Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report.

BACKGROUND: The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. METHODS: Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. RESULTS: 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2-4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. CONCLUSION: ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.

Capturing patients' needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems.

BACKGROUND: Contemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients' needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay. METHODS: A systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological Abstracts using keywords related to functioning ('Functioning', 'Functional status', 'Function*, 'ICF', 'International Classification of Functioning, Disability and Health', 'Activities of Daily Living' or 'ADL') and casemix systems ('Casemix', 'case mix', 'Diagnosis Related Groups', 'Function Related Groups', 'Resource Utilization Groups' or 'AN-SNAP'). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors' discussion of results, study limitations and implications was extracted. RESULTS: Ten included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients. CONCLUSION: Further exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient's needs for services and to better predict resource use.

Strengthening quality of care through standardized reporting based on the World Health Organization's reference classifications.

QUALITY ISSUE: Responding to person's health and related needs requires the availability of health information that reflects relevant aspects of a health condition and how this health condition impacts on a person's daily life. INITIAL ASSESSMENT: Health information is routinely collected at different time points by diverse professionals, in different settings for various purposes with varying methods. Consequently, health information is not always comparable, posing a challenge to the regular monitoring of quality. CHOICE OF SOLUTION: The World Health Organization's (WHO) International Classification of Diseases (ICD), International Classification of Functioning, Disability and Health (ICF), and International Classification of Health Interventions (ICHI; under development) are complementary and serve as meaningful reference classifications for comparing data on persons' health and related interventions across health systems. IMPLEMENTATION: We developed a systematic approach of translating routinely collected information into a standardized report based on the three WHO reference classifications and the Rehab-Cycle®. Subsequently, we have demonstrated its application using five random case records of individuals attending a rehabilitation program. EVALUATION: All identified concepts were able to be linked to WHO's reference classifications. The ICF served as a tool to standardize information on rehabilitation goals and their achievement. The ICHI served as the basis for reporting the interventions that were documented in the case records, including the intervention targets that were derived from the ICF codes. LESSONS LEARNED: Our experience shows that, it is possible to translate routinely collected information into standardized reports by linking existing narrative records with WHO's reference classifications.

Mapping the content of the Patient-Reported Outcomes Measurement Information System (PROMIS®) using the International Classification of Functioning, Health and Disability.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS (®) ) is a US National Institutes of Health initiative that has produced self-reported item banks for physical, mental and social health. OBJECTIVE: To describe the content of PROMIS at the item level using the World Health Organization's International Classification of Functioning, Disability and Health (ICF). METHODS: All PROMIS adult items (publicly available as of 2012) were assigned to relevant ICF concepts. The content of the PROMIS adult item banks was then described using the mapped ICF code descriptors. RESULTS: The 1,006 items in the PROMIS instruments could all be mapped to ICF concepts at the second level of classification, with the exception of three items of global or general health that mapped across the first-level classification of ICF activity and participation component (d categories). Individual PROMIS item banks mapped from 1 to 5 separate ICF codes indicating one-to-one, one-to-many and many-to-one mappings between PROMIS item banks and ICF second-level classification codes. PROMIS supports measurement of the majority of major concepts in the ICF body functions (b) and activity and participation (d) components using PROMIS item banks or subsets of PROMIS items that could, with care, be used to develop customized instruments. Given that the focus of PROMIS is on measurement of person health outcomes, concepts in body structures (s) and some body functions (b), as well as many ICF environmental factor, have minimal coverage in PROMIS. DISCUSSION: The PROMIS-ICF mapped items provide a basis for users to evaluate the ICF-related content of specific PROMIS instruments and to select PROMIS instruments in ICF-based measurement applications.

Concept analysis of the patient reported outcomes measurement information system (PROMIS(®)) and the international classification of functioning, disability and health (ICF).

PURPOSE: The Patient Reported Outcomes Measurement Information System (PROMIS (®) ) is a US National Institutes of Health initiative that has produced self-report outcome measures, using a framework of physical, mental, and social health defined by the World Health Organization in 1948 (WHO, in Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 1948). The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is a comprehensive classification system of health and health-related domains that was put forward in 2001. The purpose of this report is to compare and contrast PROMIS and ICF conceptual frameworks to support mapping of PROMIS instruments to the ICF classification system . METHODS: We assessed the objectives and the classification schema of the PROMIS and ICF frameworks, followed by content analysis to determine whether PROMIS domain and sub-domain level health concepts can be linked to the ICF classification. RESULTS: Both PROMIS and ICF are relevant to all individuals, irrespective of the presence of health conditions, person characteristics, or environmental factors in which persons live. PROMIS measures are intended to assess a person's experiences of his or her health, functional status, and well-being in multiple domains across physical, mental, and social dimensions. The ICF comprehensively describes human functioning from a biological, individual, and social perspective. The ICF supports classification of health and health-related states such as functioning, but is not a specific measure or assessment of health, per se. PROMIS domains and sub-domain concepts can be meaningfully mapped to ICF concepts. CONCLUSIONS: Theoretical and conceptual similarities support the use of PROMIS instruments to operationalize self-reported measurement for many body function, activity and participation ICF concepts, as well as several environmental factor concepts. Differences observed in PROMIS and ICF conceptual frameworks provide a stimulus for future research and development.

The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: the course and consequences of posttraumatic stress disorder in Vietnam-era veteran twins).

PURPOSE: To assess the relationship of posttraumatic stress disorder (PTSD) with health functioning and disability in Vietnam-era Veterans. METHODS: A cross-sectional study of functioning and disability in male Vietnam-era Veteran twins. PTSD was measured by the Composite International Diagnostic Interview; health functioning and disability were assessed using the Veterans RAND 36-Item Health Survey (VR-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). All data collection took place between 2010 and 2012. RESULTS: Average age of the 5,574 participating Veterans (2,102 Vietnam theater and 3,472 non-theater) was 61.0 years. Veterans with PTSD had poorer health functioning across all domains of VR-36 and increased disability for all subscales of WHODAS 2.0 (all p < .001) compared with Veterans without PTSD. Veterans with PTSD were in poorer overall health on the VR-36 physical composite summary (PCS) (effect size = 0.31 in theater and 0.47 in non-theater Veterans; p < .001 for both) and mental composite summary (MCS) (effect size = 0.99 in theater and 0.78 in non-theater Veterans; p < .001 for both) and had increased disability on the WHODAS 2.0 summary score (effect size = 1.02 in theater and 0.96 in non-theater Veterans; p < .001 for both). Combat exposure, independent of PTSD status, was associated with lower PCS and MCS scores and increased disability (all p < .05, for trend). Within-pair analyses in twins discordant for PTSD produced consistent findings. CONCLUSIONS: Vietnam-era Veterans with PTSD have diminished functioning and increased disability. The poor functional status of aging combat-exposed Veterans is of particular concern.

ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group.

This paper outlines the approach that the WHO's Family of International Classifications (WHO-FIC) network is undertaking to create ICD-11. We also outline the more focused work of the Quality and Safety Topic Advisory Group, whose activities include the following: (i) cataloguing existing ICD-9 and ICD-10 quality and safety indicators; (ii) reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering; (iii) substantial restructuring of the health-care related injury concepts coded in the ICD-10 chapters 19/20, (iv) mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats; (v) the review of vertical chapter content in all chapters of the ICD-11 beta version and (vi) downstream field testing of ICD-11 prior to its official 2015 release. The transition from ICD-10 to ICD-11 promises to produce an enhanced classification that will have better potential to capture important concepts relevant to measuring health system safety and quality-an important use case for the classification.

Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys.

Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity.

Including information about co-morbidity in estimates of disease burden: results from the World Health Organization World Mental Health Surveys.

BACKGROUND: The methodology commonly used to estimate disease burden, featuring ratings of severity of individual conditions, has been criticized for ignoring co-morbidity. A methodology that addresses this problem is proposed and illustrated here with data from the World Health Organization World Mental Health Surveys. Although the analysis is based on self-reports about one's own conditions in a community survey, the logic applies equally well to analysis of hypothetical vignettes describing co-morbid condition profiles. METHOD: Face-to-face interviews in 13 countries (six developing, nine developed; n=31 067; response rate=69.6%) assessed 10 classes of chronic physical and nine of mental conditions. A visual analog scale (VAS) was used to assess overall perceived health. Multiple regression analysis with interactions for co-morbidity was used to estimate associations of conditions with VAS. Simulation was used to estimate condition-specific effects. RESULTS: The best-fitting model included condition main effects and interactions of types by numbers of conditions. Neurological conditions, insomnia and major depression were rated most severe. Adjustment for co-morbidity reduced condition-specific estimates with substantial between-condition variation (0.24-0.70 ratios of condition-specific estimates with and without adjustment for co-morbidity). The societal-level burden rankings were quite different from the individual-level rankings, with the highest societal-level rankings associated with conditions having high prevalence rather than high individual-level severity. CONCLUSIONS: Plausible estimates of disorder-specific effects on VAS can be obtained using methods that adjust for co-morbidity. These adjustments substantially influence condition-specific ratings.

Developing the World Health Organization Disability Assessment Schedule 2.0.

OBJECTIVE: To describe the development of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for measuring functioning and disability in accordance with the International Classification of Functioning, Disability and Health. WHODAS 2.0 is a standard metric for ensuring scientific comparability across different populations. METHODS: A series of studies was carried out globally. Over 65,000 respondents drawn from the general population and from specific patient populations were interviewed by trained interviewers who applied the WHODAS 2.0 (with 36 items in its full version and 12 items in a shortened version). FINDINGS: The WHODAS 2.0 was found to have high internal consistency (Cronbach's alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient: 0.98); good concurrent validity in patient classification when compared with other recognized disability measurement instruments; conformity to Rasch scaling properties across populations, and good responsiveness (i.e. sensitivity to change). Effect sizes ranged from 0.44 to 1.38 for different health interventions targeting various health conditions. CONCLUSION: The WHODAS 2.0 meets the need for a robust instrument that can be easily administered to measure the impact of health conditions, monitor the effectiveness of interventions and estimate the burden of both mental and physical disorders across different populations.

Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys.

BACKGROUND: Although significant associations of childhood adversities with adult mental disorders are widely documented, most studies focus on single childhood adversities predicting single disorders. AIMS: To examine joint associations of 12 childhood adversities with first onset of 20 DSM-IV disorders in World Mental Health (WMH) Surveys in 21 countries. METHOD: Nationally or regionally representative surveys of 51 945 adults assessed childhood adversities and lifetime DSM-IV disorders with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Childhood adversities were highly prevalent and interrelated. Childhood adversities associated with maladaptive family functioning (e.g. parental mental illness, child abuse, neglect) were the strongest predictors of disorders. Co-occurring childhood adversities associated with maladaptive family functioning had significant subadditive predictive associations and little specificity across disorders. Childhood adversities account for 29.8% of all disorders across countries. CONCLUSIONS: Childhood adversities have strong associations with all classes of disorders at all life-course stages in all groups of WMH countries. Long-term associations imply the existence of as-yet undetermined mediators.

The impact of comorbidity of mental and physical conditions on role disability in the US adult household population.

CONTEXT: There is limited information that accounts for comorbidity on the impact of role disability associated with a wide range of mental and physical disorders in population-based samples. OBJECTIVE: To estimate the comparative effects of common mental and physical conditions on role disability in the general population using a novel method that accounts for comorbidity. DESIGN: Direct interviews about physical and mental conditions during the past year. SETTING: The National Comorbidity Survey Replication, a nationally representative series of face-to-face interviews. PATIENTS: A nationally representative sample of adults living in households (N = 5962 respondents, 18 years and older). MAIN OUTCOME MEASURE: Disability in major life roles was assessed with the World Health Organization Disability Assessment Schedule. Simulations that allow for complex interactions among conditions were used to estimate the conditions' effects on disability days, when respondents were completely unable to carry out their usual daily activities because of problems with mental or physical health, in the past 12 months. RESULTS: An estimated 53.4% of US adults have 1 or more of the mental or physical conditions assessed in the survey. These respondents report an average 32.1 more role-disability days in the past year than demographically matched controls, equivalent to nearly 3.6 billion days of role disability in the population. Musculoskeletal disorders and major depression had the greatest effects on disability days. Mental conditions accounted for more than half as many disability days as all physical conditions at the population level. Associations of specific conditions with disability decreased substantially after controlling for comorbidity, suggesting that prior studies, which generally did not control for comorbidity, overestimated disease-specific effects. CONCLUSION: The staggering amount of health-related disability associated with mental and physical conditions should be considered in establishing priorities for the allocation of health care and research resources.

Using the international classification of functioning, disease and health in attention-deficit/hyperactivity disorder: separating the disease from its epiphenomena.

This paper discusses the description of attention-deficit/hyperactivity disorder (ADHD) as a possible "disease entity" and the "disabilities" associated with it. It builds on the nosological descriptions of ADHD from International Classification of Disease (ICD) and Diagnostic and Statistical Manual of Mental Disorders (DSM) perspectives and introduces the distinct disability dimension from the International Classification of Functioning, Disability and Health (ICF) perspective. It advocates for separating assessment of disease and disability dimensions and then utilizing these constructs jointly by using both the ICD and ICF classifications. The ICF analyzes functioning in relation to a health condition in terms of 1) body functions and body structures, 2) activities of the person and participation of the person in society, and 3) contextual factors such as environmental factors and personal factors. The separation of signs/symptoms and consequences permits better understanding of the disease pathophysiology on the one hand and the consequences (eg, its impact on the person, family, peers, school, work, and social life) on the other hand. It will therefore enable us to better understand the nature of ADHD because the core body functions associated with the disorder will be better delineated. In addition, capturing environmental factors may help people with ADHD by modifying their environments. The ICF provides a good outcome monitoring and evaluation tool for the assessment of treatment response. As in many other disorders, diagnosis alone is not a sufficient predictor of health care needs, utilization, costs, or outcomes. When one adds disability as a predictor, our capacity to predict these parameters is increased dramatically. It is therefore suggested that the ICF framework be considered in future ADHD research activities.

Age of onset of mental disorders: a review of recent literature.

PURPOSE OF REVIEW: The aim of this article is to review recent epidemiological research on age-of-onset of mental disorders, focusing on the WHO World Mental Health surveys. RECENT FINDINGS: Median and inter-quartile range (IQR; 25th-75th percentiles) of age-of-onset is much earlier for phobias (7-14, IQR 4-20) and impulse-control disorders (7-15; IQR 4-35) than other anxiety disorders (25-53, IQR 15-75), mood disorders (25-45, IQR 17-65), and substance disorders (18-29, IQR 16-43). Although less data exist for nonaffective psychosis, available evidence suggests that median age-of-onset is in the range late teens through early 20s. Roughly half of all lifetime mental disorders in most studies start by the mid-teens and three quarters by the mid-20s. Later onsets are mostly secondary conditions. Severe disorders are typically preceded by less severe disorders that are seldom brought to clinical attention. SUMMARY: First onset of mental disorders usually occur in childhood or adolescence, although treatment typically does not occur until a number of years later. Although interventions with early incipient disorders might help reduce severity-persistence of primary disorders and prevent secondary disorders, additional research is needed on appropriate treatments for early incipient cases and on long-term evaluation of the effects of early intervention on secondary prevention.

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

OBJECTIVE: Despite growing interest in adult attention deficit hyperactivity disorder (ADHD), little is known about its prevalence or correlates. METHOD: A screen for adult ADHD was included in a probability subsample (N=3,199) of 18-44-year-old respondents in the National Comorbidity Survey Replication, a nationally representative household survey that used a lay-administered diagnostic interview to assess a wide range of DSM-IV disorders. Blinded clinical follow-up interviews of adult ADHD were carried out with 154 respondents, oversampling those with positive screen results. Multiple imputation was used to estimate prevalence and correlates of clinician-assessed adult ADHD. RESULTS: The estimated prevalence of current adult ADHD was 4.4%. Significant correlates included being male, previously married, unemployed, and non-Hispanic white. Adult ADHD was highly comorbid with many other DSM-IV disorders assessed in the survey and was associated with substantial role impairment. The majority of cases were untreated, although many individuals had obtained treatment for other comorbid mental and substance-related disorders. CONCLUSIONS: Efforts are needed to increase the detection and treatment of adult ADHD. Research is needed to determine whether effective treatment would reduce the onset, persistence, and severity of disorders that co-occur with adult ADHD.

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

BACKGROUND: Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood. METHODS: A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders). RESULTS: Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD. CONCLUSIONS: No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.

An international study of psychological problems in primary care. Preliminary report from the World Health Organization Collaborative Project on 'Psychological Problems in General Health Care'.

This article describes a large longitudinal multicenter collaborative study that investigated the form, frequency, course, and outcome of psychological problems that were seen in primary health care settings in 15 different sites around the world. The research employed a two-stage sampling design in which the 12-item General Health Questionnaire was administered to 26,422 persons aged 18 to 65 years who were consulting health care services. Of these persons, 5604 were selected for detailed examinations using standardized instruments and were followed up at 3 months and 1 year to provide information on course and outcome. All assessment instruments have been translated into 13 different languages. The project has produced a database that allows for the exploration of the nature of psychological disorders experienced by patients in general medical care and their association with physical illness, illness behavior, and disability over time.

Progress toward achieving a common language in psychiatry. Results from the field trial of the clinical guidelines accompanying the WHO classification of mental and behavioral disorders in ICD-10.

In preparing for the 10th revision of the International Classification of Diseases (ICD-10), the Division of Mental Health of the World Health Organization organized an international field trial to help evaluate draft clinical descriptions and diagnostic guidelines that were produced to facilitate use of the chapter dealing with mental and behavioral disorders. These clinical guidelines were prepared in equivalent versions in most of the world's widely spoken languages. The field trial aimed to obtain data that would help in assessing whether the classification fits the diagnoses made in different countries, whether it is easy to use, and whether psychiatrists after a short period of familiarization with the classification can reach agreement about their diagnoses and classification. The field trial was carried out at 112 clinical centers in 39 countries by 711 clinicians who conducted 15,302 individual assessments. The trial included joint clinical assessments of patients and case history exercises. The results of the joint assessment part of the trial are reported here. Most clinicians reported that the draft document was easy to use and that the classification provided a good fit for the vast majority of the clinical conditions encountered. While interrater reliability was satisfactory for most categories, some (for example, those dealing with personality disorders) were somewhat difficult to use, and reliability of assignment for those was lower. The trial demonstrated that the ICD-10 chapter dealing with mental and behavioral disorders is on the whole suitable for general use. It provided valuable indications about changes needed for subsequent versions and demonstrated the feasibility of large-scale international research on classification and diagnosis in psychiatry.

Lifetime panic-depression comorbidity in the National Comorbidity Survey.

BACKGROUND: The National Comorbidity Survey is a nationally representative survey of the prevalences and correlates of DSM-III-R disorders in the US household population. METHODS: Retrospective age-at-onset reports were used to study predictive relationships between lifetime panic and depression. RESULTS: Strong associations were found between the lifetime prevalences of panic and major depressive episodes (odds ratios: for panic attacks with depression, 6.2; for panic disorder with depression, 6.8). These associations were not significantly influenced by the inclusion or exclusion of respondents with mania. Temporally primary depression predicted a first onset of subsequent panic attacks but not of panic disorder. Temporally primary panic attacks, with or without panic disorder and whether or not the panic was persistent, predicted a first onset of subsequent major depression. The associations between panic attack and depression were attenuated in models that controlled for prior traumatic life experiences and histories of other DSM-III-R disorders. CONCLUSIONS: Lifetime panic-depression comorbidity characterizes most community respondents with panic disorder and a substantial few of those with major depression. The absence of a dose-response relationship suggests that primary panic attack is a marker, rather than a causal risk factor, of subsequent depression. Primary depression, in comparison, appears to be a genuine risk factor for secondary panic attacks. That primary depression predicts panic attacks but not panic disorder suggests that secondary panic is a severity marker of depression rather than a comorbid condition. These results are far from definitive because they are based on retrospective reports, lay-administered diagnostic interviews, and only 1 survey. However, they raise important questions that could lead to a fundamental rethinking of panic-depression comorbidity if they are replicated in future epidemiological and clinical studies.

The prevalence and effects of adult attention deficit/hyperactivity disorder on work performance in a nationally representative sample of workers.

OBJECTIVE: The prevalence and workplace consequences of adult attention deficit/hyperactivity disorder (ADHD) are unknown. METHODS: An ADHD screen was included in a national household survey (n = 3198, ages 18-44). Clinical re-interviews calibrated the screen to diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition ADHD. Diagnoses among workers were compared with responses to the WHO Health and Work Performance Questionnaire (HPQ). RESULTS: A total of 4.2% of workers had ADHD. ADHD was associated with 35.0 days of annual lost work performance, with higher associations among blue collar (55.8 days) than professional (12.2 days), technical (19.8 days), or service (32.6 days) workers. These associations represent 120 million days of annual lost work in the U.S. labor force, equivalent to dollar 19.5 billion lost human capital. CONCLUSIONS: ADHD is a common and costly workplace condition. Effectiveness trials are needed to estimate the region of interest of workplace ADHD screening and treatment programs.