Risk and functional significance of psychotic experiences among individuals with depression in 44 low- and middle-income countries

BACKGROUND

Studies on whether the co-occurrence of psychotic experiences (PEs) and depression confers a more pronounced decrement in health status and function compared with depression alone are scarce in the general adult population.

METHOD

Data on 195 479 adults aged ⩾18 years from the World Health Survey were analysed. Using the World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI), depression in the past 12 months was categorized into four groups: depressive episode, brief depressive episode, subsyndromal depression, and no depression. Past 12-month psychotic symptoms were assessed using four questions on positive symptoms from the CIDI. Health status across seven domains (cognition, interpersonal activities, sleep/energy, self-care, mobility, pain/discomfort, vision) and interviewer-rated presence of a mental health problem were assessed. Multivariable logistic and linear regression analyses were performed to assess the associations.

RESULTS

When compared with those with no depression, individuals with depression had higher odds of reporting at least one PE, and this was seen across all levels of depression severity: subsyndromal depression [odds ratio (OR) 2.38, 95% confidence interval (CI) 2.02-2.81], brief depressive episode (OR 3.84, 95% CI 3.31-4.46) and depressive episode (OR 3.75, 95% CI 3.24-4.33). Having coexisting PEs and depression was associated with a higher risk for observable illness behavior and a significant decline in health status in the cognition, interpersonal activities and sleep/energy domains, compared with those with depression alone.

CONCLUSIONS

This coexistence of depression and PEs is associated with more severe social, cognitive and sleep disturbances, and more outwardly apparent illness behavior. Detecting this co-occurrence may be important for treatment planning.

Psychotic symptoms and smoking in 44 countries

OBJECTIVE

To assess the association between psychotic symptoms and smoking among community-dwelling adults in 44 countries.

METHOD

Data from the World Health Survey (WHS) for 192 474 adults aged ≥18 years collected in 2002-2004 were analyzed. The Composite International Diagnostic Interview was used to identify four types of past 12-month psychotic symptoms. Smoking referred to current daily and non-daily smoking. Heavy smoking was defined as smoking ≥30 tobacco products/day.

RESULTS

The pooled age-sex-adjusted OR (95% CI) of psychotic symptoms (i.e., at least one psychotic symptom) for smoking was 1.35 (1.27-1.43). After adjustment for potential confounders, compared to those with no psychotic symptoms, the ORs (95% CIs) for smoking for 1, 2, and ≥3 psychotic symptoms were 1.20 (1.08-1.32), 1.25 (1.08-1.45), and 1.36 (1.13-1.64) respectively. Among daily smokers, psychotic symptoms were associated with heavy smoking (OR = 1.45, 95% CI = 1.10-1.92), and individuals who initiated daily smoking at ≤15 years of age were 1.22 (95% CI = 1.05-1.42) times more likely to have psychotic symptoms.

CONCLUSIONS

An increased awareness that psychotic symptoms are associated with smoking is important from a public health and clinical point of view. Future studies that investigate the underlying link between psychotic symptoms and smoking prospectively are warranted.

Degree of cognitive impairment and mortality: a 17-year follow-up in a community study

BACKGROUND

To test the hypothesis that cognitive impairment in older adults is associated with all-cause mortality risk and the risk increases when the degree of cognitive impairment augments; and then, if this association is confirmed, to report the population-attributable fraction (PAF) of mortality due to cognitive impairment.

METHOD

A representative random community sample of individuals aged over 55 was interviewed, and 4557 subjects remaining alive at the end of the first year of follow-up were included in the analysis. Instruments used in the assessment included the Mini-Mental Status Examination (MMSE), the History and Aetiology Schedule (HAS) and the Geriatric Mental State (GMS)-AGECAT. For the standardised degree of cognitive impairment Perneczky et al's MMSE criteria were applied. Mortality information was obtained from the official population registry. Multivariate Cox proportional hazard models were used to test the association between MMSE degrees of cognitive impairment and mortality risk. We also estimated the PAF of mortality due to specific MMSE stages.

RESULTS

Cognitive impairment was associated with mortality risk, the risk increasing in parallel with the degree of cognitive impairment (Hazard ratio, HR: 1.18 in the 'mild' degree of impairment; HR: 1.29 in the 'moderate' degree; and HR: 2.08 in the 'severe' degree). The PAF of mortality due to severe cognitive impairment was 3.49%.

CONCLUSIONS

A gradient of increased mortality-risk associated with severity of cognitive impairment was observed. The results support the claim that routine assessment of cognitive function in older adults should be considered in clinical practice.

Gender differences in psychotropic use across Europe: Results from a large cross-sectional, population-based study

BACKGROUND

In many epidemiological studies, women have been observed to consume psychotropic medication more often than men. However, the consistency of this relationship across Europe, with differences in mental health care (MHC) resources and reimbursement policies, is unknown.

METHODS

Questions on 12-month psychotropic use (antidepressants, benzodiazepines, antipsychotics, mood stabilizers) were asked to 34,204 respondents from 10 European countries of the EU-World Mental Health surveys. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) criteria were used to determine 12-month prevalence of mood/anxiety disorders using the Composite International Diagnostic Interview (v3.0).

RESULTS

For all participating countries, women were significantly more likely than men to use psychotropic medication within the previous 12 months (overall-OR=2.04, 95% CI: 1.81-2.31). This relationship remained significant after adjusting for common sociodemographic factors (age, income level, employment status, education, marital status) and country-level indicators (MHC provision, private household out-of-pocket expenditure, and Gender Gap Index). In multivariable gender-stratified risk-factor analysis, both women and men were more likely to have taken psychotropic medication with increasing age, decreasing income level, and mental health care use within the past 12 months, with no significant differences between genders. When only including participants with a mental disorder, gender differences overall were still significant with any 12-month mood disorder but not with any 12-month anxiety disorder, remaining so after adjusting for sociodemographic characteristics and country-level indicators.

CONCLUSIONS

Women use psychotropic medication consistently more often than men, yet reasons for their use are similar between genders. These differences also appear to be contingent on the specific mental disorder.

Suicidality and its relationship with depression, alcohol disorders and childhood experiences of violence: results from the ESEMeD study

BACKGROUND

Suicidality constitutes a major health concern in many countries. The aim of the present paper was to analyse 10 of its risk factors and their interdependence.

METHODS

Data on suicidality, mental disorders and experience of childhood violence was collected from 8796 respondents in the European Study of the Epidemiology of Mental Disorders (ESEMeD). The CIDI was used to assess mental disorders. Individuals were randomly divided into two subgroups. In one, a Graphical Markov model to predict suicidality was constructed, in the second, predictors were cross-validated.

RESULTS

Lifetime suicidality was predicted mainly by lifetime depression and early experiences of violence, with a pseudo R-square of 12.8%. In addition, alcohol disorders predicted suicidality, but played a minor role compared with the other risk factors in this sample.

CONCLUSION

In addition to depression, early experience of violence constitutes an important risk factor of suicidality.

LIMITATIONS

This is a cross-sectional and retrospective study assessing risk factors for suicidality, not for suicide itself.

Cannabis and bipolar disorder: does quitting cannabis use during manic/mixed episode improve clinical/functional outcomes?

OBJECTIVE

To examine whether bipolar disorder patients who stop cannabis use during a manic/mixed episode have better clinical and functional outcomes than continued use or never use.

METHOD

Data from the European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM), a 2-year prospective observational study in adults with a manic/mixed episode of bipolar disorder, was used. Three cannabis use groups were: current use (between 12-week and 24-month visits); no current but previous use (during first 12 weeks); and never use. Associations between cannabis use and outcomes were analyzed using regression models.

RESULTS

Of 1922 patients analyzed, 6.9% were current users, 4.6% previous users, and 88.5% never users. Clinical outcomes differed between groups (P<0.019): previous users had highest rates of remission (68.1%) and recovery (38.7%), and lowest rates of recurrence (42.1%) and relapse (29.8%). Logistic regression showed previous users had similar outcomes to never users (all P>0.05), whereas current users had lower recovery (P=0.004) and remission (P=0.014), higher recurrence (P=0.014), greater work impairment (P=0.016), and were more likely not to be living with partner (P=0.006) than never users.

CONCLUSION

Bipolar patients who stop using cannabis during manic/mixed episode have similar clinical and functional outcomes to never users, while continued use is associated with higher risk of recurrence and poorer functioning.

Mild cognitive impairment diagnosed with the new DSM-5 criteria: prevalence and associations with non-cognitive psychopathology

OBJECTIVE

To contrast the prevalence of mild cognitive impairment (MCI) as diagnosed using DSM-5 criteria (DSM5-MCI) with MCI as diagnosed using Petersen's criteria (P-MCI) and to explore the association of both with non-cognitive psychopathological symptoms (NCPS).

METHOD

A two-phase epidemiological screening was implemented in a population-based sample of individuals aged 55+ (n = 4803). The Geriatric Mental State (GMS) was the main psychopathological instrument used, and AGECAT was used to make psychiatric diagnoses. Research psychiatrists diagnosed DSM5-MCI and P-MCI using operational criteria. Logistic regression models were then used to investigate the association of MCI with anxiety and depression and with NCPS.

RESULTS

Weighted prevalence of DSM5-MCI and P-MCI was, respectively, 3.72% and 7.93% for the aged 65+. NCPS were common in both MCI categories, but negative-type symptoms such as 'anergia' and 'observed slowness' were considerably more frequent among persons with DSM5-MCI. Anxiety and depression diagnostic categories were associated with both P-MCI and DSM5-MCI, but affective-type symptoms were mainly associated with P-MCI. Some negative-type symptoms were inversely associated with P-MCI, and no association was observed with DSM5-MCI.

CONCLUSION

The prevalence of DSM5-MCI was half that of P-MCI. Negative-type NCPS were more frequently and typically associated with DSM5-MCI.

Analysis of burden in caregivers of people with Alzheimer's disease using self-report and supervision hours

OBJECTIVES

This study aimed to describe the baseline characteristics of informal carers of community-living Alzheimer's disease (AD) patients by AD severity group and to identify factors associated with two measures of caregiver burden.

DESIGN AND SETTING

GERAS is a prospective observational study in France, Germany, and the UK, designed to assess costs and resource use associated with AD, for patients and their caregivers, stratified by disease severity.

PARTICIPANTS

1497 community-dwelling AD patients and their primary caregivers.

MEASUREMENTS

Subjective caregiver burden assessed using the Zarit Burden Interview [ZBI] and time spent supervising patients (an objective measure of burden recorded using the Resource Utilization in Dementia instrument) during the month before the baseline visit were recorded. Separate multiple linear regression analyses using ZBI total score and caregiver supervision time as dependent variables were performed to identify patient and caregiver factors independently associated with caregiver burden.

RESULTS

Increasing AD severity was associated with both subjective caregiver burden (ZBI total score) and overall caregiver time, which includes supervision time (both p<0.001, ANOVA). Better patient functioning (on instrumental activities of daily living) was independently associated with both a lower ZBI total score and less supervision time, whereas higher levels of caregiver distress due to patient behavior were associated with greater caregiver burden. Other factors independently associated with an increased ZBI total score included younger caregiver age, caregiver self-reported depression, caring for a male patient, and longer time since AD diagnosis. Caregivers living with the patient, being a male caregiver, patient living in a rural location, higher patient behavioral problem subdomain scores for apathy and psychosis, more patient emergency room visits, not receiving food delivery and receiving financial support for caregiving were all associated with greater caregiver supervision time.

CONCLUSION

Our results show that subjective caregiver burden and caregiver time are influenced by different factors, reinforcing the need to consider both aspects of caregiving when trying to minimize the burden of AD. However, interventions that minimize caregiver distress and improve patient functioning may impact on both subjective and objective burden.

Mood and anxiety disorders across the adult lifespan: a European perspective

BACKGROUND

The World Mental Health Survey Initiative (WMHSI) has advanced our understanding of mental disorders by providing data suitable for analysis across many countries. However, these data have not yet been fully explored from a cross-national lifespan perspective. In particular, there is a shortage of research on the relationship between mood and anxiety disorders and age across countries. In this study we used multigroup methods to model the distribution of 12-month DSM-IV/CIDI mood and anxiety disorders across the adult lifespan in relation to determinants of mental health in 10 European Union (EU) countries.

METHOD

Logistic regression was used to model the odds of any mood or any anxiety disorder as a function of age, gender, marital status, urbanicity and employment using a multigroup approach (n = 35500). This allowed for the testing of specific lifespan hypotheses across participating countries.

RESULTS

No simple geographical pattern exists with which to describe the relationship between 12-month prevalence of mood and anxiety disorders and age. Of the adults sampled, very few aged ≥ 80 years met DSM-IV diagnostic criteria for these disorders. The associations between these disorders and key sociodemographic variables were relatively homogeneous across countries after adjusting for age.

CONCLUSIONS

Further research is required to confirm that there are indeed stages in the lifespan where the reported prevalence of mental disorders is low, such as among younger adults in the East and older adults in the West. This project illustrates the difficulties in conducting research among different age groups simultaneously.

Cross-national differences in the prevalence and correlates of burden among older family caregivers in the World Health Organization World Mental Health (WMH) Surveys

BACKGROUND

Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiological research has not yet examined the implications of these trends for burdens experienced by aging family caregivers. Method Cross-sectional community surveys in 20 countries asked 13 892 respondents aged 50+ years about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status and type of condition.

RESULTS

Among the 26.9-42.5% respondents in high-, upper-middle-, and low-/lower-middle-income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours per week in those giving any time were 16.6-23.6 (169.9-205.8 h/week per 100 people aged 50+ years). Burden in low-/lower-middle-income countries was 2- to 3-fold higher than in higher-income countries, with any financial burden averaging 14.3% of median family income in high-, 17.7% in upper-middle-, and 39.8% in low-/lower-middle-income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings.

CONCLUSIONS

Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low-/lower-middle-income countries.

Use of general practitioners versus mental health professionals in six European countries: the decisive role of the organization of mental health-care systems

OBJECTIVE

To investigate patterns of use of general practitioners (GPs) and/or mental health professionals (MHPs) for mental health reasons, across six European countries, and the extent to which these patterns of use are associated with differences in mental health-care delivering systems.

METHODS

Data are based on the European Study of the Epidemiology of Mental Disorders (ESEMeD): a cross-sectional survey of a representative sample of 8,796 non-institutionalized adults from six European countries, conducted between 2001 and 2003 using computer-assisted interviews with the CIDI-3.0. Countries were classified into: MHP- for countries where access to medical professionals tends to predominate (Belgium, France, Italy), and MHP+ where access to non-medical MHPs predominates (Germany, Spain, The Netherlands).

RESULTS

Among respondents consulting GPs and/or MHPs in the past year (n = 1,019), respondents from the MHP- group more often consulted GPs (68 vs. 55 % in MHP+ group), GPs and psychiatrists (23 vs. 14 %). People from the MHP+ group more often used MHPs only (45 vs. 32 %), GPs and non-medical MHPs (16 vs. 8 %). GPs from the MHP+ group were more inclined to refer patients to MHPs. Factors associated with use of GPs versus MHPs were: being over 49 years, not highly educated, lower income and suffering from mood or severe mental disorders.

CONCLUSIONS

Differences in the use of GPs versus MHPs are markedly linked to individual as well as organizational factors. Interventions are needed, in countries fostering medical access, to reimburse sessions with non-medical MHPs and improve cooperation between professionals to obtain better practice in access to care.

Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys

Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity.

Complex interaction between symptoms, social factors, and gender in social functioning in a community-dwelling sample of schizophrenia

Social functioning (SF) is the ultimate target aimed in treatment plans in schizophrenia, thus it is critical to know what are the factors that determine SF. Gender is a well-established variable influencing SF, yet it is not known how social variables and symptoms interact in schizophrenia patients. Furthermore, it remains unclear whether the interaction between social variables and symptoms is different in men compared to women. Our aim is to test whether social variables are better predictors of SF in community-dwelled individuals with schizophrenia, and whether men and women differ in how symptoms and social variables interact to impact SF. Community-dwelling individuals with schizophrenia (N = 231) were randomly selected from a register. Participants were assessed with symptom measures (PANSS), performance-based social scale (LSP), objective social and demographic variables. Stratification by gender and stepwise multivariate regression analyses by gender were used to find the best-fitting models that predict SF in both gender. Men had poorer SF than women in spite of showing similar symptom scores. On stepwise regression analyses, gender was the main variable explaining SF, with a significant contribution by disorganized and excitatory symptoms. Age of onset made a less marked, yet significant, contribution to explain SF. When the sample was stratified by gender, disorganized symptoms and 'Income' variable entered the model and accounted for a 30.8% of the SF variance in women. On the other hand, positive and disorganized symptoms entered the model and accounted for a 36.1% of the SF variance in men. Community-dwelling men and women with schizophrenia differ in the constellation of variables associated with SF. Symptom scores still account for most of the variance in SF in both genders.

Prevalence and correlates of respiratory and non-respiratory panic attacks in the general population

BACKGROUND

Panic attacks are heterogeneous with regards to symptom profile. Subtypes of panic attacks have been proposed, of which the most investigated is respiratory panic attacks (RPA). Limited information exists about RPA in the general population.

METHOD

The prevalence and correlates of RPA and non-respiratory panic attacks (NRPA) were examined in a subsample (n=8.796) of individuals participating in a cross-sectional survey of the adult general population of six European countries. Panic attacks, mental disorders, and chronic physical conditions were assessed with the Composite International Diagnostic Interview (CIDI) 3.0. Data on use of health services and disability were obtained.

RESULTS

The lifetime prevalence of RPA was 6.77 and the 12-month prevalence was 2.26. No robust associations of RPA with sociodemographic characteristics, mental disorders or physical conditions were found as compared to NRPA. RPA were associated with increased use of health services but similar disability in comparison to NRPA.

LIMITATIONS

Few direct data are available on the validity of the CIDI to assess RPA. Other definitions of RPA exist in the literature.

CONCLUSIONS

Our findings suggest that there are very few differences between RPA and NRPA and do not support the need of subtyping panic attacks in current classification systems.

2-Year course of bipolar disorder type I patients in outpatient care: factors associated with remission and functional recovery

EMBLEM is a 2-year, prospective, observational study that enrolled patients initiating/changing oral treatment for an acute manic/mixed episode. This paper analysed remission and functional recovery in 1656 patients who entered the 2-year long-term phase. Cox models identified variables significantly associated with achieving remission and functional recovery at 2years. Of these patients, 64% achieved remission and 34% achieved functional recovery. Patients with a higher CGI-BP overall score at baseline, who had depressive episodes in the year before inclusion and who had poor social functioning (work or social impairment, not living independently or without a spouse/partner) were less likely to achieve remission or recovery. Prescription of typical antipsychotics and prescription of antidepressants at the first visit of the long-term treatment phase (12weeks) were independent predictors of lower remission and recovery rates. In conclusion, functional recovery occurred in approximately half of those who achieved remission. Impairment of work and social functioning was consistently associated with lower remission and recovery rates.

Assessment of medication adherence in a cohort of patients with bipolar disorder

INTRODUCTION

This study aimed to identify factors associated with medication adherence in bipolar disorder (BPD) patients.

METHODS

EMBLEM is a 2-year, prospective, observational study on the outcomes of BPD patients initiating or changing treatment for a manic/mixed episode. Data were collected at baseline, during the first 12 weeks of treatment (acute phase) and up to 24 months of follow-up (maintenance phase). Adherence was assessed by investigators at every visit. Repeated measures logistic regression analyses identified variables associated with adherence.

RESULTS

Of 1,831 patients included in the analysis, 76.6% were adherent and 23.4% were non-adherent with their BPD medication during the maintenance phase. Patients were more likely to be adherent if they had insight into their illness at week 12. Patients were less likely to be adherent if they had cannabis abuse/dependence during the acute phase, work impairment or higher CGI hallucinations/delusions at baseline

DISCUSSION

Psychotic symptoms, poor insight, cannabis abuse/dependence and work impairment are negatively related to medication adherence during maintenance therapy of bipolar disorder. Patients with these characteristics may need a different therapeutic approach.