Civilians in World War II and DSM-IV mental disorders: results from the World Mental Health Survey Initiative.

PURPOSE: Understanding the effects of war on mental disorders is important for developing effective post-conflict recovery policies and programs. The current study uses cross-sectional, retrospectively reported data collected as part of the World Mental Health (WMH) Survey Initiative to examine the associations of being a civilian in a war zone/region of terror in World War II with a range of DSM-IV mental disorders. METHODS: Adults (n = 3370) who lived in countries directly involved in World War II in Europe and Japan were administered structured diagnostic interviews of lifetime DSM-IV mental disorders. The associations of war-related traumas with subsequent disorder onset-persistence were assessed with discrete-time survival analysis (lifetime prevalence) and conditional logistic regression (12-month prevalence). RESULTS: Respondents who were civilians in a war zone/region of terror had higher lifetime risks than other respondents of major depressive disorder (MDD; OR 1.5, 95% CI 1.1, 1.9) and anxiety disorder (OR 1.5, 95% CI 1.1, 2.0). The association of war exposure with MDD was strongest in the early years after the war, whereas the association with anxiety disorders increased over time. Among lifetime cases, war exposure was associated with lower past year risk of anxiety disorders (OR 0.4, 95% CI 0.2, 0.7). CONCLUSIONS: Exposure to war in World War II was associated with higher lifetime risk of some mental disorders. Whether comparable patterns will be found among civilians living through more recent wars remains to be seen, but should be recognized as a possibility by those projecting future needs for treatment of mental disorders.

Growing up in the shadow of Chornobyl: adolescents' risk perceptions and mental health.

PURPOSE: Despite long-term research on risk perceptions of adults after ecological disasters, little is known about the legacy for the generation exposed to toxic elements as infants. This study examined Chornobyl-related risk perceptions and their relationship to mental health in adolescents raised in Kyiv in the aftermath of the accident. METHODS: Risk perceptions, 12-month DSM-IV major depression (MDD)/generalized anxiety disorder (GAD), and current symptomatology were examined in 265 evacuee adolescents, 261 classmate controls, and 327 population-based controls 19 years after the accident. Competing risk factors, including maternal risk perceptions and MDD/GAD, were taken into account. RESULTS: Significantly more evacuees (48.7%) than controls (33.4-40.0%) reported at least one negative perception of Chornobyl; 18.1% of evacuees versus 10.0-12.8% of controls reported 2-4. In contrast, 75.7% of evacuee mothers versus 34.8-37.6% of controls endorsed 2-4 negative perceptions. In the unadjusted analyses, adolescents' perceptions were associated with both MDD/GAD and symptomatology. After adjusting for competing risk factors, their perceptions were associated with symptomatology only (p < 0.01). Among the competing risk factors, gender, self-esteem, life events, and peer support were significantly associated with MDD/GAD. These measures, along with quality of parental communication, father belligerence when drunk, and maternal MDD/GAD, were significantly associated with symptoms. CONCLUSIONS: More evacuee teens reported negative risk perceptions than controls, but these perceptions were only modestly associated with mental health. Instead, the strongest risk factors comported with epidemiologic studies conducted in other parts of the world. Research is needed to determine whether children raised in the aftermath of other ecological disasters demonstrate similar resilience.

Subjective health legacy of the Chornobyl accident: a comparative study of 19-year olds in Kyiv.

BACKGROUND: Since the Chornobyl accident in 1986, the physical health of exposed children in Ukraine has been monitored, but their perceived health has not been studied. This study examines health perceptions of Ukrainian adolescents exposed to radioactive fallout in utero or as infants, and the epidemiologic and Chornobyl-related influences on self-reported health. METHOD: We assessed three groups of 19-year olds in Kyiv: 262 evacuees from contaminated areas near the plant; 261 classmate controls; and 325 population-based controls. The evacuees and classmates were previously assessed at age 11. Structured interviews were conducted with the adolescents and their mothers (N = 766), followed by general physical examinations (N = 722) and blood tests (N = 707). Proportional odds logistic regression and multi-group path analysis were the major statistical tests. RESULTS: The examination and blood test results were similar across groups except for a significantly elevated rate of thyroid enlargement found by palpation in evacuees (17.8%) compared former classmates (8.7%) and population-based controls (8.0%). In addition, four evacuees and one population control had had a thyroidectomy. Compared to controls, the evacuees rated their health the least positively and reported more medically diagnosed illnesses during the 5 years preceding the interview, particularly thyroid disease, migraine headache, and vascular dystony. The consistent risk factors (p < 0.001) for these subjective health reports were evacuee status, female gender, multiple hospitalizations, and health risk perception regarding Chornobyl. All three groups of mothers rated their children's health more negatively than the adolescents themselves, and maternal ratings were uniquely associated with the adolescents' health reports in the adjusted models. In the longitudinal evacuee and classmate subsamples, path analysis showed that mothers' health ratings when the children were age 11 predicted their later evaluations which in turn were associated with the adolescent self-reports. CONCLUSION: The more negative self-evaluations of the evacuees were linked to a number of risk factors, including multiple hospitalizations, health risk perceptions, and epidemiologic risk factors. The increased rate of thyroid cancer and other diagnoses no doubt contributed to the evacuees' less positive subjective health. The strong effect of the mothers' perceptions argues in favor of developing risk communication programs for families rather than for mothers or adolescents as separate target groups.

Determinants of participation in a longitudinal two-stage study of the health consequences of the Chornobyl nuclear power plant accident.

BACKGROUND: The determinants of participation in long-term follow-up studies of disasters have rarely been delineated. Even less is known from studies of events that occurred in eastern Europe. We examined the factors associated with participation in a longitudinal two-stage study conducted in Kyiv following the 1986 Chornobyl nuclear power plant accident. METHODS: Six hundred child-mother dyads (300 evacuees and 300 classmate controls) were initially assessed in 1997 when the children were 11 years old, and followed up in 2005-6 when they were 19 years old. A population control group (304 mothers and 327 children) was added in 2005-6. Each assessment point involved home interviews with the children and mothers (stage 1), followed by medical examinations of the children at a clinic (stage 2). Background characteristics, health status, and Chornobyl risk perceptions were examined. RESULTS: The participation rates in the follow-up home interviews were 87.8% for the children (88.6% for evacuees; 87.0% for classmates) and 83.7% for their mothers (86.4% for evacuees and 81.0% for classmates). Children's and mothers' participation was predicted by one another's study participation and attendance at the medical examination at time 1. Mother's participation was also predicted by initial concerns about her child's health, greater psychological distress, and Chornobyl risk perceptions. In 1997, 91.2% of the children had a medical examination (91.7% of evacuees and 90.7% of classmates); in 2005-6, 85.2% were examined (83.0% of evacuees, 87.7% of classmates, 85.0% of population controls). At both times, poor health perceptions were associated with receiving a medical examination. In 2005-6, clinic attendance was also associated with the young adults' risk perceptions, depression or generalized anxiety disorder, lower standard of living, and female gender. CONCLUSION: Despite our low attrition rates, we identified several determinants of selective participation consistent with previous research. Although evacuee status was not associated with participation, Chornobyl risk perceptions were strong predictors of mothers' follow-up participation and attendance at the medical examinations. Understanding selective participation offers valuable insight for future longitudinal disaster studies that integrate psychiatric and medical epidemiologic research.

Descriptive epidemiology of intimate partner aggression in Ukraine.

AIMS: Partner aggression is believed to be widespread in Eastern Europe although systematic evidence is sparse. Using data from the World Mental Health (WMH) survey in Ukraine, we present the first population-based findings on the descriptive epidemiology of partner aggression among married adults. METHODS: Married men (n = 558) and women (n = 558) were interviewed with the WMH-Composite International Diagnostic Interview (WMH-CIDI) module assessing aggression in the marriage. Risk factors included demographic characteristics, witnessing parental aggression, early onset and adult episodes of DSM-IV psychiatric and alcohol disorders, and marital problem severity. RESULTS: More women than men reported aggression by their spouse in the past year (12.7 vs. 5.8%) or ever in the marriage (20.1 vs. 8.6%), while ~11 and 19% of both sexes behaved aggressively against their spouse in these time periods. Among men, the unique risk factors for behaving aggressively were being married once, witnessing parental violence, early onset alcohol abuse, and intermittent explosive disorders (IED); the risk factors for reporting that their wives were aggressive were early onset alcohol abuse, IED and marital problems. Among women, the risk factors for behaving aggressively were younger age, unemployment, living in a rural area, early onset alcohol abuse, mood/anxiety disorders, and marital problems; the risk factors for reporting that their husbands behaved aggressively were younger age, early onset alcohol abuse, and marital problems. CONCLUSIONS: Partner aggression is a significant public health issue in Ukraine predicted by alcohol abuse and IED before and after age 20 for men and women.

Somatic symptoms in women 11 years after the Chornobyl accident: prevalence and risk factors.

Exposure to the Chornobyl nuclear power plant explosion resulted in widespread, persistent somatic complaints, but little is known about the nature and risk factors for these conditions. This study compares the health reports of 300 women evacuated to Kyiv from the contamination zone around the plant and 300 controls with a child in the same homeroom as the evacuees in 1997. The interview addressed somatic concerns, risk factors for poor health, and Chornobyl-related stress. Compared with controls, evacuees reported significantly more health problems and rated their health more poorly overall. These differences remained significant after controlling for demographic and clinical risk factors, including the tendency to amplify physical symptoms. Significantly more evacuees received a diagnosis of a Chornobyl-related illness by a local physician, believed that their health and their children's health had been adversely affected, and were positive for Chornobyl-induced post-traumatic stress disorder. After controlling for these Chornobyl stress variables, the differences in number of health problems commonly attributed to Chornobyl remained significant but differences in general health ratings did not. The perceptions of controls were similar to those of women in a national sample. The relationship between Chornobyl stress and illness was twice as strong in evacuees (odds ratio = 6.95) as in Kyiv controls (odds ratio = 3.34) and weakest in the national sample (odds ratio = 1.64). The results confirm the persistence and nonspecificity of the subjective medical consequences of Chornobyl and are consistent with the hypothesis that traumatic events exert their greatest negative impacts on health in vulnerable or disadvantaged groups.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.

CONTEXT: Little is known about the extent or severity of untreated mental disorders, especially in less-developed countries. OBJECTIVE: To estimate prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders in 14 countries (6 less developed, 8 developed) in the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative. DESIGN, SETTING, AND PARTICIPANTS: Face-to-face household surveys of 60 463 community adults conducted from 2001-2003 in 14 countries in the Americas, Europe, the Middle East, Africa, and Asia. MAIN OUTCOME MEASURES: The DSM-IV disorders, severity, and treatment were assessed with the WMH version of the WHO Composite International Diagnostic Interview (WMH-CIDI), a fully structured, lay-administered psychiatric diagnostic interview. RESULTS: The prevalence of having any WMH-CIDI/DSM-IV disorder in the prior year varied widely, from 4.3% in Shanghai to 26.4% in the United States, with an interquartile range (IQR) of 9.1%-16.9%. Between 33.1% (Colombia) and 80.9% (Nigeria) of 12-month cases were mild (IQR, 40.2%-53.3%). Serious disorders were associated with substantial role disability. Although disorder severity was correlated with probability of treatment in almost all countries, 35.5% to 50.3% of serious cases in developed countries and 76.3% to 85.4% in less-developed countries received no treatment in the 12 months before the interview. Due to the high prevalence of mild and subthreshold cases, the number of those who received treatment far exceeds the number of untreated serious cases in every country. CONCLUSIONS: Reallocation of treatment resources could substantially decrease the problem of unmet need for treatment of mental disorders among serious cases. Structural barriers exist to this reallocation. Careful consideration needs to be given to the value of treating some mild cases, especially those at risk for progressing to more serious disorders.

Psychological well-being and risk perceptions of mothers in Kyiv, Ukraine, 19 years after the Chornobyl disaster.

BACKGROUND: The Chornobyl nuclear power plant explosion in April 1986 was one of the worst ecological disasters of the 20th century. As with most disasters, its long-term mental health consequences have not been examined. AIMS: This study describes the psychological well-being and risk perceptions of exposed women 19-20 years later and the risk factors associated with mental health. METHODS: We assessed Chornobyl-related post-traumatic stress disorder (PTSD), major depressive episode (MDE) and overall distress among three groups of women in Kyiv, Ukraine (N = 797): mothers of small children evacuated to Kyiv in 1986 from the contaminated area near the plant (evacuees); mothers of their children's classmates (neighbourhood controls); and population-based controls from Kyiv. Risk perceptions and epidemiologic correlates were also obtained. RESULTS: Evacuees reported poorer well-being and more negative risk perceptions than controls. Group differences in psychological well-being remained after adjustment for epidemiologic risk factors but became non-significant when Chornobyl risk perceptions were added to the models. CONCLUSIONS: The relatively poorer psychological well-being among evacuees is largely explained by their continued concerns about the physical health risks stemming from the accident. We suggest that this is due to the long-term, non-resolvable nature of health fears associated with exposure.

Cross-national prevalence and risk factors for suicidal ideation, plans and attempts.

BACKGROUND: Suicide is a leading cause of death worldwide; however, the prevalence and risk factors for the immediate precursors to suicide - suicidal ideation, plans and attempts - are not wellknown, especially in low- and middle-income countries. AIMS: To report on the prevalence and risk factors for suicidal behaviours across 17 countries. METHOD: A total of 84 850 adults were interviewed regarding suicidal behaviours and socio-demographic and psychiatric risk factors. RESULTS: The cross-national lifetime prevalence of suicidal ideation, plans, and attempts is 9.2% (s.e.=0.1), 3.1% (s.e.=0.1), and 2.7% (s.e.=0.1). Across all countries, 60% of transitions from ideation to plan and attempt occur within the first year after ideation onset. Consistent cross-national risk factors included being female, younger, less educated, unmarried and having a mental disorder. Interestingly, the strongest diagnostic risk factors were mood disorders in high-income countries but impulse control disorders in low- and middle-income countries. CONCLUSION: There is cross-national variability in the prevalence of suicidal behaviours, but strong consistency in the characteristics and risk factors for these behaviours. These findings have significant implications for the prediction and prevention of suicidal behaviours.

Suicide ideation, plans and attempts in Ukraine: findings from the Ukraine World Mental Health Survey.

BACKGROUND: Because the suicide rates in Eastern Europe have increased, the epidemiology of suicide behaviors in this part of the world is in urgent need of study. Using data from the Ukraine site of the World Mental Health (WMH) Survey Initiative, we present the first population-based findings from a former Soviet country on the descriptive epidemiology of suicide ideation, plans and attempts, and their links to current functioning and service utilization. METHOD: In 2002, a nationally representative sample of 4725 adults in Ukraine was interviewed with the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Risk factors included demographic characteristics, trauma, smoking, and parental and personal psychiatric disorders. Current functional impairments and recent service utilization were assessed. RESULTS: The lifetime prevalence of suicide ideation was 8.2%. The average age of onset was 31. The key risk factors were female sex, younger age, trauma, parental depression, and prior alcohol, depressive and intermittent explosive disorders, especially the presence of co-morbidity. Ideators had poorer functioning and greater use of health services. One-third of ideators had a plan, and one-fifth made an attempt. Among ideators, young age, smoking and prior psychiatric disorders were risk factors for these behaviors. CONCLUSIONS: Together with the increasing suicide rate, these results suggest that suicide intervention programs in Ukraine should focus on the generation of young adults under 30. The associations with co-morbidity, impairments in current functioning and greater service use indicate that a physician education program on suicidality should be comprehensive in scope and a public health priority in Ukraine.

Smoking initiation and nicotine dependence symptoms in Ukraine: findings from the Ukraine World Mental Health survey.

OBJECTIVES: Cigarette smoking is a major cause of morbidity and mortality in former Soviet countries. This study examined the personal, familial and psychiatric risk factors for smoking initiation and development of nicotine dependence symptoms in Ukraine. STUDY DESIGN: Cross-sectional survey. METHODS: Smoking history and dependence symptoms were ascertained from N=1711 adults in Ukraine as part of a national mental health survey conducted in 2002. Separate analyses were conducted for men and women. RESULTS: The prevalence of lifetime regular smoking was 80.5% in men and 18.7% in women, with median ages at initiation among smokers of 17 and 18, respectively. Furthermore, 61.2% of men and 11.9% of women were current smokers; among the subgroup of lifetime smokers, 75.9% of men and 63.1% of women currently smoked. The youngest female cohort (born 1965-1984) was 26 times more likely to start smoking than the oldest. Smoking initiation was also linked to childhood externalizing behaviors and antecedent use of alcohol in both genders, as well as marital status and personal alcohol abuse in men, and childhood urbanicity and birth cohort in women. Dependence symptoms developed in 61.7% of male and 47.1% of female smokers. The rate increased sharply in the first four years after smoking initiation. Dependence symptoms were related to birth cohort and alcohol abuse in both genders, as well as growing up in a suburb or town and childhood externalizing behaviors in men, and parental antisocial behavior in women. CONCLUSIONS: Increased smoking in young women heralds a rising epidemic in Ukraine and underscores the need for primary prevention programs, especially in urban areas. Our findings support the importance of childhood and alcohol-related risk factors, especially in women, while pre-existing depression and anxiety disorders were only weakly associated with starting to smoke or developing dependence symptoms.

Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative.

Data are presented on the lifetime prevalence, projected lifetime risk, and age-of-onset distributions of mental disorders in the World Health Organization (WHO)'s World Mental Health (WMH) Surveys. Face-to-face community surveys were conducted in seventeen countries in Africa, Asia, the Americas, Europe, and the Middle East. The combined numbers of respondents were 85,052. Lifetime prevalence, projected lifetime risk, and age of onset of DSM-IV disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI), a fully-structured lay administered diagnostic interview. Survival analysis was used to estimate lifetime risk. Median and inter-quartile range (IQR) of age of onset is very early for some anxiety disorders (7-14, IQR: 8-11) and impulse control disorders (7-15, IQR: 11-12). The age-of-onset distribution is later for mood disorders (29-43, IQR: 35-40), other anxiety disorders (24-50, IQR: 31-41), and substance use disorders (18-29, IQR: 21-26). Median and IQR lifetime prevalence estimates are: anxiety disorders 4.8-31.0% (IQR: 9.9-16.7%), mood disorders 3.3-21.4% (IQR: 9.8-15.8%), impulse control disorders 0.3-25.0% (IQR: 3.1-5.7%), substance use disorders 1.3-15.0% (IQR: 4.8-9.6%), and any disorder 12.0-47.4% (IQR: 18.1-36.1%). Projected lifetime risk is proportionally between 17% and 69% higher than estimated lifetime prevalence (IQR: 28-44%), with the highest ratios in countries exposed to sectarian violence (Israel, Nigeria, and South Africa), and a general tendency for projected risk to be highest in recent cohorts in all countries. These results document clearly that mental disorders are commonly occurring. As many mental disorders begin in childhood or adolescents, interventions aimed at early detection and treatment might help reduce the persistence or severity of primary disorders and prevent the subsequent onset of secondary disorders.

Psychiatry in Ukraine.

Ukraine, at 603 700 km2, has the second largest landmass in Europe. It has a population of about 47.4 million. Ukraine is a lower-middle-income country with a gross national income per capita of US$1260 (World Bank, 2002).

Epidemiology of heavy alcohol use in Ukraine: findings from the world mental health survey.

AIMS: To describe the epidemiology of heavy alcohol use in Ukraine, using data from the world mental health (WMH) survey in Ukraine. METHODS: The WMH composite international diagnostic interview was administered in 2002 to a national probability sample of Ukrainian adults (n=4725). An algorithm for classifying heavy use in the past year was developed from self-reports about the quantity and frequency of drinking, and its convergent validity was demonstrated. Prevalence rates and socio-demographic risk factors were examined separately for men and women. RESULTS: The 12-month rates of heavy alcohol use were 38.7% in men and 8.5% in women (22.0% overall). Among heavy alcohol users, 92% of men and 52% of women consumed at least 80 g of ethanol in a typical drinking day on a monthly basis in the year before the interview. The most significant risk factors in men and women were age (26-54 years for men; 18-25 years for women), living in the Southeast region, being in the labour force whether employed or unemployed, and for men, low education and being the father of a young child. A highly significant linear relationship of number of risk factors with heavy alcohol use was found for both sexes. CONCLUSIONS: The rates for men were similar to those reported in a Russian national survey with the exception of Southeast Ukraine where the rate was >10% higher. The highest rates were among men who were middle-aged, fathers and unemployed. Future prospective studies are needed to assess the impact of heavy alcohol use on Ukrainian health, mental health and occupational and social functioning.

Epidemiology of psychiatric and alcohol disorders in Ukraine: findings from the Ukraine World Mental Health survey.

BACKGROUND: This study presents the lifetime, 12-month, and 1-month prevalence estimates of nine psychiatric and alcohol disorders in Ukraine assessed as part of the World Health Organization (WHO) World Mental Health (WMH) research program. The Ukraine WMH survey is the first psychiatric epidemiologic study in a former Soviet Union country to administer a structured psychiatric interview to a nationally representative sample. METHOD: In 2002, a national probability sample of 4,725 respondents ages 18 and older were interviewed with the WMH version of the Composite International Diagnostic Interview (WMH-CIDI). Prevalence estimates, age-of-onset curves, comorbidity, demographic and geographic risk factors, and treatment seeking were examined. RESULTS: Close to one third of the population experienced at least one Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) disorder in their lifetime, 17.6% experienced an episode in the past year, and 10.6% had a current disorder. There was no gender difference in the overall prevalence rates. In men, the most common diagnoses were alcohol disorders (26.5% lifetime) and mood disorders (9.7% lifetime); in women, they were mood disorders (20.8% lifetime) and anxiety disorders (7.9% lifetime). The odds ratios for most pairs of disorders were highly significant. Age of onset was primarily in the teens and early 20s. Age, education, and living in the Eastern region of Ukraine were significant risk factors across disorders, with respondents older than 50 years having the highest prevalence of mood disorder and the lowest prevalence of alcoholism and intermittent explosive disorder. Only a minority of respondents talked to a professional about their symptoms. CONCLUSION: Prevalence estimates of alcoholism among men and recent depression among women were higher in Ukraine than in comparable European surveys. The results argue for the need to develop and implement educational programs focused on the recognition and treatment of mental and alcohol disorders for the general population, psychiatrists, and general medical providers, who are the main source of mental health care.