Association of Cannabis Use With Self-harm and Mortality Risk Among Youths With Mood Disorders

Key Points

Question  Is cannabis use disorder associated with heightened risk of self-harm, suicide, and mortality among youths with mood disorders?

Findings  This population-based cohort study of Medicaid-enrolled youths with mood disorders found that the presence of cannabis use disorder was significantly associated with an increased risk of nonfatal self-harm, all-cause mortality, and death by unintentional overdose and homicide.

Meaning  Cannabis use disorder is common among adolescents and young adults with mood disorders and is associated with an elevated risk of self-harm, overall mortality, and death by unintentional overdose and homicide in this already vulnerable population.

Importance  Cannabis use and cannabis use disorder (CUD) are common among youths and young adults with mood disorders, but the association of CUD with self-harm, suicide, and overall mortality risk is poorly understood in this already vulnerable population.

Objective  To examine associations of CUD with self-harm, suicide, and overall mortality risk in youths with mood disorders.

Design, Setting, and Participants  A population-based retrospective cohort study was performed using Ohio Medicaid claims data linked with death certificate data. The analysis included 204 780 youths (aged 10-24 years) with a diagnosis of mood disorders between July 1, 2010, and December 31, 2017, who were followed up to 365 days from the index diagnostic claim until the end of enrollment, the self-harm event, or death. Statistical analysis was performed from April 4 to July 17, 2020.

Exposure  Physician-diagnosed CUD defined using outpatient and inpatient claims from 180 days prior to the index mood disorder diagnostic claim through the 365-day follow-up period.

Main Outcomes and Measures  Nonfatal self-harm, all-cause mortality, and deaths by suicide, unintentional overdose, motor vehicle crashes, and homicide. Marginal structural models using inverse probability weights examined associations between CUD and outcomes.

Results  This study included 204 780 youths (133 081 female participants [65.0%]; mean [SD] age at the time of mood disorder diagnosis, 17.2 [4.10] years). Cannabis use disorder was documented for 10.3% of youths with mood disorders (n = 21 040) and was significantly associated with older age (14-18 years vs 10-13 years: adjusted risk ratio [ARR], 9.35; 95% CI, 8.57-10.19; and 19-24 years vs 10-13 years: ARR, 11.22; 95% CI, 10.27-12.26), male sex (ARR, 1.79; 95% CI, 1.74-1.84), Black race (ARR, 1.39; 95% CI, 1.35-1.44), bipolar or other mood disorders (bipolar disorders: ARR, 1.24; 95% CI, 1.21-1.29; other mood disorders: ARR, 1.20; 95% CI, 1.15-1.25), prior history of self-harm (ARR, 1.66; 95% CI, 1.52-1.82), previous mental health outpatient visits (ARR, 1.26; 95% CI, 1.22-1.30), psychiatric hospitalizations (ARR, 1.66; 95% CI, 1.57-1.76), and mental health emergency department visits (ARR, 1.54; 95% CI, 1.47-1.61). Cannabis use disorder was significantly associated with nonfatal self-harm (adjusted hazard ratio [AHR], 3.28; 95% CI, 2.55-4.22) and all-cause mortality (AHR, 1.59; 95% CI, 1.13-2.24), including death by unintentional overdose (AHR, 2.40; 95% CI, 1.39-4.16) and homicide (AHR, 3.23; 95% CI, 1.22-8.59). Although CUD was associated with suicide in the unadjusted model, it was not significantly associated in adjusted models.

Conclusions and Relevance  Cannabis use disorder is a common comorbidity and risk marker for self-harm, all-cause mortality, and death by unintentional overdose and homicide among youths with mood disorders. These findings should be considered as states contemplate legalizing medical and recreational marijuana, both of which are associated with increased CUD.

Mood disorders in youths, including depression and bipolar disorders, are associated with increased risk of disability and mortality, including suicide, and account for nearly 4% of the burden of disease worldwide.¹ Previous studies have identified high rates of co-occurrence for cannabis use and cannabis use disorders (CUDs) in youths and young adults with mood disorders,^2-4 and there is evidence that cannabis use may interfere with recovery from depression.⁵ Although recent reviews of the association between cannabis use and all-cause mortality in the general population have been inconclusive,^6,7 some evidence supports an elevated risk of motor vehicle traffic deaths and drug overdose–related injury in cannabis users.⁶

Cannabis use has also been associated with a heightened risk of suicidal behavior in adults, as well as a greater likelihood of dying by suicide.^8,9 In a sample of 277 adult same-sex twin pairs, cannabis users were 2.9 times more likely to attempt suicide than non–cannabis-dependent co-twins.¹⁰ Another longitudinal study of young adults found a strong association between regular cannabis use and suicide attempts after adjusting for a wide array of confounders (odds ratio [OR], 2.9; 95% CI, 1.3-6.1).¹¹ A follow-up study of Swedish conscripts reported that those who used cannabis more than 50 times by age 18 years were at increased risk of dying by suicide.¹² A case-control study comparing individuals who died by suicide with those who died of unintentional injuries linked CUD with heightened suicide risk (OR, 2.85; 95% CI, 1.31-6.24).¹³ A large case-control study of 1463 suicides and 7392 natural deaths found an association between any cannabis use and suicide risk after adjusting for depression, alcohol use, and mental health services.^14,15 Another longitudinal study with a 4-year follow-up of 6445 patients with CUD in Denmark found an increased risk of suicide for both male patients (OR, 2.28; 95% CI, 1.54-3.37) and female patients (OR, 4.82; 95% CI, 2.47-9.39) among those with CUD.¹⁶

To our knowledge, no studies to date have examined the association of CUD with overall mortality risk and nonfatal self-harm in the vulnerable population of youths with mood disorders. Given the high prevalence of CUD, as well as the elevated risk of suicide in youths with mood disorders,¹⁷ a better understanding of the association between CUD and suicide risk in this population could prove critical to suicide prevention efforts, given that both mood disorders and CUD are potentially remediable risk factors. The aim of this study was to examine the association of CUD with the risk of mortality risk, self-harm, and suicide among youths and young adults with diagnosed mood disorders. We hypothesized that youths with comorbid mood disorders and CUD would be at increased risk for nonfatal self-harm, all-cause mortality, deaths by suicide, unintentional overdose, motor vehicle crashes, and homicide, relative to those with mood disorders but not CUD.

A retrospective cohort design was used to examine the association of CUD with nonfatal self-harm and mortality among youths and young adults with a diagnosis of mood disorders. The study population included all those between 10 and 24 years of age who had 2 or more outpatient claims for mood disorders (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 296.0-296.9, 300.4, 301.13, and 311 or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] codes F30-F39) between July 1, 2010, and December 31, 2017, and were continuously enrolled in Ohio’s Medicaid program during the 180-day period prior to the index diagnostic claim (first diagnosis for mood disorder). Those with a diagnosis of schizophrenia (n = 16 467; ICD-9-CM codes 295, 297, and 298 and ICD-10 codes F20-F29) were excluded, resulting in a sample of 204 780. Youths were followed up to 365 days, until the end of enrollment, the event, or other death, whichever came first. All procedures were approved by The Ohio State University institutional review board, and a waiver of informed consent was granted because the study involved secondary data only, with deidentified patient information; the research involved only minimal risk to participants; and it would not affect the rights and welfare of participants.

Data were abstracted from Ohio Medicaid claims data and death certificate files. Medicaid claims data were obtained from the state’s Department of Job and Family Services, while death records were obtained from the state’s Department of Health. Medicaid claims data included information on eligibility status and paid claims for inpatient and outpatient services. Eligibility files included information on monthly enrollment status and demographic characteristics of enrollees. Institutional and professional files provided information on service claims for hospitalizations, physician visits (office or hospital based), and other outpatient services and included dates of service, Current Procedural Terminology and Healthcare Common Procedure Coding System procedure codes, and up to 15 ICD-9-CM and/or ICD-10 diagnoses.

Information on suicide and all-cause mortality was abstracted from death certificates. Data on suicides and all causes of death were based on ICD-10 cause of death codes reported on death certificates. Medicaid claims data were linked with the death certificate file using an algorithm from prior studies^18,19 that incorporates social security numbers, date of birth, and sex.

Primary outcomes of interest were nonfatal self-harm (ICD-9-CM codes E950-E959 and ICD-10 codes X71-X83), suicide deaths (ICD-10 codes X60-X84, Y87.0, and *U03), all causes of death, drug overdose or poisoning (ICD-10 codes X40-X44), motor vehicle deaths (ICD-10 codes V02-V04, V09.0, V09.2, V12-V14, V19.0-V19.2, V19.4-V19.6, V20-V79, V80.3-V80.5, V81.0-V81.1, V82.0-V82.1, V83-V86, V87.0-V87.8, V88.0-V88.8, V89.0, and V89.2), and homicides (ICD-10 codes X85-Y09, Y87.1, and *U01-*U02). Individuals with a self-harm event were subsequently followed up for mortality within the year. We included all-cause mortality as an outcome in addition to specific causes of death because prior research has shown an association between CUD and all-cause mortality.⁷

The primary exposure variable was recent or current CUD (ICD-9-CM codes 304.30-304.33 and 305.20-305.23 and ICD-10 code F12). If an individual had a CUD claim during the 6 months prior to the mood diagnosis claim, the participant was classified as having CUD during the entire follow-up period. If no prior CUD claims existed, individuals were classified as non-CUD until the first CUD claim during follow-up, when they were reclassified as CUD. If no CUD claims occurred in the 6 months prior to or during follow-up, the individual remained classified as non-CUD throughout the study. This variable was treated as a time-varying covariate, allowing the analysis to account for when cannabis use was first diagnosed.

Covariates included demographic, clinical, and treatment characteristics. Demographic variables included age at time of index diagnosis (10-13, 14-18, or 19-24 years), sex, race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, or other [Asian American, Native American or Alaska Native, Native Hawaiian or other Pacific Islander, and more than 1 race] as reported by Medicaid), area of residence (metropolitan or nonmetropolitan), and Medicaid eligibility (disability, foster care, low income, or other [incarceration and unknown Medicaid eligibility categories]). Clinical variables were identified based on medical claims submitted during the 180 days prior to the index diagnosis date. They included psychiatric and medical comorbidities and prior history of nonfatal self-harm (ICD-9-CM codes E950-E959 and ICD-10 codes X71-X83). Psychiatric comorbidities were present if 2 or more claims were associated with the diagnosis. They included attention-deficit/hyperactivity disorders (ADHD), conduct disorders, other substance use disorders (excluding CUD), anxiety disorders, and other mental health disorders. The following chronic medical conditions were examined²⁰: type 1 and 2 diabetes and other diabetes, seizure disorders, cerebral palsy, asthma, cancer, congenital anomalies, major organ disease, autoimmune disease, trisomy, congenital heart disease, and sickle cell disease (eTable in the Supplement). Treatment variables included any inpatient, outpatient, or emergency department mental health care during the 180 days preceding the index diagnosis.

Statistical analysis was performed from April 4 to July 17, 2020. Data for all variables were tabulated and summarized. Absolute counts in addition to percentages and risk estimates were reported for all exposures and outcomes, following Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) standards.²¹ Association of CUD with covariates (demographics, psychiatric and other medical comorbidities, prior history of self-harm, and prior psychiatric care) was modeled using Poisson regression, to account for variable length of follow-up per participant. Risk ratios and 95% CIs were reported for both unadjusted and adjusted models (which included all covariates). Association of CUD with outcomes was modeled using Cox proportional hazards regression models with time-varying covariates to account for timing of CUD. Hazard ratios (HRs) and 95% CIs were reported for both unadjusted and covariate-adjusted models. Owing to small outcome numbers, inverse probability weights from marginal structural models accounted for confounding.²² Stabilized weights were used for improved efficiency and better coverage of 95% CIs.²³ Two marginal structural models were fit, one that controlled for demographic covariates (age, sex, race/ethnicity, eligibility status, and residence) and a second that controlled for demographics and all additional covariates. All analyses were performed using SAS, version 9.4 (SAS Institute Inc) and R, version 4.0.0 (R Foundation for Statistical Computing),²⁴ with R package ipw used to fit marginal structural models.²⁵

The sample included 204 780 youths and young adults aged 10 to 24 years with a mood disorder (Table 1). Mean (SD) age was 17.2 (4.1) years at the time of mood disorder diagnosis. Most participants were female (133 081 [65.0%]), non-Hispanic White (136 950 [66.9%]), enrolled in Medicaid owing to poverty (179 370 [87.6%]), and living in a metropolitan location (157 850 [77.1%]). The most common primary diagnosis was depressive disorder (148 970 [72.7%]); 25 352 participants (12.4%) had bipolar disorder and 30 458 (14.9%) had another mood disorder (ie, unspecified mood disorder or persistent mood disorder). Attention-deficit/hyperactivity disorder (25 416 [12.4%]), anxiety (21 102 [10.3%]), and other mental health disorders (26 787 [13.1%]) were the most common psychiatric comorbidities. Only 17 018 participants (8.3%) had a chronic medical condition, 1995 (1.0%) had prior self-harm, 5303 (2.6%) had prior psychiatric hospitalizations, 11 112 (5.4%) had prior mental health emergency department visits, and 102 995 (50.3%) had prior mental health outpatient visits. A total of 21 040 participants (10.3%) received a diagnosis of CUD.

Associations between demographic, clinical, and treatment characteristics and any CUD during the study are presented in Table 2. Older age groups (14-18 years and 19-24 years) were at higher risk than the youngest age group (10-13 years) in both unadjusted and adjusted models (14-18 years vs 10-13 years, adjusted risk ratio [ARR], 9.35; 95% CI, 8.57-10.19; and 19-24 years vs 10-13 years, ARR, 11.22; 95% CI, 10.27-12.26). Male participants had a higher risk of CUD than female participants (ARR, 1.79; 95% CI, 1.74-1.84). The non-Hispanic Black group had a higher relative risk than the non-Hispanic White group (ARR, 1.39; 95% CI, 1.35-1.44). Those eligible for Medicaid through disability were at lower risk (ARR, 0.61; 95% CI, 0.58-0.65), while those in foster care were at higher risk (ARR, 1.10; 95% CI, 1.02-1.18) for CUD compared with the group eligible for Medicaid owing to poverty. Those living in a metropolitan county were also at increased risk for CUD compared with those living in a nonmetropolitan county (ARR, 1.21; 95% CI, 1.17-1.26).

Youths with bipolar disorders and other mood disorders were at increased risk for CUD compared with those with depressive disorders (bipolar disorders: ARR, 1.24; 95% CI, 1.21-1.29; and other mood disorders: ARR, 1.20; 95% CI, 1.15-1.25). Youths with conduct disorders and other substance use disorders were at higher risk for CUD than those without these disorders (conduct disorders: ARR, 1.46; 95% CI, 1.38-1.53; and substance use disorders: ARR, 2.83; 95% CI, 2.73-2.93). However, those with comorbid ADHD, other mental health disorders, and chronic medical conditions had a lower risk for CUD than those without the conditions (ADHD: ARR, 0.82; 95% CI, 0.78-0.86; other mental health disorders: ARR, 0.72; 95% CI, 0.69-0.76; and chronic medical conditions: ARR, 0.89; 95% CI, 0.84-0.93). Prior self-harm (ARR, 1.66; 95% CI, 1.52-1.82), psychiatric hospitalizations (ARR, 1.66; 95% CI, 1.57-1.76), mental health outpatient visits (ARR, 1.26; 95% CI, 1.22-1.30), and mental health emergency department visits (ARR, 1.54; 95% CI, 1.47-1.61) were all associated with increased risk for CUD.

Associations of CUD with nonfatal self-harm, suicides, and all other mortality categories appear in Table 3. Cannabis use disorder was strongly associated with all outcomes in the unadjusted models. Unadjusted HRs for CUD ranged from 2.13 (95% CI, 1.89-2.40) for nonfatal self-harm to 6.38 (95% CI, 4.05-10.04) for unintentional overdose. The association between CUD and nonfatal self-harm was significant and remained significant after adjustment for all covariates (HR, 3.28; 95% CI 2.55-4.22). Those with CUD were at 3.46 (95% CI, 1.48-8.07) times the risk of suicide compared with those without CUD in the unadjusted model. After adjusting for age, sex, race/ethnicity, Medicaid eligibility status, and residence, the association between CUD and suicide was nonsignificant (HR, 2.23; 95% CI, 0.93-5.39). After further adjusting for all additional covariates (psychiatric comorbidities, including other substance use disorders; chronic medical conditions; prior self-harm; and prior inpatient, emergency department, and outpatient treatment) the association was nonsignificant (HR, 1.22; 95% CI, 0.44-3.43). Hazard ratios between CUD and all nonsuicide mortality outcomes were attenuated after adjusting for demographic covariates but remained statistically significant, except for mortality due to motor vehicle deaths; this latter category occurred infrequently (20 total occurrences). Hazard ratios were attenuated further after including all other covariates but remained statistically significant, with an HR of 1.59 (95% CI, 1.13-2.24) for all-cause mortality, and the strongest associations for homicides (HR, 3.23; 95% CI 1.22-8.59) and unintentional overdose (HR, 2.40; 95% CI, 1.39-4.16).

Cannabis is the most commonly used illicit drug among US adolescents and the most common drug problem reported by US teens presenting for substance use treatment.²⁶ In our study population of youths aged 10 to 24 years with mood disorders, 10.3% received a diagnosis of CUD, a rate significantly higher than that reported in the general population (2.2% for adolescents and 5.2% for young adults).²⁶ Those with CUD in addition to their mood disorder were significantly more likely to engage in nonfatal self-harm and to die. Unintentional overdoses, suicide, and homicide were the 3 most frequent causes of death. Increased risk for nonfatal self-harm, unintentional overdose, and homicide remained significant even after controlling for a wide array of potentially confounding variables. Cannabis use disorder was significantly associated with increased suicides and motor vehicle deaths in the univariable analysis but not after adjusting for potential confounders. Study findings highlight the importance of cannabis use as a potentially remediable risk factor for self-harm and death in youths with mood disorders, particularly among African American youths and those in foster care. Overall, these findings are particularly troubling, especially in the context of increasing statewide medical and recreational legalization of marijuana, which has been associated with increased CUD in adolescents.^27,28

Although no prior studies have, to our knowledge, examined the association between CUD and mortality among youths with mood disorders, our findings are generally consistent with findings of adult studies. Cannabis use has been associated with nonfatal self-harm, suicidal ideation, and suicide in adults.^10,29-32 In addition, cannabis use has been linked with increased risk of unintentional traffic-related injuries and other types of unintentional injuries in adults^7,33-37 and is often detected in homicide victims.^33,37 One prospective register-based cohort study of the association between CUD and all-cause mortality among adults with severe mental illness (ie, schizophrenia, bipolar disorder, and depression) reported that CUD was associated with all-cause mortality and unintentional death in individuals with schizophrenia but not for individuals with bipolar disorder or depression.³⁸

It is unclear how cannabis use is associated with all-cause mortality. The observed heightened risk of unintentional overdoses could be associated with the misuse of substances other than cannabis (eg, opioids, cocaine, or amphetamines). Cannabis use may be associated with greater impulsivity, increased risk-taking behaviors, and impaired judgment, and may increase vulnerability to development of manic symptoms,³⁹ as well as decreased likelihood of help seeking. The increased risk of self-harm in those with CUD might be associated with negative associations of cannabis with mood and increased severity of depression and/or anxiety,^40-43 an impulsive response to a stressful event,⁴⁴ and/or emergence of psychotic symptoms.⁴⁵ For example, a meta-analysis of 14 studies and more than 76 000 adolescent or adult participants showed that cannabis users had a moderate increase in risk for developing depression (OR, 1.17; 95% CI, 1.05-1.30) and that heavy users were at even greater risk (OR, 1.62; 95% CI, 1.21-2.16) compared with light users or nonusers.⁴¹ A subsequent meta-analysis of 11 studies examining more than 23 000 adolescents indicated that those who use cannabis are at significantly increased risk for depression (OR, 1.37; 95% CI, 1.16-1.62), suicidal ideation (OR, 1.50; 95% CI, 1.11-2.03), and suicide attempt (OR, 3.46; 95% CI, 1.53-7.84) in young adulthood.⁹ Cannabis may also interfere with the course of treatment for those with mood disorders and may affect adherence to medication treatment and psychotherapy.^46,47

Several limitations of this study should be considered. First, substance use disorders, including CUD, are underdiagnosed,⁴⁸ which would likely result in underestimation of associations. Cannabis use disorder is also inconsistently reported; that is, individuals who see more clinicians may be more likely to receive the diagnosis. Second, death records may misclassify suicide deaths as unintentional or undetermined deaths, leading to underreporting of suicide and underestimation of associations from this sample.⁴⁹ Third, because the data are from a single state Medicaid population, study findings may not be generalizable to other states or non-Medicaid populations, although there is no reason to believe that these results would not be typical, as Ohio is a microcosm of the US as a whole in terms of its geographical and demographic characteristics. Fourth, because the data are observational, it is not possible to infer causality. Fifth, although we controlled for a wide range of potential confounders, it is impossible to exclude confounding owing to unmeasured factors. For example, we were unable to control for other potentially relevant factors (eg, trauma history or chaotic home life) that are often associated with mortality. Sixth, some outcomes occurred infrequently, which reduced power to detect a difference between participants with and without CUD. Seventh, diagnostic classification of mood disorders is based on clinical diagnoses, not standardized diagnostic procedures.

However, there are several strengths of this study. First, we examined a large population-based sample of youths and young adults with mood disorders. Second, we reported on specific reasons for death, including some not examined previously in cohort studies. Third, we controlled for multiple potentially confounding variables, including demographics, psychiatric and medical comorbidities, prior history of self-harm, and prior treatment history. Fourth, we conducted a longitudinal analysis of mortality risk. Fifth, we measured the association of CUD with outcomes. The few existing cohort studies concern relatively infrequent users of cannabis, for whom potential damaging effects are less likely to be detected.⁷

Mood disorders in youths and young adults are associated with increased risk of self-harm and mortality, including suicide. Comorbid CUD and mood disorders are associated with an even higher risk of self-harm and death in already vulnerable youths with mood disorders. All-cause deaths, unintentional overdose deaths, and homicide are more common among youths and young adults with comorbid CUD and mood disorders, even after controlling for many other relevant risk factors. Although this observational study calls attention to these associations, it is unable to contribute to our understanding of causality or mechanism. Youths with mood disorders of greater severity and intractability might be more inclined to use cannabis than youths with less severe mood disorders, and cannabis use can also exacerbate symptoms of mood disorders and interfere with the successful treatment of youths already with depression or bipolar disorder. Risk reduction via decreasing rates of CUD nevertheless appears to be a reasonable strategy to pursue. Family-based models and individual approaches such as cognitive behavioral therapy both alone and with motivational enhancement therapy have been shown to be efficacious for treatment of children and adolescents with substance use disorder, including CUD.⁵⁰ In light of legislative action across the US to permit both recreational marijuana use and medical marijuana use, which have been shown to increase rates of CUD, information about the known risks, including mortality, and benefits associated with cannabis should be readily available to youths and young adults, their parents, health care professionals, and legislators. A national study examining the mortality risk for youths and young adults with comorbid mood disorders and CUD could further inform policy and treatment trials.

Accepted for Publication: August 19, 2020.

Published Online: January 19, 2021. doi:10.1001/jamapediatrics.2020.5494

Corresponding Author: Cynthia A. Fontanella, PhD, Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, 1670 Upham Dr, Columbus, OH 43210 (cynthia.fontanella@osumc.edu).

Author Contributions: Dr Fontanella had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fontanella, Bridge, Campo, Fristad.

Acquisition, analysis, or interpretation of data: Fontanella, Steelesmith, Brock, Bridge, Campo.

Drafting of the manuscript: Fontanella, Steelesmith, Brock.

Critical revision of the manuscript for important intellectual content: Fontanella, Steelesmith, Bridge, Campo, Fristad.

Statistical analysis: Steelesmith, Brock, Bridge.

Obtained funding: Bridge.

Supervision: Fontanella, Bridge.

Conflict of Interest Disclosures: Dr Fontanella reported receiving grants from the National Institute of Mental Health during the conduct of the study. Dr Brock reported receiving National Center for Advancing Translational Sciences Award UL1TR002733 during the conduct of the study. Dr Bridge reported receiving grants from the National Institute of Mental Health during the conduct of the study; and being a member of the Scientific Advisory Board of Clarigent Health. Dr Fristad reported receiving royalties from American Psychiatric Press, Child & Family Psychological Services, Guilford Press, and Janssen outside the submitted work. No other disclosures were reported.

Funding/Support: This research was funded by grant R01MH117594 from the National Institute of Mental Health

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed in the manuscript of those of the authors and do not necessarily reflect the views of the National Institute of Mental Health.