The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)

The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication

CONTEXT

Little is known about the epidemiology of intermittent explosive disorder (IED).

OBJECTIVE

To present nationally representative data on the prevalence and correlates of DSM-IV IED.

DESIGN

The World Health Organization Composite International Diagnostic Interview was used to assess DSM-IV anxiety disorders, mood disorders, substance use disorders, and impulse control disorders.

SETTING

The National Comorbidity Survey Replication, a face-to-face household survey carried out in 2001-2003.

PARTICIPANTS

A nationally representative sample of 9282 people 18 years and older.

MAIN OUTCOME MEASURE

Diagnoses of DSM-IV IED.

RESULTS

Lifetime and 12-month prevalence estimates of DSM-IV IED were 7.3% and 3.9%, with a mean 43 lifetime attacks resulting in 1359 dollars in property damage. Intermittent explosive disorder-related injuries occurred 180 times per 100 lifetime cases. Mean age at onset was 14 years. Sociodemographic correlates were uniformly weak. Intermittent explosive disorder was significantly comorbid with most DSM-IV mood, anxiety, and substance disorders. Although the majority of people with IED (60.3%) obtained professional treatment for emotional or substance problems at some time in their life, only 28.8% ever received treatment for their anger, while only 11.7% of 12-month cases received treatment for their anger in the 12 months before interview.

CONCLUSIONS

Intermittent explosive disorder is a much more common condition than previously recognized. The early age at onset, significant associations with comorbid mental disorders that have later ages at onset, and low proportion of cases in treatment all make IED a promising target for early detection, outreach, and treatment.

A major depression prognosis calculator based on episode duration

Background

Epidemiological data have shown that the probability of recovery from an episode declines with increasing episode duration, such that the duration of an episode may be an important factor in determining whether treatment is required. The objective of this study is to incorporate episode duration data into a calculator predicting the probability of recovery during a specified interval of time.

Methods

Data from two Canadian epidemiological studies were used, both studies were components of a program undertaken by the Canadian national statistical agency. One component was a cross-sectional psychiatric epidemiological survey (n = 36,984) and the other was a longitudinal study (n = 17,262).

Results

A Weibull distribution provided a good description of episode durations reported by subjects with major depression in the cross-sectional survey. This distribution was used to develop a discrete event simulation model for episode duration calibrated using the longitudinal data. The resulting estimates were then incorporated into a predictive calculator. During the early weeks of an episode, recovery probabilities are high. The model predicts that approximately 20% will recover in the first week after diagnostic criteria for major depression are met. However, after six months of illness, recovery during a subsequent week is less than 1%.

Conclusion

The duration of an episode is relevant to the probability of recovery. This epidemiological feature of depressive disorders can inform prognostic judgments. Watchful waiting may be an appropriate strategy for mild episodes of recent onset, but the risks and benefits of this strategy must be assessed in relation to time since onset of the episode.

Comorbid painful physical symptoms and depression: prevalence, work loss, and help seeking

BACKGROUND

Painful physical symptoms (PPS) are frequent in patients with Major Depressive Episode (MDE). Here, the 12-month prevalence and sociodemographic characteristics of PPS were examined taking into account somatic comorbidity; quantitative and qualitative aspects of MDE with or without PPS were investigated as well as their impact on work loss days (WLD). Finally, help seeking and delay in help seeking were explored.

METHODS

In a cross-sectional, population-based study, a representative random sample of non-institutionalised adults from Belgium, France, Germany, Italy, the Netherlands and Spain (N = 21,425) was interviewed using the World Mental Health Composite Diagnostic Interview (CIDI 3.0 of the WHO).

RESULTS

PPS were reported by 29% of respondents without MDE and by 50% in those with MDE. Female gender, higher age and lower educational level were predictive of PPS. PPS were more frequent in more severely depressed patients but no qualitative differences were found in MDE with and MDE without PPS. An additive effect of MDE and PPS was found on the WLD score. Whether a comorbid somatic disorder was present or not did not change the findings. Finally, respondents with MDE and PPS had lower rates of help seeking for emotional reasons and show a trend to delay their help seeking longer.

LIMITATIONS

The most important limitation of this study was its reliance on self-report data about somatic disorders.

CONCLUSION

Approximately one in two persons with a mood disorder also reported the presence of PPS. MDE and PPS result in decreased productivity and in lower rates of help seeking.

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.

Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication

OBJECTIVE

Despite its inclusion in DSM-IV, little is known about the prevalence or correlates of adult separation anxiety disorder or its relationship to the childhood disorder. Results of the first epidemiological study of adult separation anxiety disorder, to the authors' knowledge, and its relationship to childhood separation anxiety disorder are presented.

METHOD

Data were from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of U.S. households. A fully structured, lay-administered diagnostic interview assessed a wide range of DSM-IV disorders, including separation anxiety disorder. No independent clinical validation was obtained of the assessment.

RESULTS

Lifetime prevalence estimates of childhood and adult separation anxiety disorders were 4.1% and 6.6%, respectively. Approximately one-third of the respondents who were classified as childhood cases (36.1%) had an illness that persisted into adulthood, although the majority classified as adult cases (77.5%) had first onset in adulthood. The assessment of separation anxiety disorder in the NCS-R was comorbid with other NCS-R or DSM-IV disorders and associated with severe role impairment in roughly half of the comorbid cases and one-fourth of the pure cases. The majority of people with estimated adult separation anxiety disorder are untreated, even though many obtain treatment for comorbid conditions.

CONCLUSIONS

Criteria for adult separation anxiety disorder should be refined in future editions of DSM because the disorder is likely to be much more common in adults than previously recognized. Research is needed to develop and evaluate treatments that take into consideration its high comorbidity with other DSM-IV disorders.

The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication

OBJECTIVE

Despite growing interest in adult attention deficit hyperactivity disorder (ADHD), little is known about its prevalence or correlates.

METHOD

A screen for adult ADHD was included in a probability subsample (N=3,199) of 18-44-year-old respondents in the National Comorbidity Survey Replication, a nationally representative household survey that used a lay-administered diagnostic interview to assess a wide range of DSM-IV disorders. Blinded clinical follow-up interviews of adult ADHD were carried out with 154 respondents, oversampling those with positive screen results. Multiple imputation was used to estimate prevalence and correlates of clinician-assessed adult ADHD.

RESULTS

The estimated prevalence of current adult ADHD was 4.4%. Significant correlates included being male, previously married, unemployed, and non-Hispanic white. Adult ADHD was highly comorbid with many other DSM-IV disorders assessed in the survey and was associated with substantial role impairment. The majority of cases were untreated, although many individuals had obtained treatment for other comorbid mental and substance-related disorders.

CONCLUSIONS

Efforts are needed to increase the detection and treatment of adult ADHD. Research is needed to determine whether effective treatment would reduce the onset, persistence, and severity of disorders that co-occur with adult ADHD.

The epidemiology of panic attacks, panic disorder, and agoraphobia in the National Comorbidity Survey Replication

CONTEXT

Only limited information exists about the epidemiology of DSM-IV panic attacks (PAs) and panic disorder (PD).

OBJECTIVE

To present nationally representative data about the epidemiology of PAs and PD with or without agoraphobia (AG) on the basis of the US National Comorbidity Survey Replication findings.

DESIGN AND SETTING

Nationally representative face-to-face household survey conducted using the fully structured World Health Organization Composite International Diagnostic Interview.

PARTICIPANTS

English-speaking respondents (N=9282) 18 years or older.

MAIN OUTCOME MEASURES

Respondents who met DSM-IV lifetime criteria for PAs and PD with and without AG.

RESULTS

Lifetime prevalence estimates are 22.7% for isolated panic without AG (PA only), 0.8% for PA with AG without PD (PA-AG), 3.7% for PD without AG (PD only), and 1.1% for PD with AG (PD-AG). Persistence, lifetime number of attacks, and number of years with attacks increase monotonically across these 4 subgroups. All 4 subgroups are significantly comorbid with other lifetime DSM-IV disorders, with the highest odds for PD-AG and the lowest for PA only. Scores on the Panic Disorder Severity Scale are also highest for PD-AG (86.3% moderate or severe) and lowest for PA only (6.7% moderate or severe). Agoraphobia is associated with substantial severity, impairment, and comorbidity. Lifetime treatment is high (from 96.1% for PD-AG to 61.1% for PA only), but 12-month treatment meeting published treatment guidelines is low (from 54.9% for PD-AG to 18.2% for PA only).

CONCLUSION

Although the major societal burden of panic is caused by PD and PA-AG, isolated PAs also have high prevalence and meaningful role impairment.

Prevalence, subtypes, and correlates of DSM-IV conduct disorder in the National Comorbidity Survey Replication

BACKGROUND

Prior research indicates that conduct disorder (CD) is associated with a range of co-morbid mental disorders. However, the actual prevalence, subtypes and patterns of co-morbidity of DSM-IV-defined CD in the general US population remains unknown.

METHOD

Retrospective assessment of CD and other DSM-IV disorders was conducted using fully structured diagnostic interviews among a nationally representative sample of respondents (n=3199) in the National Comorbidity Survey Replication (NCS-R).

RESULTS

The estimated lifetime prevalence of CD in the US is 9.5% (12.0% among males and 7.1% among females), with a median age-of-onset of 11.6 (0.2) years. Latent class analysis (LCA) identified five CD subtypes characterized by rule violations, deceit/theft, aggression, severe covert behaviors, and pervasive CD symptoms. A dose-response relationship was revealed between CD subtype severity and risk of subsequent disorders. Results also indicated that CD typically precedes mood and substance use disorders, but most often occurs after impulse control and anxiety disorders. Although both active and remitted CD is associated with increased risk of the subsequent first onset of other mental disorders, remitted CD is associated with significantly lower risk of subsequent disorders.

CONCLUSIONS

CD is prevalent and heterogeneous in the US population, and more severe subtypes and the presence of active CD are associated with higher risk of co-morbid disorders. Future prospective studies using general population samples will further inform the nature and course of this disorder.

Do Children Know Their Parent’s HIV Status? Parental Reports of Child Awareness in a Nationally Representative Sample

OBJECTIVE

To determine the rates and predictors of child awareness of parental human immunodeficiency virus (HIV) status and the effect of that knowledge on children.

METHODS

Interviews were conducted with 274 parents from a nationally representative sample of HIV-infected adults receiving health care for HIV. The outcome measures were parental report of child's awareness of parental HIV status, how others reacted to child's parent having HIV, and reasons for nondisclosure.

RESULTS

HIV-infected parents reported that 44% of their children (5-17 years old) were aware of their parent's HIV status, and parents had discussed with 90% of those children the possibility that HIV or acquired immunodeficiency syndrome (AIDS) might lead to their parent's death. Multivariate analyses revealed that parents with higher income, with an HIV risk group of heterosexual intercourse, with higher CD4 counts, with greater social isolation, and with younger children were less likely than others to report that their child knew the parent was HIV positive. Parents reported that 11% of children worried they could catch HIV from their parent. Reasons children did not know their parent's HIV status included that the parent was worried about the emotional consequences of disclosure (67%), was worried the child would tell other people (36%), and did not know how to tell their child (28%).

CONCLUSIONS

HIV-infected parents often worry about the emotional consequences of disclosure to their children and that their children may tell others. More than a quarter of parents reported not knowing how to tell their children. Clinicians may be able to support and guide HIV-infected parents in deciding whether, when, and how to disclose their infection to their children.

Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being

BACKGROUND

Large-scale community studies of the prevalence of mental disorders using standardised assessment tools are rare in sub-Saharan Africa.

AIMS

To conduct such a study.

METHOD

Multistage stratified clustered sampling of households in the Yoruba-speaking parts of Nigeria. Face-to-face interviews used the World Mental Health version of the Composite International Diagnostic Interview (WMH-CIDI).

RESULTS

Of the 4984 people interviewed (response rate 79.9%), 12.1% had a lifetime rate of at least one DSM-IV disorder and 5.8% had 12-month disorders. Anxiety disorders were the most common (5.7% lifetime, 4.1% 12-month rates) but virtually no generalised anxiety or post-traumatic stress disorder were identified. Of the 23% who had seriously disabling disorders, only about 8% had received treatment in the preceding 12 months. Treatment was mostly provided by general medical practitioners; only a few were treated by alternative practitioners such as traditional healers.

CONCLUSIONS

The observed low rates seem to reflect demographic and ascertainment factors. There was a large burden of unmet need for care among people with serious disorders.

Mental disorders in a population sample with musculoskeletal disorders

Background

Studies using clinical and volunteer samples have reported an elevated prevalence of mood disorders in association with rheumatoid arthritis and osteoarthritis. Clinical studies using anxiety rating scales have reported inconsistent results, but studies using diagnostic instruments have reported that anxiety disorders may be even more strongly associated with arthritis than is depression. One study reported an association between lifetime substance use disorders and arthritis.

Methods

Data from iteration 1.2 of the Canadian Community Health Survey (CCHS) were used. This was a large-scale national Canadian health survey which administered the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects randomly selected from the national population. In the CCHS 1.2, subjects were asked whether they had been diagnosed by a health professional with arthritis or rheumatism.

Results

Subjects reporting arthritis or rheumatism had an elevated prevalence of mood, anxiety and substance use disorders. The strength of association resembled that seen in an omnibus category reporting any chronic condition, but was weaker than that seen with back pain or fibromyalgia. The effect of arthritis or rheumatism interacted with age, such that the odds ratios became smaller with increasing age. Mood and anxiety disorders, along with arthritis or rheumatism made an independent contribution to disability.

Conclusion

Arthritis is associated with psychiatric morbidity in the general population, and this morbidity is seen across a variety of mental disorders. The strength of association is consistent with that seen in persons with other self-reported medical conditions.

The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication

OBJECTIVE

Despite growing interest in adult attention deficit hyperactivity disorder (ADHD), little is known about its prevalence or correlates.

METHOD

A screen for adult ADHD was included in a probability subsample (N=3,199) of 18-44-year-old respondents in the National Comorbidity Survey Replication, a nationally representative household survey that used a lay-administered diagnostic interview to assess a wide range of DSM-IV disorders. Blinded clinical follow-up interviews of adult ADHD were carried out with 154 respondents, oversampling those with positive screen results. Multiple imputation was used to estimate prevalence and correlates of clinician-assessed adult ADHD.

RESULTS

The estimated prevalence of current adult ADHD was 4.4%. Significant correlates included being male, previously married, unemployed, and non-Hispanic white. Adult ADHD was highly comorbid with many other DSM-IV disorders assessed in the survey and was associated with substantial role impairment. The majority of cases were untreated, although many individuals had obtained treatment for other comorbid mental and substance-related disorders.

CONCLUSIONS

Efforts are needed to increase the detection and treatment of adult ADHD. Research is needed to determine whether effective treatment would reduce the onset, persistence, and severity of disorders that co-occur with adult ADHD.

Prevalencia de los trastornos mentales y factores asociados: resultados del estudio ESEMeD-España

BACKGROUND AND OBJECTIVE

The ESEMeD-Spain project is an epidemiological study about mental disorders in Spain. We present 12 month-prevalence and lifetime-prevalence of the main mood, anxiety and alcohol use disorders; the influence of sociodemographic factors on its presence and age of onset of the disorders.

SUBJECTS AND METHOD

Cross-sectional household survey of a representative sample of the population of Spain 18 years or older. Sample size was 5.473 individuals. The WHO World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH-CIDI) was used. Response rate was 78.6%. Results have been weighted to represent the population of Spain.

RESULTS

19.5% of the individuals presented a mental disorder sometime in their lifetime (lifetime-prevalence) and 8.4% in the last 12 months (12 month-prevalence). The most frequent mental disorder was major depressive episode, with a 12-month prevalence of 3.9% and a lifetime-prevalence of 10.5%. The other most lifetime prevalent disorders were specific phobia, alcohol abuse disorder, and dysthymia. Factors associated to presenting a mental disorder were being female, being separated, divorced or widowed, and being unemployed, on sick leave or incapacitated. Social phobia, agoraphobia and specific phobia appear at younger ages, while mood disorders and panic disorder appears later in life.

CONCLUSIONS

The ESEMeD-Spain study can provide careful outcomes to understand the impact of mental disorders in Spain.

Twelve-month use of mental health services in four areas in Japan: findings from the World Mental Health Japan Survey 2002-2003

The aim of the present study was to provide basic descriptive data regarding utilization of 12-month mental health services in the Japanese community population. Face-to-face household surveys were carried out in four areas (two urban cities and two rural municipalities), and a total of 1663 persons participated (overall response rate: 56.4%). For data collection, the structured psychiatric interview, World Mental Health version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) was used, allowing DSM-IV diagnoses, severity, and service utilization. It was found that 7.3% of total respondents had received any service, either professional or non-professional, in the past 12 months, including 20.0% of those with 12-month DSM-IV disorders and 6.2% of those without. Thirty-three percent of those with any mood disorder used any service, and 26.8% of those used some type of health care. The probability of people with 13-15 years of education receiving mental health treatment was fourfold higher than those with >or=16 years of education. Gender, age, or income were not found to contribute to utilization of mental health services. The results confirm that the majority of people with a recent psychiatric disorder have not used mental health care or other support systems. The mental health care system in Japan has improved over the past decade, but not enough for people suffering from mental disturbances.

Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey

BACKGROUND

Mental disorders are believed to account for a large portion of disease burden worldwide. However, no national studies have been undertaken to assess this assumption in the Arab world.

METHODS

As part of the WHO World Mental Health (WMH) Survey Initiative, a nationally representative psychiatric epidemiological survey of 2857 adults (aged 18 years) was done in Lebanon between September, 2002, and September, 2003, through a study called LEBANON (Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation). 12-month prevalence and severity of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) disorders, and treatment were assessed with the WHO Composite International Diagnostic Interview (CIDI, version 3.0). Information was also obtained for sociodemographics and exposure to traumatic events in the Lebanon wars.

FINDINGS

308 (17.0%) of respondents met criteria for at least one 12-month DSM-IV/CIDI disorder, 108 (27.0%) of whom were classified serious and an additional 112 (36.0%) moderate. Nearly half of respondents had a history of exposure to war-related traumatic events. Significantly elevated odds ratios (OR) of mood, anxiety, and impulse-control disorders were associated with two (OR 2.0-3.6) or more (2.2-9.1) war-related traumatic events, resulting in substantially higher proportions of moderate and severe 12-month mental disorders in respondents exposed to multiple war-related traumata (16.8-20.4%) compared with other respondents (3.3-3.5%). Only 47 (10.9%) respondents with 12-month disorders obtained treatment. 85% of people were treated in the general medical sector and the mental-health-care system, and the rest by religious or spiritual advisers, counsellors, herbalists, or fortune-tellers.

INTERPRETATION

Mental disorders are common in Lebanon, with a prevalence equivalent to that in Western Europe. However, the number of individuals with mental disorders who are not receiving treatment is considerably higher in Lebanon than in Western countries.

Perceived Barriers To Mental Health Service Use Among Individuals With Mental Disorders in the Canadian General Population

BACKGROUND

Eliminating barriers to care is important for improving health service use. However, the barriers to mental health care have not been well investigated.

OBJECTIVES

This study was designed to provide information about the barriers to mental health service use and to identify clinical factors associated with perceived barriers among individuals with depressive-, anxiety-, and substance use-related disorders in the communities.

DESIGN

A cross-sectional analysis using data from the Canadian Community Health Survey-Mental Health and Well-being was instituted.

SUBJECTS

Participants with depressive-, anxiety-, and substance use-related disorders in the past 12 months, assessed by the World Mental Health-Composite International Diagnostic Interview, were included (n = 4094).

RESULTS

In participants with mental disorders, 19.5% reported barriers to mental health service use. The percentage of perceived barriers due to acceptability was higher than those for barriers due to accessibility and availability. Participants with comorbid mental disorders were more likely to have experienced barriers than those with one disorder in both mental health service users and in the nonusers. Role impairment was a significant factor predicting barriers to care, overall and in the service nonusers, in the groups having anxiety disorders only, having any depressive or anxiety disorders, and having any alcohol or drug dependence.

CONCLUSIONS

Clinical characteristics play an important role in perceiving barriers to mental health care. Future efforts should pay particular attention to the needs of those with chronic and severe mental health problems and focus on improving the effectiveness of mental health services.

Concordance of the Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized clinical assessments in the WHO World Mental Health surveys

The DSM-IV diagnoses generated by the fully structured lay-administered Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) in the WHO World Mental Health (WMH) surveys were compared to diagnoses based on follow-up interviews with the clinician-administered non-patient edition of the Structured Clinical Interview for DSM-IV (SCID) in probability subsamples of the WMH surveys in France, Italy, Spain, and the US. CIDI cases were oversampled. The clinical reappraisal samples were weighted to adjust for this oversampling. Separate samples were assessed for lifetime and 12-month prevalence. Moderate to good individual-level CIDI-SCID concordance was found for lifetime prevalence estimates of most disorders. The area under the ROC curve (AUC, a measure of classification accuracy that is not influenced by disorder prevalence) was 0.76 for the dichotomous classification of having any of the lifetime DSM-IV anxiety, mood and substance disorders assessed in the surveys and in the range 0.62-0.93 for individual disorders, with an inter-quartile range (IQR) of 0.71-0.86. Concordance increased when CIDI symptom-level data were added to predict SCID diagnoses in logistic regression equations. AUC for individual disorders in these equations was in the range 0.74-0.99, with an IQR of 0.87-0.96. CIDI lifetime prevalence estimates were generally conservative relative to SCID estimates. CIDI-SCID concordance for 12-month prevalence estimates could be studied powerfully only for two disorder classes, any anxiety disorder (AUC = 0.88) and any mood disorder (AUC = 0.83). As with lifetime prevalence, 12-month concordance improved when CIDI symptom-level data were added to predict SCID diagnoses. CIDI 12-month prevalence estimates were unbiased relative to SCID estimates. The validity of the CIDI is likely to be under-estimated in these comparisons due to the fact that the reliability of the SCID diagnoses, which is presumably less than perfect, sets a ceiling on maximum CIDI-SCID concordance.

Mental and physical comorbid conditions and days in role among persons with arthritis

OBJECTIVE

To estimate the prevalence of comorbidity among people with arthritis in the US adult population and to determine the role of comorbidity in accounting for the association of arthritis with days out of role (a measure of inability to work or carry out normal activities).

METHODS

Data come from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 9,282 respondents ages 18 and older carried out in 2001 to 2003. Arthritis was assessed by self-report in a chronic-conditions checklist, along with a wide range of other physical conditions. Mental and substance use disorders were ascertained with the World Health Organization Composite International Diagnostic Interview (CIDI). Number of days out of role was assessed for the 30 days before the interview.

RESULTS

Arthritis was reported by 27.3% of respondents, 80.9% of whom also reported at least one other physical or mental disorder, including 45.6% with another chronic pain condition, 62.3% with another chronic physical condition, and 24.3% with a 12-month mental disorder. Arthritis was significantly associated with days out of role, but comorbidity explained more than half of this association. No significant interactions were found between arthritis and the other conditions in predicting days out of role.

CONCLUSION

Comorbidity is the rule rather than the exception among people with arthritis. Comorbidity accounts for most of the days out of role associated with arthritis. The societal burden of arthritis needs to be understood and managed within the context of these comorbid conditions.

Specifying race-ethnic differences in risk for psychiatric disorder in a USA national sample

BACKGROUND

Epidemiological studies have found lower than expected prevalence of psychiatric disorders among disadvantaged race-ethnic minority groups in the USA. Recent research shows that this is due entirely to reduced lifetime risk of disorders, as opposed to persistence. Specification of race-ethnic differences with respect to clinical and social characteristics can help identify the protective factors that lead to lower lifetime risk among disadvantaged minority groups.

METHOD

Data on 5424 Hispanics, non-Hispanic Blacks, and non-Hispanic Whites came from the National Comorbidity Survey Replication, a nationally representative survey conducted with the World Mental Health version of the Composite International Diagnostic Interview. Race-ethnic differences in risk of disorders were compared across specific diagnoses, ages of onset, cohorts and levels of education.

RESULTS

Both minority groups had lower risk for common internalizing disorders: depression, generalized anxiety disorder, and social phobia. In addition, Hispanics had lower risk for dysthymia, oppositional-defiant disorder and attention deficit hyperactivity disorder; non-Hispanic Blacks had lower risk for panic disorder, substance use disorders and early-onset impulse control disorders. Lower risk among Hispanics, relative to non-Hispanic Whites, was found only among the younger cohort (age

CONCLUSION

The pattern of race-ethnic differences in risk for psychiatric disorders suggests the presence of protective factors that originate in childhood and have generalized effects on internalizing disorders. For Hispanics, but not for non-Hispanic Blacks, the influence of these protective factors has emerged only recently.

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Key Words Collapse

MESH Headings

• Adolescent
• Adult
• Black People/statistics & numerical data
• Demography
• Diagnostic and Statistical Manual of Mental Disorders
• Ethnicity
• Female
• Hispanic or Latino/statistics & numerical data
• Humans
• Male
• Mental Disorders/diagnosis
• Mental Disorders/ethnology
• Middle Aged
• Prevalence
• Risk Assessment
• Risk Factors
• United States/epidemiology
• White People/statistics & numerical data
• Black or African American

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Grants

• R01 DA016558 NIDA NIH HHS
• MH46376 NIMH NIH HHS
• K01 MH066057 NIMH NIH HHS
• U01-MH60220 NIMH NIH HHS
• R01 MH52861 NIMH NIH HHS
• K01 MH66057-02 NIMH NIH HHS
• K01 MH066057-03 NIMH NIH HHS
• R01 MH046376 NIMH NIH HHS
• R01 MH069864 NIMH NIH HHS
• R01-MH069864 NIMH NIH HHS
• R01 MH049098 NIMH NIH HHS
• K05 DA015799 NIDA NIH HHS
• U01 MH060220 NIMH NIH HHS
• R13-MH066849 NIMH NIH HHS
• U13 MH066849 NIMH NIH HHS
• R13 MH066849 NIMH NIH HHS

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Affiliation(s)

Joshua Breslau Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
Sergio Aguilar-Gaxiola
Kenneth S Kendler
Maxwell Su
David Williams
Ronald C Kessler

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Clinical differences among patients treated for mental health problems in general medical and specialty mental health settings in the National Comorbidity Survey Replication

OBJECTIVE

General medical (GM) treatments for mental health disorders are less likely than specialty mental health (SMH) treatments to be adequate. We explored whether differences in the clinical characteristics of patients treated in each sector (GM-only or SMH-only) or in both sectors (GM+SMH) may help to explain this finding.

METHOD

We analyzed data from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 5692 English-speaking adult household residents that was carried out in 2001-2003. The NCS-R used a fully structured diagnostic interview to assess DSM-IV disorders, including mood, anxiety, impulse control and substance use disorders. We classified disorders in terms of a three-category severity gradient (serious, moderate and mild) based on information about clinically significant distress and role impairment. We collected self-report data on chronic physical conditions, sociodemographics and type of treatment received for emotional and substance use problems in the 12 months before the interview.

RESULTS

Patients who received GM+SMH treatment had more severe mental disorders and a higher prevalence of mood and anxiety disorders than patients who received treatment in only one of the two sectors. Patients seen in the GM-only and GM+SMH sectors had more chronic physical conditions than patients seen in the SMH-only sector.

CONCLUSION

Patient characteristics may partially explain the lower intensity and adequacy of GM treatment.

A European approach to rural-urban differences in mental health: the ESEMeD 2000 comparative study

OBJECTIVE

The study aimed to answer the following questions: Are there any rural-urban differences in mental health, once sociodemographic variables are controlled for, and are any of these differences observed in EU countries? Did the individuals suffering from mental health disorders have the same characteristics in rural and urban areas, particularly concerning self-reported impairment?

METHOD

The European Study of the Epidemiology of Mental Disorders (ESEMeD 2000 study) is a cross-sectional, in-person, household interview survey based on probability samples representative of the adult population of 6 European countries: Belgium, France, Germany, Italy, the Netherlands, and Spain. The rural population is defined as those living in towns with fewer than 10,000 inhabitants, and the urban population is defined as those living in towns or cities with 10,000 or more inhabitants. A stratified, multistage, random sample without replacement was drawn in each country. The overall response rate of the study was about 61.2% (weighted response rate).

RESULTS

The study results confirmed previous findings on the variation in mood disorders between rural and urban areas. Overall, urbanicity seemed to be linked to a higher risk of mental health disorders, particularly depressive disorders, whereas the link to anxiety disorders was only moderate and there was no link at all to alcohol disorders. Country differences concerned male respondents and not female respondents, with the exception of Belgium, where the differences concerned women only (and showed fewer disorders in rural areas).

CONCLUSIONS

This study will, hopefully, stimulate further intra-European studies using comparable methods and instruments to look at the experience across the European continent and introduce steps to harmonize rural-urban population limits across diverse countries.

Describing the longitudinal course of major depression using Markov models: data integration across three national surveys

Background

Most epidemiological studies of major depression report period prevalence estimates. These are of limited utility in characterizing the longitudinal epidemiology of this condition. Markov models provide a methodological framework for increasing the utility of epidemiological data. Markov models relating incidence and recovery to major depression prevalence have been described in a series of prior papers. In this paper, the models are extended to describe the longitudinal course of the disorder.

Methods

Data from three national surveys conducted by the Canadian national statistical agency (Statistics Canada) were used in this analysis. These data were integrated using a Markov model. Incidence, recurrence and recovery were represented as weekly transition probabilities. Model parameters were calibrated to the survey estimates.

Results

The population was divided into three categories: low, moderate and high recurrence groups. The size of each category was approximated using lifetime data from a study using the WHO Mental Health Composite International Diagnostic Interview (WMH-CIDI). Consistent with previous work, transition probabilities reflecting recovery were high in the initial weeks of the episodes, and declined by a fixed proportion with each passing week.

Conclusion

Markov models provide a framework for integrating psychiatric epidemiological data. Previous studies have illustrated the utility of Markov models for decomposing prevalence into its various determinants: incidence, recovery and mortality. This study extends the Markov approach by distinguishing several recurrence categories.

Small signal, big noise: performance of the CIDI depression module

OBJECTIVES

With the release of data from the Canadian Community Health Survey: Mental Health and Well-Being (Cycle 1.2), researchers have, for the first time, information on several psychiatric disorders from a nationally representative sample of Canadians residing in households. This survey used the Composite International Diagnostic Interview (CIDI) to identify persons with one or more psychiatric disorders. In this paper, our primary purpose was to evaluate the evidence supporting the validity of the CIDI--that is, the extent to which the depression diagnoses generated by the CIDI reflect true cases of depression.

METHOD

We conducted a critical review of the CIDI, focusing on the depression module.

RESULTS

Reliability studies indicate that the CIDI performs reliably, as measured by interrater reliability. However, the use of different versions of the CIDI and the occasional exclusion of the Depression module from studies suggest that the reliability of the CIDI Depression module remains unconfirmed. The most critical issue in regard to the CIDI's performance is that clinical samples are used to test validity. A clinical sample has a higher prevalence of depression than a community sample.

CONCLUSION

The results generated by the CIDI in a community setting likely will have a high false-positive rate, resulting in a falsely elevated prevalence rate. Given the widespread application of the CIDI internationally, addressing the outstanding concerns about validity with proper validation studies should become an international priority.

The prevalence and correlates of nonaffective psychosis in the National Comorbidity Survey Replication (NCS-R)

BACKGROUND

To estimate the prevalence and correlates of clinician-diagnosed DSM-IV nonaffective psychosis (NAP) in a national household survey.

METHODS

Data came from the United States National Comorbidity Survey Replication (NCS-R). A screen for NAP was followed by blinded sub-sample clinical reappraisal interviews. Logistic regression was used to impute clinical diagnoses to respondents who were not re-interviewed. The method of Multiple Imputation (MI) was used to estimate prevalence and correlates.

RESULTS

Clinician-diagnosed NAP was well predicted by the screen (area under the curve [AUC] = .80). The MI prevalence estimate of NAP (standard error in parentheses) is 5.0 (2.6) per 1000 population lifetime and 3.0 (2.2) per 1000 past 12 months. The vast majority (79.4%) of lifetime and 12-month (63.7%) cases met criteria for other DSM-IV hierarchy-free disorders. Fifty-eight percent of 12-month cases were in treatment, most in the mental health specialty sector.

CONCLUSIONS

The screen for NAP in the NCS-R greatly improved on previous epidemiological surveys in reducing false positives, but coding of open-ended screening scale responses was still needed to achieve accurate prediction. The lower prevalence estimate than in total-population incidence studies raises concerns that systematic nonresponse bias causes downward bias in survey prevalence estimates of NAP.

Antidepressant utilization in Canada

OBJECTIVE

Antidepressant utilization can be used as an indicator of appropriate treatment for major depression. The objective of this study was to characterize antidepressant utilization in Canada, including the relationships of antidepressant use with sociodemographic variables, past-year and lifetime depression, number of past depressive episodes, and other possible indications for antidepressants.

METHOD

We examined data from the Canadian Community Health Survey (CCHS) Cycle 1.2. The CCHS was a nationally representative mental health survey (N=36,984) conducted in 2002 that included a diagnostic instrument for past-year and lifetime major depressive episodes and other psychiatric disorders and a record of past-year antidepressant use.

RESULTS

Overall, 5.8% of Canadians were taking antidepressants, higher than the annual prevalence of major depressive episode (4.8%) in the survey. Among persons with a past-year major depressive episode, the frequency of antidepressant use was 40.4%. After application of adjustments for probable successful outcomes of treatment, the estimated frequency of antidepressant use for major depression was more than 50%. Frequency of antidepressant treatment among those with a history of depression but without a past-year episode increased with the number of previous episodes. Among those taking antidepressants over the past year, only 33.1% had had a past-year episode of major depression. Migraine, fibromyalgia, anxiety disorder, or past depression was present in more than 60% of those taking antidepressants without a past-year episode of depression.

CONCLUSIONS

The CCHS results suggest that antidepressant use has increased substantially since the early 1990s, and also that these medications are employed extensively for indications other than depression.

Psychotropic medication use in Canada

BACKGROUND

Psychotropic medication use can be employed as an indicator of appropriate treatment for mental disorders. The Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2) offers the first opportunity to characterize Canadian psychotropic medication use on a national level within diagnostic groups as assessed by a full version of the Composite International Diagnostic Interview (CIDI).

METHOD

We assessed the prevalence of antidepressant, sedative-hypnotic, mood stabilizer, psychostimulant, and antipsychotic use over 2 days overall and in subgroups defined by CIDI-diagnosed disorders and demographics. We employed sampling weights and bootstrap methods.

RESULTS

Overall psychotropic drug utilization was 7.2%. Utilization was higher for women and with increasing age. With any lifetime CIDI-diagnosed disorder assessed in the CCHS 1.2, utilization was 19.3%, whereas without such disorders, it was 4.1%. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly used antidepressants for those with a past-year major depressive episode (17.8%), followed by venlafaxine (7.4%). Among people aged 15 to 19 years, antidepressant use was 1.8% overall and 11.7% among those with past-year depression; SSRIs made up the majority of use. Sedative-hypnotics were used by 3.1% overall, increasing with age to 11.1% over 75 years.

CONCLUSIONS

International comparison is difficult because of different evaluation methods, but antidepressant use may be higher and antipsychotic use lower in Canada than in recent European and American reports. In light of the relative lack of contemporary evidence for antidepressant efficacy in adolescents, it is likely that antidepressant use among those aged 15 to 19 years will continue to decline. The increased use of sedative-hypnotics with age is of concern, given the associated risk of adverse effects among seniors.

Epidemiology of psychiatric and alcohol disorders in Ukraine: findings from the Ukraine World Mental Health survey

BACKGROUND

This study presents the lifetime, 12-month, and 1-month prevalence estimates of nine psychiatric and alcohol disorders in Ukraine assessed as part of the World Health Organization (WHO) World Mental Health (WMH) research program. The Ukraine WMH survey is the first psychiatric epidemiologic study in a former Soviet Union country to administer a structured psychiatric interview to a nationally representative sample.

METHOD

In 2002, a national probability sample of 4,725 respondents ages 18 and older were interviewed with the WMH version of the Composite International Diagnostic Interview (WMH-CIDI). Prevalence estimates, age-of-onset curves, comorbidity, demographic and geographic risk factors, and treatment seeking were examined.

RESULTS

Close to one third of the population experienced at least one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder in their lifetime, 17.6% experienced an episode in the past year, and 10.6% had a current disorder. There was no gender difference in the overall prevalence rates. In men, the most common diagnoses were alcohol disorders (26.5% lifetime) and mood disorders (9.7% lifetime); in women, they were mood disorders (20.8% lifetime) and anxiety disorders (7.9% lifetime). The odds ratios for most pairs of disorders were highly significant. Age of onset was primarily in the teens and early 20s. Age, education, and living in the Eastern region of Ukraine were significant risk factors across disorders, with respondents older than 50 years having the highest prevalence of mood disorder and the lowest prevalence of alcoholism and intermittent explosive disorder. Only a minority of respondents talked to a professional about their symptoms.

CONCLUSION

Prevalence estimates of alcoholism among men and recent depression among women were higher in Ukraine than in comparable European surveys. The results argue for the need to develop and implement educational programs focused on the recognition and treatment of mental and alcohol disorders for the general population, psychiatrists, and general medical providers, who are the main source of mental health care.

Psychological aftermath of the Lviv air show disaster: a prospective controlled study

OBJECTIVE

To investigate the psychological aftermath of an air show disaster using prospectively obtained epidemiologic data.

METHOD

Participants in a recently completed epidemiologic mental health survey in Lviv (disaster site) and controls from western Ukraine were interviewed shortly before and 6 months after a gruesome air show disaster.

RESULTS

The Lviv group reported more psychopathology and post-traumatic stress symptom severity, but less anomie than controls. Somatization symptoms were similar in the two groups. Predisaster mental health and postdisaster threat were the strongest risk factors while demographic characteristics, emotional support, and repeated television viewing of the event were only weakly associated with postdisaster mental health.

CONCLUSION

This is the first prospective study to find a significantly higher rate of disorder as well as post-traumatic stress disorder symptomatology after a disaster. The risk factor findings suggest avenues for targeting postdisaster interventions.

[Psychotropic drug use and mental psychiatric disorders in France; results of the general population ESEMeD/MHEDEA 2000 epidemiological study]

INTRODUCTION

The use of psychotropic drugs is high in France and has increased over the last two decades. To date, no national study evaluating psychotropic drug use in the context of the diagnosis of psychiatric disorders has been performed. Such data has now been generated in the ESEMeD/MHEDEA 2000 study, which has allowed comparison of the situation in France with that in five other European countries (Germany, Belgium, Spain, the Netherlands and Italy).

OBJECTIVES

1) To describe the declared use of psychotropic drugs (globally and by therapeutic class) in order to evaluate annual prevalence, treatment duration and demographic factors associated with use. 2) To estimate the proportion of subjects with an anxiety disorder, mood disorder or alcohol-related disorder (abuse or dependence) that have been appropriately treated with an antidepressant or anxiolytic drug. 3) to evaluate the proportion of psychotropic drug users who fulfil diagnostic criteria for these three classes of psychiatric disorder.

METHODS

This was a transversal survey carried out between 2001 and 2003 of non-institutionalised subjects aged 18 or over in the general population of Germany (n = 3,555), Belgium (n = 2,419), Spain (n = 5,473), France (n = 2,894), the Netherlands (n = 2,372) and Italy (n = 4,712). In France, the sampling source used was a randomly generated list of telephone numbers. Subjects were interviewed at home by professional interviewers. The WMH-CIDI questionnaire was used.

RESULTS

In France, 21% of subjects interviewed (n = 580) had taken at least one psychotropic drug during the year. For 19%, this was an anxiolytic or hypnotic (AX-HY), for 6.0% an antidepressant (AD), for 0.8% an antipsychotic (AP) and for 0.4% a mood regulating drug (TY). The distribution of users of AX-HY according to treatment duration was the following: 44% (1 to 15 days), 13% (16 to 30 days), 14% (1 to 3 months), 6.7% (3 to 6 months) and 23% (> 6 months). For users of ADs, the distribution was: 21% (1 to 15 days), 7.8% (16 to 30 days), 18% (1 to 3 months), 12% (3 to 6 months) and 42% (> 6 months). For subjects fulfilling diagnostic criteria for a mood disorder in the previous year or over their lifetime, 43% and 29% respectively had taken an AX-HY in the last twelve months and 29% and 16% an AD. For those who fulfilled diagnostic criteria for an anxiety disorder in the previous year or over their lifetime, the use of an AX-HY, in the last twelve months, concerned 43% and 30% of subjects respectively, whilst that of AD concerned 16% and 14%. For previous year or lifetime alcohol-related disorders, AX-HY use, in the last twelve months, concerned 63% and 22% of subjects respectively and use of ADs 9.3% and 7.2%. Amongst users of AX-HY in the last twelve months, a previous year or lifetime diagnosis of mood disorders was made for 16% and 39% of subjects respectively. Amongst users of ADs, the respective prevalence was 31% and 64%. A twelve-month and lifetime diagnosis of anxiety disorders was identified in 22% and 37% of users of AX-HY and among 27% and 50% of users of AD respectively. A twelve-month and lifetime diagnosis of alcohol-related disorders was found in 2.5% and 6.6% of users of AX-HY and among 1.1% and 7.8% of users of AD respectively. 68% of users of AX-HY had fulfilled none of these diagnostic criteria in the previous 12 months and 46% had never fulfilled them in their lifetime. With respect to AD users, the proportion who did not meet these diagnostic criteria in the previous 12 months was 56%, compared to 20% over their lifetime. Comparison of the French data from the study with those of the entire European sample showed that the annual prevalence of AX-HY and AD use was higher in France with mean treatment durations that were shorter. For antipsychotics and mood regulators, no clear differences were observed between France and the six countries of the study taken together.

DISCUSSION

Over the last two decades, use of AX-HY seems to have decreased in France, even though it remains higher than that observed in the other European countries participating in this study. This high use can be explained in part by the observation that, in around half the cases, it corresponds to occasional use. In contrast, the use of antidepressants has increased. In subjects with recent mood disorders or anxiety disorders, the use of AX-HY remains higher than that of antidepressants. Finally among users of AX-HY, only half of them had presented a mood disorder, anxiety disorder or alcohol use disorder during their lifetime, whereas this proportion rose to 80% for users of antidepressants.

Twelve-month prevalence, severity, and treatment of common mental disorders in communities in Japan: preliminary finding from the World Mental Health Japan Survey 2002-2003

To estimate the prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders (4th edn; DSM-IV) mental disorders in community populations in Japan, face-to-face household surveys were conducted in four community populations in Japan. A total of 1663 community adults responded (overall response rate, 56%). The DSM-IV disorders, severity, and treatment were assessed with the World Mental Health version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay-administered psychiatric diagnostic interview. The prevalence of any WMH-CIDI/DSM-IV disorder in the prior year was 8.8%, of which 17% of cases were severe and 47% were moderate. Among specific disorders, major depression (2.9%), specific phobia (2.7%), and alcohol abuse/dependence (2.0%) were the most prevalent. Although disorder severity was correlated with probability of treatment, only 19% of the serious or moderate cases received medical treatment in the 12 months before the interview. Older and not currently married individuals had a greater risk of having more severe DSM-IV disorders if they had experienced any within the previous 12 months. Those who had completed high school or some college were more likely to seek medical treatment than those who had completed college. The study confirmed that the prevalence of DSM-IV mental disorders was equal to that observed in Asian countries but lower than that in Western countries. The percentage of those receiving medical treatment was low even for those who suffered severe or moderate disorders. Possible strategies are discussed.

Empirical evidence for an invariant three-factor structure of the Parental Bonding Instrument in six European countries

The objective of the present study was to test the Parental Bonding Instrument's (PBI) three-factor structure (care, overprotection, and authoritarianism) found by [Cox, B.J., Enns, M.W., Clara, I.P. 2000, The Parental Bonding Instrument: confirmatory evidence for a three-factor model in a psychiatric clinical sample and in the National Comorbidity Survey, Social Psychiatry and Psychiatric Epidemiology 35 (2000) 353-357.] on an eight-item short form of the scale. A total of 8813 respondents from the six European countries participating in the ESEMeD project (Belgium, France, Germany, Italy, The Netherlands, and Spain) completed either the PBI-paternal or the PBI-maternal scale. Maximum likelihood confirmatory factor analysis was used to compare the original factor model of Cox et al. with a three-factor solution that emerged from an exploration of the structure with principal component factor analysis. When gender and age subgroups, as well as different countries, were taken into account, the accuracy of the model was confirmed. The fit indices for the new model indicated a generally better model fit than the ones for the model originally developed by Cox et al. Further efforts should be directed to the modeling of the dimension authoritarianism. The results provide the opportunity to estimate the influence of the extracted factors on mental disorders in different countries. The application of the short form of the PBI seems suitable primarily for large epidemiological studies.

Prevalence and treatment of mental disorders, 1990 to 2003

BACKGROUND

Although the 1990s saw enormous change in the mental health care system in the United States, little is known about changes in the prevalence or rate of treatment of mental disorders.

METHODS

We examined trends in the prevalence and rate of treatment of mental disorders among people 18 to 54 years of age during roughly the past decade. Data from the National Comorbidity Survey (NCS) were obtained in 5388 face-to-face household interviews conducted between 1990 and 1992, and data from the NCS Replication were obtained in 4319 interviews conducted between 2001 and 2003. Anxiety disorders, mood disorders, and substance-abuse disorders that were present during the 12 months before the interview were diagnosed with the use of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for emotional disorders was categorized according to the sector of mental health services: psychiatry services, other mental health services, general medical services, human services, and complementary-alternative medical services.

RESULTS

The prevalence of mental disorders did not change during the decade (29.4 percent between 1990 and 1992 and 30.5 percent between 2001 and 2003, P=0.52), but the rate of treatment increased. Among patients with a disorder, 20.3 percent received treatment between 1990 and 1992 and 32.9 percent received treatment between 2001 and 2003 (P<0.001). Overall, 12.2 percent of the population 18 to 54 years of age received treatment for emotional disorders between 1990 and 1992 and 20.1 percent between 2001 and 2003 (P<0.001). Only about half those who received treatment had disorders that met diagnostic criteria for a mental disorder. Significant increases in the rate of treatment (49.0 percent between 1990 and 1992 and 49.9 percent between 2001 and 2003) were limited to the sectors of general medical services (2.59 times as high in 2001 to 2003 as in 1990 to 1992), psychiatry services (2.17 times as high), and other mental health services (1.59 times as high) and were independent of the severity of the disorder and of the sociodemographic characteristics of the respondents.

CONCLUSIONS

Despite an increase in the rate of treatment, most patients with a mental disorder did not receive treatment. Continued efforts are needed to obtain data on the effectiveness of treatment in order to increase the use of effective treatments.

Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication

BACKGROUND

Little is known about the general population prevalence or severity of DSM-IV mental disorders.

OBJECTIVE

To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication.

DESIGN AND SETTING

Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview.

PARTICIPANTS

Nine thousand two hundred eighty-two English-speaking respondents 18 years and older.

MAIN OUTCOME MEASURES

Twelve-month DSM-IV disorders.

RESULTS

Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population.

CONCLUSION

Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.

Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication

BACKGROUND

Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood.

METHODS

A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders).

RESULTS

Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD.

CONCLUSIONS

No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.

Markov models of major depression for linking psychiatric epidemiology to clinical practice

BACKGROUND: Most epidemiological studies of major depression report estimates of period prevalence. Such estimates are useful for public health applications, but are not very helpful for informing clinical practice. Period prevalence is determined predominantly by incidence and episode duration, but it is difficult to connect these epidemiological concepts to clinical issues such as risk and prognosis. Incidence is important for primary and secondary prevention, and prognostic information is useful for clinical decision-making. The objective of this study was to decompose period prevalence data for major depression into its constituent elements, thereby enhancing the value of these estimates for clinical practice. Data from a series of population-based Canadian studies were used in the analysis. Markov models depicting incidence, prevalence and recovery from major depressive episodes were developed. Monte Carlo simulation was used to constrain model parameters to the epidemiological data. RESULTS: The association of sex with major depression was found to be due to a higher incidence in women. In distinction, the higher prevalence in unmarried subjects was mostly due to a different prognosis. Age-related changes in prevalence were influenced by both factors. Education, which was not found to be associated with major depression in the survey data, had no impact either on risk or prognosis. CONCLUSION: The period prevalence of major depression is influenced both by incidence (risk) and episode duration (prognosis). Mathematical modeling of the underlying epidemiological relationships can make such data more readily interpretable in relation to clinical practice.

A CASE-CONTROL STUDY OF ALCOHOL AND SUBSTANCE USE DISORDERS AS RISK FACTORS FOR NON-FATAL INJURY

AIMS

While alcohol use is thought to be a major risk factor for both fatal and non-fatal injuries, the association of substance use disorders (alcohol use disorders, AUD and substance use disorders, SUD) with occurrence of injury has not received the same attention. To report the association of AUD and SUD, according to diagnostic and statistics manual of mental disorders-IV (DSM-IV) and international classification of diseases 10 (ICD-10) criteria, and the risk of non-fatal injuries.

METHODS

A case-control study: Cases included 653 injured patients, 18-65-years-old, who attended one emergency department (ED). Controls included 1131 subjects from a representative sample of residents of Mexico City, of the same age group. Information on drug and alcohol use was obtained by interview using the world mental health version of the composite international diagnostic interview (WMH-CIDI).

RESULTS

Among injured patients, the prevalence of substance abuse or dependence within the last 12 months was 12.3% for alcohol and 2.5% for other substances (marijuana, cocaine, tranquilizers, amphetamines, others). Among residents of Mexico City, these prevalences were 1.8 and 0.3%, respectively. Adjusted odds ratios (OR) of injury according to alcohol and substance use were 4.95 (95% confidence interval (CI): 2.87-8.52) for alcohol and 2.58 (0.73-9.17) for other substances. An important level of comorbid alcohol and substance use disorders was also found.

CONCLUSIONS

Efforts in the ED should be carried out to treat and/or refer patients with alcohol and substance use disorders, and special care should be taken to address comorbid cases.

Prévalence et comorbidité des troubles psychiatriques dans la population générale française : résultats de l’étude épidémiologique ESEMeD/MHEDEA 2000/ (ESEMeD)

INTRODUCTION

ESEMeD is the first international epidemiological study using a random sampling method that has allowed the prevalence of psychiatric disorders in France to be measured with precision and compared directly with that observed in other European countries.

OBJECTIVES

1) To determine the 12 month and lifetime prevalence of mood -disorders, anxiety disorders and alcohol-related disorders. 2) To estimate the comorbidity between these disorders. 3) To evaluate potential demographic risk factors for these disorders.

METHODS

This was a transversal survey carried out between 2001 and 2003 of non-institutionalised subjects aged 18 or over in the general population of Germany (n = 3,555), Belgium (n = 2,419), Spain (n = 5,473), France (n = 2,894), the Netherlands (n = 2,372) and Italy (n = 4,712). In France, the sampling source was a randomly generated list of telephone numbers. Subjects were interviewed at home by professional interviewers. The WMH-CIDI questionnaire was used.

RESULTS

The participation rate was 46% for France and 61% for all six countries combined. The 12 month and lifetime prevalence rates observed were respectively 6.0% and 21,4% for major depressive episodes, 1.6% and 7.9% for dysthymia, 2.1% and 6.0% for the generalised -anxiety disorders, 1.2% and 3.0% for panic disorders, 0.6% and 1.8% for agoraphobia, 2.2% and 3.9% for post-traumatic stress disorder, 1.7% and 4.7% for social phobia, 4.7% and 11,6% for specific phobia, 0.5% and 4.1% for alcohol abuse and 0.3% and 1.6% for alcohol dependence. Mood disorders and anxiety disorders were significantly more frequent in women, whilst alcohol-related disorders were more frequent in men. The prevalence of all three types of disorder was lower in elderly subjects and in those living in a rural environment. Mood disorders and alcohol-related disorders were more frequent in individuals living alone and mood disorders more frequent in those without paid employment. 38% of subjects with mood disorder also presented an anxiety disorder or an alcohol-related disorder. The comorbidity of mood and anxiety disorders was more frequent in women, younger subjects and those living alone. The comorbidity rate in subjects with anxiety disorders was 26% and did not differ between genders. For alcohol-related disorders, there was a striking difference in comorbidity rate between men and women: 26% in the former and 67% in the latter.

CONCLUSION

This study underlines the high prevalence of mood disorders, anxiety disorders and alcohol-related disorders in France and demonstrates a high degree of comorbidity between them. For this reason, it is important to evaluate and take into account potential comorbidity in the management of individuals with psychiatric disorders.

Clinical calibration of DSM-IV diagnoses in the World Mental Health (WMH) version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMHCIDI)

An overview is presented of the rationale, design, and analysis plan for the WMH-CIDI clinical calibration studies. As no clinical gold standard assessment is available for the DSM-IV disorders assessed in the WMH-CIDI, we adopted the goal of calibration rather than validation; that is, we asked whether WMH-CIDI diagnoses are 'consistent' with diagnoses based on a state-of-the-art clinical research diagnostic interview (SCID; Structured Clinical Interview for DSM-IV) rather than whether they are 'correct'. Consistency is evaluated both at the aggregate level (consistency of WMH-CIDI and SCID prevalence estimates) and at the individual level (consistency of WMH-CIDI and SCID diagnostic classifications). Although conventional statistics (sensitivity, specificity, Cohen's kappa) are used to describe diagnostic consistency, an argument is made for considering the area under the receiver operator curve (AUC) to be a more useful general-purpose measure of consistency. In addition, more detailed analyses are used to evaluate consistency on a substantive level. These analyses begin by estimating prediction equations in a clinical calibration subsample, with WMH-CIDI symptom-level data used to predict SCID diagnoses, and using the coefficients from these equations to assign predicted probabilities of SCID diagnoses to each respondent in the remainder of the sample. Substantive analyses then investigate whether estimates of prevalence and associations when based on WMH-CIDI diagnoses are consistent with those based on predicted SCID diagnoses. Multiple imputation is used to adjust estimated standard errors for the imprecision introduced by SCID diagnoses being imputed under a model rather than measured directly. A brief illustration of this approach is presented in comparing the precision of SCID and predicted SCID estimates of prevalence and correlates under varying sample designs.

The US National Comorbidity Survey Replication (NCS-R): design and field procedures

The National Comorbidity Survey Replication (NCS-R) is a survey of the prevalence and correlates of mental disorders in the US that was carried out between February 2001 and April 2003. Interviews were administered face-to-face in the homes of respondents, who were selected from a nationally representative multi-stage clustered area probability sample of households. A total of 9,282 interviews were completed in the main survey and an additional 554 short non-response interviews were completed with initial non-respondents. This paper describes the main features of the NCS-R design and field procedures, including information on fieldwork organization and procedures, sample design, weighting and considerations in the use of design-based versus model-based estimation. Empirical information is presented on non-response bias, design effect, and the trade-off between bias and efficiency in minimizing total mean-squared error of estimates by trimming weights.

The development and implementation of the National Comorbidity Survey Replication, the National Survey of American Life, and the National Latino and Asian American Survey

This paper provides an overview of the development and implementation of the Collaborative Psychiatric Epidemiology Surveys (CPES): the National Comorbidity Survey Replication (NCS-R), the National Survey of American Life (NSAL), and the National Latino and Asian American Study (NLAAS). It describes the instrument development and testing phases, the development of training and other project materials, interviewer recruitment and training activities, and data collection procedures and outcomes. The last section offers recommendations for other researchers who undertake similar studies and who might benefit from the experiences learned in the development and operation of NCS-R, NSAL and NLAAS.

Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic in the development of cross-cultural measures for a psychiatric epidemiology and services study of Latinos

This paper describes the development, translation and adaptation of measures in the National Latino and Asian American Study (NLAAS). We summarize the techniques used to attain cultural relevance; semantic, content and technical equivalency; and internal consistency of the measures across languages and Latino sub-ethnic groups. We also discuss some of the difficulties and thallenges encountered in doing this work. The following three main goals are addressed in this paper: (1) attaining cultural relevance by formulating the research problem with attention to the fundamental cultural and contextual differences of Latinos and Asians as compared to the mainstream population; (2) developing cultural equivalence in the standardized instruments to be used with these populations; and (3) assessing the generalizability of the measures - i.e., that the measures do not fluctuate according to culture or translation. We present details of the processes and steps used to achieve these three goals in developing measures for the Latino population. Additionally, the integration of both the etic and emic perspectives in the instrument adaptation model is presented.