ANRV337-PU29-08 ARI 14 February 2008 16:0
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Annu. Rev. Public Health 2008. 29:115–29
The Annual Review of Public Health is online at
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This article’s doi:
10.1146/annurev.publhealth.29.020907.090847
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copyright covering this paper.
The Descriptive
Epidemiology of Commonly
Occurring Mental Disorders
in the United States∗
Ronald C. Kessler1 and Philip S. Wang2
1
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
02115; email: kessler@hcp.med.harvard.edu
2
Division of Services and Intervention Research, National Institute of Mental Health,
Bethesda, Maryland 20892-9629; email: wangphi@mail.nih.gov
Key Words
mental illness, prevalence, comorbidity, age of onset, illness burden
Abstract
Data are reviewed on the descriptive epidemiology of commonly
occurring DSM-IV mental disorders in the United States. These
disorders are highly prevalent: Roughly half the population meets
criteria for one or more such disorders in their lifetimes, and roughly
one fourth of the population meets criteria in any given year. Most
people with a history of mental disorder had first onsets in childhood
or adolescence. Later onsets typically involve comorbid disorders.
Some anxiety disorders (phobias, separation anxiety disorder) and
impulse-control disorders have the earliest age of onset distribu-
tions. Other anxiety disorders (panic disorder, generalized anxiety
disorder, post-traumatic stress disorder), mood disorders, and sub-
stance disorders typically have later ages of onset. Given that most
seriously impairing and persistent adult mental disorders are asso-
ciated with child-adolescent onsets and high comorbidity, increased
efforts are needed to study the public health implications of early
detection and treatment of initially mild and currently largely un-
treated child-adolescent disorders.
115
 ANRV337-PU29-08 ARI 14 February 2008 16:0
INTRODUCTION
Data on the epidemiology of commonly oc-
DSM: American curring mental disorders in the United States
Psychiatric
have proliferated over the past two decades
Association’s
owing to the development of diagnostic crite-
Diagnostic and
ria in the DSM system that are amenable to
Statistical Manual of
Mental Disorders operationalization and to the subsequent cre-
ation of fully structured research diagnostic
NCS: National
Comorbidity Survey interviews based on these criteria, which were
used to carry out large-scale community epi-
ECA:
Epidemiologic demiological surveys. We begin by presenting
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
Catchment Area a brief historical overview of these recent de-
Fully structured velopments, and then we turn to a more de-
diagnostic tailed review of the results from the National
Access provided by 114.5.108.204 on 10/28/21. For personal use only.
interview: used by a
Comorbidity Survey Replication (NCS-R)
trained lay
(30), the most recent nationally representative
interviewer who has
epidemiological survey of mental disorders.
no clinical
experience. Asks
questions with
largely structured
A BRIEF HISTORICAL
response options
(e.g., yes-no; OVERVIEW
often-sometimes- The first survey to employ a fully structured
rarely-never)
research diagnostic interview to assess the
prevalence and correlates of DSM disorders
was the Epidemiologic Catchment Area
(ECA) study. The ECA was administered in
the early 1980s in population samples selected
from mental health catchment areas in five
U.S. communities (47) using a diagnostic
interview developed specifically for the study,
which was called the Diagnostic Interview
Schedule (DIS) (45). The DIS was designed
to be used by trained lay interviewers and
to generate diagnoses that approximated
those made blindly by experienced clini-
cians. Methodological studies showed that
concordance of DIS diagnoses with clinical
diagnoses was statistically significant, but far
from perfect (4, 46).
The DIS was subsequently adopted and
used in similar surveys in other parts of
the world (16). Both the ECA and these
later ECA-influenced surveys in other coun-
tries documented high prevalence of men-
tal disorders and widespread unmet need for
treatment. However, because the ECA study
was not nationally representative, questions
116 Kessler · Wang
were raised about whether the striking re-
sults regarding prevalence and treatment held
throughout the United States. These ques-
tions were especially acute with regard to
treatment because the ECA sites were all in ur-
ban areas in which the survey catchment areas
were quite close to major medical schools with
strong psychiatry departments. This sampling
feature raised concerns that unmet need for
treatment due to low access might be consid-
erably greater in other areas of the country
than demonstrated by the ECA sample.
These concerns were answered a decade
later in the National Comorbidity Survey
(NCS) (29), the first nationally representa-
tive survey to assess the prevalence and cor-
relates of DSM disorders. The NCS, like the
ECA, carried out face-to-face interviews with
a fully-structured diagnostic interview to as-
sess the prevalence and correlates of DSM dis-
orders. However, whereas the ECA studied
DSM-III disorders, the NCS studied DSM-
III-R disorders. The NCS, like the ECA, doc-
umented high prevalence of mental disorders
and substantial unmet need for treatment.
The NCS also documented that much of the
treatment provided for mental disorders in
the United States at the time of the survey, in
the early 1990s, failed to meet even the most
minimal published criteria for treatment ade-
quacy (51, 52).
As with the ECA, the NCS was followed
by a number of replications in other parts of
the world. These replications were greater in
number than after the ECA, however, because
the interview schedule used in the NCS was
developed by the World Health Organization
(WHO) to include not only DSM criteria but
also ICD-10 criteria. In addition, in an effort
to foster cross-national comparative studies,
WHO carried out developmental work for
the survey in many different countries and
made the instrument available in many dif-
ferent languages (48). WHO created a cross-
national research consortium that brought to-
gether the investigators who carried out the
many replications of the NCS to collaborate
in systematic cross-national comparisons (21).
 ANRV337-PU29-08 ARI 14 February 2008 16:0
High prevalence, early age of onset, substan-
tial persistence, and high comorbidity were
all documented consistently in these compar-
ative analyses (17).
Perhaps the most concerning issue raised
by the ECA, NCS, and the other surveys that
followed them was that the number of peo-
ple estimated to meet criteria for a mental
disorder in any given year was much higher
than the number that could realistically be
treated. Commentators suggested that this
observation might represent less of a prob-
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
lem than it might at first seem because some
untreated cases almost certainly have mild or
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self-limiting disorders that do not need treat-
ment (42). However, in the absence of infor-
mation about disorder severity there was no
way to know how many cases were in ques-
tion. The ECA and NCS were unable to pro-
vide definitive data on this issue because the
main concern of these surveys was to make
categorical assessments of specific DSM dis-
orders. Clinical severity of these disorders
was not a major focus. Nonetheless, post hoc
analysis provided some indirect information
about severity. These analyses strongly sug-
gested that a substantial proportion of DSM
cases in the general U.S. population are mild
(42). Comparable results were obtained in sec-
ondary analyses of surveys carried out in other
developed countries (6, 11).
Because the results regarding disorder
severity based on the ECA and NCS method-
ology were post hoc, the next generation of
epidemiological surveys invested much more
heavily in assessing severity. The U.S. survey
involved in this effort was the NCS Repli-
cation (NCS-R) (30), which was carried out
a decade after the NCS (2001–2003) using
a substantially expanded interview that in-
cluded a wider range of disorders and much
more detailed information about disorder
severity (32). This expanded interview was
also used in a series of community epidemi-
ological surveys coordinated by the WHO in
its World Mental Health (WMH) Survey Ini-
tiative (27). In the United States, a ten-year
follow-up of the original baseline NCS sam-
ple was carried out in parallel with the NCS-R
to study patterns and predictors of onset and
progression of mental disorders (31).
NCS-R: NCS
The NCS-R and the other WMH surveys Replication
documented, consistent with the results of the
WMH Surveys:
post-hoc ECA and NCS analyses, that many surveys carried out in
mental disorders are mild (11, 25). However, the World Health
the NCS follow-up study documented some- Organization’s
thing else that was quite important: A substan- World Mental
Health Survey
tial proportion of initially mild mental dis-
Initiative
orders progress to become serious disorders
within a decade (31). This progression was
common especially for seldom-treated child-
adolescent onset anxiety disorders, raising the
question of whether expanded early detection
and treatment of mild disorders during the
school years might have an important public
health effect in preventing the subsequent de-
velopment of more serious disorders.
The NCS-R, as a replication of the NCS,
was also used to study time trends in the
prevalence and treatment of mental disor-
ders during the 1990s. This was an impor-
tant exercise because substantial changes oc-
curred in mental health care delivery in the
United States during the decade between the
NCS and the NCS-R. The Substance Abuse
and Mental Health Services Administration
(SAMSHA) found that annual encounters in
specialty mental health treatment centers in-
creased by nearly 50% between 1992 and
2000 (38). The National Ambulatory Medical
Care Survey documented that people receiv-
ing health care treatment for depression more
than tripled between 1987 and 1997 (44). The
Robert Wood Johnson Foundation Commu-
nity Tracking Survey documented that the
proportion of people with serious mental ill-
ness who received specialty care increased by
nearly 20% between 1997–1998 and 2000–
2001 (39). To the extent that these increases
in treatment were effective, we might expect
that the prevalence of mental disorders would
be lower in the NCS-R than in the NCS.
However, this was not the case. Compari-
son of the NCS-R with the NCS found that
the prevalence of DSM disorders among peo-
ple in the age range 18–54 (the age range
www.annualreviews.org • Epidemiology of Mental Disorders 117
 ANRV337-PU29-08 ARI 14 February 2008 16:0
included in both surveys in the U.S. household
population) did not change during the decade
between the two surveys (26). The prevalence
DSM-IV: The
Fourth Edition of estimate was 29.4% in the NCS and 30.5%
the DSM in the NCS-R. However, treatment was
CIDI: WHO’s found to increase dramatically, from 20.3%
Composite of people with a disorder receiving treat-
International ment in the NCS to 32.9% in the NCS-R.
Diagnostic Interview Significant treatment increases were limited,
Lifetime though, were much more pronounced in the
prevalence: general medical sector than in other parts of
Proportion of
the treatment system (159% increase) com-
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
population ever
having a disorder as pared with a lower increase among psychi-
of time of atrists, and showed an even lower increase
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assessment, among psychologists and other mental health
recognizing that professionals (a 59% increase). Despite these
some could have a
increases, most people with mental disorders
subsequent onset
remain untreated, and those in treatment of-
SCID: Structured
ten received suboptimal treatment (53).
Clinical Interview
for DSM-IV
THE NATIONAL COMORBIDITY
SURVEY REPLICATION
As implied above, the most recent estimates
of the prevalence and correlates of DSM-IV
mental disorders in the United States come
from the NCS-R. Because the remainder of
this review presents an overview of NCS-R
findings, we now discuss the NCS-R de-
sign. The NCS-R is a nationally represen-
tative household survey of 9282 respondents
ages 18 and older in the coterminous United
States who were interviewed face to face in
their homes between February 2001 and April
2003. The survey included a diagnostic assess-
ment in a wide range of DSM-IV disorders
in addition to measures of many risk factors
and correlates. The response rate was 70.9%.
More details on the NCS-R design and field
procedures are presented elsewhere (23).
DSM-IV diagnoses were made in the
NCS-R using Version 3.0 of the WHO’s
Composite International Diagnostic Inter-
view (CIDI) (32), a fully structured lay-
administered diagnostic interview that gener-
ates diagnoses according to the definitions and
criteria of both the ICD-10 (54) and DSM-IV
(2) diagnostic systems (32). DSM-IV criteria
118 Kessler · Wang
are used in all results reported here. The core
CIDI disorders assessed in the NCS-R in-
clude mood disorders (major depressive disor-
der, dysthymic disorder, and bipolar disorder),
anxiety disorders (panic disorder, agorapho-
bia, specific phobia, social phobia, generalized
anxiety disorder, post-traumatic stress disor-
der, obsessive-compulsive disorder, and sep-
aration anxiety disorder), substance disorders
(alcohol and drug abuse and dependence), and
impulse control disorders (intermittent ex-
plosive disorder, oppositional defiant disor-
der, conduct disorder, and attention-deficit/
hyperactivity disorder). Lifetime prevalence,
age of onset, and 12-month prevalence were
assessed separately for each disorder (24). A
blinded clinical reappraisal study using the
Structured Clinical Interview for DSM-IV
(SCID) (13) as the clinical gold standard found
generally good concordance between DSM-
IV diagnoses based on the CIDI and the SCID
for anxiety, mood, and substance disorders,
with area under the receiver operator char-
acteristic curve in the range .65–.88 for indi-
vidual diagnoses (15). The CIDI diagnoses of
impulse-control disorders were not validated.
ESTIMATES OF LIFETIME
PREVALENCE
Table 1 shows the lifetime prevalence esti-
mates of the mental disorders assessed in the
NCS-R. Some 46.4% of respondents had an
estimated lifetime history of at least one of
the DSM-IV disorders assessed in the survey,
whereas 27.7% of respondents had a lifetime
history of two or more disorders and 17.3%
had three or more disorders. The most preva-
lent class of disorders was anxiety disorders
(28.8%), followed by impulse-control disor-
ders (24.8%), mood disorders (20.8%), and
substance use disorders (14.6%). The most
prevalent individual lifetime disorders were
major depressive disorder (16.6%), alcohol
abuse (13.2%), specific phobia (12.5%), and
social phobia (12.1%).
Investigators sound significant differences
in prevalence estimates with age for almost
 ANRV337-PU29-08 ARI 14 February 2008 16:0

Table 1Lifetime prevalence of DSM-IV/WMH-CIDI disorders in the total NCS-R sample and by age.a
Reproduced with permission from Kessler et al. (24)
Total 18–29 30–44 45–59 60+
% (se) % (se) % (se) % (se) % (se) χ2 3
I. Anxiety disorders
Panic disorder 4.7 (0.2) 4.4 (0.4) 5.7 (0.5) 5.9 (0.4) 2.0 (0.4) 52.6b
Agoraphobia without panic 1.4 (0.1) 1.1 (0.2) 1.7 (0.3) 1.6 (0.3) 1.0 (0.3) 4.5
Specific phobia 12.5 (0.4) 13.3 (0.8) 13.9 (0.8) 14.1 (1.0) 7.5 (0.7) 54.3b
Social phobia 12.1 (0.4) 13.6 (0.7) 14.3 (0.8) 12.4 (0.8) 6.6 (0.5) 109.0b
Generalized anxiety disorder 5.7 (0.3) 4.1 (0.4) 6.8 (0.5) 7.7 (0.7) 3.6 (0.5) 39.9b
PTSDc 6.8 (0.4) 6.3 (0.5) 8.2 (0.8) 9.2 (0.9) 2.5 (0.5) 37.9b
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

OCDd 1.6 (0.3) 2.0 (0.5) 2.3 (0.9) 1.3 (0.6) 0.7 (0.4) 6.8
SADe 5.2 (0.4) 5.2 (0.6) 5.1 (0.6) – –e – –e 0.0e
disorderf 89.9b
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Any anxiety 28.8 (0.9) 30.2 (1.1) 35.1 (1.4) 30.8 (1.7) 15.3 (1.5)
II. Mood disorders
Major depressive disorder 16.6 (0.5) 15.4 (0.7) 19.8 (0.9) 18.8 (1.1) 10.6 (0.8) 49.9b
Dysthymia 2.5 (0.2) 1.7 (0.3) 2.9 (0.4) 3.7 (0.7) 1.3 (0.3) 10.6b
Bipolar I–II disorders 3.9 (0.2) 5.9 (0.6) 4.5 (0.3) 3.5 (0.4) 1.0 (0.3) 62.0b
Any mood disorder 20.8 (0.6) 21.4 (0.9) 24.6 (0.9) 22.9 (1.2) 11.9 (1.0) 58.0b
III. Impulse-control disorders
ODD 8.5 (0.7) 9.5 (0.9) 7.5 (0.8) – –e – –e 3.0g
∗g
OD 9.5 (0.8) 10.9 (1.0) 8.2 (0.8) – –e – –e 7.6
ADHD 8.1 (0.6) 7.8 (0.8) 8.3 (0.9) – –e – –e 0.2g
Intermittent explosive disorder 5.2 (0.3) 7.4 (0.7) 5.7 (0.6) 4.9 (0.4) 1.9 (0.5) 74.7b
Any impulse−control disorder 24.8 (1.1) 26.8 (1.7) 23.0 (1.3) – –e – –e 4.0bg
IV. Substance disorders
Alcohol abuse 13.2 (0.6) 14.3 (1.0) 16.3 (1.1) 14.0 (1.1) 6.2 (0.7) 60.2b
Alcohol dependence 5.4 (0.3) 6.3 (0.7) 6.4 (0.6) 6.0 (0.7) 2.2 (0.4) 45.2b
Drug abuse 7.9 (0.4) 10.9 (0.9) 11.9 (1.0) 6.5 (0.6) 0.3 (0.2) 168.7b
Drug dependence 3.0 (0.2) 3.9 (0.5) 4.9 (0.6) 2.3 (0.4) 0.2 (0.1) 90.0b
Any substance disorder 14.6 (0.6) 16.7 (1.1) 18.0 (1.1) 15.3 (1.0) 6.3 (0.7) 71.4b
V. Any disorder
Anyf 46.4 (1.1) 52.4 (1.7) 55.0 (1.6) 46.5 (1.8) 26.1 (1.7) 115.4b
Two or more disordersf 27.7 (0.9) 33.9 (1.3) 34.0 (1.5) 27.0 (1.6) 11.6 (1.0) 148.3b
Three or more disordersf 17.3 (0.7) 22.3 (1.2) 22.5 (1.1) 15.9 (1.3) 5.3 (0.7) 140.7b
VI. Sample sizes
Part I (9282) (2338) (2886) (2221) (1837)
Part II (5692) (1518) (1805) (1462) (907)
Part II OCD subsample (1808) (493) (566) (457) (292)
a Abbreviations: ADHD: attention-deficit/hyperactivity disorder; CD: conduct disorder; OCD: obsessive-compulsive disorder; ODD: oppositional-defiant disorder;
PTSD: post-traumatic stress disorder; SAD: separation anxiety disorder.
b Significant age difference at the 0.05 level.
c PTSD was assessed only in the Part II sample (n = 5692).
d OCD was assessed only in a random one third of the Part II sample (n = 1808).
e SAD, ODD, CD, and ADHD were assessed only among Part II respondents in the age range 18–44 (n = 3199).
f These summary measures were analyzed in the full Part II sample (n = 5692). OCD, SAD, ODD, CD, and ADHD were coded as absent among respondents who

were not assessed for these disorders.

g The χ 2 test evaluates statistical significance of age-related differences in estimated prevalence. χ 2 is evaluated with one degree of freedom for SAD, ODD, CD,

ADHD, and any impulse-control disorder.

www.annualreviews.org • Epidemiology of Mental Disorders 119

 ANRV337-PU29-08 ARI 14 February 2008 16:0
all the disorders assessed in the NCS-R, with
generally monotonic increases found starting
with the youngest (ages 18–29) to the next
AOO: age of onset
oldest (for the most part, ages 30–44) age
Projected lifetime
groups, followed by a decline in the oldest age
risk: Proportion of
population estimated group(s). The lifetime prevalence estimates of
to have a disorder at the disorders considered in the survey were
some time in their always lowest in the oldest age group (60+),
lives based on with the most extreme examples of this pat-
statistical projection
tern of differences occurring for drug abuse,
drug dependence, post-traumatic stress disor-
der, and bipolar disorder.
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
The NCS-R is not alone in finding these
age patterns in estimated lifetime preva-
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lence. Most community epidemiological sur-
veys find very similar patterns (17). A number
of methodological factors could account for
this pattern. For instance, people living in in-
stitutions (including nursing homes and other
assisted-living facilities) are usually excluded
from general population surveys, and people
who die early are always excluded, which in-
correctly implied that elderly survey partici-
pants were especially healthy. It is noteworthy
in this regard that mental disorders have sig-
nificant risk factors for early mortality (8). The
lower reported lifetime prevalence of men-
tal disorders among older respondents may
also be due to a genuine cohort effect, that is,
the risk could actually be increasing in people
born in the younger generations. Regardless
of the interpretation of the pattern, though,
the implication is that lifetime prevalence es-
timates in community surveys should be con-
sidered lower bounds on the estimates in re-
cent cohorts.
AGE OF ONSET
Although age of onset (AOO) is one of the
least commonly studied aspects of descriptive
epidemiology, it has important implications
for clinical practice and research. The dearth
of information on AOO of mental disorders
is presumably due to reluctance on the part of
epidemiologists to rely on the retrospective
reports obtained in general-population sur-
veys. However, analysis of these data shows
120 Kessler · Wang
that the patterns are substantively plausible
and generally consistent with those found in
prospective studies. An examination of AOO
distributions is important for at least two rea-
sons. The first reason is that information on
AOO allows us to distinguish between life-
time prevalence (the proportion of the popu-
lation who had a disorder at some time in their
lives up to their age at interview) and pro-
jected lifetime risk (the estimated proportion
of the population who will have the disorder
by the end of their lives). Lifetime risk cannot
be estimated directly from community surveys
because respondents differ in age and, there-
fore, number of years at risk. However, pro-
jections of estimated future risk can be made
from AOO distributions.
Second, an understanding of AOO is im-
portant for targeting research on prevention
of mental disorders (3), early intervention
with prodromal or incipient mental disorders
(33), and primary prevention of secondary
disorders (19). In the absence of AOO
information, we would have no way to know
the appropriate age range to target preventive
interventions. A related issue is that early
AOO is often associated with greater disorder
severity (28), persistence (10), and lack of
treatment response (43). On the basis of these
associations, AOO information can be useful
in making projections of aggregate illness
course associated with primary and secondary
disorders.
The disorder-specific estimates of AOO in
the NCS-R, which are shown elsewhere (24),
are very similar to those in the other WMH
surveys (22) in all major respects. In all these
surveys, the impulse-control disorders have
the earliest AOO distributions of any disor-
ders studied, with median AOO in middle
childhood for attention-deficit/hyperactivity
disorder (ADHD), middle-late childhood
for oppositional-defiant disorder (ODD) and
conduct disorder (CD), and late childhood
to late adolescence for intermittent explo-
sive disorder (IED). Impulse-control disor-
ders also have an extremely narrow age
range of onset risk. For example, 80% of all
 ANRV337-PU29-08 ARI 14 February 2008 16:0
lifetime ADHD cases begins in the age range
4–11, whereas the vast majority of ODD and
CD cases begins between ages 5 and 15. Fully
half of all lifetime IED begins in childhood or
adolescence.
Some anxiety disorders—the phobias and
separation anxiety disorder (SAD)—also have
very early AOO distributions in the NCS-
R, with median AOO in the range of early-
middle childhood and interquartile range
(IQR; 25th–75th percentiles of the AOO dis-
tributions) of 4–20 years of age. The other
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
anxiety disorders, in comparison, have consid-
erably later AOO distributions than the pho-
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bias and SAD do, although the cross-national
variation in both median AOO (age range 25–
53) and IQR AOO (age range 15–75) is con-
siderably wider than for the impulse-control
disorders or the phobias or SAD. The mood
disorder AOO distributions are quite simi-
lar to those for the later-onset anxiety disor-
ders, with consistently low prevalence until
the early teens followed by a roughly linear
increase through late middle age and a declin-
ing increase thereafter. The median AOO of
mood disorders has a very wide range across
countries (ages 25–45) and an even wider IQR
(ages 17–65).
Finally, the AOO distributions of sub-
stance use disorders in the NCS-R are quite
tightly grouped in that few onsets occur prior
to the mid-teens and cumulative increase in
onset is rapid in adolescence and early adult-
hood. Considerable variation exists, however,
in the sharpness of the change in the slope
as well as in the age range of this change,
leading to wider variation in both the me-
dian (ages 18–29) and the interquartile range
(ages 16–43) of the AOO distributions than
for impulse-control disorders or early-onset
anxiety disorders but lower variation than for
mood disorders or other anxiety disorders.
PROJECTED LIFETIME RISK
As noted in the previous section, one impor-
tant reason for estimating AOO distributions
is to obtain data on projected lifetime risk. It
is noteworthy that the projected lifetime risk
of a given DSM-IV disorder in the NCS was,
on average, one third higher than estimated
Comorbidity: the
lifetime prevalence. This means that for ev- joint occurrence of
ery 10 people who already have a history of two or more
any given mental disorder, 3–4 people in the disorders in the same
population are likely to develop the disorder at person
some point in the future. Not surprising, the
highest class-specific proportional increase in
projected lifetime risk vs. prevalence was as-
sociated with mood disorders, and the low-
est was associated with impulse-control dis-
orders. This demonstrates the fact that many
mood disorders begin in middle age or old
age, whereas most impulse-control disorders
begin in childhood or adolescence.
The high comorbidity known to exist
among impulse-control disorders (18, 20, 35)
is expected to result in many respondents
who developed child or adolescent impulse-
control disorders or early-onset anxiety disor-
ders and experienced subsequent onsets of co-
morbid disorders that typically have later ages
of onset, such as substance, mood, or later-
onset anxiety disorders. This possibility was
investigated in the NCS-R by comparing the
risk-to-prevalence ratios of any disorder vs.
individual disorders. Most projected new on-
sets of individual disorders were found to be
secondary disorders, as indicated by the fact
that the risk-to-prevalence ratio for any dis-
order was close to 1.0. Very similar patterns
were found in other WMH surveys (22).
TWELVE-MONTH PREVALENCE
AND SEVERITY
Mental disorders that were active within the
12 months of the NCS-R interview were clas-
sified by severity using a complex classifica-
tion scheme. Cases were classified serious if
they had any of the following: a 12-month
suicide attempt with serious lethality intent;
work disability or substantial work limitation
due to a mental or substance disorder; a posi-
tive screen for nonaffective psychosis, bipo-
lar I or II disorder; substance dependence
with serious role impairment (as defined by
www.annualreviews.org • Epidemiology of Mental Disorders 121
 ANRV337-PU29-08 ARI 14 February 2008 16:0
disorder-specific impairment questions); an
impulse-control disorder with repeated seri-
ous violence; or any disorder that resulted
Twelve-month
prevalence: in 30+ days out of role in the year. Cases
proportion of a not defined serious were defined as moder-
population that ate if they had any of the following: sui-
reports having a cide gesture, plan, or ideation; substance de-
particular experience
pendence without serious role impairment;
(e.g., meeting
criteria for a mental at least moderate work limitation due to a
disorder) at any time mental or substance disorder; or any disor-
in the 12 months der with at least moderate role impairment
prior to the interview in two or more domains of the Sheehan Dis-
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
ability Scales (SDS) [the SDS assessed dis-
ability in work role performance, household
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maintenance, social life, and intimate rela-
tionships on 0–10 visual analogue scales with
verbal descriptors, and associated scale scores
of none (0), mild (1–3), moderate (4–6), se-
vere (7–9), and very severe (10)] (36). All other
cases were classified mild. This classification
scheme is somewhat more refined than the
one used in comparative analyses of all WMH
surveys (11) because the NCS-R has more de-
tailed information than the other WMH sur-
veys. To assess the meaningfulness of these
severity ratings, number of days in the past
12 months when respondents were totally un-
able to carry out their normal daily activities
because of mental or substance problems was
compared across categories. The mean of this
variable was significantly higher (F2,5689 =
17.7, p < 0.001) among respondents classified
serious (88.3) than those classified moderate
(4.7) or mild (1.9).
Table 2 shows the 12-month prevalence
estimates of the DSM-IV disorders assessed
in the NCS-R. The highest of these esti-
mates is for specific phobia (8.7%), social
phobia (6.8%), and major depressive disorder
(6.7%). Among classes, anxiety disorders are
the most prevalent (18.1%), followed by mood
disorders (9.5%), impulse-control disorders
(8.9%), and substance disorders (3.8%). The
12-month prevalence of any of these disor-
ders is estimated to be 26.2%, with more than
half of cases (14.4% of the total sample) hav-
ing only one disorder and smaller proportions
having two (5.8%) or more (6.0%).
122 Kessler · Wang
Of 12-month cases, 22.3% were classified
serious, 37.3% moderate, and 40.4% mild.
Having a serious disorder was strongly re-
lated to comorbidity, with 9.6% of those with
one diagnosis, 25.5% with two, and 49.9%
with three or more diagnoses classified as se-
rious cases. Among disorder classes, mood dis-
orders had the highest percentage of serious
cases (45.0%) and anxiety disorders the lowest
(22.8%). The anxiety disorder with the high-
est proportion of serious cases was obsessive-
compulsive disorder (50.6%), whereas bipo-
lar disorder had the highest proportion of
serious cases (82.9%) among mood disor-
ders, ODD had the highest (49.6%) among
impulse-control disorders, and drug depen-
dence had the highest (56.5%) among sub-
stance disorders.
Tetrachoric correlations between all log-
ically possible pairs of these disorders were
estimated and found to be nearly all positive
and statistically significant (25). The highest
correlations involved well-known syndromes:
bipolar disorder (major depressive episode
with mania-hypomania), double-depression
(major depressive episode with dysthymia),
anxious-depression (major depressive episode
with generalized anxiety disorder), comorbid
mania-hypomania and ADHD, panic disor-
der with agoraphobia, comorbid social phobia
with agoraphobia, and comorbid substance
disorders (both alcohol abuse and dependence
with drug abuse and dependence).
The correlation matrix was explored with
factor analysis, and a two-factor solution was
the best fit (25). Rotation to a varimax solution
showed that the first factor had high factor
loadings for internalizing disorders (anxiety
disorders, major depressive episode), whereas
the second factor had high factor loadings for
externalizing disorders (CD, substance disor-
ders). This pattern is very similar to the one
found in previous factor analyses of comor-
bidity matrices using community epidemio-
logical studies (20, 34, 49).
Among the 219 or 524,288 logically pos-
sible multivariate disorder profiles that can
be made from the 19 NCS-R disorders
 ANRV337-PU29-08 ARI 14 February 2008 16:0

Table 2 Twelve-month prevalence and severity of DSM-IV/WMH-CIDI disorders (n = 9282).

Originally published in Kessler et al. (25), used with permission
Severitya
Total Serious Moderate Mild
% (se) % (se) % (se) % (se)
I. Anxiety disorders
Panic disorder 2.7 (0.2) 44.8 (3.2) 29.5 (2.7) 25.7 (2.5)
Agoraphobia without panic 0.8 (0.1) 40.6 (7.2) 30.7 (6.4) 28.7 (8.4)
Specific phobia 8.7 (0.4) 21.9 (2.0) 30.0 (2.0) 48.1 (2.1)
Social phobia 6.8 (0.3) 29.9 (2.0) 38.8 (2.5) 31.3 (2.4)
Generalized anxiety disorder 3.1 (0.2) 32.3 (2.9) 44.6 (4.0) 23.1 (2.9)
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

Post-traumatic stress disorderb 3.5 (0.3) 36.6 (3.5) 33.1 (2.2) 30.2 (3.4)
Obsessive-compulsive disorderc 1.0 (0.3) 50.6 (12.4) 34.8 (14.1) 14.6 (5.7)
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Separation anxiety disorderd 0.9 (0.2) 43.3 (9.2) 24.8 (7.5) 31.9 (12.2)
Any anxiety disordere 18.1 (0.7) 22.8 (1.5) 33.7 (1.4) 43.5 (2.1)
II. Mood disorders
Major depressive disorder 6.7 (0.3) 30.4 (1.7) 50.1 (2.1) 19.5 (2.1)
Dysthymia 1.5 (0.1) 49.7 (3.9) 32.1 (4.0) 18.2 (3.4)
Bipolar I–II disorders 2.6 (0.2) 82.9 (3.2) 17.1 (3.2) 0.0 (0.0)
Any mood disorder 9.5 (0.4) 45.0 (1.9) 40.0 (1.7) 15.0 (1.6)
III. Impulse-control disorders
Oppositional-defiant disorderd 1.0 (0.2) 49.6 (8.0) 40.3 (8.7) 10.1 (4.8)
Conduct disorderd 1.0 (0.2) 40.5 (11.1) 31.6 (7.5) 28.0 (9.1)
Attention-deficit/hyperactivity 4.1 (0.3) 41.3 (4.3) 35.2 (3.5) 23.5 (4.5)
disorderd
Intermittent explosive disorder 2.6 (0.2) 23.8 (3.3) 74.4 (3.5) 1.7 (0.9)
Any impulse-control disorderd,f 8.9 (0.5) 32.9 (2.9) 52.4 (3.0) 14.7 (2.3)
IV. Substance disorders
Alcohol abuseb 3.1 (0.3) 28.9 (2.6) 39.7 (3.7) 31.5 (3.3)
Alcohol dependenceb 1.3 (0.2) 34.3 (4.5) 65.7 (4.5) 0.0 (0.0)
Drug abuseb 1.4 (0.1) 36.6 (5.0) 30.4 (5.8) 33.0 (6.8)
Drug dependenceb 0.4 (0.1) 56.5 (8.2) 43.5 (8.2) 0.0 (0.0)
Any substance disorderb 3.8 (0.3) 29.6 (2.8) 37.1 (3.5) 33.4 (3.2)
V. Any disorder
Anye 26.2 (0.8) 22.3 (1.3) 37.3 (1.3) 40.4 (1.6)
One disordere 14.4 (0.6) 9.6 (1.3) 31.2 (1.9) 59.2 (2.3)
Two disorderse 5.8 (0.3) 25.5 (2.1) 46.4 (2.6) 28.2 (2.0)
Three or more disorderse 6.0 (0.3) 49.9 (2.3) 43.1 (2.1) 7.0 (1.3)
a Percentages in the three severity columns are repeated as proportions of all cases and sum to 100% across each row.
b Assessed in the Part II sample (n = 5692).
c Assessed in a random one third of the Part II sample (n = 1808).
d Assessed in the Part II sample among respondents in the age range 18–44 (n = 3199).
e Estimated in the Part II sample. No adjustment is made for the fact that one or more disorders in the category were not assessed for all Part

II respondents.
f The estimated prevalence of any impulse-control disorder is larger than the sum of the individual disorders because the prevalence of

intermittent explosive disorder, the only impulse-control disorder that was assessed in the total sample, is reported here for the total sample
rather than for the subsample of respondents among whom the other impulse-control disorders were assessed (Part II respondents in the age
range 18–44). The estimated prevalence of any impulse-control disorder, in comparison, is estimated in the latter subsample. Intermittent
explosive disorder has a considerably higher estimated prevalence in this subsample than in the total sample.

www.annualreviews.org • Epidemiology of Mental Disorders 123

 ANRV337-PU29-08
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
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ARI 14 February 2008 16:0
assessed, 433 were observed (25). Nearly 80%
of these patterns involved highly comorbid
cases (three or more disorders), which ac-
counted for 27.0% of all respondents with a
disorder and 55.9% of all instances of these
disorders. The distribution of comorbidity in
these profiles was significantly different (χ 2 3
= 110.2, p < 0.001) from the distribution we
would expect to find if the multivariate struc-
ture among the disorders was due entirely to
the two-way associations that are the focus of
factor analysis. The full set of implications of
this finding is not yet clear, but one important
implication is that the structure of comorbid-
ity is too complex to study merely with the
kinds of factor-analytic models that have been
used up to now.
DISCUSSION
The results of the NCS-R and other commu-
nity epidemiological surveys are limited by the
fact that they focus on the household popula-
tion and exclude population segments likely
to have high proportions of the severely men-
tally ill (e.g., the homeless and people living in
institutions). Furthermore, systematic survey
nonresponse (i.e., people with mental disor-
ders having a higher survey refusal rate than
those without disorders) and systematic non-
reporting (i.e., recall failure, conscious nonre-
porting, or error in the diagnostic evaluation)
could lead to bias in the estimates of disor-
der prevalence or unmet need for treatment in
these surveys, particularly for lifetime events.
Given what we know about the associations
between true prevalence and these errors (1,
9, 12, 23, 50), it is likely that disorder preva-
lence is underestimated. This makes the high
prevalence estimates found in these surveys all
the more striking.
An additional limitation is that surveys like
the NCS-R use fully structured diagnostic
interviews administered by trained lay inter-
viewers rather than clinician-administered in-
terviews. This practice could introduce im-
precision into prevalence estimates. However,
as noted above, clinical reappraisal interviews
124 Kessler · Wang
generally support these lay diagnoses in the
aggregate, arguing against an overestimation
of prevalence based on invalidity of diagnoses
from lay interviews. Indeed, the more gen-
eral pattern is for clinical interviews to di-
agnose more cases than lay interviews. Fur-
thermore, the fact that the diagnoses in these
interviews do not include all those in DSM-
IV adds another layer of conservative bias to
the overall prevalence estimates. It seems safe
to conclude, on the basis of these considera-
tions, that a very high proportion of people in
the general U.S. population meet criteria for
a DSM-IV disorder.
Along with their high prevalence, perhaps
the most striking finding is the generally early
AOO of mental disorders, with first onsets
concentrated in the first two decades of life
and later-onset disorders occurring largely as
temporally secondary comorbid conditions.
These findings are, of course, limited by the
fact that they are based on retrospective re-
call, but the results based on these retrospec-
tive reports are consistent with the results of
epidemiological surveys of children and ado-
lescents. These early AOO distributions sug-
gest that mental disorders are uniquely bur-
densome to the young. This contrasts sharply
with almost all chronic physical disorders,
which have conditional risks that increase with
age rather than having their highest risk in
childhood or adolescence, typically peaking in
late middle or old age (41).
The cohort effect in the NCS-R, with in-
creasing prevalence of many types of disor-
ders in more recent cohorts, deserves further
consideration. This pattern varied in plausi-
ble ways (e.g., largest with substance disor-
ders, which are independently known to have
increased among cohorts that went through
adolescence beginning in the 1970s) and had
plausible sociodemographic correlates (e.g.,
increasing similarity of women and men in
substance use disorders in recent cohorts).
These patterns argue for the cohort effect in
the survey data being caused at least in part
by substantive rather than entirely method-
ological factors. Nonetheless, methodological
 ANRV337-PU29-08 ARI 14 February 2008 16:0

effects are likely based on the fact that longi-
tudinal studies demonstrate that mental dis-
orders are associated with early mortality (7)
and that resolved mental disorders reported
in baseline interviews often are not reported
in follow-up interviews (5). To the extent that
these biases are at work, the high prevalence
found in the younger NCS-R cohorts might
also apply to older cohorts. The only way to
resolve this uncertainty is to carry out par-
allel longitudinal surveys of mental disorders
in successive cohorts, possibly along the lines
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org
Despite these uncertainties, the NCS-R
findings of high lifetime prevalence, early
AOO, high comorbidity, and substantial per-
sistence, when coupled with independent data
documenting adverse effects of mental disor-
ders on role functioning (14, 37, 40), suggest
that greater attention should be paid to public
health interventions that target the childhood
and adolescent years when mental disorders
so often begin. With appropriately balanced
considerations of potential risks and bene-
fits, focus is also needed on early interven-

of the surveys of drug use that the National tions aimed at preventing the progression of
Institute of Drug Abuse and, more recently, primary disorders and the onset of comorbid
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the Substance Abuse and Mental Health Ser- disorders to supplement the current focus on
vices Administration have carried out since treatment of more serious disorders begin-
the 1970s to monitor trends in drug use. ning in adulthood.

SUMMARY POINTS
1. The prevalence of mental disorders in the United States is very high, with roughly half
the population meeting criteria for one or more DSM-IV disorders at some time in
their lives and more than one fourth of the population meeting criteria for a disorder
in any given year.
2. Most people with a lifetime mental disorder had their first onset in childhood or
adolescence.
3. Later-onset disorders typically are temporally secondary comorbid conditions.
4. Disorder severity is strongly associated with high comorbidity, even though the tem-
porally primary disorder is often relatively mild.
5. Little is known about the public health effects of early detection and intervention to
treat child-adolescent disorders on the subsequent progression of primary disorders
or the onset of temporally secondary comorbid disorders, but this is an obvious area
for future investigation.

FUTURE ISSUES
1. Little is known about the epidemiology of child mental disorders. Controversy ex-
ists, in fact, about how best to assess mental illness in children. Reports obtained
from parents, teachers, and children themselves often differ greatly. Resolution of
uncertainties about measurement and expansion of available data about prevalence,
correlates, and changes over the course of childhood and adolescence are needed.
2. Long-term longitudinal studies are needed of the associations between childhood
mental disorders and adult mental disorders and about risk factors for persistence-
progression in the transition to adulthood as well as throughout the adult years.

www.annualreviews.org • Epidemiology of Mental Disorders 125

 ANRV337-PU29-08 ARI 14 February 2008 16:0

3. Although categorical models of mental disorder are dominant in the existing DSM
system, considerable evidence shows that dimension models might make more sense
for many mental disorders. Future epidemiological research is needed to help shed
light on this issue.
4. Advances in our understanding of the genetics of mental disorders will make it in-
creasingly important to integrate the collection of genetic information into population
epidemiological studies.
5. Expansion of our understanding of risk and protective factors for the onset and per-
sistence of mental disorders requires more serious efforts than researchers have made
up to now to search for and analyze the effects of natural experiments and natural
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

quasi-experiments that manipulate either exposure to stress or access to one or more

resilience or vulnerability factors.
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DISCLOSURE STATEMENT
R.K. has been a consultant for Astra Zeneca, BristolMyersSquibb, Eli Lilly and Co,
GlaxoSmithKline, Pfizer, and Wyeth and has had research support for his epidemiological stud-
ies from Bristol-Myers Squibb, Eli Lilly and Company, Ortho-McNeil, Pfizer, and the Pfizer
Foundation.

ACKNOWLEDGMENTS
Preparation of this paper was supported by NIMH grant U01-MH60220 with supplemental
support from the National Institute on Drug Abuse (NIDA), the Substance Abuse and Mental
Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation (RWJF;
Grant 044780), and the John W. Alden Trust and was carried out in conjunction with the World
Health Organization World Mental Health (WMH) Survey Initiative. The core activities of
WMH are supported by the National Institute of Mental Health (R01 MH070884), the John D.
and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service
(R13-MH066849, R01-MH069864, and R01 DA016558), the Fogarty International Center
(FIRCA R03-TW006481), the Pan American Health Organization, Eli Lilly and Company,
McNeil Pharmaceutical, Inc., GlaxoSmithKline, and Bristol-Myers Squibb. A complete list
of WMH publications can be found at http://www.hcp.med.harvard.edu/wmh/. The views
and opinions expressed in this article are those of the authors and should not be construed to
represent the views of any of the sponsoring organizations, agencies, or the U.S. Government.
The authors appreciate the helpful comments from Kathleen Merikangas, Michael Von Korff,
and Hans-Ulrich Wittchen on an earlier draft of this review.

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www.annualreviews.org • Epidemiology of Mental Disorders 129

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Annual Review of
Public Health

Contents Volume 29, 2008

Commentary
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

Public Health Accreditation: Progress on National Accountability

Hugh H. Tilson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p pxv
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Symposium: Climate Change and Health

Mitigating, Adapting, and Suffering: How Much of Each?
Kirk R. Smith p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p pxxiii
Ancillary Benefits for Climate Change Mitigation and Air Pollution
Control in the World’s Motor Vehicle Fleets
Michael P. Walsh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p1
Co-Benefits of Climate Mitigation and Health Protection in Energy
Systems: Scoping Methods
Kirk R. Smith and Evan Haigler p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 11
Health Impact Assessment of Global Climate Change: Expanding
on Comparative Risk Assessment Approaches for Policy Making
Jonathan Patz, Diarmid Campbell-Lendrum, Holly Gibbs,
and Rosalie Woodruff p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 27
Heat Stress and Public Health: A Critical Review
R. Sari Kovats and Shakoor Hajat p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 41
Preparing the U.S. Health Community for Climate Change
Richard Jackson and Kyra Naumoff Shields p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 57

Epidemiology and Biostatistics

Ecologic Studies Revisited
Jonathan Wakefield p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 75
Recent Declines in Chronic Disability in the Elderly U.S. Population:
Risk Factors and Future Dynamics
Kenneth G. Manton p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 91

vii
 AR337-FM ARI 22 February 2008 17:45

The Descriptive Epidemiology of Commonly Occurring Mental

Disorders in the United States
Ronald C. Kessler and Philip S. Wang p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p115
The Women’s Health Initiative: Lessons Learned
Ross L. Prentice and Garnet L. Anderson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p131
U.S. Disparities in Health: Descriptions, Causes, and Mechanisms
Nancy E. Adler and David H. Rehkopf p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p235

Environmental and Occupational Health

Industrial Food Animal Production, Antimicrobial Resistance,
and Human Health
Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

Ellen K. Silbergeld, Jay Graham, and Lance B. Price p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p151

The Diffusion and Impact of Clean Indoor Air Laws
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Michael P. Eriksen and Rebecca L. Cerak p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p171

Ancillary Benefits for Climate Change Mitigation and Air Pollution
Control in the World’s Motor Vehicle Fleets
Michael P. Walsh p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p1
Co-Benefits of Climate Mitigation and Health Protection in Energy
Systems: Scoping Methods
Kirk R. Smith and Evan Haigler p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 11
Health Impact Assessment of Global Climate Change: Expanding on
Comparative Risk Assessment Approaches for Policy Making
Jonathan Patz, Diarmid Campbell-Lendrum, Holly Gibbs, and
Rosalie Woodruff p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 27
Heat Stress and Public Health: A Critical Review
R. Sari Kovats and Shakoor Hajat p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 41
Preparing the U.S. Health Community for Climate Change
Richard Jackson and Kyra Naumoff Shields p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 57
Protective Interventions to Prevent Aflatoxin-Induced Carcinogenesis
in Developing Countries
John D. Groopman, Thomas W. Kensler, and Christopher P. Wild p p p p p p p p p p p p p p p p p p p187

Public Health Practice

Protective Interventions to Prevent Aflatoxin-Induced Carcinogenesis
in Developing Countries
John D. Groopman, Thomas W. Kensler, and Christopher P. Wild p p p p p p p p p p p p p p p p p p p187
Regionalization of Local Public Health Systems in the Era of
Preparedness
Howard K. Koh, Loris J. Elqura, Christine M. Judge, and Michael A. Stoto p p p p p p p p205

viii Contents
 AR337-FM ARI 22 February 2008 17:45

The Effectiveness of Mass Communication to Change Public Behavior

Lorien C. Abroms and Edward W. Maibach p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p219
U.S. Disparities in Health: Descriptions, Causes, and Mechanisms
Nancy E. Adler and David H. Rehkopf p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p235
The Diffusion and Impact of Clean Indoor Air Laws
Michael P. Eriksen and Rebecca L. Cerak p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p171
Public Health Services and Cost-Effectiveness Analysis
H. David Banta and G. Ardine de Wit p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p383

Social Environment and Behavior

Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

Creating Healthy Food and Eating Environments: Policy

and Environmental Approaches
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Mary Story, Karen M. Kaphingst, Ramona Robinson-O’Brien,

and Karen Glanz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p253
Why Is the Developed World Obese?
Sara Bleich, David Cutler, Christopher Murray, and Alyce Adams p p p p p p p p p p p p p p p p p p p273
Global Calorie Counting: A Fitting Exercise for Obese Societies
Shiriki K. Kumanyika p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p297
The Health and Cost Benefits of Work Site Health-Promotion
Programs
Ron Z. Goetzel and Ronald J. Ozminkowski p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p303
The Value and Challenges of Participatory Research: Strengthening
Its Practice
Margaret Cargo and Shawna L. Mercer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p325
A Critical Review of Theory in Breast Cancer Screening Promotion
across Cultures
Rena J. Pasick and Nancy J. Burke p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p351
The Effectiveness of Mass Communication to Change Public Behavior
Lorien C. Abroms and Edward W. Maibach p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p219
U.S. Disparities in Health: Descriptions, Causes, and Mechanisms
Nancy E. Adler and David H. Rehkopf p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p235

Health Services
A Critical Review of Theory in Breast Cancer Screening Promotion
across Cultures
Rena J. Pasick and Nancy J. Burke p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p351
Nursing Home Safety: Current Issues and Barriers to Improvement
Andrea Gruneir and Vincent Mor p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p369

Contents ix
 AR337-FM ARI 22 February 2008 17:45

Public Health Services and Cost-Effectiveness Analysis

H. David Banta and G. Ardine de Wit p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p383
The Impact of Health Insurance on Health
Helen Levy and David Meltzer p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p399
The Role of Health Care Systems in Increased Tobacco Cessation
Susan J. Curry, Paula A. Keller, C. Tracy Orleans, and Michael C. Fiore p p p p p p p p p p p411

Indexes

Cumulative Index of Contributing Authors, Volumes 20–29 p p p p p p p p p p p p p p p p p p p p p p p p429

Annu. Rev. Public Health 2008.29:115-129. Downloaded from www.annualreviews.org

Cumulative Index of Chapter Titles, Volumes 20–29 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p434

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Errata

An online log of corrections to Annual Review of Public Health articles may be found
at http://publhealth.annualreviews.org/

x Contents