Psychometric properties of the World Health Organization Disability Assessment Schedule used in the European Study of the Epidemiology of Mental Disorders

This study assessed the factor structure, internal consistency, and discriminatory validity of the World Health Organization Disability Assessment Schedule (WHODAS) version used in the European Study of the Epidemiology of Mental Disorders (ESEMeD). In total 8796 adults were assessed using the ESEMeD WHODAS (22 severity and 8 frequency items). An Exploratory Factor Analysis (EFA) with promax rotation was done with a random 50%. The other half was used for confirmatory factor analysis (CFA) comparing models (a) suggested by EFA; (b) hypothesized a priori; and (c) reduced with four items. A CFA model with covariates was conducted in the whole sample to assess invariance across Mediterranean (Spain, France and Italy) and non-Mediterranean (Belgium, Germany and the Netherlands) countries. Cronbach's alphas and discriminatory validity were also examined. EFA identified seven factors (explained variance: 80%). The reduced model (six factors, four frequency items excluded) presented the best fit [Confirmatory Fit Index (CFI) = 0.992, Tucker-Lewis Index (TLI) = 0.996, Root Mean Square Error of Approximation (RMSEA) = 0.024]. The second-order factor structure also fitted well (CFI = 0.987, TLI = 0.991, RMSEA = 0.036). Measurement non-invariance was found for Embarrassment. Cronbach's alphas ranged from 0.84 for Participation to 0.93 for Mobility. Preliminary data suggest acceptable discriminatory validity. Thus, the ESEMeD WHODAS may well be a valuable shortened version of the WHODAS-II, but future users should reconsider the filter questions.

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.

Obesity and mental disorders in the general population: results from the world mental health surveys

OBJECTIVES

(1) To investigate whether there is an association between obesity and mental disorders in the general populations of diverse countries, and (2) to establish whether demographic variables (sex, age, education) moderate any associations observed.

DESIGN

Thirteen cross-sectional, general population surveys conducted as part of the World Mental Health Surveys initiative.

SUBJECTS

Household residing adults, 18 years and over (n=62 277).

MEASUREMENTS

DSM-IV mental disorders (anxiety disorders, depressive disorders, alcohol use disorders) were assessed with the Composite International Diagnostic Interview (CIDI 3.0), a fully structured diagnostic interview. Obesity was defined as a body mass index (BMI) of 30 kg/m(2) or greater; severe obesity as BMI 35+. Persons with BMI less than 18.5 were excluded from analysis. Height and weight were self-reported.

RESULTS

Statistically significant, albeit modest associations (odds ratios generally in the range of 1.2-1.5) were observed between obesity and depressive disorders, and between obesity and anxiety disorders, in pooled data across countries. These associations were concentrated among those with severe obesity, and among females. Age and education had variable effects across depressive and anxiety disorders.

CONCLUSIONS

The findings are suggestive of a modest relationship between obesity (particularly severe obesity) and emotional disorders among women in the general population. The study is limited by the self-report of BMI and cannot clarify the direction or nature of the relationship observed, but it may indicate a need for a research and clinical focus on the psychological heterogeneity of the obese population.

Higher cortisol awakening response in young adolescents with persistent anxiety problems

OBJECTIVE

The aims of the present study were to test the association between current anxiety problems and basal cortisol levels in a large population sample of young preadolescents, and to test if HPA-axis activity differs between individuals with no, only current, or persistent anxiety problems.

METHOD

Cortisol levels of 10- to 12-year olds (n = 1,768) from the general population were measured on three time points during the day. A self-report questionnaire (RCADS) was used to assess current anxiety, a parent-report questionnaire (TPBQ) to assess anxiety problems at age 4.

RESULTS

Associations between cortisol levels and current anxiety problems were not found. However, individuals with persistent anxiety problems had higher morning cortisol levels and a higher cortisol awakening response.

CONCLUSION

Apparently, only persistent, and not current, anxiety problems are associated with higher HPA-axis activity. Alterations in HPA-axis activity might underlie persistent anxiety problems, or result from the stress accompanied by persistent anxiety problems.

Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder

BACKGROUND

Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD).

AIMS

To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative.

METHOD

An ADHD screen was administered to respondents aged 18-44 years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability.

RESULTS

Estimates of ADHD prevalence averaged 3.4% (range 1.2-7.3%), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders.

CONCLUSIONS

Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case.

Convergent genetic modulation of the endocrine stress response involves polymorphic variations of 5-HTT, COMT and MAOA

Highly prevalent stress-related disorders such as major depression (MD) are characterised by a dysregulation of the neuroendocrine system. Although heritability for these disorders is high, the role of genes in the underlying pathophysiology is poorly understood. Here, we show that polymorphic variations in genes coding for serotonin transporter (5-HTT), catechol-O-methyl transferase (COMT) and monoamine oxidase A (MAOA) as well as sex differences influence the regulation of hypothalamic-pituitary-adrenal (HPA)-axis response to acute psychological and endocrine challenges. In our sample, the effects of COMT on the release of adrenocorticotrophin hormone (ACTH) depend on the presence of the low-expression MAOA variant in the same individual. By including individuals varying in their degree of susceptibility to MD, we showed evidence of interactions between 5-HTT and MD susceptibility in baseline cortisol, and between MAOA and MD susceptibility in baseline ACTH measures, indicating a role for these genotypes in stable-state endocrine regulation. Collectively, these results indicate that the simultaneous investigation of multiple monoaminergic genes in interaction with gender have to be measured to understand the endocrine regulation of stress. These findings point towards a genetic susceptibility to stress-related disorders.

Perceived parental rearing of bipolar offspring

OBJECTIVE

To explore the impact of growing up with a parent with a bipolar disorder. First, we compared parental rearing behavior perceived by young adult offspring of bipolar parents with parental rearing behavior perceived by same aged young adults from the general population. Secondly, we examined the associations between perceived parental rearing behavior and parental psychopathology and psychopathology in offspring.

METHOD

Subjects were 129 offspring of 80 bipolar parents and their spouses and 1122 young adults from the general population. In offspring the Structured Clinical Interview for DSM-IV was used to assess DSM-IV diagnoses and the EMBU was used to assess perceived parental rearing in both groups.

RESULTS

In general, offspring growing up in a family with a bipolar parent perceived their mothers as less rejecting, more emotionally warm and less overprotecting and their fathers as less emotionally warm and less overprotecting compared with young adults from the general population. Perceived rejection was related to psychopathology in offspring.

CONCLUSION

Overall, parental rearing in families with a parent with a bipolar disorder is not more dysfunctional, as perceived by their offspring, than in families from the general population. Offspring with a bipolar disorder perceive their parents as more rejecting.

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.

Functional disability of mental disorders and comparison with physical disorders: a study among the general population of six European countries

OBJECTIVE

To examine the association of mental and physical disorders with multiple domains of functioning and compare the two.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders, a general population study in which adults (n > 21,000) from Belgium, France, Germany, Italy, the Netherlands and Spain were assessed using the Composite International Diagnostic Interview (mental disorders), World Health Organization Disability Assessment Schedule second edition (functional disability) and self-report (physical disorders). Means in different groups were compared using the Mann-Whitney U-test and multiple regression analyses.

RESULTS

Mental disorders were related to disability in all domains of functioning: anxiety disorders the most, followed by mood disorders, and finally alcohol disorders. The findings suggest that mental disorders are associated with similar or higher levels of disability in all domains, except getting around, than arthritis and heart disease.

CONCLUSION

Mental disorders are associated with a similar or higher negative impact on daily functioning than arthritis and heart disease.

Prediction of change in level of problem behavior among children of bipolar parents

OBJECTIVE

To determine the effects of familial loading, birth weight, and family problems on change in parent-reported problems across a 14-month period among children of bipolar parents.

METHOD

Emotional and behavioral problems in a sample of 140 offspring of bipolar parents and familial loading in first- and second-degree relatives were assessed at two measurements. Parents reported the birth weight of their offspring and completed a questionnaire on family problems. Multiple linear regression analyses were performed to assess associations of the three predictors with change in problem scores at follow-up.

RESULTS

Familial loading of unipolar disorder was a unique predictor for an increase in problem scores from the first to the second measurement with beta-coefficients ranging from 0.17 to 0.25. Birth weight and family problems were not associated with change in problem scores across the two measurements.

CONCLUSION

Familial loading of unipolar disorder predicted an increase in behavioral and emotional problems across the 14-month follow-up.

Case management to improve major depression in primary health care: a systematic review

BACKGROUND

Deficits in the care of depression lead to poor medication adherence, which increases the risk of an unfavourable outcome for this care. This review evaluates effects on symptoms and medication adherence of case management in primary health care.

METHOD

A systematic literature search was performed. The quality of the studies was rated according to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria. To conduct a subgroup analysis interventions were classified as either 'standard' or 'complex' case management.

RESULTS

Thirteen studies met the inclusion criteria. In a meta-analysis we calculated a standard mean difference/effect size on symptom severity after 6-12 months of -0.40 (95% CI -0.60 to -0.20). Patients in the intervention groups were more likely to achieve remission after 6-12 months [relative risk (RR) 1.39, 95% CI 1.30-1.48]. The relative risk for clinical response was 1.82 (95% CI 1.68-2.05). Patients in intervention groups had better medication adherence than the control group (RR 1.5, 95% CI 1.28-1.86). We found heterogeneous results when assessing effects of different types of intervention.

CONCLUSIONS

We conclude that case management improves management of major depression in primary health-care settings.

Short-term effects of enhanced treatment for depression in primary care: results from a randomized controlled trial

BACKGROUND

Depression is a highly prevalent, often recurring or persistent disorder. The majority of patients are initially seen and treated in primary care. Effective treatments are available, but possibilities for providing adequate follow-up care are often limited in this setting. This study assesses the effectiveness of primary-care-based enhanced treatment modalities on short-term patient outcomes.

METHOD

In a randomized controlled trial we evaluated a psycho-educational self-management intervention. We included 267 adult patients meeting criteria for a DSM-IV diagnosis of major depressive disorder, assessed by a structured psychiatric interview. Patients were randomly assigned to: the Depression Recurrence Prevention (DRP) program (n=112); a combination of the DRP program with psychiatric consultation (PC+DRP, n=39); a combination with brief cognitive behavior therapy (CBT+DRP, n=44); and care as usual (CAU, n=72). Follow-up assessments were made at 3 months (response 90%) and 6 months (85%).

RESULTS

Patient acceptance of enhanced care was good. The mean duration of the index episode was 11 weeks (S.D.=9.78) and similar in CAU and enhanced care. Recovery rate after 6 months was 67% overall; 17% of all participants remained depressed for the entire 6-month period.

CONCLUSION

Enhanced care did not result in better short-term outcomes. We found no evidence that the DRP program was more effective than CAU and no indications for added beneficial effects of either the psychiatric evaluation or the CBT treatment to the basic format of the DRP program. Observed depression treatment rates in CAU were high.

Depression after myocardial infarction is a risk factor for declining health related quality of life and increased disability and cardiac complaints at 12 months

OBJECTIVE

To study the prospective effects of post-myocardial infarction (MI) depressive disorder on health status, including self reported cardiac symptoms, disability, and health related quality of life, at 12 months after MI while controlling for cardiac condition and health status at three months after MI.

METHODS

Longitudinal study of a cohort of 468 adults with MI recruited from four hospitals in the north of The Netherlands between September 1997 and September 2000. Assessment of depressive disorder in the year after MI according to International classification of disease, 10th revision criteria. Assessment of health status at three and 12 months by the RAND 36 item health survey, the health complaints scale, self rated cardiac complaints, and disability.

RESULTS

Patients with post-MI depressive disorder were more likely than those without to have poor quality of life, more health complaints, more cardiac complaints, and more disability at 12 months' follow up. In multivariate analyses adjusted for cardiac condition, health status at three months, age, sex, and pre-MI depression, the prospective association of post-MI depression with poor health status remained for most of the indicators. Severity of the post-MI depression further contributed to aspects of poor health status.

CONCLUSIONS

In a prospective study design, post-MI depression had strong effects on poor health status exceeding the effects of cardiac condition and its short term consequences. Efforts to improve health status after MI should therefore include standard assessment and guideline based treatment of post-MI depressive disorder.

Internalizing and externalizing problems in adolescence: general and dimension-specific effects of familial loadings and preadolescent temperament traits

BACKGROUND

We investigated the links between familial loading, preadolescent temperament, and internalizing and externalizing problems in adolescence, hereby distinguishing effects on maladjustment in general versus dimension-specific effects on either internalizing or externalizing problems.

METHOD

In a population-based sample of 2230 preadolescents (10-11 years) familial loading (parental lifetime psychopathology) and offspring temperament were assessed at baseline by parent report, and offspring psychopathology at 2.5-years follow-up by self-report, teacher report and parent report. We used purified measures of temperament and psychopathology and partialled out shared variance between internalizing and externalizing problems.

RESULTS

Familial loading of internalizing psychopathology predicted offspring internalizing but not externalizing problems, whereas familial loading of externalizing psychopathology predicted offspring externalizing but not internalizing problems. Both familial loadings were associated with Frustration, low Effortful Control, and Fear. Frustration acted as a general risk factor predicting severity of maladjustment; low Effortful Control and Fear acted as dimension-specific risk factors that predicted a particular type of psychopathology; whereas Shyness, High-Intensity Pleasure, and Affiliation acted as direction markers that steered the conditional probability of internalizing versus externalizing problems, in the event of maladjustment. Temperament traits mediated one-third of the association between familial loading and psychopathology. Findings were robust across different composite measures of psychopathology, and applied to girls as well as boys.

CONCLUSIONS

With regard to familial loading and temperament, it is important to distinguish general risk factors (Frustration) from dimension-specific risk factors (familial loadings, Effortful Control, Fear), and direction markers that act as pathoplastic factors (Shyness, High-Intensity Pleasure, Affiliation) from both types of risk factors. About one-third of familial loading effects on psychopathology in early adolescence are mediated by temperament.

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.

Determinants of salivary cortisol levels in 10-12 year old children; a population-based study of individual differences

The hypothalamic-pituitary-adrenal (HPA)-axis is a central component of the body's neuroendocrine response to stress. Its major end-product cortisol has profound effects on mood and behavior. Although it has often been suggested, it remains unknown whether differences in HPA-axis physiology are part of an individual's vulnerability to psychopathology, and constitute a causal factor in its development. In order to study the contribution of HPA-axis physiology to the development of psychopathology, we measured HPA-axis physiology in a community-cohort of 1768 10-12 year-old children. The aims of the here presented study were twofold: (1) to obtain data on HPA-axis function in a large cohort of pre- and early-adolescent children, both in terms of total hormonal output and in terms of the dynamics of cortisol secretion (by means of the cortisol awakening response); and (2) to study potential confounders of the cortisol-psychopathology relationship in this age group, such as season of sampling, age, gender, pubertal development, perinatal variables and BMI. We found a wide interindividual variability in HPA-axis function. An increase in cortisol in the first 30 min after awakening was present in 70.7% of children, but the increase appears lower in children than in adults. In addition, this study suggests that season of sampling and gender may act as potential confounders in the cortisol-psychopathology relationship. We will follow these children longitudinally for the development of psychopathology in the period from childhood into adulthood. This period covers adolescence, which is a critical time for the appearance and development of psychiatric disorders.

Care staff training in detection of depression in residential homes for the elderly: randomised trial

BACKGROUND

Many people with depression in residential care homes for the elderly do not receive treatment because their depression remains undetected.

AIMS

To determine the effects of staff training on the detection, treatment and outcome of depression in residents of ten homes.

METHOD

We conducted a randomised controlled trial in ten residential homes. The intervention consisted of a training programme for staff and collaborative evaluation by staff and a mental health specialist of residents with possible depression.

RESULTS

Recognition of depression increased more in homes where staff received the training than in the control homes. Treatment rates also increased compared with control homes, but the increase was not significant. Residents with depressive symptoms had a more favourable course when staff had received training. Moreover, the prevalence of depressive symptoms decreased, but the decrease was not significant.

CONCLUSIONS

Training of care staff results in the increased detection of depression in the elderly, a trend towards more treatment and better outcomes.

Depression as an independent determinant of decreased heart rate variability in patients post myocardial infarction

OBJECTIVE

Depression is associated with an increased risk of cardiac morbidity and mortality in patients following myocardial infarction (MI). Our objective was to investigate the potential role of the autonomic nervous system in mediating this detrimental effect.

METHODS

The study group consisted of 95 consecutive post-MI patients without depression and 53 post-MI patients with depression. Depressive symptoms were assessed by the Beck Depression Inventory (BDI). Activity of the autonomic nervous system was assessed by analysing heart rate variability (HRV) using 24-hour ambulatory electrocardiographic recordings as obtained three months post MI.

RESULTS

Higher age, female gender and left ventricular ejection fraction <0.40 were associated with lower HRV (SDANN, and very-low-frequency and low-frequency power, but not RMSSD and high-frequency power), as was depression. In the multivariate analysis, age and left ventricular ejection fraction but not gender emerged to be independently associated with HRV. After adjustment for these two covariates, depression remained significantly associated with low HRV.

CONCLUSIONS

Patients with depression in the present post-MI study are characterised by decreased longer-range HRV compared with the patients without depression, independent of other clinical variables. This observation supports the concept that one of the mechanisms underlying the detrimental effect of depression on post-MI prognosis may be that depression adds to the autonomic derangement post MI.

[Chronic heart failure and depression: the limitations of specialization-specific multidisciplinary guidelines]

Recently two monodisciplinary guidelines, 'Mood disorders' and 'Chronic heart failure', were upgraded to multidisciplinary guidelines in order to guarantee an appropriate long-term care trajectory for these patients. Neither guideline mentions clinically relevant interactions despite the extensive research in this area over the past decade. The guideline for chronic heart failure should include information on how to detect patients who are depressed or at risk of depression and that depressed patients are at risk of non-compliance with the cardiac treatment. In the guideline for mood disorders excess mortality and the need for combined treatment with cardiologists should be mentioned.

Obstetric optimality and emotional problems and substance use in young adulthood

BACKGROUND

Pregnancy and delivery are complex processes, and isolated obstetric complications rare and often accompanied or followed by a number of others.

AIMS

To study the relationship between the overall obstetric situation (as opposed to single obstetric risk factors) and emotional and substance use disorders in young adulthood, and to analyse whether these links are mediated by temperaments in childhood.

STUDY DESIGN

In a prospective birth cohort (n=3162), questionnaires were sent to mothers and teachers when the child was 7-10 years old, and to the children when they were 20-25 years old.

SUBJECTS

Six hundred and eighty-two cohort members with complete data sets at three ages (perinatal, childhood, and young adulthood).

OUTCOME MEASURES

Emotional problems and substance use in young adulthood.

MAIN RESULTS

Substance use in young adulthood was predicted better by the overall obstetrical optimality score than emotional problems were. Links studied were stronger for men than for women.

CONCLUSIONS

This study demonstrated the use of an aggregated obstetrical optimality score in analysing the associations between early risk factors and emotional problems and substance use in young adulthood.