Longitudinal associations between alcohol use, smoking, genetic risk scoring and symptoms of depression in the general population: a prospective 6-year cohort study

BACKGROUND

Alcohol consumption, smoking and mood disorders are leading contributors to the global burden of disease and are highly comorbid. Yet, their interrelationships have remained elusive. The aim of this study was to examine the multi-cross-sectional and longitudinal associations between (change in) smoking and alcohol use and (change in) number of depressive symptoms.

METHODS

In this prospective, longitudinal study, 6646 adults from the general population were included with follow-up measurements after 3 and 6 years. Linear mixed-effects models were used to test multi-cross-sectional and longitudinal associations, with smoking behaviour, alcohol use and genetic risk scores for smoking and alcohol use as independent variables and depressive symptoms as dependent variables.

RESULTS

In the multi-cross-sectional analysis, smoking status and number of cigarettes per day were positively associated with depressive symptoms (p < 0.001). Moderate drinking was associated with less symptoms of depression compared to non-use (p = 0.011). Longitudinally, decreases in the numbers of cigarettes per day and alcoholic drinks per week as well as alcohol cessation were associated with a reduction of depressive symptoms (p = 0.001-0.028). Results of genetic risk score analyses aligned with these findings.

CONCLUSIONS

While cross-sectionally smoking and moderate alcohol use show opposing associations with depressive symptoms, decreases in smoking behaviour as well as alcohol consumption are associated with improvements in depressive symptoms over time. Although we cannot infer causality, these results open avenues to further investigate interventions targeting smoking and alcohol behaviours in people suffering from depressive symptoms.

The relationship between mental disorders and actual and desired subjective social status

AIMS

Mental disorders are associated with lower subjective social status (SSS), but a more nuanced understanding of this relationship is needed. We examined the influence of disorder age of onset and recency on SSS and studied whether mental disorders are also associated with the discrepancy between actual and desired SSS.

METHOD

Data are from the baseline and second wave of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). Mental disorders were assessed with the Composite International Diagnostic Interview (CIDI 3.0), while both actual and desired SSS were assessed with a ten-rung ladder. Linear regression was used to examine the association between mental disorders and SSS.

RESULTS

Of 5303 participants, 2237 had a lifetime mental disorder at baseline. These participants reported significantly lower actual SSS (6.28) at follow-up than healthy participants (6.66, B = -0.38 [95% CI -0.48 to -0.27], p < 0.001) and a significantly greater actual-desired SSS discrepancy (1.14 v. 1.05 after controlling for actual SSS, B = 0.09 [0.01-0.17], p = 0.024). Lower age of onset of the first mental disorder was marginally significantly associated with lower actual SSS (B = 0.006 [0.000-0.012], p = 0.046). More recent disorders were also associated with lower actual SSS (B = 0.015 [0.005-0.026], p = 0.005), such that participants whose disorder remitted ⩾6 years before baseline were statistically indistinguishable from healthy participants.

CONCLUSIONS

Lifetime mental disorders are associated with lower actual SSS and a slightly greater discrepancy between actual and desired SSS. However, people with mental disorders in (long-term) remission have a similar social status as healthy participants.

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.

Psychotic experiences and religiosity: data from the WHO World Mental Health Surveys

OBJECTIVES

Religiosity is often associated with better health outcomes. The aim of the study was to examine associations between psychotic experiences (PEs) and religiosity in a large, cross-national sample.

METHODS

A total of 25 542 adult respondents across 18 countries from the WHO World Mental Health Surveys were assessed for PEs, religious affiliation and indices of religiosity, DSM-IV mental disorders and general medical conditions. Logistic regression models were used to estimate the association between PEs and religiosity with various adjustments.

RESULTS

Of 25 542 included respondents, 85.6% (SE = 0.3) (n = 21 860) respondents reported having a religious affiliation. Overall, there was no association between religious affiliation status and PEs. Within the subgroup having a religious affiliation, four of five indices of religiosity were significantly associated with increased odds of PEs (odds ratios ranged from 1.3 to 1.9). The findings persisted after adjustments for mental disorders and/or general medical conditions, as well as religious denomination type. There was a significant association between increased religiosity and reporting more types of PEs.

CONCLUSIONS

Among individuals with religious affiliations, those who reported more religiosity on four of five indices had increased odds of PEs. Focussed and more qualitative research will be required to unravel the interrelationship between religiosity and PEs.

Demographic and need factors of early, delayed and no mental health care use in major depression: a prospective study

BACKGROUND

Despite the availability of evidence based treatments, many people with major depression receive no or delayed professional treatment, which may put them at risk for adverse outcomes. The aim of this study was to examine which demographic and need factors distinguish early, delayed and no treatment use.

METHODS

Data were obtained from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). People with a diagnosis of major depression in the past 12 months were included (N = 434). Mental health care use was assessed during this same period and at follow up (three years later). Multinomial regression analysis was used to distinguish early, delayed and no mental health care users with respect to demographic and need factors.

RESULTS

The majority of participants accessed treatment early (62%). Early treatment users were characterized by more severe and persistent symptoms and were more likely not to have a partner compared to no treatment users. The majority of those without treatment reached remission in three years (85%). Delayed treatment users were, compared to early users, characterized by relatively mild symptoms and a persistent or new major depressive disorder at follow up.

CONCLUSIONS

Early access to treatment and the finding that need factors determine mental health care use among people with depression show that the filters along the pathway to treatment are not influenced by unfavorable determinants like education or age.

Posttraumatic stress disorder in the World Mental Health Surveys

BACKGROUND

Traumatic events are common globally; however, comprehensive population-based cross-national data on the epidemiology of posttraumatic stress disorder (PTSD), the paradigmatic trauma-related mental disorder, are lacking.

METHODS

Data were analyzed from 26 population surveys in the World Health Organization World Mental Health Surveys. A total of 71 083 respondents ages 18+ participated. The Composite International Diagnostic Interview assessed exposure to traumatic events as well as 30-day, 12-month, and lifetime PTSD. Respondents were also assessed for treatment in the 12 months preceding the survey. Age of onset distributions were examined by country income level. Associations of PTSD were examined with country income, world region, and respondent demographics.

RESULTS

The cross-national lifetime prevalence of PTSD was 3.9% in the total sample and 5.6% among the trauma exposed. Half of respondents with PTSD reported persistent symptoms. Treatment seeking in high-income countries (53.5%) was roughly double that in low-lower middle income (22.8%) and upper-middle income (28.7%) countries. Social disadvantage, including younger age, female sex, being unmarried, being less educated, having lower household income, and being unemployed, was associated with increased risk of lifetime PTSD among the trauma exposed.

CONCLUSIONS

PTSD is prevalent cross-nationally, with half of all global cases being persistent. Only half of those with severe PTSD report receiving any treatment and only a minority receive specialty mental health care. Striking disparities in PTSD treatment exist by country income level. Increasing access to effective treatment, especially in low- and middle-income countries, remains critical for reducing the population burden of PTSD.

Job strain as a risk factor for clinical depression: systematic review and meta-analysis with additional individual participant data

BACKGROUND

Adverse psychosocial working environments characterized by job strain (the combination of high demands and low control at work) are associated with an increased risk of depressive symptoms among employees, but evidence on clinically diagnosed depression is scarce. We examined job strain as a risk factor for clinical depression.

METHOD

We identified published cohort studies from a systematic literature search in PubMed and PsycNET and obtained 14 cohort studies with unpublished individual-level data from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium. Summary estimates of the association were obtained using random-effects models. Individual-level data analyses were based on a pre-published study protocol.

RESULTS

We included six published studies with a total of 27 461 individuals and 914 incident cases of clinical depression. From unpublished datasets we included 120 221 individuals and 982 first episodes of hospital-treated clinical depression. Job strain was associated with an increased risk of clinical depression in both published [relative risk (RR) = 1.77, 95% confidence interval (CI) 1.47-2.13] and unpublished datasets (RR = 1.27, 95% CI 1.04-1.55). Further individual participant analyses showed a similar association across sociodemographic subgroups and after excluding individuals with baseline somatic disease. The association was unchanged when excluding individuals with baseline depressive symptoms (RR = 1.25, 95% CI 0.94-1.65), but attenuated on adjustment for a continuous depressive symptoms score (RR = 1.03, 95% CI 0.81-1.32).

CONCLUSIONS

Job strain may precipitate clinical depression among employees. Future intervention studies should test whether job strain is a modifiable risk factor for depression.

The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium

BACKGROUND

Considerable research has documented that exposure to traumatic events has negative effects on physical and mental health. Much less research has examined the predictors of traumatic event exposure. Increased understanding of risk factors for exposure to traumatic events could be of considerable value in targeting preventive interventions and anticipating service needs.

METHOD

General population surveys in 24 countries with a combined sample of 68 894 adult respondents across six continents assessed exposure to 29 traumatic event types. Differences in prevalence were examined with cross-tabulations. Exploratory factor analysis was conducted to determine whether traumatic event types clustered into interpretable factors. Survival analysis was carried out to examine associations of sociodemographic characteristics and prior traumatic events with subsequent exposure.

RESULTS

Over 70% of respondents reported a traumatic event; 30.5% were exposed to four or more. Five types - witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury - accounted for over half of all exposures. Exposure varied by country, sociodemographics and history of prior traumatic events. Being married was the most consistent protective factor. Exposure to interpersonal violence had the strongest associations with subsequent traumatic events.

CONCLUSIONS

Given the near ubiquity of exposure, limited resources may best be dedicated to those that are more likely to be further exposed such as victims of interpersonal violence. Identifying mechanisms that account for the associations of prior interpersonal violence with subsequent trauma is critical to develop interventions to prevent revictimization.

Does social defeat mediate the association between childhood trauma and psychosis? Evidence from the NEMESIS-2 Study

OBJECTIVE

Based on theoretical considerations and animal studies, mediation of 'social defeat' (SD) in the association between childhood trauma (CT) and psychosis was investigated.

METHOD

Trained interviewers administered a structured interview assessing CT, psychotic experiences and other psychopathology in 6646 participants in the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2).

RESULTS

Childhood trauma was associated with psychotic experiences making up the extended psychosis phenotype (EPP), as well as with a diagnosis of psychotic disorder (PD). Similarly, CT was associated with a priori selected items indexing SD (discouraged, hopeless, worthless, loss of self-confidence, low self-esteem, better off dead, suicidal thoughts) and with a measure of affective dysregulation (AD), which in turn were also associated with psychosis. While SD and AD individually acted as mediators in the association between CT and EPP, only SD acted as a mediator in the association between CT and PD. Cannabis use did not mediate the association between CT and EPP or PD.

CONCLUSION

The present results suggest a developmental model implicating SD as an important mediator in the link between childhood adverse experiences and later development of psychotic experiences. The combined mediation by SD and AD is compatible with an 'affective pathway' to early psychosis.

Sexual minority status and psychotic symptoms: findings from the Netherlands Mental Health Survey and Incidence Studies (NEMESIS)

BACKGROUND

Ethnic minority position is associated with increased risk for psychotic outcomes, which may be mediated by experiences of social exclusion, defeat and discrimination. Sexual minorities are subject to similar stressors. The aim of this study is to examine whether sexual minorities are at increased risk for psychotic symptoms and to explore mediating pathways.

METHOD

A cross-sectional survey was performed assessing cumulative incidence of psychotic symptoms with the Composite International Diagnostic Interview in two separate random general population samples (NEMESIS-1 and NEMESIS-2). Participants were sexually active and aged 18-64 years (n = 5927, n = 5308). Being lesbian, gay or bisexual (LGB) was defined as having sexual relations with at least one same-sex partner during the past year. Lifetime experience of any psychotic symptom was analysed using logistic regression, adjusted for gender, educational level, urbanicity, foreign-born parents, living without a partner, cannabis use and other drug use.

RESULTS

The rate of any psychotic symptom was elevated in the LGB population as compared with the heterosexual population both in NEMESIS-1 [odds ratio (OR) 2.56, 95% confidence interval (CI) 1.71-3.84] and NEMESIS-2 (OR 2.30, 95% CI 1.42-3.71). Childhood trauma, bullying and experience of discrimination partly mediated the association.

CONCLUSIONS

The finding that LGB orientation is associated with psychotic symptoms adds to the growing body of literature linking minority status with psychosis and other mental health problems, and suggests that exposure to minority stress represents an important mechanism.

Replication in two independent population-based samples that childhood maltreatment and cannabis use synergistically impact on psychosis risk

BACKGROUND

There may be biological plausibility to the notion that cannabis use and childhood trauma or maltreatment synergistically increase the risk for later development of psychotic symptoms. To replicate and further investigate this issue, prospective data from two independent population-based studies, the Greek National Perinatal Study (n=1636) and The Netherlands Mental Health Survey and Incidence Study (NEMESIS) (n=4842), were analyzed.

METHOD

Two different data sets on cannabis use and childhood maltreatment were used. In a large Greek population-based cohort study, data on cannabis use at age 19 years and childhood maltreatment at 7 years were assessed. In addition, psychotic symptoms were assessed using the Community Assessment of Psychic Experiences (CAPE). In NEMESIS, the Composite International Diagnostic Interview (CIDI) was used to assess psychotic symptoms at three different time points along with childhood maltreatment and lifetime cannabis use.

RESULTS

A significant adjusted interaction between childhood maltreatment and later cannabis use was evident in both samples, indicating that the psychosis-inducing effects of cannabis were stronger in individuals exposed to earlier sexual or physical mistreatment [Greek National Perinatal Study: test for interaction F(2, 1627)=4.18, p=0.02; NEMESIS: test for interaction χ2(3)=8.08, p=0.04].

CONCLUSIONS

Cross-sensitivity between childhood maltreatment and cannabis use may exist in pathways that shape the risk for expression of positive psychotic symptoms.

Ethics and prevention of overweight and obesity: an inventory

Efforts to counter the rise in overweight and obesity, such as taxes on certain foods and beverages, limits to commercial advertising, a ban on chocolate drink at schools or compulsory physical exercise for obese employees, sometimes raise questions about what is considered ethically acceptable. There are obvious ethical incentives to these initiatives, such as improving individual and public health, enabling informed choice and diminishing societal costs. Whereas we consider these positive arguments to put considerable effort in the prevention of overweight indisputable, we focus on potential ethical objections against such an effort. Our intention is to structure the ethical issues that may occur in programmes to prevent overweight and/or obesity in order to encourage further debate. We selected 60 recently reported interventions or policy proposals targeting overweight or obesity and systematically evaluated their ethically relevant aspects. Our evaluation was completed by discussing them in two expert meetings. We found that currently proposed interventions or policies to prevent overweight or obesity may (next to the benefits they strive for) include the following potentially problematic aspects: effects on physical health are uncertain or unfavourable; there are negative psychosocial consequences including uncertainty, fears and concerns, blaming and stigmatization and unjust discrimination; inequalities are aggravated; inadequate information is distributed; the social and cultural value of eating is disregarded; people's privacy is disrespected; the complexity of responsibilities regarding overweight is disregarded; and interventions infringe upon personal freedom regarding lifestyle choices and raising children, regarding freedom of private enterprise or regarding policy choices by schools and other organizations. The obvious ethical incentives to combat the overweight epidemic do not necessarily override the potential ethical constraints, and further debate is needed. An ethical framework to support decision makers in balancing potential ethical problems against the need to do something would be helpful. Developing programmes that are sound from an ethical point of view is not only valuable from a moral perspective, but may also contribute to preventing overweight and obesity, as societal objections to a programme may hamper its effectiveness.

Can obsessions drive you mad? Longitudinal evidence that obsessive-compulsive symptoms worsen the outcome of early psychotic experiences

OBJECTIVE

Although there is substantial comorbidity between psychotic disorder and obsessive-compulsive disorder (OCD), little is known about how these clinical phenotypes, and their subclinical extended phenotypes, covary and impact on each other over time. This study examined cross-sectional and longitudinal associations between both (extended) phenotypes in the general population.

METHOD

Data were obtained from the three waves of the NEMESIS-study. A representative population sample of 7076 participants were assessed using the composite international diagnostic interview (CIDI) at baseline (T(0)), 1 year later at T(1) and again 2 years later at T(2).

RESULTS

At T(0), a lifetime diagnosis of psychotic disorder was present in 1.5% of the entire sample, in 11.5% of the people with any OC symptom and in 23.0% of individuals diagnosed with OCD. OC symptoms at T(0) predicted incident psychotic symptoms at T(2). Similarly, T(0) psychotic symptoms predicted T(2) OC symptoms. The likelihood of persistence of psychotic symptoms or transition to psychotic disorder was higher if early psychosis was accompanied by co-occurring OC symptoms, but not the other way around.

CONCLUSION

OCD and the psychosis phenotype cluster together and predict each other at (sub)clinical level. The co-occurrence of subclinical OC and psychosis may facilitate the formation of a more 'toxic' form of persistent psychosis.

Subthreshold symptoms and obsessive-compulsive disorder: evaluating the diagnostic threshold

BACKGROUND

In this study we compared subjects with obsessive and/or compulsive symptoms who did not meet all criteria for obsessive-compulsive disorder (OCD) (subthreshold subjects) to subjects with full-blown OCD and also to subjects without obsessions or compulsions.

METHOD

The data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a large representative sample of the general Dutch population (n=7076). Using the Composite International Diagnostic Interview, Version 1.1 (CIDI 1.1), three groups were distinguished: subjects without lifetime obsessions or compulsions (94.2%), subthreshold subjects (4.9%) and subjects with full-blown OCD according to DSM-III-R (0.9%). These three groups were compared on various items, including psychological vulnerability, health and functional status, psychiatric co-morbidity and seeking treatment.

RESULTS

Subthreshold and OCD subjects had similar scores on the majority of the items measured. Thus, there was little difference between subthreshold and OCD subjects in health, functional status, psychological vulnerability and psychiatric co-morbidity. However, OCD and subthreshold subjects scored worse on most of these items when compared to the controls without obsessions or compulsions.

CONCLUSION

Having obsessions and compulsions is associated with substantial suffering and disability. Most subjects with obsessions and/or compulsions are not diagnosed with OCD according to the DSM-III-R criteria although these subjects generally display similar consequences to full-blown OCD subjects. We recommend that these subthreshold cases receive special attention in the development of DSM-V.

Are attitudes towards mental health help-seeking associated with service use? Results from the European Study of Epidemiology of Mental Disorders

OBJECTIVE

To investigate the prevailing attitudes towards mental health help-seeking in Europe, their correlates, and whether these attitudes are associated with actual service use for mental health problems.

METHOD

Data were derived from the European Study of Epidemiology of Mental Disorders, a survey representative of the adult population of six countries: Belgium, France, Germany, Italy, the Netherlands and Spain (n = 8,796). The World Mental Health Composite International Diagnostic Interview was used to assess attitudes and DSM-IV diagnoses. The attitudes referred to beliefs that the respondents would seek professional help when faced with a serious emotional problem, would feel comfortable talking about personal problems with a professional, would not be embarrassed if friends knew about the professional help, and respondents' perceived effectiveness of mental health care.

RESULTS

Almost a third of the respondents held the view that professional care was worse than or equal to no help when faced with serious emotional problems. Female gender, being younger than 65 years of age, high income, living in Spain or Italy, presence of mood disorder and previous service use were associated with at least two of the four assessed attitudes towards mental health help-seeking. All four attitudes were significantly associated with mental health care use, also after adjustment for previous service use.

CONCLUSION

The low perceived effectiveness of professional care calls for serious action aiming to improve the visibility and credibility of the mental health care sector.

[Attitudes to the seeking of psychiatric help from mental health care professionals and actually seeking help: differences in Europe]

BACKGROUND

Little is known about attitudes to seeking help from mental health care professionals.

AIM

To investigate these attitudes and their correlates, and find out whether these attitudes are associated with the use of care services.

METHOD

Data were derived from the European Study of Epidemiology of Mental Disorders, a survey that is representative of the adult population of six countries (n = 8,796).

RESULTS

Almost a third of respondents were of the opinion that professional help was worse than or equivalent to no help at all, in relation to serious psychiatric problems. Females, respondents under the age of 65, with a higher income, living in Spain or Italy, with a mood disorder, and those who had previously sought mental health care, more often stated that they would seek professional help if beset by a serious mental health problem. All these groups, except for the younger than 65, also reported more often that they would feel comfortable discussing mental health problems with a professional or that they were receiving this kind of help. All these attitudes were associated with an increased chance that persons would use professional help if beset by mental health problems.

CONCLUSION

Definite steps need to be taken to increase the visibility and credibility of the mental health services.

Incidence of social phobia and identification of its risk indicators: a model for prevention

OBJECTIVE

This study seeks to examine the incidence of social phobia in the general population and to establish a number of risk indicators.

METHOD

Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS) which is a population based prospective study (n=7076). A sample of adults aged 18-64 years (n=5618) were re-interviewed 1 year later using Composite International Diagnostic Interview (CIDI).

RESULTS

The 12-month incidence of DSM-III-R social phobia was 1.0%. Low education, low mastery, low self-esteem, emotional neglect in childhood and ongoing difficulties were found to be risk indicators. After including other mental disorders as risk indicators in the model, the incidence was found to be more common among those with low mastery, major depression, subthreshold social phobia, emotional neglect, negative life events, and low education.

CONCLUSION

The incidence of social phobia can be predicted relatively well with psychosocial variables and comorbidity.

Familiality of depression in the community; associations with gender and phenotype of major depressive disorder

INTRODUCTION

Although associations between family history and depression have been shown in clinical patients, it is unknown if they also apply to subjects living in the community. The present study considers the relationship between family loading and depression phenotype characteristics in a large community-based sample.

METHOD

In a Dutch representative population sample of 7,076 individuals, lifetime diagnosis of depression was classified according to severity, course and age of onset. A family loading score of depression (FLSD) was computed by taking the proportion of the first-degree relatives for whom a history of depression was reported.

RESULTS

There was a strong association between FLSD and lifetime diagnosis of MDD. Severity, recurrence and early onset of depression were the specific phenotypic characteristics associated with familiality. The effects of FLSD and gender were independent.

CONCLUSION

Associations between family history and risk for depression in the community confirm those reported from clinical-based studies using direct interviewing of relatives. A stronger degree of familiality is associated with specific phenotypic characteristics of depression.

Mental disorders and personality traits as determinants of impaired work functioning

BACKGROUND

Both mental disorders and personality characteristics are associated with impaired work functioning, but these determinants have not yet been studied together. The aim of this paper is to examine the impairing effects that mental disorders and personality characteristics (i.e. neuroticism, locus of control and self-esteem) have on work functioning.

METHOD

Data for a representative sample of 3570 working people were derived from the first two waves of the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective cohort study in the Dutch adult population.

RESULTS

Higher neuroticism, more external locus of control and lower self-esteem were each significantly associated with subsequent impairment in work functioning, independently of any effects from mental disorders. Associations between mental disorders and subsequent work impairment disappeared once personality traits were taken into account. Personality traits did not moderate the relationships between mental disorders and work functioning.

CONCLUSIONS

Working people with vulnerable personalities have a greater risk of impaired work functioning, independent of the risk from any mental disorder they may have.

The prevalence and effects of adult attention-deficit/hyperactivity disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative

OBJECTIVES

To estimate the prevalence and workplace consequences of adult attention-deficit/hyperactivity disorder (ADHD).

METHODS

An ADHD screen was administered to 18-44-year-old respondents in 10 national surveys in the WHO World Mental Health (WMH) Survey Initiative (n = 7075 in paid or self-employment; response rate 45.9-87.7% across countries). Blinded clinical reappraisal interviews were administered in the USA to calibrate the screen. Days out of role were measured using the WHO Disability Assessment Schedule (WHO-DAS). Questions were also asked about ADHD treatment.

RESULTS

An average of 3.5% of workers in the 10 countries were estimated to meet DSM-IV criteria for adult ADHD (inter-quartile range: 1.3-4.9%). ADHD was more common among males than females and less common among professionals than other workers. ADHD was associated with a statistically significant 22.1 annual days of excess lost role performance compared to otherwise similar respondents without ADHD. No difference in the magnitude of this effect was found by occupation, education, age, gender or partner status. This effect was most pronounced in Colombia, Italy, Lebanon and the USA. Although only a small minority of workers with ADHD ever received treatment for this condition, higher proportions were treated for comorbid mental/substance disorders.

CONCLUSIONS

ADHD is a relatively common condition among working people in the countries studied and is associated with high work impairment in these countries. This impairment, in conjunction with the low treatment rate and the availability of cost-effective therapies, suggests that ADHD would be a good candidate for targeted workplace screening and treatment programs.

A prospective study of the transition rates of subthreshold (hypo)mania and depression in the general population

BACKGROUND

Previous work suggests that subthreshold depression and subthreshold (hypo)mania are common, although little is known about the prognosis in terms of transition to clinical disorder. This paper presents data on the temporal relationship between subthreshold and clinical expression of mood phenotypes.

METHOD

In a random general population sample of 7076 individuals, symptoms of depression and (hypo)mania were measured with the Composite International Diagnostic Interview (CIDI) at baseline, after 1 year, and 2 years later.

RESULTS

At baseline, the lifetime prevalences of depressive and (hypo)manic symptoms were 17.2% and 1.2% respectively. Predictive values of mood symptoms for a DSM-III-R mood disorder ranged from 14.3% to 50%. (Hypo)manic mood symptoms had much higher predictive values than unipolar manifestations, not only for bipolar disorder but also for major depression.

CONCLUSIONS

The subthreshold expressions of depression and (hypo)mania are prevalent and continuous with more severe clinical states. The cross-prediction of mood symptoms may support a continuum from depressive to (hypo)manic symptoms. The high predictive value of (hypo)manic symptoms for mood disorders suggests that the experience of (hypo)manic symptoms is a stronger indicator of vulnerability for mood dysregulation than the experience of depressive symptoms.

Prevalence of bipolar disorder in the general population: a Reappraisal Study of the Netherlands Mental Health Survey and Incidence Study

OBJECTIVE

The Netherlands Mental Health Survey and Incidence Study (NEMESIS) is a Dutch population study using a fully structured interview (Composite International Diagnostic Interview, CIDI), administered by trained interviewers. Based on all three assessments of NEMESIS, 2.4% of the respondents were identified with lifetime bipolar disorder (DSM-III-R). The primary aim of the study was to estimate the prevalence of bipolar disorder in the same population based on a semistructured interview administered by clinicians.

METHOD

Seventy-four persons identified with a lifetime CIDI/DSM-III-R bipolar disorder and 40 persons with a major depressive disorder (MDD) were reinterviewed with the Structured Clinical Interview for DSM (SCID).

RESULTS

Based on the SCID, 30 of 74 respondents with a CIDI/DSM-III-R bipolar disorder and eight of 40 respondents with MDD met DSM-IV criteria for bipolar disorder or cyclothymia, corresponding with an adjusted lifetime prevalence in these groups of 1% (95% CI: 0.7-1.3%) and 4.2% (95% CI: 1.6-6.9%) respectively.

CONCLUSION

Compared with the SCID, the CIDI on the one hand overdiagnoses bipolar disorder but on the other hand underdiagnoses bipolar disorder.

The societal costs and quality of life of patients suffering from bipolar disorder in the Netherlands

OBJECTIVE

To assess the societal costs and quality of life of patients suffering from bipolar disorder in the Netherlands.

METHOD

Forty persons with a lifetime diagnosis of bipolar disorder (SCID/DSM-IV) and representative for the Dutch general population were interviewed to collect data on direct (use of medical resources) and indirect (productivity losses because of absence from work and reduced efficiency at work) costs of illness. Respondents' quality of life was also assessed. Prevalence (5.2%) of bipolar disorder was used to estimate total costs.

RESULTS

Total costs of bipolar disorder were estimated at US 1.83 billion dollars (total direct costs = US 454 million dollars; total indirect costs = US 1.37 billion dollars). Participants' quality-of-life scores were lower than those of the general population.

CONCLUSION

The societal costs form patients suffering of bipolar disorder in the Netherlands were high, especially the indirect costs because of absence from work. The quality of life of bipolar patients was lower than the general population.

Rapid onset of comorbidity of common mental disorders: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

OBJECTIVE

In a cohort of subjects with no history of psychopathology, we determined a 3-year incidence and the risk factors of comorbid and pure mood, anxiety and substance use disorders.

METHOD

Data were obtained from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a longitudinal community study in which 4796 adults were interviewed in 1996, 1997 and 1999 with the Composite International Diagnostic Interview.

RESULTS

Of 2869 cases at risk, 10.8% developed an incident disorder within 3 years, of which 16.1% was comorbid. Neuroticism, childhood trauma and parental psychiatric history were more strongly associated with comorbid than with pure disorders. No differences emerged in events occurring in the first year after baseline, but events in the period thereafter showed markedly stronger associations with comorbidity and pure mood disorder than with pure anxiety and substance use disorder. Functional disability was also linked more strongly to comorbidity and pure mood disorder.

CONCLUSION

Clear risk factors exist for the rapid onset of comorbidity. Interventions are needed to prevent rapid comorbidity in subjects who recently developed a primary disorder.

Upward trends in the use of community mental health and social work services in the Netherlands between 1979 and 1995: are particular sociodemographic groups responsible?

OBJECTIVE

We investigate 1) trends in use of community mental health care (CMHC) and community social work (CSW) by Dutch households in 1979-1995; 2) whether such trends can be explained by long-term relative changes in service use or in sizes of particular household categories.

METHOD

Data was derived from the Facilities Use Surveys, cross-sectional population studies recording Dutch household characteristics and service use since 1979. A simulation technique was used to explain trends in service use.

RESULTS

Use of CMHC and CSW virtually doubled in recent decades. Such trends are not explained by increasing relative service utilization in particular household categories, and only marginally by shifts in the relative sizes of such categories. They are attributable to growing rates of utilization throughout society.

CONCLUSION

Trends in service use are explained by broad changes in help-seeking behaviour. Policymakers should act on these findings to narrow the persisting inequalities in service uptake.

Does educational background explain inequalities in care service use for mental health problems in the Dutch general population?

OBJECTIVE

To investigate whether (1) education predicts the use of care services for mental health problems, independently of mental disorder and functional impairment and (2) education modifies the association between mental disorder and service use.

METHOD

Predictors of service use were recorded at baseline, and service use itself at 12-month follow-up, in a representative sample (N=7076) of the Dutch population, using the Composite International Diagnostic Interview.

RESULTS

People with more education were less likely to use primary care but more likely to use mental health care. The effects on both types of care remained significant after adjustment for mental disorder and functional impairment. Lower education tended to strengthen the association between mood or anxiety disorder and primary care use.

CONCLUSION

Further research on inequalities in service use will benefit from additional explanatory analyses and from the inclusion of sociopsychological variables, like cost-benefit considerations in decisions to use services.

Predictors of incident care service utilisation for mental health problems in the Dutch general population

BACKGROUND

The determinants of first-time ('incident') use of primary care and mental health care services for mental health problems have not been previously investigated. Such information is needed to identify new client groups and to gain a better understanding of causal factors.

METHOD

Data were derived from the Netherlands Mental Health Survey and Incidence Study, NEMESIS, a prospective general population study of adults. Potential predictors of care use (psychiatric disorders, burden of illness, sociodemographic characteristics) were recorded in the first wave of the study, and the utilisation of care services in the second wave. Psychiatric diagnoses were based on the Composite International Diagnostic Interview (CIDI) 1.1.

RESULTS

Six of the ten indicators linked to the frequent utilisation of care were found not to be associated with incident use: higher age, lower income, living alone, paid employment, mood disorders and anxiety disorders. Four other indicators showed associations with both frequent and incident use: female gender, higher numbers of restricted activity days, poorer social functioning and unmet care needs. Two predictors of incident use only were lower educational attainment and being in treatment for a somatic disorder.

CONCLUSION

New clients who come to primary health care or mental health care services with mental health problems are found in all age groups. They are more likely to be women, to have less education, to be in treatment for a somatic disorder and to have functional problems related to their mental health problems.