The prevalence of specific psychiatric disorders in Puerto Rico

A systematic review of the epidemiology of somatisation disorder and hypochondriasis

BACKGROUND

This paper reviews current knowledge regarding the prevalence and associated features of somatisation disorder and hypochondriasis in population-based and primary care samples.

METHOD

A systematic review of the literature, which used a standardised definition of somatisation disorder or hypochondriasis and which examined the characteristics and associated features of these disorders in population-based samples or primary care settings.

RESULTS

In population-based studies the prevalence of somatisation disorder and hypochondriasis was too low to examine associated features reliably. In studies using abridged criteria, a clear female predominance was not found in either disorder; there was a consistent relationship with few years of education. There was a close relationship with anxiety and depressive disorders, with a linear relationship between numbers of somatic and other symptoms of distress in several studies, including longitudinal studies. No studies showed that these symptom clusters fulfil the criteria of characteristic onset, course and prognosis required to merit the status of discrete psychiatric disorders.

CONCLUSIONS

On existing evidence, somatisation disorder and hypochondriasis cannot be regarded as definite psychiatric disorders. There is some evidence that numerous somatic symptoms or illness worry may be associated with impairment and high health care utilisation in a way that cannot be solely explained by concurrent anxiety and depression, but further research using population-based samples is required.

Lifetime rates of alcoholism in adults with anxiety, depression, or co-morbid depression/anxiety: a community survey of Ontario

BACKGROUND

Separate lines of research have demonstrated strong associations linking alcohol misuse with major depression on the one hand, and anxiety disorders on the other. In the current study we examined the possible confounding and/or additive effects of co-morbid depression/anxiety in understanding these relationships.

METHODS

A total of 7195 individuals in Ontario, aged 15-64, were interviewed using the CIDI. Based on lifetime diagnoses, we compared rates of alcohol abuse/dependence in four groups consisting of normal controls, individuals with unipolar major depression but no anxiety disorders, individuals with one or more anxiety disorders without depression, and individuals with co-morbid major depression and anxiety. Age of onset of alcoholism in the four study groups was also compared.

RESULTS

In both genders, there were significantly higher rates of alcoholism in all three psychiatric groups relative to controls. In females only, there was also a significantly higher rate of alcoholism in the depressed/anxious group than in the pure anxious group. The age of onset of alcoholism was the same across all four study groups.

LIMITATIONS

Due to limitations related to sample size, we combined subjects with various anxiety disorders into a single anxiety group and concurrent and sequential co-morbidity were not distinguished.

CONCLUSIONS

Both gender effects and depression/anxiety co-morbidity may be important considerations in the design and interpretation of studies on alcohol misuse. This may be particularly relevant when considering the strength of the association between alcoholism and anxiety disorders in women. Depression and anxiety do not appear to influence the age of onset of alcoholism. Furthermore, no single temporal pattern of onset was identified in individuals with all three disorders, suggesting no obvious cause-effect relationship among them.

Population prevalence of psychiatric disorders in Chile: 6-month and 1-month rates

BACKGROUND

Few South American studies have examined current prevalence rates of psychiatric disorders.

AIMS

To examine prevalence rates in a nationally representative adult population from Chile.

METHOD

The Composite International Diagnostic Interview was administered to a stratified random sample of 2978 individuals from four provinces representative of the country's population. Six-month and 1-month prevalence rates were estimated. Demographic correlates, comorbidity and service use were examined.

RESULTS

Nearly a fifth of the Chilean population had had a psychiatric disorder during the preceding 6 months. The 6-month and 1-month prevalence rates were 19.7% and 16.7% respectively. For the 6-month prevalence the five most common disorders were simple phobia, social phobia, agoraphobia, major depressive disorder and alcohol dependence. Less than 30% of those with any psychiatric diagnosis had a comorbid psychiatric disorder and the majority of them had sought treatment from mental health services.

CONCLUSIONS

Current prevalence studies are useful indicators of service needs. People with comorbid psychiatric conditions have high rates of service use. The low rate of comorbidity in Chile merits further study.

Prevalence and incidence studies of mood disorders: a systematic review of the literature

OBJECTIVE

To present the results of a systematic review of literature published between January 1, 1980, and December 31, 2000, that reports findings on the prevalence and incidence of mood disorders in both general population and primary care settings.

METHOD

We conducted a literature search of epidemiologic studies of mood disorders, using Medline and HealthSTAR databases and canvassing English-language publications. Eligible publications were restricted to studies that examined subjects aged at least 15 years and over. We used a set of predetermined inclusion and exclusion criteria to identify relevant studies. We extracted and analyzed prevalence and incidence data for heterogeneity.

RESULTS

Of general population studies, a total of 18 prevalence and 5 incidence studies met eligibility criteria. We found heterogeneity across 1-year and lifetime prevalence of major depressive disorder (MDD), dysthymic disorder and bipolar I disorder. The corresponding pooled rates for 1-year prevalence were 4.1 per 100, 2.0 per 100, and 0.72 per 100, respectively. For lifetime prevalence, the corresponding pooled rates were 6.7 per 100, 3.6 per 100, and 0. per 100, respectively. Significant variation was observed among 1-year incidence rates of MDD, with a correspond ing pooled rate of 2.9 per 100.

CONCLUSIONS

The prevalence of mood disorders reported in high-quality studies is generally lower than rates commonly reported in the general psychiatric literature. When controlled for common methodological confounds, variation in prevalence rates persists across studies and deserves continued study. Methodological variation among studies that have examined the prevalence of depression in primary health care services is so large that comparative analyses cannot be achieved.

Cultural Context of Caregiving: Differences in Depression Between Puerto Rican and Non-Latina White Mothers of Adults With Mental Retardation

Differences in depression between Puerto Rican and non-Latina White mothers providing care to their adult child with mental retardation were examined. The focus of this study is on how family problems may mediate the effect of the adult's behavior problems on the mother's level of depressive symptoms and how this process differs across the two groups of mothers. As hypothesized, family problems was a stronger predictor of depressive symptoms for Puerto Rican mothers than for non-Latina White mothers. In addition, Puerto Rican mothers were in poorer physical health, which further accounted for differences in depression between the two groups.

Epidemiology and natural course of social fears and social phobia

OBJECTIVE

To summarize epidemiological studies providing data on prevalence, incidence, comorbidity, natural course, risk factors and consequences of social phobia (SP).

METHOD

Data from cross-sectional studies and prospective longitudinal studies in particular are considered.

RESULTS

These studies portray SP as a frequent mental disorder, which begins typically in early adolescence, and is highly comorbid with other anxiety disorders, as well as secondary depression and substance abuse disorders. Several possible risk factors have already been identified for the onset and unfavorable course of SP; some of them have been tested in prospective longitudinal studies. SP is a chronic disorder when compared with other mental disorders and when subclinical symptomatic levels are considered. Impairment caused by SP is considerable and increases over a patient's life span. The negative impact of SP is not only reflected in subjective well-being and reduced quality of life but also in social role functioning, and it impacts negatively on career progression.

CONCLUSION

Prospective longitudinal studies in representative samples drawn from the general population provide information that allows the overall direct and indirect costs of the disorder (treatment costs, disability, social welfare) to be determined, and enables an improvement in long-term care strategies as well as preventive efforts to be established.

Lifetime and 6-month prevalence of DSM-III-R psychiatric disorders in an urban community in Japan

We conducted a community-based interview survey of a random sample of residents aged 20 years or older in an urban community in Japan using the University of Michigan Version of the WHO Composite International Diagnostic Interview for selected mood and anxiety disorders and alcohol abuse/dependence according to DSM-III-R. The final sample consisted of 1029 respondents (response rate, 57%). The lifetime and 6-month prevalences of selected mood, anxiety and alcohol use disorders were low in general. Alcohol abuse/dependence was more prevalent in men than in women. Younger respondents had a greater risk of generalized anxiety disorder and alcohol dependence. A greater risk of mood, anxiety and alcohol use disorders was observed among a recent birth cohort. We confirmed a lower prevalence of mood and anxiety disorders and alcohol use disorders in a community population in Japan than in Western countries, observations that were similar to previous ones in East-Asian countries. The patterns of demographic correlates and comorbidity are similar to those of most other countries.

Somatization disorder in young adult population

Somatization is a widespread problem in health care. We estimated the occurrence of Somatization Disorder (SD) using three different case-finding methods in a general population cohort. The sample consists of 1,598 subjects born in 1966. The case-finding methods according to the DSM-III-R criteria for SD were: 1) Finnish Hospital Discharge Register (FHDR) data, 2) analysis of the patient records in public outpatient care 1982-1997, and 3) Structured Clinical Interview for DSM-III-R (SCID) for 321 selected cases. The prevalence of SD was 1.1% (N = 18), giving a female-to-male ratio of 5:1. All cases were found among the public outpatient care records. No cases appeared in the FHDR or were recognized in the psychiatric interview. The lifetime prevalence of SD was comparable with previous western population studies. Methodologically, information from outpatient records may be more sensitive in detecting SD than hospital diagnosis or even psychiatric interview. Clinically we stress the importance of recognizing these cases by liaison psychiatrists especially because SD has been recognized as being difficult to treat among somatic and primary health service providers and because some promising treatment alternatives such as cognitive-behavioral therapy and antidepressants have emerged for SD patients.

Ethnicity and four personality disorders

The current study examined the relationship between ethnicity and DSM-IV personality disorders. The distribution of four personality disorders--borderline (BPD), schizotypal (STPD), avoidant (AVPD), and obsessive-compulsive (OCPD)--along with their criteria sets, were compared across three ethnic groups (Caucasians, African Americans, and Hispanics) using both a clinician-administered diagnostic interview and a self-report instrument. Participants were 554 patients drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS) who comprised these three ethnic groups and met personality disorder criteria based on reliably administered semistructured interviews. Chi-square analyses revealed disproportionately higher rates of BPD in Hispanic than in Caucasian and African American participants and higher rates of STPD among African Americans when compared to Caucasians. Self-report data reflected similar patterns. The findings suggest that in treatment-seeking samples, Caucasians, Hispanics, and African Americans may present with different patterns of personality pathology. The factors contributing to these differences warrant further investigation.

Cultural specificity and comparison in psychiatric epidemiology: walking the tightrope in American Indian research

Increasingly, the mental health needs of populations are measured using large-sample surveys with standardized measures and methods. Such efforts, however, rarely include sufficient number of smaller, culturally defined populations to draw defensible conclusions about their needs. Furthermore, without some adaptation, the standardized methods and measures may yield invalid results in such populations. Using a recently completed psychiatric epidemiology and services study with American Indian populations as a case example, this paper outlines issues facing epidemiologists working in such culturally diverse contexts. The issues discussed include the following: (1) persuading the scientific community and potential sponsors that work with distinct or culturally defined populations is important; (2) framing research questions and activities to meet the needs of communities; (3) defining a population of inference; (4) balancing the needs for comparability and cultural specificity; (5) maximizing scientific validity in light of the challenges in sample acquisition; and (6) developing and implementing data collection methods that uphold scientific standards but are also realistic given the context. The authors draw on their experiences--most recently in the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project (AI-SUPERPFP)--to illustrate these issues and suggest ways to address each. A goal of this paper is to challenge those invested in conducting culturally valid epidemiologic work in such populations to better articulate the nature of these efforts.

Risk factors in relation to an emergence of bipolar disorder: a systematic review

OBJECTIVE

There is a consensus that genetic factors are important in the causation of bipolar disorder (BPD); however, little is known about other risk factors in the aetiology of BPD. Our aim was to review the literature on such risk factors - risk factors other than family history of affective disorders - as predictors for the initial onset of BPD.

METHODS

We conducted a literature search using the MEDLINE, PsycINFO and EMBASE databases. We selected factors of interest including demographic factors, factors related to birth, personal, social and family backgrounds, and history of medical conditions. The relevant studies were extracted systematically according to a search protocol.

RESULTS

We identified approximately 100 studies that addressed the associations between antecedent environmental factors and a later risk for BPD. Suggestive findings have been provided regarding pregnancy and obstetric complications, winter-spring birth, stressful life events, traumatic brain injuries and multiple sclerosis. However, evidence is still inconclusive. Childbirth is likely to be a risk factor. The inconsistency across studies and methodological issues inherent in the study designs are also discussed.

CONCLUSION

Owing to a paucity of studies and methodological issues, risk factors of BPD other than family history of affective disorders have generally been neither confirmed nor excluded. We call for further research.

Education and income: which is more important for mental health?

STUDY OBJECTIVE

To assess which indicators of socioeconomic status are associated with an increased prevalence of common mental disorders.

DESIGN

Cross sectional household survey.

SETTING

Santiago, Chile.

PARTICIPANTS

Random sample of adults aged 16-65 residing in private households.

MAIN RESULTS

Less education (odds ratio 2.44, 95% confidence intervals 1.50 to 3.97), a recent income decrease (odds ratio 2.14, 1.70 to 2.70), and poor housing (odds ratio 1.53, 1.05 to 2.23), were the only socioeconomic status variables that remained significantly associated with an increased prevalence of common mental disorders after adjustments. The prevalence of common mental disorders was also higher among people with manual unskilled occupations, overcrowded housing, and lower per capita income but these associations disappeared after adjustment for other explanatory and confounding variables.

CONCLUSIONS

There is a strong, inverse, and independent association between education and common mental disorders. However, income was not associated with the prevalence of common mental disorders, after adjusting for other socioeconomic variables. Similar results have been found in other Latin American studies but British studies tend to find the opposite, that income but not education is associated with common mental disorders. Understanding the impact of socioeconomic factors on mental health requires research in poor as well as rich countries.

Clinical algorithms as a tool for psychotherapy with Latino clients

Clinical algorithms have the advantage of being able to integrate clinical, cultural, and environmental factors into a unified method of planning and implementing treatment. A model for practice is proposed that uses 3 algorithms as guides for conducting psychotherapy with Latino clients, the uses of which are illustrated in a single, ongoing case vignette. The algorithm format has the additional advantage of easily adapting itself for data gathering for research purposes.

Frequency of hospitalisations and inpatient care costs of manic episodes: in patients with bipolar I disorder in France

BACKGROUND

Bipolar disorder is a chronic illness that may involve multiple relapses and result in substantial psychosocial impairment. However, very few recent studies have investigated the economic burden of the disease.

OBJECTIVE

To assess the frequency of hospitalisation and the inpatient care costs associated with manic episodes in patients with bipolar I disorder in France.

METHOD

A cost-of-illness study was conducted based on available data using a hospital payer perspective. The lifetime prevalence of manic episodes was estimated from published epidemiological data using a random-effects meta-analysis. Data were obtained by a computerised literature search using the main scientific and medical databases. Additional epidemiological references were identified from published studies and textbooks. Data on frequency of hospitalisation and length of stay were collected from a large psychiatric university hospital. Data on unit costs for inpatient care were obtained from the accounting system of the largest hospital group in Paris, France for the year 1999.

RESULTS

Extrapolating from international data on the average prevalence of bipolar I disorder, the proportion of rapid cycling patients and the average cycle duration, we estimated the annual number of manic episodes in patients with bipolar I disorder to be around 265,000 in France. Based on hospital data in Paris, the proportion of manic episodes that require hospitalisation was estimated to be around 63%. The average length of stay was 32.4 days and the hospitalisation-related costs were estimated to be around 8.8 billion French francs (Euro 3 billion) [1999 values].

CONCLUSION

Our study highlights the lack of medical and economic data on the frequency and hospitalisation-related costs of manic episodes in patients with bipolar I disorder in France. As the lifetime prevalence of bipolar I disorder may be as high as 3% among adults, further studies are required in order to provide representative national data and to allow economic evaluations of costs related to bipolar I disorder in France.

The epidemiology of major depressive episodes: results from the International Consortium of Psychiatric Epidemiology (ICPE) Surveys

Absence of a common diagnostic interview has hampered cross-national syntheses of epidemiological evidence on major depressive episodes (MDE). Community epidemiological surveys using the World Health Organization Composite International Diagnostic Interview administered face-to-face were carried out in 10 countries in North America (Canada and the US), Latin America (Brazil, Chile, and Mexico), Europe (Czech Republic, Germany, the Netherlands, and Turkey), and Asia (Japan). The total sample size was more than 37,000. Lifetime prevalence estimates of hierarchy-free DSM-III-R/DSM-IV MDE varied widely, from 3% in Japan to 16.9% in the US, with the majority in the range of 8% to 12%. The 12-month/lifetime prevalence ratio was in the range 40% to 55%, the 30-day/12-month prevalence ratio in the range 45% to 65%, and median age of onset in the range 20 to 25 in most countries. Consistent socio-demographic correlates included being female and unmarried. Respondents in recent cohorts reported higher lifetime prevalence, but lower persistence than those in earlier cohorts. Major depressive episodes were found to be strongly co-morbid with, and temporally secondary to, anxiety disorders in all countries, with primary panic and generalized anxiety disorders the most powerful predictors of the first onset of secondary MDE. Major depressive episodes are a commonly occurring disorder that usually has a chronic-intermittent course. Effectiveness trials are needed to evaluate the impact of early detection and treatment on the course of MDE as well as to evaluate whether timely treatment of primary anxiety disorders would reduce the subsequent onset, persistence, and severity of secondary MDE.

Depression scale scores in 8-17-year-olds: effects of age and gender

BACKGROUND

The excess of unipolar depression in females emerges in adolescence. However, studies of age effects on depression scale scores have produced divergent estimates of changes from childhood to adolescence.

METHOD

We explored possible reasons for this discrepancy in two large, longitudinal samples of twins and singletons aged 8-17.

RESULTS

There were no differences between twins and singletons in their scores on the Short Mood and Feelings Questionnaire (SMFQ), a 13-item self-report depression scale. SMFQ scores for boys fell over this age-range, while those for girls fell from age 9 to age 11 and then increased from age 12 to age 17. The mean scores of girls under 12 and those 12 and over differed by only around one-fifth of a standard deviation. However, given the non-normal distribution of the scores, a cut point that selected the upper 6% of scores created the expected female:male ratio of 2:1.

CONCLUSIONS

Implications for future research on adolescent depression are discussed.

Prevalence and incidence studies of schizophrenic disorders: a systematic review of the literature

OBJECTIVE

To present the results of a systematic review of the literature published between January 1, 1980, and December 31, 2000, that reports findings on the prevalence and incidence of schizophrenia and related disorders.

METHOD

We conducted a literature search of schizophrenia-related epidemiological studies, using Medline and HealthSTAR databases and canvassing English-language publications. We used a set of predetermined inclusion-exclusion criteria to identify relevant studies. Eligible publications were restricted to age ranges of 18 years and over for prevalence studies and 15 years and over for incidence studies. Prevalence and incidence data were extracted and analyzed for heterogeneity.

RESULTS

A total of 18 prevalence and 8 incidence studies met eligibility criteria for the review. Heterogeneity analysis revealed significant differences across 1-year and lifetime prevalence and 1-year incidence of schizophrenia. The corresponding pooled rates were: 0.34 per 100, 0.55 per 100, and 11.1 per 100,000, respectively; the variation in rates between studies was generally between 2- and 5-fold.

CONCLUSIONS

Although we restricted this review to studies using rigorous and relatively homogeneous methods, there remains significant heterogeneity of prevalence and incidence rates. This strengthens support for the hypothesis that there is real variation in the distribution of schizophrenia around the world. Health planners need to have local data on schizophrenia rates to improve the accuracy of their interventions, while clinicians and researchers need to continue to investigate the etiology of this variation.

DSM-IV axis II comorbidity with borderline personality disorder in monolingual Hispanic psychiatric outpatients

The authors examined the comorbidity of DSM-IV borderline personality disorder (BPD) with other personality disorders (PD) in a series of adult monolingual (Spanish only) Hispanic psychiatric outpatients with substance use disorders. One hundred outpatients (69 men and 31 women) were assessed with the Spanish version of the Diagnostic Interview for DSM-IV Personality Disorders. PD co-occurrence in the group of patients with BPD (N = 34) was statistically compared with that in the group without BPD (N = 66). Bonferroni-corrected chi-square analysis showed significant diagnostic comorbidity with BPD for antisocial, avoidant, and depressive PD. However, analyses conducted separately by gender showed no significant comorbidity of any PD with BPD in women and significant comorbidity with antisocial, avoidant, and depressive PD in men. These results suggest that in monolingual Hispanic psychiatric outpatients with substance use disorders, gender may play a role in the nature of BPD comorbidity. The BPD diagnosis may represent a broader range of psychopathology in Hispanic men than women.

TMD prevalence in rural and urban Native American populations

The purpose of this study was to assess the prevalence of TMD in a consecutive sample of 102 subjects from the Native American population living in an urban setting and 90 subjects living in a rural setting. The study utilized a clinical examination and standardized questionnaires. The sample age ranged from five to 84 years of age. The subjects were asked to estimate pain frequency, severity and daily pattern of jaw pain, difficulty in opening, joint clicking, and sleeping problems. Examination was performed on joint, masticatory, and cervical muscles, as well as occlusion. Data was collected and statistically analyzed. Statistically significant differences were found; however, the only statistically significant difference that might have clinical significance was more facial pain in the urban population.

Incidence of major depression: prediction from subthreshold categories in the Stirling County Study

BACKGROUND

Validity of the newly-proposed categories of Minor Depression (MinD) and Subsyndromal Depression (SSD) would be strengthened if they were found to be related to the incidence of Major Depressive Episode (MDE). In this report, the subsequent incidence of MDE was assessed in terms of baseline evidence about the two subthreshold categories and Dysthymic Disorder (DysD).

METHODS

The Diagnostic Interview Schedule was used to interview 489 subjects twice between 1991 and 1995 as part of the Stirling County Study. Life table methods were used to calculate incidence rates and log linear analysis was employed for statistical assessment.

RESULTS

The average annual incidence of MDE was 10 per 1000. The rates associated with the baseline categories were 210 per 1000 for DysD, 21 for MinD; 13 for SSD; and four for the remainder of subjects who constituted the reference group. Only the incidence related to DysD was significantly higher than that for the reference group. Comparing Time 1 and Time 2, one-third of the subjects gained or lost symptoms and the comorbidity of MDE and DysD increased.

LIMITATIONS

The study population was, on average, 63 years of age. Older age and the small size of the cohort may have influenced the findings. Another limitation may relate to the use of lifetime rather than current symptomatology.

CONCLUSIONS

DysD is strongly associated with MDE suggesting that the chronic and episodic forms of unipolar depression constitute one disorder. The other subthreshold categories should be further investigated in terms of prodromal qualities. The persistence of dysphoria, as in DysD, may be a more important feature of the depression prodrome than the number of symptoms.

Social phobia: overview of community surveys

OBJECTIVE

Social phobia has in recent years been recognized as a considerable public health concern. This paper presents an overview of community studies that have estimated the prevalence of social phobia, its subtypes, and specific social fears in the adult general population. Sociodemographic findings are also summarized.

METHOD

Forty-three epidemiological studies from 1980 to the present were located in electronic databases and by complementary searches of citations in journal articles and book chapters.

RESULTS

Recent surveys estimate the lifetime prevalence of social phobia at about 7-13% in Western countries. However, prevalence rates vary considerably and are prone to several influencing methodological variables such as the diagnostic criteria, diagnostic threshold, assessment method, number of situational probes, and prevalence period selected by the researcher.

CONCLUSION

Although there are difficulties in delineating social phobia from subsyndromal social anxiety or shyness, social phobia is even when narrowly defined remarkably common in the general population.

A European perspective on depression in the community: the DEPRES study

Depression is one of the most prevalent disorders in the general population, causing personal and social disability and impairment. Major studies assessing the diagnosis and management of depression have shown that it is often underdiagnosed and undertreated. A pan-European study aimed at assessing the extent and consequences of depression in six different countries is reported in this article. Different types of depressive profiles are analyzed and their respective management has been compared. The importance of improving diagnosis and treatment of depression is underlined. Appropriate management of depression depends on the recognition of depressive symptoms by patients, their possibility of seeking care, and the ability of the primary care physician to recognize the disorder and prescribe the appropriate medicines. Improvement in all of these fields is necessary.

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.

Gender and outpatient mental health service use

The purpose of this study is to describe gender differences in the use of outpatient mental health services and to identify potential determinants of this use. The study sample, N = 7475 respondents 18-64 years, was drawn from the Mental Health Supplement to the Ontario Health Survey. For theoretical and empirical reasons, type of mental disorder was defined as: a Mood and/or Anxiety Disorder (Mood/Anx) or a Substance Use Disorder and/or Antisocial Behaviours (Subs/Asb) within the past year. Use was defined in relation to providers seen within the past year. Descriptive and multiple logistic regression analyses were employed including type of mental disorder, social and economic factors. Female gender remained positively associated with any use despite adjustments (adjusted OR: 1.7; 95% CI: 1.2: 2.4). The magnitude of this association was consistent across the levels of the study variables and various measures of use except volume of use where there were no gender differences. Mood/Anx appeared to mediate the gender-use relationship and was strongly associated with use (adjusted OR: 8.4; 95% CI: 5.9; 11.9). Subs/Asb was also related to use (adjusted OR: 2.6; 95% CI: 1.5; 4.3) but not to the same degree as Mood/Anx. Mood/Anx explained 60% of the crude Subs/Asb-use relationship. The evidence to suggest that Subs/Asb mediated the gender-use relationship was mixed. These findings raise questions about gender differences in illness and reporting behaviours and the health care system in its preferential treatment of women and those with Mood/Anx.

Epidemiology, patterns of comorbidity, and associated disabilities of social phobia

Social phobia is a common condition, with current prevalence estimates in the range of 4% to 6% and a lifetime risk of 7% to 13%. It has an early onset and, without appropriate intervention, it has a disproportionately higher risk for persistence compared with other anxiety disorders. Presentation differs between age groups; the disorder in teenagers and in those in their early 20s tends to look different in terms of types of problems and the associated distress to that expected in the 30s and 40s age groups, when these individuals have already endured 20 years of suffering and disability. There is an increased risk for depression and substance abuse disorders even in adolescence, in addition to an increased risk for psychosocial impairment and disability resembling that experienced by depressed outpatients. This finding is particularly true in cases affected by generalized SP, which might have slightly different etiologic pathways than the nongeneralized type. Social phobia is in itself a disabling disorder, and individuals who develop comorbid conditions have a more severe level of disability. Early recognition, diagnosis, and treatment of SP could minimize sufferers' problems throughout their subsequent lives, preventing the development of comorbidity and a worsened prognosis. Developing models for early recognition and treatment should improve the outcome for the patient, as well as reduce future demand on health care resources. Epidemiologic studies, with their methodologic strengths and unique methods, can be instrumental in this respect. They may, for example, provide time-efficient, simple screening tools for use by physicians or even patients, based on the existing diagnostic instruments used in epidemiologic surveys. They may provide further guidance in making treatment decisions and developing treatment algorithms by offering criteria, which with additional vulnerability and risk factors, will lead to more severe, chronic, and comorbid course in a given case.

The validity of drug use responses in a household survey in Puerto Rico: comparison of survey responses of cocaine and heroin use with hair tests

BACKGROUND

Despite the widespread use of household surveys to assess the epidemiology of illicit drug use and abuse, there is very little information about the willingness of respondents to disclose their use of drugs in household studies outside the US.

METHODS

As part of a household study of substance use disorders in Puerto Rico, we collected hair specimens from a sub-sample of 114 respondents. Hair specimens were screened using a radio immunoassay. Screened-positive specimens were confirmed using gas chromatography/mass spectrometry.

RESULTS

Using hair-test results as the standard, specificity of self-reports was 98% or higher for both drugs. The sensitivity of all self-reports was low, although lifetime use reports had somewhat higher sensitivities. The sensitivity of self-reports of recent cocaine use was particularly low, 7.1%. The sensitivity of heroin use reports was somewhat higher, 33.3% for recent use and 66.7% for lifetime use. The estimate of recent cocaine use based on hair tests was 13.7 times the estimate generated from interview reports. For heroin use, the test-based estimate was 2.9 times the rate generated from the interview reports. A shift from the cut-off level of 0.2 ng/mg to 0.5 ng/mg had only a marginal improvement on validity, with sensitivity increasing from 7.1% to 11.1% for self-reported recent cocaine use.

CONCLUSIONS

The results suggest that drug users, for the most part, are not willing to disclose their use of drugs in household surveys in Puerto Rico. Methods to increase the willingness of respondents to disclose their use of drugs are needed.

Gender and health services use for a mental health problem

This study addresses whether the predictors of seeking help for a mental health problem differ by gender. An adaptation of Andersen's Socio-Behavioral Model is used to identify factors associated with seeking care for a mental health problem. Data are derived from two waves of a community survey undertaken in 1992-1993 and in 1993-1994 among a probability sample of adults (18-69 years), residing in poor areas of Puerto Rico. Paired data was used from those individuals who responded to both waves of the survey for a total of 3221 community respondents. Responses from wave 1 were used to predict mental health service use in wave 2. The dependent variable is any use of outpatient mental health services in the year preceding the second interview. Logistic regression was used to model the effects of the independent variables on use. Males and females were found to use mental health services in nearly equal proportions. Gender did not have a main effect on use when other covariates were controlled. Significant interactions with gender were found for several predictors of use. The largest intervention effects were encountered in our need for care indicators. Having a definite need for mental health care and poor self-rated mental health had a larger effect on predicting use of services for men than they do for women. It is concluded that strategies designed to improve access to mental health services for minority disadvantaged populations ought to take into account gender differences in the predictors of use. Studies addressing factors influencing health services utilization for a mental health problem should consider stratifying their sample by gender. Future research should establish whether or not these findings are sustained with other population groups.

Social anxiety disorder

In 1990s, it was found that GSAD is more common, more disabling, and more chronic than previously realized. For the first time, there are good data about a range of effective treatment options that can offer these patients substantial relief and protection from their disability.

Common mental disorders in Santiago, Chile: prevalence and socio-demographic correlates

BACKGROUND

There have been relatively few surveys in Latin America that have attempted to estimate the prevalence of psychiatric morbidity in private households.

AIMS

To determine the prevalence of common mental disorders and socio-demographic correlates among adults from Santiago, Chile.

METHOD

Cross-sectional survey of private households with a probabilistic sampling design was used. Common mental disorders were measured using the Clinical Interview Schedule-Revised (CIS-R).

RESULTS

Three thousand eight hundred and seventy adults were interviewed. Twenty-five per cent were CIS-R cases and 13% met criteria for an ICD-10 diagnosis. Low education, female gender, unemployment, separation, low social status and lone parenthood were associated with a higher prevalence.

CONCLUSIONS

Prevalence rates were higher than those found in urban areas of Great Britain, both for ICD-10 diagnoses and 'non-specific neurotic disorders'. Similar socio-demographic factors were associated with an increased prevalence of common mental disorders in Chile as in the UK. There is a need to unify methodologies to be able to compare results internationally.

Onset of obsessive-compulsive disorder: premorbid conditions and prodromal phase

This article focuses on the clinical onset of obsessive-compulsive disorder (OCD), specifically addressing the age of onset, gradual and acute onset, and whether there are some types of premorbid conditions or a prodromal phase that predispose individuals to the onset of OCD. Clinical and epidemiological studies have come to different conclusions regarding age at onset as well as regarding differences between the sexes. Data gleaned from research to date have demonstrated a relationship between OCD and obsessive-compulsive personality disorder (OCPD), although OCPD does not appear to be the more prevalent personality disorder among patients with OCD. Preliminary research has suggested that Axis I disorders may predispose individuals to OCD onset; however, the significance of this relationship remains to be clarified. Evidence of the association between OCD and subthreshold obsessive-compulsive syndrome suggests that these disorders lie on a continuum of severity, with some cases developing OCD while others do not.

Stress and psychiatric disorder in urban Rawalpindi. Community survey

BACKGROUND

Recent studies in rural areas of Pakistan have yielded high prevalence rates of common mental disorders, especially among women.

AIMS

To investigate emotional distress and common mental disorders in a poor urban district using the same survey method.

METHOD

First-stage screening of a slum district of Rawalpindi used the Bradford Somatic Inventory. Psychiatric interviews were conducted with stratified samples using the ICD-10 research diagnostic criteria.

RESULTS

On a conservative estimate, 25% of women and 10% of men suffered from anxiety and depressive disorders. Levels of emotional distress increased with age in both men and women. Women living in joint households reported more distress than those living in unitary families. Higher levels of education were associated with lower risk of common mental disorders, especially in younger women. Emotional distress was negatively correlated with socio-economic variables among women.

CONCLUSIONS

This study found levels of emotional distress and psychiatric morbidity in a poor district of Rawalpindi to be less than half those in a nearby rural village in the Punjab, although rates in women were still double those in men. Possible explanations are that more healthy people migrate to the cities or that urban living is more conducive to good mental health in Pakistan.

The growing public health importance of common mental disorders. The forgotten reality of the less developed world

Non-communicable diseases are growing rapidly and mental problems represent a large proportion of this group. Most mental health burden is to be found in the community and at primary health care. There are large disparities in prevalence rates between and within countries. Latin American countries have consistently shown higher prevalence rates than most other countries in the world.

One-year prevalence and incidence of depression among first-year university students in Japan: a preliminary study

A structured interview was used to examine the 1-year incidence and prevalence of depression among 116 first-year university students. While 24 of the subjects (20.7%) met the Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) criteria for Major Depressive Episode (MDE), 62 (53.4%) met the Diagnostic and Statistical Manual of Mental Disorders 3rd ed. Revised (DSM-III-R) criteria for MDE, and 27 (23.3%) also met the Research Diagnostic Criteria (RDC) for Major Depressive Disorder (MDD) for the 12 months prior to the interview. Moreover, 23 of the subjects (19.8%) had onset of the DSM-IV criteria for MDE, 54 (46.6%) had onset of the DSM-III-R criteria for MDE, 24 (20.7%) had onset of the RDC for MDD, during the same time period. These high rates of depression may be explained by the students' difficulties in and by their readjustment after entering university.

The epidemiology and cross-national presentation of obsessive-compulsive disorder

One of the challenges facing modern psychiatry is to determine to what extent the diagnostic categories clinicians have represent valid constructs. Epidemiologic studies are helpful in this regard when their findings are consistent across various cultural or geographic settings or with those of clinical studies. The cross-national epidemiologic data on OCD reviewed in this article are remarkable for their consistency in rates, age at onset, and comorbidity across diverse countries, a fact which lends additional support to the validity of the diagnosis of OCD. The variability in symptom presentation across national sites suggests that cultural factors may affect the symptom expression; however, why the rates of OCD and other psychiatric disorders are so much lower in Taiwan than in other sites, including another Asian site, is unclear. Epidemiologic studies of adolescents and of adults have shown similar prevalence of OCD and substantial comorbidity with major depression and other anxiety disorders. Studies of adolescent populations indicate that OCD symptoms are fairly common among adolescents but not necessarily predictive of developing the full disorder within 1 year of follow-up. Family studies have suggested an association between OCD and TS and other CMT disorders. Clinical studies have suggested an association between Sydenham's chorea and OCD. These various studies provide a growing body of knowledge regarding the nature of OCD. Together with evidence of the substantial demand on mental health services by those afflicted with OCD, the epidemiologic data make a compelling case for additional efforts to improve the understanding and treatment of this troubling disorder.

Hispanic ethnicity and risk for combat-related posttraumatic stress disorder

Hispanic veterans are said to exhibit higher risk of developing posttraumatic stress disorder (PTSD) than veterans of other racial/ethnic backgrounds. This prediction is based largely on findings from the National Vietnam Veterans Readjustment Study (NVVRS; R. A. Kulka et al., 1990a, 1990b). This article first summarizes the findings of the NVVRS with regard to race/ethnicity and PTSD, and then it makes a careful assessment of both the external and the internal validity of these findings. Conceptual issues are addressed and, where possible, further analyses of the NVVRS data set are conducted to identify factors that account for ethnic differences in rates of the disorder. Possible mediators of the effects of Hispanic ethnicity on vulnerability to PTSD are identified, including psychosocial factors (racial/ethnic discrimination and alienation) and sociocultural influences (stoicism and normalization of stress, alexithymia, and fatalism). Areas in which future research is needed are indicated.

Angstsyndrome in Ost- und Westdeutschland: Eine repräsentative Bevölkerungserhebung

Zusammenfassung. In einer für Gesamtdeutschland repräsentativen Bevölkerungserhebung wurden Häufigkeit, Intensität und Behandlung von Angstsyndromen bei 2948 Personen mit Hilfe eines psychometrischen Angstinventars und eines vollstandardisierten Interviews für soziodemographische Variablen und Behandlungserfahrungen erfaßt. Die Ergebnisse zeigen eine Punktprävalenzrate von 8.8 % für Gesamtdeutschland, wobei der Wert im Osten mit 16.3 % mehr als doppelt so hoch ist wie im Westen (7 %). Deutlich gehäuft sind Angstsyndrome u. a. bei Frauen, jungen und alten Personen, Personen mit Verlusterlebnissen (Scheidung, Trennung, Todesfall) und fehlender Vollbeschäftigung. Bemerkenswert sind die Ergebnisse der Behandlung: Die Behandlungsrate liegt bei lediglich vier von zehn Betroffenen. Wenn behandelt wurde, dann vor allem medikamentös und durch Nicht-Spezialisten, Psychotherapie wurde selten eingesetzt, Verhaltenstherapie nur in 1 % aller Behandlungsfälle. Die durchschnittlichen Erfolgsquoten der Behandlungen waren niedrig. Angesichts der hohen Prävalenzen und der Mangelbzw. Fehlversorgung ergibt sich ein dringender Handlungsbedarf.

Häufigkeit und Komorbidität Somatoformer Störungen bei Jugendlichen: Ergebnisse der Bremer Jugendstudie

Zusammenfassung. Anhand von Daten der Bremer Jugendstudie werden in diesem Artikel Ergebnisse hinsichtlich der Häufigkeit und Komorbidität sowie psychosozialer Beeinträchtigung durch Somatoforme Störungen bei Jugendlichen dargestellt. 136 Jugendliche (13,1 %) erfüllten die Kriterien für eine Somatoforme Störung, wobei signifikant mehr Mädchen als Jungen von diesen Störungen betroffen waren. Von den Subtypen Somatoformer Störungen trat als häufigste die Undifferenzierte Somatoforme Störung auf, gefolgt von der Schmerzstörung und der Konversionsstörung. Auf der Symptomebene wurden Kopfschmerzen, das Gefühl eines Kloßes im Hals und Schmerzen im Bauchbereich am häufigsten mitgeteilt. Fast die Hälfte der Jugendlichen mit Somatoformen Störungen erfüllte die Kriterien für mindestens eine weitere Störung. Obwohl ein Drittel dieser Jugendlichen psychosozial beeinträchtigt war, wurde nur ein kleiner Teil von ihnen behandelt.

The epidemiology of major depression: implications of occurrence, recurrence, and stress in a Canadian community sample

OBJECTIVE

To study the effects of stress process variables on the prevalence of major depressive disorder (MDD) and to explore the factors related to its onset and recurrence, using measures of stress and disorder that are more comprehensive than those in previous studies of depression.

METHOD

Data were collected from a randomly selected community sample of 1393 adult respondents in Toronto, Ontario. Depression was measured using the Composite International Diagnostic Interview (CIDI).

RESULTS

Bivariate and multivariate analyses examine demographic and stress process correlates of MDD to assess their impact on both occurrence and recurrence. The effects of childhood experiences on lifetime MDD are examined as risk factors for the initial onset of depression. With respect to occurrence, the multivariate analyses tended to show agreement with established findings. Results using a subsample of people with lifetime depression to predict recurrence tended to mirror results using the full sample, except with respect to gender, birthplace, and, to a certain degree, stress differences. Finally, traumas experienced in childhood, as well as early childhood experiences involving parental substance abuse and mental health problems, were significant predictors of the onset of major depressive disorder.

CONCLUSION

This research currently represents the only Canadian community study to examine the relationship between stress, social support, coping, and depression using outcome measures that approximate Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. In addition, it is among the few that use a comprehensive measure of life stress encompassing childhood experiences and current operant stress (both events and chronic problems).

Transtornos depressivos em usuários de drogas injetáveis infectados pelo HIV: um estudo controlado

OBJETIVO: Estudar os transtornos psiquiátricos em pacientes usuários de drogas injetáveis infectados pelo HIV. MÉTODOS: Pacientes que se apresentavam para tratamento da dependência de drogas, foram divididos em dois grupos de acordo com a sorologia para o HIV (vírus da imunodeficiência humana), vírus causador da síndrome da imunodeficiência adquirida (AIDS). Trinta pacientes HIV-positivos e 30 pacientes HIV-negativos submeteram-se a uma entrevista estruturada para avaliação de transtornos psiquiátricos. Inicialmente, foram analisados os transtornos depressivos e os relacionados ao uso de substâncias psicoativas. RESULTADOS: Os resultados revelaram que o diagnóstico de dependência de cocaína foi mais freqüente em pacientes infectados pelo HIV do que nos não-infectados. A sorologia positiva para o HIV não foi fator associado a maior prevalência de depressão. As tentativas de suicídio foram freqüentes nesta amostra, mas as freqüências foram iguais nos dois grupos. CONCLUSÃO: Os pacientes HIV-positivos tendem a diminuir ou cessar o consumo de cocaína após conhecimento de sua sorologia.

Obsessive-compulsive syndromes in older adolescents

OBJECTIVE

This report presents data on the prevalence of both obsessive-compulsive disorder (OCD) and subthreshold obsessive-compulsive syndrome (sOCS) in a representative sample of older male adolescents living in Piedmont, Italy.

METHOD

A total of 1,883 recruits to the Italian Defence Force were interviewed using the OC portion of the Diagnostic Interview Schedule. A diagnosis of sOCS was made for individuals who had obsessive and/or compulsive symptoms but who failed to meet one of the severity criteria of impairment.

RESULTS

The point and lifetime prevalence rates of OCD were 2.0% and 2.6%, respectively. In total, 12.3% of the subjects received a current diagnosis of sOCS. No differences were found when examining prevalence rates according to area of residence or occupational status of the subjects.

CONCLUSION

Our findings suggest that OCD is as common in older male adolescents as it is in adults, and that sOCS, being commonly endorsed in a general adolescent population, may represent a normal phenomenon in older adolescents.

Research on culture-bound syndromes: new directions

The unprecedented inclusion of culture-bound syndromes in DSM-IV provides the opportunity for highlighting the need to study such syndromes and the occasion for developing a research agenda to study them. The growing ethnic and cultural diversity of the U.S. population presents a challenge to the mental health field to develop truly cross-cultural approaches to mental health research and services. In this article, the authors provide a critique of previous analyses of the relationship between culture-bound syndromes and psychiatric diagnoses. They highlight the problems in previous classificatory exercises, which tend to focus on subsuming the culture-bound syndromes into psychiatric categories and fail to fully investigate these syndromes on their own terms. A detailed research program based on four key questions is presented both to understand culture-bound syndromes within their cultural context and to analyze the relationship between these syndromes and psychiatric disorders. Results of over a decade of research on ataques de nervios, a Latino-Caribbean cultural syndrome, are used to illustrate this research program. The four questions focus on the nature of the phenomenon, the social-cultural location of sufferers, the relationship of culture-bound syndromes to psychiatric disorders, and the social and psychiatric history of the syndrome in the life course of the sufferer.

The costs of schizophrenia in Puerto Rico

Mental illnesses generate social costs by reducing the productive capacity of manpower and increasing government and private expenditure in mental health services. The social costs associated with a mental illness depend on several factors: the level of impairment caused; the type of specialized service required, such as medical treatment; the chronicity of the disorder; and the age of onset of the disorder. Finally, the total cost to society depends on the size of the population affected by the disorder. Results confirm those of other research, which has found schizophrenia to be a costly illness. Annual loss of income represents 3.7% of the annual gross national product of the island. The expenditures for mental health services are 26.8% of the total budget of the Mental Health Secretariat. The large human capital cost caused by the disorder justifies more funds for research and treatment for people who are schizophrenic.

The comorbidity of alcohol dependence and affective disorders: treatment implications

This paper reviews recent literature on the prevalence of alcohol dependence and affective disorders (major depression, dysthymia), the comorbidity of these conditions and the effects of comorbid affective disorders on the outcome of treatment for alcohol dependence. Alcohol dependence and affective disorders co-occur at significantly higher rates than would be expected by chance within the general population. This comorbidity is further elevated in samples of people seeking treatment for alcohol dependence, suggesting that the co-occurrence of affective disorders may be an important determinant of treatment seeking. The results of a number of recent placebo-controlled studies have suggested that pharmacological treatment with anti-depressants may enhance the efficacy of treatment for alcohol dependence in individuals with comorbid affective disorders.

Becoming modern after all these years: social change and mental health in Latin America

This paper takes a critical standpoint, both theoretical and methodological, to revisit Inkeles and Smith's hypothesis on the association between modernization and mental health. First it is proposed a critical evaluation of the premises of the conceptual treatment of the relationships between social change and mental health prevailing during the past two decades. Secondly, results from epidemiologic research on the psychological outcomes of social development in Latin America are reviewed, emphasizing the methodological improvements which occurred during the past two decades. Selected findings of an epidemiological survey recently conducted in urban Brazil are then presented, focusing on a case-control analysis of the socio-economic correlates of individual mental health. Finally, some of the implications of the new evidence concerning the social change and mental health hypothesis are discussed, as an attempt to interpret these findings in the light of recent developments of theories on social change and health in the contemporary world.

The emerging epidemiology of hypomania and bipolar II disorder

The literature on the lifetime prevalence of the bipolar spectrum suggests rates of 3-6.5%. The Zurich cohort study identified a prevalence rate up to age 35 of 5.5% of DSM-IV hypomania/mania and a further 2.8% for brief hypomania (recurrent and lasting 1-3 days). The validity of DSM-IV hypomania and brief hypomania was demonstrated by a family history of mood disorders, a history of suicide attempts and treatment for depression. Comorbidity with anxiety disorders and substance abuse was found equally in both subtypes of hypomania. The study suggests that recurrent brief hypomania belongs to the bipolar spectrum. The findings should be verified on larger national cohorts in other epidemiological and clinical studies.

Expression of symptomatic distress by Puerto Rican and Euro-American patients with depression and schizophrenia

Latinos, principally Puerto Rican, and Euro-American psychiatric outpatients diagnosed with schizophrenia or major depression were compared on their responses to the Brief Symptom Inventory (BSI). The internal consistency reliability of the BSI dimensions and factor structures were comparable in the two cultural groups. Puerto Rican respondents scored significantly higher than Euro-Americans on the Global Severity Index, an index of distress, as well as on several subscales of the instrument. Multiple regression analysis suggested differences in expression of symptoms between Latinos and Euro-Americans only for obsessive compulsive and anxiety symptoms once general severity of symptom expression was controlled. Differences in symptom expression on the BSI associated with ethnicity were greater than those associated with diagnosis.

Nosological validity of dysthymia. Part I: historical, epidemiological and clinical data

Dysthymia is the last diagnostic label introduced after a series of precursors to describe a disorder whose nosological status has long been dubious. The results of published epidemiological, as well as clinical studies about its presentation, course and outcome partly support the validity of this construct — although their interpretation is limited by methodological difficulties: same prevalence in many locations in the world, always lower than that of major depression, somewhat specific clinical pattern, course and outcome.