Receiving threatening or obscene messages from a partner and mental health, self-harm and suicidality: results from the Adult Psychiatric Morbidity Survey.

PURPOSE: Threatening or obscene messaging is repeated, unwanted texts, emails, letters or cards experienced by the recipient as threatening or obscene, and causing fear, alarm or distress. It is rarely examined as an aspect of intimate partner violence. We describe the prevalence of exposure to threatening/obscene messaging from a current or ex-partner; characteristics of victims; and associations with other forms of violence and abuse, mental disorder, self-harm, and suicidality. METHODS: Cross-sectional probability-sample survey of the general population in England aged 16 + . Multivariable regression modelling tested associations between receipt of threatening/obscene messaging and current common mental disorder, past-year self-harm and suicidality. RESULTS: Threatening/obscene messages were received from a current/ex-partner by 6.6% (95%CI: 5.9-7.3) of adults who had been in a relationship; 1.7% received these in the past year. Victims were more likely to be female, under 35, single or divorced, socioeconomically disadvantaged, and to have experienced other forms of sexual and partner violence and abuse. Those who received threatening/obscene messages in the past year were more likely to experience common mental disorder (adjusted odds ratio 1.89; 1.01-3.55), self-harm (2.31; 1.00-5.33), and suicidal thoughts (2.00; 1.06-3.78). CONCLUSION: Threatening/obscene messaging commonly occurs in the context of intimate partner violence. While often occurring alongside sexual and physical violence, messaging has an additional association with mental disorder and suicidality. Routine enquiry in service settings concerning safety, including those working with people who have escaped domestic violence, should ask about ongoing contact from previous as well as current partners. This should include asking about messaging, as well as other forms of potentially technology-enabled abuse which may become increasingly common.

Innovations in community-based mental health care: an overview of meta-analyses.

In the last four decades, mental health services for people with Severe Mental Illness (SMI) have seen asylums replaced by a balanced model of Community Mental Healthcare (CMH). Innovative approaches and strategies in the field of CMH have been extensively researched. However, this research has been hampered by issues limiting their capacity to inform clinicians and policymakers. We conducted an overview of meta-analyses of the effectiveness of innovative CMH models focussing on clinical and psychosocial outcomes in comparisons with standard care in adults with SMI. Based on the 12 eligible studies, we appraised, synthesised and graded the resulting evidence. There was moderate quality evidence that case management, Early Intervention Services (EIS) and caregiver-directed interventions were superior to standard care in reducing hospital admission. In relation to psychosocial outcomes, EIS showed high quality evidence of a small effect on global functioning. There was moderate quality evidence for a similar effect of Intensive Case Management, and for a large effect of family intervention. For quality of life, both EIS and self-management education had a small effect, with moderate quality. The level of research about effective CMH models is therefore substantial. However, several gaps related to innovative CMH not yet covered in meta-analytic synthesis, need to be filled.

The mental health of ex-prisoners: analysis of the 2014 English National Survey of Psychiatric Morbidity.

PURPOSE: Prisoners experience extremely high rates of psychiatric disturbance. However, ex-prisoners have never previously been identified in representative population surveys to establish how far this excess persists after release. Our purpose was to provide the first community-based estimate of ex-prisoners' mental health in England using the data from the 2014 Adult Psychiatric Morbidity Survey (APMS). METHODS: APMS 2014 provides cross-sectional data from a random sample (N = 7546) of England's household population aged 16 or above. Standardised instruments categorised psychiatric disorders and social circumstances. Participants who had been in prison were compared with the rest of the sample. RESULTS: One participant in seventy had been in prison (1.4%; 95% CI 1.1-1.7; n = 103). Ex-prisoners suffered an excess of current psychiatric problems, including common mental disorders (CMDs), psychosis, post-traumatic disorder, substance dependence, and suicide attempts. They were more likely to screen positive for attention-deficit/hyperactivity disorder and autistic traits, to have low verbal IQ, and to lack qualifications. They disclosed higher rates of childhood adversity, including physical and sexual abuse and local authority care. The odds (1.88; 95% CI 1.02-3.47) of CMDs were nearly doubled in ex-prisoners, even after adjusting for trauma and current socioeconomic adversity. CONCLUSIONS: Prison experience is a marker of enduring psychiatric vulnerability, identifying an important target population for intervention and support. Moreover, the psychiatric attributes of ex-prisoners provide the context for recidivism. Without effective liaison between the criminal justice system and mental health services, the vulnerability of ex-prisoners to relapse and to reoffending will continue, with consequent personal and societal costs.

Revisiting the one in four: the prevalence of psychiatric disorder in the population of England 2000-2014.

Mental health problems are often said to affect one in four people in Britain, although with no consistent explanation of what the figure includes. We used three English national population surveys of psychiatric morbidity from 2000, 2007 and 2014 to provide prevalence rates for recent psychiatric problems. We combined disorders progressively to demonstrate the effects of cumulation. Psychosis had a prevalence of around 1%, severe common mental disorders added about 8%, and including less-severe common mental disorders gave a value around one in six. The figure of one in four required the inclusion of various other disorders. These values were strikingly stable over the surveys.

The prevalence of metabolic syndrome in people with severe mental illness: a mediation analysis.

BACKGROUND: People with severe mental illness (SMI) generally have high rates of metabolic syndrome (MetS). Proposed explanations remain conjectural. Relatively little is known about Mets in SMI in Southern Europe, an area with generally healthy dietary traditions. PURPOSE: To establish prevalence rates of MetS in an Italian sample, and testing hypotheses about putative reasons for the excess in the SMI group. METHODS: We compared the prevalence and correlates of MetS in inpatients with SMI and controls randomly chosen from patients undergoing routine maxillofacial surgery. We employed formal tests of mediation. RESULTS: The MetS prevalence rate was 26.1 % in the SMI group and 15.9 % in the comparison group. After controlling for age, people with SMI were three times more likely to have MetS than their non-SMI counterparts. Smoking and a family history of cardiovascular disease were strongly related to MetS in both groups. However, these factors could not explain the excess of MetS in the SMI group, and we found no effect of antipsychotic dose. CONCLUSIONS: SMI remained prominent in increasing the likelihood of MetS in this low prevalence population, and putative determinants of MetS were common to people with SMI and to controls. Explanations for high MetS rates in SMI may lie in health behaviours other than smoking.

The structure of paranoia in the general population.

BACKGROUND: Psychotic phenomena appear to form a continuum with normal experience and beliefs, and may build on common emotional interpersonal concerns. AIMS: We tested predictions that paranoid ideation is exponentially distributed and hierarchically arranged in the general population, and that persecutory ideas build on more common cognitions of mistrust, interpersonal sensitivity and ideas of reference. METHOD: Items were chosen from the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) questionnaire and the Psychosis Screening Questionnaire in the second British National Survey of Psychiatric Morbidity (n = 8580), to test a putative hierarchy of paranoid development using confirmatory factor analysis, latent class analysis and factor mixture modelling analysis. RESULTS: Different types of paranoid ideation ranged in frequency from less than 2% to nearly 30%. Total scores on these items followed an almost perfect exponential distribution (r = 0.99). Our four a priori first-order factors were corroborated (interpersonal sensitivity; mistrust; ideas of reference; ideas of persecution). These mapped onto four classes of individual respondents: a rare, severe, persecutory class with high endorsement of all item factors, including persecutory ideation; a quasi-normal class with infrequent endorsement of interpersonal sensitivity, mistrust and ideas of reference, and no ideas of persecution; and two intermediate classes, characterised respectively by relatively high endorsement of items relating to mistrust and to ideas of reference. CONCLUSIONS: The paranoia continuum has implications for the aetiology, mechanisms and treatment of psychotic disorders, while confirming the lack of a clear distinction from normal experiences and processes.

Influence of intrinsic and extrinsic religiosity on youth cannabis use: A structural equation modelling analysis on national survey on drug use and health (NSDUH) 2015-2019.

Religiosity may reduce the risk of substance use in adults and young people. However, religiosity is a complex construct, variously defined and assessed. We explored the role of different religious components: intrinsic (subjective), extrinsic-personal (service attendance) and extrinsic-social (church-based social activities) in deterring cannabis use among adolescents. Combining several years (2015-2019) of NSDUH data on 68,263 adolescents between 12 and 17 years, a structural equation modelling (SEM) approach was used to evaluate pathways from intrinsic and extrinsic components of religiosity to cannabis use. We analyzed the role of several covariates, including comorbid depression and secular volunteering activities. About 15% of participants said they had used cannabis at some level in the previous year. Some degree of intrinsic and of extrinsic-personal religiosity was reported by 66% and 25% of the sample. 57% were committed to at least one faith-based activity, while 74% reported participation in non-faith-based community activities. The SEM regression model -controlling for putative confounders- showed that both intrinsic and extrinsic-personal religious components reduced the likelihood of cannabis use (Cannabis use coeff.: -0.065, p = 0.001; coeff.: -0.176, p < 0.001, respectively). However, the extrinsic-social component had no effect on refraining from cannabis use, despite involvement in non-faith based volunteering activities was protectively associated. Support for secular volunteering programs may be a cost-effective mechanism for reducing cannabis use. Moreover, whilst promoting religiosity is beyond the scope of any preventive programs, religious practices should be considered relevant protective factors, deserving consideration and support in terms of public health.

A real-world study of the effectiveness of DBT in the UK National Health Service.

OBJECTIVES: Dialectical behavioral therapy (DBT) has gained widespread popularity as a treatment for borderline personality disorder (BPD), and its efficacy has been demonstrated in several trials. The aim of this study was to evaluate the effectiveness of DBT delivered by staff with a level of training readily achievable in National Health Service care settings for individuals with a Cluster B personality disorder. DESIGN: Randomized control trial methodology was used to compare DBT to treatment as usual (TAU). METHOD: Forty-two participants entered the trial. Diagnostic and outcome measures were undertaken at assessment, at 6 months, and at 1 year. The clinical outcomes in routine evaluation--outcome measure (CORE-OM) were utilized as the primary outcome measure. RESULTS: Both the DBT and TAU groups improved on the range of measures employed. The DBT group showed a slightly greater decrease in CORE-OM risk scores, suicidality, and post-traumatic stress disorder symptom severity. However, the TAU group showed comparable reductions in all measures and a larger decrease in para-suicidal behaviours and risk. CONCLUSIONS: DBT may be an effective treatment delivered by community outpatient services for individuals with a Cluster B personality disorder. Further studies are needed to consider the impact of experience and adherence to DBT in improving outcome.

Intimate partner violence, suicidality, and self-harm: a probability sample survey of the general population in England.

BACKGROUND: Intimate partner violence (IPV) is a recognised risk factor for psychiatric disorders. There is little current evidence on IPV and self-harm and suicidality, and we therefore aimed to investigate the associations between experience of lifetime and past-year IPV with suicidal thoughts, suicide attempt, and self-harm in the past year. METHODS: We analysed the 2014 Adult Psychiatric Morbidity Survey, a cross-sectional survey of 7058 adults (aged ≥16 years) in England, which used a multistage random probability sampling design and involved face-to-face interviews. Participants were asked about experience of physical violence and sexual, economic, and emotional abuse from a current or former partner, and about suicidal thoughts, suicide attempts, and self-harm. Other adversities were recorded through an adapted version of the List of Threatening Experiences. Multivariable logistic regression models quantified associations between different indicators of lifetime and past-year IPV, with past-year non-suicidal self-harm, suicidal thoughts, and suicide attempts. All analyses were weighted. FINDINGS: Using weighted percentages, we found that a fifth (21·4%) of 7058 adults reported lifetime experience of IPV, and that 27·2% of women and 15·3% of men had experienced IPV. Among women, 19·6% had ever experienced emotional IPV, 18·7% physical IPV, 8·5% economic IPV, and 3·7% sexual IPV, which was higher than in men (8·6%, 9·3%, 3·6%, and 0·3%, respectively). Findings for ethnicity were unclear. Lifetime prevalence of IPV was higher in those living in rented accommodation or deprived neighbourhoods. Among people who had attempted suicide in the past year, 49·7% had ever experienced IPV and 23·1% had experienced IPV in the past year (including 34·8% of women and 9·4% of men). After adjusting for demographics, socioeconomics, and lifetime experience of adversities, the odds ratio of a past-year suicide attempt were 2·82 (95% CI 1·54-5·17) times higher in those who have ever experienced IPV, compared with those who had not. Fully adjusted odds ratios for past-year self-harm (2·20, 95% CI 1·37-3·53) and suicidal thoughts (1·85, 1·39-2·46) were also raised in those who had ever experienced IPV. INTERPRETATION: IPV is common in England, especially among women, and is strongly associated with self-harm and suicidality. People presenting to services in suicidal distress or after self-harm should be asked about IPV. Interventions designed to reduce the prevalence and duration of IPV might protect and improve the lives of people at risk of self-harm and suicide. FUNDING: UK Prevention Research Partnership.

Child sexual abuse reported by an English national sample: characteristics and demography.

AIM: The 2007 adult psychiatric morbidity survey in England provides detailed information of high quality about sexual abuse. Given the major psychiatric implications of child sexual abuse (CSA), we aimed to establish its sociodemographic distribution in the general population. METHOD: The experience of sexual abuse was elicited in a random sample of the English household population (N = 7,353), using computer assisted self-completion interviewing. Respondents were handed a laptop, and entered their responses to detailed questions. The interviewer was blind to their responses. CSA was defined as occurring before the age of 16. RESULTS: 2.9% of women and 0.8% of men reported CSA involving non-consensual intercourse, figures that rose to 11.1 and 5.3% if experiences involving sexual touching were included. CSA was common before puberty, but peaked in adolescence. CSA greatly increased the chance in adulthood both of further sexual abuse (OR 10.6; CI 8.9-12.6), and of prostitution (OR 3.3; CI 1.9-5.5). There was no association with ethnicity or social class, but people over 65 were less likely to report CSA. The odds of CSA were doubled in those not brought up with both biological parents until the age of 16. CONCLUSION: CSA is common, particularly in women, and is not the preserve of any particular social group. Its frequency and its association with psychiatric consequences render it a major public health issue.

Direct medical mental health care costs of schizophrenia in France, Germany and the United Kingdom - findings from the European Schizophrenia Cohort (EuroSC).

OBJECTIVES: To quantify and compare the resource consumption and direct costs of medical mental health care of patients suffering from schizophrenia in France, Germany and the United Kingdom. METHODS: In the European Cohort Study of Schizophrenia, a naturalistic two-year follow-up study, patients were recruited in France (N=288), Germany (N=618), and the United Kingdom (N=302). Data about the use of services and medication were collected. Unit cost data were obtained and transformed into United States Dollar Purchasing Power Parities (USD-PPP). Mean service use and costs were estimated using between-effects regression models. RESULTS: In the French/German/UK sample estimated means for a six-month period were respectively 5.7, 7.5 and 6.4 inpatient days, and 11.0, 1.3, and 0.7 day-clinic days. After controlling for age, sex, number of former hospitalizations and psychopathology (CGI score), mean costs were 3700/2815/3352 USD-PPP. CONCLUSIONS: Service use and estimated costs varied considerably between countries. The greatest differences were related to day-clinic use. The use of services was not consistently higher in one country than in the others. Estimated costs did not necessarily reflect the quantity of service use, since unit costs for individual types of service varied considerably between countries.

Prevalence of non-suicidal self-harm and service contact in England, 2000-14: repeated cross-sectional surveys of the general population.

BACKGROUND: The number of people presenting to hospital emergency departments after self-harming has increased in England. However, most people who self-harm do not present to hospitals, so whether this rise reflects an increase in the prevalence of self-harm in the community is unknown. Also unknown is whether the prevalence of non-suicidal self-harm (NSSH) or suicidal self-harm, or both, has increased. We aimed to establish temporal trends in the prevalence of NSSH in England. METHODS: We analysed data from participants in the 2000 (n=7243), 2007 (n=6444), and 2014 (n=6477) Adult Psychiatric Morbidity Surveys of the general population, selecting those aged 16-74 years and living in England. We used weighted data and controlled for complex survey design. We generated temporal trends in lifetime prevalence and methods of, and motivations for, NSSH, and consequent service contact. We used multiple variable logistic regression analyses to investigate factors associated with service contact. FINDINGS: The prevalence of self-reported lifetime NSSH increased from 2·4% (95% CI 2·0-2·8) in 2000, to 6·4% (5·8-7·2) in 2014. Increases in prevalence were noted in both sexes and across age groups-most notably in women and girls aged 16-24 years, in whom prevalence increased from 6·5% (4·2-10·0) in 2000, to 19·7% (15·7-24·5) in 2014. The proportion of the population reporting NSSH to relieve unpleasant feelings of anger, tension, anxiety, or depression increased from 1·4% (95% CI 1·0-2·0) to 4·0% (3·2-5·0) in men and boys, and from 2·1% (1·6-2·7) to 6·8% (6·0-7·8) in women and girls, between 2000 and 2014. In 2014, 59·4% (95% CI 54·7-63·9) of participants who had engaged in NSSH reported no consequent medical or psychological service contact, compared with 51·2% (42·2-60·0) in 2000 and 51·8% (47·3-56·4) in 2007. Male participants and those aged 16-34 years were less likely to have contact with health services than were female participants and older people. INTERPRETATION: The prevalence of NSSH has increased in England, but resultant service contact remains low. In 2014, about one in five female 16-24-year-olds reported NSSH. There are potential lifelong implications of NSSH, such as an increased frequency of suicide, especially if the behaviours are adopted as a long-term coping strategy. Self-harm needs to be discussed with young people without normalising it. Young people should be offered help by primary care, educational, and other services to find safer ways to deal with emotional stress. FUNDING: NHS Digital, English Department of Health and Social Care, and the National Institute for Health Research.

A large-scale validation study of the Medication Adherence Rating Scale (MARS).

Adherence to medication is an important predictor of illness course and outcome in psychosis. The Medication Adherence Rating Scale (MARS) is a ten-item self-report measure of medication adherence in psychosis [Thompson, K., Kulkarni, J., Sergejew, A.A., 2000. Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophrenia Research. 42. 241-247]. Although initial results suggested that the scale has good reliability and validity, the development sample was small. The current study aimed to establish the psychometric properties of the MARS in a sample over four times larger. The scale was administered to 277 individuals with psychosis, along with measures of insight and psychopathology. Medication adherence was independently rated by each individual's keyworker. Results showed the internal consistency of the MARS to be lower than in the original sample, though adequate. MARS total score correlated weakly with keyworker-rated adherence, hence concurrent validity of the scale appeared only moderate to weak. The three factor structure of the MARS was replicated. Examination of the factor scores suggested that the factor 1 total score, which corresponds to the Medication Adherence Questionnaire [Morisky,D.E., Green,L.W. and Levine,D.M., 1986. Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care. 24, 67-74] may be a preferable measure of medication adherence behaviour to the total scale score.

Diabetes, common mental disorders, and disability: findings from the UK National Psychiatric Morbidity Survey.

OBJECTIVES: To determine a) the associations between diabetes and common mental disorders in a nationally representative sample and the effect of key covariates on such associations and b) the association of comorbid common mental disorders on the quality of life and diabetes self-care indicators. METHODS: In a cross-sectional survey, people with diabetes were identified from a sample of 8580 individuals aged 16 to 74 years, drawn from the 2000 UK National Psychiatric Morbidity Survey. Diabetes was ascertained by self-report and prescribed medications. Psychiatric morbidity was assessed using the Revised Clinical Interview Schedule. Quality of life was measured using the Short Form-12, and questions were asked regarding diabetes self-care and functioning. RESULTS: A total of 249 individuals were identified with diabetes. People with diabetes were more likely to suffer from common mental disorders (odds ratio (OR) = 1.5; 95% Confidence Interval (CI): 1.1-2.2; p < .05), and in particular mixed anxiety and depression (OR: 1.7; 95% CI: 1.1-2.6; p < .05), after controlling for age, gender, ethnicity, and socioeconomic status. The increased risk was uniform across diabetes subtypes. Among people with diabetes, common mental disorders were significantly associated with impaired health-related quality of life, more days off work, nonadherence, and difficulties with diabetes self-care. CONCLUSIONS: People with diabetes are more likely to suffer from common mental disorders, a finding which is highly relevant, given that psychiatric comorbidity in people with diabetes is also associated with higher levels of functional impairment, impaired quality of life, and difficulties with diabetes self-care.

A prospective study of Quality of life in schizophrenia in three European countries.

Only a small number of studies have tried to identify factors influencing the subjective QoL of patients suffering from schizophrenia in a longitudinal design. These studies suffer from small clinical samples or compare baseline data only with a single follow-up. The European Schizophrenia Cohort Study overcomes these shortcomings by providing data from five time points on 1208 patients in psychiatric treatment in three European countries over a period of 2 years. QoL was measured with the brief version of Lehman's Quality of Life Interview. Random effects, between-effects and within-effects regression models were computed in order to measure the influence on subjective QoL of patients' socio-demographic and clinical characteristics and objective QoL. Objective QoL scores were generally found to be related to the equivalent subjective QoL scores. People's financial situation, and depressive and positive symptoms had a general effect on almost all subjective domains. The significant effects of objective finances on subjective domains like health and social relations raise interesting possibilities for intervention. Sufficient financial resources appear to be a necessary condition for achieving satisfactory QoL in schizophrenia patients. However, changes in individual's characteristics and circumstances did not relate as strongly as expected to changes in QoL, suggesting effective intervention may be difficult.

Acting on persecutory delusions: the importance of safety seeking.

OBJECTIVE: Acting on delusions is a significant clinical issue. The concept of safety behaviours--actions carried out with the intention of reducing perceived threat--provides a new way of understanding acting on delusions. A study was conducted with the aim of examining the prevalence and correlates of safety behaviours related to persecutory delusions. METHOD: One hundred patients with persecutory delusions were assessed for safety behaviours, acting on delusions, anxiety, depression, and psychotic symptoms. Case note data were collected on instances of serious violence or suicide attempts. RESULTS: Ninety-six patients had used safety behaviours in the last month. Greater use of safety behaviours was associated with higher levels of distress. A history of violence or suicide attempts was associated with greater use of safety behaviours. Safety behaviours were significantly associated with acting on delusions, but not with the negative symptoms of psychosis. CONCLUSION: Safety behaviours are a common form of acting on persecutory delusions. These behaviours have the consequence that they are likely to prevent the processing of disconfirmatory evidence and will therefore contribute to delusion persistence.

Treatment seeking by individuals with obsessive-compulsive disorder from the british psychiatric morbidity survey of 2000.

OBJECTIVE: For several reasons, many individuals with obsessive-compulsive disorder (OCD) do not seek treatment. However, data on treatment seeking from community samples are scant. This study analyzed service use by adults with OCD living in private households in Great Britain. METHODS: Data from the British Survey of Psychiatric Morbidity of 2000, in which 8,580 individuals were surveyed, were analyzed. Service use was compared for those with OCD, with other neuroses, with different subtypes of OCD (only obsessions, only compulsions, or both), and with OCD and comorbid neuroses. RESULTS: Persons with OCD (N=114) were more likely than persons with other neuroses (N=1,395) to be receiving treatment (40% compared with 23%, p<.001). However, those with OCD alone (N=38) were much less likely than those with OCD and a comorbid disorder to be in treatment (14% compared with 56%, p<.001). In the previous year, 9.4% of persons with OCD had seen a psychiatrist and 4.6% had seen a psychologist. Five percent were receiving cognitive-behavioral therapy, 2% were taking selective serotonin reuptake inhibitors, and 10% were taking tricyclics. CONCLUSIONS: Most persons with OCD were not in contact with a mental health professional, and apparently very few were receiving appropriate treatments. Very few persons with noncomorbid OCD were receiving treatment. Individuals with OCD who are in treatment may not be disclosing their obsessions and compulsions and may be discussing other emotional symptoms, leading to inappropriate treatment strategies. Public awareness of OCD symptoms should be raised, and primary care professionals should inquire about them with all patients who have depressive or anxiety disorders.

Obsessive-compulsive disorder: prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000.

OBJECTIVE: There is little information about obsessive-compulsive disorder in large representative community samples. The authors aimed to establish obsessive-compulsive disorder prevalence and its clinical typology among adults in private households in Great Britain and to obtain generalizable estimates of impairment and help-seeking. METHOD: Data from the British National Psychiatric Morbidity Survey of 2000, comprising 8,580 individuals, were analyzed using appropriate measurements. The study compared individuals with obsessive-compulsive disorder, individuals with other neurotic disorders, and a non-neurotic comparison group. ICD-10 diagnoses were derived from the Clinical Interview Schedule-Revised. RESULTS: The authors identified 114 individuals (74 women, 40 men) with obsessive-compulsive disorder, with a weighted 1-month prevalence of 1.1%. Most individuals (55%) in the obsessive-compulsive group had obsessions only. Comorbidity occurred in 62% of these individuals, which was significantly greater than the group with other neuroses (10%). Co-occurring neuroses were depressive episode (37%), generalized anxiety disorder (31%), agoraphobia or panic disorder (22%), social phobia (17%), and specific phobia (15%). Alcohol dependence was present in 20% of participants, mainly men, and drug dependence was present in 13%. Obsessive-compulsive disorder, compared with other neurotic disorders, was associated with more marked social and occupational impairment. One-quarter of obsessive-compulsive disorder participants had previously attempted suicide. Individuals with pure and comorbid obsessive-compulsive disorder did not differ according to most indices of impairment, including suicidal behavior, but pure individuals were significantly less likely to have sought help (14% versus 56%). CONCLUSIONS: A rare yet severe mental disorder, obsessive-compulsive disorder is an atypical neurosis, of which the public health significance has been underestimated. Unmet need among individuals with pure obsessive-compulsive disorder is a cause for concern, requiring further investigation of barriers to care and interventions to encourage help-seeking.