CONTEXT: Epidemiologic studies of adults show that DSM-IV intermittent explosive disorder (IED) is a highly prevalent and seriously impairing disorder. Although retrospective reports in these studies suggest that IED typically begins in childhood, no previous epidemiologic research has directly examined the prevalence or correlates of IED among youth. OBJECTIVE: To present epidemiologic data on the prevalence and correlates of IED among US adolescents in the National Comorbidity Survey Replication Adolescent Supplement. DESIGN: United States survey of adolescent (age, 13-17 years) DSM-IV anxiety, mood, behavior, and substance disorders. SETTING: Dual-frame household-school samples. PARTICIPANTS: A total of 6483 adolescents (interviews) and parents (questionnaires). MAIN OUTCOME MEASURES: The DSM-IV disorders were assessed with the World Health Organization Composite International Diagnostic Interview (CIDI). RESULTS: Nearly two-thirds of adolescents (63.3%) reported lifetime anger attacks that involved destroying property, threatening violence, or engaging in violence. Of these, 7.8% met DSM-IV/CIDI criteria for lifetime IED. Intermittent explosive disorder had an early age at onset (mean age, 12.0 years) and was highly persistent, as indicated by 80.1% of lifetime cases (6.2% of all respondents) meeting 12-month criteria for IED. Injuries related to IED requiring medical attention reportedly occurred 52.5 times per 100 lifetime cases. In addition, IED was significantly comorbid with a wide range of DSMIV/CIDI mood, anxiety, and substance disorders, with 63.9% of lifetime cases meeting criteria for another such disorder. Although more than one-third (37.8%) of adolescents with 12-month IED received treatment for emotional problems in the year before the interview, only 6.5% of respondents with 12-month IED were treated specifically for anger. CONCLUSIONS: Intermittent explosive disorder is a highly prevalent, persistent, and seriously impairing adolescent mental disorder that is both understudied and undertreated. Research is needed to uncover risk and protective factors for the disorder, develop strategies for screening and early detection, and identify effective treatments.

Rumination is a risk factor for depressive and anxiety symptoms in adolescents. Previous investigations of the mechanisms linking rumination to internalizing problems have focused primarily on cognitive factors. We investigated whether interpersonal stress generation plays a role in the longitudinal relationship between rumination and internalizing symptoms in young adolescents. Adolescents (Grades 6-8, N = 1,065) from an ethnically diverse community completed measures of depressive and anxiety symptoms, perceived friendship quality, and peer victimization at two assessments, 7 months apart. We determined whether rumination predicted increased exposure to peer victimization and whether changes in perceived friendship quality mediated this relationship. We also evaluated whether peer victimization mediated the association between rumination and internalizing symptoms. Adolescents who engaged in high levels of rumination at baseline were more likely to experience overt, relational, and reputational victimization at a subsequent time point 7 months later, controlling for baseline internalizing symptoms and victimization. Increased communication with peers was a significant partial mediator of this association for relational (z = 1.98, p = .048) and reputational (z = 2.52, p = .024) victimization. Exposure to overt (z = 3.37, p = .014), relational (z = 3.67, p \textless .001), and reputational (z = 3.78, p \textless .001) victimization fully mediated the association between baseline rumination and increases in internalizing symptoms over the study period. These findings suggest that interpersonal stress generation is a mechanism linking rumination to internalizing problems in adolescents and highlight the importance of targeting interpersonal factors in treatment and preventive interventions for adolescents who engage in rumination.

BACKGROUND: Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity. AIMS: To examine the associations of parent with respondent disorders. METHOD: Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews. RESULTS: Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle- than low-/lower-middle-income countries, and consistently higher for behaviour (11.0-19.9%) than other (7.1-14.0%) disorders. CONCLUSIONS: Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.

CONTEXT: Community epidemiological data on the prevalence and correlates of adolescent mental disorders are needed for policy planning purposes. Only limited data of this sort are available. OBJECTIVE: To present estimates of 12-month and 30-day prevalence, persistence (12-month prevalence among lifetime cases and 30-day prevalence among 12-month cases), and sociodemographic correlates of commonly occurring DSM-IV disorders among adolescents in the National Comorbidity Survey Replication Adolescent Supplement. DESIGN: The National Comorbidity Survey Replication Adolescent Supplement is a US national survey of DSM-IV anxiety, mood, behavior, and substance disorders among US adolescents based on face-to-face interviews in the homes of respondents with supplemental parent questionnaires. SETTING: Dual-frame household and school samples of US adolescents. PARTICIPANTS: A total of 10,148 adolescents aged 13 to 17 years (interviews) and 1 parent of each adolescent (questionnaires). MAIN OUTCOME MEASURES: The DSM-IV disorders assessed with the World Health Organization Composite International Diagnostic Interview and validated with blinded clinical interviews based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Good concordance (area under the receiver operating characteristic curve >=0.80) was found between Composite International Diagnostic Interview and Schedule for Affective Disorders and Schizophrenia for School-Age Children diagnoses. RESULTS: The prevalence estimates of any DSM-IV disorder are 40.3% at 12 months (79.5% of lifetime cases) and 23.4% at 30 days (57.9% of 12-month cases). Anxiety disorders are the most common class of disorders, followed by behavior, mood, and substance disorders. Although relative disorder prevalence is quite stable over time, 30-day to 12-month prevalence ratios are higher for anxiety and behavior disorders than mood or substance disorders, suggesting that the former are more chronic than the latter. The 30-day to 12-month prevalence ratios are generally lower than the 12-month to lifetime ratios, suggesting that disorder persistence is due more to episode recurrence than to chronicity. Sociodemographic correlates are largely consistent with previous studies. CONCLUSIONS: Among US adolescents, DSM-IV disorders are highly prevalent and persistent. Persistence is higher for adolescents than among adults and appears to be due more to recurrence than chronicity of child-adolescent onset disorders.

Limited data are available on lifetime prevalence and age-of-onset distributions of psychological disorders and suicidal behaviors among Army personnel. We used simulation methods to approximate such estimates based on analysis of data from a U.S. national general population survey with the sociodemographic profile of U.S. Army personnel. Estimated lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety, mood, behavior, or substance disorder in this sample was 53.1% (17.7% for mood disorders, 27.2% for anxiety disorders, 22.7% for behavior disorders, and 14.4% for substance disorders). The vast majority of cases had onsets before the expected age of enlistment if they were in the Army (91.6%). Lifetime prevalence was 14.2% for suicidal ideation, 5.4% for suicide plans, and 4.5% for suicide attempts. The proportion of estimated preenlistment onsets was between 68.4% (suicide plans) and 82.4% (suicidal ideation). Externalizing disorders with onsets before expected age of enlistment and internalizing disorders with onsets after expected age of enlistment significantly predicted postenlistment suicide attempts, with population attributable risk proportions of 41.8% and 38.8%, respectively. Implications of these findings are discussed for interventions designed to screen, detect, and treat psychological disorders and suicidality in the Army.

CONTEXT: Estimates of DSM-IV disorder prevalence are high; stringent criteria to define need for services are desired. OBJECTIVE: To present US national data on the prevalence and sociodemographic correlates of 12-month serious emotional disturbance (SED), defined by the US Substance Abuse and Mental Health Services Administration, from the National Comorbidity Survey Replication Adolescent Supplement. DESIGN: The National Comorbidity Survey Replication Adolescent Supplement is a national survey of DSM-IV anxiety, mood, behavior, and substance disorders among US adolescents. SETTING: Dual-frame household and school samples of US adolescents. PARTICIPANTS: Total of 6483 pairs of adolescents aged 13 to 17 (interviews) and parents (questionnaires). MAIN OUTCOME MEASURES: The DSM-IV disorders were assessed with the World Health Organization Composite International Diagnostic Interview and validated with blinded clinical interviews based on the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Serious emotional disturbance was operationalized as a DSM-IV/Composite International Diagnostic Interview disorder with a score of 50 or less on the Children's Global Assessment Scale (ie, moderate impairment in most areas of functioning or severe impairment in at least 1 area). Concordance of Composite International Diagnostic Interview SED diagnoses with blinded Schedule for Affective Disorders and Schizophrenia for School-Age Children diagnoses was good. RESULTS: The estimated prevalence of SED was 8.0%. Most SEDs were due to behavior (54.5%) or mood (31.4%) disorders. Although respondents with 3 or more disorders made up only 29.0% of those with 12-month DSM-IV/Composite International Diagnostic Interview disorders, they constituted 63.5% of SEDs. Predictive effects of high comorbidity were significantly greater than the product of their disorder-specific odds ratios and consistent across disorder types. Associations of sociodemographic variables with SED were generally nonsignificant after controlling for disorder type and number. CONCLUSIONS: The high estimated 12-month prevalence of DSM-IV disorders among US adolescents is largely due to mild cases. The significant between-disorder differences in risk of SED and the significant effect of high comorbidity have important public health implications for targeting interventions.

The aim of the study was to examine the social networks of sexual minority youths and to determine the associations between social networks and depressive symptoms. Data were obtained from the National Longitudinal Study of Adolescent Health (Add Health), a nationally representative cohort study of American adolescents (N = 14,212). Wave 1 (1994-1995) collected extensive information about the social networks of participants through peer nomination inventories, as well as measures of sexual minority status and depressive symptoms. Using social network data, we examined three characteristics of adolescents' social relationships: (1) social isolation; (2) degree of connectedness; and (3) social status. Sexual minority youths, particularly females, were more isolated, less connected, and had lower social status in peer networks than opposite-sex attracted youths. Among sexual minority male (but not female) youths, greater isolation as well as lower connectedness and status within a network were associated with greater depressive symptoms. Moreover, greater isolation in social networks partially explained the association between sexual minority status and depressive symptoms among males. Finally, a significant 3-way interaction indicated that the association between social isolation and depression was stronger for sexual minority male youths than non-minority youths and sexual minority females. These results suggest that the social networks in which sexual minority male youths are embedded may confer risk for depressive symptoms, underscoring the importance of considering peer networks in both research and interventions targeting sexual minority male adolescents.

OBJECTIVES: Although previous research has shown that low socioeconomic status (SES) is associated with mental illness, it is unclear which aspects of SES are most important. We investigated this issue by examining associations between 5 aspects of SES and adolescent mental disorders. METHODS: Data came from a national survey of US adolescents (n = 6483). Associations among absolute SES (parental income and education), relative SES (relative deprivation, subjective social status), and community level income variation (Gini coefficient) with past-year mental disorders were examined. RESULTS: Subjective social status (mean 0, variance 1) was most consistently associated with mental disorder. Odds ratios with mood, anxiety, substance, and behavior disorders after controlling for other SES indicators were all statistically significant and in the range of 0.7 to 0.8. Associations were strongest for White adolescents. Parent education was associated with low risk for anxiety disorder, relative deprivation with high risk for mood disorder, and the other 2 indicators were associated with none of the disorders considered. CONCLUSIONS: Associations between SES and adolescent mental disorders are most directly the result of perceived social status, an aspect of SES that might be more amenable to interventions than objective aspects of SES.

We used structural MRI and EEG to examine brain structure and function in typically developing children in Romania (n = 20), children exposed to institutional rearing (n = 29), and children previously exposed to institutional rearing but then randomized to a high-quality foster care intervention (n = 25). In so doing, we provide a unique evaluation of whether placement in an improved environment mitigates the effects of institutional rearing on neural structure, using data from the only existing randomized controlled trial of foster care for institutionalized children. Children enrolled in the Bucharest Early Intervention Project underwent a T1-weighted MRI protocol. Children with histories of institutional rearing had significantly smaller cortical gray matter volume than never-institutionalized children. Cortical white matter was no different for children placed in foster care than never-institutionalized children but was significantly smaller for children not randomized to foster care. We were also able to explain previously reported reductions in EEG $\alpha$-power among institutionally reared children compared with children raised in families using these MRI data. As hypothesized, the association between institutionalization and EEG $\alpha$-power was partially mediated by cortical white matter volume for children not randomized to foster care. The increase in white matter among children randomized to an improved rearing environment relative to children who remained in institutional care suggests the potential for developmental "catch up" in white matter growth, even following extreme environmental deprivation.

BACKGROUND: More than half a million U.S. women and more than 100,000 men are treated for injuries from intimate partner violence (IPV) annually, making IPV perpetration a major public health problem. However, little is known about causes of perpetration across the life course. PURPOSE: This paper examines the role of "stress sensitization," whereby adult stressors increase risk for IPV perpetration most strongly in people with a history of childhood adversity. METHODS: The study investigated a possible interaction effect between adulthood stressors and childhood adversities in risk of IPV perpetration, specifically, whether the difference in risk of IPV perpetration associated with past-year stressors varied by history of exposure to childhood adversity. Analyses were conducted in 2010 using de-identified data from 34,653 U.S. adults from the 2004-2005 follow-up wave of the National Epidemiologic Survey on Alcohol and Related Conditions. RESULTS: There was a significant stress sensitization effect. For men with high-level childhood adversity, past-year stressors were associated with an 8.8 percentage point (pp) increased risk of perpetrating compared to a 2.3 pp increased risk among men with low-level adversity. Women with high-level childhood adversity had a 14.3 pp increased risk compared with a 2.5 pp increased risk in the low-level adversity group. CONCLUSIONS: Individuals with recent stressors and histories of childhood adversity are at particularly elevated risk of IPV perpetration; therefore, prevention efforts should target this population. Treatment programs for IPV perpetrators, which have not been effective in reducing risk of perpetrating, may benefit from further investigating the role of stress and stress reactivity in perpetration.

BACKGROUND: This study evaluates associations of commonly co-occurring childhood adversities with physical violence in dating relationships to identify potential strategies for refining and targeting dating violence prevention programmes. METHODS: Data on 5130 adult respondents to a nationally representative survey with at least one dating relationship before the age of 21 years were analysed. Logistic regression models assessed associations between 12 childhood adversities and physical dating violence (PDV). RESULTS: Adjusting for the number of co-occurring adversities, 10 of the 12 childhood adversities were significantly associated with PDV perpetration or victimisation (OR 1.5-2.8). The population attributable risk proportion of PDV due to all 12 childhood adversities was 53.4%. Childhood adversities with the highest attributable risk proportions were sexual abuse (13.8%), interparental violence (11.6%) and parent mental illness (10.7%). Multivariate prediction equations ranked respondents by their childhood adversity risk profiles; 46.4% of PDV cases occurred in the top two risk deciles. CONCLUSIONS: Assessment of a broad range of childhood exposures to familial adversities may help to identify adolescents at particularly high risk of PDV and to guide prevention efforts.

BACKGROUND: Children raised in institutional settings experience marked deprivation in social and environmental stimulation. This deprivation may disrupt brain development in ways that increase risk for psychopathology. Differential hemispheric activation of the frontal cortex is an established biological substrate of affective style that is associated with internalizing psychopathology. Previous research has never characterized the development of frontal electroencephalogram asymmetry in children or evaluated whether adverse rearing environments alter developmental trajectories. METHODS: A sample of 136 children (mean age = 23 months) residing in institutions in Bucharest, Romania, and a sample of community control subjects (n = 72) participated. Half of institutionalized children were randomized to a foster care intervention. Electroencephalogram data were acquired at study entry and at ages 30, 42, and 96 months. A structured diagnostic interview of psychiatric disorders was completed at 54 months. RESULTS: Children exhibited increases in right relative to left hemisphere frontal activation between the second and fourth years of life, followed by an increase in left relative to right hemisphere activation. Children reared in institutions experienced a prolonged period of increased right hemisphere activation and a blunted rebound in left frontal activation. Foster care placement was associated with improved developmental trajectories but only among children placed before 24 months. The development trajectory of frontal electroencephalogram asymmetry in early childhood predicted internalizing symptoms at 54 months. CONCLUSIONS: Exposure to adverse rearing environments can alter brain development, culminating in heightened risk for psychopathology. Interventions delivered early in life have the greatest potential to mitigate the long-term effects of these environments.

Although significant associations between childhood socio-economic status (SES) and adult mental disorders have been widely documented, SES has been defined using several different indicators often considered alone. Little research has examined the relative importance of these different indicators in accounting for the overall associations of childhood SES with adult outcomes. Nor has previous research distinguished associations of childhood SES with first onsets of mental disorders in childhood, adolescence, and adulthood from those with persistence of these disorders into adulthood in accounting for the overall associations between childhood SES and adult mental disorders. Disaggregated data of this sort are presented here for the associations of childhood SES with a wide range of adult DSM-IV mental disorders in the US National Comorbidity Survey Replication (NCS-R), a nationally-representative sample of 5692 adults. Childhood SES was assessed retrospectively with information about parental education and occupation and childhood family financial adversity. Associations of these indicators with first onset of 20 DSM-IV disorders that included anxiety, mood, behavioral, and substance disorders at different life-course stages (childhood, adolescence, early adulthood, and mid-later adulthood) and the persistence/severity of these disorders were examined using discrete-time survival analysis. Lifetime disorders and their ages-of-onset were assessed retrospectively with the WHO Composite International Diagnostic Interview. Different aspects of childhood SES predicted onset, persistence, and severity of mental disorders. Childhood financial hardship predicted onset of all classes of disorders at every life-course stage with odds-ratios (ORs) of 1.7-2.3. Childhood financial hardship was unrelated, in comparison, to disorder persistence or severity. Low parental education, although unrelated to disorder onset, significantly predicted disorder persistence and severity, whereas parental occupation was unrelated to onset, persistence, or severity. Some, but not all, of these associations were explained by other co-occurring childhood adversities. These specifications have important implications for mental health interventions targeting low-SES children.

BACKGROUND: Although losses are important consequences of disasters, few epidemiological studies of disasters have assessed complicated grief (CG) and none assessed CG associated with losses other than death of loved one. METHODS: Data come from the baseline survey of the Hurricane Katrina Community Advisory Group, a representative sample of 3,088 residents of the areas directly affected by Hurricane Katrina. A brief screen for CG was included containing four items consistent with the proposed DSM-V criteria for a diagnosis of bereavement-related adjustment disorder. RESULTS: Fifty-eight and half percent of respondents reported a significant hurricane-related loss: Most-severe losses were 29.0% tangible, 9.5% interpersonal, 8.1% intangible, 4.2% work/financial, and 3.7% death of loved one. Twenty-six point one percent respondents with significant loss had possible CG and 7.0% moderate-to-severe CG. Death of loved one was associated with the highest conditional probability of moderate-to-severe CG (18.5%, compared to 1.1-10.5% conditional probabilities for other losses), but accounted for only 16.5% of moderate-to-severe CG due to its comparatively low prevalence. Most moderate-to-severe CG was due to tangible (52.9%) or interpersonal (24.0%) losses. Significant predictors of CG were mostly unique to either bereavement (racial-ethnic minority status, social support) or other losses (prehurricane history of psychopathology, social competence.). CONCLUSIONS: Nonbereavement losses accounted for the vast majority of hurricane-related possible CG despite risk of CG being much higher in response to bereavement than to other losses. This result argues for expansion of research on CG beyond bereavement and alerts clinicians to the need to address postdisaster grief associated with a wide range of losses.

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.

BACKGROUND: Although numerous studies have examined the role of latent predispositions to internalizing and externalizing disorders in the structure of comorbidity among common mental disorders, none examined latent predispositions in predicting development of comorbidity. METHODS: A novel method was used to study the role of latent variables in the development of comorbidity among lifetime DSM-IV disorders in the National Comorbidity Surveys. Broad preliminary findings are briefly presented to describe the method. The method used survival analysis to estimate time-lagged associations among 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders. A novel estimation approach examined the extent to which these predictive associations could be explained by latent canonical variables representing internalizing and externalizing disorders. RESULTS: Consistently significant positive associations were found between temporally primary and secondary disorders. Within-domain time-lagged associations were generally stronger than between-domain associations. The vast majority of associations were explained by a model that assumed mediating effects of latent internalizing and externalizing variables, although the complexity of this model differed across samples. A number of intriguing residual associations emerged that warrant further investigation. CONCLUSIONS: The good fit of the canonical model suggests that common causal pathways account for most comorbidity among the disorders considered. These common pathways should be the focus of future research on the development of comorbidity. However, the existence of several important residual associations shows that more is involved than simple mediation. The method developed to carry out these analyses provides a unique way to pinpoint these significant residual associations for subsequent focused study.

BACKGROUND: Emotion regulation deficits have been consistently linked to psychopathology in cross-sectional studies. However, the direction of the relationship between emotion regulation and psychopathology is unclear. This study examined the longitudinal and reciprocal relationships between emotion regulation deficits and psychopathology in adolescents. METHODS: Emotion dysregulation and symptomatology (depression, anxiety, aggressive behavior, and eating pathology) were assessed in a large, diverse sample of adolescents (N=1065) at two time points separated by seven months. Structural equation modeling was used to examine the longitudinal and reciprocal relationships between emotion dysregulation and symptoms of psychopathology. RESULTS: The three distinct emotion processes examined here (emotional understanding, dysregulated expression of sadness and anger, and ruminative responses to distress) formed a unitary latent emotion dysregulation factor. Emotion dysregulation predicted increases in anxiety symptoms, aggressive behavior, and eating pathology after controlling for baseline symptoms but did not predict depressive symptoms. In contrast, none of the four types of psychopathology predicted increases in emotion dysregulation after controlling for baseline emotion dysregulation. CONCLUSIONS: Emotion dysregulation appears to be an important transdiagnostic factor that increases risk for a wide range of psychopathology outcomes in adolescence. These results suggest targets for preventive interventions during this developmental period of risk.

BACKGROUND: Lesbian, gay and bisexual (LGB) populations evidence higher rates of psychiatric disorders than heterosexuals, but most LGB individuals do not have mental-health problems. The present study examined risk modifiers at the social/contextual level that may protect LGB individuals from the development of psychiatric disorders. METHODS: Data are drawn from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N = 34,653), a nationally representative study of non-institutionalized US adults. Risk variables included social isolation and economic adversity. High state-level concentration of same-sex couples, obtained from the US Census, was examined as a protective factor. RESULTS: The past-year prevalence of major depression and generalized anxiety disorder was lower among LGB respondents living in states with higher concentrations of same-sex couples, compared with LGB respondents in states with lower concentrations. Additionally, the increased risk for mood and anxiety disorders among LGB individuals exposed to economic adversity and social isolation was evident only in states with low concentrations of same-sex couples. These interactions between the risk and protective factors were not found among heterosexuals, suggesting specificity of the effects to LGB individuals. Results were not attenuated after controlling for socio-demographic factors, state-level income inequality, state-level policies targeting LGBs and state-level attitudes towards LGB-relevant issues. CONCLUSIONS: These results provide evidence for the protective effect of social/contextual influences on the prevalence of psychiatric disorders in LGB individuals. Measures of the social environment should be incorporated into future research on the mental health of LGB populations.