Person: Hwang, Irving
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Hwang
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Hwang, Irving
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Publication Parental psychopathology and the risk of suicidal behavior in their offspring: results from the World Mental Health surveys(Springer Nature, 2010) Gureje, O; Oladeji, Bibilola; Hwang, Irving; Chiu, Wai; Kessler, Ronald; Sampson, Nancy; Alonso, Jose; Andrade, Luis; Beautrais, A; Borges, G; Bromet, E; Bruffaerts, R; de Girolamo, G; de Graaf, R; Gal, G; He, Y; Hu, C; Iwata, N; Karam, E G; Kovess-Masféty, V; Matschinger, H; Moldovan, M V; Posada-Villa, J; Sagar, R; Scocco, P; Seedat, S; Tomov, Toma; Nock, MatthewPrior research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well-understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive-aggression (e,g., antisocial personality) and anxiety/agitation (e.g., panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55,299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (i.e., time-since-most-recent-episode controlling for age-of-onset and time-since-onset) of subsequent suicidal behavior (suicide ideation, plans, and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental anti-social personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt also was found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of inter-generational transmission of suicidal behavior.Publication Mental Disorders, Comorbidity, and Pre-enlistment Suicidal Behavior Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Wiley-Blackwell, 2015) Nock, Matthew; Ursano, Robert J.; Heeringa, Steven G.; Stein, Murray B.; Jain, Sonia; Raman, Rema; Sun, Xiaoying; Chiu, Wai; Colpe, Lisa J.; Fullerton, Carol S.; Gilman, Stephen Edward; Hwang, Irving; Naifeh, James A.; Rosellini, Anthony; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Kessler, RonaldWe examined the associations between mental disorders and suicidal behavior (ideation, plans, and attempts) among new soldiers using data from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; n=38,507). Most new soldiers with a pre-enlistment history of suicide attempt reported a prior mental disorder (59.0%). Each disorder examined was associated with increased odds of suicidal behavior (ORs=2.6–8.6). Only PTSD and disorders characterized by irritability and impulsive/aggressive behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder) predicted unplanned attempts among ideators. Mental disorders are important predictors of pre-enlistment suicidal behavior among new soldiers and should figure prominently in suicide screening and prevention efforts.Publication Prevalence and correlates of suicidal behavior among new soldiers in the US Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Wiley-Blackwell, 2014) Ursano, Robert J.; Heeringa, Steven G.; Stein, Murray B.; Jain, Sonia; Raman, Rema; Sun, Xiaoying; Chiu, Wai; Colpe, Lisa J.; Fullerton, Carol S.; Gilman, Stephen Edward; Hwang, Irving; Naifeh, James A.; Nock, Matthew; Rosellini, Anthony; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Kessler, RonaldBackground The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self-reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers. Method The New Soldier Study (NSS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured self-administered measures to estimate preenlistment histories of suicide ideation, plans, and attempts among new soldiers reporting for Basic Combat Training in 2011–2012. Survival models examined sociodemographic correlates of each suicidal outcome. Results Lifetime prevalence estimates of preenlistment suicide ideation, plans, and attempts were 14.1, 2.3, and 1.9%, respectively. Most reported onsets of suicide plans and attempts (73.3–81.5%) occurred within the first year after onset of ideation. Odds of these lifetime suicidal behaviors among new soldiers were positively, but weakly associated with being female, unmarried, religion other than Protestant or Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, or Hispanic. Conclusions Lifetime prevalence estimates of suicidal behaviors among new soldiers are consistent with retrospective reports of preenlistment prevalence obtained from soldiers later in their Army careers. Given that prior suicidal behaviors are among the strongest predictors of later suicides, consideration should be given to developing methods of obtaining valid reports of preenlistment suicidality from new soldiers to facilitate targeting of preventive interventions.Publication Lifetime Prevalence of Dsm-Iv Mental Disorders Among New Soldiers in the U.S. Army: Results From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Wiley-Blackwell, 2014) Rosellini, Anthony; Heeringa, Steven G.; Stein, Murray B.; Ursano, Robert J.; Chiu, Wai; Colpe, Lisa J.; Fullerton, Carol S.; Gilman, Stephen Edward; Hwang, Irving; Naifeh, James A.; Nock, Matthew; Petukhova, Maria; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Kessler, RonaldBackground The prevalence of 30-day mental disorders with retrospectively-reported early onsets is significantly higher in the U.S. Army than among socio-demographically matched civilians. This difference could reflect high prevalence of pre-enlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits. Methods The New Soldier Study (NSS) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully-structured measures to estimate lifetime prevalence of 10 DSM-IV disorders in new soldiers reporting for Basic Combat Training in 2011-2012 (n=38,507). Prevalence was compared to estimates from a matched civilian sample. Multivariate regression models examined socio-demographic correlates of disorder prevalence and persistence among new soldiers. Results Lifetime prevalence of having at least one internalizing, externalizing, or either type of disorder did not differ significantly between new soldiers and civilians, although three specific disorders (generalized anxiety, posttraumatic stress, and conduct disorders) and multi-morbidity were significantly more common among new soldiers than civilians. Although several socio-demographic characteristics were significantly associated with disorder prevalence and persistence, these associations were uniformly weak. Conclusions New soldiers differ somewhat, but not consistently, from civilians in lifetime pre-enlistment mental disorders. This suggests that prior findings of higher prevalence of current disorders with pre-enlistment onsets among soldiers than civilians are likely due primarily to a more persistent course of early-onset disorders in the context of the special stresses experienced by Army personnel.Publication Thirty-Day Prevalence ofDSM-IVMental Disorders Among Nondeployed Soldiers in the US Army(American Medical Association (AMA), 2014) Kessler, Ronald; Heeringa, Steven G.; Stein, Murray B.; Colpe, Lisa J.; Fullerton, Carol S.; Hwang, Irving; Naifeh, James A.; Nock, Matthew; Petukhova, Maria; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Ursano, Robert J.Importance Although high rates of current mental disorder are known to exist in the US Army, little is known about the proportions of these disorders that had onsets prior to enlistment. Objective To estimate the proportions of 30-day DSM-IV mental disorders among nondeployed US Army personnel with first onsets prior to enlistment and the extent which role impairments associated with 30-day disorders differ depending on whether the disorders had pre- vs post-enlistment onsets. Design, Setting, and Participants A representative sample of 5428 soldiers participating in the Army Study to Assess Risk and Resilience in Servicemembers completed self-administered questionnaires and consented to linkage of questionnaire responses with administrative records. Main Outcomes and Measures Thirty-day DSM-IV internalizing (major depressive, bipolar, generalized anxiety, panic, and posttraumatic stress) and externalizing (attention-deficit/hyperactivity, intermittent explosive, alcohol/drug) disorders were assessed with validated self-report scales. Age at onset was assessed retrospectively. Role impairment was assessed with a modified Sheehan Disability Scale. Results A total of 25.1% of respondents met criteria for any 30-day disorder (15.0% internalizing; 18.4% externalizing) and 11.1% for multiple disorders. A total of 76.6% of cases reported pre-enlistment age at onset of at least one 30-day disorder (49.6% internalizing; 81.7% externalizing). Also, 12.8% of respondents reported severe role impairment. Controlling for sociodemographic and Army career correlates, which were broadly consistent with other studies, 30-day disorders with pre-enlistment (χ28 = 131.8, P < .001) and post-enlistment (χ27 = 123.8, P < .001) ages at onset both significantly predicted severe role impairment, although pre-enlistment disorders were more consistent powerful predictors (7 of 8 disorders significant; odds ratios, 1.6-11.4) than post-enlistment disorders (5 of 7 disorders significant; odds ratios, 1.5-7.7). Population-attributable risk proportions of severe role impairment were 21.7% for pre-enlistment disorders, 24.3% for post-enlistment disorders, and 43.4% for all disorders. Conclusions and Relevance Interventions to limit accession or increase resilience of new soldiers with pre-enlistment mental disorders might reduce prevalence and impairments of mental disorders in the US Army.Publication Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents: Results From the National Comorbidity Survey Replication Adolescent Supplement(American Medical Association (AMA), 2013) Nock, Matthew; Green, Jennifer; Hwang, Irving; McLaughlin, Katie; Nancy A. Sampson, BA; Zaslavsky, Alan; Kessler, RonaldContext Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (ie, suicide ideation, plans, and attempts). Objectives To estimate the lifetime prevalence of suicidal behaviors among US adolescents and the associations of retrospectively reported, temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors. Design Dual-frame national sample of adolescents from the National Comorbidity Survey Replication Adolescent Supplement. Setting Face-to-face household interviews with adolescents and questionnaires for parents. Participants A total of 6483 adolescents 13 to 18 years of age and their parents. Main Outcome Measures Lifetime suicide ideation, plans, and attempts. Results The estimated lifetime prevalences of suicide ideation, plans, and attempts among the respondents are 12.1%, 4.0%, and 4.1%, respectively. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders are also predictors of plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%), treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring. Conclusions Suicidal behaviors are common among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have preexisting mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.Publication Prevalence and Correlates of Suicidal Behavior Among Soldiers(American Medical Association (AMA), 2014) Nock, Matthew; Stein, Murray B.; Heeringa, Steven G.; Ursano, Robert J.; Colpe, Lisa J.; Fullerton, Carol S.; Hwang, Irving; Naifeh, James A.; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Kessler, RonaldImportance The suicide rate among US Army soldiers has increased substantially in recent years. Objectives To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal behaviors among nondeployed US Army soldiers. Design, Setting, and Participants A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey. Main Outcomes and Measures Lifetime suicidal ideation, suicide plans, and suicide attempts. Results The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates. Most reported onsets of plans and attempts among ideators (58.3%-63.3%) occur within the year of onset of ideation. Post-enlistment attempts are positively related to being a woman (with an odds ratio [OR] of 3.3 [95% CI, 1.5-7.5]), lower rank (OR = 5.8 [95% CI, 1.8-18.1]), and previously deployed (OR = 2.4-3.7) and are negatively related to being unmarried (OR = 0.1-0.8) and assigned to Special Operations Command (OR = 0.0 [95% CI, 0.0-0.0]). Five mental disorders predict post-enlistment first suicide attempts in multivariate analysis: pre-enlistment panic disorder (OR = 0.1 [95% CI, 0.0-0.8]), pre-enlistment posttraumatic stress disorder (OR = 0.1 [95% CI, 0.0-0.7]), post-enlistment depression (OR = 3.8 [95% CI, 1.2-11.6]), and both pre- and post-enlistment intermittent explosive disorder (OR = 3.7-3.8). Four of these 5 ORs (posttraumatic stress disorder is the exception) predict ideation, whereas only post-enlistment intermittent explosive disorder predicts attempts among ideators. The population-attributable risk proportions of lifetime mental disorders predicting post-enlistment suicide attempts are 31.3% for pre-enlistment onset disorders, 41.2% for post-enlistment onset disorders, and 59.9% for all disorders. Conclusions and Relevance The fact that approximately one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders suggests that pre-enlistment mental disorders might be targets for early screening and intervention. The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (ie, restricting access to lethal means [such as firearms]) as a suicide prevention strategy.Publication Field procedures in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Wiley-Blackwell, 2013) Heeringa, Steven G.; Gebler, Nancy; Colpe, Lisa J.; Fullerton, Carol S.; Hwang, Irving; Kessler, Ronald; Naifeh, James A.; Nock, Matthew; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Stein, Murray B.; Ursano, Robert J.The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study of unprecedented size and complexity designed to generate actionable evidence-based recommendations to reduce U.S. Army suicides and increase basic knowledge about determinants of suicidality by carrying out coordinated component studies. A number of major logistical challenges were faced in implementing these studies. The current report presents an overview of the approaches taken to meet these challenges, with a special focus on the field procedures used to implement the component studies. As detailed in the paper, these challenges were addressed at the onset of the initiative by establishing an Executive Committee, a Data Coordination Center (the Survey Research Center [SRC] at the University of Michigan), and study-specific design and analysis teams that worked with staff on instrumentation and field procedures. SRC staff, in turn, worked with the Office of the Deputy Under Secretary of the Army (ODUSA) and local Army Points of Contact (POCs) to address logistical issues and facilitate data collection. These structures, coupled with careful fieldworker training, supervision, and piloting contributed to the major Army STARRS data collection efforts having higher response rates than previous large-scale studies of comparable military samples.Publication Response bias, weighting adjustments, and design effects in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)(Wiley-Blackwell, 2013) Kessler, Ronald; Heeringa, Steven G.; Colpe, Lisa J.; Fullerton, Carol S.; Gebler, Nancy; Hwang, Irving; Naifeh, James A.; Nock, Matthew; Sampson, Nancy; Schoenbaum, Michael; Zaslavsky, Alan; Stein, Murray B.; Ursano, Robert J.The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multi-component epidemiological and neurobiological study designed to generate actionable recommendations to reduce U.S. Army suicides and increase knowledge about determinants of suicidality. Three Army STARRS component studies are large-scale surveys: one of new soldiers prior to beginning Basic Combat Training (BCT; n=50,765 completed self-administered questionnaires); another of other soldiers exclusive of those in BCT (n=35,372); and a third of three Brigade Combat Teams about to deploy to Afghanistan who are being followed multiple times after returning from deployment (n= 9,421). Although the response rates in these surveys are quite good (72.0-90.8%), questions can be raised about sample biases in estimating prevalence of mental disorders and suicidality, the main outcomes of the surveys based on evidence that people in the general population with mental disorders are under-represented in community surveys. This paper presents the results of analyses designed to determine whether such bias exists in the Army STARRS surveys and, if so, to develop weights to correct for these biases. Data are also presented on sample inefficiencies introduced by weighting and sample clustering and on analyses of the trade-off between bias and efficiency in weight trimming.Publication Mental disorders among college students in the World Health Organization World Mental Health Surveys(Cambridge University Press (CUP), 2016) Auerbach, Randy; Alonso, Jose; Axinn, W. G.; Cuijpers, P.; Ebert, D. D.; Green, J. G.; Hwang, Irving; Kessler, Ronald; Liu, Howard; Mortier, Philippe; Nock, Matthew; Pinder-Amaker, Stephanie; Sampson, Nancy; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Andrade, L. H.; Benjet, C.; Caldas-de-Almeida, J. M.; Demyttenaere, K.; Florescu, S.; de Girolamo, G.; Gureje, O.; Haro, J. M.; Karam, E. G.; Kiejna, A.; Kovess-Masfety, V.; Lee, S.; McGrath, J. J.; O, S.; Pennell, B.-E.; Scott, K.; ten Have, M.; Torres, Y.; Zaslavsky, Alan; Zarkov, Z.; Bruffaerts, R.Background Although mental disorders are significant predictors of educational attainment throughout the entire educational career, most research on mental disorders among students has focused on the primary and secondary school years. Methods The World Health Organization World Mental Health Surveys were used to examine the associations of mental disorders with college entry and attrition by comparing college students (n = 1,572) and nonstudents in the same age range (18–22; n = 4,178), including nonstudents who recently left college without graduating (n = 702) based on surveys in 21 countries (4 low/lower-middle income, 5 upper middle-income, 1 lower-middle or upper-middle at the times of two different surveys, and 11 high income). Lifetime and 12-month prevalence and age-of-onset of DSM-IV anxiety, mood, behavioural and substance disorders were assessed with the Composite International Diagnostic Interview. Results One-fifth (20.3%) of college students had 12-month DSM-IV/CIDI disorders. 83.1% of these cases had pre-matriculation onsets. Disorders with pre-matriculation onsets were more important than those with post-matriculation onsets in predicting subsequent college attrition, with substance disorders and, among women, major depression the most important such disorders. Only 16.4% of students with 12-month disorders received any 12-month healthcare treatment for their mental disorders. Conclusions Mental disorders are common among college students, have onsets that mostly occur prior to college entry, in the case of pre-matriculation disorders are associated with college attrition, and are typically untreated. Detection and effective treatment of these disorders early in the college career might reduce attrition and improve educational and psychosocial functioning.