Prevalence and treatment of common mental disorders in the English national population, 1993-2007.

BACKGROUND: The National Psychiatric Morbidity Surveys include English cross-sectional household samples surveyed in 1993, 2000 and 2007. AIMS: To evaluate frequency of common mental disorders (CMDs), service contact and treatment. METHOD: Common mental disorders were identified with the Clinical Interview Schedule - Revised (CIS-R). Service contact and treatment were established in structured interviews. RESULTS: There were 8615, 6126 and 5385 participants aged 16-64. Prevalence of CMDs was consistent (1993: 14.3%; 2000: 16.0%; 2007: 16.0%), as was past-year primary care physician contact for psychological problems (1993: 11.3%; 2000: 12.0%; 2007: 11.7%). Antidepressant receipt in people with CMDs more than doubled between 1993 (5.7%) and 2000 (14.5%), with little further increase by 2007 (15.9%). Psychological treatments increased in successive surveys. Many with CMDs received no treatment. CONCLUSIONS: Reduction in prevalence did not follow increased treatment uptake, and may require universal public health measures together with individual pharmacological, psychological and computer-based interventions.

How do child and adolescent mental health problems influence public sector costs? Interindividual variations in a nationally representative British sample.

BACKGROUND: Policy and practice guidelines emphasize that responses to children and young people with poor mental health should be tailored to needs, but little is known about the impact on costs. We investigated variations in service-related public sector costs for a nationally representative sample of children in Britain, focusing on the impact of mental health problems. METHODS: Analysis of service uses data and associated costs for 2461 children aged 5-15 from the British Child and Adolescent Mental Health Surveys. Multivariate statistical analyses, including two-part models, examined factors potentially associated with interindividual differences in service use related to emotional or behavioural problems and cost. We categorized service use into primary care, specialist mental health services, frontline education, special education and social care. RESULTS: Marked interindividual variations in utilization and costs were observed. Impairment, reading attainment, child age, gender and ethnicity, maternal age, parental anxiety and depression, social class, family size and functioning were significantly associated with utilization and/or costs. CONCLUSIONS: Unexplained variation in costs could indicate poor targeting, inequality and inefficiency in the way that mental health, education and social care systems respond to emotional and behavioural problems.

Religion, spirituality and mental health: results from a national study of English households.

BACKGROUND: Religious participation or belief may predict better mental health but most research is American and measures of spirituality are often conflated with well-being. AIMS: To examine associations between a spiritual or religious understanding of life and psychiatric symptoms and diagnoses. METHOD: We analysed data collected from interviews with 7403 people who participated in the third National Psychiatric Morbidity Study in England. RESULTS: Of the participants 35% had a religious understanding of life, 19% were spiritual but not religious and 46% were neither religious nor spiritual. Religious people were similar to those who were neither religious nor spiritual with regard to the prevalence of mental disorders, except that the former were less likely to have ever used drugs (odds ratio (OR) = 0.73, 95% CI 0.60-0.88) or be a hazardous drinker (OR = 0.81, 95% CI 0.69-0.96). Spiritual people were more likely than those who were neither religious nor spiritual to have ever used (OR = 1.24, 95% CI 1.02-1.49) or be dependent on drugs (OR = 1.77, 95% CI 1.20-2.61), and to have abnormal eating attitudes (OR = 1.46, 95% CI 1.10-1.94), generalised anxiety disorder (OR = 1.50, 95% CI 1.09-2.06), any phobia (OR = 1.72, 95% CI 1.07-2.77) or any neurotic disorder (OR = 1.37, 95% CI 1.12-1.68). They were also more likely to be taking psychotropic medication (OR = 1.40, 95% CI 1.05-1.86). CONCLUSIONS: People who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder.

Influence of problematic child-teacher relationships on future psychiatric disorder: population survey with 3-year follow-up.

BACKGROUND: Teacher-pupil relationships have been found to mediate behavioural, social and psychological outcomes for children at different ages according to teacher and child report, but most studies have been small. AIMS: To explore later psychiatric disorder among children with problematic teacher-pupil relationships. METHOD: Secondary analysis of a population-based cross-sectional survey of children aged 5-16 with a 3-year follow-up. RESULTS: Of the 3799 primary-school pupils assessed, 2.5% of parents reported problematic teacher-pupil relationships; for secondary-school pupils (n = 3817) this rose to 6.6%. Among secondary-school pupils, even when children with psychiatric disorder at baseline were excluded and we adjusted for baseline psychopathology score, problematic teacher-pupil relationships were statistically significantly related to higher levels of psychiatric disorder at 3-year follow-up (odds ratio (OR) = 1.93, 95% CI 1.07-3.51 for any psychiatric disorder, OR = 3.00, 95% CI 1.37-6.58 for conduct disorder). Results for primary-school pupils were similar but non-significant at this level of adjustment. CONCLUSIONS: This study underlines the need to support teachers and schools to develop positive relationships with their pupils.

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.

Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data.

BACKGROUND: Approximately one in ten children aged 5-15 in Britain has a conduct, hyperactivity or emotional disorder. METHODS: The British Child and Adolescent Mental Health Surveys (BCAMHS) identified children aged 5-15 with a psychiatric disorder, and their use of health, education and social care services. Service costs were estimated for each child and weighted to estimate the overall economic impact at national level. RESULTS: Additional health, social care and education costs associated with child psychiatric disorders totalled £1.47bn in 2008. The lion's share of the costs falls to frontline education and special education services. CONCLUSIONS: There are huge costs to the public sector associated with child psychiatric disorder, particularly the education system. There is a pressing need to explore ways to reduce these costs while improving health and well-being.

The relationship between personal debt and specific common mental disorders.

BACKGROUND: Personal debt is now recognized as one of the many factors associated with common mental disorders (CMD). We aim to estimate the prevalence of 'specific' mental disorders based on ICD-10 research diagnostic criteria by type of debt and quantify the additional influence of addictive behaviours. METHOD: A random probability sample comprising 7461 respondents were interviewed for the third national survey of psychiatric morbidity of adults in England carried out in 2007. The prevalence of CMD was estimated from the administration of the CIS-R. Respondents were asked about sources of debt and their borrowing choices. RESULTS: In 2007, 8.5% of adults were in arrears. Adults in debt were three times more likely than those not in debt to have CMD. The increased likelihood of CMD among those in arrears was found for all CMD and was irrespective of source of debt--housing, utilities and purchases on credit. The situation was exacerbated among those with addictive behaviours--alcohol or drug dependence or problem gambling. Those with multiple sources of debt and who had to obtain money from pawnbrokers and moneylenders had the highest rate of CMD, ≈ 50%. CONCLUSIONS: Debt is one of the major risk factors for CMD. This has practical implications for both health services and financial services, which both need to be alert to the association and adapt and train their respective services accordingly so that people in debt can access help for mental disorders and people with mental disorders can access help for debt.

Feelings of loneliness among adults with mental disorder.

PURPOSE: Loneliness can affect people at any time and for some it can be an overwhelming feeling leading to negative thoughts and feelings. The current study, based on the Adult Psychiatric Morbidity Survey in England, 2007, quantified the association of loneliness with a range of specific mental disorders and tested whether the relationship was influenced by formal and informal social participation and perceived social support.Methods Using a random probability sample design,7,461 adults were interviewed in a cross-sectional national survey in England in 2007. Common Mental Disorders were assessed using the revised Clinical Interview Schedule;the diagnosis of psychosis was based on the administration of the Schedules of the Clinical Assessment of Neuropsychiatry, while loneliness was derived from an item in the Social Functioning Questionnaire.Results Feelings of loneliness were more prevalent in women (OR = 1.34, 95 % CI 1.20­1.50, P\0.001) as well as in those who were single (OR = 2.24, 95 % C I1.96­2.55, P<0.001), widowed, divorced or separated(OR = 2.78, 95 % CI 2.38­3.23, P<0.001), economically inactive (OR = 1.24, 95 % CI 1.11­1.44,P = 0.007), living in rented accommodation (OR = 1.73,95 % CI 1.53­1.95, P<0.001) or in debt (OR = 2.47,95 % CI 2.07­1.50, P<0.001). Loneliness was associated with all mental disorders, especially depression [corrected].

Ethnic inequalities in the use of health services for common mental disorders in England.

PURPOSE: The purpose of this study is to investigate whether minority ethnic people were less likely to receive treatment for mental health problems than the white population were, controlling for symptom severity. METHOD: We analysed data from 23,917 participants in the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. Survey response rates were 79, 69 and 57 %, respectively. The revised Clinical Interview Schedule was used to adjust for symptom severity. RESULTS: Black people were less likely to be taking antidepressants than their white counterparts were (Odds ratio 0.4; 95 % confidence interval 0.2-0.9) after controlling for symptom severity. After controlling for symptom severity and socioeconomic status, people from black (0.7; 0.5-0.97) and South Asian (0.5; 0.3-0.8) ethnic groups were less likely to have contacted a GP about their mental health in the last year. CONCLUSIONS: Interventions to reduce these inequalities are needed to ensure that NHS health care is delivered fairly according to need to all ethnic groups.

Insomnia, worry, anxiety and depression as predictors of the occurrence and persistence of paranoid thinking.

PURPOSE: Our theoretical model proposes that insomnia, worry, and negative affect are important determinants of paranoid thinking. Anxiety produces anticipation of threat, depression increases the sense of vulnerability, worry leads to implausible ideas, and insomnia exacerbates negative affect and creates an altered perceptual state. The study objective was to examine for the first time these factors as predictors of the onset of new paranoid thinking and of the persistence of existing paranoid thinking. METHOD: A total of 2,382 participants in the 2000 British National Psychiatric Morbidity Survey were followed-up 18 months after their first assessment. Baseline assessments were used to predict the development and persistence of paranoid thinking at follow-up. Data were weighted to be representative of the general household population. RESULTS: Insomnia, worry, anxiety, depression and depressive ideas were each substantial predictors both of new inceptions of paranoia and of the persistence of existing paranoid thinking. Worry and insomnia were the strongest predictors. For example, insomnia at the first assessment led to a more than threefold increase in later inceptions of paranoid thinking. CONCLUSIONS: The study indicates that insomnia, worry, anxiety and depression are potential risk factors for new inceptions of paranoid thinking. The results also corroborate an emerging literature indicating that anxiety, worry and depression may encourage the persistence of paranoid thinking. The study provides the first longitudinal evidence linking insomnia and paranoia. The important clinical implication is that the use of interventions for common mental health difficulties in people with psychosis may have the additional benefit of reducing paranoia.

Age and birth cohort differences in the prevalence of common mental disorder in England: National Psychiatric Morbidity Surveys 1993-2007.

BACKGROUND: There are concerns that the prevalence of mental disorder is increasing. AIMS: To determine whether the prevalence of common adult mental disorders has increased over time, using age-period-cohort analysis. METHOD: The study consisted of a pseudocohort analysis of a sequence of three cross-sectional surveys of the English household population. The main outcome was common mental disorder, indicated by a score of 12 or above on the Revised Clinical Interview Schedule (CIS-R). Secondary outcomes were neurotic symptoms likely to require treatment, indicated by a CIS-R score of 18 or over, and individual subscale scores for fatigue, sleep problems, irritability and worry. RESULTS: There were 8670 participants in the 1993 survey, 6977 in the 2000 survey and 6815 in the 2007 survey. In men a significant increase in common mental disorder occurred between the cohort born in 1943-9 and that born in 1950-6 (odds ratio 1.4, 95% CI 1.1-1.9) but prevalence in subsequent cohorts remained largely stable. More extended increases in prevalence of sleep problems and mental disorders were observed in women, but not consistently across cohorts or measures. CONCLUSIONS: We found little evidence that the prevalence of common mental disorder is increasing.

Psychiatric morbidity in prisoners with intellectual disabilities: analysis of prison survey data for England and Wales.

A substantial number of prisoners have intellectual disabilities. We analysed data on a sample drawn from all prisons in England and Wales. Intellectual disability was defined as Quick Test scores equivalent to an IQ of ≤65. We found a significantly higher prevalence of probable psychosis, attempted suicide and cannabis use in prisoners with intellectual disabilities. Presence of intellectual disability was twice as likely to be associated with probable psychosis but the relationship was fully mediated by self-rated health status. It is important to identify this group as early as possible in order to provide timely interventions to cope in adverse environments and manage substance misuse.

Childhood sexual abuse and psychosis: data from a cross-sectional national psychiatric survey in England.

BACKGROUND: A number of studies in a range of samples attest a link between childhood sexual abuse and psychosis. AIMS: To use data from a large representative general population sample (Adult Psychiatric Morbidity Survey 2007) to test hypotheses that childhood sexual abuse is linked to psychosis, and that the relationship is consistent with mediation by revictimisation experiences, heavy cannabis use, anxiety and depression. METHOD: The prevalence of psychosis was established operationally in a representative cross-sectional survey of the adult household population of England (n = 7353). Using computer-assisted self-interview, a history of various forms of sexual abuse was established, along with the date of first abuse. RESULTS: Sexual abuse before the age of 16 was strongly associated with psychosis, particularly if it involved non-consensual sexual intercourse (odds ratio (OR) = 10.14, 95% CI 4.8-21.3, population attributable risk fraction 14%). There was evidence of partial mediation by anxiety and depression, but not by heavy cannabis use nor revictimisation in adulthood. CONCLUSIONS: The association between childhood sexual abuse and psychosis was large, and may be causal. These results have important implications for the nature and aetiology of psychosis, for its treatment and for primary prevention.

The meaning of reporting forgetfulness: a cross-sectional study of adults in the English 2007 Adult Psychiatric Morbidity Survey.

OBJECTIVES: we measured subjective memory impairment (SMI) across the whole adult age range in a representative, national survey. Age is the strongest risk factor for dementia and SMI may be a precursor of objective cognitive impairment. We therefore hypothesised that SMI prevalence would rise with age in a non-demented population. METHOD: we analysed data from the English 2007 Adult Psychiatric Morbidity Survey, representative of people in private households. Participants were asked whether they had noticed problems with forgetting in the last month, or forgotten anything important in the last week; and completed the modified Telephone Interview for Cognitive Status. RESULTS: of those contacted, 7,461 (57%) participated. After excluding participants screening positive for dementia, 2,168 (31.7%) reported forgetfulness in the last month, while 449 (6.4%) had forgotten something important in the last week. Reporting forgetfulness was not associated with age. In a multivariate analysis including cognition and age, the only significant associates of reporting forgetfulness were anxiety, depressive and somatic symptoms. CONCLUSIONS: our hypothesis that subjective forgetfulness prevalence would rise with age in a non-demented population was not supported. Although subjective forgetfulness can be an early symptom of future or mild dementia, it is common and non-specific and-at population level-is more likely to be related to mood than to be an early symptom of dementia. Asking those presenting with subjective forgetfulness additional questions about memory and functional decline and objective forgetfulness is likely to help clinicians to detect those at risk of dementia.

Health of national service veterans: an analysis of a community-based sample using data from the 2007 Adult Psychiatric Morbidity Survey of England.

PURPOSE: In the context of increasing concerns for the health of UK armed forces veterans, this study aims to compare the prevalence of current mental, physical and behavioural difficulties in conscripted national service veterans with population controls, and to assess the impact of length of service in the military. The compulsory nature of national service sets these veterans apart from younger veterans. METHOD: Data are drawn from a nationally representative community-dwelling sample of England. We compared 484 male national service veterans to 301 male non-veterans aged 65+ years. RESULTS: There were no differences in mental, behavioural or physical outcomes, except that veterans were less likely to have "any mental disorder" than non-veterans (age adjusted OR = 0.56, 95% CI 0.31, 0.99). Longer serving veterans were older but were not different in terms of mental, behavioural or physical outcomes. CONCLUSIONS: Community-dwelling national service veterans are at no greater risk of current adverse mental, physical or behavioural health than population controls.

Development and psychometric properties of the Mental Health Knowledge Schedule.

OBJECTIVE: Stigma has been conceptualized as comprised of 3 constructs: knowledge (ignorance), attitudes (prejudice), and behaviour (discrimination). We are not aware of a psychometrically tested instrument to assess knowledge about mental health problems among the general public. Our paper presents the results of the development stage and the psychometric properties of the Mental Health Knowledge Schedule (MAKS), an instrument to assess stigma-related mental health knowledge among the general public. METHODS: We describe the development of the MAKS in addition to 3 studies that were carried out to evaluate the psychometric properties of the MAKS. Adults aged 25 to 45 years in socioeconomic groups: B, C1, and C2 completed the instrument via face-to-face interview (n = 92) and online (n = 403). RESULTS: Internal reliability and test-retest reliability is moderate to substantial. Validity is supported by extensive review by experts (including service users and international experts in stigma research). CONCLUSION: The lack of a valid outcome measure to assess knowledge is a shortcoming of evaluations of stigma interventions and programs. The MAKS was found to be a brief and feasible instrument for assessing and tracking stigma-related mental health knowledge. This instrument should be used in conjunction with other attitude- and behaviour-related measures.

Service utilization by children with conduct disorders: findings from the 2004 Great Britain child mental health survey.

Children with conduct disorders (CD) and their families are in contact with multiple agencies, but there is limited evidence on their patterns of service utilization. The aim of this study was to establish the patterns, barriers and correlates of service use by analysing the cohort of the 2004 Great Britain child mental health survey (N = 7,977). Use of social services was significantly higher by children with CD than emotional disorders (ED) in the absence of co-morbidity, while use of specialist child mental health and paediatric was significantly higher by children with hyperkinetic disorders (HD) than CD. Children who had comorbid physical disorders used more primary healthcare services compared to those without physical disorders. Utilization of specialist child mental heath and social services was significantly higher among children with unsocialized CD than socialized CD and oppositional defiant disorders. Services utilization and its correlates varied with the type of service. Overall, specialist services use was associated with co-morbidity with learning disabilities, physical and psychiatric disorders. Several correlates of services use in CD appeared non-specific, i.e. associated with use of different services indicating the possibility of indiscriminate use of different types of services. The findings led to the conclusion that there is the need for effective organization and co-ordination of services, and clear care pathways. Involvement of specialist child mental health services should be requested in the presence of mental health co-morbidity.

An estimate of the veteran population in England: based on data from the 2007 Adult Psychiatric Morbidity Survey.

BACKGROUND: The health and well-being of military veterans has recently generated much media and political interest. Estimating the current and future size of the veteran population is important to the planning and allocation of veteran support services. METHODS: Data from a 2007 nationally representative residential survey of England (the Adult Psychiatric Morbidity Survey) were extrapolated to the whole population to estimate the number of veterans currently residing in private households in England. This population was projected forward in two ten-year blocks up to 2027 using a current life table. RESULTS: It was estimated that in 2007, 3,771,534 (95% CI: 2,986,315-4,910,205) veterans were living in residential households in England. By 2027, this figure was predicted to decline by 50.4 per cent, mainly due to large reductions in the number of veterans in the older age groups (65-74 and 75+ years). CONCLUSION: Approximately three to five million veterans are currently estimated to be living in the community in England. As the proportion of National Service veterans reduces with time, the veteran population is expected to halve over the next 20 years.

Predictors of Service Use for Mental Health Problems Among British Schoolchildren.

BACKGROUND: Most previous studies of service use in relation to mental health have examined services in the USA. We wanted to provide up-to-date findings from a general population sample of British schoolchildren. METHOD: A total of 2461 children aged 5-15 from the 1999 British Child and Adolescent Mental Health Survey were followed up for 3 years. We examine the relationship between a wide variety of potential predictors gathered in 1999 and the use of services over the following 3 years. RESULTS: Contact with most services was predicted by three factors: the impact of psychopathology; contact with teachers or primary health care; and parents' and teachers' perceptions that the child had significant difficulties. Other predictors were specific to each service. CONCLUSIONS: Education of parents, teachers and other important adults might increase the proportion of children with impairing psychiatric disorders reaching services.