Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys

BACKGROUND

The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data.

METHODS

Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI).

RESULTS

Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes).

CONCLUSIONS

The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

The cross-national epidemiology of DSM-IV intermittent explosive disorder

BACKGROUND

This is the first cross-national study of intermittent explosive disorder (IED).

METHOD

A total of 17 face-to-face cross-sectional household surveys of adults were conducted in 16 countries (n = 88 063) as part of the World Mental Health Surveys initiative. The World Health Organization Composite International Diagnostic Interview (CIDI 3.0) assessed DSM-IV IED, using a conservative definition.

RESULTS

Lifetime prevalence of IED ranged across countries from 0.1 to 2.7% with a weighted average of 0.8%; 0.4 and 0.3% met criteria for 12-month and 30-day prevalence, respectively. Sociodemographic correlates of lifetime risk of IED were being male, young, unemployed, divorced or separated, and having less education. The median age of onset of IED was 17 years with an interquartile range across countries of 13-23 years. The vast majority (81.7%) of those with lifetime IED met criteria for at least one other lifetime disorder; co-morbidity was highest with alcohol abuse and depression. Of those with 12-month IED, 39% reported severe impairment in at least one domain, most commonly social or relationship functioning. Prior traumatic experiences involving physical (non-combat) or sexual violence were associated with increased risk of IED onset.

CONCLUSIONS

Conservatively defined, IED is a low prevalence disorder but this belies the true societal costs of IED in terms of the effects of explosive anger attacks on families and relationships. IED is more common among males, the young, the socially disadvantaged and among those with prior exposure to violence, especially in childhood.

Age-adjusted relative suicide risk by marital and employment status over the past 25 years in Japan

BACKGROUND

There have been no longitudinal studies in Japan examining national-level data for suicide risk by marital and employment status. We examined the age-adjusted relative suicide risk (RR) by marital and employment status from national data acquired for all suicides in Japan occurring in the past 25 years.

METHODS

All deaths identified as suicides according to ICD-9 and ICD-10 were extracted from vital statistics data of Japan for the years 1980, 1985, 1990, 1995, 2000 and 2005. Population statistics for Japanese residents aged ≥15 years were obtained from the census.

RESULTS

Suicide rates for almost all categories analyzed decreased in both genders between 1985 and 1990 and increased between 1995 and 2000, especially among men. Unemployed and divorced men had a consistently higher RR in each year analyzed. Unemployed and divorced women had a higher risk than those in other categories, especially in 2000 and 2005. In women, particularly in 1980, 1985 and 1990, those who were unemployed and never married had a similar RR to those who were unemployed and divorced.

CONCLUSIONS

Unemployed and divorced people were at a high risk of suicide over the past 25 years, particularly in 2000 and 2005. Our findings suggest that the effects of divorce and unemployment on suicide risk are synergistic.

Age patterns in the prevalence of DSM-IV depressive/anxiety disorders with and without physical co-morbidity

BACKGROUND

Physical morbidity is a potent risk factor for depression onset and clearly increases with age, yet prior research has often found depressive disorders to decrease with age. This study tests the possibility that the relationship between age and mental disorders differs as a function of physical co-morbidity.

METHOD

Eighteen general population surveys were carried out among household-residing adults as part of the World Mental Health (WMH) surveys initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). The effect of age was estimated for 12-month depressive and/or anxiety disorders with and without physical or pain co-morbidity, and for physical and/or pain conditions without mental co-morbidity.

RESULTS

Depressive and anxiety disorders decreased with age, a result that cannot be explained by organic exclusion criteria. No significant difference was found in the relationship between mental disorders and age as a function of physical/pain co-morbidity. The majority of older persons have chronic physical or pain conditions without co-morbid mental disorders; by contrast, the majority of those with mental disorders have physical/pain co-morbidity, particularly among the older age groups.

CONCLUSIONS

CIDI-diagnosed depressive and anxiety disorders in the general population decrease with age, despite greatly increasing physical morbidity with age. Physical morbidity among persons with mental disorder is the norm, particularly in older populations. Health professionals, including mental health professionals, need to address barriers to the management of physical co-morbidity among those with mental disorders.

Disclosure preferences regarding cancer diagnosis and prognosis: to tell or not to tell?

Telling people that they have cancer has a great impact on their lives, so many doctors are concerned about how they should inform patients about a cancer diagnosis and its prognosis. We conducted a general population survey in Japan to investigate people's preferences on receiving this information. There were no significant differences in respondents' preferences according to the seriousness of the cancer. Full disclosure of the diagnosis was preferred by 86.1% of the respondents, while 2.7% wanted non-disclosure. As for the initial provision of information, the majority preferred partial disclosure concerning the prospects of complete recovery (64.5%) and the expected length of survival (64.1%). Those who responded negatively to the statement, "If I am close to the end of my life, I want to be informed of the fact so I can choose my own way of life", were more likely to want non-disclosure on diagnosis. The results suggest that, at the first opportunity of providing information, a disclosure policy of giving patients full details of their diagnosis and some information on prognosis can satisfy the preferences of most patients. Contrary to popular belief, the seriousness of the cancer and people's demographic characteristics displayed little impact in this study.

Are the care levels of people with dementia correctly assessed for eligibility of the Japanese long-term care insurance?

BACKGROUND

A new long-term care insurance system was launched in Japan in April 2000.

OBJECTIVES

We performed the first national survey on special units of psychiatric hospitals for dementia patients to examine whether their disabilities were well reflected in the eligibility assessment.

METHODS

Of all 248 dementia special units of psychiatric hospitals in Japan, 180 units (72.6%) participated in the survey. Five patients were randomly selected in each unit, and we used data of 802 (89.1%) of 900 patients whose care levels were obtained by the primary computer assessment. These patients were assessed using the Mini-Mental State Examination (MMSE), dementia rating scale by Gottfries et al. (1982) (GBS), and Activities of Daily Living (ADL). The mean score (SD) of the MMSE was 9.3 (6.9).

RESULTS

Multiple regression analysis revealed that the scores of motor function in GBS, ADL, MMSE, and the degree of bedridden explained 73% of the variation of care level. The higher care levels were inversely related to lower MMSE scores. In the group of people who were not bedridden, the MMSE score sharply decreased even though their physical functions were maintained. There were no significant differences in the MMSE scores among the care level 1 and 5 groups except between care level 1 and 3 after controlling for the motor function scores in GBS.

CONCLUSIONS

Our results suggest that care level and cognitive impairment are generally correlated in the primary assessment, but some adjustment measure for cognitive impairment is needed in mildly or moderately physically disabled patients.

Factors affecting psychiatric nurses' intention to leave their current job

Using the National Institute for Occupational Safety and Health job stress questionnaire, the authors examined psychiatric nurses' intention to leave their job in relation to their perceived risk of assault, their job satisfaction, and their supervisory support. Respondents were 1,494 nurses (response rate, 76.5 percent) employed in 27 psychiatric hospitals in Japan. Forty-four percent reported intention to leave their job, and 89 percent of those perceived a risk of assault. Younger age, fewer previous job changes, less supervisory support, lower job satisfaction, and more perceived risk of assault were significant predictors of intention to leave. Organizational efforts are necessary to retain frontline professional staff.

Behavioral and emotional problems in Chinese children: teacher reports for ages 6 to 11

This study examined the applicability of the Chinese Version of Teacher's Report Form (TRF-CV) and estimated the prevalence of behavioral problems in a general population sample of 2,936 children aged 6 through 11 years in the Shandong Province of China. Teachers completed the TRF-CV and the Conners Hyperkinesis Index (CHI). The TRF-CV total scale showed satisfactory 2-week test-retest reliability (r = .83) and internal consistency (Cronbach's alpha = .94). The TRF-CV Total Problems, Attention Problems, Delinquent Behavior, and Aggressive Behavior had acceptable concurrent validity with the CHI (mean r = .62). With the TRF-CV Total Problems score of 26 as a cutoff, an overall correct classification rate of 90% for clinical sample and nonreferral required children was obtained. Exploratory factor analysis yielded six syndromes: Aggressive/Delinquent Behavior, Withdrawn/Depressed, Somatic Complaints, Attention Problems, Social Problems, and Thought Problems, with significant correlations with corresponding American cross-informant syndromes (mean r = .84). The overall prevalence rate of behavioral problems was 15.5% (95% CI = 14.2-16.8%), with a boy-to-girl ratio of 2.0:1 (chi2 = 59.70, p < .001). Younger boys exhibited more externalizing problems. These findings indicate that the TRF-CV is applicable for Chinese children, and the prevalence of behavioral problems shown by it among Chinese children seems comparable to that found in other countries. Although most of the American syndromes were well replicated, the differences in the present subjects, when submitted to principal components analysis, from American samples from whom the original syndromes were derived, could have prevented the study from replicating distinctions between aggressive vs. delinquent and depressed vs. withdrawn syndromes.