Perceived need for care, help seeking, and perceived barriers to care for alcohol use disorders in a national sample.

OBJECTIVE: The aims of this study were to examine the rates and correlates of help seeking, perceived need for care, and perceived barriers to care among people with an alcohol use disorder in a large nationally representative sample. METHODS: Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions for persons 18 years and older (N=43,093). Three main groups were defined: people who sought help, people who perceived a need for care but did not seek help, and people who neither perceived a need nor sought help. RESULTS: Almost one-third (N=11,843, or 28%) of survey respondents met DSM-IV criteria for a lifetime alcohol use disorder. Most individuals with an alcohol use disorder (81%) did not report seeking care or perceiving a need for help. Those who were younger, were married, had higher income, had higher education, and did not have an adverse general medical condition were significantly less likely to perceive a need for help or to seek help for an alcohol use disorder. Respondents who did not perceive a need for help or seek it were significantly less likely to have an additional axis I or axis II disorder. CONCLUSIONS: Knowledge of the factors that influence perceived need for help could aid in developing interventions directed toward increasing the rates of help seeking among people with an alcohol use disorder. Regular screening for alcohol use disorders in primary health care settings is recommended.

Demographic and social variables associated with problem gambling among men and women in Canada.

Knowledge of demographic and social correlates of problem gambling among men and women in general population samples is limited. Such research is important for identifying individuals who may become problem gamblers. The current research used a gender-stratified analysis using logistic regression models in a nationally representative sample to identify correlates of problem gambling among men and women. Data were from the Canadian Community Health Survey Cycle 1.2 (CCHS 1.2; data collected in 2002; response rate 77%). The 12-month prevalence of problem gambling among men and women who endorsed gambling in the past year was 4.9% and 2.7%, respectively. For women, increased odds of problem gambling was associated with middle age, middle to low levels of income, a high school diploma or less, being never-married, higher levels of life stress, and negative coping abilities. For men, being aged 70 or greater decreased the odds of problem gambling, while being separated, widowed, or divorced, lower levels of social support, and negative coping abilities increased the odds of problem gambling. These findings have important public health implications for identifying men and women who may be more likely to become problem gamblers in the general population.

Factors associated with multiple versus single episode suicide attempts in the 1990-1992 and 2001-2003 United States national comorbidity surveys.

This study sought to examine psychiatric and childhood traumatic event correlates of multiple suicide attempts (MSA) compared with single suicide attempts (SSA) in 2 nationally representative samples of the United States general population. Data came from the National Comorbidity Survey (n = 5,401; age 18-54; response rate = 82.4%) and the National Comorbidity Survey Replication (n = 4,083; age 18-54; response rate = 70.9%). Multiple logistic regressions were used to compare individuals with MSA to those with a SSA on the variables of interest after adjusting for sociodemographic variables. Individuals with a history of MSA had significantly higher odds of experiencing several traumatic events in childhood in the 2 surveys. Most notably, comorbidity of 3 or more mental disorders and the presence of at least 1 anxiety disorder distinguished individuals with MSA from those with a SSA in both surveys, suggesting the potential importance of these variables in association with multiple suicide attempts.

Exploring the correlates of suicide attempts among individuals with major depressive disorder: findings from the national epidemiologic survey on alcohol and related conditions.

OBJECTIVE: There are no previous studies describing the correlates of suicide attempts in individuals with major depressive disorder in a nationally representative sample. This study explores the sociodemographic variables, mental disorders, and specific depressive symptoms associated with suicide attempts in depression. METHOD: Data were drawn from Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a large (N = 43,093) nationally representative survey of mental illness in the United States conducted between 2001 and 2002. Persons with lifetime major depressive disorder (N = 5128; diagnosed according to DSM-IV) were categorized according to the presence (N = 865) or absence (N = 4263) of a lifetime history of suicide attempts. Multivariate logistic regression was used to compare the 2 groups across a broad range of socio-demographic and mental disorder correlates, as well as to compare specific depressive symptoms associated with a history of suicide attempts. Positive predictive values (PPVs) were calculated to evaluate the effectiveness of each correlate in predicting suicide attempts. Analyses were conducted separately for men and women. RESULTS: Sociodemographic factors significantly associated with a history of suicide attempts included Hispanic or Latino ethnicity (p < .05), younger age (p < .01), and low annual income (p < .01). A history of suicide attempt was significantly associated with any anxiety, personality, or substance use disorder among both men and women (all p < .01). Personality disorder comorbidity was most predictive of suicide attempt. In men, suicide attempts had a strong association with dependent personality disorder (adjusted odds ratio [AOR] = 3.81; 95% CI = 1.14 to 12.73), whereas in women, suicide attempts had a strong association with antisocial personality disorder (AOR = 2.71; 95% CI = 1.72 to 4.25). Dependent personality disorder predicted suicide attempt in almost three quarters of depressed men (PPV = 74.3%; 95% CI = 54.2 to 87.6). The depressive symptom most strongly associated with a history of suicide attempts in both men and women was feelings of worthlessness (AOR = 5.48, 95% CI = 3.36 to 8.94 for men; AOR = 4.93, 95% CI = 3.56 to 6.84 for women). CONCLUSIONS: This study contributes to the existing literature on risk factors for suicide attempts in depressed individuals. Identifying specific depressive symptoms and comorbid mental illnesses may improve the clinical assessment of suicide risk in people with major depressive disorder.

Effect of regulatory warnings on antidepressant prescription rates, use of health services and outcomes among children, adolescents and young adults.

BACKGROUND: Regulatory bodies worldwide, including Health Canada, have issued warnings about prescribing antidepressants to children and adolescents. We sought to determine whether the Health Canada warning had the desired effects on prescribing patterns and outcomes and whether it had any unintended health consequences. METHODS: We examined data from prescription and health care databases representing more than 265 000 children, adolescents and young adults annually to determine changes in the rates of antidepressant prescription, use of health services and outcomes in these populations in the 9 years before and the 2 years after the Health Canada warning. We also examined the data for unintended changes in these rates among patients with anxiety disorders. We used young adults as the comparison group because they were not targeted by the warning. RESULTS: Following the warning, the rate of antidepressant prescriptions decreased among children and adolescents (relative risk [RR] 0.86, 95% confidence interval [CI] 0.81-0.91) and among young adults (RR 0.90, 95% CI 0.86-0.93). Ambulatory visits because of depression decreased among children and adolescents (RR 0.90, 95% CI 0.85-0.96) and young adults (RR 0.91, 95% CI 0.87-0.96). The rate of completed suicides among children and adolescents rose significantly after the warning (RR 1.25, 95% CI 1.08-1.44; annual rate per 1000 = 0.04 before and 0.15 after the warning). There was no equivalent change in the rate of completed suicides among young adults (RR 1.01, 95% CI 0.93-1.10; annual rate per 1000 = 0.15 before and 0.22 after the warning). Among patients with an anxiety disorder, the prescription rates did not change among children and adolescents, except for a decrease in the use of selective serotonin reuptake inhibitors other than fluoxetine, but the rates among young adults changed similar to the pattern of changes in the overall prescribing of antidepressants. There was also a significant decrease in the rate of physician visits because of anxiety disorders among young adults after the warning. INTERPRETATION: Health advisories and warnings issued by regulatory bodies may have unintended consequences on the provision of care, delivery of health services and clinical outcomes. Further efforts are required to ensure that health warnings do not result in unexpected harm.

Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel.

CONTEXT: Although military personnel are trained for combat and peacekeeping operations, accumulating evidence indicates that deployment-related exposure to traumatic events is associated with mental health problems and mental health service use. OBJECTIVE: To examine the relationships between combat and peacekeeping operations and the prevalence of mental disorders, self-perceived need for mental health care, mental health service use, and suicidality. DESIGN: Cross-sectional, population-based survey. SETTING: Canadian military. PARTICIPANTS: A total of 8441 currently active military personnel (aged 16-54 years). MAIN OUTCOME MEASURES: The DSM-IV mental disorders (major depressive disorder, posttraumatic stress disorder, generalized anxiety disorder, panic disorder, social phobia, and alcohol dependence) were assessed using the World Mental Health version of the World Health Organization Composite International Diagnostic Interview, a fully structured lay-administered psychiatric interview. The survey included validated measures of self-perceived need for mental health treatment, mental health service use, and suicidal ideation. Lifetime exposure to peacekeeping and combat operations and witnessing atrocities or massacres (ie, mutilated bodies or mass killings) were assessed. RESULTS: The prevalences of any past-year mental disorder assessed in the survey and self-perceived need for care were 14.9% and 23.2%, respectively. Most individuals meeting the criteria for a mental disorder diagnosis did not use any mental health services. Deployment to combat operations and witnessing atrocities were associated with increased prevalence of mental disorders and perceived need for care. After adjusting for the effects of exposure to combat and witnessing atrocities, deployment to peacekeeping operations was not associated with increased prevalence of mental disorders. CONCLUSIONS: This is the first study to use a representative sample of active military personnel to examine the relationship between deployment-related experiences and mental health problems. It provides evidence of a positive association between combat exposure and witnessing atrocities and mental disorders and self-perceived need for treatment.

Perceived barriers to mental health service utilization in the United States, Ontario, and the Netherlands.

OBJECTIVE: Although rates of mental health service utilization differ dramatically across countries, little information is available about differences in self-reported barriers to mental health service utilization. Perceived barriers were examined in three locations with differing health care systems. METHODS: Data came from three methodologically similar population-based surveys of adults conducted in the 1990s in Ontario, Canada (N=6,261), the United States (N=5,384), and the Netherlands (N=6,031) that assessed DSM-III-R nonpsychotic mental disorders with the Composite International Diagnostic Interview. Respondents who reported a need for professional help were asked to indicate reasons for not seeking care. Multiple logistic regression analyses were used to determine the sociodemographic, mental disorder, and location-specific correlates of each perceived barrier. RESULTS: The pattern of reported barriers to mental health service utilization was similar across locations: attitudinal barriers (thoughts that the problem would get better on its own) were more prevalent than structural barriers (inability to get an appointment). Fear of stigmatization was not commonly endorsed. With adjustment for sociodemographic factors and type of mental disorder, low-income respondents were significantly more likely to report a financial barrier in the United States than in either Ontario or the Netherlands. CONCLUSIONS: Across locations, attitudinal barriers were more likely to be endorsed than structural barriers to service utilization. The most striking reported cross-national difference was structural, with many more U.S. respondents (especially those with low incomes) reporting financial barriers than respondents in either Ontario or the Netherlands.

Does co-morbid depressive illness magnify the impact of chronic physical illness? A population-based perspective.

OBJECTIVE: To examine the relative and combined impact of depressive and chronic physical conditions on functional status and health-care use in the general population. METHOD: Canadian, representative, population-based cross-sectional survey (n=130,880). Major depressive disorder (MDD) in the past 12 months was assessed by structured interview, and physical disorders, activity reduction, role impairment and work absence by self-report. The relative impact of MDD and six common chronic physical illnesses (asthma, arthritis, back problems, chronic obstructive pulmonary disease, heart disease and diabetes) was estimated using multivariate regression, adjusting for sociodemographic characteristics and overall chronic physical illness burden. RESULTS: After adjusting for sociodemographic characteristics, alcohol dependence and chronic physical illness burden, the presence of co-morbid MDD was associated with significantly greater (approximately double the) likelihood of health-care utilization and increased functional disability and work absence compared to the presence of a chronic physical illness without co-morbid MDD. This impact of MDD was seen across each of the six chronic physical illnesses examined in this study, with the strongest associations seen for work absence. CONCLUSIONS: These observations confirm prior findings of a strong association at the population level between major depression and health-care use and role impairment among persons with chronic physical disorders. They also point to the significant impact of co-morbid major depression on health-care seeking, disability and work absence in persons with chronic physical illness, underscoring the need for greater efforts to design and test the impact of detection and treatment programs for such individuals.

Perceived need for mental health treatment in a nationally representative Canadian sample.

OBJECTIVE: The optimal method of determining how many people in the general population need help for emotional problems remains unclear. This study aimed to examine the prevalence and correlates of self-perceived need for mental health services (that is, help seeking and perceived need) in a large, population-based sample. METHODS: Data came from the Canadian Community Health Survey 1.2 (n = 36,816, respondent age 15 years and over, and response rate 77%). Respondents were asked whether they had sought help in the past year from any professional for emotional problems and whether they felt they needed help for emotional symptoms but had not sought treatment. The Composite International Diagnostic Interview (CIDI) was used to make DSM-IV mental disorder diagnoses. RESULTS: The past-year prevalences of help seeking and perceived need were 8.7% and 2.9%, respectively. After adjusting for the presence of DSM-IV disorders assessed in the survey, sociodemographic factors, illness severity, social supports, and the presence of physical health conditions were associated with help seeking and perceived need. Independent of DSM diagnoses, sociodemographics, and social supports, perceived need and help seeking were associated with increased levels of distress, disability, and suicidal ideation and attempts. CONCLUSIONS: This study illustrates that, in addition to the presence of a DSM diagnosis, the respondent's self-perceived need for mental health treatment is important in the assessment of need for mental health services in the community.

Mental health service use in a nationally representative Canadian survey.

BACKGROUND: Previous Canadian surveys have noted a wide range of prevalence rates for mental health service use and found no consistent relation between type of contact with mental health professionals and severity of illness. This study is the first investigation to examine the prevalence and correlates of mental health service use in a nationally representative Canadian survey. METHODS: The Canadian Community Health Survey Cycle 1.1 was conducted between 2000 and 2001 (n = 125,493; respondent age 12 years and over; response rate; 84.7%). Respondents were asked whether they had contacted a professional because of emotional symptoms in the past year and about their experience of barriers to treatment. DSM-IV major depression and alcohol dependence diagnoses were assessed with the Composite International Diagnostic Interview Short Form. The relation between a range of measures of clinical severity and the type of professional contacted for emotional symptoms was examined. RESULTS: The prevalence of 12-month help seeking for emotional symptoms was 8.3% (99%CI, 8.10 to 8.55); an additional 0.6% (99%CI, 0.49 to 0.62) of the sample perceived a need for treatment without seeking care. Respondents endorsing contact with multiple professionals or with psychiatrists only had higher levels of severity than those who had contact with family doctors only or nonphysician professionals only. CONCLUSIONS: Although untreated depression remains a significant problem in Canada, more severe illness was more likely to be associated with seeing a psychiatrist (or multiple professionals), indicating a relation between greater severity of mental illness and receiving more specialized care.

Psychometric properties of an index of emotional distress in the U.S. National Comorbidity Survey.

BACKGROUND: The National Comorbidity Survey (NCS; Kessler et al. 1994) was a nationwide household survey of the U.S. population designed to produce data on the prevalence and correlates of psychiatric disorders. The NCS dataset is now in public-use format and continues to be widely used for ongoing research efforts. The NCS dataset included a set of 14 items that have face validity as a measure of current emotional distress (depression and anxiety) and could serve as a potentially useful continuous measure of psychological distress. However, there have been no published studies on its psychometric properties and this measure has not yet been utilized by researchers using the NCS dataset. This paper provides an evaluation of the psychometric properties of the NCS Distress Index. METHOD: The NCS Part II public-use dataset (N = 5877) was used. Detailed diagnostic information was collected along with 14 items assessing current psychological distress and measures of Neuroticism and Openness to Experience. RESULTS: The NCS Distress Index was found to be internally consistent (Alpha = 0.92) and a series of principal-components analyses demonstrated that the measure is most accurately conceptualized as a single-factor measure of general distress. The construct validity of the Distress Index was supported by its associations with the measures of Neuroticism and Openness to Experience. A series of comparisons between diagnostic groups also supported the construct validity of the measure. For example, those with disorders characterized by depressed mood and worry scored higher on the Distress Index than those with disorders characterized by fear and hyperarousal. CONCLUSIONS: The NCS Distress Index is a psychometrically sound measure of current emotional distress. Future studies utilizing the NCS public-use dataset could potentially benefit from the inclusion of this measure in addition to more commonly investigated categorical variables such as diagnosable disorders.