300 word each answer and you have 9 different work

Annu. Rev. Clin. Psychol. 2007. 3:137–58

First published online as a Review in Advance on December 6, 2006

The Annual Review of Clinical Psychology is online at http://clinpsy.annualreviews.org

This article’s doi: 10.1146/annurev.clinpsy.3.022806.091444

Copyright c© 2007 by Annual Reviews. All rights reserved

1548-5943/07/0427-0137$20.00

Key Words

bipolar disorder, depression, manic-depression, major depressive disorder

Abstract The results of recent community epidemiological research are re- viewed, documenting that major depressive disorder (MDD) is a highly prevalent, persistent, and often seriously impairing disorder, and that bipolar disorder (BPD) is less prevalent but more persis- tent and more impairing than MDD. The higher persistence and severity of BPD results in a substantial proportion of all seriously impairing depressive episodes being due to threshold or subthresh- old BPD rather than to MDD. Although the percentage of people with mood disorders in treatment has increased substantially since the early 1990s, a majority of cases remain either untreated or under- treated. An especially serious concern is the misdiagnosis of depres- sive episodes due to BPD as due to MDD because the majority of depression treatment involves medication provided by primary care doctors in the absence of psychotherapy. The article closes with a discussion of future directions for research.

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Prevalence, Comorbidity, and Service Utilization for Mood Disorders in the United States at the Beginning of the Twenty-first Century Ronald C. Kessler,1 Kathleen R. Merikangas,2

and Philip S. Wang3 1 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts 02115, 2 Intramural Research Program, Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Bethesda, Maryland 20892, 3 Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland 20892; email: [email protected]

Contents

INTRODUCTION . . . . . . . . . . . . . . . . . 138 METHODS . . . . . . . . . . . . . . . . . . . . . . . . 139 LIFETIME AND 12-MONTH

PREVALENCE . . . . . . . . . . . . . . . . . . 142 AGE-OF-ONSET

DISTRIBUTIONS . . . . . . . . . . . . . . 142 PERSISTENCE . . . . . . . . . . . . . . . . . . . . 144 COMORBIDITY . . . . . . . . . . . . . . . . . . . 144 CLINICAL SEVERITY . . . . . . . . . . . . . 145 SEVERITY OF ROLE

IMPAIRMENT . . . . . . . . . . . . . . . . . . 146 TREATMENT . . . . . . . . . . . . . . . . . . . . . 148 OVERVIEW . . . . . . . . . . . . . . . . . . . . . . . 149 FUTURE DIRECTIONS . . . . . . . . . . . 149

INTRODUCTION

Although community surveys of mental disor- ders have been carried out in the United States since the end of World War II (Comstock & Helsing 1976, Helgason 1964, Lin 1953), it was not until the early 1980s that the develop- ment of fully structured diagnostic interviews made it possible to estimate the prevalence of specific mental disorders in these surveys (Robins et al. 1981, Robins & Regier 1991). Although a number of large-scale surveys us- ing fully structured diagnostic interviews have been carried out since that time, changes in the criteria for mood disorders in successive editions of the American Psychiatric Asso- ciation’s Diagnostic and Statistical Manual of Mental Disorders (DSM) have hampered ef- forts to replicate results. The most recent na- tionally representative population data on the prevalence and correlates of mood disorders come from the National Comorbidity Survey Replication (NCS-R) (Kessler & Merikangas 2004). The current report presents an overview of NCS-R results on the preva- lence, comorbidity, and treatment of mood disorders.

The term “prevalence” refers to the pro- portion of the population that has a disor-

der in some specified interval of time (Susser et al. 2006). The two most commonly studied prevalence estimates in the literature are life- time prevalence (the proportion of the pop- ulation that has a history of the disorder as of the point in time of the assessment) and 12-month prevalence (the proportion of the population that had the disorder at some time in the 12 months before the assessment). The ratio of 12-month to lifetime prevalence has been used as a rough indirect indicator of dis- order persistence (Kessler et al. 2005), but this ratio is difficult to interpret because it does not take into consideration time since first onset. The latter is a joint function of age at onset and age at interview. Age at onset is typically assessed retrospectively in surveys of mood disorders in an effort to calculate the age-of- onset (AOO) distribution (Burke et al. 1991), a curve that shows the increase in the lifetime prevalence of the disorder with increasing age. The AOO curve is of interest both because it allows us to make projections of lifetime risk and because it helps us understand variation in onset risk across the life course.

Few surveys of mental illness tell us much about the persistence of mood disorders over the life course, although as noted in the pre- vious paragraph, attempts have been made to make inferences about persistence by com- paring 12-month and lifetime prevalence es- timates. In addition to the difficulty with this approach being a joint function of age at on- set and age at interview, it is also problematic because recall bias is likely in reports about AOO (Simon & VonKorff 1992). A num- ber of recent surveys have consequently at- tempted to improve on this approach by ask- ing explicit questions about course (Kessler & Ustun 2004). A small number of longitudinal studies also exist that have examined persis- tence directly either in community samples (Mattisson et al. 2005, Murphy et al. 2004) or in clinical samples (Judd et al. 2000). Recent findings from the NCS-R are reviewed that extend our findings in this area.

We also review evidence regarding the se- riousness of mood disorders in the general

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Fully structured diagnostic interviews: interviews based on respondent answers to largely structured questions and do not require interview clinical judgments of responses

NCS-R: National Comorbidity Survey Replication

Comorbidity: the joint occurrence of two or more disorders in the same person either at a specified point in time or over a specified interval of time

Prevalence: the proportion of the population that has a given disorder at a point either in time or at some point in an interval of time

population both in terms of clinical severity and in terms of severity of role impairment. A good deal is known about the severity of mood disorders among people who seek treatment ( Judd et al. 2002, Paykel et al. 2006). Little is known, though, about whether untreated cases of mood disorder are similarly severe. This is an important issue in estimating the societal burden of mood disorders for pur- poses of policy planning. The main approach to making such estimates up to now has been to use information about clinical cases to make inferences about the severity of community cases (Morrow et al. 1998). This approach is almost certainly flawed. The NCS-R took a different approach to this problem by build- ing into the community survey fully struc- tured versions of the standard clinical sever- ity measures used in treatment studies. As described in the body of the paper, surprising results about the severity of mood disorders in the community emerged from the analysis of these data.

Comorbidity is known to be a com- mon feature of mood disorders (Goodwin & Jamison 1990, Kessler 1995) and has been studied in order to investigate the underly- ing processes leading to the joint occurrence of multiple disorders (Khan et al. 2005) as well as to investigate the effects of temporally primary disorders on secondary disorders (Hettema et al. 2003). However, only a lim- ited amount of work has been done to investi- gate the comorbidity of mood disorders with a wide range of other conditions in large rep- resentative community surveys (Kessler et al. 1996). Recent results in this area are reviewed below.

Finally, we review the most recent NCS-R data on patterns of treatment of mood dis- orders in the United States. We know from tracking administrative databases that the number of people seeking treatment for men- tal disorders increased dramatically in the 1990s (Olfson et al. 2002b, 2004). Much less is known, though, about correlates of that trend or about adequacy of the increased treatment. Important trend results based on compari-

AOO (age-of-onset) curve: a curve that shows the cumulative lifetime probability of occurrence of a given disorder as a function of age

son of the baseline NCS and the subsequent NCS-R are reviewed here.

METHODS

The NCS-R is a psychiatric epidemiological survey of English-speaking adult household residents of the continental United States. Interviews were carried out with 9282 re- spondents between February 2001 and April 2003. Informed consent was obtained prior to data collection. The response rate was 70.9%. Respondents were given a $50 incentive for participation. In addition, a probability sub- sample of hard-to-recruit predesignated re- spondents was selected for a brief telephone nonrespondent survey, the results of which were used to weight the main sample for non- response bias. Nonrespondent survey partic- ipants were given a $100 incentive. A series of clinical reappraisal studies was carried out in various NCS-R subsamples in which clin- ical interviewers contacted respondents sub- sequent to their participation in the NCS- R and evaluated these respondents for the presence of various DSM-IV (Am. Psychiatr. Assoc. 1994) disorders blinded to the diag- nostic assessments in the main survey. Sep- arate consent was obtained and financial in- centive provided for participation in clinical reappraisal interviews. The Human Subjects Committees of Harvard Medical School and the University of Michigan both approved these recruitment and consent procedures.

The NCS-R interview was administered in two parts. Part I included a core diagnostic as- sessment of all respondents. Part II included questions about correlates and additional dis- orders administered to all Part I respondents who met lifetime criteria for any core disor- der plus a roughly one-in-three probability subsample of other respondents (n 5692). An assessment of work performance, which we discuss below, was included in Part II in the subsample of 3378 respondents were ei- ther employed or self-employed 20 hours or more per week in the month before the inter- view. The records for Part II respondents were

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=

CIDI: World Health Organization’s Composite International Diagnostic Interview

MDD: major depressive disorder

BPD: bipolar disorder

MDE: major depressive episode (due to either BPD or MDD)

weighted to adjust for differential probability of selection into Part II and for differential nonresponse. A more detailed discussion of NCS-R sampling and weighting is presented elsewhere (Kessler et al. 2004a).

NCS-R diagnoses are based on Version 3.0 of the World Health Organization’s Composite International Diagnostic Inter- view (CIDI) (Kessler & Ustun 2004), a fully structured lay-administered diagnostic inter- view. DSM-IV criteria were used to define all disorders. Both lifetime and 12-month prevalence were assessed. The core disor- ders assessed in addition to mood disor- ders include anxiety disorders (panic disor- der, generalized anxiety disorder, phobias, obsessive-compulsive disorder, and posttrau- matic stress disorder), impulse-control dis- orders (oppositional-defiant disorder, con- duct disorder, attention-deficit/hyperactivity disorder, and intermittent explosive disor- der), and substance disorders (alcohol and drug abuse with or without dependence). Or- ganic exclusion rules were used in making all diagnoses. As detailed elsewhere (Kessler et al. 2004a, 2005), blinded clinical reinter- views using the nonpatient version of the Structured Clinical Interview for DSM-IV (SCID) (First et al. 2002) with a probabil- ity subsample of NCS-R respondents found generally good concordance between CIDI/ DSM-IV diagnoses of anxiety and substance disorders and independent clinical assess- ments. Impulse-control disorder diagnoses were not validated, as the SCID clinical reap- praisal interviews did not include an assess- ment of these disorders.

The DSM-IV mood disorders assessed in the NCS-R include major depressive disor- der (MDD) and bipolar disorder (BPD). Di- agnosis of BPD required separate assessments of major depressive episode (MDE), mania, and hypomania. Respondents were classified as having lifetime MDD if they ever had MDE and never had either mania or hypomania. They were classified as having lifetime bipo- lar I disorder (BP-I) if they ever had a manic episode. They were classified as having life-

time bipolar II disorder (BP-II) if they ever had a hypomanic episode (in the absence of a lifetime manic episode) and ever had MDE. Mixed episodes and rapid cycling subtypes of bipolar disorder were not assessed, leading to a likely overestimation of number of lifetime episodes of mania/hypomania and MDE due to double counting. Organic exclusions were made in making diagnoses.

We also investigated subthreshold BPD, which was defined as occurring in any of three situations: (a) if the respondent had a history of recurrent (two or more lifetime episodes) subthreshold hypomania (at least two DSM- IV Criterion B symptoms along with all other criteria for hypomania) in the presence of in- tercurrent MDE; (b) if the respondent had a history of recurrent hypomania in the absence of recurrent MDE with or without subthresh- old MDE; or (c) if the respondent had a history of recurrent subthreshold hypomania in the absence of intercurrent MDE with or without subthreshold MDE. The reduction in number of required symptoms for a determination of subthreshold hypomania was confined to two Criterion B symptoms (from the DSM-IV re- quirement of three—four if the mood is only irritable) in order to retain the core features of hypomania in the subthreshold definition. Recurrent hypomania or subthreshold hypo- mania in the absence of intercurrent MDE was included in the definition because it is part of the DSM-IV definition of BPD not other- wise specified. For purposes of this review, we define the bipolar spectrum as a lifetime his- tory of BP-I, BP-II, or subthreshold BPD as specified above. All diagnoses excluded cases with plausible organic causes.

As described in more detail elsewhere (Haro et al. 2007, Kessler et al. 2004a, 2005), a comparison of CIDI and SCID diagnoses in a clinical reappraisal sample showed good con- cordance at the individual level for lifetime prevalence of MDE (κ 0.59), with 78% of CIDI lifetime cases confirmed by the SCID. At the aggregate level, the CIDI lifetime MDE prevalence estimate was significantly lower than the SCID estimate (χ 2 1 8.1,

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p 0.004). CIDI-SCID concordance was also excellent for any BPD (i.e., BP-I, BP-II, or subthreshold BPD; κ 0.94), with 88% of CIDI cases confirmed by the SCID and an insignificant difference in CIDI versus SCID prevalence estimates (χ 2 1 0.6, p 0.45) (Kessler et al. 2007). Concordance (κ) for in- dividual BPD diagnoses was lower, but still acceptable: 0.88 for BP-I, 0.50 for BP-II, and 0.51 for subthreshold BPD, and 0.89 for ei- ther BP-II or subthreshold BPD, with CIDI versus SCID prevalence differences consis- tently insignificant (χ 2 1 0.1–0.3, p 0.56– 0.75). The much lower κ values for BP-II and subthreshold BPD than for BP-I reflects the fact that the CIDI distinguishes respon- dents with these disorders with good accuracy in comparison to respondents without BPD, but has difficulty distinguishing between BP-II and subthreshold BPD.

AOO of MDE, mania, hypomania, and subthreshold hypomania was assessed with retrospective self-reports at the syndrome level. Respondents with lifetime MDD were defined as 12-month cases if they were in an episode at any time in the 12 months before interview. Respondents with lifetime BPD were defined as 12-month cases if they had an episode of MDE, mania, hypomania, or subthreshold hypomania at any time in the 12 months before interview. Persistence was assessed by asking respondents to estimate the number of years in their life when they had a major depressive episode and, separately, the number of years when they had a manic or hypomanic episode.

Clinical severity was assessed among 12-month cases using a fully structured self- report version of the Quick Inventory of De- pressive Symptoms Self-Report (Q-IDS-SR) (Rush et al. 2003) for MDE and the Young Mania Rating Scale (YMRS) (Young et al. 1978) for mania/hypomania. The structured YMRS was based on a fully structured respon- dent report version developed for parent re- ports (Gracious et al. 2002). Standard QIDS and YMRS cut-points were used to define episodes as severe (including original QIDS

and YMRS ratings of very severe, with ratings in the range 16+ on the QIDS and 25+ on the YMRS), moderate (11–15 on the QIDS; 15– 24 on the YMRS), mild (6–10 on the QIDS; 9– 14 on the YMRS), or not clinically significant (0–5 on the QIDS; 0–8 on the YMRS). Sever- ity was assessed for the most severe month in the past year. No data were collected on the accuracy of these retrospective reports.

Severity of role impairment among 12-month cases was assessed with the Shee- han Disability Scales (SDS; Leon et al. 1997). As with the YMRS and QIDS, the SDS scales asked respondents to focus on the one month in the past year when their mania/hypomania or MDE symptoms were most severe. The SDS questions asked respondents to rate sepa- rately how much the condition interfered dur- ing that month with their home management, work, social life, and personal relationships using a 0–10 visual analogue scale of none (0), mild (1–3), moderate (4–6), severe (7–9), and very severe (10).

Questions were asked about lifetime and 12-month treatment that distinguished treatment by a psychiatrist, other mental health professional, general medical provider, human services professional (e.g., minis- ter, social worker in a welfare agency), and complementary-alternative treatment provider (e.g., native healer, relaxation ther- apist). Questions about 12-month treatment also assessed medication. Antidepressants were classified as the only appropriate medi- cations for MDD, while mood stabilizers, an- ticonvulsants, and antipsychotics were clas- sified as appropriate medications for BPD. Antidepressants and other psychotropic med- ications in the absence of antimanic agents were classified as inappropriate for the treat- ment of BPD. In the case of BPD, 12-month treatment was assessed separately among re- spondents with 12-month BPD and lifetime but not 12-month BPD (i.e., maintenance treatment). Appropriateness of medication was examined separately for those in treat- ment with a psychiatrist and general medical provider.

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LIFETIME AND 12-MONTH PREVALENCE

Prevalence estimates of DSM-IV MDD in the total NCS-R sample are 16.2% lifetime and 6.6% in the 12 months before the interview. These are equivalent to national population projections of approximately 33 million U.S. adults with lifetime MDD and 13 million with 12-month MDD (Kessler et al. 2003b). These estimates are intermediate between those in earlier large-scale U.S. surveys (Blazer et al. 1994, Weissman et al. 1991) and very similar to estimates in a separate national survey car- ried out at about the same time as the NCS-R (Hasin et al. 2005). The NCS-R estimates are likely to be more accurate than those in these other surveys in that the concordance between CIDI and SCID diagnoses in the NCS-R is higher than in these or other community epi- demiological surveys carried out over the past two decades (Kessler et al. 1998b, Wittchen 1994). We attribute this improved accuracy to the fact that the CIDI was refined for use in the NCS-R to improve the clinical sensitiv- ity of diagnostic assessment. The lower CIDI MDD prevalence estimates in the NCS-R than in the baseline NCS (Blazer et al. 1994) are consistent with the fact that these re- finements reduced false positives. Contrary to the recent assertion of critics that preva- lence estimates such as these, based on fully structured interviews in a community sample, substantially overestimate the prevalence of clinically significant disorders (Narrow et al. 2002), our comparison of CIDI with SCID prevalence estimates shows that, if anything, the CIDI underestimates the lifetime preva- lence of clinician-diagnosed major depressive episodes, while only marginally overestimat- ing 12-month prevalence.

Lifetime prevalence estimates of BPD are 1.0% for BP-I, 1.1% for BP-II, and 2.4% for subthreshold BPD (4.4% overall), equivalent to nearly 9 million U.S. adults. Twelve-month prevalence estimates are 0.6% for BP-I, 0.8% for BP-II, and 1.4% for subthreshold BPD (2.8% overall), equivalent to more than 5 mil-

lion U.S. adults (Merikangas et al. 2007). The BP-I and BP-II prevalence estimates are con- sistent with estimates from earlier population- based studies (Angst 2004, Bauer & Pfennig 2005, Pini et al. 2005, Tohen & Angst 2002, Waraich et al. 2004, Weissman et al. 1996, Wittchen et al. 2003), with the exception of an implausibly high lifetime prevalence esti- mate of BP-I (3.3%) using a measure with no evidence of clinical validity in another recent national survey of the United States (Grant et al. 2005). It is noteworthy that the NCS-R clinical reappraisal study confirmed the much lower NCS-R BP-I prevalence es- timate. The NCS-R definition of subthresh- old BPD, in comparison, is more restrictive than the definitions proposed by clinical re- searchers (Akiskal & Benazzi 2005, Akiskal et al. 2000, Angst 1998, Angst et al. 2003) due to the fact that no information was included in the survey on brief episodes that could be as- sessed in more flexible semistructured clinical interviews. This means that the NCS-R sub- threshold BPD prevalence estimates are likely to be lower bound estimates, although they are broadly consistent with the results of two large community epidemiological surveys in Europe (Regeer et al. 2004, Szadoczky et al. 1998).

AGE-OF-ONSET DISTRIBUTIONS

Retrospective AOO reports were obtained us- ing a special question series designed to stim- ulate active memory search and to bound recall inaccuracy (Simon & VonKorff 1995). Experimental research has shown that this question sequence yields responses with a much more plausible AOO distribution than do standard AOO questions (Knauper et al. 1999). The AOO distribution was then gener- ated using the two-part actuarial method (SAS Institute 2001) for each DSM-IV disorder as- sessed in the survey (Kessler et al. 2005). Me- dian AOO (i.e., the fiftieth percentile on the AOO distribution) of MDD is 32, with an in- terquartile range (IQR; i.e., the years between

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the twenty-fifth and seventy-fifth percentiles of the AOO distribution) of 25 years (between ages 19 and 44). Median AOO of BPD is somewhat earlier for BP-I (18) and BP-II (20) than subthreshold BPD (22), with an IQR of roughly two decades for all three types of BPD (from the late teens through the late thirties). It is noteworthy that median AOO is much later for mood disorders than for anxiety dis- orders (age 11) or impulse-control disorders (age 11). AOO is also less concentrated in a narrow age range for mood disorders than for impulse-control disorders or most anxiety dis- orders. For example, the IQR is only 8 years for any impulse-control disorder (ages 7–15), 7 years for specific phobia (ages 5–12), and 7 years for social phobia (ages 8–15).

These AOO distribution estimates are consistent with those reported in previous epidemiological surveys (Christie et al. 1988, World Health Organ. Int. Consort. Psychi- atr. Epidemiol. 2000) both for mood disor- ders themselves and in findings that anxi- ety disorders, impulse-control disorders, and substance disorders have earlier AOOs than mood disorders. However, we are aware of no previous attempt to examine the tempo- ral concentration of AOO or to highlight the concentration of onset ages for most disorders in a very narrow time span. It is also strik- ing, in light of evidence reported below on the strong comorbidities of mood disorders with other DSM-IV disorders, that the up- per bounds of the AOO IQRs for disorders with narrow ranges are all quite early: age 15 for impulse-control disorders and for anxiety disorders with narrow IQRs and age 27 for substance disorders. These are opposite the patterns found for almost all chronic physi- cal disorders, where conditional risk increases with age and the upper bound of the IQR is in late middle age or old age (Murray & Lopez 1996).

The finding that comorbid disorders typ- ically have an earlier age of onset than mood disorders is also consistent with prospective family studies of at-risk children (Loeber et al.

1988, Warner et al. 1999). Although this find- ing implies that temporally primary disorders are risk factors for the subsequent first onset of mood disorders, it is less clear whether this is because these earlier disorders are causal risk factors or, alternatively, because they are markers of other more fundamental causes. If they were causal risk factors, we would expect that their successful treatment before the on- set of secondary mood disorders would reduce the risk of subsequent mood disorders occur- ring. This would not be the case if the ear- lier disorders were risk markers. We are aware of no experimental studies that have evalu- ated the effect of early treatment of primary anxiety or impulse control disorders (ICDs) on the prevention of subsequent mood dis- orders. However, two intriguing findings in the baseline NCS are consistent with the pre- diction that such interventions might be suc- cessful. The first is that active anxiety dis- orders are more powerful predictors of the subsequent onset of MDD than are remit- ted anxiety disorders (Kessler et al. 1998a). The second is that the risk of subsequent ma- jor depression among survey respondents with prior panic disorder is lower for those who re- ceive treatment for their panic than for those who do not (Goodwin & Olfson 2001). It is noteworthy that the second of these find- ings runs counter to the obvious noncausal interpretation of the first finding: that persis- tent panic is a severity marker rather than a causal risk factor for later MDD. If this non- causal interpretation were true, we would ex- pect to find that survey respondents who re- ceived treatment for their panic would have a higher risk of subsequent MDD than those whose panic was untreated due to the selec- tion bias for the most severe cases to have the highest probability of seeking treatment. The fact that the opposite pattern exists suggests that the causal interpretation has some plau- sibility and that early treatment of primary anxiety might be a neglected opportunity for the prevention of MDD and possibly also of BPD.

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PERSISTENCE

Persistence, indirectly indicated by the ra- tio of 12-month prevalence to lifetime preva- lence, is higher for BP-I (63.3%) and BP-II (73.2%) than for subthreshold BPD (59.5%), and lowest for MDD (40.7%). The same pattern is found for retrospectively reported number of years in episode (means of 10.3 BP-I, 11.6 BP-II, 6.8 subthreshold BPD, and 5.8 for MDD) and number of lifetime episodes (77.6 BP-I, 63.6 BP-II, 31.8 sub- threshold BPD, and 8.5 for MDD). More detailed analysis (results available on request from first author) showed that low persistence of subthreshold BPD is limited to cases with- out a history of MDE.

The finding that the ratio of 12-month CIDI MDD prevalence to lifetime prevalence is approximately 40% is broadly consistent with the finding of ratios between one-third and one-half in most previous epidemiologi- cal surveys carried out throughout the world (Andrade et al. 2003, Weissman et al. 1996). These ratios, in turn, are indirectly consis- tent with both retrospective reports in cross- sectional community surveys (Kessler et al. 1996, Weissman et al. 1991) and prospec- tive assessments in a small number of com- munity (Angst & Merikangas 1997, Murphy et al. 1984) and clinical (Keller 1985) samples, all of which suggest that MDD is typically an episodically chronic-recurrent disorder. The much higher estimates of persistence of BPD are consistent with prospective studies in clin- ical samples and with family studies (Fisfalen et al. 2005, Kupka et al. 2005). These results, consistent with the recommendation of the recent Surgeon General’s Report on Mental Health (U.S. Department of Health and Hu- man Services 1999), suggest that MDD and BPD should be classified as chronic diseases, along with such physical diseases as cancer, diabetes, and heart disease.

COMORBIDITY

Nearly three-fourths of respondents with life- time MDD also met criteria for at least one of

the other DSM-IV/CIDI disorders assessed in the NCS-R (Kessler et al. 2003b). This in- cludes 59.0% with at least one lifetime co- morbid anxiety disorder, 31.9% with at least one lifetime comorbid ICD, and 24.0% with at least one lifetime comorbid substance use disorder. Lifetime comorbidity is even higher among respondents with 12-month MDD, implying that comorbid MDD is more per- sistent (i.e., more likely to be either chronic or recurrent) than pure MDD. Approximately two-thirds (65.2%) of respondents with 12-month MDD met criteria for at least one other 12-month disorder, with comorbid anx- iety disorders (57.5%) again more common than either comorbid substance use disorders (8.5%) or comorbid ICDs (20.8%). Compari- son of retrospective age of onset reports shows that MDD is temporally primary (i.e., re- ported to have started at an earlier age) in relation to all other comorbid disorders in only 12.4% of lifetime cases and 12.2% of 12-month cases, although temporal priority is much more common in cases of comorbidity with substance use disorders (41.3%–49.2%) than with either anxiety disorders (13.7%– 14.6%) or ICDs (17.9%–20.9%).

The vast majority of NCS-R respondents with a history of either threshold (i.e., BP-I or BP-II; 97.7%–95.8%) or subthreshold (88.4%) BPD also met criteria for another lifetime DSM-IV/CIDI disorder (Merikangas et al. 2007). The extent of comorbidity is consistently somewhat higher for threshold than for subthreshold BPD. Included here are 63.1%–86.7% of respondents with life- time BPD who have a history of at least one lifetime comorbid anxiety disorder, 56.1%– 71.2% with at least one lifetime comorbid ICD, and 35.5%–60.3% with at least one life- time comorbid substance use disorder. As with MDD, lifetime comorbidity is even higher among respondents with 12-month BPD, im- plying that comorbid BPD is more persistent (i.e., more likely to be either chronic or recur- rent) than pure MDD. Comparison of retro- spective age of onset reports shows that BPD is temporally secondary (i.e., reported to have

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started at a later age) in relation to all other co- morbid disorders in the vast majority of cases.

A comparison of odds ratios (ORs) for the associations of MDD and BPD across the range of comorbid conditions consid- ered in the NCS-R analysis finds little ev- idence of strong variation. In other words, the strength of association of mood disor- ders with other DSM-IV disorders is rela- tively constant across the range of anxiety, impulse-control, and substance use disorders. The main exceptions are higher ORs of MDD with generalized anxiety disorder and panic disorder than with other comorbid conditions and a stronger OR of BPD with obsessive- compulsive disorder than with other comor- bid conditions. By far the higher ORs in- volving both MDD and BPD are those with a number of comorbid disorders rather than with a type of the latter disorders. Mood disor- ders are especially highly associated with the existence of three or more other hierarchy- free DSM-IV/CIDI disorders. This “multi- morbidity” (Angst et al. 2000) (i.e., comor- bidity with multiple conditions) is suggestive of disturbances in multiple regulatory systems and should be a topic for future research.

The finding that MDD is highly comor- bid with anxiety and substance disorders is consistent with previous epidemiological re- search (Kessler 1997, Merikangas et al. 1996). Although there is much less epidemiological evidence about comorbidity between MDD and ICD in community samples, signifi- cant MDD-ICD comorbidity has been doc- umented in clinical studies (Lejoyeux et al. 2002, Zimmerman et al. 2002). It is notewor- thy that even though comorbid ICD is of- ten thought to be more strongly related to BPD than to MDD (McElroy et al. 1996), the NCS-R found strong comorbidity between ICD and MDD. This could reflect either fac- tors broader than those responsible for BPD or the existence of what has recently been called a “soft bipolar spectrum” in which co- morbid ICD among patients with MDD rep- resents a marker of bipolar susceptibility. The notion of a soft bipolar spectrum underlying

MDD-ICD comorbidity implies that comor- bid ICD is a risk marker for the subsequent onset of mania or hypomania and is a pos- sibility that needs to be evaluated in future prospective epidemiological studies.

The finding that BPD has extremely high comorbidity with other DSM-IV disorders is consistent with prior clinical (Brown 2005, Strakowski & DelBello 2000) and population- based (Grant et al. 2005, Keller 2006, Mitchell et al. 2004, Pini et al. 2005, Regier et al. 1990) studies, although comorbidity with substance use disorders was more promi- nently featured in previous studies. The higher comorbidity found in the NCS-R with anxiety and impulse-control disorders was less consistently studied in previous research (Freeman et al. 2002, MacKinnon et al. 2002). Despite the higher disorder-specific comor- bidity noted above of threshold BPD than of subthreshold BPD, it is interesting to note that comorbidity with at least one other disor- der was found to be nearly as common among subthreshold (88.4%) as threshold (95.8%– 97.7%) cases.

CLINICAL SEVERITY

Although a great deal of research has exam- ined the clinical severity of patients in treat- ment, little is known about the clinical sever- ity of community cases. This is an issue of considerable interest in light of the high esti- mated prevalence of mood disorders in com- munity surveys and the suspicion of some critics that these prevalence estimates are ex- aggerated. Thirty-eight percent of NCS-R respondents with 12-month MDD were clas- sified as being seriously–severely depressed based on QIDS assessments, while the re- maining 62.0% of cases were classified as mildly–moderately depressed (Kessler et al. 2003b). Even higher proportions of cases with 12-month MDE related to BPD were rated serious–severe. This was true for not only MDE associated with BP-I (where 70.5% of cases were rated serious–severe) and BP-II (84.0%), but also subthreshold BPD (46.4%).

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YMRS ratings of the 12-month episode sever- ity of mania/hypomania placed the major- ity of cases in the severe range for BP-I (70.2%) and BP-II (55.4%) and a minority for subthreshold BPD (31.5%), with almost all of the remainder for threshold BPD and a majority of those for subthreshold BPD in the mild–moderate range (Merikangas et al. 2007).

The finding that more than one-third of 12-month community cases of MDD were rated serious–severe on a standard clinical rat- ing scale is indirectly consistent with a grow- ing body of evidence that major depression is one of the most seriously impairing of all chronic conditions (Wang et al. 2003b). The fact that even higher proportions of MDE as- sociated with BPD were rated serious–severe is consistent with evidence that the depres- sive episodes of people with BPD are, on av- erage, more severe than those of people with MDD. The finding that the proportions of depressive episodes rated severe were higher for BP-II than BP-I is also consistent with previous research (Judd & Akiskal 2003b). Perhaps the more striking result regarding clinical severity, though, is that a higher pro- portion of depressive episodes associated with subthreshold BPD than MDD were rated serious–severe. This finding, coupled with the finding that nearly one-third of subthreshold BPD hypomanic episodes were classified se- vere and with the finding that most of the re- mainder of subthreshold cases were classified mild–moderately severe, strongly argues for the clinical significance of subthreshold BPD.

SEVERITY OF ROLE IMPAIRMENT

The NCS-R analyses documented substantial role impairments associated with both MDD (Kessler et al. 2003b) and BPD (Merikangas et al. 2007) in the areas of work, household responsibilities, social life, and personal rela- tions based on assessments with the Sheehan disability scales. As with clinical severity, the results show that subthreshold BPD is associ-

ated with as much, if not more, role impair- ment than MDD, arguing for the significance of subthreshold BPD.

As reviewed in more detail elsewhere (Kessler et al. 2006b), most research on mood disorders and role impairment focuses on days out of role among people in the work- force. This focus is a natural one from a healthcare policy perspective, as employer- sponsored plans account for the vast majority of all health insurance in the United States and the authors of cost-of-illness studies generally aim to make an argument to these employer- purchasers that human capital investments in expanded treatment of mood disorders would be cost-effective from the employer perspec- tive. However, these studies have largely fo- cused on MDE to the exclusion of mania or hypomania and have failed to distinguish episodes of MDE due to MDD and BPD (Greenberg et al. 1993, 1996, 2003; Rice & Miller 1993). Although several recent cost-of- illness studies (Begley et al. 2001, Das Gupta & Guest 2002, Wyatt & Henter 1995) and reviews (Dean et al. 2004, Kleinman et al. 2003) have focused on the costs of BPD, none has presented comparative information on the workplace costs of MDD and BPD.

An NCS-R analysis of the workplace costs of mood disorders attempted to address this gap in previous research by examining the prevalence and workplace costs of mood dis- orders in the U.S. civilian labor force (Kessler et al. 2006b). Work performance was as- sessed with the World Health Organization Health and Work Performance Question- naire (HPQ) (Kessler et al. 2003a, 2004b), a self-report instrument that combines in- formation about absenteeism (missed days of work) and presenteeism (low performance while at work transformed to lost workday equivalents) into a summary measure of over- all lost workdays in the year of interview. In- formation about salary was used to transform the measures of lost work performance from a time metric to a salary metric for purposes of estimating human capital loss associated with mood disorders.

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The analysis showed that MDD and BPD are both associated with significant lost work performance, with annualized estimates of 27.2 excess lost workdays per worker with MDD and 65.5 excess lost workdays per worker with BPD. Disaggregation showed that absenteeism, although important to this total, was less important than presenteeism. This means that workers with mood dis- orders both miss more days of work than workers in the same jobs having the same so- ciodemographic profiles but without a mood disorder and, even more importantly, that workers with mood disorders are substan- tially less productive on days when they are at work than are workers without mood dis- orders. Projections of individual-level associ- ations to the total U.S. civilian labor force based on information about disorder preva- lence and salaries of workers with mood disor- ders yield estimates of 225.0 million workdays and $36.6 billion salary-equivalent lost pro- ductivity per year associated with MDD and 96.2 million lost workdays and $14.1 billion salary-equivalent lost productivity per year as- sociated with BPD.

The finding that both BPD and MDD are both associated with substantial losses in work performance is broadly consistent with other surveys of workplace costs (Calabrese et al. 2003, Dean et al. 2004, Greenberg et al. 2003, Kleinman et al. 2003, Wang et al. 2003b). The estimated annual population-level work- place cost of MDD is in the range of the two other recent studies that estimated the work- place costs of MDE—$31.0 billion (Stewart et al. 2003) and $51.5 billion (Greenberg et al. 2003). The larger of these two is probably up- wardly biased because it is based on an analysis of days out of role (i.e., including weekends) rather than days out of work. No previous es- timates of the population-level workplace cost of BPD are available to compare to the NCS- R estimate.

Roughly three-fourths of employed NCS- R respondents with 12-month BPD had depressive episodes in the 12 months be- fore interview (63.1% who also had manic-

hypomanic episodes and 11.1% who had only depressive episodes). Persistence (days in depressive episodes in the 365 days be- fore interview) was found consistently to be higher in BPD (mean: 134.0–164.0 across the bipolar spectrum; median: 90–150) than MDD (mean: 98.1; median: 60; z 2.7, p 0.010). The individual-level eleva- tion of lost work performance in BPD was consistently higher among respondents with 12-month MDE than only manic- hypomanic episodes. Furthermore, BPD with MDE was consistently associated with sig- nificantly more lost work performance than MDD.

The finding that BPD is associated with substantially more lost work performance than MDD at the individual level is not un- expected in light of the greater severity of BPD than MDD, although aggregate impair- ment is greater for MDD than BPD because of the higher prevalence of the former than latter disorder. Perhaps more surprising is the finding that the higher individual-level im- pairment of BPD than MDD is due largely to MDE being more impairing in the con- text of BPD than MDD rather than to mania- hypomania being more impairing than MDE. The finding that mania-hypomania in the absence of MDE is associated with signifi- cantly less work impairment than BPD with MDE is consistent with the observation in a prospective patient study that functional im- pairment is associated with variation in de- pressive symptoms but not manic symptoms (Bauer et al. 2001).

An important practical problem related to the finding that MDE in BPD is the syndrome associated with most impairment is that MDE due to BPD is sometimes incorrectly treated as if it is due to MDD (Hirschfeld 2004, Judd & Akiskal 2003a). This problem is exacer- bated by the fact that people with BPD re- port considerably more distress due to their depressive than to their manic symptoms (Calabrese et al. 2003). Antidepressant medi- cations, of course, can trigger the onset of ma- nia among patients with MDE due to BPD.

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= =

This issue, though, involves the consideration of treatment, a topic that we turn to next.

TREATMENT

Slightly more than half (56.7%) of NCS-R respondents with 12-month MDD received some type of treatment in the 12 months be- fore their interview. The specialty sector was involved in the highest proportion of these cases (54.9%) and the human services sec- tor in the lowest proportion (16.4%) (Kessler et al. 2003b). Treatment met conventional cri- teria for adequacy based on minimal concor- dance with published treatment guidelines, however, in only 41.7% of cases. This means that no more than 20.9% of all people with 12-month MDD (i.e., 36.9% of the 56.7% in treatment) received adequate treatment. Although a higher proportion of serious– severe (72.4%) than mild–moderate (47.1%) 12-month NCS-R cases received treatment, severity was not significantly related either to the sector in which treatment was received or to the adequacy of treatment. Sector of treatment, however, was found to be related to treatment adequacy, with a significantly higher 62.3% of patients treated in the spe- cialty mental health sector versus 42.4% of patients treated in the general medical sector receiving adequate treatment.

Treatment of 12-month BPD was higher than treatment of MDD: 67.3% BP-I, 65.8% BP-II, and 36.7% subthreshold BPD. Nonpsychiatrist mental health professionals were the most common providers (35.4% BP-I, 33.8% BP-II, and 20.6% subthresh- old BPD). Multisector treatment was the norm, with a 1.7-sector mean. As with MDD, a significantly higher proportion of cases in specialty (45.0%) than general medical (9.0%) treatment received appropriate med- ication. A significantly higher proportion of cases in general medical (73.1%) than spe- cialty (43.4%) treatment received inappro- priate medication. A significant gradient was found in the proportion of all 12-month cases (ignoring whether they received treat-

ment) that received appropriate medication: 25.0% BP-I, 15.4% BP-II, and 8.1% sub- threshold BPD. The proportion receiving in- appropriate medication was also higher for BP-I (38.7%) and BP-II (38.9%) than for sub- threshold BPD (23.8%). The opposite pat- tern was found for the proportion receiving no medication (36.3% BP-I, 45.7% BP-II, and 68.1% subthreshold BPD). A signifi- cant gradient also was found in the propor- tion of lifetime cases without a 12-month episode (ignoring whether they received 12- month treatment) that received appropriate maintenance medication: 17.9% BP-I, 15.6% BP-II, and 3.2% subthreshold BPD. The pro- portion of all lifetime cases that received in- appropriate medication was also higher for BP-I (35.3%) than BP-II (24.5%) or sub- threshold BPD (21.5%). The opposite pat- tern was found for the proportion receiving no medication (46.8% BP-I, 59.9% BP-II, and 75.3% subthreshold BPD).

The results document serious problems in the treatment of people with mood disorders in the United States. Increasing use of some modalities, most notably pharmacotherapies and physician-administered psychotherapies (Kessler et al. 2003b; Olfson et al. 2002a,b; Wang et al. 2000), has generated hope that mental disorders are now being treated much more effectively than in the past. The NCS- R results suggest that such optimism is pre- mature. Mental health service use for mood disorders remains disturbingly low: a substan- tial proportion of cases did not receive any care in the prior year, and many of those who successfully accessed health care failed to get adequate treatment according to estab- lished treatment guidelines. These results are broadly consistent with those of other stud- ies of treatment quality for mood disorders (Blanco et al. 2002; Wang et al. 2000, 2002; Young et al. 2001).

The frequent use of treatments with un- certain benefit is striking. This is especially worrisome for complementary-alternative treatments (e.g., energy healers, massage therapists), which account for a substantial

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minority of all visits for the treatment of mood disorders despite a paucity of data support- ing their efficacy (Eisenberg et al. 1993, 1998; Hypericum Depression Trial Study Group 2002; Kessler et al. 2001b,c; Wang et al. 2003a; Weaver 1995). A challenge for the providers of conventional services is to deter- mine why complementary-alternative treat- ment has such great appeal and whether le- gitimate aspects related to this appeal (e.g., a greater orientation to patient-centered care) can be adopted by conventional mental health care providers to increase the attractiveness of evidence-based treatments.

On the positive side, the proportion of NCS-R respondents with mood disorders who reported 12-month mental health ser- vice use is considerably higher than found a decade earlier in the baseline NCS (Kessler et al. 1999) and a decade before that in the ECA study (Regier et al. 1993). By far the greatest part of this expansion, though, oc- curred in the general medical sector. General medical doctors act as gatekeepers respon- sible for initiating mental health treatments themselves and for deciding who to triage for specialty care (Forrest 2003, Trude & Stoddard 2003). Increasing awareness of men- tal disorders on the part of primary care physi- cians, coupled with an increase in consumer demand stimulated by direct-to-consumer ad- vertising, have probably also played roles in this growth (Kessler & Wang 1999, Kroenke 2003, Simon et al. 1999, Spitzer et al. 1999). However, the fact that only a small minor- ity of patients treated in the general medi- cal sector receives minimally adequate care makes these trends concerning. Reasons for the low rate of treatment adequacy are un- clear, but presumably involve both provider (e.g., competing demands, inadequate reim- bursements for treating mental disorders, less training and experience in treating mental disorders) and patient factors (e.g., worse compliance with treatments than in men- tal health specialty sectors) (Klinkman 1997, Pincus et al. 2003, Williams 1998, Williams et al. 1999).

WMH: World Mental Health Survey Initiative of the World Health Organization

OVERVIEW

This brief review of NCS-R results shows clearly that mood disorders are highly preva- lent, highly persistent, and highly impairing. We have seen that although mood disorders are currently treated much more commonly than in the past, they are still substantially undertreated. We also presented evidence re- garding the relatively high prevalence and sig- nificance of subthreshold bipolar disorders, a series of syndromes of growing interest among specialists in research on the bipolar spectrum (Angst et al. 2003, Judd & Akiskal 2003b). Parallel information was not reviewed on the MDD spectrum, including recurrent brief depression (Pezawas et al. 2005) and minor depression (Judd et al. 2003), as sub- threshold MDD has not yet been examined in the NCS-R. A great many other topics in the descriptive epidemiology of mood dis- orders were not covered in this review that need to be noted here in light of the fact that they have been reviewed elsewhere. Among the most important of these are informa- tion on child and adolescent mood disor- ders (Kessler et al. 2001a), risk and protec- tive factors for the onset and persistence of mood disorders (Goodwin & Jamison 1990, Gotlib & Hammen 2002), sociodemographic correlates of mood disorders (Kessler et al. 2003b, Merikangas et al. 2007), and bar- riers to obtaining treatment (Wang et al. 2005).

FUTURE DIRECTIONS

We also need to know much more than we currently do about time-space variation in the prevalence and correlates of mood disorders. The World Health Organization’s World Mental Health (WMH) Survey Initiative is an exciting new undertaking that is address- ing this issue by carrying out coordinated na- tionally representative surveys like the NCS- R in more than 30 countries throughout the world (http://www.hcp.med.harvard.edu/ wmh). A number of WMH lines of work

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SUMMARY POINTS

1. Mood disorders are highly prevalent.

2. Mood disorders are highly persistent.

3. Mood disorders are highly impairing.

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deal with mood disorders. Perhaps the most fascinating of these is the attempt to study time-space variation in the association be­ tween gender and major depression. The goal here is to determine whether the female pre­ ponderance consistently found in Western countries exists throughout the world and whether the magnitude of this association changes over time in specific countries as the roles of women change with the moderniza­ tion of the country.

We also need to increase our understand­ ing of mood disorders epidemiology using genetically informative epidemiological study designs. Important work along these lines has been carried out in regional studies (Kendler & Prescott 2006), but this needs to be ex­ panded both geographically and conceptually. Epidemiological designs that collect DNA also hold great promise (Caspi et al. 2003) and will almost certainly be used more often in the future. Indeed, a number of the WMH surveys mentioned in the previous paragraph are collecting DNA from all respondents in order to create a repository for future genetic epidemiological studies.

A great deal of interest currently exists in using epidemiological research to help re­ fine the diagnostic criteria for mood disor­ ders in the DSM and ICD diagnostic systems (Zimmerman et al. 2006). This interest is mo­ tivated by the fact that both these diagnos­ tic systems are scheduled for major updates at the end of this decade (Helzer & Hudziak 2002, Schachter et al. 2002). Epidemiological data such as those in the NCS-R can be of great value in evaluating the implications of proposed changes in diagnostic criteria. How­ ever, in order to maximize usefulness in this way, the epidemiological surveys need to in­

clude questions and skip pattern rules that facilitate the analysis of proposed diagnostic changes. This was done in the NCS-R as well as in the WMH surveys. We consequently an­ ticipate that considerable research on diag­ nostic criteria will emerge from these surveys over the next decade.

Finally, as we learn more and more about risk factors for and social consequences of mood disorders, we will need to increase the extent to which epidemiological studies are blended with quasi-experimental and experi­ mental policy interventions. Kling and his as­ sociates (2007), for example, evaluated the ef­ fects of neighborhood disorganization on the mental health of residents by carrying out an epidemiological survey of low-income single mothers who applied for housing vouchers al­ located by the Department of Housing and Urban Development on the basis of a lot­ tery. Half of the applicants were randomly selected to receive the vouchers, creating a unique opportunity to study neighborhood ef­ fects on the mental health of high-risk chil­ dren. Experimental manipulations of this sort embedded in larger epidemiological surveys have enormous potential to expand our under­ standing of the correlates of mood disorders as well as of other mental disorders. Experiments of nature could be used in this same way. For example, Costello and her associates (2003) used the opening of a casino on an American Indian reservation midway between the two waves of an epidemiological survey to evalu­ ate the impact of increased parental income on child mental health. A great many exper­ iments of nature exist that could be used in a similar way to expand our understanding of the environmental determinants of mood disorders.

4. Subthreshold bipolar disorders are considerably more common and impairing than is generally recognized.

5. Although mood disorders are currently treated much more commonly in the United States than in the past, they are still substantially undertreated both in the sense that many people with mood disorders are not receiving treatment and also in the sense that many of the people with mood disorders in treatment receive suboptimal treatment.

ACKNOWLEDGMENTS

This article represents a review of previously published results from the National Comor- bidity Survey Replication (NCS-R). Portions of this paper appeared previously in Kessler et al. (2003) and are reproduced here with the permission of the publisher. Sources include: for the epidemiology of major depressive disorder, Kessler et al. (2005); for the lifetime prevalence and age-of-onset distributions of DSM-IV disorders, Kessler et al. (2005); for the prevalence, severity, and comorbidity of twelve-month DSM-IV disorders, Wang et al. (2005) and Kessler et al. (2006a). The NCS-R is supported by the National Institute of Men- tal Health (U01-MH60220) with supplemental support from the National Institute of Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation (grant #044780), and the John W. Alden Trust. The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or the U.S. government. A com- plete list of NCS publications and the full text of all NCS-R instruments can be found at http://www.hcp.med.harvard.edu/ncs. The NCS-R is carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative, which is sup- ported by the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the U.S. Public Health Service (1R13MH066849, R01-MH069864, and R01 DA016558), Eli Lilly and Company, GlaxoSmithKline, Ortho-McNeil Pharmaceutical, Inc., and the Pan American Health Organization. A complete list of WMH publications and instruments can be found at http://www.hcp.med.harvard.edu/wmhcidi.

LITERATURE CITED

Akiskal HS, Benazzi F. 2005. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J. Clin. Psychiatry 66:914–21

Akiskal HS, Bourgeois ML, Angst J, Post R, Moller H, Hirschfeld R. 2000. Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J. Affect. Disord. 59(Suppl. 1):S5–30

American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: Am. Psychiatr. Assoc.

Andrade L, Caraveo-Anduaga JJ, Berglund P, Bijl RV, Dragomericka E, et al. 2003. The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) surveys. Int. J. Methods Psychiatr. Res. 12:3–21

Angst J. 1998. The emerging epidemiology of hypomania and bipolar II disorder. J. Affect. Disord. 50:143–51

www.annualreviews.org • Mood Disorders in the United States 151

A nn

u. R

ev . C

li n.

P sy

ch ol

. 2 00

7. 3:

13 7-

15 8.

D ow

nl oa

de d

fr om

w w

w .a

nn ua

lr ev

ie w

s. or

g

ANRV307-CP03-06 ARI 20 February 2007 19:1

by $

{i nd

iv id

ua lU

se r.

di sp

la yN

am e}

o n

01 /1

0/ 14

. F or

p er

so na

l us

e on

ly .

Angst J. 2004. Bipolar disorder—a seriously underestimated health burden. Eur. Arch. Psychiatry Clin. Neurosci. 254:59–60

Angst J, Gamma A, Benazzi F, Ajdacic V, Eich D, Rossler W. 2003. Toward a redefinition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J. Affect. Disord. 73:133–46

Angst J, Merikangas K. 1997. The depressive spectrum: diagnostic classification and course. J. Affect. Disord. 45:31–39; discussion 39–40

Angst J, Sellaro R, Merikangas KR. 2000. Depressive spectrum diagnoses. Comp. Psychiatry 41:39–47

Bauer M, Pfennig A. 2005. Epidemiology of bipolar disorders. Epilepsia 46(Suppl. 4):8–13 Bauer MS, Kirk GF, Gavin C, Williford WO. 2001. Determinants of functional outcome and

healthcare costs in bipolar disorder: a high-intensity follow-up study. J. Affect. Disord. 65:231–41

Begley CE, Annegers JF, Swann AC, Lewis C, Coan S, et al. 2001. The lifetime cost of bipolar disorder in the US: an estimate for new cases in 1998. Pharmacoeconomics 19:483–95

Blanco C, Laje G, Olfson M, Marcus SC, Pincus HA. 2002. Trends in the treatment of bipolar disorder by outpatient psychiatrists. Am. J. Psychiatry 159:1005–10

Blazer DG, Kessler RC, McGonagle K, Swartz M. 1994. The prevalence and distribution of major depression in a national community sample: the National Comorbidity Survey. Am. J. Psychiatry 151:979–86

Brown ES. 2005. Bipolar disorder and substance abuse. Psychiatr. Clin. North Am. 28:415–25 Burke KC, Burke JDJ, Rae DS, Regier DA. 1991. Comparing age at onset of major depression

and other psychiatric disorders by birth cohorts in five U.S. community populations. Arch. Gen. Psychiatry 48:789–95

Calabrese JR, Hirschfeld RM, Reed M, Davies MA, Frye MA, et al. 2003. Impact of bipolar disorder on a U.S. community sample. J. Clin. Psychiatry 64:425–32

Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, et al. 2003. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 301:386–89

Christie KA, Burke JDJ, Regier DA, Rae DS, Boyd JH, Locke BZ. 1988. Epidemiologic evi- dence for early onset of mental disorders and higher risk of drug-abuse in young adults. Am. J. Psychiatry 145:971–75

Comstock GW, Helsing KJ. 1976. Symptoms of depression in two communities. Psychol. Med. 6:551–63

Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. 2003. Prevalence and development of psychiatric disorders in childhood and adolescence. Arch. Gen. Psychiatry 60:837–44

Das Gupta R, Guest JF. 2002. Annual cost of bipolar disorder to U.K. society. Br. J. Psychiatry 180:227–33

Dean BB, Gerner D, Gerner RH. 2004. A systematic review evaluating health-related quality of life, work impairment, and healthcare costs and utilization in bipolar disorder. Curr. Med. Res. Opin. 20:139–54

Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey SA, et al. 1998. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 280:1569–75

Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. 1993. Uncon- ventional medicine in the United States. Prevalence, costs, and patterns of use. N. Engl. J. Med. 328:246–52

First MB, Spitzer RL, Gibbon M, Williams JBW. 2002. Structured Clinical Interview for DSM- IV Axis I Disorders, Research Version, Non-patient Edition (SCID-I/NP). New York: Biometr. Res., NY State Psychiatr. Inst.

152 Kessler · Merikangas · Wang

A nn

u. R

ev . C

li n.

P sy

ch ol

. 2 00

7. 3:

13 7-

15 8.

D ow

nl oa

de d

fr om

w w

w .a

nn ua

lr ev

ie w

s. or

g

ANRV307-CP03-06 ARI 20 February 2007 19:1

by $

{i nd

iv id

ua lU

se r.

di sp

la yN

am e}

o n

01 /1

0/ 14

. F or

p er

so na

l us

e on

ly .

Fisfalen ME, Schulze TG, DePaulo JRJ, DeGroot LJ, Badner JA, McMahon FJ. 2005. Familial variation in episode frequency in bipolar affective disorder. Am. J. Psychiatry 162:1266–72

Forrest CB. 2003. Primary care in the United States. Primary care gatekeeping and referrals: effective filter or failed experiment? Br. Med. J. 326:692–95

Freeman MP, Freeman SA, McElroy SL. 2002. The comorbidity of bipolar and anxiety disor- ders: prevalence, psychobiology, and treatment issues. J. Affect. Disord. 68:1–23

An encyclopedic review of the worldwide literature on all aspects of bipolar disorders.

Goodwin FK, Jamison KR. 1990. Manic-Depressive Illness. New York: Oxford Univ. Press

Goodwin R, Olfson M. 2001. Treatment of panic attack and risk of major depressive disorder in the community. Am. J. Psychiatry 158:1146–48

An excellent review of the literature on depressive disorders.

Gotlib IH, Hammen CL, ed. 2002. Handbook of Depression. New York: Guilford Gracious BL, Youngstrom EA, Findling RL, Calabrese JR. 2002. Discriminative validity of

a parent version of the Young Mania Rating Scale. J. Am. Acad. Child Adolesc. Psychiatry 41:1350–59

Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, et al. 2005. Prevalence, correlates, and comorbidity of bipolar I disorder and Axis I and II disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J. Clin. Psychiatry 66:1205–15

The most recent synthesis of information on the societal costs of depression, putting the annual costs of depression in the United States at a staggering $83 billion.

Greenberg PE, Kessler RC, Birnbaum HG, Leong SA, Lowe SW, et al. 2003. The economic burden of depression in the United States: How did it change between 1990 and 2000? J. Clin. Psychiatry 64:1465–75

Greenberg PE, Kessler RC, Nells TL, Finkelstein SN, Berndt ER. 1996. Depression in the workplace: an economic perspective. In Perspectives in Psychiatry: Selective Serotonin Re- uptake Inhibitors, Second Edition. Advances in Basic Research and Clinical Practice, ed. JP Feighner, WF Boyer, pp. 327–63. New York: Wiley

Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. 1993. The economic burden of de- pression in 1990. J. Clin. Psychiatry 54:405–18

Haro JM, Brugha TS, de Girolamo G, Kessler RC, Lepine JP. 2007. Validity of the Composite International Diagnostic Interview in the WHO World Mental Health Surveys. Int. J. Methods Psychiatr. Res. In press

Hasin DS, Goodwin RD, Stinson FS, Grant BF. 2005. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch. Gen. Psychiatry 62:1097–106

Helgason T. 1964. Epidemiology of mental disorders in Iceland. Acta Psychiatr. Scand. 40:115– 32

Helzer JE, Hudziak JJ, eds. 2002. Defining Psychopathology in the 21st Century: DSM-V and Beyond. Washington, DC: Am. Psychiatr. Press

Hettema JM, Prescott CA, Kendler KS. 2003. The effects of anxiety, substance use and conduct disorders on risk of major depressive disorder. Psychol. Med. 33:1423–32

Hirschfeld RM. 2004. Bipolar depression: the real challenge. Eur. Neuropsychopharmacol. 14(Suppl. 2):S83–88

Hypericum Depression Trial Study Group. 2002. Effect of hypericum perforatum (St. John’s wort) in major depressive disorder: a randomized controlled trial. JAMA 287:1807–14

An important report from the Collaborative Psychobiology of Depression Study that followed bipolar patients over many years and documented that their time in depressive episodes was much greater than their time in manic-hypomanic episodes.

Judd LL, Akiskal HS. 2003a. Depressive episodes and symptoms dominate the longitu- dinal course of bipolar disorder. Curr. Psychiatry Rep. 5:417–18

Judd LL, Akiskal HS. 2003b. The prevalence and disability of bipolar spectrum disorders in the US population: reanalysis of the ECA database taking into account subthreshold cases. J. Affect. Disord. 73:123–31

www.annualreviews.org • Mood Disorders in the United States 153

A nn

u. R

ev . C

li n.

P sy

ch ol

. 2 00

7. 3:

13 7-

15 8.

D ow

nl oa

de d

fr om

w w

w .a

nn ua

lr ev

ie w

s. or

g

ANRV307-CP03-06 ARI 20 February 2007 19:1

by $

{i nd

iv id

ua lU

se r.

di sp

la yN

am e}

o n

01 /1

0/ 14

. F or

p er

so na

l us

e on

ly .

Judd LL, Akiskal HS, Schettler PJ, Coryell W, Maser J, et al. 2003. The comparative clin- ical phenotype and long-term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders? J. Affect. Disord. 73:19–32

Judd LL, Akiskal HS, Schettler PJ, Endicott J, Maser J, et al. 2002. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch. Gen. Psychiatry 59:530– 37

Judd LL, Akiskal HS, Zeller PJ, Paulus M, Leon AC, et al. 2000. Psychosocial disability during the long-term course of unipolar major depressive disorder. Arch. Gen. Psychiatry 57:375– 80

Keller MB. 1985. Chronic and recurrent affective disorders: incidence, course and influencing factors. In Chronic Treatments in Neuropsychiatry, ed. D Kemali, G Racagni, pp. 111–20. New York: Raven

Keller MB. 2006. Prevalence and impact of comorbid anxiety and bipolar disorder. J. Clin. Psychiatry 67(Suppl. 1):5–7

An important synthesis of results from the most prominent existing program of population genetic twin-family research on the epidemiology of common mental disorders.

Kendler KS, Prescott CA. 2006. Genes, Environment, and Psychopathology. New York: Guilford

Kessler RC. 1995. Epidemiology of psychiatric comorbidity. In Textbook in Psychiatric Epidemi- ology, ed. MT Tsuang, M Tohen, GEP Zahner, pp. 179–97. New York: Wiley

Kessler RC. 1997. The prevalence of psychiatric comorbidity. In Treatment Strategies for Patients with Psychiatric Comorbidity, ed. S Wetzler, WC Sanderson, pp. 23–48. New York: Wiley

Kessler RC, Abelson J, Demler O, Escobar JI, Gibbon M, et al. 2004a. Clinical calibration of DSM-IV diagnoses in the World Mental Health (WMH) version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMHCIDI). Int. J. Methods Psychiatr. Res. 13:122–39

Kessler RC, Akiskal HS, Ames M, Birnbaum H, Greenberg P, et al. 2006a. Prevalence and effects of mood disorders on work performance in a nationally representative sample of U.S. workers. Am. J. Psychiatry 163(9):1561–68

Kessler RC, Akiskal HS, Angst J, Guyer ME, Hirschfeld RMA, et al. 2007. Validity of the Assessment of Bipolar Spectrum Disorders in the WHO CIDI 3.0. J. Affect. Disord. In press

Kessler RC, Akiskal HS, Angst J, Hirschfeld R, Merikangas K, et al. 2006b. The workplace costs of mood disorders: bringing bipolar spectrum disorders into the equation. J. Health Product. 1:3–8

Kessler RC, Ames M, Hymel PA, Loeppke R, McKenas DK, et al. 2004b. Using the World Health Organization Health and Work Performance Questionnaire (HPQ) to evaluate the indirect workplace costs of illness. J. Occup. Environ. Med. 46:S23–37

Kessler RC, Avenevoli S, Ries Merikangas K. 2001a. Mood disorders in children and adoles- cents: an epidemiologic perspective. Biol. Psychiatry 49:1002–14

Kessler RC, Barber C, Beck A, Berglund P, Cleary PD, et al. 2003a. The World Health Organization Health and Work Performance Questionnaire (HPQ). J. Occup. Environ. Med. 45:156–74

The most recent and definitive data on the descriptive epidemiology of major depression in the United States.

Kessler RC, Berglund P, Demler O, Jin R, Koretz D, et al. 2003b. The epidemiol- ogy of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA 289:3095–105

Kessler RC, Berglund P, Demler O, Jin R, Walters EE. 2005. Lifetime prevalence and age-of- onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry 62:593–602

154 Kessler · Merikangas · Wang

A nn

u. R

ev . C

li n.

P sy

ch ol

. 2 00

7. 3:

13 7-

15 8.

D ow

nl oa

de d

fr om

w w

w .a

nn ua

lr ev

ie w

s. or

g

ANRV307-CP03-06 ARI 20 February 2007 19:1

by $

{i nd

iv id

ua lU

se r.

di sp

la yN

am e}

o n

01 /1

0/ 14

. F or

p er

so na

l us

e on

ly .

Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, et al. 2001b. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann. Intern. Med. 135:262–68

Kessler RC, Merikangas KR. 2004. The National Comorbidity Survey Replication (NCS-R): background and aims. Int. J. Methods Psychiatr. Res. 13:60–68

Kessler RC, Nelson CB, McGonagle KA, Liu J, Swartz M, Blazer DG. 1996. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the U.S. National Comorbidity Survey. Br. J. Psychiatry 168:17–30

Kessler RC, Soukup J, Davis RB, Foster DF, Wilkey SA, et al. 2001c. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am. J. Psychiatry 158:289–94

Kessler RC, Stang PE, Wittchen HU, Ustun TB, Roy-Byrne PP, Walters EE. 1998a. Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch. Gen. Psychiatry 55:801–8

Kessler RC, Ustun TB. 2004. The World Mental Health (WMH) survey initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int. J. Methods Psychiatr. Res. 13:93–121

Kessler RC, Wang PS. 1999. Screening measures for behavioral health assessment. In SPM Handbook of Health Assessment Tools, ed. G Hyner, K Peterson, J Travis, J Dewey, J Foerster, E Framer, pp. 33–40. Pittsburgh, PA: Soc. Prospect. Med.

Kessler RC, Wittchen HU, Abelson JM, McGonagle K, Schwarz N, et al. 1998b. Method- ological studies of the Composite International Diagnostic Interview (CIDI) in the U.S. National Comorbidity Survey. Int. J. Methods Psychiatr. Res. 7:33–55

Kessler RC, Zhao S, Katz SJ, Kouzis AC, Frank RG, et al. 1999. Past year use of outpatient services for psychiatric problems in the National Comorbidity Survey. Am. J. Psychiatry 156:115–23

Khan AA, Jacobson KC, Gardner CO, Prescott CA, Kendler KS. 2005. Personality and co- morbidity of common psychiatric disorders. Br. J. Psychiatry 186:190–96

Kleinman L, Lowin A, Flood E, Gandhi G, Edgell E, Revicki D. 2003. Costs of bipolar disorder. Pharmacoeconomics 21:601–22

Kling JR, Liebman JB, Katz LF. 2007. Experimental analysis of neighborhood effects. Econo- metrica. In press

Klinkman MS. 1997. Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. Gen. Hosp. Psychiatry 19:98–111

Knauper B, Cannell CF, Schwarz N, Bruce ML, Kessler RC. 1999. Improving the accuracy of major depression age of onset reports in the U.S. National Comorbidity Survey. Int. J. Methods Psychiatr. Res. 8:39–48

Kroenke K. 2003. Patients presenting with somatic complaints: epidemiology, psychiatric co- morbidity and management. Int. J. Methods Psychiatr. Res. 12:34–43

Kupka RW, Luckenbaugh DA, Post RM, Suppes T, Altshuler LL, et al. 2005. Comparison of rapid-cycling and nonrapid-cycling bipolar disorder based on prospective mood ratings in 539 outpatients. Am. J. Psychiatry 162:1273–80

Lejoyeux M, Arbaretaz M, McLoughlin M, Ades J. 2002. Impulse control disorders and de- pression. J. Nerv. Ment. Dis. 190:310–14

Leon AC, Olfson M, Portera L, Farber L, Sheehan DV. 1997. Assessing psychiatric impairment in primary care with the Sheehan Disability Scale. Int. J. Psychiatry Med. 27:93–105

Lin TY. 1953. A study of incidence of mental disorders in Chinese and other cultures. Psychiatry 16:315–35

www.annualreviews.org • Mood Disorders in the United States 155

A nn

u. R

ev . C

li n.

P sy

ch ol

. 2 00

7. 3:

13 7-

15 8.

D ow

nl oa

de d

fr om

w w

w .a

nn ua

lr ev

ie w

s. or

g

ANRV307-CP03-06 ARI 20 February 2007 19:1

by $

{i nd

iv id

ua lU

se r.

di sp

la yN

am e}

o n

01 /1

0/ 14

. F or

p er

so na

l us

e on

ly .

Loeber R, Farrington DP, Stouthamer-Loeber M, Van Kammen WB. 1988. Antisocial Behavior and Mental Health Problems: Explanatory Factors in Childhood and Adolescence. Mahwah, NJ: Erlbaum

MacKinnon DF, Zandi PP, Cooper J, Potash JB, Simpson SG, et al. 2002. Comorbid bipolar disorder and panic disorder in families with a high prevalence of bipolar disorder. Am. J. Psychiatry 159:30–35

Mattisson C, Bogren M, Nettelbladt P, Munk-Jorgensen P, Bhugra D. 2005. First incidence depression in the Lundby Study: a comparison of the two time periods 1947–1972 and 1972–1997. J. Affect. Disord. 87:151–60

McElroy SL, Pope HG, Keck PEJ, Hudson JI, Phillips KA, Strakowski SM. 1996. Are impulse- control disorders related to bipolar disorder? Comp. Psychiatry 37:229–40

The most recent and definitive data on the descriptive epidemiology of bipolar disorders in the United States.

Merikangas KR, Akiskal HS, Angst J, Greenberg PE, Hirschfeld RMA, et al. 2007. Lifetime and 12-month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry. In press

Merikangas KR, Angst J, Eaton WW, Canino G, Rubio-Stipec M, et al. 1996. Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force. Br. J. Psychiatry 168:58–67

Mitchell PB, Slade T, Andrews G. 2004. Twelve-month prevalence and disability of DSM-IV bipolar disorder in an Australian general population survey. Psychol. Med. 34:777–85

Morrow RH, Hyder AA, Murray CJ, Lopez AD. 1998. Measuring the burden of disease. Lancet 352:1859–61

Murphy JM, Horton NJ, Laird NM, Monson RR, Sobol AM, Leighton AH. 2004. Anxiety and depression: a 40-year perspective on relationships regarding prevalence, distribution, and comorbidity. Acta Psychiatr. Scand. 109:355–75

Murphy JM, Sobol AM, Neff RK, Olivier DC, Leighton AH. 1984. Stability of prevalence: depression and anxiety disorders. Arch. Gen. Psychiatry 41:990–97

Murray CJL, Lopez AD. 1996. Global Health Statistics. Cambridge, MA: Harvard Univ. Press Narrow WE, Rae DS, Robins LN, Regier DA. 2002. Revised prevalence estimates of mental

disorders in the United States: using a clinical significance criterion to reconcile 2 surveys’ estimates. Arch. Gen. Psychiatry 59:115–23

Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA. 2002a. National trends in the outpatient treatment of depression. JAMA 287:203–9

Olfson M, Marcus SC, Druss B, Pincus HA. 2002b. National trends in the use of outpatient psychotherapy. Am. J. Psychiatry 159:1914–20

Olfson M, Marcus SC, Wan GJ, Geissler EC. 2004. National trends in the outpatient treatment of anxiety disorders. J. Clin. Psychiatry 65:1166–73

Paykel ES, Abbott R, Morriss R, Hayhurst H, Scott J. 2006. Sub-syndromal and syndromal symptoms in the longitudinal course of bipolar disorder. Br. J. Psychiatry 189:118–23

Pezawas L, Angst J, Kasper S. 2005. Recurrent brief depression revisited. Int. Rev. Psychiatry 17:63–70

Pincus HA, Hough L, Houtsinger JK, Rollman BL, Frank RG. 2003. Emerging models of depression care: multi-level (‘6 P’) strategies. Int. J. Methods Psychiatr. Res. 12:54–63

Pini S, de Queiroz V, Pagnin D, Pezawas L, Angst J, et al. 2005. Prevalence and burden of bipolar disorders in European countries. Eur. Neuropsychopharmacol. 15:425–34

Regeer EJ, ten Have M, Rosso ML, Hakkaart-van Roijen L, Vollebergh W, Nolen WA. 2004. Prevalence of bipolar disorder in the general population: a reappraisal study of the Netherlands Mental Health Survey and Incidence Study. Acta Psychiatr. Scand. 110:374–82

156 Kessler · Merikangas · Wang

A nn

u. R

ev . C

li n.

P sy

ch ol

. 2 00

7. 3:

13 7-

15 8.

D ow

nl oa

de d

fr om

w w

w .a

nn ua

lr ev

ie w

s. or

g

ANRV307-CP03-06 ARI 20 February 2007 19:1

by $

{i nd

iv id

ua lU

se r.

di sp

la yN

am e}

o n

01 /1

0/ 14

. F or

p er

so na

l us

e on

ly .

Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, et al. 1990. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) study. JAMA 264:2511–18

Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. 1993. The de facto U.S. Mental and Addictive Disorders Service System: Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Arch. Gen. Psychiatry 50:85–94

Rice DP, Miller LS. 1993. The economic burden of affective disorders. Adv. Health Econ. Health Serv. Res. 14:37–53

Robins LN, Helzer JE, Croughan JL, Ratcliff KS. 1981. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics and validity. Arch. Gen. Psychiatry 38:381–89

Robins LN, Regier DA, eds. 1991. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: Free Press. 449 pp.

Rush AJ, Trivedi MH, Ibrahim HM, Carmody TJ, Arnow B, et al. 2003. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self- report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol. Psychiatry 54:573–83

SAS Institute. 2001. SAS/STAT Software: Changes and Enhancements, Release 8.2. Cary, NC: SAS Publ.

Schachter MF, Kupfer DJ, Regier DA, First MB. 2002. A Research Agenda for DSM-V. Wash- ington, DC: Am. Psychiatr. Assoc. Press

Simon GE, VonKorff M. 1992. Reevaluation of secular trends in depression rates. Am. J. Epidemiol. 135:1411–22

Simon GE, VonKorff M. 1995. Recall of psychiatric history in cross-sectional surveys: impli- cations for epidemiologic research. Epidemiol. Rev. 17:221–27

Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. 1999. An international study of the relation between somatic symptoms and depression. N. Engl. J. Med. 341:1329–35

Spitzer RL, Kroenke K, Williams JB. 1999. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 282:1737–44

Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. 2003. Cost of lost productive work time among US workers with depression. JAMA 289:3135–44

Strakowski SM, DelBello MP. 2000. The co-occurrence of bipolar and substance use disorders. Clin. Psychol. Rev. 20:191–206

Susser E, Schwartz S, Morabia A, Bromet EJ. 2006. Psychiatric Epidemiology: Searching for the Causes of Mental Disorders. New York: Oxford Univ. Press

Szadoczky E, Papp Z, Vitrai J, Rihmer Z, Furedi J. 1998. The prevalence of major depressive and bipolar disorders in Hungary. results from a national epidemiologic survey. J. Affect. Disord. 50:153–62

Tohen M, Angst J. 2002. Epidemiology of bipolar disorder. In Textbook in Psychiatric Epidemi- ology, ed. M Tsuang, M Tohen, pp. 427–44. New York: Wiley

Trude S, Stoddard JJ. 2003. Referral gridlock: primary care physicians and mental health services. J. Gen. Intern. Med. 18:442–49

U.S. Dep. Health Human Serv. 1999. Mental health: a report of the Surgeon General. Rockville, MD: U.S. Dep. Health Human Serv., Subst. Abuse Mental Health Serv. Admin., Cent. Mental Health Serv., Natl. Inst. Health, Natl. Inst. Mental Health

www.annualreviews.org • Mood Disorders in the United States 157

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ev . C

li n.

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. 2 00

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e on

ly .

Wang PS, Berglund PA, Kessler RC. 2000. Recent care of common mental disorders in the United States: prevalence and conformance with evidence-based recommendations. J. Gen. Intern. Med. 15:284–92

Wang PS, Berglund PA, Kessler RC. 2003a. Patterns and correlates of contacting clergy for mental disorders in the United States. Health Serv. Res. 38:647–73

Wang PS, Demler O, Kessler RC. 2002. Adequacy of treatment for serious mental illness in the United States. Am. J. Public Health 92:92–98

Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. 2005. Twelve-month use of mental health services in the U.S.: results from the National Comorbidity Survey Replication (NCS-R). Arch. Gen. Psychiatry 62:629–40

Wang PS, Simon GE, Kessler RC. 2003b. The economic burden of depression and the cost- effectiveness of treatment. Int. J. Methods Psychiatr. Res. 12:22–33

Waraich P, Goldner EM, Somers JM, Hsu L. 2004. Prevalence and incidence studies of mood disorders: a systematic review of the literature. Can. J. Psychiatry 49:124–38

Warner V, Weeisman MM, Mufson L, Wickramaratne PJ. 1999. Grandparents, parents, and grandchildren at high risk for depression: a three generation study. J. Am. Acad. Child Adolesc. Psychiatry 38:289–96

Weaver AJ. 1995. Has there been a failure to prepare and support parish-based clergy in their role as frontline community mental health workers: a review. J. Pastoral Care 49:129–47

Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, et al. 1996. Cross-national epidemiology of major depression and bipolar disorder. JAMA 276:293–99

Weissman MM, Livingston Bruce M, Leaf PJ, Florio LP, Holzer CI. 1991. Affective disorders. In Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, ed. LN Robins, DA Regier, pp. 53–80. New York: Free Press

Williams JBW. 1998. Competing demands: Does care for depression fit in primary care? J. Gen. Intern. Med. 13:137–39

Williams JWJ, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. 1999. Primary care physicians’ approach to depressive disorders. Effects of physician specialty and practice structure. Arch. Fam. Med. 8:58–67

Wittchen HU. 1994. Reliability and validity studies of the WHO Composite International Diagnostic Interview (CIDI): a critical review. J. Psychiatr. Res. 28:57–84

Wittchen HU, Mhlig S, Pezawas L. 2003. Natural course and burden of bipolar disorders. Int. J. Neuropsychopharmacol. 6:145–54

World Health Organ. Int. Consort. Psychiatr. Epidemiol. 2000. Cross-national comparisons of the prevalences and correlates of mental disorders. Bull. World Health Organ. 78:413–26

Wyatt RJ, Henter I. 1995. An economic evaluation of manic-depressive illness—1991. Soc. Psychiatry Psychiatr. Epidemiol. 30:213–19

Young AS, Klap R, Sherbourne CD, Wells KB. 2001. The quality of care for depressive and anxiety disorders in the United States. Arch. Gen. Psychiatry 58:55–61

Young RC, Biggs JT, Ziegler VE, Meyer DA. 1978. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry 133:429–35

Zimmerman M, Chelminski I, McDermut W. 2002. Major depressive disorder and Axis I diagnostic comorbidity. J. Clin. Psychiatry 63:187–93

Zimmerman M, McGlinchey JB, Young D, Chelminski I. 2006. Diagnosing major depressive disorder introduction: an examination of the DSM-IV diagnostic criteria. J. Nerv. Ment. Dis. 194:151–54

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Annual Review of Clinical Psychology

Volume 3, 2007 Contents

Mediators and Mechanisms of Change in Psychotherapy Research Alan E. Kazdin 1

Evidence-Based Assessment John Hunsley and Eric J. Mash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Internet Methods for Delivering Behavioral and Health-Related Interventions (eHealth) Victor Strecher 53

Drug Abuse in African American and Hispanic Adolescents: Culture, Development, and Behavior José Szapocznik, Guillermo Prado, Ann Kathleen Burlew, Robert A. Williams, and Daniel A. Santisteban 77

Depression in Mothers Sherryl H. Goodman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

Prevalence, Comorbidity, and Service Utilization for Mood Disorders in the United States at the Beginning of the Twenty-first Century Ronald C. Kessler, Kathleen R. Merikangas, and Philip S. Wang 137

Stimulating the Development of Drug Treatments to Improve Cognition in Schizophrenia Michael F. Green 159

Dialectical Behavior Therapy for Borderline Personality Disorder Thomas R. Lynch, William T. Trost, Nicholas Salsman, and Marsha M. Linehan 181

A Meta-Analytic Review of Eating Disorder Prevention Programs: Encouraging Findings Eric Stice, Heather Shaw, and C. Nathan Marti . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207

Sexual Dysfunctions in Women Cindy M. Meston and Andrea Bradford 233

Relapse and Relapse Prevention Thomas H. Brandon, Jennifer Irvin Vidrine, and Erika B. Litvin 257

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Marital and Family Processes in the Context of Alcohol Use and Alcohol Disorders Kenneth E. Leonard and Rina D. Eiden 285

Unwarranted Assumptions about Children’s Testimonial Accuracy Stephen J. Ceci, Sarah Kulkofsky, J. Zoe Klemfuss, Charlotte D. Sweeney, and Maggie Bruck 311

Expressed Emotion and Relapse of Psychopathology Jill M. Hooley 329

Sexual Orientation and Mental Health Gregory M. Herek and Linda D. Garnets 353

Coping Resources, Coping Processes, and Mental Health Shelley E. Taylor and Annette L. Stanton 377

Indexes

Cumulative Index of Contributing Authors, Volumes 1–3 403

Cumulative Index of Chapter Titles, Volumes 1–3 405

Errata

An online log of corrections to Annual Review of Clinical Psychology chapters (if any) may be found at http://clinpsy.AnnualReviews.org

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