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1.  TWELVE-MONTH TREATMENT OF PSYCHIATRIC DISORDERS IN THE SOUTH AFRICAN STRESS AND HEALTH SURVEY (WORLD MENTAL HEALTH SURVEY INITIATIVE) 
Background
The proportion of people with mental disorders in treatment is relatively small in low and middle income countries. However, little is known about patterns of recent service use in a country like South Africa.
Methods
A nationally representative household survey of 4351 adult South Africans was carried out. Twelve-month DSM-IV disorders were determined using the WHO Composite International Diagnostic Interview (CIDI). Prevalence and correlates of treatment were assessed among respondents with anxiety, mood and substance use disorders.
Results
One-fourth (25.5%) of respondents with a 12-month disorder had received treatment in the past 12 months either from a psychiatrist (3.8%), nonpsychiatrist mental health specialist (2.9%), general medical provider (16.6%), human services provider (6.6%), or complementary-alternative medical (CAM) provider (5.9%). Only 27.6% of severe cases had received any treatment. In addition, 13.4% of respondents with no disorder had accessed services in the past year. Blacks were significantly more likely than other racial groups to access the CAM sector while Whites were more likely to have seen a psychiatrist.
Conclusions
The majority of South Africans with a 12-month mental disorder have unmet treatment needs. In addition to a greater allocation of resources to mental health services, more community outreach and awareness initiatives are needed.
doi:10.1007/s00127-008-0399-9
PMCID: PMC3222914  PMID: 18677573
2.  LIFETIME PREVALENCE OF PSYCHIATRIC DISORDERS IN SOUTH AFRICA 
BACKGROUND
Data on the lifetime prevalence of psychiatric disorders in South Africa are of interest, not only for the purposes of developing evidence-based mental health policy, but also in view of South Africa’s particular historical and demographic circumstances.
METHODS
A nationally representative household survey was conducted between 2002 and 2004 using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate diagnoses. The dataset analysed included 4351 adult South Africans of all racial groups.
RESULTS
Lifetime prevalence of DSM-IV/CIDI disorders was determined for anxiety disorders (15.8%), mood disorders (9.8%), substance use disorders (13.4%), and any disorder (30.3%). Lifetime prevalence of substance abuse, but not other disorders, differed significantly across racial groups. Median age of onset was earlier for substance use disorders (21) than for anxiety disorders (32) or mood disorders (37).
CONCLUSION
In comparison to data from other countries, South Africa has a particularly high lifetime prevalence of substance use disorders. These disorders have an early age of onset, providing an important target for the planning of local mental health services.
doi:10.1192/bjp.bp.106.029280
PMCID: PMC2718689  PMID: 18245026
3.  Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study 
BMC Psychiatry  2013;13:182.
Background
South Africa’s unique history, characterised by apartheid, a form of constitutional racial segregation and exploitation, and a long period of political violence and state-sponsored oppression ending only in 1994, suggests a high level of trauma exposure in the general population. The aim of this study was to document the epidemiology of trauma and posttraumatic stress disorder (PTSD) in the South African general population.
Methods
The South African Stress and Health Study is a nationally representative survey of South African adults using the WHO’s Composite International Diagnostic Interview (CIDI) to assess exposure to trauma and presence of DSM-IV mental disorders.
Results
The most common traumatic events were the unexpected death of a loved one and witnessing trauma occurring to others. Lifetime and 12-month prevalence rates of PTSD were 2.3% and 0.7% respectively, while the conditional prevalence of PTSD after trauma exposure was 3.5%. PTSD conditional risk after trauma exposure and probability of chronicity after PTSD onset were both highest for witnessing trauma. Socio-demographic factors such as sex, age and education were largely unrelated to PTSD risk.
Conclusions
The occurrence of trauma and PTSD in South Africa is not distributed according to the socio-demographic factors or trauma types observed in other countries. The dominant role of witnessing in contributing to PTSD may reflect the public settings of trauma exposure in South Africa and highlight the importance of political and social context in shaping the epidemiology of PTSD.
doi:10.1186/1471-244X-13-182
PMCID: PMC3716970  PMID: 23819543
Posttraumatic stress disorder; Trauma; South Africa
4.  12-MONTH PREVALENCE AND TREATMENT OF MENTAL DISORDERS IN LEBANON 
Lancet  2006;367(9515):1000-1006.
SUMMARY
Background:
Mental disorders are thought to account for a significant portion of disease burden throughout the world. However, no national studies have been conducted to assess this assumption in the Arab world.
Methods:
As part of the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative, a nationally representative psychiatric epidemiological survey of n = 2857 adults (ages 18+) was carried out in Lebanon (the Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation: LEBANON). Twelve-month prevalence and severity of DSM-IV disorders and treatment were assessed with the WHO Composite International Diagnostic Interview (CIDI, Version 3.0). Information was also obtained about socio-demographics and exposure to traumatic events in the Lebanon wars.
Findings:
One-sixth (17.0%) of respondents met criteria for at least one 12-month DSM-IV/CIDI disorder, 27.0% of whom were classified serious and an additional 36.0% moderate. Nearly half of respondents had a history of exposure to war-related traumatic events. Significantly elevated odd-ratios (OR) of mood, anxiety and impulse-control disorders were associated with two (OR = 2.0-3.6) or more (OR = 2.2-9.1) war-related traumatic events, resulting in substantially higher proportions of moderate or severe 12-month mental disorders among respondents exposed to multiple war-related traumata (16.8-20.4%) than other respondents (3.3-3.5%). Only 10.9% of respondents with 12-month disorders obtained treatment. Two-thirds of treatment was provided in the general medical sector.
Interpretation:
Mental disorders are common in Lebanon. Prevalence is similar to WMH surveys in Western Europe. Unmet need for treatment is considerably higher in Lebanon than in Western countries.
doi:10.1016/S0140-6736(06)68427-4
PMCID: PMC2030488  PMID: 16564362
5.  Prevalence, Severity, and Comorbidity of Twelve-month DSM-IV Disorders in the National Comorbidity Survey Replication (NCS-R) 
Archives of general psychiatry  2005;62(6):617-627.
Context
Little is known about the general population prevalence or severity of DSM-IV mental disorders.
Objective
To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse-control, and substance disorders in the recently completed US National Comorbidity Survey Replication (NCS-R).
Design and Setting
Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, WHO World Mental Health (WMH) Survey version of the Composite International Diagnostic Interview (WMH-CIDI).
Participants
9282 English-speaking respondents ages 18 and older.
Main Outcome Measures
Twelve-month DSM-IV disorders.
Results
Twelve-month prevalence estimates are anxiety 18.1%, mood 9.5%, impulse-control 8.9%, substance 3.8%, and any disorder 26.2%. 22.3% of 12-month cases are classified serious, 37.3% moderate, and 40.4% mild. 55% carry only a single diagnosis, 22% two, and 23% three or more. Latent class analysis detects seven multivariate disorder classes, including three highly comorbid classes representing 7% of the population.
Conclusions
Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
doi:10.1001/archpsyc.62.6.617
PMCID: PMC2847357  PMID: 15939839
6.  Prevalence of Lifetime DSM-IV Affective Disorders among Older African Americans, Black Caribbeans, Latinos, Asians and Non-Hispanic Whites 
Objectives
The purpose of this study is to estimate lifetime prevalence of 7 psychiatric affective disorders for older non-Hispanic Whites, African Americans, Caribbean Blacks, Latinos and Asian Americans and examine demographic, socioeconomic, and immigration correlates of those disorders.
Design
Data are taken from the older sub-sample of the Collaborative Psychiatric Epidemiology Surveys. Selected measures of lifetime DSM-IV psychiatric disorders were examined (i.e., panic disorder, agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder, major depressive disorder, and dysthymia).
Setting
Community epidemiologic survey.
Participants
Nationally representative sample of adults aged 55 and older (n=3,046).
Measurements
Disorders were assessed using the DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI).
Results
Major depressive disorder and social phobia were the two most prevalent disorders among the 7 psychiatric conditions. Overall, non-Hispanic Whites and Latinos consistently had higher prevalence rates of disorders, African Americans had lower prevalence of major depression and dysthymia, and Asian Americans were typically less likely to report affective disorders than their counterparts. There is variation across groups in the association of demographic, socioeconomic, and immigration variables with disorders.
Conclusions
This study furthers our understanding of the racial and ethnic differences in the prevalence of DSM-IV disorders among older adults and the correlates of those disorders. It highlights the importance of examining both between-and within-group differences in disorders and the complexity of the mechanisms associated with differences across groups. Findings from this study underscores the need for future research that more clearly delineates subgroup differences and similarities.
doi:10.1002/gps.2790
PMCID: PMC3391316  PMID: 21987438
Depression; anxiety; elderly; race; ethnicity
7.  Lifetime mental disorders and suicidal behaviour in South Africa 
African journal of psychiatry  2011;14(2):134-139.
Background
There is relatively little data on the relationship between lifetime mental disorders and suicidal behaviour in low and middle income countries. This study examines the relationship between lifetime mental disorders, and subsequent suicide ideation, plans, and suicide attempts in South Africa.
Method
A national survey of 4185 South African adults was conducted using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate psychiatric diagnoses and suicidal behaviour. Bivariate, multivariate and discrete-time survival analyses were employed to investigate the associations between mental disorders and subsequent suicide ideation, plans, and attempts.
Results
Sixty-one percent of people who seriously considered killing themselves at some point in their lifetime reported having a prior DSM-IV disorder. Mental disorders predict the onset of suicidal ideation, but have weaker effects in predicting suicide plans or attempts. After controlling for comorbid mental disorders, PTSD was the strongest predictor of suicidal ideation and attempts. There is a relationship between number of mental disorders and suicidal behaviour, with comorbidity having significantly sub-additive effects.
Conclusion
Consistent with data from the developed world, mental disorders are strong predictors of suicidal behaviour, and these associations are more often explained by the prediction of ideation, rather than the prediction of attempts amongst ideators. This suggests some universality of the relevant mechanisms underlying the genesis of suicidal thoughts, and the progression to suicide attempts.
PMCID: PMC3224178  PMID: 21687912
Suicide; Survey; South Africa; Mental Disorders
8.  The association between substance use and common mental disorders in young adults: results from the South African Stress and Health (SASH) Survey 
The Pan African Medical Journal  2014;17(Suppl 1):11.
Introduction
Although substance use is commonly associated with mental disorders, limited data on this association are available from low and middle income countries such as South Africa. The aims of the study were i) to determine patterns of substance use in young adults, ii) to identify trends of common psychiatric disorders in relation to use of specific substances, and iii) to determine whether specific psychiatric disorders were associated with use of specific substances in the South African population.
Methods
Data were drawn from the South African Stress and Health (SASH) study, a nationally-representative, cross-sectional survey of South African households that forms part of a World Health Organisation (WHO) World Mental Health (WMH) initiative to standardise information on the global burden of mental illness and its correlates. Data from a subset (n = 1766; aged 18 to 30 years) of the SASH sample of 4351 individuals were analysed. The Composite International Diagnostic Interview Version 3 (CIDI 3.0) was used to elicit basic demographic details and information regarding mental illness and substance use. Multiple regression analyses, adjusted for age and gender, were used to identify associations between mental disorders and substance use.
Results
Significant associations were found between substance use and mood and anxiety disorders, with a particularly strong relationship between cannabis use and mental disorder.
Conclusion
The results are consistent with those from previous studies, and reinforce the argument that comorbid substance use and mental disorders constitute a major public health burden.
doi:10.11694/pamj.supp.2014.17.1.3328
PMCID: PMC3946226  PMID: 24624244
SASH; comorbidity; mental disorders; substance use
9.  Mental health service use among South Africans for mood, anxiety and substance use disorders 
Background
Europe and North America have low rates of mental health service use despite high rates of mental disorder. Little is known about mental health service use among South Africans.
Design
A nationally representative survey of 4 351 adults. Twelve-month DSM-IV (Diagnostic and Statistical Manual, 4th edition) diagnoses, severity, and service utilisation were determined using the World Health Organization Composite International Diagnostic Interview (CIDI). Twelve-month treatment was categorised by sector and province. South Africans in households and hostel quarters were interviewed between 2002 and 2004 in all nine provinces.
Outcome measures
4 317 respondents 18 years and older were analysed. Bivariate logistic regression models predicted (i) 12-month treatment use of service sectors by gender, and (ii) 12-month treatment use by race by gender.
Results
Of respondents with a mental disorder, 25.2% had sought treatment within the previous 12 months; 5.7% had used any formal mental health service. Mental health service use was highest for adults with mood and anxiety disorders, and among those with a mental disorder it varied by province, from 11.4% (Western Cape) to 2.2% (Mpumalanga). More women received treatment, and this was largely attributable to higher rates of treatment in women with mood disorders. Age, income, education and marital status were not significantly associated with mental health service use. Race was associated with the treatment sector accessed in those with a mental disorder.
Conclusions
There is a substantial burden of untreated mental disorders in the South African population, across all provinces and even in those with substantial impairment. Greater allocation of resources to mental health services and more community awareness initiatives are needed to address the unmet need.
PMCID: PMC3192004  PMID: 19588797
10.  Prevalence and age-of-onset distributions of DSM IV mental disorders and their severity among school going Omani adolescents and youths: WMH-CIDI findings 
Background
There is a dearth of studies exploring the magnitude of mental disorders amongst adolescents and youths in the Arab world. To our knowledge, this phase 2 survey in Oman is the first nationally representative school-based study to determine the prevalence of DSM-IV mental disorders (lifetime and over the preceding 12 months), their age-of-onset distributions and determine their severity over the past 12 months using the World Mental Health-Composite International Diagnostic Interview, the WMH-CIDI, used for international comparison.
Methods
A total of 1,682 (91.61%) students out of 1836 students who formed the phase 2 random sub-sample of a multi-stage, stratified, random sampling design (phase 1), participated in the face-to-face structured interview using the Arabic-version of WMH-CIDI 3.0.
Results
The phase 1 results using the General Health Questionnaire (GHQ-12) and Child Depression Inventory (CDI) showed depressive symptoms to be 17% prevalent in the larger sample of 5409 adolescents and youths. Amongst the phase 2 respondents from this sample, 13.9% had at least one DSM IV diagnostic label. The lifetime prevalence of Major Depressive Disorder (MDD) was 3.0%; Bipolar Mood Disorder (BMD) was 1%, Specific phobia 5.8% and Social phobia 1.6%. The female gender was a strong predictor of a lifetime risk of MDD (OR 3.3, 95% CI 1.7-6.3, p = 0.000); Any Mood Disorders (OR 2.5, 95% CI 1.4-4.3, p = 0.002) and Specific Phobia (OR 1.5, 95% CI 1.0-2.4, p = 0.047). The severity of illness for cases diagnosed with 12 month DSM IV disorders was found to be 80% lower in females (OR 0.2, 95%CI 0.0-0.8). The estimates over the previous 12 month period when compared with the lifetime prevalence showed a 25% to 40% lower prevalence for MDD, Specific phobia, Social phobia, Any Anxiety Disorders (AAD) and Any Mood disorders (AMD) while the rate was 80% lower for Separation Anxiety Disorder/Adult Separation Anxiety (SAD/ASA). Mood disorders were significantly lower in the 14-16 age groups (70% lower) in comparison to the older age groups and AMD showed a linear increase in prevalence across increasing age groups (p = 0.035).
Conclusion
The implications of the present findings are not clear cut, however this study endorses the adult CIDI studies findings that mental disorders do begin earlier in life. The relatively lower prevalence of DSM IV depressive disorders cautions against any conclusive interpretation of the inflated results based on the exclusive study of the depressive symptoms alone in the same sample in the same time period. The female gender proved to be a strong predictor of lifetime risk of MDD, any mood disorder and specific phobia. Under-reporting by males or some other gender-specific factors may have contributed to such a discrepancy. The odds of the severity of illness for cases with 12 month DSM IV disorders were significantly lower in females.
doi:10.1186/1753-2000-3-29
PMCID: PMC2761855  PMID: 19781098
11.  The epidemiology of major depression in South Africa: Results from the South African Stress and Health study 
Background
Mental disorders are a major contributor to the burden of disease in all regions of the world. There are limited data on the epidemiology of major depressive disorder in South Africa.
Methods
A nationally representative household survey was conducted between 2002 and 2004 using the World Health Organization Composite International Diagnostic Interview (CIDI) to establish a diagnosis of depression. The dataset analysed included 4 351 adult South Africans of all racial groups.
Results
The prevalence of major depression was 9.7% for lifetime and 4.9% for the 12 months prior to the interview. The prevalence of depression was significantly higher among females than among males. The prevalence was also higher among those with a low level of education. Over 90% of all respondents with depression reported global role impairment.
Conclusion
In comparison with data from other countries, South Africa has lower rates of depression than the USA but higher rates than Nigeria. The findings are broadly consistent with previous findings in South Africa. These findings are the first step in documenting a level of need for care in a context of significant under-funding of mental health services and research in South Africa
PMCID: PMC3195337  PMID: 19588800
12.  Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative 
Archives of general psychiatry  2011;68(3):241-251.
Context
There is limited information on the prevalence and correlates of bipolar spectrum disorder in international population-based studies using common methodology.
Objective
To describe the prevalence, impact, patterns of comorbidity, and patterns of service utilization for bipolar spectrum disorder in the WHO World Mental Health survey (WMH) initiative.
Design
Cross-sectional face-to-face household surveys
Participants
61,392 community adults in 11 countries in the Americas, Europe, and Asia
Main Outcome Measure
DSM-IV disorders, severity, and treatment assessed with the World Mental Health version of the WHO Composite International Diagnostic Interview (WMH CIDI 3.0), a fully-structured lay-administered psychiatric diagnostic interview.
Results
The aggregate lifetime prevalence of BP-I disorder was 0.6%, BP-II was 0.4%, subthreshold BP was 1.4%, and Bipolar Spectrum (BPS) was 2.4%. Twelve-month prevalence of BP-I disorder was 0.4%, BP-II was 0.3%, subthreshold BP was 0.8%, and BPS was 1.5%. Severity of both manic and depressive symptoms, and suicidal behavior increased monotonically from subthreshold BP to BP-I. By contrast, role impairment was similar across bipolar subtypes. Symptom severity was greater for depressive than manic episodes, with approximately 75% of respondents with depression and 50% of respondents with mania reporting severe role impairment. Three-quarters of those with BPS met criteria for at least one other disorder, with anxiety disorders, particularly panic attacks, being the most common comorbid condition. Less than half of those with lifetime BPS received mental health treatment, particularly in low-income countries where only 25% reported contact with the mental health system.
Conclusions
Despite cross-site variation in the prevalence rates of bipolar spectrum disorder, the severity, impact, and patterns of comorbidity were remarkably similar internationally. The uniform increases in clinical correlates, suicidal behavior and comorbidity across each diagnostic category provide evidence for the validity of the concept of a bipolar spectrum. BPS treatment needs are often unmet, particularly in low-income countries.
doi:10.1001/archgenpsychiatry.2011.12
PMCID: PMC3486639  PMID: 21383262
13.  Non-fatal suicidal behavior among South Africans 
Background
Suicide represents 1.8% of the global burden of disease, yet the prevalence and correlates of suicidal behavior in low income countries are unclear. This study examines the prevalence, age of onset and sociodemographic correlates of suicide ideation, planning, and attempts among South Africans.
Method
Nationally representative data are from the South Africa Stress and Health Study (SASH), a national household probability sample of 4,351 South African respondents aged 18 years and older conducted between 2002 and 2003, using the World Health Organization version of the composite international diagnostic interview (CIDI). Bivariate and survival analyses were employed to delineate patterns and correlates of nonfatal suicidal behavior. Transitions are estimated using life table analysis. Risk factors are examined using survival analysis.
Results
The risk for attempted suicide is highest in the age group 18–34 and Coloureds had highest lifetime prevalence for attempts. Cumulative probabilities are 43% for the transition from ideation to a plan, 65% from a plan to an attempt, and 12% from ideation to an unplanned attempt. About 7.5% of unplanned and 50% of planned first attempts occur within 1 year of the onset of ideation. South Africans at higher risk for suicide attempts were younger, female, and less educated.
Conclusions
The burden of nonfatal suicidality in South Africa underscores the need for suicide prevention to be a national priority. Suicide prevention efforts should focus on planned attempts due to the rapid onset and unpredictability of unplanned attempts.
doi:10.1007/s00127-008-0348-7
PMCID: PMC2754160  PMID: 18473134
suicide attempts; self-harming behaviors; South Africa; sociodemographic; ethnicity
14.  Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys 
PLoS Medicine  2008;5(7):e141.
Background
Alcohol, tobacco, and illegal drug use cause considerable morbidity and mortality, but good cross-national epidemiological data are limited. This paper describes such data from the first 17 countries participating in the World Health Organization's (WHO's) World Mental Health (WMH) Survey Initiative.
Methods and Findings
Household surveys with a combined sample size of 85,052 were carried out in the Americas (Colombia, Mexico, United States), Europe (Belgium, France, Germany, Italy, Netherlands, Spain, Ukraine), Middle East and Africa (Israel, Lebanon, Nigeria, South Africa), Asia (Japan, People's Republic of China), and Oceania (New Zealand). The WHO Composite International Diagnostic Interview (CIDI) was used to assess the prevalence and correlates of a wide variety of mental and substance disorders. This paper focuses on lifetime use and age of initiation of tobacco, alcohol, cannabis, and cocaine. Alcohol had been used by most in the Americas, Europe, Japan, and New Zealand, with smaller proportions in the Middle East, Africa, and China. Cannabis use in the US and New Zealand (both 42%) was far higher than in any other country. The US was also an outlier in cocaine use (16%). Males were more likely than females to have used drugs; and a sex–cohort interaction was observed, whereby not only were younger cohorts more likely to use all drugs, but the male–female gap was closing in more recent cohorts. The period of risk for drug initiation also appears to be lengthening longer into adulthood among more recent cohorts. Associations with sociodemographic variables were consistent across countries, as were the curves of incidence of lifetime use.
Conclusions
Globally, drug use is not distributed evenly and is not simply related to drug policy, since countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones. Sex differences were consistently documented, but are decreasing in more recent cohorts, who also have higher levels of illegal drug use and extensions in the period of risk for initiation.
Louisa Degenhardt and colleagues report an international survey of 17 countries that finds clear differences in drug use across different regions of the world.
Editors' Summary
Background.
Understanding how much disability and death a particular disease causes (known as the “burden of disease”) is important. Knowing the burden of a disease in a country contributes to the development of healthier nations by directing strategies and policies against the disease. Researchers' understanding of the burden of diseases across different countries was piecemeal until the 1990 launch of a special World Health Organization (WHO) project, the Global Burden of Disease Project. In 2002, on the basis of updated information from this ongoing project, the WHO estimated that 91 million people were affected by alcohol use disorders and 15 million by drug use disorders.
Why Was This Study Done?
It is widely accepted that alcohol, tobacco, and illegal drug use are linked with a considerable amount of illness, disability, and death. However, there are few high-quality data quantifying the amount across different countries, especially in less-developed countries. The researchers therefore set out to collect basic patterns of alcohol, tobacco, cannabis, and cocaine use in different countries. They documented lifetime use of these substances in each county, focusing on young adults. They also wanted to examine the age of onset of use and whether the type of drugs used was affected by one's social and economic status.
What Did the Researchers Do and Find?
Data on drug use were available from 54,069 survey participants in 17 countries. The 17 countries were determined by the availability of collaborators and on funding for the survey. Trained lay interviewers carried out face-to-face interviews (except in France where the interviews were done over the telephone) using a standardized, structured diagnostic interview for psychiatric conditions. Participants were asked if they had ever used (a) alcohol, (b) tobacco (cigarettes, cigars or pipes), (c) cannabis (marijuana, hashish), or (d) cocaine. If they had used any of these drugs, they were asked about the age they started using each type of drug. The age of first tobacco smoking was not assessed in New Zealand, Japan, France, Germany, Belgium, The Netherlands, Italy, or Spain. The interviewers also recorded the participants' sex, age, years of education, marital status, employment, and household income.
The researchers found that in the Americas, Europe, Japan, and New Zealand, alcohol had been used by the vast majority of survey participants, compared to smaller proportions in the Middle East, Africa, and China. The global distribution of drug use is unevenly distributed with the US having the highest levels of both legal and illegal drug use among all countries surveyed. There are differences in both legal and illegal drug use among different socioeconomic groups. For example, males were more likely than females to have used all drug types; younger adults were more likely than older adults to have used all drugs examined; and higher income was related to drug use of all kinds. Marital status was found to be linked only to illegal drug use—the use of cocaine and cannabis is more likely in people who have never been married or were previously married. Drug use does not appear to be related to drug policy, as countries with more stringent policies (e.g., the US) did not have lower levels of illegal drug use than countries with more liberal policies (e.g., The Netherlands).
What Do These Findings Mean?
These findings present comprehensive and useful data on the patterns of drug use from national samples representing all regions of the world. The data will add to the understanding of the global burden of disease and should be useful to government and health organizations in developing policies to combat these problems. The study does have its limitations—for example, it surveyed only 17 of the world's countries, within these countries there were different rates of participation, and it is unclear whether people accurately report their drug use when interviewed. Nevertheless, the study did find clear differences in drug use across different regions of the world, with the US having among the highest levels of legal and illegal drug use of all the countries surveyed.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050141.
Facts and figures on alcohol are available from the World Health Organization, including information about the burden of disease worldwide as a result of alcohol
Information on the management of substance abuse is available from WHO
Information on the Global Burden of Disease Project is also available from WHO
Researchers from the University of New South Wales, Australia and the University of Queensland co-chair, sponsors the Global Burden of Disease Mental Disorders and Illicit Drug Use Expert Group, which examines illicit drug use and disorders
The UN World Drug Report is available from the UN Office on Drugs and Crime
The University of New South Wales also runs the Secretariat for the Reference Group to the United Nations on HIV and Injecting Drug Use
doi:10.1371/journal.pmed.0050141
PMCID: PMC2443200  PMID: 18597549
15.  Perceived discrimination and mental health disorders: The South African Stress and Health study 
Objectives
To describe the demographic correlates of perceived discrimination and explore the association between perceived discrimination and psychiatric disorders.
Design
A national household survey was conducted between 2002 and 2004 using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate diagnoses of psychiatric disorders. Additional instruments provided data on perceived discrimination and related variables.
Setting
A nationally representative sample of adults in South Africa.
Subjects
4 351 individuals aged 18 years and older.
Outcomes
12-month and lifetime mood, anxiety and substance use disorders.
Results
In the multivariate analyses, acute and chronic racial discrimination were associated with an elevated risk of any 12-month DSM-IV disorder when adjusted for socio-demographic factors, but this association was no longer statistically significant when adjusted for other sources of social stress. In fully adjusted models, acute racial discrimination was associated with an elevated risk of lifetime substance use disorders. Acute and chronic non-racial discrimination were associated with an elevated risk of 12-month and lifetime rates of any disorder, even after adjustment for other stressors and potentially confounding psychological factors. The association of chronic non-racial discrimination and 12-month and lifetime disorder was evident across mood, anxiety, and substance use disorders in the fully adjusted models.
Conclusion
The risk of psychiatric disorders is elevated among persons who report experiences of discrimination. These associations are more robust for chronic than for acute discrimination and for non-racial than for racial discrimination. Perceived discrimination constitutes an important stressor that should be taken into account in the aetiology of psychiatric disorders.
PMCID: PMC3191948  PMID: 19588802
16.  The South African Stress and Health (SASH) study: 12-month and lifetime prevalence of common mental disorders 
Background
The South African Stress and Health (SASH) study is the first large-scale population-based study of common mental disorders in the country. This paper provides data on the 12-month and lifetime prevalence of these conditions.
Methods
Data from a nationally representative sample of 4 351 adults were analysed. Mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). An extensive survey questionnaire detailed contextual and socio-demographic factors, onset and course of mental disorders, and risk factors. Simple weighted cross-tabulation methods were used to estimate prevalence, and logistic regression analysis was used to study correlates of 12-month and lifetime prevalence.
Results
The lifetime prevalence for any disorder was 30.3%, and the most prevalent 12-month and lifetime disorders were the anxiety disorders. The Western Cape had the highest 12-month and lifetime prevalence rates, and the lowest rates were in the Northern Cape.
Conclusions
The SASH study shows relatively high 12-month and lifetime prevalence rates. These findings have significant implications for planning mental health services.
PMCID: PMC3191537  PMID: 19588796
17.  Age differences in the prevalence and comorbidity of DSM-IV major depressive episodes: Results from the WHO World Mental Health Survey Initiative 
Depression and anxiety  2010;27(4):351-364.
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 comorbidity 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 carried out in 10 developed countries (n = 51,771) 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 comorbidity. 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 comorbid mental disorders generally either decreased or remained stable with age, while comorbidity of MDE with mental disorders generally increased with age. Prevalence of physical conditions, in comparison, generally increased with age, while comorbidity 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.
doi:10.1002/da.20634
PMCID: PMC3139270  PMID: 20037917
Elderly; Depression; Disability; Comorbidity; Epidemiology
18.  Emotional Support, Negative Interaction and DSM IV Lifetime Disorders among Older African Americans: Findings from the National Survey of American Life (NSAL) 
Objectives
Both emotional support and negative interaction with family members have been linked to mental health. However, few studies have examined the associations between emotional support and negative interaction and psychiatric disorders in late life. This study investigated the relationship between emotional support and negative interaction on lifetime prevalence of mood and anxiety disorders among older African Americans.
Design
The analyses utilized the National Survey of American Life.
Methods
Logistic regression and negative binomial regression analyses were used to examine the effect of emotional support and negative interaction with family members on the prevalence of lifetime DSM-IV mood and anxiety disorders.
Participants
Data from 786 African Americans aged 55 years and older were used.
Measurement
The DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to assess mental disorders. Three dependent variables were investigated: the prevalence of lifetime mood disorders, the prevalence of lifetime anxiety disorders, and the total number of lifetime mood and anxiety disorders.
Results
Multivariate analysis found that emotional support was not associated with any of the three dependent variables. Negative interaction was significantly and positively associated with the odds of having a lifetime mood disorder, a lifetime anxiety disorder and the number of lifetime mood and anxiety disorders.
Conclusions
This is the first study to investigate the relationship between emotional support, negative interaction with family members and psychiatric disorders among older African Americans. Negative interaction was a risk factor for mood and anxiety disorders among older African Americans, whereas emotional support was not significant.
doi:10.1002/gps.2383
PMCID: PMC2955427  PMID: 20157904
Social support; anxiety; mood disorder; depression; elderly blacks; support network; extended family
19.  The mental health impact of AIDS-related mortality in South Africa: a national study 
Background
Few data exist on how the HIV/AIDS epidemic may influence population mental health. The associations were examined between knowing someone who died of HIV/AIDS and common mental disorders among South African adults.
Methods
Between 2002 and 2004, a nationally representative sample of 4351 adults were interviewed about personally knowing someone who died of HIV/AIDS, and the World Health Organization Composite International Diagnostic Interview was used to generate psychiatric diagnoses for depression, anxiety and substance abuse disorders during the preceding 12 months based on the Diagnostic and Statistical Manual, 4th edition (DSM-IV).
Results
Overall, 42.2% of the sample knew someone who died of HIV/AIDS, and 16.5% met the criteria for at least one DSM-IV diagnosis. Individuals who knew someone who died of HIV/AIDS were significantly more likely to have any DSM-IV defined disorder, including any depressive, anxiety or substance-related disorder (p<0.001 for all associations). In multivariate models adjusted for participant demographic characteristics, life events and socioeconomic status, individual disorders significantly associated with knowing someone who died of HIV/AIDS included generalised anxiety disorder, social phobia and alcohol/drug dependence or abuse. Based on these results, it is estimated that up to 15% of 12-month DSM-IV disorders in the South African adult population may be related to knowing someone who died of HIV/AIDS.
Conclusion
These novel data suggest that AIDS-related mortality may contribute substantially to the burden of mental disorders in settings of high HIV prevalence. While this finding requires further investigation, these data suggest the need to strengthen mental health services in communities where HIV/AIDS is prevalent.
doi:10.1136/jech.2008.080861
PMCID: PMC3203694  PMID: 19074926
20.  Intermittent Explosive Disorder in South Africa: Prevalence, Correlates, and the Role of Traumatic Exposures 
Psychopathology  2009;42(2):92-98.
Background
The epidemiology of DSM-IV intermittent explosive disorder (IED) is not well characterized in developing country settings. In South Africa, given the high rates of violence and trauma, there is particular interest in traumatic exposures as potential risk factors for IED.
Methods
We examined the prevalence and predictors of IED in a nationally representative sample of 4351 South African adults. IED and other diagnoses based on DSM-IV criteria were assessed using the World Health Organization Composite International Diagnostic Interview (CIDI). A 28 item scale was constructed to measure exposure to traumatic events.
Results
Overall, 2.0% of participants (95% CI: 0–4.9%) fulfilled criteria for the narrow definition of IED and 9.5% (95% CI: 6.6–12.3%) fulfilled criteria for the broad definition of IED. Individuals with IED experienced high rates of comorbid anxiety, mood, and substance use disorders compared to non-IED participants. In multivariate analysis, a diagnosis of IED was associated with Caucasian and mixed-race ethnicity, psychiatric comorbidity and exposure to multiple traumatic events.
Conclusion
These data suggest a relatively high prevalence of IED in South Africa. By reducing violence and trauma, and by providing appropriate psychological support to trauma survivors, we may be able to reduce rates of IED.
doi:10.1159/000203341
PMCID: PMC3237393  PMID: 19225243
21.  Perpetration of gross human rights violations in South Africa: Association with psychiatric disorders 
Background
A nationally representative study of psychiatric disorders in South Africa provided an opportunity to study the association between perpetration of human rights violations (HRVs) during apartheid and psychiatric disorder. Prior work has suggested an association between perpetration and post-traumatic stress disorder (PTSD), but this remains controversial.
Methods
Subjects reported on their perpetration of human rights violations, purposeful injury, accidental injury and domestic violence. Lifetime and 12-month prevalence of DSM-IV (Diagnostic and Statistical Manual, 4th edition) disorders were assessed with Version 3.0 of the World Health Organization Composite International Diagnostic Interview (CIDI 3.0). Socio-demographic characteristics of these groups were calculated. Odds ratios for the association between the major categories of psychiatric disorders and perpetration were assessed.
Results
HRV perpetrators were more likely to be male, black and more educated, while perpetrators of domestic violence (DV) were more likely to be female, older, married, less educated and with lower income. HRV perpetration was associated with lifetime and 12-month anxiety and substance use disorders, particularly PTSD. Purposeful and DV perpetration were associated with lifetime and 12-month history of all categories of disorders, whereas accidental perpetration was associated most strongly with mood disorders.
Conclusion
Socio-demographic profiles of perpetrators of HRV and DV in South Africa differ. While the causal relationship between perpetration and psychiatric disorders deserves further study, it is possible that some HRV and DV perpetrators were themselves once victims. The association between accidental perpetration and mood disorder also deserves further attention.
PMCID: PMC3191946  PMID: 19588803
22.  RISK FOR POSTTRAUMATIC STRESS DISORDER ASSOCIATED WITH DIFFERENT FORMS OF INTERPERSONAL VIOLENCE IN SOUTH AFRICA 
Social science & medicine (1982)  2008;67(10):1589-1595.
The South African population is exposed to multiple forms of violence. Using nationally representative data from 4,351 South African adults, this study examined the relative risk for posttraumatic stress disorder (PTSD) associated with political, domestic, criminal, sexual and other (miscellaneous) forms of assault in the South African population. Violence exposure was assessed using the ‘worst event’ list from the WHO’s Composite International Diagnostic Interview (CIDI) and a separate questionnaire assessing experiences of human rights abuses, and lifetime PTSD was assessed according to the APA’s Diagnostic and Statistical Manual of Mental Disorders criteria using the CIDI. Findings indicated that over a third of the South African population has been exposed to some form of violence. The most common forms of violence experienced by men were criminal and miscellaneous assaults, while physical abuse by an intimate partner, childhood physical abuse and criminal assaults were most common for women. Among men, political detention and torture were the forms of violence most strongly associated with a lifetime diagnosis of PTSD, while rape had the strongest association with PTSD among women. At a population level, criminal assault and childhood abuse were associated with the greatest number of PTSD cases among men, while intimate partner violence was associated with the greatest number of PTSD cases among women. Recommendations for mental health service provision in South Africa and for future research on the relative risk for PTSD are offered.
doi:10.1016/j.socscimed.2008.07.023
PMCID: PMC2610682  PMID: 18774211
South Africa; post-traumatic stress disorder (PTSD); violence; relative risk
23.  Lessons Learned from the Clinical Reappraisal Study of the Composite International Diagnostic Interview with Latinos 
Given recent adaptations of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), new methodological studies are needed to evaluate the concordance of CIDI diagnoses with clinical diagnostic interviews. This paper summarizes lessons learned from a clinical reappraisal study done with U. S. Latinos. We compare CIDI diagnoses with independent clinical diagnosis using the World Mental Health Structured Clinical Interview for DSM-IV (WMH SCID 2000). Three sub-samples stratified by diagnostic status (CIDI positive, CIDI negative, or CIDI subthreshold for a disorder) based on nine disorders were randomly selected for a telephone re-interview using the SCID. We calculated sensitivity, specificity, and weight-adjusted Cohen's kappa. Weighted 12 month prevalence estimates of the SCID are slightly higher than those of the CIDI for generalized anxiety disorder, alcohol abuse/dependence, and drug abuse/dependence. For Latinos, CIDI-SCID concordance at the aggregate disorder level is comparable, albeit lower, to other published reports. The CIDI does very well identifying negative cases and classifying disorders at the aggregate level. Good concordance was also found for major depressive episode and panic disorder. Yet, our data suggests that the CIDI presents problems for assessing PTSD and GAD. Recommendations on how to improve future versions of the CIDI for Latinos are offered.
doi:10.1002/mpr.280
PMCID: PMC2729144  PMID: 19507168
concordance; reliability; validity; diagnosis; CIDI; SCID; Latinos
24.  Worldwide Use of Mental Health Services for Anxiety, Mood, and Substance Disorders: Results from 17 Countries in the WHO World Mental Health (WMH) Surveys 
Lancet  2007;370(9590):841-850.
Background
Mental disorders are leading causes of disability worldwide, including in low- and middle-income countries least able to bear such burdens. To begin understanding and improving their treatment, we describe mental health care in 17 countries of the WHO World Mental Health (WMH) Survey Initiative.
Methods
Face-to-face household surveys were conducted among 84,848 community adult respondents in low- or middle- (Colombia, Lebanon, Mexico, Nigeria, China, South Africa, Ukraine) and high-income countries (Belgium, France, Germany, Israel, Italy, Japan, Netherlands, New Zealand, United States). 12-month DSM-IV disorders, their severity, and mental health service use were assessed with the WMH Composite International Diagnostic Interview.
Findings
Respondents using any 12-month mental health services (57 [1.6%; Nigeria] to 1477 [17.9%; US]) was generally lower in less-developed than developed countries and tended to track with countries’ percentages of GDP spent on health care. Although disorder seriousness was related to service use, only 5 (11.0%; China) to 46 (62.1%; Belgium) of severe cases received any care in the prior year. General medical sectors were the largest sources of mental health services. Among respondents initiating treatments, 152 (70.2%; Germany) to 129 (94.5%; Italy) received any follow-up care and 1 (10.4%; Nigeria) to 113 (42.3%; France) received treatments meeting minimal standards for adequacy. Being male, married, less-educated, and in the extremes of age or income were associated with undertreatment.
Interpretation
Unmet needs for mental health treatment are pervasive and especially dire in less-developed countries. Alleviating these unmet needs will require expansion and optimal allocation of treatment resources.
doi:10.1016/S0140-6736(07)61414-7
PMCID: PMC2847360  PMID: 17826169
Mental disorders; mental health service use; WMH surveys
25.  Life stress and mental disorders in the South African Stress and Health study 
Background
Although stressful life events (SLEs) are associated with psychopathology, the contribution from distal and proximal events and the specificity of their association with common mental disorders require further exploration. We examined the association of recent life events and past adversities to mood, anxiety, substance use and impulse control disorders in South Africa.
Methods
Data were analysed from the South African Stress and Health study, a population-based study of mental disorders in a nationally representative sample of 4 351 adults. Psychiatric disorders were assessed with the Composite International Diagnostic Interview (CIDI). This included questions covering early and later SLEs (negative life events, relationship stress, partner violence, social strain and adverse events during childhood) and various socio-demographic variables. Logistic regression models were constructed for 3 957 respondents (2 371 female, 1 586 male) with no missing covariate data, to assess life stress and socio-demographic predictors of 12-month and lifetime disorder.
Results
Recent negative life events and relationship problems were significant predictors of any 12-month disorder and any lifetime disorder. Physical partner violence predicted any lifetime disorder. There was evidence of specificity for the prediction of mood versus anxiety disorders, with childhood adversity specifically associated with mood disorders but not anxiety disorders. Single marital status was the strongest socio-demographic predictor of any 12-month and any lifetime disorder.
Conclusions
Stressful life events, distal and proximal, contribute significantly and independently to the prediction of major psychiatric disorders among South Africans, underscoring the importance of screening adversities in adults with common mental disorders, and of providing appropriate adjunctive interventions.
PMCID: PMC3203647  PMID: 19588801

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