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1.  Determinants of the use of specialist mental health services by nursing home residents. 
Health Services Research  1994;29(2):169-185.
OBJECTIVE. This study examines the effects of resident and facility characteristics on the probability of nursing home residents receiving treatment by mental health professionals. DATA SOURCES/STUDY SETTING. The study uses data from the Institutional Population Component of the 1987 National Medical Expenditure Survey, a secondary data source containing data on 3,350 nursing home residents living in 810 nursing homes as of January 1, 1987. STUDY DESIGN. Andersen's health services use model (1968) is used to estimate a multivariate logistic equation for the effects of independent variables on the probability that a resident has received services from mental health professionals. Important variables include resident race, sex, and age; presence of several behaviors and reported mental illnesses; and facility ownership, facility size, and facility certification. DATA COLLECTION/EXTRACTION METHODS. Data on 188 residents were excluded from the sample because information was missing on several important variables. For some additional variables residents who had missing information were coded as negative responses. This left 3,162 observations for analysis in the logistic regressions. PRINCIPAL FINDINGS. Older residents and residents with more ADL limitations are much less likely than other residents to have received treatment from a mental health professional. Residents with reported depression, schizophrenia, or psychoses, and residents who are agitated or hallucinating are more likely to have received treatment. Residents in government nursing homes, homes run by chains, and homes with low levels of certification are less likely to have received treatment. CONCLUSIONS. Few residents receive treatment from mental health professionals despite need. Older, physically disabled residents need special attention. Care in certain types of facilities requires further study. New regulations mandating treatment for mentally ill residents will demand increased attention from nursing home administrators and mental health professionals.
PMCID: PMC1069997  PMID: 8005788
2.  The Role of Health Systems Factors in Facilitating Access to Psychotropic Medicines: A Cross-Sectional Analysis of the WHO-AIMS in 63 Low- and Middle-Income Countries 
PLoS Medicine  2012;9(1):e1001166.
In a cross-sectional analysis of WHO-AIMS data, Ryan McBain and colleagues investigate the associations between health system components and access to psychotropic drugs in 63 low and middle income countries.
Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue.
Methods and Findings
This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability.
Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.
Please see later in the article for the Editors' Summary
Editors' Summary
Mental disorders—conditions that involve impairment of thinking, emotions, and behavior—are extremely common. Worldwide, mental illness affects about 450 million people and accounts for 13.5% of the global burden of disease. About one in four people will have a mental health problem at some time in their life. For some people, this will be a short period of mild depression, anxiety, or stress. For others, it will be a serious, long-lasting condition such as schizophrenia, bipolar disorder, or major depression. People with mental health problems need help and support from professionals and from their friends and families to help them cope with their illness but are often discriminated against, which can make their illness worse. Treatments include counseling and psychotherapy (talking therapies), and psychotropic medicines—drugs that act mainly on the brain. Left untreated, many people with serious mental illnesses commit suicide.
Why Was This Study Done?
About 80% of people with mental illnesses live in low- and middle-income countries (LAMICs) where up to 85% of patients remain untreated. Access to psychotropic medicines, which constitute an essential and cost-effective component in the treatment of mental illnesses, is particularly poor in many LAMICs. To improve this situation, it is necessary to understand what health systems factors limit the availability and affordability of psychotropic drugs; a health system is the sum of all the organizations, institutions, and resources that act together to improve health. In this cross-sectional study, the researchers look for associations between specific health system components and access to psychotropic medicines by analyzing data collected from LAMICs using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). A cross-sectional study analyzes data collected at a single time. WHO-AIMS, which was created to evaluate mental health systems primarily in LAMICs, is a 155-item survey that Ministries of Health and other country-based agencies can use to collect information on mental health indicators.
What Did the Researchers Do and Find?
The researchers used WHO-AIMS data from 63 countries/country regions and multiple regression analysis to evaluate the role of mental health legislation, human rights implementation, mental health care financing, human resources, and advocacy in shaping medicine availability and affordability. For each of these health systems domains, the researchers developed one or more summary measurements. For example, they measured financing as the percentage of government health expenditure directed toward mental health. Availability of psychotropic medicines was defined as the percentage of mental health facilities in which at least one psychotropic medication for each therapeutic category was always available. Affordability was measured by calculating the percentage of daily minimum wage needed to purchase medicine by the average consumer. The availability of psychotropic medicines was related to features of all five mental health systems domains, report the researchers. Notably, having a national mental health plan (part of the legislation domain) and the participation (advocacy) of family-based organizations in mental health legislation formulation were associated with 15% and 17% greater availability of medicines, respectively. By contrast, only the levels of human resources and financing, and the availability of mental health care in prisons (part of the human rights domain) were associated with the affordability of psychotropic medicines. Once overall country development was taken into account, most of the associations between health systems factors and medicine availability remained significant, while the associations between health systems factors and medicine affordability were no longer significant. In part, this was because country development was more strongly associated with affordability and explained most of the relationships: for example, countries with greater overall development have higher expenditures on mental health and greater medicine affordability compared to availability.
What Do These Findings Mean?
These findings indicate that access to psychotropic medicines in LAMICs is related to key components within the mental health systems of these countries but that availability and affordability are affected to different extents by these components. They also show that country development plays a strong role in determining affordability but has less effect on determining availability. Because cross-sectional data were used in this study, these findings only indicate associations; they do not imply causality. They are also limited by the relatively small number of observations included in this study, by the methods used to collect mental health systems data in many LAMICs, and by the possibility that some countries may have reported biased results. Despite these limitations, these findings suggest that strengthening specific mental health system features may be an important way to facilitate access to psychotropic medicines but also highlight the role that country wealth and development play in promoting the treatment of mental disorders.
Additional Information
Please access these Web sites via the online version of this summary at 10.1371/journal.pmed.1001166.
The US National Institute of Mental Health provides information on all aspects of mental health (in English and Spanish)
The UK National Health Service Choices website provides information on mental health; its Live Well feature provides practical advice on dealing with mental health problems and personal stories
The UK charity Mind provides further information about mental illness, including personal stories
MedlinePlus provides links to many other sources of information on mental health (in English and Spanish)
Information on WHO-AIMS, including versions of the instrument in several languages, and WHO-AIMS country reports are available
PMCID: PMC3269418  PMID: 22303288
3.  Relationships among sense of coherence, resources, and mental health in urban and rural residents in Japan 
BMC Public Health  2012;12:1107.
The salutogenic model states that coping resources are defined within sociocultural and historical contexts and that various social and historical factors influence the availability of such resources. Though previous studies have suggested the need for an interregional comparison of psychological and social resources, few studies have undertaken such an investigation. The aim of this study is to investigate the associations among coping resources, sense of coherence (SOC), and health status in a comparison of urban and rural residents.
General residents (aged 30–69 years) in two areas were targeted for the current study. Through a random sampling selection, 1,000 residents from each area were picked, and an anonymous questionnaire was mailed to each resident. Ultimately, 269 and 363 valid responses from the urban and rural areas, respectively, were analyzed. SOC, both social and psychological resources, and mental health were assessed. To examine relationships between SOC and resources associated with mental health, mental health was defined as a dependent variable. Hierarchical multiple regression was conducted with variables entered from sociodemographic characteristics, social and psychological resources, and SOC.
Regarding regional characteristics, social capital and participation in community activities were significantly greater in the rural area than in the urban area. Urban residents reported significantly higher self-esteem and optimism than rural residents. SOC showed the most significant association with mental health in both areas. Mental health was significantly associated with physical activity limitations and life stressors in both areas. However, the associations were weakened when social and psychological resources and SOC were added, which demonstrated their buffering effect on the negative influence of life stressors on health. When SOC was added, the association of self-esteem with mental health disappeared in both areas, but optimism in the urban area and humor in the rural area were directly and independently associated with mental health.
Our findings indicate that resources available to urban and rural residents are characteristic of the area where they live, and that social and psychological resources as well as SOC are associated with better mental health. Possible directions for health support strategies, reflecting regional characteristics, are suggested.
PMCID: PMC3552666  PMID: 23259917
Sense of Coherence; Salutogenic model; Regional differences; Coping resources; Mental health; Population-based study; Japan
4.  Mental health literacy as a function of remoteness of residence: an Australian national study 
BMC Public Health  2009;9:92.
Although there have been many population studies of mental health literacy, little is known about the mental health literacy of people who reside in rural areas. This study sought to determine the impact of remoteness on public knowledge of depression and schizophrenia.
The mental health literacy of residents of major cities, inner regional, and outer-remote (including outer regional, remote, and very remote) regions were compared using data from a 2003–04 Australian national survey of the mental health literacy of 3998 adults. Measures included the perceived helpfulness of a range of professionals, non-professionals and interventions, and the causes, prognosis, and outcomes after treatment for four case vignettes describing depression, depression with suicidal ideation, early schizophrenia and chronic schizophrenia. Participant awareness of Australia's national depression initiative and depression in the media, their symptoms of depression and exposure to the conditions depicted in the vignettes were also compared.
Mental health literacy was similar across remoteness categories. However, inner regional residents showed superior identification of the disorders depicted in the suicidal ideation and chronic schizophrenia vignettes. They were also more likely to report having heard of Australia's national depression health promotion campaign. Conversely, they were less likely than major city residents to rate the evidence-based treatment of psychotherapy helpful for depression. Both inner regional and outer-remote residents were less likely to rate psychologists as helpful for depression alone. The rural groups were more likely to rate the non-evidence based interventions of drinking and painkillers as helpful for a depression vignette. In addition, outer-remote residents were more likely to identify the evidence based treatment of antipsychotics as harmful for early schizophrenia and less likely to endorse psychiatrists, psychologists, social workers and general practitioners as helpful for the condition.
Mental health awareness campaigns in rural and remote regions may be most appropriately focused on communicating which interventions are effective for depression and schizophrenia and which mental health and other professionals are trained in the best-practice delivery and management of these. There is also a need to communicate to rural residents that alcohol and pain relievers are not an effective solution for depression.
PMCID: PMC2670295  PMID: 19327161
5.  A spatial epidemiological analysis of self-rated mental health in the slums of Dhaka 
The deprived physical environments present in slums are well-known to have adverse health effects on their residents. However, little is known about the health effects of the social environments in slums. Moreover, neighbourhood quantitative spatial analyses of the mental health status of slum residents are still rare. The aim of this paper is to study self-rated mental health data in several slums of Dhaka, Bangladesh, by accounting for neighbourhood social and physical associations using spatial statistics. We hypothesised that mental health would show a significant spatial pattern in different population groups, and that the spatial patterns would relate to spatially-correlated health-determining factors (HDF).
We applied a spatial epidemiological approach, including non-spatial ANOVA/ANCOVA, as well as global and local univariate and bivariate Moran's I statistics. The WHO-5 Well-being Index was used as a measure of self-rated mental health.
We found that poor mental health (WHO-5 scores < 13) among the adult population (age ≥15) was prevalent in all slum settlements. We detected spatially autocorrelated WHO-5 scores (i.e., spatial clusters of poor and good mental health among different population groups). Further, we detected spatial associations between mental health and housing quality, sanitation, income generation, environmental health knowledge, education, age, gender, flood non-affectedness, and selected properties of the natural environment.
Spatial patterns of mental health were detected and could be partly explained by spatially correlated HDF. We thereby showed that the socio-physical neighbourhood was significantly associated with health status, i.e., mental health at one location was spatially dependent on the mental health and HDF prevalent at neighbouring locations. Furthermore, the spatial patterns point to severe health disparities both within and between the slums. In addition to examining health outcomes, the methodology used here is also applicable to residuals of regression models, such as helping to avoid violating the assumption of data independence that underlies many statistical approaches. We assume that similar spatial structures can be found in other studies focussing on neighbourhood effects on health, and therefore argue for a more widespread incorporation of spatial statistics in epidemiological studies.
PMCID: PMC3123168  PMID: 21599932
6.  Mental health literacy among residents in Shanghai 
Shanghai Archives of Psychiatry  2013;25(4):224-235.
The recent adoption of China's new national mental health law provides a good opportunity to obtain baseline information about community mental health literacy in the country.
Assess knowledge and attitudes about mental disorders among residents in Shanghai.
A total of 1953 residents aged 15 or above selected from all 19 districts in Shanghai completed two self-report questionnaires – the Mental Health Knowledge Questionnaire (MHKQ) and the Case Assessment Questionnaire (CAQ). MHKQ total scores range from 0 to 20 (higher scores indicate better mental health literacy). The CAQ presents respondents with five case vignettes and possesses nine questions after each vignette measuring respondents' knowledge and attitudes towards these mental illnesses.
Correct response rates for the 20 MHKQ items ranged from 26 to 98%, with a mean rate of 72%. The internal consistency (alpha) of the 20 items on the MHKQ was 0.69, but this decreased to 0.59 after removing four items about mental health promotion. A 5-factor model for the 20 items in the MHKQ was identified using exploratory factor analysis on one-half of the surveys, but the model was only partially validated in the confirmatory factor analysis using the second half of the surveys. On the CAQ, rates of correct recognition of mania, depression, schizophrenia with positive symptoms, schizophrenia with negative symptoms and anxiety were 42%, 35%, 30%, 19% and 21%, respectively. Work stress (37.3%), problems with thinking (30.0%) and negative life events (24.4%) were reported to be the three main causes of mental disorders. Seeing a counselor (34.2%) or a psychiatrist (33.3%) were the two most common suggestions for help-seeking. Higher education and younger age were related with better mental health literacy and higher rates of recognition of common mental disorders.
Mental health literacy in Shanghai appears to be increasing, but the reliability and validity of the instruments used to assess mental health literacy (MHKQ and CAQ) have not been adequately assessed so this result must be considered preliminary. Further work, preferably including both qualitative and quantitative components, is needed to revise these instruments before they can be used to assess the effectiveness of mental health promotion campaigns.
PMCID: PMC4054559  PMID: 24991160
7.  Mental Health and Related Factors after the Great East Japan Earthquake and Tsunami 
PLoS ONE  2014;9(7):e102497.
Mental health is one of the most important issues facing disaster survivors. The purpose of this study is to determine the prevalence and correlates of mental health problems in survivors of the Great East Japan Earthquake and Tsunami at 6–11 months after the disaster. The questionnaire and notification were sent to the survivors in three municipalities in the Tohoku area of the Northern part of Honshu, Japan’s largest island, between September 2011 and February 2012. Questionnaires were sent to 12,772, 11,411, and 18,648 residents in the Yamada, Otsuchi, and Rikuzentakata municipalities, respectively. Residents were asked to bring the completed questionnaires to their health check-ups. A total of 11,124 or (26.0%) of them underwent health check-ups, and 10,198 were enrolled. We excluded 179 for whom a K6 score was missing and two who were both 17 years of age, which left 10,025 study participants (3,934 male and 6,091 female, mean age 61.0 years). K6 was used to measure mental health problems. The respondents were classified into moderate (5–12 of K6) and serious mental health problems (13+). A total of 42.6% of the respondents had moderate or serious mental health problems. Multivariate analysis showed that women were significantly associated with mental health problems. Other variables associated with mental health problems were: younger male, health complaints, severe economic status, relocations, and lack of a social network. An interaction effect of sex and economic status on severe mental health problems was statistically significant. Our findings suggest that mental health problems were prevalent in survivors of the Great East Japan Earthquake and Tsunami. For men and women, health complaints, severe economic status, relocations, and lack of social network may be important risk factors of poor mental health. For men, interventions focusing on economic support may be particularly useful in reducing mental health problems after the disaster.
PMCID: PMC4109922  PMID: 25057824
8.  European network for promoting the physical health of residents in psychiatric and social care facilities (HELPS): background, aims and methods 
BMC Public Health  2009;9:315.
People with mental disorders have a higher prevalence of physical illnesses and reduced life expectancy as compared with the general population. However, there is a lack of knowledge across Europe concerning interventions that aim at reducing somatic morbidity and excess mortality by promoting behaviour-based and/or environment-based interventions.
Methods and design
HELPS is an interdisciplinary European network that aims at (i) gathering relevant knowledge on physical illness in people with mental illness, (ii) identifying health promotion initiatives in European countries that meet country-specific needs, and (iii) at identifying best practice across Europe. Criteria for best practice will include evidence on the efficacy of physical health interventions and of their effectiveness in routine care, cost implications and feasibility for adaptation and implementation of interventions across different settings in Europe. HELPS will develop and implement a "physical health promotion toolkit". The toolkit will provide information to empower residents and staff to identify the most relevant risk factors in their specific context and to select the most appropriate action out of a range of defined health promoting interventions. The key methods are (a) stakeholder analysis, (b) international literature reviews, (c) Delphi rounds with experts from participating centres, and (d) focus groups with staff and residents of mental health care facilities.
Meanwhile a multi-disciplinary network consisting of 15 European countries has been established and took up the work. As one main result of the project they expect that a widespread use of the HELPS toolkit could have a significant positive effect on the physical health status of residents of mental health and social care facilities, as well as to hold resonance for community dwelling people with mental health problems.
A general strategy on health promotion for people with mental disorders must take into account behavioural, environmental and iatrogenic health risks. A European health promotion toolkit needs to consider heterogeneity of mental disorders, the multitude of physical health problems, health-relevant behaviour, health-related attitudes, health-relevant living conditions, and resource levels in mental health and social care facilities.
PMCID: PMC2741451  PMID: 19715560
9.  Coping strategies, depression, and anxiety among Ontario family medicine residents 
Canadian Family Physician  2005;51(2):243.
To assess the current prevalence of depression and anxiety among Ontario family medicine residents, and to describe their coping strategies.
Surveys mailed to residents integrated DSM-IV diagnostic criteria and a previously validated Patient Health Questionnaire.
Ontario family medicine programs from June to August 2002.
Residents entering, advancing in, or graduating from residency programs: approximately 216 yearly for a total of 649 residents.
Types and frequency of coping skills used by residents; prevalence of depressive and anxiety disorders.
Response rate for residents entering programs was 46% and for graduating residents was 30% (37% response rate overall). Prevalence of depressive disorders was 20% (13% major depressive disorders, 7% other depressive syndromes)(odds ratio [OR] 3.4, confidence interval [CI] 2.7 to 7.5, P <.001). Prevalence of generalized anxiety disorder was 12%, and 2% of residents met criteria for panic syndrome (OR 4.3, CI 1.6 to 11.8, P =.002). Rates were similar for men and women. Medical training was commonly identified as a negative influence on the mental health of troubled residents.
Residents most often turned to family and friends when they needed help (43.7% of respondents). About 17.3% saw their family doctors, 15.4% counselors, and 7.9% psychiatrists. Some residents (13.4%) used medication to deal with their affective symptoms, 7.1% underwent cognitive-behavioural therapy, and 8.3% required a leave of absence from their programs.
More than half (61.8%) indicated recreational use of alcohol and drugs, 1.2% identified use due to addiction, and 5.9% used drugs to help cope with their problems. Four respondents admitted concern that they might commit suicide during residency; a different three had made previous attempts.
Affective disorders (both depression and anxiety syndromes) are three to four times more common among Ontario family practice residents than in the general population; male and female residents are equally affected. Most residents with these problems report negative effects on their function at work. Medical training is the most commonly identified negative influence on mental health. While residents most often obtain help from family members and friends, many seek professional help.
PMCID: PMC1472973  PMID: 16926935
10.  No psychiatry? Assessment of family medicine residents' training in mental health issues. 
Canadian Family Physician  1999;45:2636-2641.
OBJECTIVE: To assess whether the mental health component of the family medicine residency program at Memorial University of Newfoundland, which contains no formal mental health training with psychiatrists, adequately prepares residents for practice, and to assess which aspects of their training enhanced their mental health skills most. DESIGN: Cross-sectional mailed survey. SETTING: A 2-year family practice residency program with a focus on training for rural practice offering integrated and eclectic multidisciplinary mental health training rather than formal psychiatry experience. PARTICIPANTS: Graduates of the family practice residency program, 1990 to 1995. Completed questionnaires were returned by 62 of 116 physicians. MAIN OUTCOME MEASURE: Confidence of respondents in dealing with 23 mental health problems. RESULTS: Respondents felt prepared to address most of the mental health needs of their patients. Higher levels of confidence were associated with lower referral rates. There was no significant relationship between time spent in practice and confidence in dealing with mental health problems. Graduates' confidence correlated with areas in the program identified as strong. CONCLUSIONS: The program appears to train family doctors effectively to meet the mental health needs of their patients.
PMCID: PMC2328665  PMID: 10587771
11.  Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2009;6(8):e1000123.
Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.
Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts.
Methods and Findings
Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9–8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5–5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies.
This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.
Please see later in the article for Editors' Summary
Editors' Summary
Suicide is a leading cause of death worldwide. Every 40 seconds, someone somewhere commits suicide. Over a year, this adds up to about 1 million self-inflicted deaths. In the USA, for example, where suicide is the 11th leading cause of death, more than 30,000 people commit suicide every year. The figures for nonfatal suicidal behavior (suicidal thoughts or ideation, suicide planning, and suicide attempts) are even more shocking. Globally, suicide attempts, for example, are estimated to be 20 times as frequent as completed suicides. Risk factors for nonfatal suicidal behaviors and for suicide include depression and other mental disorders, alcohol or drug abuse, stressful life events, a family history of suicide, and having a friend or relative commit suicide. Importantly, nonfatal suicidal behaviors are powerful predictors of subsequent suicide deaths so individuals who talk about killing themselves must always be taken seriously and given as much help as possible by friends, relatives, and mental-health professionals.
Why Was This Study Done?
Experts believe that it might be possible to find ways to decrease suicide rates by answering three questions. First, which individual mental disorders are predictive of nonfatal suicidal behaviors? Although previous studies have reported that virtually all mental disorders are associated with an increased risk of suicidal behaviors, people often have two or more mental disorders (“comorbidity”), so many of these associations may reflect the effects of only a few disorders. Second, do some mental disorders predict suicidal ideation whereas others predict who will act on these thoughts? Finally, are the associations between mental disorders and suicidal behavior similar in developed countries (where most studies have been done) and in developing countries? By answering these questions, it should be possible to improve the screening, clinical risk assessment, and treatment of suicide around the world. Thus, in this study, the researchers undertake a cross-national analysis of the associations among mental disorders (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV]) and nonfatal suicidal behaviors.
What Did the Researchers Do and Find?
The researchers collected and analyzed data on the lifetime presence and age-of-onset of mental disorders and of nonfatal suicidal behaviors in structured interviews with nearly 110,000 participants from 21 countries (part of the World Health Organization's World Mental Health Survey Initiative). The lifetime presence of each of the 16 disorders considered (mood disorders such as depression; anxiety disorders such as post-traumatic stress disorder [PTSD]; impulse-control disorders such as attention deficit/hyperactivity disorder; and substance misuse) predicted first suicide attempts in both developed and developing countries. However, the increased risk of a suicide attempt associated with each disorder varied. So, for example, in developed countries, after controlling for comorbid mental disorders, major depression increased the risk of a suicide attempt 3-fold but drug abuse/dependency increased the risk only 2-fold. Similarly, although the strongest predictors of suicide attempts in developed countries were mood disorders, in developing countries the strongest predictors were impulse-control disorders, substance misuse disorders, and PTSD. Other analyses indicate that mental disorders were generally more predictive of the onset of suicidal thoughts than of suicide plans and attempts, but that anxiety and poor impulse-control disorders were the strongest predictors of suicide attempts in both developed and developing countries.
What Do These Findings Mean?
Although this study has several limitations—for example, it relies on retrospective self-reports by study participants—its findings nevertheless provide a more detailed understanding of the associations between mental disorders and subsequent suicidal behaviors than previously available. In particular, its findings reveal that a wide range of individual mental disorders increase the chances of an individual thinking about suicide in both developed and developing countries and provide new information about the mental disorders that predict which people with suicidal ideas will act on such thoughts. However, the findings also show that only half of people who have seriously considered killing themselves have a mental disorder. Thus although future suicide prevention efforts should include a focus on screening and treating mental disorders, ways must also be found to identify the many people without mental disorders who are at risk of suicidal behaviors.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Institute of Mental Health provides information about suicide in the US: statistics and prevention
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
The World Health Organization provides global statistics about suicide and information on suicide prevention
MedlinePlus provides links to further information and advice about suicide and about mental health (in English and Spanish)
Further details about the World Mental Health Survey Initiative and about DSM-IV are available
PMCID: PMC2717212  PMID: 19668361
12.  Thinking inside the bubble: evidence for a new contextual unit in urban mental health 
Objective: Previous quantitative research has suggested that there is a link between housing, the urban environment, and mental health. However, methodological and design issues make it difficult to disentangle the relative influence of dwelling specific and wider urban environmental influences on individual mental health. The aim of this study was to explore the link between the dwelling, the immediate urban environment, and mental health to generate a new conceptual framework by which understanding of dwelling and urban environmental influences on mental health can be advanced.
Design and participants: Qualitative interviews and focus groups were conducted with 32 inner city residents. Participants, stratified by sex and mental health status, were randomly recruited from a wider quantitative survey. An almost equal number of men and women as well as people with or without mental health problems participated, allowing for comparison of experience. Data were analysed inductively to generate an appropriate theoretical framework regarding dwelling and urban environmental influences on mental health.
Setting: An inner city neighbourhood of about 6200 people in north west London. Most of that population live in public housing.
Main results: The principal study finding is that between the dwelling unit and the neighbourhood unit, evidence was found for another meaningful contextual unit of analysis, the "residential bubble" through which effects on mental health can be mediated. The residential bubble describes a limited area of three dimensional space that surrounds a dwelling, encompassing immediate neighbours (above, below, and adjacent) and shared public space bordering the dwelling. Positive events and processes within the bubble had a beneficial influence on mental health whereas negative ones tended to have a damaging influence. These seemed to disproportionately have an impact on people with pre-existing mental health problems.
Conclusion: The concept of the "residential bubble" may be a meaningful new contextual unit of analysis in urban mental health. This may have important implications with regards to interventions and measurement development.
PMCID: PMC1732909  PMID: 16166366
13.  Psychosocial Interventions for Perinatal Common Mental Disorders Delivered by Providers Who Are Not Mental Health Specialists in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis 
PLoS Medicine  2013;10(10):e1001541.
In a systematic review and meta-analysis, Kelly Clarke and colleagues examine the effect of psychosocial interventions delivered by non–mental health specialists for perinatal common mental disorders in low- and middle-income countries.
Please see later in the article for the Editors' Summary
Perinatal common mental disorders (PCMDs) are a major cause of disability among women. Psychosocial interventions are one approach to reduce the burden of PCMDs. Working with care providers who are not mental health specialists, in the community or in antenatal health care facilities, can expand access to these interventions in low-resource settings. We assessed effects of such interventions compared to usual perinatal care, as well as effects of interventions based on intervention type, delivery method, and timing.
Methods and Findings
We conducted a systematic review, meta-analysis, and meta-regression. We searched databases including Embase and the Global Health Library (up to 7 July 2013) for randomized and non-randomized trials of psychosocial interventions delivered by non-specialist mental health care providers in community settings and antenatal health care facilities in low- and middle-income countries. We pooled outcomes from ten trials for 18,738 participants. Interventions led to an overall reduction in PCMDs compared to usual care when using continuous data for PCMD symptomatology (effect size [ES] −0.34; 95% CI −0.53, −0.16) and binary categorizations for presence or absence of PCMDs (odds ratio 0.59; 95% CI 0.26, 0.92). We found a significantly larger ES for psychological interventions (three studies; ES −0.46; 95% CI −0.58, −0.33) than for health promotion interventions (seven studies; ES −0.15; 95% CI −0.27, −0.02). Both individual (five studies; ES −0.18; 95% CI −0.34, −0.01) and group (three studies; ES −0.48; 95% CI −0.85, −0.11) interventions were effective compared to usual care, though delivery method was not associated with ES (meta-regression β coefficient −0.11; 95% CI −0.36, 0.14). Combined group and individual interventions (based on two studies) had no benefit compared to usual care, nor did interventions restricted to pregnancy (three studies). Intervention timing was not associated with ES (β 0.16; 95% CI −0.16, 0.49). The small number of trials and heterogeneity of interventions limit our findings.
Psychosocial interventions delivered by non-specialists are beneficial for PCMDs, especially psychological interventions. Research is needed on interventions in low-income countries, treatment versus preventive approaches, and cost-effectiveness.
Please see later in the article for the Editors' Summary
Editors' Summary
Perinatal common mental health disorders are among the most common health problems in pregnancy and the postpartum period. In low- and middle-income countries, about 16% of women during pregnancy and about 20% of women in the postpartum period will suffer from a perinatal common mental health disorder. These disorders, including depression and anxiety, are a major cause of disability in women and have been linked to young children under their care being underweight and stunted.
Why Was This Study Done?
While research shows that both pharmacological (e.g., antidepressants or anti-anxiety medications) and non-pharmacological (e.g., psychotherapy, education, or health promotion) interventions are effective for preventing and treating perinatal common mental disorders, most of this research took place in high-income countries. These findings may not be applicable in low-resource settings, where there is limited access to mental health care providers such as psychiatrists and psychologists, and to medications. Thus, non-pharmacological interventions delivered by providers who are not mental health specialists may be important as ways to treat perinatal common mental health disorders in these types of settings. In this study the researchers systematically reviewed research estimating the effectiveness of non-pharmacological interventions for perinatal common mental disorders that were delivered by providers who were not mental health specialists (including health workers, lay persons, and doctors or midwives) in low- and middle-income countries. The researchers also used meta-analysis and meta-regression—statistical methods that are used to combine the results from multiple studies—to estimate the relative effects of these interventions on mental health symptoms.
What Did the Researchers Do and Find?
The researchers searched multiple databases using key search terms to identify randomized and non-randomized clinical trials. Using specific criteria, the researchers retrieved and assessed 37 full papers, of which 11 met the criteria for their systematic review. Seven of these studies were from upper middle-income countries (China, South Africa, Columbia, Mexico, Argentina, Cuba, and Brazil), and four trials were from the lower middle-income countries of Pakistan and India, but there were no trials from low-income countries. The researchers assessed the quality of the selected studies, and one study was excluded from meta-analysis because of poor quality.
Combining results from the ten remaining studies, the researchers found that compared to usual perinatal care (which in most cases included no mental health care), interventions delivered by a providers who were not mental health specialists were associated with an overall reduction in mental health symptoms and the likelihood of being diagnosed with a mental health disorder. The researchers then performed additional analyses to assess relative effects by intervention type, timing, and delivery mode. They observed that both psychological interventions, such as psychotherapy and cognitive behavioral therapy, and health promotion interventions that were less focused on mental health led to significant improvement in mental health symptoms, but psychological interventions were associated with greater effects than health promotion interventions. Interventions delivered both during pregnancy and postnatally were associated with significant benefits when compared to usual care; however, when interventions were delivered during pregnancy only, the benefits were not significantly greater than usual care. When investigating mode of delivery, the researchers observed that both group and individual interventions were associated with improvements in symptoms.
What Do These Findings Mean?
These findings indicate that non-pharmacological interventions delivered by providers who are not mental health specialists could be useful for reducing symptoms of perinatal mental health disorders in middle-income countries. However, these findings should be interpreted with caution given that they are based on a small number of studies with a large amount of variation in the study designs, settings, timing, personnel, duration, and whether the intervention was delivered to a group, individually, or both. Furthermore, when the researchers excluded studies of the lowest quality, the observed benefits of these interventions were smaller, indicating that this analysis may overestimate the true effect of interventions. Nevertheless, the findings do provide support for the use of non-pharmacological interventions, delivered by non-specialists, for perinatal mental health disorders. Further studies should be undertaken in low-income countries.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides information about perinatal mental health disorders
The UK Royal College of Psychiatrists has information for professionals and patients about perinatal mental health disorders
PMCID: PMC3812075  PMID: 24204215
14.  Mental Health and Exposure to Patient Distress Among Families of Nursing Home Residents with Advanced Dementia 
The effect of suffering among patients with advanced dementia on their family members' mental health has not been investigated.
To describe family members' exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family member mental health.
Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0–120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range, 0–24), and SF-12® mental health subscale.
Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were: feeling the resident had had enough (33.2%), choking (21.1%) and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores > 0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score > 0 (AOR 2.31, 95% CI 1.55, 3.43) and have lower SF-12 scores (adjusted parameter estimate −1.51, 95% CI −2.56, −0.47).
Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.
PMCID: PMC3136630  PMID: 21402461
Dementia; caregivers; mental health; nursing home
15.  The Communities First (ComFi) study: protocol for a prospective controlled quasi-experimental study to evaluate the impact of area-wide regeneration on mental health and social cohesion in deprived communities 
BMJ Open  2014;4(10):e006530.
Recent systematic reviews have highlighted the dearth of evidence on the effectiveness of regeneration on health and health inequalities. ‘Communities First’ is an area-wide regeneration scheme to improve the lives of people living in the most deprived areas in Wales (UK). This study will evaluate the impact of Communities First on residents’ mental health and social cohesion.
Methods and analysis
A prospective controlled quasi-experimental study of the association between residence in Communities First regeneration areas in Caerphilly county borough and change in mental health and social cohesion. The study population is the 4226 residents aged 18–74 years who responded to the Caerphilly Health and Social Needs Study in 2001 (before delivery) and 2008 (after delivery of Communities First). Data on the location, type and cost of Communities First interventions will be extracted from records collected by Caerphilly county borough council. The primary outcome is the change in mental health between 2001 and 2008. Secondary outcomes are changes: in common mental disorder case status (using survey and general practice data), social cohesion and mental health inequalities. Multilevel models will examine change in mental health and social cohesion between Communities First and control areas, adjusting for individual and household level confounding factors. Further models will examine the effects of (1) different types of intervention, (2) contamination across areas, (3) length of residence in a Communities First area, and (4) population migration. We will carry out a cost-consequences analysis to summarise the outcomes generated for participants, as well as service utilisation and utility gains.
Ethics and dissemination
This study has had approval from the Information Governance Review Panel at Swansea University (Ref: 0266 CF). Findings will be disseminated through peer-review publications, international conferences, policy and practice partners in local and national government, and updates on our study website (
PMCID: PMC4202000  PMID: 25314962
16.  Single mothers in Ontario: sociodemographic, physical and mental health characteristics 
OBJECTIVE: To examine the sociodemographic, physical and mental health characteristics of single mothers in Ontario. DESIGN: Cross-sectional. SETTING: Ontario. PARTICIPANTS: Ontario residents aged 15 years or older who participated in the Ontario Health Supplement survey conducted between December 1990 and April 1991; of 9953 eligible participants, 1540 were mothers with at least 1 dependent child (less than 16 years of age). OUTCOME MEASURES: Prevalence rates of sociodemographic, physical and mental health characteristics. RESULTS: Single mothers were significantly more likely than the mothers in 2-parent families to be poor, to be 25 years of age or less, to have mental health problems (dissatisfaction with multiple aspects of life, affective disorder ever and 1 or more psychiatric disorders in the past year or ever) and to use mental health services. When compared by income level, poor single mothers had a higher prevalence of all mental health outcomes measured; the difference was significant for anxiety disorder in the past year or ever and for 1 or more psychiatric disorders in the past year or ever. In a logistic regression analysis, single-mother status was found to have the strongest independent effect on predicting mental health morbidity and utilization of mental health services; the next strongest was low income. CONCLUSIONS: Single mothers are more likely to be poor, to have an affective disorder and to use mental health services than mothers in 2-parent families. The risk of mental health problems is especially pronounced among poor single mothers. Further studies are needed to determine which aspects of single motherhood, apart from economic status, affect mental health outcomes.
PMCID: PMC1232827  PMID: 9068569
17.  Study Protocol for the Fukushima Health Management Survey 
Journal of Epidemiology  2012;22(5):375-383.
The accidents that occurred at the Fukushima Daiichi Nuclear Power Plant after the Great East Japan Earthquake on 11 March 2011 have resulted in long-term, ongoing anxiety among the residents of Fukushima, Japan. Soon after the disaster, Fukushima Prefecture launched the Fukushima Health Management Survey to investigate long-term low-dose radiation exposure caused by the accident. Fukushima Medical University took the lead in planning and implementing this survey. The primary purposes of this survey are to monitor the long-term health of residents, promote their future well-being, and confirm whether long-term low-dose radiation exposure has health effects. This report describes the rationale and implementation of the Fukushima Health Management Survey.
This cohort study enrolled all people living in Fukushima Prefecture after the earthquake and comprises a basic survey and 4 detailed surveys. The basic survey is to estimate levels of external radiation exposure among all 2.05 million residents. It should be noted that internal radiation levels were estimated by Fukushima Prefecture using whole-body counters. The detailed surveys comprise a thyroid ultrasound examination for all Fukushima children aged 18 years or younger, a comprehensive health check for all residents from the evacuation zones, an assessment of mental health and lifestyles of all residents from the evacuation zones, and recording of all pregnancies and births among all women in the prefecture who were pregnant on 11 March. All data have been entered into a database and will be used to support the residents and analyze the health effects of radiation.
The low response rate (<30%) to the basic survey complicates the estimation of health effects. There have been no cases of malignancy to date among 38 114 children who received thyroid ultrasound examinations. The importance of mental health care was revealed by the mental health and lifestyle survey and the pregnancy and birth survey. This long-term large-scale epidemiologic study is expected to provide valuable data in the investigation of the health effects of low-dose radiation and disaster-related stress.
PMCID: PMC3798631  PMID: 22955043
cohort study; radiation; disaster; thyroid gland; mental health
18.  Lifetime Prevalence of Mental Disorders in Lebanon: First Onset, Treatment, and Exposure to War  
PLoS Medicine  2008;5(4):e61.
There are no published data on national lifetime prevalence and treatment of mental disorders in the Arab region. Furthermore, the effect of war on first onset of disorders has not been addressed previously on a national level, especially in the Arab region. Thus, the current study aims at investigating the lifetime prevalence, treatment, age of onset of mental disorders, and their relationship to war in Lebanon.
Methods and Findings
The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation study was carried out on a nationally representative sample of the Lebanese population (n = 2,857 adults). Respondents were interviewed using the fully structured WHO Composite International Diagnostic Interview 3.0. Lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder was 25.8%. Anxiety (16.7%) and mood (12.6%) were more common than impulse control (4.4%) and substance (2.2%) disorders. Only a minority of people with any mental disorder ever received professional treatment, with substantial delays (6 to 28 y) between the onset of disorders and onset of treatment. War exposure increased the risk of first onset of anxiety (odds ratio [OR] 5.92, 95% confidence interval [CI] 2.5–14.1), mood (OR 3.32, 95% CI 2.0–5.6), and impulse control disorders (OR 12.72, 95% CI 4.5–35.7).
About one-fourth of the sample (25.8%) met criteria for at least one of the DSM-IV disorders at some point in their lives. There is a substantial unmet need for early identification and treatment. Exposure to war events increases the odds of first onset of mental disorders.
In a survey of 2,857 adults in Lebanon, Elie Karam and colleagues found a lifetime prevalence of any DSM-IV psychiatric disorder of 25.8%.
Editors' Summary
Mental illnesses—persistent problems with thinking, with feelings, with behavior, and with coping with life—are very common. In the UK about a quarter, and in the US, almost half, of people have a mental illness at some time during their life. Depression, for example, persistently lowers a person's mood and can make them feel hopeless and unmotivated. Anxiety—constant, unrealistic worries about daily life—can cause sleep problems and physical symptoms such as stomach pains. People with impulse-control disorders, have problems with controlling their temper or their impulses which may sometimes lead to hurting themselves or other people. These and other mental illnesses seriously affect the work, relationships, and quality of life of the ill person and of their family. However, most people with mental illnesses can lead fulfilling and productive lives with the help of appropriate medical and nonmedical therapies.
Why Was This Study Done?
Recent epidemiological surveys (studies that investigate the factors that affect the health of populations) have provided important information about the burden of mental disorders in some industrialized countries. However, little is known about the global prevalence of mental disorders (the proportion of people in a population with each disorder at one time) or about how events such as wars affect mental health. This information is needed so that individual countries can provide effective mental-health services for their populations. To provide this information, the World Mental Health (WMH) Survey Initiative is undertaking large-scale psychiatric epidemiological surveys in more than 29 countries. As part of this Initiative, researchers have examined the prevalence and treatment of mental disorders in Lebanon and have asked whether war in this country has affected the risk of becoming mentally ill.
What Did the Researchers Do and Find?
The researchers randomly selected a sample of nearly 3,000 adults living in Lebanon and interviewed them using an Arabic version of the World Health Organization's “Composite International Diagnostic Interview” (CIDI 3.0). This interview tool generates diagnoses of mental disorders in the form of “DSM-IV codes,” the American Psychiatric Association's standard codes for specific mental disorders. The researchers also asked the study participants about their experience of war-related traumatic events such as being a civilian in a war zone or being threatened by a weapon. The researchers found that one in four Lebanese had had one or more DSM-IV disorder at some time during their life. Major depression was the single most common disorder. The researchers also calculated that by the age of 75 years, about one-third of the Lebanese would probably have had one or more DSM-IV disorder. Only half of the Lebanese with a mood disorder ever received professional help; treatment rates for other mental disorders were even lower. The average delay in treatment ranged from 6 years for mood disorders to 28 years for anxiety disorders. Finally, exposure to war-related events increased the risk of developing an anxiety, mood, or impulse-control disorder by about 6-fold, 3-fold, and 13-fold, respectively.
What Do These Findings Mean?
These findings indicate that the prevalence of mental illness in Lebanon is similar to that in the UK and the US, the first time that this information has been available for an Arabic-speaking country. Indeed, the burden of mental illness in Lebanon may actually be higher than these findings suggest, because the taboos associated with mental illness may have stopped some study participants from reporting their problems. The findings also show that in Lebanon exposure to war-related events greatly increases the risk of developing for the first time several mental disorders. Further studies are needed to discover whether this finding is generalizable to other countries. Finally, these findings indicate that many people in Lebanon who develop a mental illness never receive appropriate treatment. There is no shortage of health-care professionals in Lebanon, so the researchers suggest that the best way to improve the diagnosis and treatment of mental disorders in this country might be to increase the awareness of these conditions and to reduce the taboos associated with mental illness, both among the general population and among health-care professionals.
Additional Information.
Please access these Web sites via the online version of this summary at
Read a related PLoS Medicine Perspective article
IDRAAC has a database that provides access to all published research articles related to mental health in the Arab World
The UK charity Mind provides information on understanding mental illness
The US National Institute of Mental Health provides information on understanding, treating, and preventing mental disorders (mainly in English but some information in Spanish)
MedlinePlus provides a list of useful links to information about mental health
Wikipedia has a page on DSM-IV codes (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Mental Health Survey Initiative and the Lebanese WHM study are described on the organizations' Web pages
PMCID: PMC2276523  PMID: 18384228
19.  Effect of Racial and Ethnic Composition of Neighborhoods in San Francisco on Rates of Mental-Health Related 911 Calls 
This study investigated the association between San Francisco neighborhoods’ racial/ethnic residential composition and the rate of mental-health-related 911 calls.
Calls to the San Francisco 911 system from January 2001 through June 2003 (n=1,341,608) were divided into mental-health-related and other calls. Police sector data in the call records were overlaid onto U.S. Census tracts to estimate sector demographic and socioeconomic characteristics. Negative binomial regression was used to estimate the association between black, Asian, Latino and white resident percentage and rates of mental-health-related calls.
Percent of black residents was associated with a lower rate of mental-health-related calls (IRR=.99, 95% CI .98–1.00). Percent of Asian and Latino residents had no significant effect.
The observed relationship between black residents and mental-health-related calls is not consistent with known emergency mental health service utilization patterns. The paradox between underutilization of the 911 system and overutilization of psychiatric emergency services deserves further investigation.
PMCID: PMC2881566  PMID: 19797379
20.  Gender and health services use for a mental health problem 
Social science & medicine (1982)  2001;53(7):865-878.
This study addresses whether the predictors of seeking help for a mental health problem differ by gender. An adaptation of Andersen’s Socio-Behavioral Model is used to identify factors associated with seeking care for a mental health problem. Data are derived from two waves of a community survey undertaken in 1992–1993 and in 1993–1994 among a probability sample of adults (18–69 years), residing in poor areas of Puerto Rico. Paired data was used from those individuals who responded to both waves of the survey for a total of 3221 community respondents. Responses from wave 1 were used to predict mental health service use in wave 2. The dependent variable is any use of outpatient mental health services in the year preceding the second interview. Logistic regression was used to model the effects of the independent variables on use. Males and females were found to use mental health services in nearly equal proportions. Gender did not have a main effect on use when other covariates were controlled. Significant interactions with gender were found for several predictors of use. The largest intervention effects were encountered in our need for care indicators. Having a definite need for mental health care and poor self-rated mental health had a larger effect on predicting use of services for men than they do for women. It is concluded that strategies designed to improve access to mental health services for minority disadvantaged populations ought to take into account gender differences in the predictors of use. Studies addressing factors influencing health services utilization for a mental health problem should consider stratifying their sample by gender. Future research should establish whether or not these findings are sustained with other population groups.
PMCID: PMC3656496  PMID: 11522134
Gender; Services use; Mental health; Puerto Rico
21.  Exploring the relationships between housing, neighbourhoods and mental wellbeing for residents of deprived areas 
BMC Public Health  2012;12:48.
Housing-led regeneration has been shown to have limited effects on mental health. Considering housing and neighbourhoods as a psychosocial environment, regeneration may have greater impact on positive mental wellbeing than mental ill-health. This study examined the relationship between the positive mental wellbeing of residents living in deprived areas and their perceptions of their housing and neighbourhoods.
A cross-sectional study of 3,911 residents in 15 deprived areas in Glasgow, Scotland. Positive mental wellbeing was measured using the Warwick-Edinburgh Mental Wellbeing Scale.
Using multivariate mulit-nomial logistic regressions and controlling for socio-demographic characteristics and physical health status, we found that several aspects of people's residential psychosocial environments were strongly associated with higher mental wellbeing. Mental wellbeing was higher when respondents considered the following: their neighbourhood had very good aesthetic qualities (RRR 3.3, 95% CI 1.9, 5.8); their home and neighbourhood represented personal progress (RRR 3.2 95% CI 2.2, 4.8; RRR 2.6, 95% CI 1.8, 3.7, respectively); their home had a very good external appearance (RRR 2.6, 95% CI 1.3, 5.1) and a very good front door (both an aesthetic and a security/control item) (RRR 2.1, 95% CI 1.2, 3.8); and when satisfaction with their landlord was very high (RRR 2.3, 95% CI 2.2,4.8). Perception of poor neighbourhood aesthetic quality was associated with lower wellbeing (RRR 0.4, 95% CI 0.3, 0.5).
This study has shown that for people living in deprived areas, the quality and aesthetics of housing and neighbourhoods are associated with mental wellbeing, but so too are feelings of respect, status and progress that may be derived from how places are created, serviced and talked about by those who live there. The implication for regeneration activities undertaken to improve housing and neighbourhoods is that it is not just the delivery of improved housing that is important for mental wellbeing, but also the quality and manner of delivery.
PMCID: PMC3293078  PMID: 22257729
22.  Development of Mental Health Indicators in Korea 
Psychiatry Investigation  2012;9(4):311-318.
Promoting mental health and preventing mental health problems are important tasks for international organizations and nations. Such goals entail the establishment of active information networks and effective systems and indicators to assess the mental health of populations. This being said, there is a need in Korea develop ways to measure the state of mental health in Korea.
This paper reviews the mental health indicator development policies and practices of seven organizations, countries, and regions: WHO, OECD, EU, United States, Australia, UK, and Scotland. Using Delphi method, we conducted two surveys of mental health indicators for experts in the field of mental health. The survey questionnaire included 5 domains: mental health status, mental health factor, mental health system, mental health service, and quality of mental health services. We considered 124 potential mental health indicators out of more than 600 from indicators of international organizations and foreign countries.
We obtained the top 30 mental health indicators from the surveys. Among them, 10 indicators belong to the mental health system. The most important five mental health indicators are suicide rate, rate of increase in mental disorder treatment, burden caused by mental disorders, adequacy of identifying problems of mental health projects and deriving solutions, and annual prevalence of mental disorders.
Our study provides information about the process for indicator development and the use of survey results to measure the mental health status of the Korean population. The aim of mental health indicator development is to improve the mental health system by better grasping the current situation. We suggest these mental health indicators can monitor progress in efforts to implement reform policies, provide community services, and involve users, families and other stakeholders in mental health promotion, prevention, care and rehabilitation.
PMCID: PMC3521105  PMID: 23251193
Mental health; Mental health indicator; Development
23.  A Transdiagnostic Community-Based Mental Health Treatment for Comorbid Disorders: Development and Outcomes of a Randomized Controlled Trial among Burmese Refugees in Thailand 
PLoS Medicine  2014;11(11):e1001757.
In a randomized controlled trial, Paul Bolton and colleagues investigate whether a transdiagnostic community-based intervention is effective for improving mental health symptoms among Burmese refugees in Thailand.
Please see later in the article for the Editors' Summary
Existing studies of mental health interventions in low-resource settings have employed highly structured interventions delivered by non-professionals that typically do not vary by client. Given high comorbidity among mental health problems and implementation challenges with scaling up multiple structured evidence-based treatments (EBTs), a transdiagnostic treatment could provide an additional option for approaching community-based treatment of mental health problems. Our objective was to test such an approach specifically designed for flexible treatments of varying and comorbid disorders among trauma survivors in a low-resource setting.
Methods and Findings
We conducted a single-blinded, wait-list randomized controlled trial of a newly developed transdiagnostic psychotherapy, Common Elements Treatment Approach (CETA), for low-resource settings, compared with wait-list control (WLC). CETA was delivered by lay workers to Burmese survivors of imprisonment, torture, and related traumas, with flexibility based on client presentation. Eligible participants reported trauma exposure and met severity criteria for depression and/or posttraumatic stress (PTS). Participants were randomly assigned to CETA (n = 182) or WLC (n = 165). Outcomes were assessed by interviewers blinded to participant allocation using locally adapted standard measures of depression and PTS (primary outcomes) and functional impairment, anxiety symptoms, aggression, and alcohol use (secondary outcomes). Primary analysis was intent-to-treat (n = 347), including 73 participants lost to follow-up. CETA participants experienced significantly greater reductions of baseline symptoms across all outcomes with the exception of alcohol use (alcohol use analysis was confined to problem drinkers). The difference in mean change from pre-intervention to post-intervention between intervention and control groups was −0.49 (95% CI: −0.59, −0.40) for depression, −0.43 (95% CI: −0.51, −0.35) for PTS, −0.42 (95% CI: −0.58, −0.27) for functional impairment, −0.48 (95% CI: −0.61, −0.34) for anxiety, −0.24 (95% CI: −0.34, −0.15) for aggression, and −0.03 (95% CI: −0.44, 0.50) for alcohol use. This corresponds to a 77% reduction in mean baseline depression score among CETA participants compared to a 40% reduction among controls, with respective values for the other outcomes of 76% and 41% for anxiety, 75% and 37% for PTS, 67% and 22% for functional impairment, and 71% and 32% for aggression. Effect sizes (Cohen's d) were large for depression (d = 1.16) and PTS (d = 1.19); moderate for impaired function (d = 0.63), anxiety (d = 0.79), and aggression (d = 0.58); and none for alcohol use. There were no adverse events. Limitations of the study include the lack of long-term follow-up, non-blinding of service providers and participants, and no placebo or active comparison intervention.
CETA provided by lay counselors was highly effective across disorders among trauma survivors compared to WLCs. These results support the further development and testing of transdiagnostic approaches as possible treatment options alongside existing EBTs.
Trial registration NCT01459068
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, one in four people will experience a mental health disorder at some time during their life. Although many evidence-based treatments (EBTs), most involving some sort of cognitive behavioral therapy (talking therapies that help people manage their mental health problems by changing the way they think and behave), are now available, many people with mental health disorders never receive any treatment for their condition. The situation is particularly bad for people living in low-resource settings, where a delivery model for EBTs based on referral to mental health professionals is problematic given that mental health professionals are scarce. To facilitate widespread access to mental health care among poor and/or rural populations in low-resource settings, EBTs need to be deliverable at the primary or community level by non-professionals. Moreover, because there is a large burden of trauma-related mental health disorders in low-resource settings and because trauma increases the risk of multiple mental health problems, treatment options that address comorbid (coexisting) mental health problems in low-resource settings are badly needed.
Why Was This Study Done?
One possible solution to the problem of delivering EBTs for comorbid mental health disorders in low-resource settings is “transdiagnostic” treatment. Many mental health EBTs for different disorders share common components. Transdiagnostic treatments recognize these facts and apply these common components to a range of disorders rather than creating a different structured treatment for each diagnosis. The Common Elements Treatment Approach (CETA), for example, trains counselors in a range of components that are similar across EBTs and teaches counselors how to choose components, their order, and dose, based on their client's problems. This flexible approach, which was designed for delivery by non-professional providers in low-resource settings, provides counselors with the skills needed to treat depression, anxiety, and posttraumatic stress—three trauma-related mental health disorders. In this randomized controlled trial, the researchers investigate the use of CETA among Burmese refugees living in Thailand, many of whom are survivors of decades-long harsh military rule in Myanmar. A randomized controlled trial compares the outcomes of individuals chosen to receive different interventions through the play of chance.
What Did the Researchers Do and Find?
The researchers assigned Burmese survivors or witnesses of imprisonment, torture, and related traumas who met symptom criteria for significant depression and/or posttraumatic stress to either the CETA or wait-list control arm of their trial. Lay counselors treated the participants in the CETA arm by delivering CETA components—for example, “psychoeducation” (which teaches clients that their symptoms are normal and experienced by many people) and “cognitive coping” (which helps clients understand that how they think about an event can impact their feelings and behavior)—chosen to reflect the client's priority problems at presentation. Participants in the control arm received regular calls from the trial coordinator to check on their safety but no other intervention. Participants in the CETA arm experienced greater reductions of baseline symptoms of depression, posttraumatic stress, anxiety, and aggression than participants in the control arm. For example, there was a 77% reduction in the average depression score from before the intervention to after the intervention among participants in the CETA arm, but only a 40% reduction in the depression score among participants in the control arm. Importantly, the effect size of CETA (a statistical measure that quantifies the importance of the difference between two groups) was large for depression and posttraumatic stress, the primary outcomes of the trial. That is, compared to no treatment, CETA had a large effect on the symptoms of depression and posttraumatic stress experienced by the trial participants.
What Do These Findings Mean?
These findings suggest that, among Burmese survivors and witnesses of torture and other trauma living in Thailand, CETA delivered by lay counselors was a highly effective treatment for comorbid mental disorders compared to no treatment (the wait-list control). These findings may not be generalizable to other low-resource settings, they provide no information about long-term outcomes, and they do not identify which aspects of CETA were responsible for symptom improvement or explain the improvements seen among the control participants. Given that the study compared CETA to no treatment rather than a placebo (dummy) or active comparison intervention, it is not possible to conclude that CETA works better that existing treatments. Nevertheless, these findings support the continued development and assessment of transdiagnostic approaches for the treatment of mental health disorders in low-resource settings where treatment access and comorbid mental health disorders are important challenges.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides background information about mental health
The US National Institute of Mental Health provides information about a range of mental health disorders and about cognitive behavioral therapy
The UK National Health Service Choices website has information about cognitive behavioral therapy, including some personal stories and links to other related mental health resources on the Choices website
A short introduction to transdiagnosis and CETA written by one of the trial authors is available
Information about this trial is available on the website
The UN Refugee Agency provides information about Burmese (Myanmar) refugees in Thailand
PMCID: PMC4227644  PMID: 25386945
24.  Potentially Inappropriate Medication Prescriptions among Elderly Nursing Home Residents: Their Scope and Associated Resident and Facility Characteristics 
Health Services Research  2004;39(5):1257-1276.
To estimate the scope of potentially inappropriate medication prescriptions (PIRx) among elderly residents in U.S. nursing homes (NHs), and to examine associated resident and facility characteristics.
Data Sources
The 1996 Medical Expenditure Panel Survey Nursing Home Component (MEPS NHC), a survey of a nationally representative sample of NHs and residents.
Study Design
The PIRx, defined by Beers's consensus criteria (1991, 1997), was identified using up to a year's worth of NH prescribed medicine data for each resident. The study sample represented 1.6 million NH residents (n=3,372).
At a minimum, 50 percent of all residents aged 65 or older, with an NH stay of three months or longer received at least one PIRx in 1996. The most common PIRx involved propoxyphene, diphenhydramine, hydroxyzine, oxybutynin, amitriptyline, cyproheptadine, iron supplements, and ranitidine. Resident factors associated with greater odds of PIRx were Medicaid coverage, no high school diploma, and nondementia mental disorders. Facility factors were more beds and lower RN-to-resident ratio. Factors associated with lower odds of PIRx were fewer medications, residents with communication problems, and being in an accredited NH. Onsite availability of pharmacists or mental health providers was not related.
With quality of care and patient safety as major public health concerns, effective policies are needed to avoid PIRx occurrences and improve the quality of prescribing among elderly residents in NHs. Additional studies are needed to determine the impact of PIRx on this NH population.
PMCID: PMC1361069  PMID: 15333108
Quality of prescribing; medication errors; patient safety; long-term care residential setting; MEPS NHC
25.  What does Self Rated Mental Health Represent 
Unlike the widely used self rated health, the self rated mental health was found unsuitable as a proxy for mental illness. This paper analyses the relationships between the self ratings of physical health, mental health and overall health, and their association of with the objective indicators for physical and mental health.
Design and methods
The study is a secondary analysis of data from a nationwide representative sample of the non-institutionalized adult residents of Israel in 2003 that was collected via computer-assisted personal interview methods [n=4859].
The self rated physical health and the self rated mental health were strongly related to each other yet the self rated mental health was not related to chronic physical conditions and the self rated physical health was not related to mental disorders. In a multiple logistic regression analysis, those with positive self rated mental health had 93 times the odds of reporting positive overall health whereas those with positive self rated physical health had 40 times the odds of reporting positive overall health.
The self rating of mental health presents a qualitatively different dimension from mental illness. The self rated mental health is two times more important than the self rated physical health in predicting the self rated overall health
Significance for public healthThe present study is an original study on the self rated physical, mental and overall health measures. Because of the wide range of associations with other health indicators, and the simplicity with which they are collected, self-rated health measures are widely used in large population surveys.The present study questions the automatic assumption that the self rated mental health functions as a proxy measure of psychiatric morbidity, and suggests that the self rated mental health is more closely related to subjective well-being. The results show that self rated mental health predicts self rated general health better than self rated physical health.
PMCID: PMC4274494  PMID: 25553310
self-report; mental-health; population surveys

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