Daytime napping, sleep duration and increased 8-year risk of type 2 diabetes in a British population.

BACKGROUND AND AIMS: Few studies have prospectively examined the relationship between daytime napping and risk of type 2 diabetes. We aimed to study the effects of daytime napping and the joint effects of napping and sleep duration in predicting type 2 diabetes risk in a middle- to older-aged British population. METHODS AND RESULTS: In 1998-2000, 13 465 individuals with no known diabetes participating in the European Prospective Investigation into Cancer-Norfolk study reported daytime napping habit and 24-h sleep duration. Incident type 2 diabetes cases were identified through multiple data sources until 31 July 2006. After adjustment for age and sex, daytime napping was associated with a 58% higher diabetes risk. Further adjustment for education, marital status, smoking, alcohol intake, physical activity, comorbidities and hypnotic drug use had little influence on the association, but additional adjustment for BMI and Waist Circumference attenuated the Odds ratio (OR) (95% CI) to 1.30 (1.01, 1.69). The adjusted ORs (95% CI) associated with short and long sleep duration were 1.46 (1.10, 1.90) and 1.64 (1.16, 2.32), respectively. When sleep duration and daytime napping were examined together, the risk of developing diabetes more than doubled for those who took day naps and had less than 6 h of sleep, compared to those who did not nap and had 6-8 h of sleep. CONCLUSION: Daytime napping was associated with an increased risk of type 2 diabetes, particularly when combined with short sleep duration. Further physiological studies are needed to confirm the interaction between different domains of sleep in relation to diabetes risk.

The association between social stress and global cognitive function in a population-based study: the European Prospective Investigation into Cancer (EPIC)-Norfolk study.

BACKGROUND: Stress is thought to exert both positive and negative effects on cognition, but the precise cognitive effects of social stress and individuals' response to stress remain unclear. We aimed to investigate the association between different measures of social stress and cognitive function in a middle- to older-aged population using data from the European Prospective Investigation into Cancer (EPIC)-Norfolk study. METHOD: Participants completed a comprehensive assessment of lifetime social adversity between 1993 and 1997 and the short form of the Mini Mental State Examination (SF-MMSE), an assessment of global cognitive function, during the third health check between 2004 and 2011 (a median of 10.5 years later). A low MMSE score was defined as a score in the bottom quartile (20-26). RESULTS: Completed MMSE scores and stress measures were available for 5129 participants aged 48-90 years. Participants who reported that their lives had been more stressful over the previous 10 years were significantly more likely to have low MMSE scores [odds ratio (OR) 1.14, 95% confidence interval (CI) 1.04-1.24 per unit increase in perceived stress], independently of sociodemographic factors, physical and emotional health. The effects were restricted to the highest level of stress and the association was stronger among participants with a lower educational level. Adaptation following life event experiences also seemed to be associated with MMSE scores after adjusting for sociodemographic factors, but the association was attenuated with further adjustment. CONCLUSIONS: In this generally high-functioning population, individuals' interpretations and responses to stressful events, rather than the events themselves, were associated with cognitive function.

Association between serotonin 5-HT-2C receptor gene (HTR2C) polymorphisms and obesity- and mental health-related phenotypes in a large population-based cohort.

OBJECTIVE: Studies have shown that common single-nucleotide polymorphisms (SNPs) in the serotonin 5-HT-2C receptor (HTR2C) are associated with antipsychotic agent-induced weight gain and the development of behavioural and psychological symptoms. We aimed to analyse whether variation in the HTR2C is associated with obesity- and mental health-related phenotypes in a large population-based cohort. METHOD: Six tagSNPs, which capture all common genetic variation in the HTR2C gene, were genotyped in 4978 men and women from the European Prospective Investigation into Cancer (EPIC)-Norfolk study, an ongoing prospective population-based cohort study in the United Kingdom. To confirm borderline significant associations, the -759C/T SNP (rs3813929) was genotyped in the remaining 16 003 individuals from the EPIC-Norfolk study. We assessed social and psychological circumstances using the Health and Life Experiences Questionnaire. Genmod models were used to test associations between the SNPs and the outcomes. Logistic regression was performed to test for association of SNPs with obesity- and mental health- related phenotypes. RESULTS: Of the six HTR2C SNPs, only the T allele of the -759C/T SNP showed borderline significant associations with higher body mass index (BMI) (0.23 kg m(-2); (95% confidence interval (CI): 0.01-0.44); P=0.051) and increased risk of lifetime major depressive disorder (MDD) (Odds ratio (OR): 1.13 (95% CI: 1.01-1.22), P=0.02). The associations between the -759C/T and BMI and lifetime MDD were independent. As associations only achieved borderline significance, we aimed to validate our findings on the -759C/T SNP in the full EPIC-Norfolk cohort (n=20 981). Although the association with BMI remained borderline significant (beta=0.20 kg m(-2); 95% CI: 0.04-0.44, P=0.09), that with lifetime MDD (OR: 1.01; 95% CI: 0.94-1.09, P=0.73) was not replicated. CONCLUSIONS: Our findings suggest that common HTR2C gene variants are unlikely to have a major role in obesity- and mental health-related traits in the general population.

Prospective association between emotional health and clinical evidence of Parkinson's disease.

BACKGROUND AND PURPOSE: Whilst disorders of emotion are commonly comorbid with Parkinson's disease (PD), evidence concerning their association with PD risk is limited. We investigate the prospective association between selected measures of emotional health and incident suspected PD. METHODS: 20,855 men and women, considered PD-free at baseline, completed a postal assessment of major depressive disorder (MDD), generalized anxiety disorder (GAD), psychological distress [defined by the five-item Mental Health Inventory (MHI-5)], and neuroticism. PD case ascertainment was based upon PD medication use, self-report questionnaires, hospital record discharge codes, and death certification, subsequently checked against general practitioner, hospital records and neurological service records. RESULTS: 175 suspected cases of incident PD were identified in 160,725 (median 7.9) person-years of follow-up (with 43 recorded in neurological service records). MDD lifetime history, GAD lifetime history, MHI-5 and neuroticism were all significantly associated with suspected PD following adjustment for age, sex, cigarette smoking, alcohol consumption, social class and education. CONCLUSIONS: This study supports an association between measures of emotional health, assessed prior to evidence of motor symptoms, and subsequent suspected PD diagnosis. However, we were unable to determine whether our measures of personality and emotional health represent genuine premorbid risk factors or early stages of PD. Long-term prospective healthy cohort studies are required to investigate the relationship between emotional health history and the evolution of the premotor and motor phases of PD.

Sense of coherence, lifestyle choices and mortality.

BACKGROUND: Based on data from the European Prospective Investigation into Cancer, Norfolk (EPIC-Norfolk) study, we have previously shown a strong sense of coherence (SOC) to be associated with a reduced rate of all-cause mortality. OBJECTIVES: To investigate the extent to which the SOC mortality association can be explained by socioeconomic status and lifestyle choices. DESIGN AND SETTING: Prospective population-based cohort study. PARTICIPANTS: 18 287 study participants aged 41-80 years who reported no pre-existing chronic disease at baseline and who completed an assessment of SOC. RESULTS: Based on 1599 deaths during a mean follow-up of 8.3 years, a strong SOC was associated with a 20% reduced risk of all-cause mortality. Measures of lifestyle choice (cigarette smoking, physical activity, dietary intakes of fruit, vegetables and fibre) and socioeconomic status (social class and education) explained 23% of this association. CONCLUSIONS: The SOC concept embraces multiple sets of chronic disease risk factors that include lifestyle choices and those associated with socioeconomic status, and is a potential aid in understanding differences in health outcomes in similar individuals.

Psychological distress, major depressive disorder, and risk of stroke.

BACKGROUND: Studies have suggested that mood status is associated with an increased risk of stroke, though mostly based on measures of depression defined by symptoms alone rather than diagnostic criteria representative of clinically important distress and impairment. We investigated this association based upon a large population-based prospective cohort study. METHODS: Baseline assessment of major depressive disorder (MDD) and of mental health well-being (defined by the Mental Health Inventory, MHI-5) was completed by 20,627 stroke-free participants, aged 41 to 80 years, in the United Kingdom European Prospective Investigation into Cancer-Norfolk study. RESULTS: During 8.5 years of follow-up, 595 incident (fatal and nonfatal) stroke endpoints were recorded. Neither past year nor lifetime MDD was associated with stroke. A one SD decrease in MHI-5 scale score (representing greater emotional distress) was associated with an 11% increased risk of stroke after adjustment for age, sex, cigarette smoking, systolic blood pressure, cholesterol, obesity, preexisting myocardial infarction, diabetes, social class, education, hypertension treatment, family history of stroke, and antidepressant medication use (hazard ratio 1.11, 95% CI 1.00 to 1.22). This association was consistent for men and for women, for fatal and nonfatal stroke, and conformed to a dose-response relationship. CONCLUSIONS: Findings from this large prospective cohort study suggest that increased psychological distress is associated with elevated stroke risk. Episodic major depressive disorder was not associated with incident stroke in this study.

Physical health-related quality of life predicts stroke in the EPIC-Norfolk.

OBJECTIVE: To examine the relationship between Short Form (SF)-36 physical functional health-related quality of life and incident stroke. METHODS: A total of 13,615 men and women participating in the European Prospective Investigation into Cancer-Norfolk who were free of stroke, myocardial infarction, and cancer at baseline were included in the study. Participants completed a health and lifestyle questionnaire and attended a health examination during 1993 to 1997. Self-reported physical functional health was assessed using physical component summary scores of SF-36 18 months later. Stroke incidence was ascertained by death certification and hospital record linkage up to 2005. RESULTS: There were 244 incident strokes (total person years = 99,191). People who reported better physical functional health had significantly lower risk of incident stroke. Using Cox proportional hazard models adjusting for age, sex, body mass index, systolic blood pressure, cholesterol, smoking, diabetes, physical activity, social class, alcohol consumption, and respiratory function, men and women who were in the top quartile of SF-36 physical component summary scores had half the risk of stroke (RR = 0.50 [0.31, 0.78]) compared to the people in the bottom quartile. The relationships remained unchanged after excluding strokes occurring within the first 2 years of follow-up. CONCLUSIONS: Physical functional health-related quality of life measured as Short Form-36 predicts subsequent stroke risk independently of known risk factors in a general population. Poor physical functional health may indicate a high-risk population for stroke who may benefit most from targeted preventive interventions such as management of known risk factors.

Psychosocial factors and incident asthma hospital admissions in the EPIC-Norfolk cohort study.

BACKGROUND: Case series and case-control studies have shown high rates of psychosocial and behavioural risk factors amongst patients admitted to hospital with severe asthma. General population studies have shown associations between psychosocial factors and prevalent asthma but few have investigated incident asthma outcomes. METHODS: Data on psychosocial factors and asthma hospital admissions were available for 20 854 participants, aged 41-80 years, in the Norfolk cohort of the European Prospective Investigation into Cancer study. Postal assessments included details of physical functioning, mood disorder history, social adversity and social support. RESULTS: A total of 686 asthma hospital admissions were recorded. Psychosocial factors present at baseline, including current mood disorders, adverse circumstances in childhood, the impact of life events experienced during adulthood and negative perceived support from a close confidant, were associated with increased rates of hospital admission independent of age, sex, indicators of socio-economic status, physical functional health, and obesity. Restricted to those participants who reported lifetime doctor-diagnosed asthma at baseline, the reported impact of adverse life events experienced in adulthood, and both confiding and negative aspects of support quality, were associated with asthma hospital admission. The magnitude of these associations was comparable to those involving indicators of socio-economic status and physical health. CONCLUSIONS: These results show that psychosocial factors are associated with incident asthma hospital admissions and highlight the potential importance of taking account of psychosocial factors, including availability and quality of support networks, in guiding long-term asthma management.

Respiratory function and self-reported functional health: EPIC-Norfolk population study.

Respiratory function is known to be associated with mortality. However, its association with health related quality of life (HRQoL) has not yet been examined. A population-based cross sectional study was conducted in 16,738 subjects aged 40-79 yrs and resident in Norfolk, to examine the association between forced expiratory volume in one second (FEV1) and HRQoL measured by the 36-item short form questionnaire. Individuals who were in the highest quintiles of FEV1 were more likely to report good physical functional health (odds ratio (OR) 1.60; 95% confidence interval (CI) 1.28-2.01 and OR 1.71; 95% CI 1.40-2.10 for males and females, respectively) controlling for age, height, weight or body mass index, smoking, physical activity, prevalent illness and social class. Being in the highest quintile for FEV1 was associated with significantly lower likelihood of poor self-reported mental functional health status in males (OR 0.78; 95% CI 0.61-0.99), but not in females (OR 1.00; 95% CI 0.82-1.22). In conclusion, forced expiratory volume in one second independently predicts self perceived physical well being in a general population across the whole normal distribution of respiratory function.

Care pathways for south Asian and white people with depressive and anxiety disorders in the community.

BACKGROUND: South Asian people with common mental disorders are less likely to have their problems recognised by their general practitioner and have lower rates of uptake of psychiatric services compared to native born white people. Less consideration has been given to their understanding of their mental health problems, their use of alternative supports and the treatment they receive in primary care. METHODS: A general population sample identified, using a semi-structured diagnostic interview, as having DSM-IIIR depressive or anxiety disorders was obtained. South Asian and white participants' appraisal of their mental health problems and their use of informal and formal assistance during the period they were unwell in the previous 6 months were compared. RESULTS: There was no difference between south Asian and white people, either in what they understood to be the matter with them or in what they perceived to be the cause of their problems. No south Asian participants reported seeking help from lay or traditional healers, while white people more often discussed their problems with a relative or friend. Most south Asian people consulted their GP and this was significantly higher than for whites. However, only around half the people in both groups reported disclosing their problem to a GP and only one in ten received psychiatric medication or was referred to specialist psychiatric services. CONCLUSIONS: Along with public education and GP training, the availability of appropriate and acceptable interventions for south Asian, and indeed white people, with common mental disorders consulting in primary care is key to ensuring that they gain access to necessary mental health care.

Obesity, confidant support and functional health: cross-sectional evidence from the EPIC-Norfolk cohort.

OBJECTIVE: To investigate the association between body mass index (BMI) and functional health according to age and the support available from a close confidant. DESIGN: A cross-sectional population-based study. PARTICIPANTS: A total of 20 921 participants in the European Prospective Investigation into Cancer and Nutrition, aged 41-80 y resident in Norfolk, England. MEASUREMENTS: Standardised clinic-based assessment of BMI, self-reported functional health status assessment (according to the anglicised Short Form 36 (SF-36) Health Survey questionnaire) and the availability (and quality) of a close confiding relationship. RESULTS: Self-reported physical functioning declined steadily with increasing age. Obesity (BMI >/=30) was strongly associated with self-reported physical functional health, equivalent to being 11 y older for men and 16 y older for women (after adjustment that included prevalent chronic physical conditions and cigarette smoking). This adverse effect of obesity on physical functional health was found to increase with age for both men and women. Perceived inadequacy of a confiding relationship was associated with reduced physical functional capacity, equivalent to being 4 y older for men and 5 y older for women. For those with markedly inadequate confidant relationships, the impact of obesity on physical functional capacity was approximately constant by age. For those not critical of the adequacy of their confiding relationships, the impact of obesity was least for those younger but rose to equivalent levels as those with markedly inadequate confidant relationships among older participants. CONCLUSIONS: The availability of a close confidant relationship (perceived as uncritical and characterised by the absence of shared negative interactions) may delay the impact of obesity in reducing physical functional capacity.

Places, people, and their physical and mental functional health.

STUDY OBJECTIVE: To investigate the impact of area of residence on functional health as represented by medical outcomes study SF-36 physical and mental component summary scores. DESIGN: Multilevel analysis of cross sectional data from the European Prospective Investigation into Cancer and Nutrition in Norfolk, UK (EPIC-Norfolk). PARTICIPANTS: A community dwelling cohort of 18399 men and women, aged 41 to 80 and resident in 162 electoral wards in Norfolk, UK. MAIN RESULTS: Significant residual variation in physical functional health was observed at the area level after controlling for important individual level socioeconomic factors (p<0.001). However, the extent of this variation was modest when compared with that at the individual level (representing 0.6% of the total). About half of this variation could be explained by area deprivation. Area deprivation was associated with impaired mental functional health but residual variation at the area level (adjusted for individual level factors) was observed only for men (0.5% of total, p = 0.02). CONCLUSIONS: Area of residence was associated with physical functional health, albeit with modest effect size. Evidence for an association between area of residence and mental functional health was weak.

Characteristics of patients and patterns of psychiatric service use in ethnic minorities.

BACKGROUND: The differential uptake of psychiatric services by ethnic minorities has been widely reported. Less attention has been given to comparisons of these patients and variations in the types of interventions they receive. AIMS: To assess whether for people accessing psychiatric services in the UK, differences exist across ethnic groups both in their sociodemographic characteristics and patterns of mental health care utilisation. METHODS: All adults resident in an inner city health district and using psychiatric services during a six-month period were identified. Demographic, clinical and service use data were collected from staff and records. These were compared across black Caribbean, Indian, Pakistani, Irish and white ethnic groups for two broad diagnostic categories: psychotic/bipolar and depressive/neurotic disorders. RESULTS: There were significant differences between ethnic groups on most demographic variables in each of the diagnostic categories. There were variations in the level of contact with different mental health professionals. The only significant difference in the use of specific services was for those with psychotic/bipolar disorders, black Caribbean patients being more likely to be detained in hospital compulsorily. CONCLUSIONS: Ethnic diversity both in the characteristics of patients and their patterns of psychiatric care should be addressed when planning and developing services.

Aftercare of depressed inpatients--service delivery and unmet needs.

BACKGROUND: In contrast to acute treatment, delivery of aftercare to depressed patients has not been well studied. Poor care may contribute to poor outcomes for treated depression. METHODS: One hundred and two patients discharged from hospital with unipolar depression were followed up 18 months later and were interviewed in detail regarding aftercare and treatment received. Unmet needs were assessed on the community version of the MRC Needs for Care Assessment. RESULTS: In the first month after discharge approximately 70 % of subjects received contacts with mental health services and in the first 3 months over 80 % received at least one contact. About 40 % were in contact with mental health services at 18 months. Needs assessment found comparatively low unmet needs, reaching highest levels (around 25 % in any 6-month period) for medication. Two-thirds of unmet needs for medication and psychotherapy were due to patient refusal or non-compliance. Aftercare levels were higher in those with more previous admissions and were unrelated to presence of personality disorder. CONCLUSIONS: There were some deficiencies in service aftercare for depressed patients in a British NHS setting, although unmet need was not high. Some aftercare failures reflect patient reluctance to receive further treatment, representing a challenge to overcome in patients entitled to autonomous choices.

Childhood adversity, gender and depression over the life-course.

BACKGROUND: Full investigation of hypotheses concerning early risk factors and episodes of depression in adult life requires consideration of the separate risks of first onset and of recurrent episodes. This paper is based upon such an investigation. METHODS: A sample of participants in a large-scale population study (n=3491) provided information through retrospective assessment of lifetime history of (putative) major depressive disorder and of their adverse experiences in childhood. A statistical model based on Poisson regression, that combined both the (survival) distribution of first onset times with the subsequent rate of episode recurrence was specified to permit investigation of the gender difference in lifetime depression and the influence of childhood adversities on adult depression. RESULTS: A gender difference (with women at increased risk) was revealed for first onsets of depression only and was found to decrease with increasing age, being no longer apparent in those aged over 50. Experience either of a frightening event or of physical abuse in childhood was associated with an increased risk of first onset in younger adults (those aged < or =30). LIMITATIONS: The method of data collection used in this study warrants some caution in the interpretation of substantive findings. CONCLUSIONS: The relationships revealed concerning the risk for early and for late first onset and the risk of recurrence suggest different causal pathways underlying the associations between risk factors experienced early in life and depression in adulthood. Analyses that take full account of episode history can aid understanding of the origins of depression in adulthood.

Lifestyle risk factors for cancer: the relationship with psychosocial work environment.

BACKGROUND: Psychosocial work characteristics (job demands, control, support, job strain and iso-strain [high job strain combined with social isolation at work]) may be linked to cancer risk, by affecting cancer-related lifestyles like smoking, high alcohol consumption, low intake of fruits and vegetables and lack of physical activity. METHODS: Cross-sectional data obtained from 3309 respondents participating in an ongoing prospective cohort study in the Netherlands on psychosocial factors and cancer risk were used to study the association between psychosocial job characteristics and lifestyle. Information on job characteristics and risk factor prevalence was collected from 20-65-year-old men and women, through self-administered questionnaires. Multiple logistic and linear regression analyses were undertaken by gender, with adjustment for age and education. RESULTS: No differences in the prevalence of lifestyle risk factors for cancer were found amongst the psychosocial work characteristics studied. Moreover, little evidence was found for a relation between job (or iso-) strain and cancer-related lifestyles in multivariate analyses. CONCLUSIONS: The present study found no support for the hypothesis that job strain or iso-strain are associated with a cancer-related lifestyle. Further research on the role of other psychosocial factors-like personality or social support outside work-in mediating associations between job characteristics and lifestyle, is warranted.

The role of life events and childhood experiences in the development of rheumatoid arthritis.

OBJECTIVE: To evaluate the role of stressful life events, including negative childhood experiences on the development of rheumatoid arthritis (RA). METHODS: Retrospective, community based, case-control study founded upon 116 cases, aged 45 to 74 years, registered with the Norfolk Arthritis Register (NOAR), who were also participants in the Norfolk European Prospective Investigation of Cancer study (EPIC). Three controls, matched for age and sex, were selected for each of the cases from among EPIC participants not suffering from arthritis. Data on adverse experiences during childhood and adulthood were available from a self-report questionnaire. The 1987 American Rheumatism Association (ARA) criteria for RA were met by 55 NOAR cases and this subset provided the primary focus for analysis. RESULTS: The number and timing of occurrence of stressful life events, as well as their subjective immediate impact, did not differ between participants who developed RA and their matched controls. Termination of pregnancy was the only specific event individually associated with a higher risk of developing RA (OR 3.74; 95% CI 1.4-9.9). Negative childhood experiences were not associated with the risk of RA. However, RA cases reported significantly slower adaptation to the effects of adverse events than controls. CONCLUSION: The results of this study do not support the hypothesis that the rate of exposure or reported impact of stressful life events and of adverse childhood experiences play an etiologic role in the development of RA.

Psychosocial aetiology of chronic disease: a pragmatic approach to the assessment of lifetime affective morbidity in an EPIC component study.

OBJECTIVES: The Health and Life Experiences Questionnaire (HLEQ) was developed for use in a prospective cohort study of 25,000 men and women living in Norfolk and forms a component study of the European Prospective Investigation into Cancer and Nutrition (EPIC). The HLEQ includes an assessment of mood status over the life course allowing a limited capacity for the imposition of diagnostic criteria to enable eventual evaluation of mental health status for chronic disease outcomes. This paper reports estimates of HLEQ Major Depressive Disorder (MDD) prevalence and compares them with those obtained through interviewer-based methods. In addition evidence for the impact of recall, clustering or cohort effects on these estimates are examined. PARTICIPANTS: 3491 eligible respondents to EPIC in Norfolk, aged 45-74 years, recruited from the first five general practices who completed the HLEQ. MAIN RESULTS: MDD prevalence estimates were found to be closely comparable to those obtained recently (by interview) in the UK and to those lifetime MDD rates determined through international studies. Risk of MDD onset was found to vary with age as expected from earlier studies using interviewer-based assessments. Limited evidence was found to show that the distribution of first onset MDD episodes were compressed during the immediate pre-assessment period. Results were also consistent with previous evidence demonstrating the raised risk of MDD among women and of the decline in gender differences with advancing age. CONCLUSIONS: These results suggest that estimates of putative MDD diagnostic status, derived through the HLEQ, and of associated demographic risk are similar to those derived by more intensive and costly assessment methods. Implications for the future study of MDD both as an outcome and as a risk factor for chronic disease are discussed.

Surviving adversity: event decay, vulnerability and the onset of anxiety and depressive disorder.

Knowledge concerning the temporal relationship between adverse experiences and the onset of anxiety and depressive disorders remains sparse despite life stress forming a pivotal component to social, neurological and cognitive science models of their aetiology. In this study two groups of married women were selected through their shared adverse experiences; for one group, the marital partner had recently died, and in the second group, the marital partner had recently experienced a myocardial infarction. These groups were assessed in close proximity to their event experiences and again approximately 3 months later. Adaptations of both the Longitudinal Interval Follow-up Evaluation and the Life Event and Difficulty Schedule were used to provide a detailed clinical and event history both preceding and following their experiences. Analysis showed clear evidence for the progressive decay in the adverse effects of life events over time; an attribute thus far largely neglected in work seeking to clarify event-illness relationships. Comparisons between fixed and time-varying effects, representative of precisely formulated models of vulnerability/resilience, confirmed the role both of previous psychiatric consultation history and of limited individual coping skills as risk factors for the onset of diagnosable disorder. Improvements in the specification of stress modelling procedures should facilitate the integration of ideas from competing aetiological models of the onset and subsequent course of anxiety and depressive disorder.

Pathways to care for alcohol use disorders.

BACKGROUND: The aim of the present study was to examine access to care for people with alcohol use disorders. METHOD: An alcohol screening questionnaire was completed by 444 respondents in a community survey. During a designated week, 1009 patients presenting in primary care were assessed by their doctor and 773 of these completed the same questionnaire. Over a six month period 223 people with alcohol use disorders were identified using specialist addiction and psychiatric services, of whom 58 were admitted to hospital. One month prevalence rates of alcohol morbidity were determined for people aged between 16 and 64 years at all five levels in the pathways to care model. RESULTS: Around half the people with alcohol morbidity in the community never consulted their general practitioner and of those who did only half had their problem identified. Case recognition was particularly poor for women, young people and Asians. The main filter to people accessing specialist services came at the point of referral from primary care. This was especially marked for young people and for ethnic minorities. CONCLUSIONS: Strategies are required to improve the identification and treatment of alcohol morbidity in primary care. Deficits in access to specialist services for women, young people and ethnic minorities need to be addressed.