Testing the hypothesis that psychotic illness begins when subthreshold hallucinations combine with delusional ideation

OBJECTIVE

While hallucinations and delusions are often considered as a single class of 'positive symptoms', little is known about their dynamic cooccurrence in relation to clinical outcome in non-help-seeking people.

METHOD

The Netherlands Mental Health and Incidence Study (NEMESIS-1) is a longitudinal study of mental disorders (n = 7075) with three measurements over a 3-year period. Risk factors, persistence of psychotic experiences, and clinical outcome were analyzed for groups with: i) no psychotic experiences, ii) only delusions, iii) only hallucinations, and iv) both delusions and hallucinations.

RESULTS

Hallucinations and delusions occurred together more often (T0, 3.5%; T1, 1.0%; T2, 0.9%) than that predicted by chance (T0, 1.0%; T1, 0.1%; T2, 0.04%). The group with both symptoms showed more 'first-rank'-like delusions compared with the group with only delusions. Having both hallucinations and delusions, compared to isolated symptoms, was associated more strongly with risk factors, comorbid affective symptoms, negative symptoms, and persistence of psychotic experiences. This was not an artifact of having more symptoms in general.

CONCLUSION

Experiencing both delusions and hallucinations is an indicator of greater etiological load resulting in more clinical outcome. A specific 'hallucinatory-delusional state' may represent an early phase of exacerbation of aberrant attribution of salience, increasing risk for clinical outcome.

Course trajectories of unipolar depressive disorders identified by latent class growth analysis

BACKGROUND

Current classification of unipolar depression reflects the idea that prognosis is essential. However, do DSM categories of major depressive disorder (MDD), dysthymic disorder (Dysth) and double depression (DD=MDD+Dysth) indeed adequately represent clinically relevant course trajectories of unipolar depression? Our aim was to test DSM categories (MDD, Dysth and DD) in comparison with empirically derived prognostic categories, using a prospectively followed cohort of depressed patients.

METHOD

A large sample (n=804) of out-patients with unipolar depression were derived from a prospective cohort study, the Netherlands Study of Depression and Anxiety (NESDA). Using latent class growth analysis (LCGA), empirically derived 2-year course trajectories were constructed. These were compared with DSM diagnoses and a wider set of putative predictors for class membership.

RESULTS

Five course trajectories were identified, ranging from mild severity and rapid remission to high severity and chronic course trajectory. Contrary to expectations, more than 50% of Dysth and DD were allocated to classes with favorable course trajectories, suggesting that current DSM categories do not adequately represent course trajectories. The class with the most favorable course trajectory differed on several characteristics from other classes (younger age, more females, less childhood adversity, less somatic illnesses, lower neuroticism, higher extraversion). Older age, earlier age of onset and lower extraversion predicted poorest course trajectory.

CONCLUSIONS

MDD, Dysth and DD did not adequately match empirically derived course trajectories for unipolar depression. For the future classification of unipolar depression, it may be wise to retain the larger, heterogeneous category of unipolar depression, adopting cross-cutting dimensions of severity and duration to further characterize patients.

Endovascular treatment options for chronic venous obstructions

Chronic venous obstructions have been treated by means of bypass surgery, until, in recent decades, it was surpassed by endovascular treatment options. Although techniques may differ, some issues should be universal. It is recommended that patients are treated under general anaesthesia. Secondly, obstructive lesions should be fully stented. Finally, self-expandable stents should mainly be used. Recanalization and stenting proved safe and efficient with excellent mid- and long-term patency rates. However, failures due to re-occlusion do occur and are basically related to imperfect stent design and/or suboptimal inflow. Therefore, the main focus should be on the development of optimal stent configuration, that is, sufficient length, highest possible radial force and flexibility. Moreover, the significance of endophlebectomy with or without creation of an arteriovenous fistula should be established.

[Prevalence of mental disorders, and trends from 1996 to 2009. Results from NEMESIS-2]

BACKGROUND

Little is known about the prevalence and trends of mental disorders in the Dutch population.

AIM

To present the prevalences of lifetime and 12-month DSM-IV mood disorders, anxiety disorders, and substance use disorders and impulse-control disorders reported in NEMESIS-2 (Netherlands Mental Health Survey and Incidence Study), and to compare the 12-month prevalence of mood disorders, anxiety disorders and substance use disorders with estimates from the first study (NEMESIS-1).

METHOD

Between November 2007 and July 2009, face-to-face interviews were conducted among 6646 subjects aged 18-64 by means of the Composite International Diagnostic Interview 3.0. Trends in mental disorders were examined with these data and NEMESIS-1 data from 1996 (n = 7076).

RESULTS

The lifetime prevalence in NEMESIS-2 was 20.2% for mood disorder, 19.6% for anxiety disorder, 19.1% for substance use disorder and 9.2% for impulse-control or behaviour disorder. For the 12-month disorders, the prevalences were 6.1%, 10.1%, 5.6% and 2.1%, respectively. Between 1996 and 2007-2009, there was no change in the 12-month prevalence of anxiety disorder and substance use disorder. The 12-month prevalence of mood disorder decreased slightly but was no longer significant after differences in the sociodemographic variables between the two studies had been taken into account.

CONCLUSION

This study shows that in the Netherlands mental disorders occur fairly frequently. Over about a decade, no clear change was found in the mental health status of the population.

Replication in two independent population-based samples that childhood maltreatment and cannabis use synergistically impact on psychosis risk

BACKGROUND

There may be biological plausibility to the notion that cannabis use and childhood trauma or maltreatment synergistically increase the risk for later development of psychotic symptoms. To replicate and further investigate this issue, prospective data from two independent population-based studies, the Greek National Perinatal Study (n=1636) and The Netherlands Mental Health Survey and Incidence Study (NEMESIS) (n=4842), were analyzed.

METHOD

Two different data sets on cannabis use and childhood maltreatment were used. In a large Greek population-based cohort study, data on cannabis use at age 19 years and childhood maltreatment at 7 years were assessed. In addition, psychotic symptoms were assessed using the Community Assessment of Psychic Experiences (CAPE). In NEMESIS, the Composite International Diagnostic Interview (CIDI) was used to assess psychotic symptoms at three different time points along with childhood maltreatment and lifetime cannabis use.

RESULTS

A significant adjusted interaction between childhood maltreatment and later cannabis use was evident in both samples, indicating that the psychosis-inducing effects of cannabis were stronger in individuals exposed to earlier sexual or physical mistreatment [Greek National Perinatal Study: test for interaction F(2, 1627)=4.18, p=0.02; NEMESIS: test for interaction χ2(3)=8.08, p=0.04].

CONCLUSIONS

Cross-sensitivity between childhood maltreatment and cannabis use may exist in pathways that shape the risk for expression of positive psychotic symptoms.

Superfluid vortex front at T→0: decoupling from the reference frame

Steady-state turbulent motion is created in superfluid (3)He-B at low temperatures in the form of a turbulent vortex front, which moves axially along a rotating cylindrical container of (3)He-B and replaces vortex-free flow with vortex lines at constant density. We present the first measurements on the thermal signal from dissipation as a function of time, recorded at 0.2T(c) during the front motion, which is monitored using NMR techniques. Both the measurements and the numerical calculations of the vortex dynamics show that at low temperatures the density of the propagating vortices falls well below the equilibrium value, i.e., the superfluid rotates at a smaller angular velocity than the container. This is the first evidence for the decoupling of the superfluid from the container reference frame in the zero-temperature limit.

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.

The 7-year course of depression and anxiety in the general population

OBJECTIVE

Insight into the long-term course of depression and anxiety.

METHOD

Data were derived from Netherlands Mental Health Survey and Incidence Study/Netherlands Study of Depression and Anxiety, epidemiologic surveys in the adult population in the Netherlands. Three hundred and three respondents with depressive and/or anxiety Composite International Diagnostic Interview (CIDI) disorder were interviewed, examining the 7-year course of depression (n = 141), anxiety (n = 102) and the comorbid state (n = 60) and possible prognostic factors. Outcomes were CIDI diagnostic status after 7 years and percentage of time during 7 years with depressive and/or anxiety symptoms, retrospectively assessed by the Life Chart Interview (LCI).

RESULTS

After 7 years, 60.7% of the subjects were free from a 12-month CIDI depression or anxiety diagnosis. The odds were higher for subjects with anxiety and comorbidity compared to subjects with depression. Low physical functioning and high neuroticism predicted the presence of a diagnosis after 7 years. During 7-year follow-up, 37.3% of the subjects were free from depressive and anxiety symptoms according to the LCI, 51.8% had symptoms <50% of the time, and 10.9%≥50% of the time. (Comorbid) anxiety resulted in a poorer course. High neuroticism and childhood adversity predicted more follow-up time with symptoms.

CONCLUSION

Course trajectories were more favorable than expected, although comorbidity resulted in poorer course. Neuroticism, physical functioning, and childhood adversity predicted an unfavorable course.

Can obsessions drive you mad? Longitudinal evidence that obsessive-compulsive symptoms worsen the outcome of early psychotic experiences

OBJECTIVE

Although there is substantial comorbidity between psychotic disorder and obsessive-compulsive disorder (OCD), little is known about how these clinical phenotypes, and their subclinical extended phenotypes, covary and impact on each other over time. This study examined cross-sectional and longitudinal associations between both (extended) phenotypes in the general population.

METHOD

Data were obtained from the three waves of the NEMESIS-study. A representative population sample of 7076 participants were assessed using the composite international diagnostic interview (CIDI) at baseline (T(0)), 1 year later at T(1) and again 2 years later at T(2).

RESULTS

At T(0), a lifetime diagnosis of psychotic disorder was present in 1.5% of the entire sample, in 11.5% of the people with any OC symptom and in 23.0% of individuals diagnosed with OCD. OC symptoms at T(0) predicted incident psychotic symptoms at T(2). Similarly, T(0) psychotic symptoms predicted T(2) OC symptoms. The likelihood of persistence of psychotic symptoms or transition to psychotic disorder was higher if early psychosis was accompanied by co-occurring OC symptoms, but not the other way around.

CONCLUSION

OCD and the psychosis phenotype cluster together and predict each other at (sub)clinical level. The co-occurrence of subclinical OC and psychosis may facilitate the formation of a more 'toxic' form of persistent psychosis.

[Positive life events and mood disorders: longitudinal evidence for a chaotic life-course hypothesis]

BACKGROUND

In psychiatric research it is often assumed that detrimental effects of negative life events on mental health can be buffered by a number of positive life events. However, there is no convincing empirical evidence that this assumption is correct; it can even be argued that positive life events act as additional stressors rather than as buffers, leading to a continuation of a chaotic life course and an increase in the risk of affective disorders.

AIM

To find out whether positive life events were associated with a higher risk of the occurrence of mood disorders and whether such an association could be explained by a number of negative life events that individuals had experienced.

METHOD

We used data from 4,796 adults, aged 18-64, collected at two measurement moments (i.e. 1997 and 1999) of NEMESIS, a Dutch prospective-epidemiological study. As a basis for our measurements we used dsm-iii-r diagnoses of major depressive disorders and dysthymia and the Life Events and Difficulties Schedules LEDS.

RESULTS

A multivariate (MPlus) path analysis demonstrated that positive life events were not, in themselves, significantly predictive of affective disorders. Positive life events were only related to the risk of mood disorders when they co-occurred with a high number of negative life events.

CONCLUSIONS

In accordance with a chaotic life-course hypothesis, positive events were not found to buffer the detrimental impact of negative life events, but when they are part of an erratic course of life they can pose an extra threat to an individual’s mental health.

Stability and dissipation of laminar vortex flow in superfluid 3He-B

A central question in the dynamics of vortex lines in superfluids is dissipation on approaching the zero temperature limit T→0. From both NMR measurements and vortex filament calculations, we find that vortex flow remains laminar up to large Reynolds numbers Re{α}∼10(3) in a cylinder filled with 3He-B. This is different from viscous fluids and superfluid 4He, where the corresponding responses are turbulent. In 3He-B, laminar vortex flow is possible in the bulk volume even in the presence of sizable perturbations from axial symmetry to below 0.2Tc. The laminar flow displays no excess dissipation beyond mutual friction, which vanishes in the T→0 limit, in contrast with turbulent vortex motion where dissipation has been earlier measured to approach a large T-independent value at T≲0.2Tc.

Work functioning in persons with depressive and anxiety disorders: the role of specific psychopathological characteristics

BACKGROUND

Depressive and anxiety disorders affect work functioning and cause high labour costs.

AIMS

To examine and compare psychopathological characteristics of depressive and anxiety disorders in their effect on work functioning.

METHOD

In 1876 working participants of the Netherlands Study of Depression and Anxiety (NESDA) associations of presence, severity, comorbidity, duration and type of DSM-IV anxiety and depressive disorders with both absenteeism (<2 weeks and >2 weeks) and work performance (reduced and impaired) were assessed.

RESULTS

People with current depressive disorders had 7.10 times greater odds for the risk of >2 weeks work-absence and 5.67 greater odds for the risk of impaired work performance, while persons with current anxiety disorders had 1.84 and 2.13 greater odds for the risk of >2 weeks absence and impaired work performance, respectively. Even when persons were recovered from depressive and anxiety disorders, they still had a higher risk of poor work functioning. Persons with comorbidity, chronic depressive disorder, a generalized anxiety disorder, and more severity of both anxiety and depressive disorder had higher odds for the risk of absenteeism and decreased work performance.

CONCLUSION

Anxiety disorders have significant negative impact on work functioning, although smaller than the effect of depressive disorders. Comorbidity, severity, type and duration of the disorder, differentiate the risk of poor work functioning.

Obsessive-compulsive symptom dimensions in the general population: results from an epidemiological study in six European countries

BACKGROUND

The prevalence of obsessive-compulsive symptom dimensions and their sociodemographic and psychopathological correlates at the population level are unknown.

METHOD

Obsessive-compulsive symptom dimensions and mental disorders were assessed with the Composite International Diagnostic Interview 3.0 in a random subsample (n=2804) of individuals participating in a cross-sectional survey of the adult general population of six European countries.

RESULTS

The lifetime prevalence of any obsessive-compulsive symptom dimension was 13%. Harm/Checking was the most prevalent dimension (8%) followed by Somatic obsessions (5%) and Symmetry/Ordering (3%). Females were more likely to have symptoms in Contamination/Cleaning (OR=3, 95%CI=1.06-8.51) and Somatic obsessions (OR=1.88, 95%CI=1.05-3.37). All symptom dimensions were associated with an increased risk of most mental (but not physical) disorders. There were some differences in prevalence between countries.

LIMITATIONS

The interference associated with each symptom dimension could not be assessed. Few direct data are available on the validity of the CIDI to assess obsessive-compulsive symptom dimensions.

CONCLUSIONS

Obsessive-compulsive symptom dimensions are relatively frequent in the general population. Their sociodemographic and psychopathological correlates may be slightly different in clinical and community samples. They are associated with an increased risk of most mental disorders.

Subthreshold symptoms and obsessive-compulsive disorder: evaluating the diagnostic threshold

BACKGROUND

In this study we compared subjects with obsessive and/or compulsive symptoms who did not meet all criteria for obsessive-compulsive disorder (OCD) (subthreshold subjects) to subjects with full-blown OCD and also to subjects without obsessions or compulsions.

METHOD

The data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a large representative sample of the general Dutch population (n=7076). Using the Composite International Diagnostic Interview, Version 1.1 (CIDI 1.1), three groups were distinguished: subjects without lifetime obsessions or compulsions (94.2%), subthreshold subjects (4.9%) and subjects with full-blown OCD according to DSM-III-R (0.9%). These three groups were compared on various items, including psychological vulnerability, health and functional status, psychiatric co-morbidity and seeking treatment.

RESULTS

Subthreshold and OCD subjects had similar scores on the majority of the items measured. Thus, there was little difference between subthreshold and OCD subjects in health, functional status, psychological vulnerability and psychiatric co-morbidity. However, OCD and subthreshold subjects scored worse on most of these items when compared to the controls without obsessions or compulsions.

CONCLUSION

Having obsessions and compulsions is associated with substantial suffering and disability. Most subjects with obsessions and/or compulsions are not diagnosed with OCD according to the DSM-III-R criteria although these subjects generally display similar consequences to full-blown OCD subjects. We recommend that these subthreshold cases receive special attention in the development of DSM-V.

Are attitudes towards mental health help-seeking associated with service use? Results from the European Study of Epidemiology of Mental Disorders

OBJECTIVE

To investigate the prevailing attitudes towards mental health help-seeking in Europe, their correlates, and whether these attitudes are associated with actual service use for mental health problems.

METHOD

Data were derived from the European Study of Epidemiology of Mental Disorders, a survey representative of the adult population of six countries: Belgium, France, Germany, Italy, the Netherlands and Spain (n = 8,796). The World Mental Health Composite International Diagnostic Interview was used to assess attitudes and DSM-IV diagnoses. The attitudes referred to beliefs that the respondents would seek professional help when faced with a serious emotional problem, would feel comfortable talking about personal problems with a professional, would not be embarrassed if friends knew about the professional help, and respondents' perceived effectiveness of mental health care.

RESULTS

Almost a third of the respondents held the view that professional care was worse than or equal to no help when faced with serious emotional problems. Female gender, being younger than 65 years of age, high income, living in Spain or Italy, presence of mood disorder and previous service use were associated with at least two of the four assessed attitudes towards mental health help-seeking. All four attitudes were significantly associated with mental health care use, also after adjustment for previous service use.

CONCLUSION

The low perceived effectiveness of professional care calls for serious action aiming to improve the visibility and credibility of the mental health care sector.

The 2-year prognosis of panic episodes in the general population

BACKGROUND

Panic disorder (PD) is generally considered to be a chronic or intermittent disorder. This view may be biased because of a lack of general population studies investigating panic from the onset of an episode onwards. Data regarding the course of subthreshold panic disorder (sub-PD) and predictors of its course are lacking.

METHOD

Using data from a large community-based survey, the Netherlands Mental Health and Incidence Study (NEMESIS), that retrospectively assessed the 2-year course of panic with a Life Chart Interview (LCI), this study investigated remission, chronicity and recurrence in subjects with new episodes of PD or sub-PD. Predictor variables of remission consisted of sociodemographics, psychobiological, environmental, psychiatric and panic-related factors.

RESULTS

In PD, remission of panic attacks occurred in 64.5% of subjects, mean time to remission was 5.7 months, and the remission rate was 5.8/100 person-months. In 43.3% of subjects panic was still present after 1 year. Recurrence of panic attacks occurred in 21.4% of those with PD who had achieved remission and for whom sufficient follow-up time was available. In general, the course of sub-PD was more favourable. Predictors of remission were female gender, the absence of ongoing difficulties, subthreshold panic and a low initial frequency of attacks.

CONCLUSIONS

These results suggest that the course of panic is diverse in the general population, thereby underlining the need for accurate predictors. This requires further research including biological data and additional psychological data. In addition, given the large proportion with a relapse, relapse prevention should be part of any treatment programme.

[Attitudes to the seeking of psychiatric help from mental health care professionals and actually seeking help: differences in Europe]

BACKGROUND

Little is known about attitudes to seeking help from mental health care professionals.

AIM

To investigate these attitudes and their correlates, and find out whether these attitudes are associated with the use of care services.

METHOD

Data were derived from the European Study of Epidemiology of Mental Disorders, a survey that is representative of the adult population of six countries (n = 8,796).

RESULTS

Almost a third of respondents were of the opinion that professional help was worse than or equivalent to no help at all, in relation to serious psychiatric problems. Females, respondents under the age of 65, with a higher income, living in Spain or Italy, with a mood disorder, and those who had previously sought mental health care, more often stated that they would seek professional help if beset by a serious mental health problem. All these groups, except for the younger than 65, also reported more often that they would feel comfortable discussing mental health problems with a professional or that they were receiving this kind of help. All these attitudes were associated with an increased chance that persons would use professional help if beset by mental health problems.

CONCLUSION

Definite steps need to be taken to increase the visibility and credibility of the mental health services.

Pain and depression in older people: comorbidity and patterns of help seeking

BACKGROUND

Chronic pain and mood disorders are common in older people. Their relationship however remains unclear. Only a few studies have investigated the role of pain in mental health service use and received psychopharmacological treatment.

METHODS

Cross-sectional study of the 65+ subsample from the European Study on the Epidemiology of Mental Disorders (ESEMeD). 4401 non-institutionalized individuals were interviewed using the third version of the Composite International Diagnostic Interview (CIDI-3.0).

RESULTS

Painful physical symptoms (PPS) were more likely in people with a 12-month major depressive episode (MDE) than in those without (OR=2.0). Help seeking for emotional problems was uncommon, but PPS were a significant predictor of help-seeking (OR=1.7). Respondents with MDE more frequently used benzodiazepines than antidepressants. The presence of PPS in respondents without depression resulted in a significant increase in the use of psychotropic medication.

CONCLUSIONS

PPS were strongly and independently associated with major depressive disorder. Their presence had an influence on help seeking behavior and use of psychotropic medication.

LIMITATIONS

The cross-sectional nature of this study does not allow determination of direction of causality.

N-acetylcysteine prevents neointima formation in experimental venous bypass grafts

Background

Neointima formation, mainly characterized by smooth muscle cell proliferation, is an important cause of venous bypass graft failure. The therapeutic potential of the antioxidant N-acetylcysteine (NAC) to attenuate smooth muscle cell proliferation and neointima formation was examined in vivo. The effects of NAC on hyperoxia-induced venous smooth muscle cell (VSMC) cytokine production and proliferation were addressed in vitro.

Methods

Rats underwent autologous epigastric vein-to-femoral artery interposition grafting. Fourteen rats received oral NAC, and a similar control group received saline. Histomorphometric analysis was performed after 7 days or 3 weeks. Cytokine analysis and cell proliferation assay were performed in cultured human VSMCs after hyperoxic or normoxic exposure and NAC administration.

Results

NAC-treated rats displayed a threefold reduction in neointimal area, a sixfold reduction in stenosis rate, and a twofold reduction in VSMC proliferation after vein graft surgery. Incubation of VSMCs in 70 per cent oxygen stimulated the release of mitogenic inflammatory cytokines interleukin (IL) 6 and IL-8. Cytokine-rich medium from these VSMCs induced proliferation of normoxic VSMCs. NAC inhibited hyperoxia-induced cytokine release and VSMC proliferation.

Conclusion

NAC attenuated neointima formation and vein graft stenosis by reducing VSMC proliferation in vivo, and prevented hyperoxia-induced cytokine production and VSMC proliferation in vitro.

Implications of modifying the duration requirement of generalized anxiety disorder in developed and developing countries

BACKGROUND

A number of western studies have suggested that the 6-month duration requirement of generalized anxiety disorder (GAD) does not represent a critical threshold in terms of onset, course, or risk factors of the disorder. No study has examined the consequences of modifying the duration requirement across a wide range of correlates in both developed and developing countries.

METHOD

Population surveys were carried out in seven developing and 10 developed countries using the WHO Composite International Diagnostic Interview (total sample=85,052). Prevalence and correlates of GAD were compared across mutually exclusive GAD subgroups defined by different minimum duration criteria.

RESULTS

Lifetime prevalence estimates for GAD lasting 1 month, 3 months, 6 months and 12 months were 7.5%, 5.2%, 4.1% and 3.0% for developed countries and 2.7%, 1.8%, 1.5% and 1.2% for developing countries, respectively. There was little difference between GAD of 6 months' duration and GAD of shorter durations (1-2 months, 3-5 months) in age of onset, symptom severity or persistence, co-morbidity or impairment. GAD lasting >or=12 months was the most severe, persistently symptomatic and impaired subgroup.

CONCLUSIONS

In both developed and developing countries, the clinical profile of GAD is similar regardless of duration. The DSM-IV 6-month duration criterion excludes a large number of individuals who present with shorter generalized anxiety episodes which may be recurrent, impairing and contributory to treatment-seeking. Future iterations of the DSM and ICD should consider modifying the 6-month duration criterion so as to better capture the diversity of clinically salient anxiety presentations.

Psychological treatment of social anxiety disorder: a meta-analysis

BACKGROUND

Older meta-analyses of the effects of psychological treatments of social anxiety disorder have found that these treatments have moderate to large effects. However, these earlier meta-analyses also included non-randomized studies, and there are many featured studies in this area which were published after the recent meta-analysis.

METHOD

We conducted a systematic literature search and identified 29 randomized studies examining the effects of psychological treatments, with a total of 1628 subjects. The quality of studies varied. For the analyses, we used the computer program comprehensive meta-analysis (version 2.2.021; Biostat, Englewood, NJ, USA).

RESULTS

The mean effect size on social anxiety measures (47 contrast groups) was 0.70, 0.80 on cognitive measures (26 contrast groups) and 0.70 both on depression (19 contrast groups) and general anxiety measures (16 contrast groups). We found some heterogeneity, so we conducted a series of subgroup analyses for different variables of the studies. Studies with waiting-list control groups had significantly larger effect sizes than studies with placebo and treatment-as-usual control groups. Studies aimed at subjects who met Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for social anxiety disorder had smaller effect sizes than studies in which other inclusion criteria were used.

CONCLUSIONS

This study once more makes it clear that psychological treatments of social anxiety disorder are effective in adults, but that they may be less effective in more severe disorders and in studies in which care-as-usual and placebo control groups are used.

Incidence of social phobia and identification of its risk indicators: a model for prevention

OBJECTIVE

This study seeks to examine the incidence of social phobia in the general population and to establish a number of risk indicators.

METHOD

Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) which is a population based prospective study (n=7076). A sample of adults aged 18-64 years (n=5618) were re-interviewed 1 year later using Composite International Diagnostic Interview (CIDI).

RESULTS

The 12-month incidence of DSM-III-R social phobia was 1.0%. Low education, low mastery, low self-esteem, emotional neglect in childhood and ongoing difficulties were found to be risk indicators. After including other mental disorders as risk indicators in the model, the incidence was found to be more common among those with low mastery, major depression, subthreshold social phobia, emotional neglect, negative life events, and low education.

CONCLUSION

The incidence of social phobia can be predicted relatively well with psychosocial variables and comorbidity.

Familiality of depression in the community; associations with gender and phenotype of major depressive disorder

INTRODUCTION

Although associations between family history and depression have been shown in clinical patients, it is unknown if they also apply to subjects living in the community. The present study considers the relationship between family loading and depression phenotype characteristics in a large community-based sample.

METHOD

In a Dutch representative population sample of 7,076 individuals, lifetime diagnosis of depression was classified according to severity, course and age of onset. A family loading score of depression (FLSD) was computed by taking the proportion of the first-degree relatives for whom a history of depression was reported.

RESULTS

There was a strong association between FLSD and lifetime diagnosis of MDD. Severity, recurrence and early onset of depression were the specific phenotypic characteristics associated with familiality. The effects of FLSD and gender were independent.

CONCLUSION

Associations between family history and risk for depression in the community confirm those reported from clinical-based studies using direct interviewing of relatives. A stronger degree of familiality is associated with specific phenotypic characteristics of depression.

Mediators of the association between depression and role functioning

OBJECTIVE

While the adverse effect of Major Depressive Episode on role functioning is well established, the exact pathways remain unclear.

METHOD

Data from The European Study of the Epidemiology of Mental Disorders, a cross-sectional survey including 21 425 adults from six European countries, were used to assess 12-month depression (Composite International Diagnostic Interview), activity limitations and role functioning in the past 30 days (Disability Assessment Schedule). An a priori model based on the World Health Organization's International Classification of Functioning, Disability and Health was designed and a structural equation model for categorical and ordinal data was used (MPlus) to estimate the extent to which six limitations mediated the association between depression and role functioning.

RESULTS

The unadjusted association between depression and role functioning was strong (0.43; SE = 0.04). In the best-fitting model, only concentration and attention problems and embarrassment mediated a significant amount of association (direct effect dropped to 0.17; SE = 0.10, which was no longer significant).

CONCLUSIONS

Targeting cognition and embarrassment in treatment could help reduce depression-associated role disfunctioning.

Mental disorders and personality traits as determinants of impaired work functioning

BACKGROUND

Both mental disorders and personality characteristics are associated with impaired work functioning, but these determinants have not yet been studied together. The aim of this paper is to examine the impairing effects that mental disorders and personality characteristics (i.e. neuroticism, locus of control and self-esteem) have on work functioning.

METHOD

Data for a representative sample of 3570 working people were derived from the first two waves of the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective cohort study in the Dutch adult population.

RESULTS

Higher neuroticism, more external locus of control and lower self-esteem were each significantly associated with subsequent impairment in work functioning, independently of any effects from mental disorders. Associations between mental disorders and subsequent work impairment disappeared once personality traits were taken into account. Personality traits did not moderate the relationships between mental disorders and work functioning.

CONCLUSIONS

Working people with vulnerable personalities have a greater risk of impaired work functioning, independent of the risk from any mental disorder they may have.

Age patterns in the prevalence of DSM-IV depressive/anxiety disorders with and without physical co-morbidity

BACKGROUND

Physical morbidity is a potent risk factor for depression onset and clearly increases with age, yet prior research has often found depressive disorders to decrease with age. This study tests the possibility that the relationship between age and mental disorders differs as a function of physical co-morbidity.

METHOD

Eighteen general population surveys were carried out among household-residing adults as part of the World Mental Health (WMH) surveys initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). The effect of age was estimated for 12-month depressive and/or anxiety disorders with and without physical or pain co-morbidity, and for physical and/or pain conditions without mental co-morbidity.

RESULTS

Depressive and anxiety disorders decreased with age, a result that cannot be explained by organic exclusion criteria. No significant difference was found in the relationship between mental disorders and age as a function of physical/pain co-morbidity. The majority of older persons have chronic physical or pain conditions without co-morbid mental disorders; by contrast, the majority of those with mental disorders have physical/pain co-morbidity, particularly among the older age groups.

CONCLUSIONS

CIDI-diagnosed depressive and anxiety disorders in the general population decrease with age, despite greatly increasing physical morbidity with age. Physical morbidity among persons with mental disorder is the norm, particularly in older populations. Health professionals, including mental health professionals, need to address barriers to the management of physical co-morbidity among those with mental disorders.

Mental disorders among persons with arthritis: results from the World Mental Health Surveys

BACKGROUND

Prior studies in the USA have reported higher rates of mental disorders among persons with arthritis but no cross-national studies have been conducted. In this study the prevalence of specific mental disorders among persons with arthritis was estimated and their association with arthritis across diverse countries assessed.

METHOD

The study was a series of cross-sectional population sample surveys. Eighteen population surveys of household-residing adults were carried out in 17 countries in different regions of the world. Most were carried out between 2001 and 2002, but others were completed as late as 2007. Mental disorders were assessed with the World Health Organization (WHO) World Mental Health-Composite International Diagnostic Interview (WMH-CIDI). Arthritis was ascertained by self-report. The association of anxiety disorders, mood disorders and alcohol use disorders with arthritis was assessed, controlling for age and sex. Prevalence rates for specific mental disorders among persons with and without arthritis were calculated and odds ratios (ORs) with 95% confidence intervals were used to estimate the association.

RESULTS

After adjusting for age and sex, specific mood and anxiety disorders occurred among persons with arthritis at higher rates than among persons without arthritis. Alcohol abuse/dependence showed a weaker and less consistent association with arthritis. The pooled estimates of the age- and sex-adjusted ORs were about 1.9 for mood disorders and for anxiety disorders and about 1.5 for alcohol abuse/dependence among persons with versus without arthritis. The pattern of association between specific mood and anxiety disorders and arthritis was similar across countries.

CONCLUSIONS

Mood and anxiety disorders occur with greater frequency among persons with arthritis than those without arthritis across diverse countries. The strength of association of specific mood and anxiety disorders with arthritis was generally consistent across disorders and across countries.

Familiality of major depressive disorder and gender differences in comorbidity

OBJECTIVE

Gender differences exist in the prevalence and psychiatric comorbidity of major depressive disorder (MDD). This study investigates whether familiality of MDD contributes to observed gender differences in comorbidity.

METHOD

Familial (f-MDD) and non-familial (nf-MDD) MDD cases from a population sample were assessed for comorbid dysthymia, anxiety disorders and alcohol-related disorders using the Composite International Diagnostic Interview (CIDI). Logistic regression analyses were performed to examine the effect of f-MDD on gender differences in comorbidity, adjusted for confounders.

RESULTS

Women with f-MDD reported significantly more comorbid dysthymia and generalized anxiety disorder (GAD) than their male counterparts; women with nf-MDD reported significantly more comorbid simple phobias and agoraphobia than their male counterparts. Gender differences in comorbid panic disorder and alcohol-related disorders occurred independently of the familial load. Adjustment for age of onset, severity and recurrence of MDD did not change these results.

CONCLUSION

Models to explain comorbidity patterns of MDD differ by gender. Familiality of MDD should be taken into account.

The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative

OBJECTIVES

To estimate the prevalence and workplace consequences of adult attention-deficit/hyperactivity disorder (ADHD).

METHODS

An ADHD screen was administered to 18-44-year-old respondents in 10 national surveys in the WHO World Mental Health (WMH) Survey Initiative (n = 7075 in paid or self-employment; response rate 45.9-87.7% across countries). Blinded clinical reappraisal interviews were administered in the USA to calibrate the screen. Days out of role were measured using the WHO Disability Assessment Schedule (WHO-DAS). Questions were also asked about ADHD treatment.

RESULTS

An average of 3.5% of workers in the 10 countries were estimated to meet DSM-IV criteria for adult ADHD (inter-quartile range: 1.3-4.9%). ADHD was more common among males than females and less common among professionals than other workers. ADHD was associated with a statistically significant 22.1 annual days of excess lost role performance compared to otherwise similar respondents without ADHD. No difference in the magnitude of this effect was found by occupation, education, age, gender or partner status. This effect was most pronounced in Colombia, Italy, Lebanon and the USA. Although only a small minority of workers with ADHD ever received treatment for this condition, higher proportions were treated for comorbid mental/substance disorders.

CONCLUSIONS

ADHD is a relatively common condition among working people in the countries studied and is associated with high work impairment in these countries. This impairment, in conjunction with the low treatment rate and the availability of cost-effective therapies, suggests that ADHD would be a good candidate for targeted workplace screening and treatment programs.

Work and family roles and the association with depressive and anxiety disorders: differences between men and women

BACKGROUND

This study examined the associations of (combinations of) social roles (employee, partner and parent) with the prevalence of anxiety and depressive disorders and whether social roles contribute to the explanation of the female preponderance in these disorders.

METHOD

This was a cross-sectional study using data from 3857 respondents aged 25-55 of NEMESIS (Netherlands Mental Health Survey and Incidence Study). Depression and anxiety disorders were measured using the CIDI 1.1.

RESULTS

The OR of depressive disorders and anxiety disorders among women compared to men was 1.71 (95% CI: 1.40-2.10). Among both genders, the partner role was associated with decreased risks of depression and anxiety and the parent role was not. The work role was a significant protective factor of depression and anxiety for men (OR=0.40; 95% CI: 0.24-0.69) but not for women (OR=0.86; 95% CI: 0.66-1.12). The effect of the work role was positive among women without children (OR=0.28; 95% CI: 0.14-0.54), but not among those with children (OR=1.01; 95% CI: 0.75-1.35). The gender risk for depression and anxiety decreased significantly by adding the work role variables into the model.

LIMITATIONS

This was a cross-sectional study. This study did not give insight into the quality of social roles.

CONCLUSION

The work role contributed to the explanation of the female preponderance in depression and anxiety disorders. Considering depression and anxiety among women, a focus upon quality and meaning of the work role, and barriers in combining the work role and parent role may be essential.

Quantum turbulence in a propagating superfluid vortex front

We present experimental, numerical, and theoretical studies of a vortex front propagating into a region of vortex-free flow of rotating superfluid 3He-B. We show that the nature of the front changes from laminar through quasiclassical turbulent to quantum turbulent with decreasing temperature. Our experiment provides the first direct measurement of the dissipation rate in turbulent vortex dynamics of 3He-B and demonstrates that the dissipation becomes mutual-friction independent with decreasing temperature, and it is strongly suppressed when the Kelvin-wave cascade on vortex lines is predicted to be involved in the turbulent energy transfer to smaller length scales.

Depression-anxiety relationships with chronic physical conditions: results from the World Mental Health Surveys

BACKGROUND

Prior research on the association between affective disorders and physical conditions has been carried out in developed countries, usually in clinical populations, on a limited range of mental disorders and physical conditions, and has seldom taken into account the comorbidity between depressive and anxiety disorders.

METHODS

Eighteen general population surveys were carried out among adults in 17 countries as part of the World Mental Health Surveys initiative (N=42, 249). DSM-IV depressive and anxiety disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). Chronic physical conditions were ascertained via a standard checklist. The relationship between mental disorders and physical conditions was assessed by considering depressive and anxiety disorders independently (depression without anxiety; anxiety without depression) and conjointly (depression plus anxiety).

RESULTS

All physical conditions were significantly associated with depressive and/or anxiety disorders but there was variation in the strength of association (ORs 1.2-4.5). Non-comorbid depressive and anxiety disorders were associated in equal degree with physical conditions. Comorbid depressive-anxiety disorder was more strongly associated with several physical conditions than were single mental disorders.

LIMITATIONS

Physical conditions were ascertained via self report, though for a number of conditions this was self-report of diagnosis by a physician.

CONCLUSIONS

Given the prevalence and clinical consequences of the co-occurrence of mental and physical disorders, attention to their comorbidity should remain a clinical and research priority.

Risk factors for suicidality in Europe: results from the ESEMED study

BACKGROUND

Precise knowledge of the epidemiology of suicidality provides necessary information for designing prevention programs. The aims of the present study were to investigate the prevalence and correlates of suicidal ideas and attempts in the general population of Europe.

METHODS

The European Study on the Epidemiology of Mental Disorders (ESEMED) is a cross-sectional household survey carried out in a probability representative sample of non-institutionalised adults (aged 18 years or older) of six European countries (Belgium, France, Germany, Italy, the Netherlands and Spain). The Composite International Diagnostic Interview (CIDI 3.0) was administered to 21,425 individuals.

RESULTS

Lifetime prevalence of suicidal ideation was 7.8% and of suicidal attempts 1.3%. Being women, younger and divorced or widowed were associated with a higher prevalence of suicide ideation and attempts. Psychiatric diagnoses were strongly related to suicidality. Among them, major depressive episode (Rate ratio 2.9 for lifetime ideas and 4.8 for lifetime attempts), dysthymia (RR 2.0 and 1.6), GAD (RR 1.8 and 2.3 for lifetime), PTSD (RR 1.9 and 2.0) and alcohol dependence (RR 1.7 and 2.5) were the most important. Population attributable risks for lifetime suicidal attempt was 28% for major depression.

LIMITATIONS

Information about suicidal ideas and attempts was self reported, psychiatric diagnoses were made using fully structured lay interviews rather than clinician-administered interviews.

CONCLUSIONS

In spite of meaningful country variation in prevalence, risk factors for suicidality are consistent in the European countries. Population prevention programmes should focus on early diagnosis and treatment of major depression and alcohol abuse and in those individuals with recent appearance of suicidal ideas.

Economic costs of minor depression: a population-based study

OBJECTIVE

Although the clinical relevance of minor depression has been demonstrated in many studies, the economic costs are not well explored. In this study, we examine the economic costs of minor depression.

METHOD

In a large-scale, population-based study in the Netherlands (n = 5504) the costs of minor depression were compared with the costs of major depression and dysthymia. Excess costs, i.e. the costs of a disorder over and above the costs attributable to other illnesses, were estimated with help of regression analysis. The direct medical costs, the direct non-medical costs and the indirect non-medical costs were calculated. The year 2003 was used as the reference year.

RESULTS

The annual per capita excess costs of minor depression were US$ 2141 (95% CI = 753-3529) higher than the base rate costs of US$ 1023, while the costs of major depression were US$ 3313 (95% CI = 1234-5390) higher than the base rate. The costs of minor depression per 1 million inhabitants were 160 million dollars per year, which is somewhat less than the costs of major depression (192 million dollars per year).

CONCLUSION

The economic costs associated with minor depression are considerable and approach those of major depression.

The persistence of depression score

OBJECTIVE

To construct a score that allows prediction of major depressive episode (MDE) persistence in individuals with MDE using determinants of persistence identified in previous research.

METHOD

Data were derived from 250 subjects from the general population with new MDE according to DSM-III-R. These subjects were recruited from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), using the Composite International Diagnostic Interview. Determinants for persistence were transformed into a practical risk score using proportional hazards models and bootstrapping techniques.

RESULTS

The risk of MDE persistence after 12 months was 23%. The score comprised measures of physical illness, social support, depression severity and recurrency, and duration of previous episodes. With increasing categories of these measures, the predicted risks increased from 7 to 40%.

CONCLUSION

We constructed the Persistence of Depression Score (PDS) showing reasonable performance. The PDS could be of importance in clinical practice to support treatment decisions.

A prospective study of the transition rates of subthreshold (hypo)mania and depression in the general population

BACKGROUND

Previous work suggests that subthreshold depression and subthreshold (hypo)mania are common, although little is known about the prognosis in terms of transition to clinical disorder. This paper presents data on the temporal relationship between subthreshold and clinical expression of mood phenotypes.

METHOD

In a random general population sample of 7076 individuals, symptoms of depression and (hypo)mania were measured with the Composite International Diagnostic Interview (CIDI) at baseline, after 1 year, and 2 years later.

RESULTS

At baseline, the lifetime prevalences of depressive and (hypo)manic symptoms were 17.2% and 1.2% respectively. Predictive values of mood symptoms for a DSM-III-R mood disorder ranged from 14.3% to 50%. (Hypo)manic mood symptoms had much higher predictive values than unipolar manifestations, not only for bipolar disorder but also for major depression.

CONCLUSIONS

The subthreshold expressions of depression and (hypo)mania are prevalent and continuous with more severe clinical states. The cross-prediction of mood symptoms may support a continuum from depressive to (hypo)manic symptoms. The high predictive value of (hypo)manic symptoms for mood disorders suggests that the experience of (hypo)manic symptoms is a stronger indicator of vulnerability for mood dysregulation than the experience of depressive symptoms.

Are apparent associations between parental representations and psychosis risk mediated by early trauma?

OBJECTIVE

It was investigated whether the reported association between representations of parental rearing style and psychosis does not represent a main effect, but instead is a proxy indicator of the true underlying risk factor of early trauma.

METHOD

In a general population sample of 4045 individuals aged 18-64 years, first ever onset of positive psychotic symptoms at 3-year follow-up was assessed using the Composite International Diagnostic Interview and clinical interviews if indicated. Representations of parental rearing style were measured with the Parental Bonding Instrument (PBI).

RESULTS

Lower baseline level of PBI parental care predicted onset of psychotic symptoms 2 years later. However, when trauma was included in the equation, a strong main effect of trauma emerged at the expense of the effect size of PBI low care.

CONCLUSION

The results suggest that associations between representations of parental rearing style and psychosis may be an indicator of the effect of earlier exposure to childhood trauma.

Early trauma may increase the risk for psychotic experiences by impacting on emotional response and perception of control

OBJECTIVE

Exposure to early trauma may increase the risk of dysfunctional responses to anomalous psychotic experiences resulting in psychotic symptom formation.

METHOD

In a three-wave longitudinal general population study, 4045 never-psychotic individuals exposed and non-exposed to trauma before the age of 16 years, according to baseline interview were interviewed for the onset of psychotic experiences 3 years later (T2). In 36 individuals with incident psychosis at T2, assessments were made, for each psychotic experience, of i) the amount of distress associated with and ii) the degree of coping and subjective control over the experience.

RESULTS

In the 16 observations of an incident psychotic experience, in the absence of distress, the baseline rate of early trauma was low (6%), whereas it was much higher in the 21 observations of an incident psychotic experience with distress [43%; odds ratio=10.0, 95% confidence interval (CI): 1.04, 96.3; P=0.046]. Similarly, coping attempts in the context of early trauma was associated with less control (reduction of 2 points on a seven-point scale, 95% CI: -4.0, -0.07).

CONCLUSION

Early experience of trauma may create lasting cognitive and affective vulnerabilities to develop clinical symptoms arising out of early, non-clinical psychotic experiences.

The epidemiology of panic disorder and agoraphobia in Europe

A literature search, in addition to expert survey, was performed to estimate the size and burden of panic disorder in the European Union (EU). Epidemiologic data from EU countries were critically reviewed to determine the consistency of prevalence estimates across studies and to identify the most pressing questions for future research. A comprehensive literature search focusing on epidemiological studies in community and clinical settings in European countries since 1980 was conducted (Medline, Web of Science, Psychinfo). Only studies using established diagnostic instruments on the basis of DSM-III-R or DSM-IV, or ICD-10 were considered. Thirteen studies from a total of 14 countries were identified. Epidemiological findings are relatively consistent across the EU. The 12-month prevalence of panic disorder and agoraphobia without history of panic were estimated to be 1.8% (0.7-2.2) and 1.3% (0.7-2.0) respectively across studies. Rates are twice as high in females and age of first onset for both disorders is in adolescence or early adulthood. In addition to comorbidity with agoraphobia, panic disorder is strongly associated with other anxiety disorders, and a wide range of somatoform, affective and substance use disorders. Even subclinical forms of panic disorder (i.e., panic attacks) are associated with substantial distress, psychiatric comorbidity and functional impairment. In general health primary care settings, there appears to be substantial underdiagnosis and undertreatment of panic disorder. Moreover, panic disorder and agoraphobia are poorly recognized and rarely treated in mental health settings, despite high health care utilization rates and substantial long-term disability.

Comorbidity of physical and mental disorders and the effect on work-loss days

OBJECTIVE

To examine the association between physical and mental disorders and the separate and joint effect of physical and mental disorders on work-loss.

METHOD

Data was derived from the Netherlands Mental Health Survey and Incidence Study. This was a general population study in which 7076 adults, aged between 18 and 64 years, were assessed using the Composite International Diagnostic Interview. Medically treated physical disorders and work-loss were assessed using self-reports.

RESULTS

All physical disorders, except injury caused by accident, were significantly related to anxiety and mood disorders, but only weakly related to substance use disorders. Both physical and mental disorders were significantly related to work-loss; mental disorders more so than physical disorders. Physical-mental (PM) comorbidity leads to a mainly additive increase in work-loss.

CONCLUSION

PM comorbidity is very common in the general population and leads to a greater absenteeism from work than pure disorders that also cause personal and social problems.

Hallucinatory experiences and onset of psychotic disorder: evidence that the risk is mediated by delusion formation

OBJECTIVE

To examine the hypothesis that the risk for onset of psychotic disorder in individuals with self-reported hallucinatory experiences (HE) would be higher in those who developed delusional ideation (DE) than in those who did not.

METHOD

A population sample of 4673 individuals were interviewed with the Composite International Diagnostic Interview at baseline and 1 and 3 years later. At year 3, clinical re-interview took place to identify onset of psychotic disorder.

RESULTS

Given the presence of HEs at baseline, the increase in risk of having the psychosis outcome at year 3 was much higher in those with DE at year 1 than in those without DE (risk difference between individuals with and without DE: 18.72%, 95% CI: 2.22-35.23, chi(2) = 4.94, df = 1, P = 0.026).

CONCLUSION

The results are in line with current psychological theories stating that clinical outcome of psychosis-like experiences is related to the development of secondary beliefs and appraisals.

Supported living in residential homes for the elderly: impact on patients and elder care workers

To enable older people with severe and persistent mental illness to live in the community, the Dutch mental health sector has developed a program for supported living in residential homes for the elderly. It provides for the permanent stationing of mental health workers (MHWs) in elder care facilities to support both the resident patients and the elder care staff. The authors examined associations between the number of MHW staff and the degree to which (1) patients were integrated into the community and (2) elder care workers had developed effective working alliances with their patients. Participants included 110 patients participating in 18 supported living programs in the Netherlands. Community integration was assessed in face-to-face interviews with the patients about their perceived influence over daily life, involvement in social activities, and social network size. The quality of the worker-patient relationship was assessed using the Dutch Working Alliance Questionnaire for Community Care, completed by the elder care worker primarily responsible for each patient. After differentiation of the MHW staff into medically trained and nurse-trained professionals, associations with outcome measures were found only for the nurse-trained staff. The more hours of nurse-trained staff capacity per patient, the more influence perceived by the patients, and the more directiveness shown by the elder care workers in their contacts with patients. The impact of supported living programs in residential homes for the elderly appears to be determined in part by the caseloads of the on-site MHWs.

Is our concept of schizophrenia influenced by Berkson's bias?

BACKGROUND

If both positive and negative dimensions of schizophrenia independently influence need for care, a higher estimate of the comorbidity between these dimensions is expected in clinical samples than would be the case if non-clinical cases were investigated (i.e. Berkson's bias). The present paper investigates whether positive and negative dimensions independently contribute to mental health care use in a general population sample.

METHOD

A prospective cohort study was conducted, in which 7076 individuals were interviewed with the Composite International Diagnostic Interview Schedule at baseline and 1 and 3 years later. Lifetime positive and negative psychotic experiences (PPE, NPE) were assessed at baseline. Mental health care use (MHC) was assessed at baseline, and prospectively 1 and 3 years later.

RESULTS

The rating of MHC was strongly associated with NPE and PPE, both retrospectively and prospectively and the effects of both variables remained strong and significant in the analyses with both variables included.

CONCLUSIONS

These results, therefore, suggest that the concept of schizophrenia, as a unitary entity with high comorbidity between positive and negative dimensions, is in part the result of Berkson's bias.

Childhood abuse as a risk factor for psychotic experiences

OBJECTIVE

To examine the hypothesis that individuals from the general population who report childhood abuse are at increased risk of developing positive psychotic symptoms.

METHOD

Data were derived from a general population sample of 4045 subjects aged 18-64 years. First ever onset of positive psychotic symptoms at 2-year follow-up were assessed using the Composite International Diagnostic Interview and additional clinical interviews if necessary. Childhood abuse was assessed at baseline.

RESULTS

Baseline reported childhood abuse predicted development of positive psychotic symptoms associated with need for care [odds ratio (OR) = 11.5, 95% CI 2.6-51.6]. This association remained after adjustment for demographic variables, reported risk factors and presence of any lifetime psychiatric diagnosis at baseline (OR = 7.3, 95% CI 1.1-49.0).

CONCLUSION

The results suggest that early childhood trauma increases the risk for positive psychotic symptoms. This finding fits well with recent models that suggest that early adversities may lead to psychological and biological changes that increase psychosis vulnerability.

Rapid onset of comorbidity of common mental disorders: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

OBJECTIVE

In a cohort of subjects with no history of psychopathology, we determined a 3-year incidence and the risk factors of comorbid and pure mood, anxiety and substance use disorders.

METHOD

Data were obtained from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a longitudinal community study in which 4796 adults were interviewed in 1996, 1997 and 1999 with the Composite International Diagnostic Interview.

RESULTS

Of 2869 cases at risk, 10.8% developed an incident disorder within 3 years, of which 16.1% was comorbid. Neuroticism, childhood trauma and parental psychiatric history were more strongly associated with comorbid than with pure disorders. No differences emerged in events occurring in the first year after baseline, but events in the period thereafter showed markedly stronger associations with comorbidity and pure mood disorder than with pure anxiety and substance use disorder. Functional disability was also linked more strongly to comorbidity and pure mood disorder.

CONCLUSION

Clear risk factors exist for the rapid onset of comorbidity. Interventions are needed to prevent rapid comorbidity in subjects who recently developed a primary disorder.

Temporal sequencing of lifetime mood disorders in relation to comorbid anxiety and substance use disorders--findings from the Netherlands Mental Health Survey and Incidence Study

BACKGROUND

Little is known about the temporal sequencing of psychiatric disorders. The aim of this study was to obtain insight into patterns of co-occurrence of DSM-III-R mood disorders in relation to anxiety and substance use disorders, their temporal sequencing and the sociodemographic and long-term vulnerability predictors of this temporal sequencing.

METHODS

Data are from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a psychiatric epidemiological study in a representative sample of 7,076 adults aged 18-64.

RESULTS

Of those who had ever experienced a mood disorder, 46 % of males and 57 % of females had a history of anxiety disorders, and 43 % and 15 % of substance use disorders. Mood disorders were associated with all anxiety and substance use disorders, except with alcohol abuse among males. In the majority of anxiety-comorbid cases, the mood disorder arose after the anxiety disorder; the pattern for substance use-comorbid disorders was more variable. Deviation from the usual sequence of major depression and anxiety disorders was more often seen among females, subjects with a higher educational level, subjects who experienced childhood parental divorce, and subjects who experienced childhood emotional neglect.

CONCLUSIONS

When comorbid with anxiety disorders, mood disorders clearly tend to be secondary. Few of the studied demographic factors, familial vulnerability factors and childhood life events predict the sequencing of mood disorders in relation to other disorders.

Discrimination and delusional ideation

BACKGROUND

In the UK and The Netherlands, people with high rates of psychosis are chronically exposed to discrimination.

AIMS

To test whether perceived discrimination is associated longitudinally with onset of psychosis.

METHOD

A 3-year prospective study of cohorts with no history of psychosis and differential rates of reported discrimination on the basis of age, gender, disability, appearance, skin colour or ethnicity and sexual orientation was conducted in the Dutch general population (n=4076). The main outcome was onset of psychotic symptoms (delusions and hallucinations).

RESULTS

The rate of delusional ideation was 0.5% (n=19) in those who did not report discrimination, 0.9% (n=4) in those who reported discrimination in one domain, and 2.7% (n=3) in those who reported discrimination in more than one domain (exact P=0.027). This association remained after adjustment for possible confounders. No association was found between baseline discrimination and onset of hallucinatory experiences.

CONCLUSIONS

Perceived discrimination may induce delusional ideation and thus contribute to the high observed rates of psychotic disorder in exposed minority populations.