Cross-national epidemiology of panic disorder and panic attacks in the world mental health surveys.

CONTEXT: The scarcity of cross-national reports and the changes in Diagnostic and Statistical Manual version 5 (DSM-5) regarding panic disorder (PD) and panic attacks (PAs) call for new epidemiological data on PD and PAs and its subtypes in the general population. OBJECTIVE: To present representative data about the cross-national epidemiology of PD and PAs in accordance with DSM-5 definitions. DESIGN AND SETTING: Nationally representative cross-sectional surveys using the World Health Organization Composite International Diagnostic Interview version 3.0. PARTICIPANTS: Respondents (n = 142,949) from 25 high, middle, and lower-middle income countries across the world aged 18 years or older. MAIN OUTCOME MEASURES: PD and presence of single and recurrent PAs. RESULTS: Lifetime prevalence of PAs was 13.2% (SE 0.1%). Among persons that ever had a PA, the majority had recurrent PAs (66.5%; SE 0.5%), while only 12.8% fulfilled DSM-5 criteria for PD. Recurrent PAs were associated with a subsequent onset of a variety of mental disorders (OR 2.0; 95% CI 1.8-2.2) and their course (OR 1.3; 95% CI 1.2-2.4) whereas single PAs were not (OR 1.1; 95% CI 0.9-1.3 and OR 0.7; 95% CI 0.6-0.8). Cross-national lifetime prevalence estimates were 1.7% (SE 0.0%) for PD with a median age of onset of 32 (IQR 20-47). Some 80.4% of persons with lifetime PD had a lifetime comorbid mental disorder. CONCLUSIONS: We extended previous epidemiological data to a cross-national context. The presence of recurrent PAs in particular is associated with subsequent onset and course of mental disorders beyond agoraphobia and PD, and might serve as a generic risk marker for psychopathology.

Proportion of patients without mental disorders being treated in mental health services worldwide.

BACKGROUND: Previous research suggests that many people receiving mental health treatment do not meet criteria for a mental disorder but are rather 'the worried well'. AIMS: To examine the association of past-year mental health treatment with DSM-IV disorders. METHOD: The World Health Organization's World Mental Health (WMH) Surveys interviewed community samples of adults in 23 countries (n = 62 305) about DSM-IV disorders and treatment in the past 12 months for problems with emotions, alcohol or drugs. RESULTS: Roughly half (52%) of people who received treatment met criteria for a past-year DSM-IV disorder, an additional 18% for a lifetime disorder and an additional 13% for other indicators of need (multiple subthreshold disorders, recent stressors or suicidal behaviours). Dose-response associations were found between number of indicators of need and treatment. CONCLUSIONS: The vast majority of treatment in the WMH countries goes to patients with mental disorders or other problems expected to benefit from treatment.

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

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

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

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

Associations of serious mental illness with earnings: results from the WHO World Mental Health surveys.

BACKGROUND: Burden-of-illness data, which are often used in setting healthcare policy-spending priorities, are unavailable for mental disorders in most countries. AIMS: To examine one central aspect of illness burden, the association of serious mental illness with earnings, in the World Health Organization (WHO) World Mental Health (WMH) Surveys. METHOD: The WMH Surveys were carried out in 10 high-income and 9 low- and middle-income countries. The associations of personal earnings with serious mental illness were estimated. RESULTS: Respondents with serious mental illness earned on average a third less than median earnings, with no significant between-country differences (chi(2)(9) = 5.5-8.1, P = 0.52-0.79). These losses are equivalent to 0.3-0.8% of total national earnings. Reduced earnings among those with earnings and the increased probability of not earning are both important components of these associations. CONCLUSIONS: These results add to a growing body of evidence that mental disorders have high societal costs. Decisions about healthcare resource allocation should take these costs into consideration.

Age differences in the prevalence and co-morbidity of DSM-IV major depressive episodes: results from the WHO World Mental Health Survey Initiative.

BACKGROUND: Although depression appears to decrease in late life, this could be due to misattribution of depressive symptoms to physical disorders that increase in late life. METHODS: We investigated this issue by studying age differences in co-morbidity of DSM-IV major depressive episodes (MDE) with chronic physical conditions in the WHO World Mental Health (WMH) surveys, a series of community epidemiological surveys of respondents in 10 developed countries (n=52,485) and 8 developing countries (n=37,265). MDE and other mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). Organic exclusion rules were not used to avoid inappropriate exclusion of cases with physical co-morbidity. Physical conditions were assessed with a standard chronic conditions checklist. RESULTS: Twelve-month DSM-IV/CIDI MDE was significantly less prevalent among respondents ages 65+ than younger respondents in developed but not developing countries. Prevalence of co-morbid mental disorders generally either decreased or remained stable with age, while co-morbidity of MDE with mental disorders generally increased with age. Prevalence of physical conditions, in comparison, generally increased with age, while co-morbidity of MDE with physical conditions generally decreased with age. Depression treatment was lowest among the elderly in developed and developing countries. CONCLUSIONS: The weakening associations between MDE and physical conditions with increasing age argue against the suggestion that the low estimated prevalence of MDE among the elderly is due to increased confounding with physical disorders. Future study is needed to investigate processes that might lead to a decreasing impact of physical illness on depression among the elderly.

Consequences of using SF-12 and RAND-12 when examining levels of well-being and psychological distress.

OBJECTIVE: To explore the consequences of using the Short-Forum Health Survey (SF-12) and the RAND-12 Health Status Inventory (RAND-12) for estimation of associations between its component scores and the levels of well-being and psychological distress. METHODS: Data from a rural community mental health survey of 5641 participants were analysed. Physical and mental health component scores of the SF-12 and RAND-12 were compared between participants with different rating on the Satisfaction with Life Scale and the Kessler-10. Descriptive graphical methods were utilized to explore the relationship between SF-12 and RAND-12 components scores against well-being and psychological distress. Proportional odds model was utilized to estimate the quantitative relationship between component scores of the SF-12 and RAND-12 against categories of well-being and psychological distress. RESULTS: Both SF-12 and RAND-12 component scores were generally positively associated with well-being and negatively associated with psychological distress. Median scores were similar despite scoring techniques used. However, distribution of scores differed whereby the RAND-12 yielded wider spread of scores in measures of well-being and psychological distressed when compared to the SF-12. A larger proportion of participants was classified as having moderate and severe disability under the RAND-12 compared to the SF-12. CONCLUSION: It is recommended that users of the SF-12 and the RAND-12 are aware of the implications of utilizing either of the scoring techniques. Scoring techniques used should ideally be based on the theoretical basis of the study with consideration of the target population. Researchers may wish to use the SF-12 if distinct uncorrelated physical and mental constructs are required and for studies on clinical populations. In contrast, RAND-12 should be used if correlated physical and mental constructs are required and if the study is on community or general populations.

Subjective well-being, sociodemographic factors, mental and physical health of rural residents.

OBJECTIVE: To ascertain the relationship between subjective well-being and sociodemographic factors, mental and physical health of a sample of rural residents. DESIGN: Cross-sectional survey with stratified random sampling of persons based on the 2000 State Electoral Role. Questionnaire was forwarded to 23 000 residents throughout a rural area. SETTING: Households within Gippsland. PARTICIPANTS: Five thousand three hundred and ninety-one adults aged 18 years and above. MAIN OUTCOME MEASURES: Residents completed a self-reported questionnaire assessing life satisfaction/subjective well-being, psychological distress, sociodemographic factors, physical and mental health problems. RESULTS: Completed survey indicated that participants with lower levels of psychological distress, physical disability and mental disability had higher odds of being satisfied with their life. Participants with severe mental disability had the lowest odds of being satisfied with life. On average, participants were satisfied with their life (mean score of 21, SD = 5.9), are within the normal range of the Kessler-10 (mean score = 16.31, SD = 5.85), had no mental disability (mean score = 51.8, SD = 7.36) on the mental component of the Short Form-12 Health Survey, but are mildly physically disabled (mean score = 48.9, SD = 7.74). CONCLUSIONS: The results of this study indicate that sociodemographic factors, psychological distress, physical health and mental health contribute to subjective well-being. Compared with other age groups, those aged 66 years and above had the highest level of life satisfaction. Those living with partner/spouse without children, with no mental or physical disability and no psychological distress had highest level of life satisfaction. Women also had higher levels of life satisfaction compared with men.

Does Interpersonal Psychotherapy improve clinical care for adolescents with depression attending a rural child and adolescent mental health service? Study protocol for a cluster randomised feasibility trial.

BACKGROUND: Depression amongst adolescents is a costly societal problem. Little research documents the effectiveness of public mental health services in mapping this problem. Further, it is not clear whether usual care in such services can be improved via clinician training in a relevant evidence based intervention. One such intervention, found to be effective and easily learned amongst novice clinicians, is Interpersonal Psychotherapy (IPT). The study described in the current paper has two main objectives. First, it aims to investigate the impact on clinical care of implementing Interpersonal Psychotherapy for Adolescents for the treatment of adolescent depression within a rural mental health service compared with Treatment as Usual (TAU). The second objective is to record the process and challenges (i.e. feasibility, acceptability, sustainability) associated with implementing and evaluating an evidence-based intervention within a community service. This paper outlines the study rationale and design for this community based research trial. METHODS/DESIGN: The study involves a cluster randomisation trial to be conducted within a Child and Adolescent Mental Health Service in rural Australia. All clinicians in the service will be invited to participate. Participating clinicians will be randomised via block design at each of four sites to (a) training and delivery of IPT, or (b) TAU. The primary measure of impact on care will be a clinically significant change in depressive symptomatology, with secondary outcomes involving treatment satisfaction and changes in other symptomatology. Participating adolescents with significant depressive symptomatology, aged 12 to 18 years, will complete assessment measures at Weeks 0, 12 and 24 of treatment. They will also complete a depression inventory once a month during that period. This study aims to recruit 60 adolescent participants and their parent/guardian/s. A power analysis is not indicated as an intra-class correlation coefficient will be calculated and used to inform sample size calculations for subsequent large-scale trials. Qualitative data regarding process implementation will be collected quarterly from focus groups with participating clinicians over 18 months, plus phone interviews with participating adolescents and parent/guardians at 12 weeks and 24 weeks of treatment. The focus group qualitative data will be analysed using a Fourth Generation Evaluation methodology that includes a constant comparative cyclic analysis method. DISCUSSION: This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting cluster randomised trials within community practice such as mental health services. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRNO12607000324415.

The Psychiatrists Training Initiative: developing an educational framework for international medical graduates in rural psychiatry.

OBJECTIVE: The aim of this paper is to outline challenges and responses in providing a holistic approach to designing and delivering education to international medical graduates (IMGs) undertaking the role of consultant psychiatrists in a rural setting. This paper examines processes underpinning the educational framework with consideration to acculturation issues in Latrobe Regional Hospital's (LRH) Psychiatrists Training Initiative. CONCLUSIONS: To engage and encourage consultant psychiatrist IMGs in an Australian rural setting, it is paramount that educational frameworks incorporate strong elements of communication skills, cross cultural communication and language, with focus on the individual and the group as part of the community.

The Bidirectional Associations Between Psychotic Experiences and DSM-IV Mental Disorders.

OBJECTIVE: While it is now recognized that psychotic experiences are associated with an increased risk of later mental disorders, we lack a detailed understanding of the reciprocal time-lagged relationships between first onsets of psychotic experiences and mental disorders. Using data from World Health Organization World Mental Health (WMH) Surveys, the authors assessed the bidirectional temporal associations between psychotic experiences and mental disorders. METHOD: The WMH Surveys assessed lifetime prevalence and age at onset of psychotic experiences and 21 common DSM-IV mental disorders among 31,261 adult respondents from 18 countries. Discrete-time survival models were used to examine bivariate and multivariate associations between psychotic experiences and mental disorders. RESULTS: Temporally primary psychotic experiences were significantly associated with subsequent first onset of eight of the 21 mental disorders (major depressive disorder, bipolar disorder, generalized anxiety disorder, social phobia, posttraumatic stress disorder, adult separation anxiety disorder, bulimia nervosa, and alcohol abuse), with odds ratios ranging from 1.3 (95% CI=1.2-1.5) for major depressive disorder to 2.0 (95% CI=1.5-2.6) for bipolar disorder. In contrast, 18 of 21 primary mental disorders were significantly associated with subsequent first onset of psychotic experiences, with odds ratios ranging from 1.5 (95% CI=1.0-2.1) for childhood separation anxiety disorder to 2.8 (95% CI=1.0-7.8) for anorexia nervosa. CONCLUSIONS: While temporally primary psychotic experiences are associated with an elevated risk of several subsequent mental disorders, these data show that most mental disorders are associated with an elevated risk of subsequent psychotic experiences. Further investigation of the underlying factors accounting for these time-order relationships may shed light on the etiology of psychotic experiences.

The relation between multiple pains and mental disorders: results from the World Mental Health Surveys.

It is unclear whether differences exist in the prevalence of mood, anxiety and alcohol use disorders among persons with multiple pain conditions compared with those with single pain problems. We conducted population surveys in 17 countries in Europe, the Americas, the Middle East, Africa, Asia, and the South Pacific. Participants were community-dwelling adults (N=85,088). Mental disorders were assessed with the Composite International Diagnostic Interview. Pain was assessed by self-report. Both multiple and single site pain problems were associated with mood and anxiety disorders, but not with alcohol abuse or dependence. In general, the prevalence of specific mood and anxiety disorders followed a linear pattern with the lowest rates found among persons with no pain, intermediate rates among those with one pain, and highest rates among those with multi-site pain problems. Relative to persons not reporting pain, the pooled estimates of the age-sex adjusted odds ratios were 1.8 (1.7-2.0) for mood disorders and 1.9 (1.8-2.1) for anxiety disorders for persons with single site pain; 3.7 (3.3-4.1) for mood disorders and 3.6 (3.3-4.0) for anxiety disorders among those with multi-site pain. Our results indicate that the presence of multiple pain conditions was strongly and comparably associated with mood and anxiety disorders in diverse cultures. This consistent pattern of associations suggests that diffuse pain and psychiatric disorders are generally associated, rather than diffuse pain representing an idiom for expressing distress that is specific to particular cultural settings or diffuse pain solely representing a form of masked depression.

A recovery-based outreach program in rural Victoria.

OBJECTIVE: A recovery-based outreach program for people with severe mental illness in regional Victoria is described. The paper covers a description of the program, the services provided and outcomes achieved. The program emphasized active collaboration between patients and clinicians as outlined in the collaborative recovery model and recognized that recovery from mental illness is an individual, personal process. CONCLUSIONS: The program provided service to 108 people over 3 years and had a positive impact on clinicians, patients and carers. The benefits of recovery orientation, multidisciplinary teams, collaborative relationships and carer involvement are discussed. The paper highlights the need for a focus on recovery and comprehensive care for people with severe mental illness.