Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder.

OBJECTIVE: We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths. METHOD: We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM). RESULTS: A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment. CONCLUSION: Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

Anticipated fear and anxiety of Automated Driving Systems: Estimating the prevalence in a national representative survey

Background: Automated Driving Systems (ADS) may reshape mobility. Yet, related fear and anxiety are largely unknown. We estimated the prevalence and risk factors of anticipated anxiety towards ADS. Method: In a nationally representative face-to-face household survey, we assessed anticipated levels of anxiety towards ADS based on DSM-5 specific phobia criteria, using structured diagnostic interviews. We estimated weighted prevalences and conducted adjusted logistic regression models. Results: Of N = 2076 respondents, 40.82% (95%-confidence interval (CI) 37.73–43.98) anticipated experiencing some symptoms of phobia of ADS, 15.22% (CI 13.19–17.51) anticipated subthreshold phobia, and 3.39% (CI 2.42–4.75) anticipated full-blown phobia of ADS. Of subjects anticipating subthreshold phobia, 74.02% showed no strong, enduring fears of driving non-automated cars and 65.07% presented no other specific phobias (full-blown anticipated phobia: 50.37% and 50.03%, respectively). Anticipated phobia highly overlapped with anticipating marked or strong fears of passively encountering ADS in traffic (odds ratio 312.4–1982.2). Conclusion: About 20% of subjects anticipated at least subthreshold and 4% of subjects anticipated full-blown phobia of ADS. It appears to be distinct from fears related to non-automated driving and other specific phobias. Our findings call for prevention and treatment of phobia of ADS as they become increasingly ubiquitous. (AU)

Anticipated fear and anxiety of Automated Driving Systems: Estimating the prevalence in a national representative survey.

Background: Automated Driving Systems (ADS) may reshape mobility. Yet, related fear and anxiety are largely unknown. We estimated the prevalence and risk factors of anticipated anxiety towards ADS. Method: In a nationally representative face-to-face household survey, we assessed anticipated levels of anxiety towards ADS based on DSM-5 specific phobia criteria, using structured diagnostic interviews. We estimated weighted prevalences and conducted adjusted logistic regression models. Results: Of N = 2076 respondents, 40.82% (95%-confidence interval (CI) 37.73-43.98) anticipated experiencing some symptoms of phobia of ADS, 15.22% (CI 13.19-17.51) anticipated subthreshold phobia, and 3.39% (CI 2.42-4.75) anticipated full-blown phobia of ADS. Of subjects anticipating subthreshold phobia, 74.02% showed no strong, enduring fears of driving non-automated cars and 65.07% presented no other specific phobias (full-blown anticipated phobia: 50.37% and 50.03%, respectively). Anticipated phobia highly overlapped with anticipating marked or strong fears of passively encountering ADS in traffic (odds ratio 312.4-1982.2). Conclusion: About 20% of subjects anticipated at least subthreshold and 4% of subjects anticipated full-blown phobia of ADS. It appears to be distinct from fears related to non-automated driving and other specific phobias. Our findings call for prevention and treatment of phobia of ADS as they become increasingly ubiquitous.

Induction of Efficacy Expectancies in an Ambulatory Smartphone-Based Digital Placebo Mental Health Intervention: Randomized Controlled Trial.

BACKGROUND: There is certain evidence on the efficacy of smartphone-based mental health interventions. However, the mechanisms of action remain unclear. Placebo effects contribute to the efficacy of face-to-face mental health interventions and may also be a potential mechanism of action in smartphone-based interventions. OBJECTIVE: This study aimed to investigate whether different types of efficacy expectancies as potential factors underlying placebo effects could be successfully induced in a smartphone-based digital placebo mental health intervention, ostensibly targeting mood and stress. METHODS: We conducted a randomized, controlled, single-blinded, superiority trial with a multi-arm parallel design. Participants underwent an Android smartphone-based digital placebo mental health intervention for 20 days. We induced prospective efficacy expectancies via initial instructions on the purpose of the intervention and retrospective efficacy expectancies via feedback on the success of the intervention at days 1, 4, 7, 10, and 13. A total of 132 healthy participants were randomized to a prospective expectancy-only condition (n=33), a retrospective expectancy-only condition (n=33), a combined expectancy condition (n=34), or a control condition (n=32). As the endpoint, we assessed changes in efficacy expectancies with the Credibility Expectancy Questionnaire, before the intervention and on days 1, 7, 14, and 20. For statistical analyses, we used a random effects model for the intention-to-treat sample, with intervention day as time variable and condition as two factors: prospective expectancy (yes vs no) and retrospective expectancy (yes vs no), allowed to vary over participant and intervention day. RESULTS: Credibility (ß=-1.63; 95% CI -2.37 to -0.89; P<.001) and expectancy (ß=-0.77; 95% CI -1.49 to -0.05; P=.04) decreased across the intervention days. For credibility and expectancy, we found significant three-way interactions: intervention day×prospective expectancy×retrospective expectancy (credibility: ß=2.05; 95% CI 0.60-3.50; P=.006; expectancy: ß=1.55; 95% CI 0.14-2.95; P=.03), suggesting that efficacy expectancies decreased least in the combined expectancy condition and the control condition. CONCLUSIONS: To our knowledge, this is the first empirical study investigating whether efficacy expectancies can be successfully induced in a specifically designed placebo smartphone-based mental health intervention. Our findings may pave the way to diminish or exploit digital placebo effects and help to improve the efficacy of digital mental health interventions. TRIAL REGISTRATION: Clinicaltrials.gov NCT02365220; https://clinicaltrials.gov/ct2/show/NCT02365220.

Impact of Childhood Maltreatment in Borderline Personality Disorder on Treatment Response to Intensive Dialectical Behavior Therapy.

Childhood maltreatment (CM), including emotional, physical, and sexual abuse and emotional and physical neglect, is associated with severity of borderline personality disorder (BPD). However, knowledge on the impact of CM on treatment response is scarce. The authors investigated whether self-reported CM or one of its subtypes affected treatment retention, depressive symptoms, and impulsivity throughout short-term intensive dialectical behavior therapy (I-DBT) in 333 patients with BPD. Data were analyzed with linear and logistic regressions and linear mixed models, using a Bayesian approach. Patients who reported childhood emotional abuse had a higher dropout rate, whereas it was lower in patients who reported childhood emotional neglect. Emotional neglect predicted a greater decrease of depressive symptoms, and global CM predicted a greater decrease of impulsivity. The authors concluded that patients with BPD who experienced CM might benefit from I-DBT in specific symptom domains. Nonetheless, the impact of emotional abuse on higher dropout needs to be considered.

Maternal psychopathology and offspring mental health service utilization in adolescents without mental disorders: a national representative survey.

We investigated whether maternal psychopathology predicts offspring mental health service utilization in adolescents without mental disorders. We used weighted data (N = 2317) from NCS-A participants (age: 13-18 years) who did not meet DSM-IV criteria for any lifetime mental disorder. Adolescent mental disorders were assessed with the WHO CIDI. Maternal psychopathology was obtained by self-report. Adolescent mental health service use was assessed with the Service Assessment for Children and Adolescents. Substantial associations between maternal psychopathology and mental health service use in offspring without mental disorders were found between affective disorders and the mental health/medical specialty (hazard ratio (HR) = 2.49, 95% confidence interval (CI) = 1.60-3.90) and any service sector (HR = 2.14, CI = 1.45-3.16), anxiety disorders and any service sector (HR = 1.63, CI = 1.13-2.35), behavior disorders and the school (HR = 3.69, CI = 1.39-9.77) and any service sector (HR = 2.81, CI = 1.12-7.07), substance use disorders and the mental health/medical specialty (HR = 3.75, CI = 1.75-8.03), the school (HR = 3.17, CI = 1.43-7.02), and any service sector (HR = 3.66, CI = 2.00-6.70), and any mental disorder and the mental health/medical specialty (HR = 2.10, CI = 1.34-3.30) and any service sector (HR = 2.03, CI = 1.40-2.92). Results were comparable when restricting analyses to offspring with no indication of suicidality and no more than three life events during the past 12 months. The likelihood of service use was higher among offspring of mothers with mental disorders, compared to mothers without mental disorders. Considering maternal mental disorder status may help to identify subjects at risk of overtreatment.

Personalized prediction of smartphone-based psychotherapeutic micro-intervention success using machine learning.

BACKGROUND: Tailoring healthcare to patients' individual needs is a central goal of precision medicine. Combining smartphone-based interventions with machine learning approaches may help attaining this goal. The aim of our study was to explore the predictability of the success of smartphone-based psychotherapeutic micro-interventions in eliciting mood changes using machine learning. METHODS: Participants conducted daily smartphone-based psychotherapeutic micro-interventions, guided by short video clips, for 13 consecutive days. Participants chose one of four intervention techniques used in psychotherapeutic approaches. Mood changes were assessed using the Multidimensional Mood State Questionnaire. Micro-intervention success was predicted using random forest (RF) tree-based mixed-effects logistic regression models. Data from 27 participants were used, totaling 324 micro-interventions, randomly split 100 times into training and test samples, using within-subject and between-subject sampling. RESULTS: Mood improved from pre- to post-intervention in 137 sessions (initial success-rate: 42.3%). The RF approach resulted in predictions of micro-intervention success significantly better than the initial success-rate within and between subjects (positive predictive value: 0.732 (95%-CI: 0.607; 0.820) and 0.698 (95%-CI: 0.564; 0.805), respectively). Prediction quality was highest using the RF approach within subjects (rand accuracy: 0.75 (95%-CI: 0.641; 0.840), Matthew's correlation coefficient: 0.483 (95%-CI: 0.323; 0.723)). LIMITATIONS: The RF approach does not allow firm conclusions about the exact contribution of each factor to the algorithm's predictions. We included a limited number of predictors and did not compare whether predictability differed between psychotherapeutic techniques. CONCLUSIONS: Our findings may pave the way for translation and encourage scrutinizing personalized prediction in the psychotherapeutic context to improve treatment efficacy.

Mediation analysis of triple networks revealed functional feature of mindfulness from real-time fMRI neurofeedback.

The triple networks, namely the default-mode network (DMN), the central executive network (CEN), and the salience network (SN), play crucial roles in disorders of the brain, as well as in basic neuroscientific processes such as mindfulness. However, currently, there is no consensus on the underlying functional features of the triple networks associated with mindfulness. In this study, we tested the hypothesis that (a) the partial regression coefficient (i.e., slope): from the SN to the DMN, mediated by the CEN, would be one of the potential mindfulness features in the real-time functional magnetic resonance imaging (rtfMRI) neurofeedback (NF) setting, and (b) this slope level may be enhanced by rtfMRI-NF training. Sixty healthy mindfulness-naïve males participated in an MRI session consisting of two non-rtfMRI-runs, followed by two rtfMRI-NF runs and one transfer run. Once the regions-of-interest of each of the triple networks were defined using the non-rtfMRI-runs, the slope level was calculated by mediation analysis and used as neurofeedback information, in the form of a thermometer bar, to assist with participant mindfulness during the rtfMRI-NF runs. The participants were asked to increase the level of the thermometer bar while deploying a mindfulness strategy, which consisted of focusing attention on the physical sensations of breathing. rtfMRI-NF training was conducted as part of a randomized controlled trial design, in which participants were randomly assigned to either an experimental group or a control group. The participants in the experimental group received contingent neurofeedback information, which was obtained from their own brain signals, whereas the participants in the control group received non-contingent neurofeedback information that originated from matched participants in the experimental group. Our results indicated that the slope level from the SN to the DMN, mediated by the CEN, was associated with mindfulness score (rtfMRI-NF runs: r = 0.53, p = 0.007; p-value was corrected from 10,000 random permutations) and with task-performance feedback score (rtfMRI-NF run: r = 0.61, p = 0.001) in the experimental group only. In addition, during the rtfMRI-NF runs the level of the partial regression coefficient feature was substantially increased in the experimental group compared to the control group (p < 0.05 from the paired t-test; the p-value was corrected from 10,000 random permutations). To the best of our knowledge, this is the first study to demonstrate a partial regression coefficient feature of mindfulness in the rtfMRI-NF setting obtained by triple network mediation analysis, as well as the possibility of enhancement of the partial regression coefficient feature by rtfMRI-NF training.

Maternal psychopathology and mental health treatment delay in adolescents from a national cohort.

OBJECTIVE: To investigate whether maternal psychopathology predicts mental health service use and treatment delay in offspring with mental disorders. DATA SOURCES: Weighted data collected between 2001 and 2004 from NCS-A participants (age: 13-18 years; N = 2939) meeting DSM-IV criteria for any lifetime mental disorder, assessed with WHO CIDI, and from their biological mothers. STUDY DESIGN: National representative cohort. DATA COLLECTION: Maternal psychopathology was assessed with self-report, adolescent mental health service use with the Service Assessment for Children and Adolescents. PRINCIPAL FINDINGS: Maternal psychopathology predicted offspring mental health service use across various service sectors, except for school services. In the mental health specialty sector, estimates were highest for maternal affective (hazard ratio (HR) = 2.17, 95 percent confidence interval (CI) = 1.66-2.82) and any mental disorder (HR = 2.13, 95 percent CI = 1.53-2.97). For offspring use of any mental health services, estimates were highest for maternal behavior (HR = 1.60, 95 percent CI = 1.15-2.21) and substance use disorders (HR = 1.57, 95 percent CI = 1.09-2.24). Treatment delay of offspring mental health service use was predicted by maternal behavior disorders. CONCLUSIONS: Maternal psychopathology fostered mental health service use in offspring with mental disorders, while maternal behavior disorders might also retard treatment. Considering parental psychopathology may help improving the prevention of unmet offspring service needs.

The psychobiology of using automated driving systems: A systematic review and integrative model.

Using vehicles with engaged automated driving systems (ADS) ('highly automated driving', HAD) will substantially impact on future society's mobility, yet the current understanding of human psychobiology related to HAD is still limited. Hence, we synthesized evidence on the psychobiology of subjects using HAD, informing an integrative model of the psychobiology of HAD, and providing guidance for reporting future research on this topic. We included (non-)randomized studies assessing human peripheral biology markers of in-vehicle-users in real or simulated driving environments, using vehicles with vs. without engaged ADS, published in English until April 2018. We systematically searched Web of Science, SCOPUS, and PubMed. The search consisted of a combination of terms describing HAD and psychobiological parameters. Risk of bias was assessed regarding randomization, blinding, incomplete outcome data, selective outcome reporting, and other potential causes. We extracted data using predefined data fields. Four out of five studies included in this review (N = 194 subjects) reported associations of use of vehicles with vs. without engaged ADS with various psychobiological parameters, including heart rate, respiratory sinus arrhythmia (RSA), indicators of electrodermal activity (EDA), and masseter electromyography (EMG). Heart rate tended to be reduced during HAD along with increased EDA and EMG, with no clear indication for changes in RSA. We cannot exclude substantial risk of bias, among others because the status of engagement of ADS was mostly non-randomized. Yet, findings suggest that HAD goes along with tractable changes in peripheral biology. Informed by the conceptual endophenotype approach (Hellhammer et al., 2018, Psychoneuroendocrinology), we propose the Embodied Driving (EMBODD) model that describes how HAD reshapes vehicle use experience, and highlight how to make future ADS equipped vehicles successful regarding user's health. Based on the review, we suggest reporting guidelines for future research on the psychobiology of HAD.

Dialectical behavior therapy skills training affects defense mechanisms in borderline personality disorder: An integrative approach of mechanisms in psychotherapy.

Objective: Borderline personality disorder (BPD) is characterized by immature defense mechanisms. Dialectical behavior therapy (DBT) is an effective treatment for BPD. However, understanding the underlying mechanisms of change is still limited. Using a transtheoretical framework, we investigated the effect of DBT skills training on defense mechanisms. Method: In this randomized controlled trial, 16 of 31 BPD outpatients received DBT skills training adjunctive to individual treatment as usual (TAU), while the remaining 15 received only individual TAU. Pre-post changes of defense mechanisms, assessed with the Defense Mechanism Rating Scale, were compared between treatment conditions using ANCOVAs. Partial correlations and linear regressions were conducted to explore associations between defenses and symptom outcome. Results: Overall defense function improved significantly more in the skills training condition (F(1, 28) = 4.57, p = .041). Borderline defenses decreased throughout skills training, but not throughout TAU only (F(1, 28) = 5.09, p = .032). In the skills training condition, an increase in narcissistic defenses was associated with higher symptom scores at discharge (ß = 0.58, p = .02). Conclusions: Although DBT does not explicitly target defense mechanisms, skills training may have favorable effects on defense function in BPD. Our findings contribute to an integrative understanding of mechanisms of change in BPD psychotherapy.

Chronology of Onset of Mental Disorders and Physical Diseases in Mental-Physical Comorbidity - A National Representative Survey of Adolescents.

BACKGROUND: The objective was to estimate temporal associations between mental disorders and physical diseases in adolescents with mental-physical comorbidities. METHODS: This article bases upon weighted data (N = 6483) from the National Comorbidity Survey Adolescent Supplement (participant age: 13-18 years), a nationally representative United States cohort. Onset of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition lifetime mental disorders was assessed with the fully structured World Health Organization Composite International Diagnostic Interview, complemented by parent report. Onset of lifetime medical conditions and doctor-diagnosed diseases was assessed by self-report. RESULTS: The most substantial temporal associations with onset of mental disorders preceding onset of physical diseases included those between affective disorders and arthritis (hazard ratio (HR) = 3.36, 95%-confidence interval (CI) = 1.95 to 5.77) and diseases of the digestive system (HR = 3.39, CI = 2.30 to 5.00), between anxiety disorders and skin diseases (HR = 1.53, CI = 1.21 to 1.94), and between substance use disorders and seasonal allergies (HR = 0.33, CI = 0.17 to 0.63). The most substantial temporal associations with physical diseases preceding mental disorders included those between heart diseases and anxiety disorders (HR = 1.89, CI = 1.41 to 2.52), epilepsy and eating disorders (HR = 6.27, CI = 1.58 to 24.96), and heart diseases and any mental disorder (HR = 1.39, CI = 1.11 to 1.74). CONCLUSIONS: Findings suggest that mental disorders are antecedent risk factors of certain physical diseases in early life, but also vice versa. Our results expand the relevance of mental disorders beyond mental to physical health care, and vice versa, supporting the concept of a more integrated mental-physical health care approach, and open new starting points for early disease prevention and better treatments, with relevance for various medical disciplines.

Smartphone-Based Psychotherapeutic Micro-Interventions to Improve Mood in a Real-World Setting.

BACKGROUND: Using mobile communication technology as new personalized approach to treat mental disorders or to more generally improve quality of life is highly promising. Knowledge about intervention components that target key psychopathological processes in terms of transdiagnostic psychotherapy approaches is urgently needed. We explored the use of smartphone-based micro-interventions based on psychotherapeutic techniques, guided by short video-clips, to elicit mood changes. METHOD: As part of a larger neurofeedback study, all subjects-after being randomly assigned to an experimental or control neurofeedback condition-underwent daily smartphone-based micro-interventions for 13 consecutive days. They were free to choose out of provided techniques, including viscerosensory attention, emotional imagery, facial expression, and contemplative repetition. Changes in mood were assessed in real world using the Multidimensional Mood State Questionnaire (scales: good-bad, GB; awake-tired, AT; and calm-nervous, CN). RESULTS: Twenty-seven men participated on at least 11 days and were thus included in the analyses. Altogether, they underwent 335, generally well-tolerated, micro-intervention sessions, with viscerosensory attention (178 sessions, 53.13%) and contemplative repetition (68 sessions, 20.30%) being the most frequently applied techniques. Mixed models indicated that subjects showed better mood [GB: b = 0.464, 95%confidence interval (CI) [0.068, 0.860], t (613.3) = 2.298, p = 0.022] and became more awake [AT: b = 0.514, 95%CI [0.103, 0.925], t (612.4) = 2.456, p = 0.014] and calmer [CN: b = 0.685, 95%CI [0.360, 1.010], t (612.3) = 4.137, p < 0.001] from pre- to post-micro-intervention. These mood improvements from pre- to post-micro-intervention were associated with changes in mood from the 1st day until the last day with regard to GB mood (r = 0.614, 95%CI [0.297, 0.809], p < 0.001), but not AT mood (r = 0.279, 95%CI [-0.122, 0.602], p = 0.167) and CN mood (r = 0.277, 95%CI [0.124, 0.601], p = 0.170). DISCUSSION: Our findings provide evidence for the applicability of smartphone-based micro-interventions eliciting short-term mood changes, based on techniques used in psychotherapeutic approaches, such as mindfulness-based psychotherapy, transcendental meditation, and other contemplative therapies. The results encourage exploring these techniques' capability to improve mood in randomized controlled studies and patients. Smartphone-based micro-interventions are promising to modify mood in real-world settings, complementing other psychotherapeutic interventions, in line with the precision medicine approach. The here presented data were collected within a randomized trial, registered at ClinicalTrials.gov (Identifier: NCT01921088) https://clinicaltrials.gov/ct2/show/NCT01921088.

Comorbidity of Mental Disorders and Chronic Pain: Chronology of Onset in Adolescents of a National Representative Cohort.

UNLABELLED: This study sought to estimate (1) the prevalence of the co-occurrence of, (2) the association between, and (3) the sequence of onset of chronic pain and mental disorders in adolescents. We used weighted data (N = 6,483) from the National Comorbidity Survey Replication Adolescent Supplement (participants' age, 13-18 years). Lifetime chronic pain was assessed by adolescent self-report; lifetime DSM-IV mental disorders were assessed by the WHO Composite International Diagnostic Interview, complemented by parent report. Among the participants in the study, 1,600 of 6,476 (25.93%) had experienced any type of chronic pain and any mental disorder in their lifetime. All types of pain were related to mental disorders. The most substantial temporal associations were those with onset of mental disorders preceding onset of chronic pain, including those between affective disorders and headaches and any chronic pain; between anxiety disorders and chronic back/neck pain, headaches, and any chronic pain; between behavior disorders and headaches and any chronic pain; and between any mental disorder and chronic back/neck pain, headaches, and any chronic pain. PERSPECTIVE: Findings indicate that affective, anxiety, and behavior disorders are early risk factors of chronic pain, thereby highlighting the relevance of child mental disorders for pain medicine. To improve prevention and interventions for chronic pain, integrative care should be considered.

Association between mental disorders and physical diseases in adolescents from a nationally representative cohort.

OBJECTIVE: Pediatric health care and research focus mostly on single morbidities, although the single-disease framework has been challenged. The main objective was to estimate associations between childhood mental disorders and physical diseases. METHODS: This study is based on weighted data (n = 6482) from the National Comorbidity Survey Replication Adolescent Supplement (age, 13-18 years). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition lifetime mental disorders were assessed using the fully structured World Health Organization Composite International Diagnostic Interview, complemented by parent report. Lifetime medical conditions and doctor-diagnosed diseases were assessed by adolescent self-report. RESULTS: Of 6469 participants, 2137 (35.33%) reported at least one mental disorder and one physical disease. The most substantial associations included those between affective disorders and diseases of the digestive system (odds ratio [OR] = 3.46, 95% confidence interval [CI] = 2.28-5.24), anxiety disorders and arthritis (OR = 2.27, CI = 1.34-3.85), anxiety disorders and heart diseases (OR = 2.41, CI = 1.56-3.73), anxiety disorders and diseases of the digestive system (OR = 2.18, CI = 1.35-3.53), and eating disorders and epilepsy/seizures (OR = 5.45, CI = 1.57-18.87). Sociodemographic factors did not account for the association between mental disorders and physical diseases. CONCLUSIONS: Findings suggest that mental disorders and physical diseases often co-occur in childhood. This association is a major public health challenge, and the child health system needs additional strategies in patient-centered care, research, medical education, health policy, and economics to develop well-coordinated interdisciplinary approaches linking mental and physical care in children.

School mental health services: signpost for out-of-school service utilization in adolescents with mental disorders? A nationally representative United States cohort.

BACKGROUND: School mental health services are important contact points for children and adolescents with mental disorders, but their ability to provide comprehensive treatment is limited. The main objective was to estimate in mentally disordered adolescents of a nationally representative United States cohort the role of school mental health services as guide to mental health care in different out-of-school service sectors. METHODS: Analyses are based on weighted data (N = 6483) from the United States National Comorbidity Survey Replication Adolescent Supplement (participants' age: 13-18 years). Lifetime DSM-IV mental disorders were assessed using the fully structured WHO CIDI interview, complemented by parent report. Adolescents and parents provided information on mental health service use across multiple sectors, based on the Service Assessment for Children and Adolescents. RESULTS: School mental health service use predicted subsequent out-of-school service utilization for mental disorders i) in the medical specialty sector, in adolescents with affective (hazard ratio (HR) = 3.01, confidence interval (CI) = 1.77-5.12), anxiety (HR = 3.87, CI = 1.97-7.64), behavior (HR = 2.49, CI = 1.62-3.82), substance use (HR = 4.12, CI = 1.87-9.04), and eating (HR = 10.72, CI = 2.31-49.70) disorders, and any mental disorder (HR = 2.97, CI = 1.94-4.54), and ii) in other service sectors, in adolescents with anxiety (HR = 3.15, CI = 2.17-4.56), behavior (HR = 1.99, CI = 1.29-3.06), and substance use (HR = 2.48, CI = 1.57-3.94) disorders, and any mental disorder (HR = 2.33, CI = 1.54-3.53), but iii) not in the mental health specialty sector. CONCLUSIONS: Our findings indicate that in the United States, school mental health services may serve as guide to out-of-school service utilization for mental disorders especially in the medical specialty sector across various mental disorders, thereby highlighting the relevance of school mental health services in the trajectory of mental care. In light of the missing link between school mental health services and mental health specialty services, the promotion of a stronger collaboration between these sectors should be considered regarding the potential to improve and guarantee adequate mental care at early life stages.