Sleep characteristics across the lifespan in 1.1 million people from the Netherlands, United Kingdom and United States: a systematic review and meta-analysis.

We aimed to obtain reliable reference charts for sleep duration, estimate the prevalence of sleep complaints across the lifespan and identify risk indicators of poor sleep. Studies were identified through systematic literature search in Embase, Medline and Web of Science (9 August 2019) and through personal contacts. Eligible studies had to be published between 2000 and 2017 with data on sleep assessed with questionnaires including ≥100 participants from the general population. We assembled individual participant data from 200,358 people (aged 1-100 years, 55% female) from 36 studies from the Netherlands, 471,759 people (40-69 years, 55.5% female) from the United Kingdom and 409,617 people (≥18 years, 55.8% female) from the United States. One in four people slept less than age-specific recommendations, but only 5.8% slept outside of the 'acceptable' sleep duration. Among teenagers, 51.5% reported total sleep times (TST) of less than the recommended 8-10 h and 18% report daytime sleepiness. In adults (≥18 years), poor sleep quality (13.3%) and insomnia symptoms (9.6-19.4%) were more prevalent than short sleep duration (6.5% with TST < 6 h). Insomnia symptoms were most frequent in people spending ≥9 h in bed, whereas poor sleep quality was more frequent in those spending <6 h in bed. TST was similar across countries, but insomnia symptoms were 1.5-2.9 times higher in the United States. Women (≥41 years) reported sleeping shorter times or slightly less efficiently than men, whereas with actigraphy they were estimated to sleep longer and more efficiently than man. This study provides age- and sex-specific population reference charts for sleep duration and efficiency which can help guide personalized advice on sleep length and preventive practices.

Neighbourhood characteristics and prevalence and severity of depression: pooled analysis of eight Dutch cohort studies.

BACKGROUND: Studies on neighbourhood characteristics and depression show equivocal results.AimsThis large-scale pooled analysis examines whether urbanisation, socioeconomic, physical and social neighbourhood characteristics are associated with the prevalence and severity of depression. METHOD: Cross-sectional design including data are from eight Dutch cohort studies (n = 32 487). Prevalence of depression, either DSM-IV diagnosis of depressive disorder or scoring for moderately severe depression on symptom scales, and continuous depression severity scores were analysed. Neighbourhood characteristics were linked using postal codes and included (a) urbanisation grade, (b) socioeconomic characteristics: socioeconomic status, home value, social security beneficiaries and non-Dutch ancestry, (c) physical characteristics: air pollution, traffic noise and availability of green space and water, and (d) social characteristics: social cohesion and safety. Multilevel regression analyses were adjusted for the individual's age, gender, educational level and income. Cohort-specific estimates were pooled using random-effects analysis. RESULTS: The pooled analysis showed that higher urbanisation grade (odds ratio (OR) = 1.05, 95% CI 1.01-1.10), lower socioeconomic status (OR = 0.90, 95% CI 0.87-0.95), higher number of social security beneficiaries (OR = 1.12, 95% CI 1.06-1.19), higher percentage of non-Dutch residents (OR = 1.08, 95% CI 1.02-1.14), higher levels of air pollution (OR = 1.07, 95% CI 1.01-1.12), less green space (OR = 0.94, 95% CI 0.88-0.99) and less social safety (OR = 0.92, 95% CI 0.88-0.97) were associated with higher prevalence of depression. All four socioeconomic neighbourhood characteristics and social safety were also consistently associated with continuous depression severity scores. CONCLUSIONS: This large-scale pooled analysis across eight Dutch cohort studies shows that urbanisation and various socioeconomic, physical and social neighbourhood characteristics are associated with depression, indicating that a wide range of environmental aspects may relate to poor mental health.Declaration of interestNone.

Prevalence and course of subthreshold anxiety disorder in the general population: A three-year follow-up study.

BACKGROUND: This study examined the prevalence, course and risk indicators of subthreshold anxiety disorder to determine the necessity and possible risk indicators for interventions. METHODS: Data were derived from the 'Netherlands Mental Health Survey and Incidence Study-2' (NEMESIS-2), a psychiatric epidemiological cohort study among the general population (n = 4528). This study assessed prevalence, characteristics, and three-year course of subthreshold anxiety disorder (n = 521) in adults, and compared them to a no anxiety group (n = 3832) and an anxiety disorder group (n = 175). Risk indicators for persistent and progressive subthreshold anxiety disorder were also explored, including socio-demographics, vulnerability factors, psychopathology, physical health and functioning. RESULTS: The three-year prevalence of subthreshold anxiety disorder was 11.4%. At three-year follow-up, 57.3% had improved, 29.0% had persistent subthreshold anxiety disorder and 13.8% had progressed to a full-blown anxiety disorder. Prevalence, characteristics and course of subthreshold anxiety disorder were in between both comparison groups. Risk indicators for persistent course partly overlapped with those for progressive course and included vulnerability and psychopathological factors, and diminished functioning. LIMITATIONS: Course analysis were restricted to the development of anxiety disorders, other mental disorders were not assessed. Moreover, due to the naturalistic design of the study the impact of treatment on course cannot be assessed. CONCLUSIONS: Subthreshold anxiety disorder is relatively prevalent and at three-year follow-up a substantial part of respondents experienced persistent symptoms or had progressed into an anxiety disorder. Risk indicators like reduced functioning may help to identify these persons for (preventative) treatment and hence reduce functional limitations and disease burden.

Gender differences in common mental disorders: a comparison of social risk factors across four European welfare regimes.

BACKGROUND: Decreasing gender differences in mental health are found largely in countries in which the roles of men and women have improved in terms of opportunities for employment, education, child care and other indicators of increasing gender equality. In this study, we examine how European welfare regimes influence this association between mental health and the social roles that men and women occupy. METHODS: The EU-World Mental Health data are used, which covers the general population in 10 European countries (n = 37 289); Countries were grouped into four welfare regions: Liberal regime (Northern Ireland), Bismarckian regime (Belgium, Germany, the Netherlands and France), Southern regime (Spain, Italy, Portugal) and Central-Eastern regime (Romania and Bulgaria). The lifetime prevalence of mood, anxiety and alcohol disorders was determined by using the Composite International Diagnostic Interview 3.0. Overall prevalence rates along with odds ratios by means of bivariate logistic regression models are calculated to compare the presence of common mental disorders in women versus men per welfare regime. RESULTS: Overall prevalence of common mental disorders is highest in the Liberal regime and lowest in the Central/Eastern regime. The gender gap in mental disorders is largest in the Southern regime and smallest in the Liberal regime. Marital status and certain employment positions help to explain variation in mental disorders across and within welfare regimes. CONCLUSION: Most prominent pathways linking gender to mental ill-health being are related to marital status and certain employment positions. However, these pathways also show substantial variation across welfare regimes.

The interplay between emotional exhaustion, common mental disorders, functioning and health care use in the working population.

OBJECTIVES: Previous research established that emotional exhaustion - the often assumed core dimension of burnout - diminishes job-related functioning, but knowledge of its association with functioning and health care utilization is largely lacking. Moreover, as exhaustion frequently co-occurs with mood and anxiety disorders (i.e. common mental disorders (CMD)), the question should be addressed whether these associations hold after adjustment for CMD, and whether CMD intensifies the burden of exhaustion. METHODS: Cross-sectional data was used from 2902 workers included in the third wave of the Netherlands Mental Health Survey and Incidence Study-2, a nationally representative face-to-face survey. Exhaustion was assessed with the exhaustion scale of the Maslach Burnout Inventory; work loss (including presenteeism and absenteeism) with the WHO Disability Assessment Schedule; and general functioning with the 36-item Short Form. Health care use is defined as ≥1 general or mental health care contact for mental health problems. Confounders included sociodemographics, job characteristics, CMD, and physical health. The Composite International Diagnostic Interview assessed CMD. RESULTS: Mild and severe exhaustion occurred in 14.9% and 2.3% of the workers, respectively, and was significantly associated with work loss, impaired emotional, physical and social functioning, and health care use, even after adjustment for confounders. Co-occurrence of CMD strengthened the association between exhaustion and work loss as well as impaired emotional and social functioning. CONCLUSIONS: Exhaustion is uniquely associated with work loss, impaired functioning and health care use. Moreover, co-occurring CMD intensified impairments in functioning. This stresses the need for clinical attention to the exhaustion dimension of burnout.

Common Mental Disorder Diagnosis and Need for Treatment are Not the Same: Findings from the NEMESIS Study.

The study aimed to determine whether some depressive, anxiety, and substance-use (DAS) disorders are mild, transient cases that remit without treatment. The first two waves of the first Netherlands Mental Health Survey and Incidence Study were used (age 18-64 years at baseline; wave two N = 5618). Mental disorders were assessed using CIDI 1.1. Past-year and past-month measures of DAS disorders, health service use, and quality of life were assessed at both waves. Individuals with a past-year DAS disorder who received no prior lifetime treatment were significantly more likely than those who received treatment to: (1) remit from their index disorder(s) without subsequent treatment, (2) be free of comorbid disorders, and (3) not have attempted suicide during follow-up (remission rates: 68.5 versus 32.0 %, respectively, p < 0.001). However, these individuals had lower quality of life compared to healthy individuals. Results were similar for past-month measures. Results show that many people who meet criteria for a DAS disorder remit without treatment. However, the lowered quality of life scores in this group nonetheless underscores the negative impact on the presence of residual symptoms.

Long-term economic consequences of child maltreatment: a population-based study.

Child maltreatment is prognostically associated with long-term detrimental consequences for mental health. These consequences are reflected in higher costs due to health service utilization and productivity losses in adulthood. An above-average sense of mastery can have protective effects in the pathogenesis of mental disorders and thus potentially cushion adverse impacts of maltreatment. This should be reflected in lower costs in individuals with a history of child maltreatment and a high sense of mastery. The aims of the study were to prognostically estimate the excess costs of health service uptake and productivity losses in adults with a history of child maltreatment and to evaluate how mastery may act as an effect modifier. Data were used on 5618 individuals participating in the Netherlands Mental Health Survey and Incidence Study (NEMESIS). We focussed on measures of child maltreatment (emotional neglect, physical, psychological and sexual abuse) and economic costs owing to health-care uptake and productivity losses when people with a history of abuse have grown into adulthood. We evaluated how mastery acted as an effect modifier. Estimates were adjusted for demographics and parental psychopathology. Post-stratification weights were used to account for initial non-response and dropout. Due to the non-normal distribution of the costs data, sample errors, 95 % confidence intervals, and p values were calculated using non-parametric bootstrapping (1000 replications). Exposure to child maltreatment occurs frequently (6.9-24.8 %) and is associated with substantial excess costs in adulthood. To illustrate, adjusted annual excess costs attributable to emotional neglect are €1,360 (95 % CI: 615-215) per adult. Mastery showed a significant effect on these figures: annual costs were €1,608 in those with a low sense of mastery, but only €474 in those with a firmer sense of mastery. Child maltreatment has profound mental health consequences and is associated with staggering long-term economic costs, rendering lack of action very costly. Our data lends credibility to the hypothesis that mastery may help to cushion the adverse consequences of child maltreatment. Further research on mastery may help to ameliorate individual burden and in addition offer some economic benefits.

Non-fatal disease burden for subtypes of depressive disorder: population-based epidemiological study.

BACKGROUND: Major depression is the leading cause of non-fatal disease burden. Because major depression is not a homogeneous condition, this study estimated the non-fatal disease burden for mild, moderate and severe depression in both single episode and recurrent depression. All estimates were assessed from an individual and a population perspective and presented as unadjusted, raw estimates and as estimates adjusted for comorbidity. METHODS: We used data from the first wave of the second Netherlands-Mental-Health-Survey-and-Incidence-Study (NEMESIS-2, n = 6646; single episode Diagnostic and Statistical Manual (DSM)-IV depression, n = 115; recurrent depression, n = 246). Disease burden from an individual perspective was assessed as 'disability weight * time spent in depression' for each person in the dataset. From a population perspective it was assessed as 'disability weight * time spent in depression *number of people affected'. The presence of mental disorders was assessed with the Composite International Diagnostic Interview (CIDI) 3.0. RESULTS: Single depressive episodes emerged as a key driver of disease burden from an individual perspective. From a population perspective, recurrent depressions emerged as a key driver. These findings remained unaltered after adjusting for comorbidity. CONCLUSIONS: The burden of disease differs between the subtype of depression and depends much on the choice of perspective. The distinction between an individual and a population perspective may help to avoid misunderstandings between policy makers and clinicians.

The association between type and number of adverse working conditions and mental health during a time of economic crisis (2010-2012).

PURPOSE: Many studies have been published on the association between adverse psychosocial working conditions and mental health, but only a few related types of adverse job conditions and a count of these adversities to workers' mental health, using standardized diagnostic interviews. This study addresses this issue. METHODS: Data were used from the second wave of the Netherlands Mental Health Survey and Incidence Study-2, a nationally representative face-to-face survey of the general population, including 3,672 workers, 166 unemployed and 239 disabled persons. Among workers, psychosocial working conditions (decision latitude, psychological job demands, job security and co-worker support) were assessed with the Job Content Questionnaire. Mental health symptoms were assessed with the Mental Health Inventory (MHI)-5 and DSM-IV diagnoses/syndromes with the Composite International Diagnostic Interview 3.0. RESULTS: Adverse psychosocial job conditions were related to workers' mental health. The strongest association was found for low job security which increased the chance of mental health symptoms and mental disorders by twofold. Workers in the poorest quality jobs, i.e. experiencing at least three adverse working conditions, had a 3 to almost 5 times higher chance of mental disorders than those in the most optimal jobs. Having a poor quality job was not associated with better mental health compared to being unemployed or disabled. In general, similar relations were found for mood, anxiety and substance use disorders. CONCLUSIONS: In planning future strategies to prevent mental disorders at the workplace, the focus should be on workers who experience job insecurity and on those who report several adversities.

Negative socioeconomic changes and mental disorders: a longitudinal study.

BACKGROUND: There is increasing interest on whether the current global economic uncertainties have an influence on the population's mental health. In this paper, we examined the association of negative socioeconomic changes, job loss and household income reductions with incident mental disorders. The moderating effect of gender was assessed. METHODS: Data come from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a representative population-based, longitudinal study. Individuals with a paid job and without a 12-month mental disorder at baseline were selected and reassessed 3 years later (2007-2009/2010-2012). Substantial household income reductions and not being at a paid job anymore were self-reported at follow-up. Multivariate logistic models were utilised to investigate the association between these negative socioeconomic changes and the incidence of mood, anxiety and substance use Diagnostic and Statistical Manual-IV disorders assessed by the Composite International Diagnostic Interview 3.0. RESULTS: After 3 years, 6% had lost their job, 11% had a substantial household income reduction and 12.2% had developed a mental disorder. Household income reductions increased the risk of any mental disorder (aOR=1.77), particularly the risk of mood (aOR=2.24). Job loss increased the risk of mood disorders (aOR=2.02). Gender modified the relationship: job loss increased the risk of any mental disorder among men (aOR=3.04) and household income reductions did so among women (aOR=2.32). CONCLUSIONS: Negative socioeconomic changes occurring within a short time period significantly increased the risk of incident mental disorders, particularly of mood disorders. Effective interventions to alleviate the public mental health impact of negative socioeconomic changes on men and women are needed.

Same-sex sexuality and psychiatric disorders in the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2).

PURPOSE: Sexual orientation has been shown to be a risk factor for psychiatric disorders. This study compared whether sexual orientation-related disparities in the prevalence of psychiatric disorders are similar based on homosexual behavior versus attraction and tested whether, with increased acceptance of homosexuality, these disparities have diminished over time. METHODS: The Composite International Diagnostic Interview 3.0 was administered with a total of 6,646 Dutch persons, aged 18 to 64 years. RESULTS: Between 2.0% and 2.5% of the participants reported same-sex sexual behavior in the preceding year or same-sex attraction. Homosexually active persons and persons with same-sex attraction reported a higher prevalence of disorders than heterosexual persons. There were more disparities in the prevalence of disorders based on sexual attraction than based on sexual behavior. Comparing these results with a previous study, showed that no significant changes over time have occurred in the pattern of health disparities. CONCLUSIONS: Sexual orientation continues to be a risk factor for psychiatric disorders, stressing the need for understanding the origins of these disparities.

Non-fatal burden of disease due to mental disorders in the Netherlands.

PURPOSE: To estimate the disease burden due to 15 mental disorders at both individual and population level. METHODS: Using a population-based survey (NEMESIS, N = 7,056) the number of years lived with disability per one million population were assessed. This was done with and without adjustment for comorbidity. RESULTS: At individual level, major depression, dysthymia, bipolar disorder, panic disorder, social phobia, eating disorder and schizophrenia are the disorders most markedly associated with health-related quality of life decrement. However, at population level, the number of affected people and the amount of time spent in an adverse health state become strong drivers of population ill-health. Simple phobia, social phobia, depression, dysthymia and alcohol dependence emerged as public health priorities. CONCLUSIONS: From a clinical perspective, we tend to give priority to the disorders that exact a heavy toll on individuals. This puts the spotlight on disorders such as bipolar disorder and schizophrenia. However, from a public health perspective, disorders such as simple phobia, social phobia and dysthymia--which are highly prevalent and tend to run a chronic course--are identified as leading causes of population ill-health, and thus, emerge as public health priorities.

Social inequalities in mental health: results from the EU contribution to the World Mental Health Surveys Initiative.

PURPOSE: The objective of the present study was to provide updated data from nine European countries about the impact of social inequalities in the prevalence of common mental disorders. METHODS: Cross-sectional household survey of a representative sample of the adult general population of Belgium, Bulgaria, Germany, Italy, The Netherlands, Northern Ireland, Portugal, Romania and Spain. In total, 34,395 individuals were included. Social inequalities in 12-month mood, anxiety and alcohol-related disorders were evaluated. RESULTS: In Europe, income seems not to be related to the prevalence of mental disorders. Unemployment and disablement are associated with mental disorders. Lower educational level augments the risk for mood disorders. Living in small (rural) areas decreases the risk for mood disorders and living in urban settings increases it. Northern Ireland, Portugal and Belgium are the countries with the highest risks for mental disorders. CONCLUSIONS: Despite some contradictions with previous literature, in Europe there are social inequalities in the prevalence of mental disorders. However, income showed not to be associated with inequalities in mental health. Being younger, unemployed or disabled, with no education or incomplete primary studies, living in urban settings, and in Northern Ireland, Portugal or Belgium were associated to an augmented prevalence of mental disorders. Policy makers could focus on mental health promotion and mental disorders prevention programmes for risk groups such as unemployed/disabled individuals. Support to vulnerable groups (unemployed or those with less education) and mental health literacy can improve European citizens' mental health.

Drop out from out-patient mental healthcare in the World Health Organization's World Mental Health Survey initiative.

BACKGROUND: Previous community surveys of the drop out from mental health treatment have been carried out only in the USA and Canada. AIMS: To explore mental health treatment drop out in the World Health Organization World Mental Health Surveys. METHOD: Representative face-to-face household surveys were conducted among adults in 24 countries. People who reported mental health treatment in the 12 months before interview (n = 8482) were asked about drop out, defined as stopping treatment before the provider wanted. RESULTS: Overall, drop out was 31.7%: 26.3% in high-income countries, 45.1% in upper-middle-income countries, and 37.6% in low/lower-middle-income countries. Drop out from psychiatrists was 21.3% overall and similar across country income groups (high 20.3%, upper-middle 23.6%, low/lower-middle 23.8%) but the pattern of drop out across other sectors differed by country income group. Drop out was more likely early in treatment, particularly after the second visit. CONCLUSIONS: Drop out needs to be reduced to ensure effective treatment.

Comparing the effects on work performance of mental and physical disorders.

OBJECTIVE: To estimate work loss days due to absenteeism and presenteeism associated with commonly occurring mental and physical disorders. METHODS: In a nationally representative face-to-face survey (Netherlands Mental Health Survey and Incidence Study-2) including 4,715 workers, the presence of 13 mental and 10 chronic physical disorders was assessed using the Composite International Diagnostic Interview 3.0 and a physical disorder checklist. Questions about absent days due to illness and days of reduced quantitative and qualitative functioning while at work were based on the WHO Disability Assessment Schedule. Total work loss days were defined as the sum of the days of these three types of loss, where days of reduced functioning were counted as half. Both individual and population-level effects of disorders on work loss were studied, taking comorbidity into account. RESULTS: Any mental disorder was associated with 10.5 additional absent days, 8.0 days of reduced-qualitative functioning and 12.0 total work loss days. For any physical disorder, the number of days was 10.7, 3.5 and 11.3, respectively. Adjusted for comorbidity, drug abuse, bipolar disorder, major depression, digestive disorders and panic disorder were associated with the highest number of additional total work loss days. At population-level, major depression, chronic back pain, respiratory disorders, drug abuse and digestive disorders contributed the most. Annual total work loss costs per million workers were estimated at 360 million for any mental disorder; and 706 million for any physical disorder. CONCLUSIONS: Policies designed to lessen the impact of commonly occurring disorders on workers will contribute to a reduction in absenteeism and presenteeism. As the indirect costs of (mental) disorders are much higher than their medical costs, prevention and treatment of these conditions may be cost-effective.

Prevalence of mental disorders and trends from 1996 to 2009. Results from the Netherlands Mental Health Survey and Incidence Study-2.

OBJECTIVE: To present prevalences of lifetime and 12-month DSM-IV mood, anxiety, substance use and impulse-control disorders from the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2), and to compare the 12-month prevalence of mood, anxiety and substance use disorders with estimates from the first study (NEMESIS-1). METHOD: Between November 2007 and July 2009, a nationally representative face-to-face survey was conducted using the Composite International Diagnostic Interview 3.0 among 6,646 subjects aged 18-64. Trends in 12-month prevalence of mental disorders were examined with these data and NEMESIS-1 data from 1996 (n = 7,076). RESULTS: Lifetime prevalence estimates in NEMESIS-2 were 20.2% for mood, 19.6% for anxiety, 19.1% for substance use disorder and 9.2% for impulse-control disorder. For 12-month disorders, these figures were 6.1, 10.1, 5.6 and 2.1%, respectively. Between 1996 and 2007-2009, the 12-month prevalence of anxiety and substance use disorder did not change. The prevalence of mood disorder decreased slightly but lost significance after controlling for differences in sociodemographic variables between the two studies. CONCLUSION: This study shows that in the Netherlands mental disorders are prevalent. In about a decade, no clear change in mental health status was found.

An updated global picture of cigarette smoking persistence among adults.

BACKGROUND: Cross-national variance in smoking prevalence is relatively well documented. The aim of this study is to estimate levels of smoking persistence across 21 countries with a hypothesized inverse relationship between country income level and smoking persistence. METHODS: Data from the World Health Organization World Mental Health Survey Initiative were used to estimate cross-national differences in smoking persistence--the proportion of adults who started to smoke and persisted in smoking by the date of the survey. RESULTS: There is large variation in smoking persistence from 25% (Nigeria) to 85% (China), with a random-effects meta-analytic summary estimate of 55% with considerable cross-national variation. (Cochran's heterogeneity Q statistic = 6845; p < 0.001). Meta-regressions indicated that observed differences are not attributable to differences in country's income level, age distribution of smokers, or how recent the onset of smoking began within each country. CONCLUSION: While smoking should remain an important public health issue in any country where smokers are present, this report identifies several countries with higher levels of smoking persistence (namely, China and India).

The disease burden of childhood adversities in adults: a population-based study.

OBJECTIVES: There is much evidence showing that childhood adversities have considerable effects on the mental and physical health of adults. It could be assumed therefore, that the disease burden of childhood adversities is high. It has not yet been examined, however, whether this is true. METHOD: We used data of a large representative sample (N=7,076) of the general population in the Netherlands. We calculated the disability weight (DW) for each respondent. The DW is a weight factor that reflects the severity of a disease or condition on a scale from 0 (perfect health) to 1 (equivalent to death). We used an algorithm based on the SF-6D to estimate DW. Because the DW indicates the proportion of a healthy life year that is reduced by the specific health state of the individual, it also possible to calculate the total number of years lost due to disability (YLD) in the population. We calculated the years lived with disability (YLD) for 9 different childhood adversities (in the areas of parental psychopathology; abuse and neglect; major life events), as well as for major categories of mental disorders and general medical disorders. RESULTS: All 9 adversities resulted in a significantly increased DW, except death of a parent before the age of 16. Adversities in the category of abuse and neglect are associated with the highest DWs (0.057), followed by parental psychopathology (0.031) and life events during childhood (0.012). All adversities (46.4% of the population reports one or more adversity) are associated with 20.7 YLD/1,000, which is more than all mental disorders together (12.9 YLD/1,000). The category of abuse/neglect has the highest YLD/1,000 (15.8), which is also higher than all mental disorders together. Adjustment for the presence of mental and general medical disorders resulted in comparable outcomes. CONCLUSIONS: Childhood adversities are more important from a public health point of view than all common mental disorders together, and should be a priority for public health interventions.

Cross-national epidemiology of DSM-IV major depressive episode.

BACKGROUND: Major depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative. METHODS: Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults. RESULTS: The average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed. CONCLUSIONS: MDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.

Treatment of suicidal people around the world.

BACKGROUND: Suicide is a leading cause of death worldwide; however, little information is available about the treatment of suicidal people, or about barriers to treatment. AIMS: To examine the receipt of mental health treatment and barriers to care among suicidal people around the world. METHOD: Twenty-one nationally representative samples worldwide (n=55 302; age 18 years and over) from the World Health Organization's World Mental Health Surveys were interviewed regarding past-year suicidal behaviour and past-year healthcare use. Suicidal respondents who had not used services in the past year were asked why they had not sought care. RESULTS: Two-fifths of the suicidal respondents had received treatment (from 17% in low-income countries to 56% in high-income countries), mostly from a general medical practitioner (22%), psychiatrist (15%) or non-psychiatrist (15%). Those who had actually attempted suicide were more likely to receive care. Low perceived need was the most important reason for not seeking help (58%), followed by attitudinal barriers such as the wish to handle the problem alone (40%) and structural barriers such as financial concerns (15%). Only 7% of respondents endorsed stigma as a reason for not seeking treatment. CONCLUSIONS: Most people with suicide ideation, plans and attempts receive no treatment. This is a consistent and pervasive finding, especially in low-income countries. Improving the receipt of treatment worldwide will have to take into account culture-specific factors that may influence the process of help-seeking.