of adolescent parenthood was addictive disorders. The population attributable risk proportions of births of first children to teenagers associated with the psychiatric disorders were 11.1% in the teenage female subsample with premarital childbearing, 6.2% in the teenage female subsample with marital childbearing, and 33.7% in the teenage male subsample with premarital parenthood. Physicians and mental health professionals who work with adolescents with psychiatric conditions should be aware of the increased risk of adolescent pregnancy and a mental health component should be added to adolescent pregnancy prevention programs.

Sources of individual differences in depressive symptoms: analysis of two samples of twins and their families.

OBJECTIVE: Self-reported symptoms of depression are commonly used in mental health research to assess current psychiatric state, yet wide variation in these symptoms among individuals has been found in both clinical and epidemiologic populations. The authors sought to understand, from a genetic-epidemiologic perspective, the sources of individual differences in depressive symptoms. METHODS: Self-reported symptoms of depression were assessed in two samples of twins and their spouses, parents, siblings, and offspring: one sample contained volunteer twins recruited through the American Association of Retired Persons and their relatives (N = 19,203 individuals) and the other contained twins from a population-based twin registry in Virginia and their relatives (N = 11,242 individuals). Model fitting by an iterative, diagonal, weighted least squares method was applied to the 80 different family relationships in the extended twin-family design. RESULTS: Independent analyses of the two samples revealed that the level of depressive symptoms was modestly familial, and familial resemblance could be explained solely by genetic factors and spousal resemblance. The estimated heritability of depressive symptoms was between 30% and 37%. There was no evidence that the liability to depressive symptoms was environmentally transmitted from parents to offspring or was influenced by environmental factors shared either generally among siblings or specifically between twins. With correction for unreliability of measurement, genetic factors accounted for half of the stable variance in depressive symptoms. CONCLUSIONS: Depressive symptoms in adulthood partly reflect enduring characteristics of temperament that are substantially influenced by hereditary factors but little, or not at all, by shared environmental experiences in the family of origin.

Stressful life events, genetic liability, and onset of an episode of major depression in women.

OBJECTIVE: This study was undertaken to clarify how genetic liability and stressful life events interact in the etiology of major depression. METHOD: Information about stressful life events and onset of major depressive episodes in the past year was collected in a population-based sample of female-female twin pairs including 2,164 individuals, 53,215 person-months of observation, and 492 onsets of depression. RESULTS: Nine "personal" and three aggregate "network" stressful events significantly predicted onset of major depression in the month of occurrence, four of which predicted onset with an odds ratio of > 10 and were termed "severe": death of a close relative, assault, serious marital problems, and divorce/breakup. Genetic liability also had a significant impact on risk of onset of depression. For severe stressful events, as well as for 10 of the 12 individual stressful events, the best-fitting model for the joint effect of stressful events and genetic liability on onset of major depression suggested genetic control of sensitivity to the depression-inducing effects of stressful life events. In individuals at lowest genetic risk (monozygotic twin, co-twin unaffected), the probability of onset of major depression per month was predicted to be 0.5% and 6.2%, respectively, for those unexposed and exposed to a severe event. In those at highest genetic risk (monozygotic twin, co-twin affected), these probabilities were 1.1% and 14.6%, respectively. Linear regression analysis indicated significant Genotype by Environment interaction in the prediction of onset of major depression. CONCLUSIONS: Genetic factors influence the risk of onset of major depression in part by altering the sensitivity of individuals to the depression-inducing effect of stressful life events.

Genetics of blood-injury fears and phobias: a population-based twin study.

Data on unreasonable fears of blood, needles, hospitals, and illness (BNHI) were collected by telephone interview from 541 MZ and 388 DZ pairs of female twins from the population-based Virginia Twin Registry. BNHI phobia was defined as the presence of fear accompanied by interference. Age at onset of phobia was found to be very similar to that of situational phobias previously assessed in the sample. Using a multiple threshold model, we found no evidence for qualitative differences between BNHI fears and BNHI phobia. The familial aggregation of fears appears to be entirely due to additive genetic variance. The possible exception to this is fear of illness, which, like BNHI phobias, seems to aggregate within families because of shared environmental factors. Although power to discriminate between the causes of familial resemblance is low, results suggest that random traumatic events and some social learning may be responsible for the onset of BNHI phobias. About two-thirds of variance is individual-specific environmental, and could include genotype x environment interaction and measurement error.

The prevalence and correlates of untreated serious mental illness.

OBJECTIVE: To identify the number of people in the United States with untreated serious mental illness (SMI) and the reasons for their lack of treatment. DATA SOURCE/STUDY DESIGN: The National Comorbidity Survey; cross-sectional, nationally representative household survey. DATA COLLECTION: An operationalization of the SMI definition set forth in the Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act identified individuals with SMI in the 12 months prior to the interview. The presence of SMI then was related to the use of mental health services in the past 12 months. PRINCIPAL FINDINGS: Of the 6.2 percent of respondents who had SMI in the year prior to interview, fewer than 40 percent received stable treatment. Young adults and those living in nonrural areas were more likely to have unmet needs for treatment. The majority of those who received no treatment felt that they did not have an emotional problem requiring treatment. Among those who did recognize this need, 52 percent reported situational barriers, 46 percent reported financial barriers, and 45 percent reported perceived lack of effectiveness as reasons for not seeking treatment. The most commonly reported reason both for failing to seek treatment (72 percent) and for treatment dropout (58 percent) was wanting to solve the problem on their own. CONCLUSIONS: Although changes in the financing of services are important, they are unlikely by themselves to eradicate unmet need for treatment of SMI. Efforts to increase both self-recognition of need for treatment and the patient centeredness of care also are needed.

Comorbidity of substance use disorders with mood and anxiety disorders: results of the International Consortium in Psychiatric Epidemiology.

This article reports the results of a cross-national investigation of patterns of comorbidity between substance use and psychiatric disorders in six studies participating in the International Consortium in Psychiatric Epidemiology. In general, there was a strong association between mood and anxiety disorders as well as conduct and antisocial personality disorder with substance disorders at all sites. The results also suggest that there is a continuum in the magnitude of comorbidity as a function of the spectrum of substance use category (use, problems, dependence), as well as a direct relationship between the number of comorbid disorders and increasing levels of severity of substance use disorders (which was particularly pronounced for drugs). Finally, whereas there was no specific temporal pattern of onset for mood disorders in relation to substance disorders, the onset of anxiety disorders was more likely to precede that of substance disorders in all countries. These results illustrate the contribution of cross-national data to understanding the patterns and risk factors for psychopathology and substance use disorders.

Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey.

Data on the prevalences, comorbidities, and cohort effects of DSM-III-R major depression (MD) and minor depression (mD) are reported for the nationally representative sample of n = 1,769 adolescents and young adults who participated in the National Comorbidity Survey. Lifetime prevalences are 15.3% (MD) and 9.9% (mD), while 30-day prevalences are 5.8% (MD) and 2.1% (mD). Most cases reported recurrent episodes (73.9% of those with MD and 69.2% with mD) and significant role impairment, including attempted suicide among 21.9% of those with MD. The majority of lifetime cases (76.7% of those with MD and 69.3% with mD) reported other comorbid lifetime NCS/ DSM-III-R disorders. Depression was temporally secondary in the majority of these cases. Number of prior disorders was more important than type of disorders in predicting subsequent depression, raising the possibility that secondary depression is a nonspecific severity marker for earlier disorders. A cohort effect for both MD and mD was documented that persisted even for episodes lasting a year or longer. Increasing prevalences of prior comorbid disorders were found to play an important part in explaining the cohort effect for depression.

The prediction of length of major depressive episodes: results from an epidemiological sample of female twins.

In order to examine factors that influence the time to recovery (TTR) from depressive episodes in women, we examined members of 1030 female-female twin pairs of known zygosity, ascertained from a population-based twin registry. We predicted, in a Cox model, TTR in 235 women with an onset of an episode of major depression (MD) in the last year meeting DSM-III-R criteria. The median and mean TTR for episodes of MD was 42 and 82 days, respectively; only 2.2% of women had not recovered by 1 year. Four variables predicted TTR: financial difficulties, obsessive-compulsive symptoms, severe life events (SLEs), and genetic risk. Dividing all depressive episodes meeting symptomatic DSM-III-R criteria into early (5-28 days) and late (> 28 days) phases, significant predictors of TTR early in the course of illness (income, parental protectiveness and separation, personality, lifetime traumas and SLEs) differed from those that predicted TTR later in the depressive episode (health, social support, obsessive-compulsive symptoms, SLEs and genetic risk). Including cases with chronic MD increased the strength of personality, financial problems and genetic risk as predictors of slow TTR. These exploratory analyses suggest that TTR from MD in women is influenced by multiple environmental, temperamental and genetic factors. Predictors of TTR early and later in the course of MD may differ qualitatively, suggesting different processes in recovery from brief versus prolonged depressions.

Associations of substance use, abuse, and dependence with subsequent suicidal behavior.

General population survey data are used to disaggregate the associations of substance use disorders with suicide attempts in order to evaluate a number of hypotheses about the processes leading to these associations. Data are from the US National Comorbidity Survey (1990-1992). Discrete-time survival analysis is used to study the effects of retrospectively reported temporally prior substance use, abuse, and dependence in predicting first onset of suicidal behavior. Alcohol and drug use predict subsequent suicide attempts after controlling for sociodemographics and comorbid mental disorders. Previous use is not a significant predictor among current nonusers. Abuse and dependence are significant predictors among users for three of the 10 substances considered (alcohol, inhalants, and heroin). The number of substances used is more important than the types of substances used in predicting suicidal behavior. Disaggregation shows that the effects of use are largely on suicidal ideation and nonplanned attempts among ideators. In comparison, the effects of use on suicide plans and planned attempts among ideators are not significant. Clinicians need to be aware that current substance use, even in the absence of abuse or dependence, is a significant risk factor for unplanned suicide attempts among ideators.

Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey.

BACKGROUND: General population data were used to study co-morbidities between lifetime social phobia and mood disorders. METHODS: Data come from the US National Comorbidity Survey (NCS). RESULTS: Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2.9), dysthymia (2.7) and bipolar disorder (5.9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10-15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders. CONCLUSIONS: Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Bulimia nervosa and major depression: a study of common genetic and environmental factors.

A genetic analysis of the co-occurrence of bulimia and major depression (MD) was performed on 1033 female twin pairs obtained from a population based register. Personal interviews were conducted and clinical diagnoses made according to DSM-III-R criteria. Additive genes, but not family environment, are found to play an important aetiological role in both bulimia and MD. The genetic liabilities of the two disorders are correlated 0.456. While unique environmental factors account for around half of the variation in liability to both bulimia and MD, these risk factors appear to be unrelated, i.e., each disorder has its own set of unique environmental risk factors. Thus, the genetic liability of bulimia and MD is neither highly specific nor entirely non-specific. There is some genetic correlation between the two disorders as well as some genetic and environmental risk factors unique to each disorder. Limitations and directions for future research are discussed.

Fetal alcohol effects in alcoholic veteran patients.

Fetal alcohol syndrome is often associated with severe physical and neuropsychiatric maldevelopment. On the other hand, some offspring of women who drank during pregnancy appear to be affected in minimal ways and function relatively well within society. We questioned whether this effect of prenatal alcohol in the adult is generally minimal. To bear on this, we determined whether we could distinguish alcohol-exposed from nonexposed individuals in a population of male veterans, selected because of both their accepted level of function within society (e.g., honorable discharge from the military) and their admission to an alcohol treatment unit (thus, a greater likelihood of parental alcoholism, because of its familial aggregation). Consecutively admitted alcoholics (cases; n = 77) with likely maternal alcohol ingestion during their pregnancy or the first 10 years of life were matched with alcoholics with no maternal alcohol exposure during these periods (controls; n = 161). Each subject completed questionnaires regarding personal birthweight, alcohol, drug, educational and work histories, and family (including parental) alcohol and drug histories. We measured height, weight, and head circumference; checked for facial and hand anomalies; and took a frontal facial photograph, from which measurements of features were made. Data were analyzed by univariate statistics and stepwise logistic regression. No case had bona fide fetal alcohol syndrome. With univariate statistical analyses, the cases differed from the controls in 10 variables, including duration of drinking, width of alae nasae, being hyperactive or having a short attention span, and being small at birth. By stepwise logistic regression, the variables marital status, small size at birth, duration of drinking, and the presence of a smooth philtrum were marginally (the first two) or definitely (the last two) significant predictors of case status. Analysis of only the 37 cases in whom maternal prenatal drinking was the most likely yielded a marginal association for small size at birth (odds ratio = 3.1, p = 0.08) and a significant association for the presence of a smooth philtrum (odds ratio = 11.9, p = 0.005). Predictability was poor in all regression models. Based on the presence of this single physical finding (smooth philtrum), we estimate that the prevalence of manifestations of fetal alcohol exposure (fetal alcohol effects) is 6 to 13% in adult male veteran children (not necessarily nonveteran offspring) of women who drank alcohol during pregnancy. Thus, in our study of adult veterans, most individuals who were born to women who drank during pregnancy could not be differentiated from normal individuals, and those who were affected were distinguished by a single, nonspecific physical finding.