Primary prevention of secondary disorders: a proposal and agenda

Substance use outcomes from the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS)

BACKGROUND

Substance use problems and anxiety disorders are both highly prevalent and frequently cooccur in youth. The present study examined the benefits of successful anxiety treatment at 3-12 years after treatment completion on substance use outcomes (i.e. diagnoses and lifetime expected use).

METHODS

The sample was from the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), a naturalistic follow-up study to the Child/Adolescent Anxiety Multimodal Study (CAMS) which randomized youth to cognitive behavioral therapy (CBT; Coping cat), medication (sertraline), their combination, or pill placebo. The first CAMELS visit occurred an average of 6.5 years following CAMS randomization. Participants were 319 youth (65.4% of the CAMS sample), aged 7-17 years at CAMS baseline assessment with a mean age of 17.6 years (range: 11-26 years) at the time of the first CAMELS follow-up. Substance use outcomes included diagnoses as well as lifetime substance use (i.e. alcohol and tobacco use).

RESULTS

Eleven of 319 (3.4%) CAMELS participants were diagnosed with a substance use disorder at the initial follow-up visit. When compared to the population lifetime rate of 11.4%, the rate of diagnoses in the posttreated sample was significantly lower. Additionally, rates of lifetime alcohol use were lower than population rates at the initial and final follow-up visits. Rates of lifetime tobacco use were similarly lower than lifetime population rates at the initial visit (driven by significantly lower rates in the CBT treatment condition), but higher by the final visit. Furthermore, treatment remission (but not treatment response) was associated with a lower rate of substance use diagnoses at the initial follow-up visit, although rates of lifetime alcohol and tobacco use did not differ by treatment outcome.

CONCLUSIONS

Anxiety treatments confer a beneficial impact on problematic substance use (i.e. diagnoses) as well as on expected substance use (i.e. alcohol and tobacco use) for on average, a period of 6.5 years.

Depression pathophysiology, risk prediction of recurrence and comorbid psychiatric disorders using genome-wide analyses

Depression is a common psychiatric disorder and a leading cause of disability worldwide. Here we conducted a genome-wide association study meta-analysis of six datasets, including >1.3 million individuals (371,184 with depression) and identified 243 risk loci. Overall, 64 loci were new, including genes encoding glutamate and GABA receptors, which are targets for antidepressant drugs. Intersection with functional genomics data prioritized likely causal genes and revealed new enrichment of prenatal GABAergic neurons, astrocytes and oligodendrocyte lineages. We found depression to be highly polygenic, with ~11,700 variants explaining 90% of the single-nucleotide polymorphism heritability, estimating that >95% of risk variants for other psychiatric disorders (anxiety, schizophrenia, bipolar disorder and attention deficit hyperactivity disorder) were influencing depression risk when both concordant and discordant variants were considered, and nearly all depression risk variants influenced educational attainment. Additionally, depression genetic risk was associated with impaired complex cognition domains. We dissected the genetic and clinical heterogeneity, revealing distinct polygenic architectures across subgroups of depression and demonstrating significantly increased absolute risks for recurrence and psychiatric comorbidity among cases of depression with the highest polygenic burden, with considerable sex differences. The risks were up to 5- and 32-fold higher than cases with the lowest polygenic burden and the background population, respectively. These results deepen the understanding of the biology underlying depression, its disease progression and inform precision medicine approaches to treatment.

Self-Identification of Mental Health Problems Among Young Adults Experiencing Homelessness

Young adults experiencing homelessness (YAEH) have high rates of mental health problems but low rates of mental health service use. This study examined identification of mental health problems among YAEH in seven U.S. cities and its relationship to service use. YAEH that screened positive for depression, psychological distress, or Post Traumatic Stress (n = 892) were asked whether they felt they had a mental health problem. One-third identified as having a mental health problem (35%), with 22% endorsing not sure. Multinomial logistic regression models found that older age, cisgender female or gender-expansive (compared to cisgender male), and LGBQ sexual orientation, were positively associated with self-identification and Hispanic race/ethnicity (compared to White) was negatively associated. Self-identification of a mental health problem was positively associated with use of therapy, medications, and reporting unmet needs. Interventions should target understanding mental health, through psychoeducation that reduces stigma, or should reframe conversations around wellness, reducing the need to self-identify.

A community-led design for an Indigenous Model of Mental Health Care for Indigenous people with depressive disorders

OBJECTIVE

To generate outcomes for the development of a culturally appropriate mental health treatment model for Indigenous Australians with depression.

METHODS

Three focus group sessions and two semi-structured interviews were undertaken over six months across regional and rural locations in South West Queensland. Data were transcribed verbatim and coded using manual thematic analyses. Transcripts were thematically analysed and substantiated. Findings were presented back to participants for authenticity and verification.

RESULTS

Three focus group discussions (n=24), and two interviews with Elders (n=2) were conducted, from which six themes were generated. The most common themes from the focus groups included Indigenous autonomy, wellbeing and identity. The three most common themes from the Elder interviews included culture retention and connection to Country, cultural spiritual beliefs embedded in the mental health system, and autonomy over funding decisions.

CONCLUSIONS

A treatment model for depression must include concepts of Indigenous autonomy, identity and wellbeing. Further, treatment approaches need to incorporate Indigenous social and emotional wellbeing concepts alongside clinical treatment approaches. Implications for public health: Any systematic approach to address the social and cultural wellbeing of Indigenous peoples must have a community-led design and delivery.

Preventive psychiatry: a blueprint for improving the mental health of young people

Preventive approaches have latterly gained traction for improving mental health in young people. In this paper, we first appraise the conceptual foundations of preventive psychiatry, encompassing the public health, Gordon's, US Institute of Medicine, World Health Organization, and good mental health frameworks, and neurodevelopmentally-sensitive clinical staging models. We then review the evidence supporting primary prevention of psychotic, bipolar and common mental disorders and promotion of good mental health as potential transformative strategies to reduce the incidence of these disorders in young people. Within indicated approaches, the clinical high-risk for psychosis paradigm has received the most empirical validation, while clinical high-risk states for bipolar and common mental disorders are increasingly becoming a focus of attention. Selective approaches have mostly targeted familial vulnerability and non-genetic risk exposures. Selective screening and psychological/psychoeducational interventions in vulnerable subgroups may improve anxiety/depressive symptoms, but their efficacy in reducing the incidence of psychotic/bipolar/common mental disorders is unproven. Selective physical exercise may reduce the incidence of anxiety disorders. Universal psychological/psychoeducational interventions may improve anxiety symptoms but not prevent depressive/anxiety disorders, while universal physical exercise may reduce the incidence of anxiety disorders. Universal public health approaches targeting school climate or social determinants (demographic, economic, neighbourhood, environmental, social/cultural) of mental disorders hold the greatest potential for reducing the risk profile of the population as a whole. The approach to promotion of good mental health is currently fragmented. We leverage the knowledge gained from the review to develop a blueprint for future research and practice of preventive psychiatry in young people: integrating universal and targeted frameworks; advancing multivariable, transdiagnostic, multi-endpoint epidemiological knowledge; synergically preventing common and infrequent mental disorders; preventing physical and mental health burden together; implementing stratified/personalized prognosis; establishing evidence-based preventive interventions; developing an ethical framework, improving prevention through education/training; consolidating the cost-effectiveness of preventive psychiatry; and decreasing inequalities. These goals can only be achieved through an urgent individual, societal, and global level response, which promotes a vigorous collaboration across scientific, health care, societal and governmental sectors for implementing preventive psychiatry, as much is at stake for young people with or at risk for emerging mental disorders.

Association between Sexual Behavior and Depression in South Korean Adolescents: A Cross-Sectional Study

Adolescent depression and suicide have become leading public health and socioeconomic problems. Determining the connection between adolescent behavior and depression can inform strategies to reduce the prevalence of depression and suicide. We investigated the association between sexual behavior and depression in South Korean adolescents. Data for this cross-sectional study were obtained from the 2017–2019 Korea Youth Risk Behavior Web-Based Survey. Data of 178,664 subjects were analyzed using chi-square tests and multivariate logistic regression. After adjusting for covariates, the prevalence of depression was found to be higher in subjects with experience of sexual intercourse (adjusted odds ratio = 1.71, 95% confidence interval = 1.59–1.83 in boys; adjusted odds ratio = 1.47, confidence interval = 1.33–1.61 in girls). On categorizing subjects into two groups based on suicidality, subjects with sexual intercourse experience had higher odds ratios for depression with suicidality (aOR:2.16 in boys, aOR:1.80in girls) than depression without suicidality (aOR:1.49 in boys, aOR:1.25 in girls). We identified the relationship between sexual behavior and the prevalence of depression; adolescents with experience of sexual intercourse were more likely to have depression with suicidality. Further research using prospective designs should serve as the basis for appropriate sex education policies to manage the relationship between sexual behavior and depression.

Experiences of pathways to mental health services for young people and their carers: a qualitative meta-synthesis review

Worldwide, growing concern with young people's mental health is spurring service reform efforts. Such reform requires a full understanding of the experiences of young people and their carers when seeking mental health help. To generate such an understanding, we conducted a meta-synthesis of qualitative literature on the perspectives of youths and their carers on navigating mental health systems. Five electronic databases were searched (Medline, PsycINFO, EMBASE, CINAHL, HealthSTAR). Studies were included if they explored the experiences of pathways to mental health services of persons aged 11-30 years and/or their carers; were published in English or French; and used qualitative methodology. Quality appraisal was conducted using the CASP tool. The synthesis of 31 included studies yielded three themes-initiating contact with mental health services; characteristics of services' response; and youths' and carers' appraisal of services. Themes about initiating contact included mental health literacy, structural barriers, and social support. Service response-related themes included complex pathways, waitlists, eligibility, and fragmented care. In terms of service appraisal, positive encounters featured providers who were accessible and perceived as caring. Negative appraisals resulted from feeling misunderstood and excluded and being ill-informed about treatment. Across diagnoses and settings, youths and carers had difficult experiences accessing mental healthcare. While individual, social, and healthcare factors shaping pathways to care varied, systemic complexities were a common inhibitor. This synthesis informs recommendations for improving mental health services and youths' pathways to them. It underlines the need for grounding reform in youths' and carers' perspectives and needs.

Mental health stigma and professional help-seeking attitudes a comparison between Cuba and Germany

Globally the burden due to mental disorders is continuously increasing. Still, professional help-seeking behavior is not fully understood. To conceive cultural determinants of help-seeking is crucial to reduce personal and social costs of (untreated) mental disorders. The current study investigates mental health stigma and help-seeking attitudes in a Cuban (n = 195) and a German (n = 165) sample. In a questionnaire survey we asked for attitudes towards mental illness and professional help-seeking in the general Cuban and German populations. The cultural context was associated with mental health stigma and professional help-seeking attitudes. Interestingly, Cuban participants reported stronger mental health stigma and more willingness to seek help. In multiple hierarchical regression analyses, community attitudes towards the mentally ill significantly predicted help-seeking attitudes, especially in the Cuban sample. Only in the German sample, more negative individual beliefs about mental illness predicted more self-stigma on help-seeking. Beyond that, cultural context moderated the association between mental health stigma and help-seeking attitudes with a stronger association between the measures in the German sample. However, gender did not predict help-seeking attitudes and self-stigma on help-seeking and no interactions between community attitudes, cultural context, and gender were found in the prediction of help-seeking attitudes. Similarities and differences between the samples are discussed in the light of the cultural contexts and peculiarities of the current samples. Concluding, implications of the current findings are reviewed.

Immunological Disturbances and Neuroimaging Findings in Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD) Comorbid Patients

Mood disorders and Major Depressive Disorder, in particular, appear to be some of the most common psychiatric disorders with a high rate of comorbidity most frequently of anxiety or substance abuse disorders (alcohol use disorder). In both cases - MDD and AUD, a number of immunological disturbances are observed, such as chronic mild inflammation response, increased level of cytokines, hypercortisolaemia, which lead to specific changes in brain neurotransmitter functions. Some of the contemporary brain imaging techniques are functional magnetic resonance imaging (fMRI) and magnetic spectroscopy which are most commonly used to assess the brain metabolism and functional connectivity changes such as altered responses to emotional stimuli in MDD or overactivation of ventromedial prefrontal areas during delayed and underactivation of dorsolateral prefrontal regions during impulsive reward decisions in AUD and dysfunction of gamma-aminobutyric acid (GABA) and/or glutamate neurotransmitter systems, low NAA and myo-Inositol in both MDD and AUD.

Nature and prevalence of combinations of mental disorders and their association with excess mortality in a population-based cohort study

The nature and prevalence of combinations of mental disorders and their associations with premature mortality have never been reported in a comprehensive way. We describe the most common combinations of mental disorders and estimate excess mortality associated with these combinations. We designed a population-based cohort study including all 7,505,576 persons living in Denmark at some point between January 1, 1995 and December 31, 2016. Information on mental disorders and mortality was obtained from national registers. A total of 546,090 individuals (10.5%) living in Denmark on January 1, 1995 were diagnosed with at least one mental disorder during the 22-year follow-up period. The overall crude rate of diagnosis of mental disorders was 9.28 (95% CI: 9.26-9.30) per 1,000 person-years. The rate of diagnosis of additional mental disorders was 70.01 (95% CI: 69.80-70.26) per 1,000 person-years for individuals with one disorder already diagnosed. At the end of follow-up, two out of five individuals with mental disorders were diagnosed with two or more disorder types. The most prevalent were neurotic/stress-related/somatoform disorders (ICD-10 F40-F48) and mood disorders (ICD-10 F30-F39), which - alone or in combination with other disorders - were present in 64.8% of individuals diagnosed with any mental disorder. Mortality rates were higher for people with mental disorders compared to those without mental disorders. The highest mortality rate ratio was 5.97 (95% CI: 5.52-6.45) for the combination of schizophrenia (ICD-10 F20-F29), neurotic/stress-related/somatoform disorders and substance use disorders (ICD-10 F10-F19). Any combination of mental disorders was associated with a shorter life expectancy compared to the general Danish population, with differences in remaining life expectancy ranging from 5.06 years (95% CI: 5.01-5.11) to 17.46 years (95% CI: 16.86-18.03). The largest excess mortality was observed for combinations that included substance use disorders. This study reports novel estimates related to the "force of comorbidity" and provides new insights into the contribution of substance use disorders to premature mortality in those with comorbid mental disorders.

Lifetime prevalence and age-of-onset distributions of mental disorders in the Saudi National Mental Health Survey

OBJECTIVES

To estimate lifetime prevalence of mental disorders in the Saudi National Mental Health Survey (SNMHS).

METHODS

The SNMHS is a face-to-face community epidemiological survey in a nationally representative household sample of citizens ages 15-65 in the Kingdom of Saudi Arabia (KSA) (n = 4,004). The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to estimate lifetime prevalence of common DSM-IV mental disorders.

RESULTS

Estimated lifetime prevalence of any DSM-IV/CIDI disorder is 34.2% and lifetime morbid risk is 38.0%. Anxiety disorders are by far the most prevalent (23.2%) followed by disruptive behavior (11.2%), mood (9.3%), eating (6.1%), and substance use (4.0%) disorders. Synthetic estimates of cohort effects suggest that prevalence of many disorders has increased in recent cohorts. Onsets typically occur in childhood for a number of anxiety and disruptive behavior disorders and in adolescence or early adulthood for most other disorders, although age-of-onset distributions for drug abuse is much later (median age of 31) than in CIDI surveys carried out in other high-income countries.

CONCLUSIONS

Lifetime mental disorders are highly prevalent in Saudi Arabia and typically have early ages-of-onset.

Comorbidity within mental disorders: a comprehensive analysis based on 145 990 survey respondents from 27 countries

AIMS

Epidemiological studies indicate that individuals with one type of mental disorder have an increased risk of subsequently developing other types of mental disorders. This study aimed to undertake a comprehensive analysis of pair-wise lifetime comorbidity across a range of common mental disorders based on a diverse range of population-based surveys.

METHODS

The WHO World Mental Health (WMH) surveys assessed 145 990 adult respondents from 27 countries. Based on retrospectively-reported age-of-onset for 24 DSM-IV mental disorders, associations were examined between all 548 logically possible temporally-ordered disorder pairs. Overall and time-dependent hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Absolute risks were estimated using the product-limit method. Estimates were generated separately for men and women.

RESULTS

Each prior lifetime mental disorder was associated with an increased risk of subsequent first onset of each other disorder. The median HR was 12.1 (mean = 14.4; range 5.2-110.8, interquartile range = 6.0-19.4). The HRs were most prominent between closely-related mental disorder types and in the first 1-2 years after the onset of the prior disorder. Although HRs declined with time since prior disorder, significantly elevated risk of subsequent comorbidity persisted for at least 15 years. Appreciable absolute risks of secondary disorders were found over time for many pairs.

CONCLUSIONS

Survey data from a range of sites confirms that comorbidity between mental disorders is common. Understanding the risks of temporally secondary disorders may help design practical programs for primary prevention of secondary disorders.

Causal beliefs of mental illness and its impact on help-seeking attitudes: a cross-sectional study among university students in Singapore

OBJECTIVES

A considerable proportion of those who suffer from mental illnesses in Singapore do not seek any form of professional help. The reluctance to seek professional help could be due to misconceptions about the causes of mental illnesses. Research has shown that help-seeking attitudes can predict actual service use. As young adults are most at risk of developing mental illnesses, this study aims to elucidate the impact of causal beliefs about mental illness on help-seeking attitudes among university students in Singapore.

DESIGN

Prior to attending an anti-stigma intervention, data on the Causal Beliefs about Mental Illness, Inventory of Attitudes towards Seeking Mental Health services and questions pertaining to sociodemographic background were collected from participants using a self-administered questionnaire. Multiple linear regressions were performed to examine the relationship between causal beliefs and help-seeking, as well as their sociodemographic correlates.

SETTINGS

A university in Singapore.

PARTICIPANTS

390 students who were studying in a University in Singapore.

RESULTS

Younger age was associated with higher scores on psychosocial attribution, while prior social contact with individuals with mental illness was significantly associated with lower scores on personality attribution. With regard to help-seeking attitudes; being a male and personality attribution were significantly associated with lower scores on 'Psychological Openness' and 'Indifference to Stigma', while psychosocial attribution was significantly associated with higher scores on 'Help-seeking Propensity'. Having prior social contact also predicted higher 'Psychological Openness', while being in Year 2 and 3 predicted lower scores on 'Indifference to Stigma'.

CONCLUSION

Findings from this study suggest that help-seeking attitudes might be influenced by causal beliefs, with personality attribution being the most impairing. Hence, to reduce the wide treatment gap in Singapore, anti-stigma interventions targeting young people could focus on addressing beliefs that attribute mental illness to the personality of the individual.

Early intervention for depression in young people: a blind spot in mental health care

Depression is a major contributor to disability across the lifespan. As a disorder that commonly has its onset in adolescence and early adulthood, and high recurrence and persistence, it is a prime candidate for early intervention. Most of the early intervention focus, however, has been confined to indicated prevention efforts. In this Personal View, we argue that early intervention for depression must expand beyond this narrow focus to include young people (aged 12-25 years old) who present with early episodes of full-threshold major depressive disorder. We discuss the development of enhanced primary care services for youth mental health, which allow young people improved access to evidence-based care. We argue that young people with severe and complex depression require particular attention: they are at high risk of lifelong disabling illness and need support to alleviate the early effects of their illnesses on their functional trajectories.

Exploring Comorbidity Within Mental Disorders Among a Danish National Population

IMPORTANCE

Individuals with mental disorders often develop comorbidity over time. Past studies of comorbidity have often restricted analyses to a subset of disorders and few studies have provided absolute risks of later comorbidity.

OBJECTIVES

To undertake a comprehensive study of comorbidity within mental disorders, by providing temporally ordered age- and sex-specific pairwise estimates between the major groups of mental disorders, and to develop an interactive website to visualize all results and guide future research and clinical practice.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study included all individuals born in Denmark between January 1, 1900, and December 31, 2015, and living in the country between January 1, 2000, and December 31, 2016. The analyses were conducted between June 2017 and May 2018.

MAIN OUTCOMES AND MEASURES

Danish health registers were used to identify mental disorders, which were examined within the broad 10-level International Statistical Classification of Diseases and Related Health Problems, 10th Revision, subchapter groups (eg, codes F00-F09 and F10-F19). For each temporally ordered pair of disorders, overall and lagged hazard ratios and 95% CIs were calculated using Cox proportional hazards regression models. Absolute risks were estimated using competing risks survival analyses. Estimates for each sex were generated.

RESULTS

A total of 5 940 778 persons were included in this study (2 958 293 men and 2 982 485 women; mean [SD] age at beginning of follow-up, 32.1 [25.4] years). They were followed up for 83.9 million person-years. All mental disorders were associated with an increased risk of all other mental disorders when adjusting for sex, age, and calendar time (hazard ratios ranging from 2.0 [95% CI, 1.7-2.4] for prior intellectual disabilities and later eating disorders to 48.6 [95% CI, 46.6-50.7] for prior developmental disorders and later intellectual disabilities). The hazard ratios were temporally patterned, with higher estimates during the first year after the onset of the first disorder, but with persistently elevated rates during the entire observation period. Some disorders were associated with substantial absolute risks of developing specific later disorders (eg, 30.6% [95% CI, 29.3%-32.0%] of men and 38.4% [95% CI, 37.5%-39.4%] of women with a diagnosis of mood disorders before age 20 years developed neurotic disorders within the following 5 years).

CONCLUSIONS AND RELEVANCE

Comorbidity within mental disorders is pervasive, and the risk persists over time. This study provides disorder-, sex-, and age-specific relative and absolute risks of the comorbidity of mental disorders. Web-based interactive data visualization tools are provided for clinical utility.

The Mutual Relationship Between Men's Drinking and Depression: A 4-Year Longitudinal Analysis

Aims

The purpose of the current study was to examine the longitudinal reciprocal relationship between depression and drinking among male adults from the general population.

Methods

This study used a panel dataset from the Korean Welfare Panel (from 2011 to 2014). The subjects were 2511 male adults aged between 20 and 65 years. Based on the Korean Version of the Alcohol Use Disorders Identification Test (AUDIT-K) scores, 2191 subjects were categorized as the control group (AUDIT-K < 12) and 320 subjects were categorized as the problem drinking group (AUDIT-K ≥ 12). An autoregressive cross-lagged modelling analysis was performed to investigate the mutual relationship between problem drinking and depression measured consecutively over time.

Results

The results indicated that alcohol drinking and depression were stable over time. In the control group, there was no significant causal relationship between problem drinking and depression while in the problem drinking group, drinking in the previous year significantly influenced depression in the following second, third and fourth years.

Conclusion

This study compared normal versus problem drinkers and showed a 4-year mutual causal relationship between depression and drinking. No longitudinal interaction between drinking and depression occurred in normal drinkers, while drinking intensified depression over time in problem drinkers.

Short summary

This study found that problem drinking was a risk factor for development of depression. Therefore, more attention should be given to problem alcohol use in the general population and evaluation of past alcohol use history in patients with depressive disorders.

Changes in percentages of perceived met needs for care over time in a Canadian longitudinal cohort

There is a paucity of research on determinants associated with changes in perceived met needs for care over time. This study used a longitudinal cohort to explore changes in percentages of perceived met needs over time and to identify its related determinants. Data analyzed was from a longitudinal community-based survey. A total of 150 participants received at least one type of help both at baseline and a 2-year follow-up. Multivariate analyses were used. Perceived met needs of the study sample slightly increased over time. People who had a higher percentage of met needs at baseline were less likely to have an increase in percentage of perceived met needs at the 2-year follow-up, whereas, those who had a higher value of wellbeing and an increase in the value of mental wellbeing over time, were associated with an increase in the percentage of met needs at the 2-year follow-up. Determinants associated with changes in percentages of perceived met needs could be the target for improving perceived need for mental health care. Findings of this study indicate the need for longitudinal studies in perceived need for mental health services.

Prospective predictors of first-onset depressive disorders in adolescent females with anxiety disorders

BACKGROUND

Anxious youth are at increased risk for later depressive disorders, but not all anxious youth develop depression. Sequential comorbidity models emphasize shared risk factors and anxiety sequelae, but some anxious youth who later develop depression may have risk factors that are relatively specific to depression, in addition to a liability to anxiety. We examined several variables that appear relatively specific to risk for depression-the personality traits of low positive affectivity and high sadness, and an electrophysiological measure of blunted response to reward - in predicting first-onset depressive disorders and depressive symptoms in clinically anxious adolescent girls.

METHODS

A sample of 114 adolescents with baseline anxiety disorders completed personality and psychopathology measures, psychophysiology tasks, and diagnostic interviews. Interviews and a measure of depressive symptoms were re-administered over 27 months.

RESULTS

After controlling for baseline depressive symptoms, blunted reward sensitivity uniquely predicted first-onset depressive disorders and depressive symptoms 27 months later. Post-hoc analyses indicated that blunted reward sensitivity only predicted first-onset depressive disorders and depressive symptoms in girls with high social anxiety symptoms.

LIMITATIONS

Analyses were unable to account for concurrent anxiety symptoms and disorders.

CONCLUSIONS

The depression-specific risk factor, blunted reward sensitivity, may comprise one pathway to subsequent depressive disorders and symptoms in anxious youth and indicate which anxious youth need intervention to prevent later depression, particularly in socially anxious girls.

[The dynamics of psychopathological symptoms of ultra high risk for psychosis in young patients with non-psychotic mental disorders]

OBJECTIVE

Based on the results of 5-year follow-up study, to describe the dynamics of psychopathological symptoms in young patients with non-psychotic forms of mental diseases met the criteria of ultra-high risk for schizophrenia who received preventive psychopharmacotherapy.

MATERIAL AND METHODS

The study included 32 young men, aged 16--25 years, presented with the symptoms of ultra-high risk of schizophrenia during the first hospitalization in 2009--2011. Follow-up was carried out in 2014--2015 (mean follow-up 5.79±0.36 years). According to ICD-10, patients were stratified into 3 groups: mood disorders, personality disorders and schizotypal disorders.

RESULTS AND CONCLUSION

According to the characteristics of subsequent development of these disorders, four types were singled out: mechanisms of the development of acute sensitive delusions (I), interpretative delusions (II), catatonic disorganization (III) and cognitive disorders pathognomonic for schizophrenia spectrum disorders (IV). Correlations between these types and nosologic disorders and their different reversibility under treatment were found. These types can be considered as predictors of outcome over the follow-up period.

Duration of untreated illness in patients with somatoform disorders

OBJECTIVE

A long duration of untreated mental illness (DUI) has been found to be associated with negative long-term outcomes. Although somatic symptom and related disorders are frequent in the general population and in primary care, data regarding the DUI of these disorders is scarce. The aim of this study was to investigate the DUI in patients with somatoform disorders.

METHODS

In a cross-sectional study, primary care patients at high risk of having a somatoform disorder were identified using the Patient Health Questionnaire (PHQ). In a second step, life-time somatoform disorder diagnosis was established using the Composite International Diagnostic Interview (CIDI). Additionally, DUI was retrospectively assessed via self-reporting and sociodemographic information was collected. Survival analysis was used to estimate the DUI and to identify patient-related predictors of DUI.

RESULTS

A total of 139 patients with somatoform disorders were included in the analyses. The mean DUI in these patients was 25.2years (median 23.1years). Higher education significantly predicted shorter DUI, whereas gender and age of onset were unrelated to DUI.

CONCLUSIONS

The results reveal a substantial delay in adequate treatment of patients with somatoform disorders. The reported DUI emphasizes the importance of improvements in the management of patients with these disorders.

Perceived needs for mental health care and barriers to treatment across age groups

PURPOSE

This study aimed to assess responses to a structured measure of perceived need for treatment to understand whether differences in treatment uptake across age groups are related to differences in: (1) perceived need for mental health care; (2) perceptions of treatment needs being met; and/or (3) perceived attitudinal and structural treatment barriers.

METHODS

Data from a nationally representative sample of the Australian population (2007 National Survey of Mental Health and Wellbeing) were analysed using logistic and multinomial regression. All participants potentially benefiting from mental health services were included in analyses; including those reporting symptoms of mental disorders, using mental health services, or self-reporting significant mental health problems in the past 12 months (n = 5733). All regression analyses were adjusted for gender, the presence of chronic physical health conditions, disorder type, and disorder severity.

RESULTS

Older adults were the least likely to report any perceived need for mental health care, and specifically reported lower needs for psychotherapy, information about available services, and support improving their ability to work. Older adults perceiving a need for mental health care were also the most likely to report having these needs met. There were no differences in attitudinal and structural barriers to treatment across age groups.

CONCLUSIONS

These results highlight that age needs to be considered in strategies for improving engagement and efficacy of mental health services, as well as the need for further research to understand what drives age differences in perceived need for mental health care.

No Reliable Evidence That Emotional Disorders Are Proximal Antecedents, Concomitants, or Short-Term Consequences of First Episode Alcohol Use Disorders in a Representative Community Sample

OBJECTIVE

Emotional disorders and alcohol use disorders (AUDs) frequently demonstrate significant 12-month and lifetime comorbid associations. This comorbidity has been incorporated into influential theories of addiction processes that posit direct or indirect causal associations between these disorder categories. There is currently no consensus, however, about the sequencing of these disorders. In this research, longitudinal data from a regionally representative community sample were used to evaluate whether emotional disorders constitute a proximal antecedent, concomitant, or short-term consequence of first episode (or index) AUDs.

METHOD

Participants were 131 persons with index AUD episodes lasting 12 months or more and 131 matched controls. For each participant with an AUD, the presence or absence of an emotional disorder was coded for three time intervals: (a) the 12 months preceding full syndrome AUD episode onset; (b) the last 12 months of the AUD episode; and (c) the 12 months following complete symptom AUD episode offset. These intervals, referenced to participant age, were matched to those of control participants, and emotional disorder rate comparisons subsequently performed both within and between groups.

RESULTS

Findings indicated an absence of significant within- or between-subject differences in emotional disorder rates, suggesting that the association between AUDs and emotional disorders is neither directional nor systematic. There was also no indication that the length of the AUD episode increased risk for an emotional disorder in the year following AUD offset.

CONCLUSIONS

Overall, this research suggests that emotional disorders are generally independent events in relation to the index AUD episode.

A Place for Sexual Dysfunctions in an Empirical Taxonomy of Psychopathology

Sexual dysfunctions commonly co-occur with various depressive and anxiety disorders. An emerging framework for understanding the classification of mental disorders suggests that such comorbidity is a manifestation of underlying dimensions of psychopathology (or "spectra"). In this review, we synthesize the evidence that sexual dysfunctions should be included in the empirical taxonomy of psychopathology as part of the internalizing spectrum, which accounts for comorbidity among the depressive and anxiety disorders. The review has four parts. Part 1 summarizes the empirical basis and utility of the empirical taxonomy of psychopathology. Part 2 reviews the prima facie evidence for the hypothesis that sexual dysfunctions are part of the internalizing spectrum (i.e., high rates of comorbidity; shared cognitive, affective, and temperament characteristics; common neural substrates and biomarkers; shared course and treatment response; and the lack of causal relationships between them). Part 3 critically analyzes and integrates the results of the eight studies that have addressed this hypothesis. Finally, Part 4 examines the implications of reconceptualizing sexual dysfunctions as part of the internalizing spectrum, and explores avenues for future research.

A Structural Equation Modeling Analysis of the Relationships between Depression, Anxiety, and Sexual Problems over Time

Sexual dysfunctions are related to depressive and anxiety disorders, but the nature of these relationships remains unclear. This study examined the relationship among symptoms of these disorders over time by comparing (a) a model that included causal relationships, (b) a model that accounted for change over time with a shared underlying factor (or latent liability) among all the disorders, and (c) a model that conceptualized sexual dysfunctions as unrelated to depressive and anxiety disorders over time. Participants (n = 1,012) completed online self-report measures of sexual dysfunctions and depressive and anxiety disorders across six time points at either weekly or monthly intervals. Models 1 and 2 provided equal best fit for men and women based on data collected four weeks apart, but there were no evident causal relationships in Model 1. Subsequent analyses using data collected one week and six months apart found Model 2 provided robust fit for women, but these data were not examined for men due to inadequate sample sizes. The results are consistent with a shared latent liability of internalizing psychopathology driving the change in these disorders over time, which provides a clear direction for an empirically driven nosology and for future research into transdiagnostic treatments.

Preventing depression and anxiety in young people: a review of the joint efficacy of universal, selective and indicated prevention

Depression and anxiety (internalizing disorders) are the largest contributors to the non-fatal health burden among young people. This is the first meta-analysis to examine the joint efficacy of universal, selective, and indicated preventive interventions upon both depression and anxiety among children and adolescents (5-18 years) while accounting for their co-morbidity. We conducted a systematic review of reviews in Medline, PsycINFO and the Cochrane Library of Systematic Reviews, from 1980 to August 2014. Multivariate meta-analysis examined the efficacy of preventive interventions on depression and anxiety outcomes separately, and the joint efficacy on both disorders combined. Meta-regressions examined heterogeneity of effect according to a range of study variables. Outcomes were relative risks (RR) for disorder, and standardized mean differences (Cohen's d) for symptoms. One hundred and forty-six randomized controlled trials (46 072 participants) evaluated universal (children with no identified risk, n = 54) selective (population subgroups of children who have an increased risk of developing internalizing disorders due to shared risk factors, n = 45) and indicated prevention (children with minimal but detectable symptoms of an internalizing disorder, n = 47), mostly using psychological-only strategies (n = 105). Reductions in internalizing disorder onset occurred up to 9 months post-intervention, whether universal [RR 0.47, 95% confidence interval (CI) 0.37-0.60], selective (RR 0.61, 95% CI 0.43-0.85) or indicated (RR 0.48, 95% CI 0.29-0.78). Reductions in internalizing symptoms occurred up to 12 months post-intervention for universal prevention; however, reductions only occurred in the shorter term for selective and indicated prevention. Universal, selective and indicated prevention interventions are efficacious in reducing internalizing disorders and symptoms in the short term. They might be considered as repeated exposures in school settings across childhood and adolescence. (PROSPERO registration: CRD42014013990.).

Substance Use and Depressive Symptoms among Adolescents Treated in a Pediatric Emergency Department

The current study examined associations between substance use and depressed mood by gender and type of substance used (no use, alcohol, marijuana or both alcohol and marijuana) in a sample of 713 adolescents (M_age = 15.3) recruited from a Pediatric Emergency Department (PED). Adolescents who reported any marijuana use had higher overall depressed mood scores compared to all other adolescents. When examined by gender, females with both alcohol and marijuana use reported the highest overall depressed mood symptoms. These results suggest the usefulness of screening and identification of depressive symptoms among adolescents presenting to a PED for substance use-related problems.

Identification with social groups is associated with mental health in adolescents: Evidence from a Scottish community sample

The promotion and maintenance of mental health is an increasingly important societal issue. Previous research has shown that identification with social groups is positively associated with adult mental wellbeing, with multiple group identifications being particularly beneficial. The aim of the current study was to investigate whether the same is true for adolescents. 1111 Scottish secondary school students aged 13-17 completed a questionnaire investigating mental health symptoms and the extent of their identification with their family, school, and friendship groups. Higher identification with each group predicted better mental health. There was also an additive effect of group identification, with the odds of reporting psychiatric disturbance decreasing for every additional group with which participants identified strongly. These effects held even when age, gender, and group contact were controlled for. Our findings have implications for the prevention and treatment of mental problems, offering an alternative to traditional ways of viewing mental illness in adolescence and beyond.

Cognitive-behavioral therapy for child anxiety confers long-term protection from suicidality

OBJECTIVE

Evidence for an independent relationship between anxiety and suicidality has been mixed. Few studies have examined this relationship in youth seeking treatment for anxiety. The present study examined the relationship between response to treatment for an anxiety disorder in childhood and suicidal ideation, plans, and attempts at a follow-up interval of 7 to 19 years. We hypothesized that successful treatment for an anxiety disorder in childhood would be protective against later suicidality.

METHOD

The present study was a 7- to 19-year (mean = 16.24 years; SD = 3.56 years) follow-up study. Adults (N = 66) completed cognitive-behavioral treatment (CBT) for anxiety as children. Information regarding suicidality at follow-up was obtained via the World Mental Health Survey Initiative version of the World Health Organization Composite International Diagnostic Interview (CIDI) and the Beck Depression Inventory-II (BDI-II).

RESULTS

Results indicate that participants who responded favorably to CBT during childhood were less likely to endorse lifetime, past-month, and past-2-week suicidal ideation than treatment nonresponders. This was consistent across self-report and interview-report of suicidal ideation. Treatment response was not significantly associated with suicide plans or attempts, although the infrequent occurrence of both limited the ability to detect findings.

CONCLUSION

Results suggest more chronic and enduring patterns of suicidal ideation among individuals with anxiety in childhood that is not successfully treated. This study adds to the literature that suggests that successful CBT for childhood anxiety confers long-term benefits and underscores the importance of the identification and evidence-based treatment of youth anxiety.

Proportion of patients without mental disorders being treated in mental health services worldwide

BACKGROUND

Previous research suggests that many people receiving mental health treatment do not meet criteria for a mental disorder but are rather 'the worried well'.

AIMS

To examine the association of past-year mental health treatment with DSM-IV disorders.

METHOD

The World Health Organization's World Mental Health (WMH) Surveys interviewed community samples of adults in 23 countries (n = 62 305) about DSM-IV disorders and treatment in the past 12 months for problems with emotions, alcohol or drugs.

RESULTS

Roughly half (52%) of people who received treatment met criteria for a past-year DSM-IV disorder, an additional 18% for a lifetime disorder and an additional 13% for other indicators of need (multiple subthreshold disorders, recent stressors or suicidal behaviours). Dose-response associations were found between number of indicators of need and treatment.

CONCLUSIONS

The vast majority of treatment in the WMH countries goes to patients with mental disorders or other problems expected to benefit from treatment.

Toward a comprehensive developmental model of smoking initiation and nicotine dependence

BACKGROUND

This study aims to identify predictors of smoking initiation and nicotine dependence (ND) to develop a comprehensive risk-factor model based on Kendler's development model for major depression.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Wave 2 (n=34,653). Risk factors were divided into five developmental tiers according to Kendler's model (childhood, early adolescence, late adolescence, adulthood, past-year). Hierarchical logistic regression models were built to predict the risk of smoking initiation and the risk of ND, given initiation. The continuation ratio (CR) was tested by ordinal logistic regression to examine whether the impact of the predictors was the same on smoking initiation or ND.

RESULTS

The final models highlighted the importance of different tiers for each outcome. The CR identified substantial differences in the predictors of smoking initiation versus ND. Childhood tier appears to be more determinant for smoking initiation while the effect of more distal tiers (i.e. childhood and early adolescence) was tempered by more proximal ones (i.e. late adolescence, adulthood and past-year) in ND, with few sex differences.

CONCLUSIONS

The differential effect of some predictors on each outcome shows the complexity of pathways from smoking initiation to ND. While some risk factors may be shared, others impact only at one stage or have even an inverse effect. An adaptation of Kendler's developmental model for major depression showed high predictive power for smoking initiation and ND.

Comorbidity of anxiety and depression in children and adolescents: 20 years after

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

Escalation to Major Depressive Disorder among adolescents with subthreshold depressive symptoms: evidence of distinct subgroups at risk

BACKGROUND

The presence of subthreshold depressive symptoms (SubD) in adolescence is associated with high prospective risk of developing Major Depressive Disorder (MDD). Little is known about variables that predict escalation from SubD to MDD. This study used a longitudinal prospective design in a community sample of adolescents to identify combinations of risk factors that predicted escalation from SubD to MDD.

METHODS

Classification tree analysis was used to identify combinations of risk factors that improved the sensitivity and specificity of prediction of MDD onset among 424 adolescents with a lifetime history of SubD.

RESULTS

Of the 424, 144 developed MDD during the follow-up period. Evidence for multiple subgroups was found: among adolescents with poor friend support, the highest risk of escalation was among participants with lifetime histories of an anxiety or substance use disorder. Among adolescents with high friend support, those reporting multiple major life events in the past year or with a history of an anxiety disorder were at highest risk of escalation.

LIMITATIONS

Study findings may not inform prevention efforts for individuals who first develop SubD during adulthood. This study did not examine the temporal ordering of predictors involved in escalation from SubD to MDD.

CONCLUSIONS

Adolescents with a history of SubD were at highest risk of escalation to MDD in the presence of poor friend support and an anxiety or substance use disorder, or in the presence of better friend support, multiple major life events, and an anxiety disorder. Findings may inform case identification approaches for adolescent depression prevention programs.

A comparative analysis of role attainment and impairment in binge-eating disorder and bulimia nervosa: results from the WHO World Mental Health Surveys

Background. Cross-national population data from the WHO World Mental Health surveys are used to compare role attainments and role impairments associated with binge-eating disorder (BED) and bulimia nervosa (BN). Methods. Community surveys assessed 23 000 adults across 12 countries for BED, BN and ten other DSM-IV mental disorders using the WHO Composite International Diagnostic Interview. Age-of-onset was assessed retrospectively. Ten physical disorders were assessed using standard conditions checklists. Analyses examined reciprocal time-lagged associations of eating disorders (EDs) with education, associations of early-onset (i.e., prior to completing education) EDs with subsequent adult role attainments and cross-sectional associations of current EDs with days of role impairment. Results. BED and BN predicted significantly increased education (females). Student status predicted increased risk of subsequent BED and BN (females). Early-onset BED predicted reduced odds of current (at time of interview) marriage (females) and reduced odds of current employment (males). Early-onset BN predicted increased odds of current work disability (females and males). Current BED and BN were both associated with significantly increased days of role impairment (females and males). Significant BED and BN effects on adult role attainments and impairments were explained by controls for comorbid disorders. Conclusions. Effects of BED on role attainments and impairments are comparable with those of BN. The most plausible interpretation of the fact that these associations are explained by comorbid disorders is that causal effects of EDs are mediated through secondary disorders. Controlled treatment effectiveness studies are needed to trace out long-term effects of BED-BN on secondary disorders.

The occasional case against broad dissemination and implementation: retaining a role for specialty care in the delivery of psychological treatments

Mental illness imposes a staggering public health burden in the United States. Although the past 40 years have witnessed tremendous advances in the identification of evidence-based practices (EBPs) in psychological treatments, gaps persist between treatment in experimental settings and services available in the community. In response, considerable attention and large financial commitments have focused in recent years on broad dissemination and implementation efforts designed to improve the quality of psychological services delivered by a variety of generalist practitioners across practice settings. Increasingly, under the influence of the Patient Protection and Affordable Care Act, it is envisioned that these generalists will practice in integrated primary care settings. These advances hold enormous potential, and yet, given the tremendous diversity of mental health problems and human suffering, broad dissemination and implementation efforts to generalists alone may not be sufficient to adequately address the burden of mental illness. Some EBPs may prove too complex for universal dissemination, and the time and expense required for quality dissemination and implementation preclude large-scale training in the treatment of low base rate disorders. As dissemination and implementation efforts work to ensure a quality generalist mental health care workforce, herein we highlight the vital need for available specialty care in the delivery of psychological treatments. Given traditional barriers that interfere with the accessibility of specialty care, we propose the transformative potential of a specialty behavioral telehealth care workforce, transacting with the generalist practitioner workforce to collectively ensure the highest quality and timely delivery of needed treatments to affected individuals.

Predicting persistency of DSM-5 alcohol use disorder and examining drinking patterns of recently remitted individuals: a prospective general population study

AIMS

To establish the 3-year persistency rate of alcohol use disorder (AUD) and its predictors, and to examine drinking patterns of recently remitted individuals.

DESIGN AND SETTING

The Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) surveyed a nationally representative sample of adults (aged 18-64 years) at baseline (response = 65.1%) and 3-year follow-up (response = 80.4%).

PARTICIPANTS

People with AUD at baseline, as defined by DSM-5 (n = 198).

MEASUREMENTS

AUD, drinking patterns and mental disorders were assessed using the Composite International Diagnostic Interview 3.0. Other predictors were assessed with an additional questionnaire. Predictors of persistency were examined with univariable and multivariable logistic regression analyses.

RESULTS

The AUD persistency rate was 29.5% [95% confidence intervals (CI) = 20.0-39.0]. In the multivariable model, the older (25-34 and 35-44) age groups had lower AUD persistency [odds ratio (OR) = 0.05; 95% CI = 0.00-0.49 and OR = 0.14; 95% CI = 0.02-0.79, respectively] than the youngest age group (18-24). A higher number of weekly drinks and a comorbid anxiety disorder predicted AUD persistency (OR = 1.03; 95% CI = 1.00-1.07 and OR = 4.56; 95% CI = 1.04-20.06, respectively). Furthermore, remission was associated with a reduction of six drinks per week between T0 and T1 . It should be noted, however, that 35.8% (95% CI = 22.4-49.2) of people in diagnostic remission still drank more than the recommended maximum (more than seven/14 drinks weekly for women/men).

CONCLUSIONS

Only a minority of people in the Netherlands with alcohol use disorder as defined by DSM-5 still have the disorder 3 years later. Factors that help to identify people at risk of alcohol use disorder persistence are: younger age, a higher number of weekly drinks and a comorbid anxiety disorder. A substantial number of people recently in diagnostic remission still drink above the maximum recommended level.

Mental health differences between frequent cannabis users with and without dependence and the general population

AIMS

To compare the prevalence of mental disorders between frequent cannabis users with and without dependence and the general population.

DESIGN

Cross-sectional comparison of interview data.

SETTING

Enriched community sample of frequent cannabis users and a representative sample of non-users and non-frequent users from the general population.

PARTICIPANTS

A total of 521 young adult (aged 18-30 years) frequent cannabis users, 252 of whom were with DSM-IV cannabis dependence (D+) and 269 without DSM-IV cannabis dependence (D-), and 1072 young adults from the general population.

MEASUREMENTS

Multinomial logistic regression was used to compare groups regarding the presence of DSM-IV mental disorders. Detailed measures of cannabis use, childhood adversity and other substance use were considered confounders.

FINDINGS

Compared with the general population, externalizing disorders were more prevalent in D- [odds ratio (OR) = 8.91, P < 0.001] and most prevalent in D+ (OR = 17.75, P < 0.001), but internalizing disorders were associated only with D+ (mood OR = 4.15, P < 0.001; anxiety OR = 2.20, P = 0.002). Associations were attenuated (and often became non-significant) after correction for childhood adversity and substance use other than cannabis. However, the prevalence of mental disorders remained higher in D+ compared with D- (OR = 2.40, P < 0.001), although cannabis use patterns were remarkably similar.

CONCLUSIONS

Cannabis use patterns, childhood adversity and the use of other substances are similar in dependent and non-dependent frequent cannabis users. With the exception of more externalizing disorders, the mental health condition of non-dependent frequent cannabis users is similar to that of the general population, whereas it is worse in dependent frequent cannabis users.

First-incidence of DSM-IV mood, anxiety and substance use disorders and its determinants: results from the Netherlands Mental Health Survey and Incidence Study-2

BACKGROUND

Prospective studies measuring first-incidence of DSM-IV mood, anxiety and substance use disorders in the general population are rare. We assessed these incidence rates in the Dutch population; and identified baseline sociodemographic, physical and psychopathological variables, and negative changes in sociodemographics and physical health between baseline and follow-up, as determinants of first-onset main categories of disorders.

METHOD

Data are from NEMESIS-2, a representative face-to-face survey including 5303 subjects aged 18-64 interviewed twice (2007-2009; 2010-2012) with the CIDI 3.0.

RESULTS

In three years, 8.86% of adults without prior psychopathology experienced any mental disorder, corresponding with 3.09 cases per 100 person-years. Incidence was highest for anxiety (1.69 per 100 person-years) and mood disorder (1.65), and lowest for substance use disorder (0.97). For the separate disorders, incidence was highest for major depression (1.58), specific phobia (0.79) and alcohol abuse (0.73). For mood and anxiety disorder, incidence rate was higher among women and for substance use disorder it was higher among men. Age was inversely related to all disorder categories. Changes in sociodemographics, like no longer living with a partner and decrease in income, were stronger determinants than the corresponding sociodemographics. Incident mood disorder was predicted by baseline anxiety and substance use disorder, incident anxiety disorder by mood and substance use disorder, and incident substance use disorder by adult ADHD.

LIMITATIONS

Validity of lifetime diagnoses can be questioned because of difficulty of accurate recall. Only determinants of categories of disorders were studied, due to low numbers of incident cases of most separate disorders.

CONCLUSION

First-onset of mental disorders in a 3-year period is not an uncommon phenomenon. Results about determinants of incident disorders are important for prevention and early intervention initiatives aimed at reducing burden of mental disorders.

Anxiety and related outcomes in young adults 7 to 19 years after receiving treatment for child anxiety

OBJECTIVE

This study evaluated follow-up outcomes associated with cognitive behavioral therapy (CBT) for childhood anxiety by comparing successfully and unsuccessfully treated participants 6.72 to 19.17 years after treatment.

METHOD

Participants were a sample of 66 youths (ages 7-14 years at time of treatment, ages 18-32 years at present follow-up) who had been diagnosed with an anxiety disorder and randomized to treatment in a randomized clinical trial on average 16.24 (SD = 3.56, range = 6.72-19.17) years prior. The present follow-up included self-report measures and a diagnostic interview to assess anxiety, depression, and substance misuse.

RESULTS

Compared with those who responded successfully to CBT for an anxiety disorder in childhood, those who were less responsive had higher rates of panic disorder, alcohol dependence, and drug abuse in adulthood. Relative to a normative comparison group, those who were less responsive to CBT in childhood had higher rates of several anxiety disorders and substance misuse problems in adulthood. Participants remained at particularly increased risk, relative to the normative group, for generalized anxiety disorder and nicotine dependence regardless of initial treatment outcome.

CONCLUSIONS

The present study is the first to assess the long-term follow-up effects of CBT treatment for an anxiety disorder in youth on anxiety, depression, and substance abuse through the period of young adulthood when these disorders are often seen. Results support the presence of important long-term benefits of successful early CBT for anxiety.

The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys

BACKGROUND

Little population-based data exist outside the United States on the epidemiology of binge eating disorder (BED). Cross-national BED data are presented here and compared with bulimia nervosa (BN) data in the World Health Organization (WHO) World Mental Health Surveys.

METHODS

Community surveys with 24,124 respondents (ages 18+) across 14 mostly upper-middle and high-income countries assessed lifetime and 12-month DSM-IV mental disorders with the WHO Composite International Diagnostic Interview. Physical disorders were assessed with a chronic conditions checklist.

RESULTS

Country-specific lifetime prevalence estimates are consistently (median; interquartile range) higher for BED (1.4%; .8-1.9%) than BN (.8%; .4-1.0%). Median age of onset is in the late teens to early 20s for both disorders but slightly younger for BN. Persistence is slightly higher for BN (6.5 years; 2.2-15.4) than BED (4.3 years; 1.0-11.7). Lifetime risk of both disorders is elevated for women and recent cohorts. Retrospective reports suggest that comorbid DSM-IV disorders predict subsequent onset of BN somewhat more strongly than BED and that BN predicts subsequent comorbid disorders somewhat more strongly than does BED. Significant comorbidities with physical conditions are due almost entirely to BN and to a somewhat lesser degree BED predicting subsequent onset of these conditions. Role impairments are similar for BN and BED. Fewer than half of lifetime BN or BED cases receive treatment.

CONCLUSIONS

Binge eating disorder represents a public health problem at least equal to BN. Low treatment rates highlight the clinical importance of questioning patients about eating problems even when not included among presenting complaints.

Aggregation of lifetime Axis I psychiatric disorders through age 30: incidence, predictors, and associated psychosocial outcomes

Longitudinal data from representative birth cohorts on the aggregation of psychiatric disorders, or the cumulative number of unique diagnosed disorders experienced by persons within a circumscribed period, are limited. As a consequence, risk factors for and psychosocial implications of lifetime disorder aggregation in the general population remain largely unknown. This research evaluates the incidence, predictors, and psychosocial sequela of lifetime disorder aggregation from childhood through age 30. Over a 14-year period, participants in the Oregon Adolescent Depression Project (probands; N = 816) were repeatedly evaluated for psychiatric disorders and assessed with multiple measures of psychosocial functioning. First-degree relatives of probands (N = 2,414) were also interviewed to establish their lifetime psychiatric history. The cumulative prevalence of common lifetime psychiatric disorders for the proband sample was 71%. Three-quarters of all proband psychiatric disorders occurred among 37% of the sample, and 82% of all disorder diagnoses were made among persons who met criteria for at least one other lifetime disorder. Lifetime disorder aggregation in probands was predicted by lifetime psychiatric disorder densities among first-degree relatives and was related to heterotypic comorbidity patterns that included disorders from both internalizing and externalizing domains, most notably major depressive and alcohol use disorders. By age 30, disorder aggregation was significantly associated with mental health care service utilization and predictive of personality disorder pathology and numerous indicators of poor psychosocial functioning. Possible implications of disorder aggregation on the conceptualization of lifetime psychiatric disorder comorbidity are discussed.

Generalized anxiety disorder is under-recognized in clinical practice in patients with alcohol dependence in France

Generalized Anxiety Disorder (GAD) is a frequent disabling disorder that often occurs with alcohol dependence. However comorbidity between substance use disorders and psychiatric disorders is often under-diagnosed. This study tried to evaluate an under-recognition of GAD by clinicians in alcoholic inpatients. Two groups of alcohol-dependent inpatients, hospitalized in the same non-academic psychiatric hospital in France, were included. The first group (Group 1) (n = 205) was included retrospectively within all patients hospitalized for alcohol dependence from may to November 2007. A record review was performed to determine the number of GAD (and other psychiatric disorders) diagnosis which was reported on these files by the clinicians. The second group (Group 2) (n = 199) was included prospectively from May to November 2008. GAD diagnosis was screened with the Worry and Anxiety Questionnaire and then confirmed with the Mini International Neurodiagnostic Interview. The two groups were similar in terms of social and demographic variables. GAD prevalence rate was significantly higher in Group 2 (30.7% with Confidence Interval [0.242; 0.371]) than in Group 1 (2.4% with Confidence Interval [0.003; 0.045]). This study confirms our hypothesis of an under-recognition of GAD by clinicians in alcohol dependant inpatients. It also confirms the high prevalence rate of comorbidity between alcohol dependence and GAD.

The psychosis high-risk state: a comprehensive state-of-the-art review

CONTEXT

During the past 2 decades, a major transition in the clinical characterization of psychotic disorders has occurred. The construct of a clinical high-risk (HR) state for psychosis has evolved to capture the prepsychotic phase, describing people presenting with potentially prodromal symptoms. The importance of this HR state has been increasingly recognized to such an extent that a new syndrome is being considered as a diagnostic category in the DSM-5.

OBJECTIVE

To reframe the HR state in a comprehensive state-of-the-art review on the progress that has been made while also recognizing the challenges that remain.

DATA SOURCES

Available HR research of the past 20 years from PubMed, books, meetings, abstracts, and international conferences.

STUDY SELECTION AND DATA EXTRACTION

Critical review of HR studies addressing historical development, inclusion criteria, epidemiologic research, transition criteria, outcomes, clinical and functional characteristics, neurocognition, neuroimaging, predictors of psychosis development, treatment trials, socioeconomic aspects, nosography, and future challenges in the field.

DATA SYNTHESIS

Relevant articles retrieved in the literature search were discussed by a large group of leading worldwide experts in the field. The core results are presented after consensus and are summarized in illustrative tables and figures.

CONCLUSIONS

The relatively new field of HR research in psychosis is exciting. It has the potential to shed light on the development of major psychotic disorders and to alter their course. It also provides a rationale for service provision to those in need of help who could not previously access it and the possibility of changing trajectories for those with vulnerability to psychotic illnesses.

Projected rates of psychological disorders and suicidality among soldiers based on simulations of matched general population data

Limited data are available on lifetime prevalence and age-of-onset distributions of psychological disorders and suicidal behaviors among Army personnel. We used simulation methods to approximate such estimates based on analysis of data from a U.S. national general population survey with the sociodemographic profile of U.S. Army personnel. Estimated lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety, mood, behavior, or substance disorder in this sample was 53.1% (17.7% for mood disorders, 27.2% for anxiety disorders, 22.7% for behavior disorders, and 14.4% for substance disorders). The vast majority of cases had onsets before the expected age of enlistment if they were in the Army (91.6%). Lifetime prevalence was 14.2% for suicidal ideation, 5.4% for suicide plans, and 4.5% for suicide attempts. The proportion of estimated preenlistment onsets was between 68.4% (suicide plans) and 82.4% (suicidal ideation). Externalizing disorders with onsets before expected age of enlistment and internalizing disorders with onsets after expected age of enlistment significantly predicted postenlistment suicide attempts, with population attributable risk proportions of 41.8% and 38.8%, respectively. Implications of these findings are discussed for interventions designed to screen, detect, and treat psychological disorders and suicidality in the Army.

Treatment gap in common mental disorders: the Singapore perspective

AIMS

The problem of wide treatment gaps in mental disorders is endemic world wide. The study aims to establish the treatment gap of common mental disorders in Singapore.

METHODS

A national sample of 6616 persons aged 18 years and above was surveyed with the World Mental Health Composite International Diagnostic Interview in which for each diagnostic module, respondents were asked a series of questions regarding treatment contact.

RESULTS

Treatment gap varied considerably between disorders; alcohol abuse had the largest treatment gap (96.2%), followed by obsessive compulsive disorder (89.8%) and alcohol dependence (88.3%). The disorder for which people were most likely to seek help was major depressive disorder. Women with dysthmia were more likely than men to seek help but this help seeking behavior was reversed among those with alcohol abuse and dependence. Age of onset was significantly associated with treatment contact with those who had an earlier age of onset less likely to have treatment contact than those with late age of onset for all disorders except obsessive compulsive disorder.

CONCLUSIONS

Our findings suggest that treatment gaps are wide even in an economically developed country like Singapore and other than sociodemographic factors, cultural influences might play an important role in help seeking behavior.

The complex role of sleep in adolescent depression

Psychological and pharmacologic treatments for youth depression yield post-acute response and remission rates that are modest at best. Improving these outcomes is an important long-term goal. The authors examine the possibility that a youth cognitive behavioral therapy insomnia intervention may be an adjunct to traditional depression-focused treatment with the aim of improving depression outcomes. This “indirect route” to improving youth depression treatment outcomes is based on research indicating that the risk of depression is increased by primary insomnia and that sleep problems interfere with depression treatment success and on emerging adult depression randomized controlled trial results. The authors describe the protocol they developed.