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

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.Eli Lilly & Company, BrazilBristol-Myers SquibbGlaxoSmithKlineJohnson & Johnson PharmaceuticalsOrtho-McNeilPfizer, IncSanofi-AventisPfizer, Inc.AstraZenecaLundbeckOrionPharmaciaRocheServierSolvaySumitomoTikvahWyeth-AyerstUS National Institute of Mental Health (NIMH/NIH)[R01MH070884]John D. and Catherine T. MacArthur FoundationPfizer FoundationUS Public Health Service[R13-MH066849]US Public Health Service[R01-MH069864]US Public Health Service[R01 DA016558]Fogarty International Center (FIRCA/NIH)[FIRCA R03-TW006481]Pan American Health Organization (PAHO)Eli Lilly & Company FoundationOrtho-McNeil Pharmaceutical, IncShireFAPESP State of Sao Paulo Research Foundation[03/00204-3]Ministry of Social ProtectionWHO(India)National Council on Science and Technology[CONACyT-G30544-H]European Commission[QLG5-1999-01042]European Commission[SANCO2004123]Piedmont Region (Italy)Fondo de Investigacion Sanitaria, Instituto de Salud Carlos III, Spain[FIS 00/0028]Ministerio de Ciencia y Tecnologia, Spain[SAF 2000-158-CE]Departament de Salut, Generalitat de Catalunya, Spain, Instituto de Salud Carlos III[CIBER CB06/02/0046]Departament de Salut, Generalitat de Catalunya, Spain, Instituto de Salud Carlos III[RETICS RD06/0011 REM-TAP]US National Institute of Mental Health (NIMH/NIH)[U01-MH60220]Robert Wood Johnson Foundation[044708]John W. Alden TrustShire Pharmaceutical