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© 2006 American Public Health Association
DOI: 10.2105/AJPH.2004.057851
RESEARCH AND PRACTICE |
Louise H. Flick is with the School of Nursing, Southern Illinois University–Edwardsville, and the School of Public Health, St Louis University, St Louis, Mo. Cynthia A. Cook is with the School of Social Service, St Louis University. Sharon M. Homan is with the School of Public Health, St Louis University. Maryellen McSweeney is with the School of Nursing, St Louis University. Claudia Campbell is with the School of Public Health, Tulane University, New Orleans, La. Lisa Parnell is with Lutheran Hospital, St Louis.
Correspondence: Requests for reprints should be sent to Louise H. Flick, DrPH, School of Nursing, Box 1066, Southern Illinois University–Edwardsville, Edwardsville, IL 62026-1066 (e-mail: lflick{at}siue.edu).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We examined the association between psychiatric disorders and tobacco use during pregnancy.
Methods. Data were derived from a population-based cohort of 744 pregnant African American and White low-income women living in urban and rural areas. The Diagnostic Interview Schedule was used to assess women for 20 different psychiatric disorders.
Results. In comparison with nonusers, persistent tobacco users (women who had used tobacco after confirmation of their pregnancy) and nonpersistent users (women who had used tobacco but not after pregnancy confirmation) were 2.5 and 2 times as likely to have a psychiatric disorder. Twenty-five percent of persistent users had at least 1 of the following diagnoses: generalized anxiety disorder, bipolar I disorder, oppositional disorder, drug abuse or dependence, and attention deficit–hyperactivity disorder.
Conclusions. In this cohort study, 5 diagnoses were more prevalent among persistent tobacco users than among nonusers, suggesting that several psychiatric disorders contribute to difficulty discontinuing tobacco use during pregnancy. Smoking cessation efforts focusing on pregnant women may need to address co-occurring psychiatric disorders if they are to be successful.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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During pregnancy, women’s motivation to discontinue tobacco use is typically high.1,2 Nearly 25% of women stop spontaneously when they learn they are pregnant.2 Although some persistent tobacco users respond to brief pregnancy cessation programs,3 the majority do not, and success has been limited even in the case of intense programs.4 Results of studies comparing persistent users with quitters suggest that social risk factors such as low educational levels, single parenthood, low income levels, greater likelihood of interpersonal problems, and risky health behaviors are more prevalent among persistent users.5
In the general population, tobacco use is associated with psychiatric disorders such as major depression, anxiety disorders, substance abuse,6–8 schizophrenia, bipolar disorder, and panic disorder.9,10 In a nationally representative study, Lasser and colleagues11 found that individuals with at least 1 current psychiatric disorder (i.e., those meeting lifetime criteria and having symptoms in the past month) were 2.7 times more likely than those without a disorder to report smoking (95% confidence interval [CI]=2.3, 3.1), and quantity of use increased with increasing numbers of disorders. Some speculate that tobacco use functions as a type of self-medication for psychiatric symptoms,12 and recent evidence indicates that tobacco produces effects on neurochemicals similar to those of antidepressants.13
Although rates of psychiatric disorders in pregnancy are unknown, estimates suggest that they are high. According to representative community studies, 20% to 30% of women have met criteria for a psychiatric disorder in the previous 12 months, with higher rates among women of childbearing age than older women.14,15 Psychiatric disorders appear to negatively affect pregnancy and infant outcomes, although it is unclear precisely how they do so. Proposed mechanisms include the neuroendocrine stress response, behavioral effects, and genetic factors.16,17 Schizophrenia has been shown to be associated with fetal growth restriction,17 preterm birth,18 and infant mortality.19 Research on depression, anxiety, and maternal stress suggests effects on fetal growth, preterm birth, and infant development.20–29
Although depression and anxiety in pregnancy have received considerable attention,30,31 few studies have examined the relation between tobacco use in pregnancy and other psychiatric symptoms or disorders.32 Because individuals with psychiatric disorders are more likely to use tobacco and to use larger amounts than those without disorders, tobacco use may partially account for the association between psychiatric disorders and negative infant outcomes. Many studies have not controlled for tobacco use, but those that have done so have shown persisting associations between psychiatric disorders and negative infant outcomes.21,25,33 Tobacco use and psychiatric disorders each appear to contribute to poor infant outcomes.
Because both rates of tobacco use and quantity of use are higher among women with psychiatric disorders,11 and because most women are highly motivated to quit during their pregnancy,1,2 psychiatric disorders may be more prevalent among those who are unable to quit when they learn they are pregnant than among those who discontinue their use of tobacco. We examined whether psychiatric disorders are more prevalent among pregnant women who persist in using tobacco.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Data Sources
We obtained the data for this study from a prospective cohort investigation of prenatal mental health and its impact on birth outcomes, use of health care services, and health service costs.
Study Population
Participants were recruited from a cohort of Medicaid-eligible pregnant women taking part in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in St Louis City and 5 rural counties in the Missouri "bootheel." The sample was stratified by area of residence (urban vs rural) and was representative of the racial (African American and White) breakdown of WIC participants in each county according to WIC records. Participants were 13 years old or older and spoke English. Among the 878 women approached, 132 (15%) refused to be interviewed or were unavailable for interviews; thus, the final sample was composed of 744 women (response rate: 85%) (see Cook et al.34 for a complete description).
Participants were interviewed once during their pregnancy at the WIC site or in their homes between February 2000 and August 2001. Birth certificates were matched by state personnel and returned in electronic file form.
The Diagnostic Interview Schedule, Version IV (DIS-IV),35 a diagnostic instrument based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ),36 was used to assess women for 20 current (i.e., previous 12 months) diagnoses. Horton et al.37 demonstrated that the DIS-IV had good to excellent reliability for most diagnoses (
= .60–.81), and validity has been demonstrated via (1) comparisons with other diagnostic structured interview assessments,38 (2) comparisons of lay administration with administration by a psychiatrist, and (3) comparisons of DIS interviews with assessments made by psychiatrists within both clinical populations39 and the general population.40,41
Participants with any reported substance use or with apparent confusion were assessed with the DIS dementia module, which is based on the Mini-Mental Status Examination42 and the Blessed Dementia Rating Scale.43 One participant with physician-diagnosed bipolar disorder was excluded because she was too confused to understand the questions.
Interviewers resided in the areas sampled and received weeklong training sessions conducted by certified DIS-IV trainers. Interviews were tape recorded. Each interviewer’s tapes were reviewed until a consistent level of quality was obtained, and then samples of the tapes were analyzed for quality control purposes throughout the data collection process. An interview coordinator provided daily supervision, and investigators held monthly debriefing sessions.
The DIS tobacco module assesses onset, recency, quantity, and frequency of tobacco product use as well as symptoms of dependence. Date of most recent use allowed a comparison with date of pregnancy confirmation. Information on number of cigarettes smoked during pregnancy was obtained from birth certificates. In these analyses, DIS data were used to define the independent variable; birth certificate data were used only to determine agreement with DIS data.
Psychiatric Disorder and Tobacco Use Definitions
Tobacco users were defined as those who had ever smoked cigarettes, cigars, or a pipe or had ever used snuff or chewing tobacco. Respondents were classified into 3 groups: those who had not used tobacco in the previous 12 months ("nonusers"), those who had used tobacco in the previous 12 months but not after their pregnancy had been confirmed by a health professional ("nonpersistent users"), and those who had used tobacco since their pregnancy had been confirmed ("persistent users").
Women who met DSM-IV criteria for at least 1 diagnosis, other than nicotine dependence, on the basis of symptoms experienced in the previous 12 months were grouped into the "any psychiatric disorder" category. Individual diagnoses included major depressive disorder (MDD), bipolar I and bipolar II disorders, dysthymia, schizophrenia, posttraumatic stress disorder (PTSD), obsessive/compulsive disorder, generalized anxiety disorder, panic disorder, social phobia, specific phobia, eating disorders (anorexia and bulimia), attention deficit–hyperactivity disorder (ADHD), antisocial personality disorder, oppositional disorder, conduct disorder, alcohol abuse or dependence, and drug abuse or dependence. Nicotine dependence was assessed but excluded from the analyses because of its close association with persistent tobacco use.
Diagnoses were made according to the scoring program provided with the DIS; all exclusion criteria were applied. Women who met lifetime criteria for major depression and criteria for a current depressive episode were classified as having a current MDD diagnosis. Women who met lifetime criteria for bipolar I disorder and criteria for a current episode of mania, hypomania, or depression were classified as having a diagnosis of current bipolar I disorder.
Data Analyses
Two-way associations between the tobacco persistence variable, potentially confounding variables, and the outcome variables were examined via 
2 tests. The SPSS statistical package (SPSS Inc, Chicago, Ill) was used in conducting all analyses. Eight potentially confounding variables were included: race (African American or White), area of residence (urban vs rural), age, previous birth (yes/no), marital status (ever vs never married), educational level, trimester in which the interview occurred, and annual income (less than the sample median for a family of 4 [$8224] vs at or above the sample median).
Dichotomous outcome variables included diagnoses of each specific psychiatric disorder, diagnoses in overall categories of disorders, and diagnoses of "any current psychiatric disorder." Diagnostic categories included anxiety disorders, affective disorders, ADHD and behavioral disorders (e.g., oppositional, conduct, and antisocial personality disorder), and any alcohol or drug abuse or dependence.
Multiple logistic regression analyses were used to calculate estimated adjusted odds ratios (ORs) for individual psychiatric diagnoses, diagnostic categories, and "any current disorder" diagnoses. The 8 potentially confounding variables were included as covariates in each model.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Tobacco use data were not available for 11 of the participants, yielding a usable sample of 733. Participants with and without tobacco data did not differ in terms of demographic characteristics.
Validity and Reliability of Self-Reported Tobacco Use
Although biological validation of tobacco use was not available, other studies have shown moderate to high correspondence between self-reported number of cigarettes smoked and cotinine levels in maternal blood or meconium.44,45 Tobacco use information derived from the DIS and tobacco use reported on birth certificates were compared. The DIS-derived data covered use from date of conception to date of the pregnancy interview, whereas birth certificates included tobacco use during the entire pregnancy. Only 4% of participants denied tobacco use during pregnancy in DIS interviews while reporting use on birth certificates, supporting the reliability of the DIS data on tobacco use in pregnancy. Nine percent of the participants reported tobacco use in the DIS interviews and denied use on birth certificates.
Sample Characteristics
The age range of the participants was 13 to 43 years (mean = 22.9 years; Table 1
). Fifty-eight percent were African American and 42% were White, 42% had not finished high school, 78% had never been married, and 59% resided in a rural area (with the remainder in St Louis City). Participants were at different pregnancy stages when they were interviewed, 20% (n = 146) in the first trimester, 43% (n = 315) in the second trimester, and 37% (n = 272) in the third trimester. Many (42%) were pregnant with their first child. Almost half of the sample had used tobacco in the previous 12 months (47%; n = 348), and 71% of tobacco users (n = 246) had persisted in their use after pregnancy confirmation.
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Table 2
shows that, excluding nicotine dependence, 26% of the participants had at least 1 diagnosis at their pregnancy interview (when nicotine dependence was included in the analysis, 31% had at least 1 diagnosis); MDD and nicotine dependence were the most prevalent single diagnoses (8% each). Individual diagnosis rates were as follows: PTSD, approximately 8%; bipolar I disorder, 6%; oppositional disorder, 5%; generalized anxiety disorder and current drug abuse or dependence, 4% each; and social phobia and specific phobia, 3% each.
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Most participants with a psychiatric diagnosis had not undergone mental health treatment in the past year. Among the 192 women with a disorder who had both treatment and tobacco data available, only 27% (n = 52) reported having received psychiatric treatment in the past year, 21% (n = 41) reported having desired treatment but not receiving it, and 52% reported not desiring treatment. Treatment status was not associated with persistent tobacco use (
24 = 6.56, P = .16).
Bivariate Analyses
In comparison with the other groups, persistent tobacco users were older, more likely to be White, less educated, and more likely to be single, and they reported lower incomes (Table 1
). Persistent users were nearly twice as likely as nonusers to have a psychiatric diagnosis (Table 2) and twice as likely to meet criteria for bipolar I disorder and PTSD; persistent use was also associated with a 2.5-times greater likelihood of social phobia and a 5-times greater likelihood of drug abuse or dependence relative to nonuse.
Multiple Logistic Regression Analyses
Logistic regression analyses were used to test for the effects of tobacco use on the likelihood of a psychiatric disorder diagnosis after adjustment for race, area of residence, age, parity, marital status, educational level, trimester of interview, and income. Table 3 shows that persistent users were 2.5 times as likely as nonusers to have met criteria for a psychiatric disorder in the previous 12 months (excluding nicotine dependence); nonpersistent users were twice as likely to have a disorder. Persistent users were 2.5 times more likely than nonusers to have an anxiety disorder (OR = 2.43), twice as likely to have an affective disorder (OR = 1.94), 3 times more likely to have a behavior disorder (OR = 2.74), and 4.5 times more likely to abuse or be dependent on alcohol or illicit drugs (OR = 4.40).
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Individual diagnoses were analyzed if there were 10 or more observed cases (a prevalence rate of 1.4% or above). Consequently, panic disorder, bipolar II disorder, dysthymia, schizophrenia, anorexia and bulimia, conduct disorder, antisocial personality disorder, alcohol abuse/dependence, and obsessive/compulsive disorder were not analyzed. Among the anxiety disorders, generalized anxiety disorder accounted for most of the effect. Relative to nonuse, persistent tobacco use (Table 4
, middle panel) was associated with a 4-times greater increase in the likelihood of generalized anxiety disorder (OR = 3.94). No association was observed with social or specific phobias.
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In the case of affective disorders, only bipolar I disorder was associated with persistent tobacco use (OR = 3.09) in comparison with nonuse; there was a 3-times greater likelihood of a bipolar I diagnosis among nonpersistent users as well. Among persistent users, the likelihood of a manic episode (a criterion for bipolar I disorder) was higher than the likelihood of bipolar I disorder (OR = 4.92). Among nonpersistent users, this difference in likelihood was almost 4 times greater (OR = 3.80). Neither MDD nor depressive episodes achieved significance. In terms of ADHD/behavioral disorders, persistent users were 8 times more likely than nonusers to meet criteria for ADHD (OR = 8.25) and 3 times more likely to have an oppositional disorder diagnosis (OR = 2.97).
There were fewer than 10 cases of the other disorders included in the affective disorder category, and these disorders were not tested. In the alcohol or drug abuse/dependence category, prevalence rates of alcohol diagnoses were low, but persistent tobacco users were 5 times more likely than nonusers to report illicit drug use or dependence (OR = 4.90). No association was observed with PTSD.
Nicotine Dependence
Participants whose sole diagnosis was nicotine dependence were excluded from the "any psychiatric disorder" analyses. Eight percent (n = 62) of the participants met the criteria for nicotine dependence, but 27 (44%) of these women also met criteria for another diagnosis. Consequently, only 35 cases (5%) were excluded from the "any disorder" analyses.
The DSM-IV criteria for nicotine dependence require clinically significant impairment or distress as manifested by at least 3 of the following symptoms in the previous 12 months: use of increasing quantities, withdrawal symptoms during attempts to stop, tolerance to nicotine, desire to or unsuccessful attempts to cut down or stop, and continuing tobacco use even when such use is known to cause or exacerbate a physical problem or psychological problems.36 Surprisingly, the majority of respondents who met criteria for nicotine dependence did not use tobacco after their pregnancy had been confirmed. Those meeting criteria for nicotine dependence accounted for only 19% of persistent tobacco users, offering further evidence that pregnancy provides strong motivation to stop.
Quantity of Consumption
To determine whether psychiatric disorders in pregnancy were associated with greater fetal exposure to tobacco among persistent users, we compared number of cigarettes consumed, as reported on birth certificates, with presence of a psychiatric disorder. Birth certificate data for 683 participants showed that 222 of these women reported smoking during pregnancy. Those with "any psychiatric diagnosis" smoked an average of 9.2 (SE = 0.84) cigarettes per day, compared with 6.5 (SE = 0.64) among those without a diagnosis (t220 = –2.59, P = .01).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Fetal exposure to tobacco is the most important modifiable risk factor for poor birth outcomes,46 and tobacco use in pregnancy is common. Tobacco use rates among pregnant women have declined since 1990, but 15 states have reported significant recent increases among pregnant teenagers.47 Although representing an area of high priority, tobacco cessation interventions focusing on pregnant women have had limited success.1,46
Evidence supports an association between tobacco use and psychiatric disorders in the general population11,48 and the detrimental effects of depression on smoking cessation efforts.49–50 However, little attention has been paid to other psychiatric disorders as factors in cessation of tobacco use during pregnancy. Our data suggest that attention to several psychiatric disorders may be warranted. Smoking cessation success rates may increase if women with such disorders are identified and offered appropriate treatment or supportive interventions.
In the present low-income sample, women who had used tobacco in the past year were 2.5 times more likely than nonusers to have a psychiatric diagnosis. This finding is comparable to the 2.7-times greater elevated risk among tobacco users in the general population reported by Lasser and colleagues.11 Lasser et al. used the Composite International Diagnostic Interview, a standardized diagnostic interview that yields consistently higher prevalence rates than the DIS with similar populations.11,15
Diagnostic Categories
When we examined diagnostic categories, we found significant associations between persistent tobacco use and each category. Persistent tobacco users were 2.5 times as likely as nonusers to have an anxiety disorder diagnosis, twice as likely to have an affective disorder diagnosis, 3 times as likely to have an ADHD/behavioral disorder diagnosis, and 4.5 times as likely to have an alcohol or drug abuse/dependence diagnosis.
Individual Disorders
The findings of our study, in which a range of disorders (assessed according to all DSM-IV criteria) were considered, do not support an association between MDD in pregnancy and persistent tobacco use. In addition, the results observed for major depressive episodes were not significant. We expected findings associated with such episodes to approximate those of studies employing measures based on counts of depressive symptoms rather than full criteria for MDD. The presence of a major depressive episode is required for a diagnosis of MDD; however, a depressive episode may also be attributed to a diagnosis other than MDD, such as bipolar I, bipolar II, or schizophrenia. Similarly, measures relying on depressive symptoms rather than the full criteria would include individuals with depressive symptoms appropriately attributed to these other disorders. Yet, even depressive episodes proved unrelated to tobacco use persistence.
That we did not find an association with either MDD or major depressive episodes was surprising given the strong associations between tobacco use and depression or depressive symptoms reported in samples of both nonpregnant and pregnant women.6,11,48,51,52 However, one recent study focusing on tobacco use and depression among adolescents indicated that the apparent association could be explained by unobservable factors.53 This issue warrants further study.
Persistent users were 3 times more likely than nonusers to have bipolar I disorder and 5 times more likely to have experienced a recent manic episode (a key criterion for bipolar I disorder). Sixty-nine percent of participants with bipolar I disorder were tobacco users, similar to the results of the Lasser et al.11 study, in which 60% of respondents with bipolar disorder reported that they smoked. Also, illicit drug abuse or dependence was highly associated with persistent tobacco use (OR = 5.3), consistent with the results of other studies.6,11,51 The strongest association occurred with ADHD; persistent tobacco users were 8 times as likely as nonusers to have an ADHD diagnosis. A combined analysis of the 5 disorders associated with tobacco use persistence showed that 24.8% of persistent tobacco users, compared with 8.1% of non-users, had at least 1 of these diagnoses.
Potential Confounding
Given that both psychiatric disorders and tobacco use are more prevalent among socially disadvantaged individuals, a potential alternate explanation for our results is confounding attributable to the sample’s socioeconomic characteristics. However, we addressed this possibility by restricting eligibility to WIC-enrolled, Medicaid-eligible women and statistically adjusting for the effects of race, educational level, age, number of children, and income.
Screening for Psychiatric Disorders
Our finding that 25% of persistent tobacco users had met criteria in the past year for at least 1 of a group of 5 disorders suggests that psychiatric disorders contribute substantially to poor success rates in tobacco cessation programs. In addition, our data indicate the importance of screening for psychiatric disorders in pregnancy, particularly when tobacco use persists. If tobacco cessation programs limit screening or focus interventions on only 1 or 2 diagnoses, opportunities to target interventions appropriately may be missed. In particular, screening for a history of bipolar disorder may prevent depressive symptoms that indicate bipolar disorder from being mistakenly attributed to MDD.
Given the apparent high prevalence rate of psychiatric disorders among pregnant women and the effects of these disorders on infant health, use of a broad measure to screen all pregnant women would be ideal. Several such measures have been developed, and work is ongoing to establish their reliability, validity, and utility so that they can be applied in clinical situations.54
Nicotine Dependence
The overall rate of nicotine dependence in our young sample was 8%. Grant et al. reported a rate of 11.5% for their representative sample of women older than 18 years.48 In contrast to the participants in the Grant et al. study, 12.3% of whom were African American and none of whom were younger than 19 years,48 more than 50% of the women in our sample were African American, and 23% were younger than 19 years. In Missouri, and in the United States as a whole, young African American women tend to smoke at lower rates than young White women; also, in the case of both races, rates are lower among younger women than among older women.55,56 These differences may account for the lower nicotine dependence rate in our sample.
In this study nicotine dependence, as the sole diagnosis, was excluded from the "any psychiatric disorder" category with minimal effect. Only 19% of persistent tobacco users were dependent on tobacco, and 44% of those with nicotine dependence had been diagnosed with at least 1 other psychiatric disorder. One fifth of those meeting criteria for nicotine dependence reported that they had discontinued use while they were pregnant, suggesting that they were motivated to stop smoking in spite of dependence symptoms. Many women resume smoking immediately after their child’s birth. WIC self-report data for our sample indicated that 26% (16 of 61) of women who stopped smoking during their pregnancy resumed before their postpartum appointment. Clearly, nicotine dependence does not explain persistent tobacco use in this sample.
Strengths and Limitations
Variations in the timing of the interviews, which introduced variations in the periods assessed, were a limitation of this study. However, multivariate analyses were used to control for trimester of interview. Obtaining a representative sample of pregnant women is challenging because of the difficulty involved in enumerating a complete population. Recruiting participants through the WIC program was a strength because it allowed sampling of a nearly complete population of pregnant women. When the study began, the Missouri WIC program served 85% of the state’s eligible pregnant women. Pregnant women also often enroll in WIC before they enter prenatal care. However, our results cannot be generalized beyond low-income women. Generalizability is further limited in that the rate of tobacco use during pregnancy (47%) was high in our sample.
In addition, we compared participants with a diagnosis of a given disorder with participants without that diagnosis (but potentially with other diagnoses). Relationships might have been stronger (but power might have been reduced) if the comparison group had been women without any diagnosis.
Finally, self-reported tobacco, drug, and alcohol use data probably introduced error as a result of underreporting.46,57 Blalock et al.52 reported that pregnant women with DSM-IV-based depressive disorders who smoke are less likely to inform their doctors that they smoke than are nondepressed women. If such differences in likelihood of reporting occurred in our sample, the results would be biased toward not finding an association with tobacco use. If women with MDD report their tobacco use less often than women with other disorders, this could account for the lack of an association between MDD and persistent tobacco use.
Conclusions
Women who persisted in using tobacco after their pregnancy had been confirmed were 2.5 times as likely as nonusers to have met the criteria for 1 of 20 psychiatric disorders in the previous 12 months. Five individual diagnoses, not including major depression, accounted for most of this effect: generalized anxiety disorder, bipolar I disorder, oppositional disorder, drug abuse or dependence, and ADHD. Also, persistent users with a psychiatric disorder smoked more cigarettes during their pregnancy than did smokers without a disorder. Although typically women are highly motivated to discontinue tobacco use during their pregnancy,1,2 pregnancy smoking cessation programs are unlikely to be fully successful without attention to psychiatric disorders.
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Acknowledgments |
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This study was funded by the National Institute of Mental Health (grant R01/MH57736-03) and by St Louis University through a research initiative and a Beaumont Faculty Development Award.
Preliminary findings of this study were presented at the 129th Annual Meeting of the American Public Health Association, October 2001, Atlanta, Ga.
The participation of the Missouri Department of Health and Senior Services and the 6 county WIC programs is gratefully acknowledged. Mary Elizabeth Gallagher assisted with administration, supervision, and data collection; Julie Baylor and Nujjaree Nettip assisted with data collection; Yin Chen assisted with analysis of the Diagnostic Interview Schedule data; Suwattana Kumsuk assisted with the literature review; and Leigh Tenkku provided administrative support. Elizabeth Tornquist and Deborah Hwa-Froelich reviewed drafts of the article.
Human Participant Protection
This study was approved by the institutional review boards of St Louis University and the Missouri Department of Health and Senior Services. All participants provided written informed consent before taking part in the study.
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Footnotes |
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Peer Reviewed
Contributors
L. H. Flick originated the study, conducted and synthesized the analyses, and led the writing. C. A. Cook and L. H. Flick designed the larger study and C. A. Cook supervised all aspects of its implementation. S. M. Homan contributed to conceptualization and analysis and provided statistical expertise. M. McSweeney contributed the sampling design and expertise in statistical analysis. C. Campbell managed secondary data collection. L. Parnell managed interview data collection. All of the authors helped to train and supervise data collectors, conceptualize ideas, interpret findings, and review the article.
Accepted for publication January 4, 2006.
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