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Original Article
January 3, 2011

Development of Lifetime Comorbidity in the World Health Organization World Mental Health Surveys

Author Affiliations

Author Affiliations: Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Drs Kessler, Petukhova, McLaughlin, Green, and Zaslavsky); Department of Psychiatry, University Medical Center Groningen, and Graduate Schools of Behavioural and Cognitive Neuroscience and for Experimental Psychopathology, University of Groningen, Groningen, the Netherlands (Dr Ormel); Shire Pharmaceuticals Research and Development, Chesterbrook, Pennsylvania (Dr Russo); Department of Psychiatry, University of Cape Town, Cape Town, South Africa (Dr Stein); School of Medicine, Center for Reducing Health Disparities, University of California, Davis (Dr Aguilar-Gaxiola); Health Services Research Unit, Institut Municipal d’Investigació Mèdica, Centro de Investigación Biomédica en Red (CIBER) en Epidemiología y Salud Pública, Barcelona, Spain (Dr Alonso); Section of Psychiatric Epidemiology, Department and Institute of Psychiatry, School of Medicine, University of São Paulo, São Paulo, Brazil (Dr Andrade); National Institute of Psychiatry, Mexico City, Mexico (Dr Benjet); Istituto de Ricovero e Cura a Carattere Scientifico Centro S. Giovanni di Dio Fatebenefratelli, Brescia, Italy (Dr de Girolamo); Netherlands Institute of Mental Health and Addiction, Utrecht (Dr de Graaf); Department of Psychiatry, University Hospital Gasthuisberg, Leuven, Belgium (Dr Demyttenaere); St George Hospital University Medical Center, Balamand University, and Faculty of Medicine, Institute for Development, Research, Advocacy and Applied Care, Medical Institute for Neuropsychological Disorders, Beirut, Lebanon (Drs Fayyad and Karam); Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBER en Salud Mental, Sant Boi de Llobregat, Barcelona, Spain (Dr Haro); Shenzhen Institute of Mental Health and Shenzhen Kangning Hospital, Shenzhen, China (Dr Hu); The Chinese University of Hong Kong, Shatin, Hong Kong (Dr Lee); Hôpital Lariboisière Fernand Widal, Assistance Publique Hôpitaux de Paris, Institut National de la Santé et de la Recherche Médicale U 705, Centre national de la recherché scientifique Unité Mixte de Recherche, 7157 University Paris Diderot and Paris Descartes, Paris, France (Dr Lepine); Department of Psychiatry, University of Leipzig, Leipzig, Germany (Dr Matchsinger); National School of Public Health and Health Services Management, Bucharest, Romania (Dr Mihaescu-Pintia); Colegio Mayor de Cundinamarca University, Bogota, Colombia (Dr Posada-Villa); All India Institute of Medical Sciences, New Delhi (Dr Sagar); and Evidence and Information for Policy/Department of Health Financing and Stewardship, World Health Organization, Geneva, Switzerland (Dr Üstün).

Arch Gen Psychiatry. 2011;68(1):90-100. doi:10.1001/archgenpsychiatry.2010.180

Context  Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity.

Objective  To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the World Health Organization World Mental Health Surveys.

Design  Nationally or regionally representative community surveys.

Setting  Fourteen countries.

Participants  A total of 21 229 survey respondents.

Main Outcome Measures  First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the World Health Organization Composite International Diagnostic Interview.

Results  Separate internalizing (anxiety and mood disorders) and externalizing (behavior and substance disorders) factors were found in exploratory factor analysis of lifetime disorders. Consistently significant positive time-lagged associations were found in survival analyses for virtually all temporally primary lifetime disorders predicting subsequent onset of other disorders. Within-domain (ie, internalizing or externalizing) associations were generally stronger than between-domain associations. Most time-lagged associations were explained by a model that assumed the existence of mediating latent internalizing and externalizing variables. Specific phobia and obsessive-compulsive disorder (internalizing) and hyperactivity and oppositional defiant disorders (externalizing) were the most important predictors. A small number of residual associations remained significant after controlling the latent variables.

Conclusions  The good fit of the latent variable model suggests that common causal pathways account for most of the comorbidity among the disorders considered herein. These common pathways should be the focus of future research on the development of comorbidity, although several important pairwise associations that cannot be accounted for by latent variables also exist that warrant further focused study.