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PubMed2001

Obsessive-compulsive disorder and separation anxiety co-morbidity in early onset panic disorder.

BACKGROUND: This study was undertaken to examine the relationship between anxiety co-morbidity and age of onset of panic disorder. METHODS: Age of onset of panic disorder and co-morbid anxiety disorders were assessed among 201 panic disorder probands with childhood separation anxiety disorder, obsessive-compulsive disorder, obsessive-compulsive symptoms, social phobia and specific phobia as part of a clinician-administered lifetime diagnostic interview. A generalized linear model was used to test the association between each anxiety co-morbidity and age of panic disorder onset while simultaneously controlling for the potential confounding effects of sociodemographic characteristics and other psychiatric co-morbidity. RESULTS: Earlier onset of panic disorder was found in patients with co-morbid obsessive-compulsive disorder, obsessive-compulsive symptoms and separation anxiety disorder, but not simple phobia or social phobia. Patients with both childhood separation anxiety disorder and obsessive-compulsive disorder had an even earlier panic onset than those with either childhood separation anxiety disorder or obsessive-compulsive disorder. CONCLUSIONS: The association between anxiety co-morbidity and earlier onset of panic disorder is specific to obsessive-compulsive disorder and childhood separation anxiety disorder.

Adolescent↗
PubMed2002

Lower prevalence of pre-morbid neurological illness in African-Caribbean than White psychotic patients in England.

BACKGROUND: It has been suggested that the increased incidence of psychosis in African-Caribbeans living in England may be due to illnesses in which social stress plays an important aetiological role. If this is the case, the prevalence of factors associated with psychosis that predate illness onset such as obstetric complications, pre-morbid neurological illness and poor childhood social adjustment may be expected to be lower in African-Caribbean than Whites psychotic patients. METHOD: Details of obstetric complications, pre-morbid neurological illness, and pre-morbid social adjustment were obtained for 337 psychotic patients by patient interview, interviews of mothers and chart review. The proportions of patients with each 'risk factor' in the African-Caribbean (N = 103) and White (N = 184) groups were compared using regression analysis; age, sex, social class, diagnosis and referral status were possible explanatory variables. RESULTS: African-Caribbean patients were less likely to have suffered a pre-morbid neurological disorder than their White counterparts (odds ratio 0.19, 95% CI 0.06-0.61). There was no significant difference in pre-morbid social adjustment or obstetric complications between the two groups, though fewer obstetric complications were reported in the African-Caribbean group (21.5%) than the White group (30.9%). CONCLUSIONS: African-Caribbean patients with psychosis have experienced less pre-morbid neurological illness.

Black or African American↗
PubMed2004

Prevalence, co-morbidity and correlates of mental disorders in the general population: results from the German Health Interview and Examination Survey (GHS).

BACKGROUND: The German National Health Interview and Examination Survey (GHS) is the first government mandated nationwide study to investigate jointly the prevalence of somatic and mental disorders within one study in the general adult population in Germany. This paper reports results from its Mental Health Supplement (GHS-MHS) on 4-week 12-month, and selected lifetime prevalence of a broad range of DSM-IV mental disorders, their co-morbidity and correlates in the community. METHODS: The sample of the GHS-MHS (n=4181; multistage stratified random sample drawn from population registries; conditional response rate: 87.6%) can be regarded as representative for the German population aged 18-65. Diagnoses are based on fully structured computer assisted clinical interviews (M-CIDI), conducted by clinically trained interviewers. RESULTS: 12-month prevalence for any DSM-IV study disorder is 31% (lifetime: 43%; 4-week: 20%) with anxiety disorders, mood disorders and somatoform syndromes being the most frequent diagnoses. Retrospective age of onset information reveals that most disorders begin early in life. Co-morbidity rates among mental disorders range from 44% to 94%. Correlates of increased rates of mental disorders and co-morbidity were: female gender (except for substance disorders), not being married, low social class, and poor somatic health status. Health care utilization for mental disorders depended on co-morbidity (30% in 'pure', 76% in highly co-morbid cases) and varied from 33% for substance use disorders to 75% for panic disorder. CONCLUSIONS: Results confirm and extend results from other national studies using the same assessment instruments with regard to prevalence, co-morbidity and sociodemographic correlates, covering a broader range of DSM-IV disorders [i.e. somatoform disorders, all anxiety disorders (except PTSD), mental disorders due to substance or general medical factor, eating disorders]. Intervention rates were higher than in previous studies, yet still low overall.

Adolescent↗
PubMed2005

Prevalence, correlates, co-morbidity, and comparative disability of DSM-IV generalized anxiety disorder in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions.

BACKGROUND: This study addressed the prevalences, correlates, co-morbidity and disability of DSM-IV generalized anxiety disorder (GAD) and other psychiatric disorders in a large national survey of the general population, the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The study presents nationally representative data, for the first time, on prevalence, correlates, co-morbidity, and comparative disability of DSM-IV GAD. METHOD: Data are taken from a large (n=43093) representative sample of the adult USA population.R: Prevalences of 12-month and lifetime GAD were 2.1% and 4.1%. Being female, middle-aged, widowed/separated/divorced, and low income increased risk, while being Asian, Hispanic, or Black decreased risk. GAD was highly co-morbid with substance use, and other anxiety, mood, and personality disorders. Co-morbidity in GAD was not substantially greater than for most other Axis I and II disorders. Disability and impairment in pure GAD were equivalent to pure mood disorders, but significantly greater than in pure substance use, and other anxiety and personality disorders. Individuals co-morbid for GAD and each mood disorder were more disabled than those with pure forms of GAD or each mood disorder. When co-morbid with GAD, nicotine dependence and other anxiety and personality disorders were not associated with increased disability over that associated with pure GAD, but GAD did show increased disability over that due to each of these disorders in pure form.Conclusions. Associations between GAD and Axis I and II disorders were strong and significant, with variation among specific disorders. Results strongly support GAD as an independent disorder with significant impairment and disability.

Adolescent↗
PubMed2005

Medical co-morbidity and validity of DSM-IV depression criteria.

BACKGROUND: Clinicians have questioned the validity of depression criteria in patients with chronic medical illness, but few empirical data address this question. METHOD: Computerized records identified two samples of managed care patients beginning depression treatment: 235 with diabetes, ischemic heart disease, or chronic obstructive lung disease and 204 without those conditions. Telephone assessments at baseline, 2 months, and 6 months included the Structured Clinical Interview for DSM-IV and other measures of depression severity and functional status. Item Response Theory analyses compared patterns of depressive symptoms across groups and specifically evaluated somatic symptoms (fatigue, change in weight or appetite, psychomotor agitation/retardation, and sleep disturbance) as indicators of depression. Logistic regression examined how change in somatic symptoms during treatment varied between patient groups. RESULTS: Overall item response analysis indicated differential item functioning between groups (chi2=33.7, df=18, p=0.017). Two of eight item-level comparisons were statistically significant; one in the predicted direction (patients with co-morbidity reported more fatigue at low levels of depression: chi2=17.9, df=1, p<0.001) and one in the opposite direction from predicted (patients with co-morbidity reported less psychomotor agitation/retardation at low levels of depression: chi2=8.0, df=1, p=0.005). Observed differences were modest: at the midpoint of the depression severity scale, patients with medical co-morbidity had a 54% probability of reporting fatigue compared to 45% in those without co-morbidity. All four somatic symptoms showed robust improvement with treatment, and this improvement did not differ significantly between patients with and without medical co-morbidity. CONCLUSIONS: We find only limited evidence that fatigue, changes in weight or appetite, psychomotor agitation/retardation, and sleep disturbance are less valid indicators of depression in patients with chronic medical illness. DSM-IV criteria for diagnosis of depression do not require significant modification for patients with medical co-morbidity.

Adult↗
PubMed2000

Social phobia in a population-based female adolescent twin sample: co-morbidity and associated suicide-related symptoms.

BACKGROUND: This report attempted to replicate and extend prior work examining social phobia (SP), co-morbid psychiatric illnesses, and the risk of suicidal ideation and suicide attempts incurred by their adolescent sufferers. METHODS: SP, alcohol dependence (ALD) and major depressive disorder (MDD) diagnoses, and suicide-related symptoms, were assessed in a population-based adolescent female twin sample. The differentiation of risks as a function of co-morbidity was explored. A trivariate model was fitted to estimate sharing of genetic and environmental vulnerability between SP and co-morbid disorders. RESULTS: The lifetime prevalence of SP was 16.3 %. Significant risk for co-morbid MDD (OR = 3.2) and ALD (OR = 2.1) was observed. Strong evidence for shared genetic vulnerability between SP and MDD (respective heritabilities 28%, 45%; genetic r = 1.0) was observed with moderate support noted for similar sharing between SP and ALD (genetic r = 0.52, heritability for ALD 63%). SP with co-morbid MDD was associated with elevated risk for ALD and for suicide-related symptoms. CONCLUSIONS: SP is a common illness often followed by co-morbid MDD and ALD. SP with comorbid MDD predicts a substantially elevated risk of ALD and suicide-related symptoms, stressing the need for early SP detection.

Adolescent↗
PubMed2003

Does co-morbid personality disorder increase the risk of suicidal behaviour in psychosis?

OBJECTIVE: To examine the association between co-morbid personality disorder (PD) and suicidal behaviour over a 2-year period in a sample of patients with psychosis. METHOD: A total of 670 patients with established psychotic illness were interviewed using a battery of instruments including a screen for co-morbid PD. The prevalence of attempted and completed suicide was measured over the next 2 years using multiple data sources. Logistic regression was used to examine whether those with co-morbid PD were at greater risk of suicidal behaviour compared with others. RESULTS: One hundred and eighty six patients (28%) were rated as having a co-morbid PD. After adjusting for all covariates, patients with co-morbid PD were significantly more likely to attempt or complete suicide over the 2-year period (adjusted odds ratio: 1.87; 95% CI: 1.02-3.42). CONCLUSION: Co-morbid PD is independently associated with an increased risk of suicidal behaviour in psychosis. Early assessment of personality status should be part of the routine assessment of all psychiatric patients.

Adult↗
PubMed1999

Morbidity in patients with clinically localized prostate cancer managed with non-curative intent. A population-based case-control study.

To compare the morbidity in patients with newly diagnosed clinically localized prostate cancer managed conservatively with the morbidity in a randomly selected age-matched background population with no history of prostate cancer. Patients younger than 75 y at diagnosis with newly diagnosed clinically localized prostate cancer reported to the Danish Cancer Registry in the period 1977-1992. Morbidity in patients and age-matched controls was extracted from The Danish Hospital Discharge Registry. Admissions were stratified by discharge diagnosis. Overall 4744 patients were hospitalized for 251,695 days within the first 10 y following diagnosis compared with 74,563 days in 4774 age-matched controls. The patients were admitted 6.7 (6.4-7.1) times more often than controls in the year following diagnosis, and 2.7 (2.6-2.8) times more often in the following 9 y. Excess morbidity declined over time. When prostate cancer-related admissions were excluded, the relative risk of admission was reduced to 1.35 (1.3-1.4) and 0.86 (0.83-0.89), respectively. The estimated costs associated with deferred therapy in patients with clinically localized prostate cancer exceeded the estimated cost in age-matched controls by approximately US$88 million, equivalent to an average extra cost per patient of approximately US$18,500. Patients with clinically localized prostate cancer managed conservatively had a significantly higher morbidity than age-matched controls due to admissions associated with prostate cancer. In future comparisons of treatment strategies, morbidity following treatment and impact on quality of life have to be included when evaluating the outcome.

Journal Article↗
PubMed2006

Greater influence of age than co-morbidity on primary treatment and complications of prostate cancer patients: an in-depth population-based study.

We investigated the influence of age and co-morbidity on treatment, the occurrence of serious non-urological complications of treatment and prognosis for prostate cancer patients diagnosed and treated in community hospitals. Additional information from a random sample of 505 prostate cancer patients (aged 40 years or older) from the Eindhoven Cancer Registry diagnosed between 1995 and 1999 was collected. In all, 43% of the prostate cancer patients aged 40-69 years and 64% of those aged 70 or older suffered from one or more serious concomitant disease that barely affected primary treatment choice. However, compared to patients without co-morbidity, patients with cardiovascular diseases underwent radical prostatectomy less often (P=0.01). In all, 38% of the patients undergoing radical prostatectomy suffered from complications during the first year after diagnosis versus about 20% of those receiving radiotherapy. The number of complications did not seem to be affected by co-morbidity. After adjustment for age, stage, grade, prostate-specific antigen level and treatment, the cumulative risk of death was almost two times higher for patients with two or more concomitant diseases than for patients without co-morbidity. After adjustment for age, prostate cancer patients with co-morbidity were not treated differently, did not suffer from more complications but had a worse prognosis, compared to those without co-morbidity.

Adult↗
PubMed1996

Helminth infections, morbidity indicators and schistosomiasis treatment history in three villages, Dongting Lake region, PR China.

In order to estimate the public health impact of helminth infections, and to provide baseline data for interventions, parasitological and morbidity surveys were conducted among inhabitants of three villages in Dongting Lake region, Hunan Province, China. Ascaris lumbricoides was found to be the most common helminth infection, followed by Trichuris trichiura and Schistosoma japonicum. Left liver enlargement was the most common indicator of morbidity. Observed numbers of multiple species infections closely correlated with expected figures generated from a simple probabilistic model. Heterogeneity was observed in age and sex-standardized infection and morbidity prevalences among the villages and occupations. Males had higher levels of infection, were more likely to suffer morbidity, and were more likely to have been treated for schistosomiasis than women. The prevalence of each morbidity indicator was positively correlated with the number of times of treatment for schistosomiasis, and negatively correlated with number of years since last treatment. The results imply that treatment history for S. japonicum infection may be a good indicator of current morbidity risk.

Adolescent↗
PubMed1998

The impact of vitamin A supplementation given during a pneumonia episode on the subsequent morbidity of children.

OBJECTIVE: To evaluate the impact of large-dose vitamin A supplementation given to infants > 6 months old (200000 IU) and to preschool children aged 1-4 years (400000 IU) during a pneumonia episode, on their subsequent morbidity and severe morbidity. METHOD: In a randomized, double-blind, placebo controlled trial, the children were followed-up with 2-weekly visits at home for 16 weeks, with the first visit 2 weeks after treatment for pneumonia was initiated. The field workers asked about the presence of morbidity on the day of the visit and in the previous two weeks and about the occurrence and number of clinic attendances and hospital admissions since the last visit. They also measured the patients respiratory rate and temperature and assessed the children for the presence of cyanosis, chest indrawing and wheezing. RESULTS: Except for the prevalence of diet refusal which was higher in the vitamin A group, no differences between the study groups were observed, either in the prevalence of morbidity or in the incidence of clinic attendances and hospital admissions. CONCLUSION: No evidence was found for a beneficial effect of vitamin A given during acute pneumonia on the subsequent morbidity and severe morbidity of children in a population with marginal vitamin A deficiency.

Brazil↗
PubMed2002

Dose distribution and morbidity after high dose rate brachytherapy for prostate cancer: influence of V150 and V200 parameters.

The purpose of this study is to identify factors predicting morbidity in patients undergoing high dose rate (HDR) brachytherapy boost with external beam irradiation for prostate cancer. Acute and late morbidity data were collected for 104 prostate cancer patients treated with an HDR boost together with external beam radiotherapy. Significant urinary and rectal morbidity were correlated with urethral and rectal point doses, and the proportions of the target volume receiving 100%, 150% and 200% (V200) or more of the prescribed dose. Rectal or urethral point doses did not predict morbidity. By contrast, the V200 was significantly higher for patients experiencing either acute or late urinary morbidity. The cut-off V200 was 15% of the target volume. Although theoretically beneficial for tumour cell kill, the treatment of significant proportions of the prostate to high dose might be associated with increased morbidity, and should preferably be avoided.

Brachytherapy↗
PubMed2002

POSSUM: a re-evaluation in patients undergoing surgery for rectal cancer. The Physiological and Operative Severity Score for Enumeration of Mortality and Morbidity.

BACKGROUND: The problem of directly comparing morbidity and mortality rates between institutions without some sort of adjustment for case mix is well documented. Scoring systems have been developed to allow comparisons to be made. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is one such system. It was designed to predict operative mortality and morbidity in differing settings and to be independent of case mix. The present study examines the use of POSSUM in colorectal practice in Saudi Arabia. METHODS: Patients referred to King Faisal Specialist Hospital between 1990 and 1998 for primary management of an histologically proven rectal cancer were identified. POSSUM mortality and morbidity scores and Portsmouth-Physiological and Operative Severity Score (P-POSSUM) mortality scores were calculated separately for each patient, and predicted rates were compared with observed rates in the patients studied. RESULTS: There were 70 men (mean age: 55.6 years; range: 25-87) and 75 women (mean age: 52.8 years; range: 26-84). One hundred and six patients underwent 'curative' surgery. Abdominoperineal resection was the most frequently performed procedure. Major anastomotic leakage following anterior resection occurred in two of fifty patients. One patient developed a pulmonary embolism but no patient developed postoperative myocardial infarction. Two patients died. The median and mean physiological and operative severity scores were 13 (range: 12-37) and 17 (range: 8-37) and 14.68 and 18.36, respectively. The overall POSSUM-predicted (using median scores) morbidity and mortality rates were 35.4% and 6.7%. The P-POSSUM-predicted (using mean scores) mortality rate was 3.5%. Observed morbidity and mortality rates were 54.5% and 1.4%. CONCLUSION: POSSUM failed to predict outcomes accurately in patients undergoing surgery for rectal cancer in Saudi Arabia. P-POSSUM also overpredicted mortality but to a lesser extent. Patient's 'wellness' and the previously identified inability of POSSUM to accurately predict death in low-risk populations may explain these findings. Care must be exercised in using the POSSUM formulae for risk adjustment in different settings.

Adult↗
PubMed2000

Psychosocial morbidity in prostate cancer: II. A comparison of patients and partners.

OBJECTIVE: To assess psychometrically a new questionnaire for measuring the psychosocial morbidity in patients with prostate cancer and in their partners, and to compare the morbidity of patients and their partners. PATIENTS AND METHODS: A sequential sample of patients with any stage of prostate cancer and attending general urology outpatient clinics was identified. The questionnaire was administered to 135 patients and their partners in their homes. The Hospital Anxiety and Depression Scale (HADS) questionnaire was also administered to permit construct validation of the new measure. Test-retest reliability was calculated by re-administering the questionnaire to 60 individuals. The hypothetical general cancer distress and social subscales of the questionnaire were also tested for internal consistency. Psychosocial morbidity scores obtained by the patients and partners were compared. RESULTS: The questionnaire had good test-retest reliability and construct validity when tested against the HADS. The general cancer distress and social subscales were internally consistent. General cancer distress was highly prevalent and significantly more severe in partners than in patients. There was some degree of general cancer distress in 47% of patients and 76% of partners, whereas severe distress was detected in 11% and 30%, respectively. Social morbidity was limited and of equal severity between the groups. Treatment-related worries and concerns about pain and physical limitation were more common among partners than patients, whereas there was no difference for worries about urinary symptoms. Sexual concerns were the least prevalent and were more of a problem for patients than partners. CONCLUSION: Psychosocial morbidity in prostate cancer is highly prevalent, not only among patients but particularly among their partners. The new questionnaire showed adequate psychometric properties for use in identifying individuals with significant psychosocial morbidity. Applying the questionnaire should permit emotional and informational support to be targeted at the most vulnerable.

Aged↗
PubMed2002

The prognostic importance of trauma scoring systems for morbidity in children with penetrating abdominal wounds: 17 years of experience.

BACKGROUND/PURPOSE: Risk factors that may independently predict morbidity in children with penetrating abdominal wounds (PAW) have not been elucidated fully. The aim of this study was to identify not only correlated risk factors for morbidity in children with PAW, but also to evaluate the independent predictive value of 3 different trauma scoring systems: the Injury Severity Score (ISS), the Penetrating Abdominal Trauma Index (PATI), and the Pediatric Trauma Score (PTS). METHODS: Between January 1983 and November 2000, 119 children (99 boys, 20 girls) presenting with PAW were reevaluated by an analysis of the relationship between overall morbidity and potential risk factors. RESULTS: Wounds were caused by firearm trauma in 85 children and stabbing in 34. Univariate analysis found that age greater than 10 years, trauma mechanism, number of intraabdominal organs injured (NOI) greater than 2, presence of penetrating injury, and ISS and PATI score were associated with greater than 3-fold increased incidence of morbidity (P <.05). The relative risk of a postoperative septic complication was higher than 2 for the following risk factors: age greater than 10 years, shotgun injury, number of organs injured greater than 2, presence of colon injury, ISS greater than 15, and PATI score greater than 15. Multivariate analysis showed that only ISS (P =.02), and PATI score (P =.03) were independently significant in predicting morbidity. CONCLUSION: ISS and PATI score were the most important indicators found to be independently associated with morbidity.

Abdominal Injuries↗
PubMed2003

The influence of co-morbidity on health-related quality of life in asthma and COPD patients.

This study examines the association between somatic co-morbidity and both general and disease-specific health-related quality of life (HRQoL) in patients with asthma and chronic obstructive pulmonary disease (COPD). A cross-sectional analysis was done among 161 COPD patients and 395 asthma patients, aged 40-75 years, recruited from general practice. In the total study population, 47% had no, 32% had one, and 21% had two or more somatic co-morbid conditions, with no significant differences between asthma and COPD patients. Co-morbidity appeared to be associated with poor disease-specific HRQoL in asthma [odds ratio (OR) = 2.08 (1.37-3.18)] and with poor general HRQoL in asthma [OR = 2.96 (1.93-4.53)] and COPD [1.81 (0.91-3.60)] patients. Poorest HRQoL was found in patients with more than one co-morbid condition. Cardiac disease and hypertension were associated with poor disease-specific HRQoL in asthma. Of all co-morbid conditions, musculoskeletal disorders were most strongly associated with poor general HRQoL. Cardiac disease was found to be associated with general and disease-specific HRQoL in asthma but not in COPD. In studies on patients with asthma or COPD aged 40-75 years, co-morbidity should be treated as a determinant of HRQoL.

Adult↗
PubMed1997

Management of co-morbid anxiety and alcohol disorders: parallel treatment of disorders.

Co-morbid alcohol-related disorders and anxiety disorders have been found to occur in alcohol treatment populations, anxiety treatment populations and the general community. People suffering from co-occurring alcohol-related and anxiety disorders are more prone to relapse to alcohol abuse, and more likely to re-enter the treatment system for either disorder than sufferers of either disorder without a co-morbid disorder. To review the current state of the management of this disorder, evidence of the prevalence of this co-morbid condition in clinical and community populations is examined, then the theoretical mechanisms that might explain this connection are reviewed. A comparison of the few treatment studies of co-morbid alcohol and anxiety disorders shows a limited number of pharmacological treatment trials and no psychotherapy outcome trials. This review shows that it is no longer sustainable to conceptualize co-morbidity of alcohol and anxiety disorders as a unitary concept, i.e. lumping alcohol-related and anxiety disorders as one global condition, but as separate distinct combinations of particular anxiety disorders, e.g. alcohol dependence and panic disorder, alcohol dependence and generalize anxiety disorder. The recommended treatment approach, supported by the evidence, is to offer separate and parallel therapy for the alcohol-related and anxiety disorder, until empirical evidence from treatment outcome studies suggest otherwise. There is an urgent need to conduct treatment outcome research for the subtypes of co-morbid alcohol and anxiety disorders.

Journal Article↗
PubMed2005

Health literacy, morbidity, and quality of life among individuals with spinal cord injury.

OBJECTIVES: Health literacy has been related to indicators of health outcomes in a number of populations, but not in spinal cord injury (SCI). The current study aimed to describe levels of health literacy in SCI and to investigate its possible associations with morbidity, health-related quality of life, functional independence, community participation, and life satisfaction. DESIGN: Cross-sectional survey of 107 community-living people with SCI recruited in a New Jersey outpatient SCI center. Primary measures were the Test of Functional Health Literacy in Adults (TOFHLA), standard questions about morbidity from the Behavioral Risk Factors Surveillance Study, the Craig Handicap Assessment and Reporting Technique (CHART), Short Form-12 (SF-12), and Diener's Satisfaction with Life Scale. RESULTS: Health literacy was marginal or inadequate (TOFHLA = 0-74) in only 14% of the sample. TOFHLA scores correlated significantly with physical health morbidity, even after control for severity of motor paralysis and education. American Spinal Injury Association (ASIA) Motor Scores were correlated with physical morbidity and CHART Physical Independence scores; and education was related to community Mobility, Occupation, and Economic Independence, and Satisfaction with Life scores, independent of other factors. Rasch analysis identified ceiling measurement limitations in the TOFHLA. CONCLUSIONS: Health literacy levels in this sample were higher than those found in other groups. Health literacy was independently related to physical health morbidity, but its associations with other outcomes were limited, entwined with education, and affected by severity of injury. Future research might examine higher-level aspects of health literacy to overcome ceiling measurement problems. Mediators of the association between health literacy and morbidity, such as health self-care behaviors, should also be examined.

Adult↗