Sampling and methods of the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

The European Study of Epidemiology of Mental Disorders (ESEMeD) project was designed to evaluate the prevalence, the impact and the treatment patterns in Europe. This paper presents an overview of the methods implemented in the project.

METHOD

ESEMeD is a cross-sectional study in a representative sample of 21 425 adults, 18 or older, from the general population of Belgium, France, Germany, Italy, the Netherlands and Spain. The Composite International Diagnostic Interview (WMH-CIDI) was administered by home interviews from January 2001 to August 2003 using Computer Assisted Personal Interview (CAPI) technology. Data quality was controlled to ensure reliability and validity of the information obtained.

RESULTS

Response rate varied from 78.6% in Spain to 45.9% in France. Less than 4% of the individuals had errors in the checking procedures performed.

CONCLUSION

The sampling methodologies, comprehensive psychiatric instruments and quality control procedures used have rendered the ESEMeD database a unique and important source of information about the prevalence, the disability burden and unmet medical needs of mental disorders within Europe.

12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project

OBJECTIVE

Comorbidity patterns of 12-month mood, anxiety and alcohol disorders and socio-demographic factors associated with comorbidity were studied among the general population of six European countries.

METHOD

Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional psychiatric epidemiological study in a representative sample of adults aged 18 years or older in Belgium, France, Germany, Italy, the Netherlands and Spain. The diagnostic instrument used was the Composite International Diagnostic Interview (WMH-CIDI). Data are based on 21 425 completed interviews.

RESULTS

In general, high associations were found within the separate anxiety disorders and between mood and anxiety disorders. Lowest comorbidity associations were found for specific phobia and alcohol abuse-the disorders with the least functional disabilities. Comorbidity patterns were consistent cross-nationally. Associated factors for comorbidity of mood and anxiety disorders were female gender, younger age, lower educational level, higher degree of urbanicity, not living with a partner and unemployment. Only younger people were at greater risk for comorbidity of alcohol disorder with mood, anxiety disorders or both.

CONCLUSION

High levels of comorbidity are found in the general population. Comorbidity is more common in specific groups. To reduce psychiatric burden, early intervention in populations with a primary disorder is important to prevent comorbidity.

[Epidemiology of mental disorders in Spain: methods and participation in the ESEMeD-Spain project]

INTRODUCTION

The ESEMeD-Spain study is part of a European project on the epidemiology of mental disorders, which is also part of a World Health Organization initiative called World Mental Health Surveys. The main objectives of the study are to estimate the prevalence of mental disorders in Spain; to analyze their association with sociodemographic variables and predisposing and protective factors; to evaluate their impact on the quality of life; and to describe and evaluate the health care received by people with mental disorders.

METHODS

A representative sample of the noninstitutionalized Spanish population older than 18 years is interviewed. Sample size is 5,500 people. The instrument used in the interviews is the Composite International Diagnostic Interview (CIDI), a questionnaire designed to be used by lay interviewers that allows the diagnosis of psychiatric disorders. Strict quality control of field work has been established. Furthermore, approximately 200 subjects are re-interviewed by a psychiatrist using the Structured Clinical Interview for DSM-IV (SCID) and several questionnaires to measure clinical severity.

RESULTS

Field work started in September 2001 and finished in November 2002. Up to Ap ril 2002, more than 4,300 people have been interviewed. Preliminary response rate has been 68.7%. Comparison of the age and gender of the study sample with the general Spanish population shows high representativeness.

CONCLUSIONS

The ESEMeD-Spain project will produce un - precedented scientific information about the epidemiology of mental disorders in Spain.

Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation. To this end, 222 COPD patients (3.2% female; 71+/-10 yrs (mean+/-SD)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient's free-phone access to the nurse ensured for an 8-week follow-up period. Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24+/-0.57 controls: 0.38+/-0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13+/-0.43 versus 0.31+/-0.62); and 2) a noticeable improvement of quality of life (delta St George's Respiratory Questionnaire (SGRQ), -6.9 versus -2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient's satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7+/-2.3 versus 4.2+/-4.1 days). A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

Interpretation of quality of life scores from the St George's Respiratory Questionnaire

The aim of the study was to obtain the general population norms for the St. George's Respiratory Questionnaire (SGRQ), a specific questionnaire for respiratory diseases. The IBERPOC project was a cross-sectional study of representative samples of the general population aged between 40-69 yrs. The study sample was composed of 862 individuals. All participants considered as "probable cases" of chronic obstructive pulmonary disease (COPD) (n=460) were eligible to complete the SGRQ and among the rest of the nonprobable COPD participants (n=3,571), 10 individuals from each defined age and sex group were eligible (n=402). Weights were applied to restore general population representativity of the sample. Mean forced expiratory volume in one second (FEV1) predicted was 89.4% (SD=16.5%; range: 16-131%). Chronbach's alpha coefficients were >0.7 in the symptoms, activity and impact scales, and >0.9 in the overall scale. Symptom scale score was significantly higher among males (11.6 versus 7.8; p<0.01) and activity scale score was significantly higher among females (12.2 versus 14.6; p=0.04). In a multiple linear regression model, respiratory diseases (asthma and COPD) and FEV1 % over pred showed the strongest association with the SGRQ total score. Smoking, sex, age and education were independently associated with the total SGRQ score. These results indicate that individuals from the general population presented some of the problems that are important when measuring health-related quality of life in respiratory patients, and provide St George's Respiratory Questionnaire norms, a useful method for interpreting the St George's Respiratory Questionnaire score in a given patient or study samples.

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) project: rationale and methods

The European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000) is a new cross-sectional study investigating the prevalence and the associated factors of mental disorders, as well as their effect on health-related quality of life and the use of services in six European countries. This paper describes the rationale, methods and the plan for the analysis of the project. A total of 22,000 individuals representative of the non-institutionalized population aged 18 and over from Belgium, France, Germany, Italy, the Netherlands and Spain are being interviewed in their homes. Trained interviewers use a computer-assisted personal interview (CAPI) including the most recent version of the Composite International Diagnostic Interview (CIDI, 2000), a well-established epidemiological survey for assessing mental disorders. This is the first international study using the standardized up-to-date methodology for epidemiological assessment. Sizeable differences in prevalence, impact and level of need that is met by the health services are expected. The analysis of these differences should facilitate the monitoring of ongoing mental health reform initiatives in Europe and provide new research hypotheses.

The spanish version of the paediatric asthma quality of life questionnaire (PAQLQ): metric characteristics and equivalence with the original version

The Paediatric Asthma Quality of Life Questionnaire (PAQLQ), developed by Juniper et al., assesses the impact of asthma on children's daily life. It contains 23 items, covering three dimensions: symptoms, activities limitation and emotional function.

AIMS

To develop an equivalent Spanish version of the PAQLQ, and to assess its measurement characteristics.

METHODS

The forward and back-translation method was used for the adaptation. A longitudinal study (assessments at the 1st and 5th weeks), with patients from the emergency and outpatient departments of three Spanish hospitals, was designed to test the properties of the new adapted version. At each visit, a trained interviewer administered the PAQLQ, a Global Index of Change and a General Health Perception scale. The Peak Expiratory Flow Rate (PEFR) was also recorded daily, together with symptoms, during the prior week.

RESULTS

Ninety-nine patients (66.7% males, 42.4% suffering an exacerbation, mean age of 11.3 years) with the following types of asthma were evaluated: mild intermittent (31.3%), mild persistent (36.4%), moderate persistent (29.3%) and severe persistent (3%). At the 1st visit, the mean pre-bronchodilator %PEFR was 87.3%. The Cronbach's alpha ranged from 0.86 to 0.95. As expected, correlations between the PAQLQ scores, and the Asthma Control Score (0.53-0.67), the General Health Perception (0.34-0.55), and the %PEFR (0.44-0.55) were moderate. The PAQLQ scores remained unchanged in stable patients while increased significantly in those showing improvements.

CONCLUSIONS

After a standard cross-cultural adaptation process, the Spanish version of the PAQLQ has shown to be equivalent to the original, with similar internal consistency reliability, validity and sensitivity to clinical changes.

Effectiveness of CPAP treatment in daytime function in sleep apnea syndrome: a randomized controlled study with an optimized placebo

Application of continuous positive airway pressure (CPAP) as the standard treatment for sleep apnea/hypopnea syndrome (SAHS) is a moot point. Studies on the effectiveness of this treatment have been challenged because of the lack of a suitable placebo. The recent description of a true placebo (sham CPAP) prompted us to conduct a randomized trial of CPAP or placebo to assess the effectiveness of CPAP in improving SAHS-related symptoms and daytime function in patients with moderate to severe SAHS. Forty-eight patients, stratified in four groups according to severity, were randomly allocated into two treatment groups (optimal and sham CPAP) for a 6-wk period. Of these, 45 completed follow-up (91% males; age: 54 +/- 10 yr; body mass index [BMI]: 32 +/- 6 kg/m(2); apnea-hypopnea index [AHI]: 54 +/- 19 events/h; and Epworth Sleepiness Scale [ESS]: 16 +/- 5). The ESS, a questionnaire on SAHS-related symptoms, Functional Outcomes Sleep Questionnaire (FOSQ), and the Short Form Health Survey (SF-36) were completed at inclusion and after treatment. After 10 d of washout, the placebo group was treated with optimal CPAP and reassessed before and after optimal CPAP. The group receiving optimal CPAP when compared with the group with sham CPAP showed considerably greater improvement in the relief of sleepiness (-9.5 versus -2.3, p < 0.001), other SAHS-related symptoms (-18.5 versus -4.5, p < 0.001), vigilance (+8.5 versus +3.4, p = 0.009), and general productivity (+4.0 versus +0.5, p = 0.04) FOSQ scales. Both groups used a similar number of hours for the optimal and the sham CPAP (4.3 versus 4.5, (p = NS). The patients initially treated with placebo CPAP improved significantly more when optimal CPAP was applied for ESS (-2.3 versus -6.7, p < 0.001) and other sleep apnea syndrome (SAS)-related symptoms (-4.5 versus -11.2, p = 0.02). Our study provides strong evidence of the effectiveness of CPAP treatment in improving symptoms and perceived health status in moderate to severe SAHS.

[Measurement of the perceived impact of sleep problems: the Spanish version of the functional outcomes sleep questionnaire and the Epworth sleepiness scale]

BACKGROUND

Excessive daytime sleepiness is a frequent symptom and a public health problem due to its association with automobile and work related accidents. The aim of this study was to develop and carry out a preliminary assessment of the Spanish version of the functional outcomes sleep questionnaire and the Epworth sleepiness scale, two instruments designed to evaluate patients with sleep disorders.

MATERIAL AND METHODS

For the adaptation, the forward and back-translation method by bilinguals was used with professional and lay panel. Once tested for feasibility and comprehension, 39 patients with obstructive sleep apnea syndrome completed the Spanish version of the FOSQ and the Epworth sleepiness scale, together with a question on self-rated health status.

RESULTS

Difficulty of translation was assessed as low and the naturalness of Spanish expressions as high for all the items of the questionnaires except for the response options of the Epworth sleepiness scale. Both questionnaires showed higher reliability than the standard proposed for individual comparisons (Cronbach's alpha > 0.9). The FOSQ vigilance scale showed a high correlation with the Epworth score (r = -0.79), while for the other scales of the FOSQ correlations were moderate (r ranging from -0.52 to -0.68). Patients who reported "regular" or "poor" health had significantly worse scores for most of the FOSQ scales.

CONCLUSION

These results suggest that the Spanish versions of both questionnaires are conceptually equivalent to the originals and that they show similar characteristics of reliability and validity. The FOSQ vigilance scale assess daytime sleepiness similarly to Epworth but the others scales of the FOSQ provide additional information for these patients.

Testing the measurement properties of the Spanish version of the SF-36 Health Survey among male patients with chronic obstructive pulmonary disease. Quality of Life in COPD Study Group

The aim of this article is to evaluate the measurement properties of the Spanish version of the SF-36 Health Survey (SF-36). In total, 321 male chronic obstructive pulmonary disease (COPD) patients attending hospital outpatient or primary health clinics were cross-sectionally administered the SF-36, the St. George's Respiratory Questionnaire (SGRQ), and a dyspnea scale. A clinical measure of respiratory function, the proportion of the predicted Forced Expiratory Volume in 1 second (%FEV1) was also obtained. Internal consistency, central tendency, and dispersion statistics of scores were calculated, as well as the percentage of respondents with the highest and lowest scores for each scale and correlations between health status and clinical measures. All patients completed the SF-36 questionnaire, and less than 1% of items were missing. The proportion of patients with the worst possible score (floor effect) ranged from 0.9-20.1% among the different scales. The proportion of patients achieving the best possible score (ceiling effect) ranged from 0-61%. Cronbach's alpha coefficients were above 0.75 except for one scale (Social Functioning, alpha = 0.55). SF-36 scores were moderate to highly correlated with SGRQ scores (coefficients ranged from -.41 to -.79). Correlations were moderate to high with dyspnea and lower but statistically significant with %FEV1. A clear gradient of SF-36 scores was found according to dyspnea levels and disease staging based on %FEV1 impairment, the gradient being more marked for the Physical Functioning, Role-Physical, and General Health scales. Data presented suggest that the Spanish version of the SF-36 is acceptable, valid, and reliable in COPD patients. Although more studies are needed, this version is adequate in international comparisons of health outcomes.