@article {kessler_development_2011, title = {Development of lifetime comorbidity in the World Health Organization world mental health surveys}, journal = {Archives of General Psychiatry}, volume = {68}, number = {1}, year = {2011}, month = {jan}, pages = {90{\textendash}100}, abstract = {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.}, keywords = {Adult, Aged, Anxiety, Attention Deficit and Disruptive Behavior Disorders, Comorbidity, Female, Health Surveys, Humans, International Cooperation, Male, Mental Disorders, Mental Health, Middle Aged, Models, Mood Disorders, Obsessive-Compulsive Disorder, Phobic Disorders, Psychological, Psychomotor Agitation, Risk Factors, Substance-Related Disorders, Time Factors, World Health Organization}, issn = {1538-3636}, doi = {10.1001/archgenpsychiatry.2010.180}, author = {Ronald C. Kessler and Ormel, Johan and Petukhova, Maria and McLaughlin, Katie A. and Green, Jennifer Greif and Russo, Leo J. and Stein, Dan J. and Zaslavsky, Alan M. and Aguilar-Gaxiola, Sergio and Alonso, Jordi and Andrade, Laura and Benjet, Corina and Girolamo, Giovanni de and de Graaf, Ron and Demyttenaere, Koen and Fayyad, John and Haro, Josep Maria and Hu, Chiyi and Karam, Aimee and Lee, Sing and Lepine, Jean-Pierre and Matchsinger, Herbert and Mihaescu-Pintia, Constanta and Posada-Villa, Jose and Sagar, Rajesh and Ust{\"u}n, T. Bedirhan} }