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1.  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
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.
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.
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.
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.
PMCID: PMC3222914  PMID: 18677573
Lancet  2006;367(9515):1000-1006.
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.
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.
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.
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.
PMCID: PMC2030488  PMID: 16564362
4.  An Epidemiological Study of Mental Disorders at Pune, Maharashtra 
The WHO Global Burden of Disease study estimates that mental and addictive disorders are among the most burdensome in the world, and their burden will increase over the next decades. The mental and behavioral disorders account for about 12% of the global burden of disease. However, these estimates and projections are based largely on literature review rather than cross-national epidemiological surveys. In India, little is known about the extent, severity and unmet need of treatment mental disorders. Thus, there was a need to carry out rigorously implemented general population surveys that estimate the prevalence of mental disorders among urban population at Pune, Maharashtra. The study attempted to address unmet need and to form a basis for formulating the mental health need of the community.
The study was undertaken to estimate the lifetime prevalence and 12 month prevalence of specific mental disorders in urban population, socio-demographic correlates of mental disorders and to assess the service utilization in individuals with mental disorders.
Materials and Methods:
The study was undertaken among adults aged 18 years and above living in house hold and in geographical area of Pune , Maharashtra. A minimum sample of 3000 completed interviews was planned using representative probabilities to population size (PPS) sampling method which ensured equal probability for every eligible member. Data listing was obtained from Census Office from recent census of 2001 data. The face to face interviews were undertaken in homes using fully structured interview schedule of World Mental Health Survey Initiative duly revised Version of WHO- Composite International Diagnostic Interview (CIDI 3.0) by trained investigators. Clinical reappraisal was carried out using Schedules for Clinical Assessment in Neuropsychiatry (SCAN) among ten percent of diagnosed cases selected randomly. Data were entered into DDE (Blaize Software) and analyzed using SPSS software package.
Overall lifetime prevalence of mental disorders was found to be 5.03%.Rates among males (5.30%) were higher as compared to females (4.73%). Among the diagnostic group , depression(3.14%) was most prevalent followed by substance use disorder (1.39%) and panic disorder (0.86%). Overall 12 month prevalence of mental disorder was found to be 3.18% which was 3.47% among males and 2.85% among females. Prevalence of depression (1.75%) was the most 12-month mental disorder, followed by substance use mental disorder (0.99%) and panic disorder (0.69%).Lifetime and twelve month prevalence of any mental disorder was the highest among employed group, followed by home makers and depression was more among married, followed by separated/divorced/widowed group and the least in unmarried group in the study. Treatment gap due to low prescription received indicated the most of the ill person did not acknowledge their need for treatment or do not received the appropriate care.
The figure of 5.03% prevalence of diagnosable psychiatric disorders in adult population points to the great need to increase the prevention strategies both at primary and secondary level to overcome the disability and economic loss to society due to mental disorders.
PMCID: PMC3361794  PMID: 22654285
Mental disorders; psychiatry service utilization; sociodemographic correlates
5.  Mental health service use among South Africans for mood, anxiety and substance use disorders 
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.
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.
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.
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
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.
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.
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).
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.
PMCID: PMC2718689  PMID: 18245026
7.  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.
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.
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.
Significant associations were found between substance use and mood and anxiety disorders, with a particularly strong relationship between cannabis use and mental disorder.
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.
PMCID: PMC3946226  PMID: 24624244
SASH; comorbidity; mental disorders; substance use
8.  Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative 
Archives of general psychiatry  2011;68(3):241-251.
There is limited information on the prevalence and correlates of bipolar spectrum disorder in international population-based studies using common methodology.
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.
Cross-sectional face-to-face household surveys
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.
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.
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.
PMCID: PMC3486639  PMID: 21383262
9.  Prevalence and age-of-onset distributions of DSM IV mental disorders and their severity among school going Omani adolescents and youths: WMH-CIDI findings 
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.
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.
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).
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.
PMCID: PMC2761855  PMID: 19781098
10.  Prevalence of Lifetime DSM-IV Affective Disorders among Older African Americans, Black Caribbeans, Latinos, Asians and Non-Hispanic Whites 
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.
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).
Community epidemiologic survey.
Nationally representative sample of adults aged 55 and older (n=3,046).
Disorders were assessed using the DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI).
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.
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.
PMCID: PMC3391316  PMID: 21987438
Depression; anxiety; elderly; race; ethnicity
11.  Religious Participation and DSM-IV Disorders among Older African Americans: Findings from the National Survey of American Life (NSAL) 
This study examined the religious correlates of psychiatric disorders.
The analysis is based on the National Survey of American Life (NSAL). The African American sample of the NSAL is a national representative sample of households with at least one African American adult 18 years or over. This study utilizes the older African American sub-sample (n=837).
Religious correlates of selected measures of lifetime DSM-IV psychiatric disorders (i.e., panic disorder, agoraphobia, social phobia, generalized anxiety disorder, obsessive compulsive disorder, posttraumatic stress, major depressive disorder, dysthymia, bipolar I & II disorders, alcohol abuse/dependence, and drug abuse/dependence) were examined.
Data from 837 African Americans aged 55 years or older are used in this analysis.
The DSM-IV World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to assess mental disorders. Measures of functional status (i.e., mobility and self-care) were assessed using the World Health Organization Disability Assessment Schedule-Second Version (WHODAS-II). Measures of organizational, non-organizational and subjective religious involvement, number of doctor diagnosed physical health conditions, and demographic factors were assessed.
Multivariate analysis found that religious service attendance was significantly and inversely associated with the odds of having a lifetime mood disorder.
This is the first study to investigate the relationship between religious participation and serious mental disorders among a national sample of older African Americans. The inverse relationship between religious service attendance and mood disorders is discussed. Implications for mental health treatment underscore the importance of assessing religious orientations to render more culturally sensitive care.
PMCID: PMC2631206  PMID: 19038894
Church Attendance; Depression; Mood Disorder
12.  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.
Little is known about the general population prevalence or severity of DSM-IV mental disorders.
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).
9282 English-speaking respondents ages 18 and older.
Main Outcome Measures
Twelve-month DSM-IV disorders.
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.
Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
PMCID: PMC2847357  PMID: 15939839
13.  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
14.  Mortality in Patients with HIV-1 Infection Starting Antiretroviral Therapy in South Africa, Europe, or North America: A Collaborative Analysis of Prospective Studies 
PLoS Medicine  2014;11(9):e1001718.
Analyzing survival in HIV treatment cohorts, Andrew Boulle and colleagues find mortality rates in South Africa comparable to or better than those in North America by 4 years after starting antiretroviral therapy.
Please see later in the article for the Editors' Summary
High early mortality in patients with HIV-1 starting antiretroviral therapy (ART) in sub-Saharan Africa, compared to Europe and North America, is well documented. Longer-term comparisons between settings have been limited by poor ascertainment of mortality in high burden African settings. This study aimed to compare mortality up to four years on ART between South Africa, Europe, and North America.
Methods and Findings
Data from four South African cohorts in which patients lost to follow-up (LTF) could be linked to the national population register to determine vital status were combined with data from Europe and North America. Cumulative mortality, crude and adjusted (for characteristics at ART initiation) mortality rate ratios (relative to South Africa), and predicted mortality rates were described by region at 0–3, 3–6, 6–12, 12–24, and 24–48 months on ART for the period 2001–2010. Of the adults included (30,467 [South Africa], 29,727 [Europe], and 7,160 [North America]), 20,306 (67%), 9,961 (34%), and 824 (12%) were women. Patients began treatment with markedly more advanced disease in South Africa (median CD4 count 102, 213, and 172 cells/µl in South Africa, Europe, and North America, respectively). High early mortality after starting ART in South Africa occurred mainly in patients starting ART with CD4 count <50 cells/µl. Cumulative mortality at 4 years was 16.6%, 4.7%, and 15.3% in South Africa, Europe, and North America, respectively. Mortality was initially much lower in Europe and North America than South Africa, but the differences were reduced or reversed (North America) at longer durations on ART (adjusted rate ratios 0.46, 95% CI 0.37–0.58, and 1.62, 95% CI 1.27–2.05 between 24 and 48 months on ART comparing Europe and North America to South Africa). While bias due to under-ascertainment of mortality was minimised through death registry linkage, residual bias could still be present due to differing approaches to and frequency of linkage.
After accounting for under-ascertainment of mortality, with increasing duration on ART, the mortality rate on HIV treatment in South Africa declines to levels comparable to or below those described in participating North American cohorts, while substantially narrowing the differential with the European cohorts.
Please see later in the article for the Editors' Summary
Editors' Summary
AIDS has killed about 36 million people since the first recorded case of the disease in 1981, and a similar number of people (including 25 million living in sub-Saharan Africa) are currently infected with HIV, the virus that causes AIDS. HIV destroys immune system cells (including CD4 cells, a type of lymphocyte), leaving infected individuals susceptible to other serious infections. Early in the AIDS epidemic, HIV-positive people usually died within 10 years of becoming infected. In 1996, effective antiretroviral therapy (ART) became available and, for people living in high-income countries, HIV infection became a chronic condition. But ART was expensive, so HIV/AIDS remained largely untreated and fatal in resource-limited countries. Then, in 2003, the international community began to work towards achieving universal access to ART. By the end of 2012, nearly two-thirds of HIV-positive people (nearly 10 million individuals) living in low- and middle-income countries who were eligible for treatment because their CD4 cell count had fallen below 350/mm3 blood or because they had developed an AIDS-defining condition were receiving treatment.
Why Was This Study Done?
It is known that a larger proportion of HIV-positive patients starting ART die during the first year of treatment in sub-Saharan Africa than in Europe and North America. This difference arises in part because patients in resource-limited settings tend to have lower CD4 counts when they start treatment than patients in wealthy countries. However, the lack of reliable data on mortality (death) in resource-limited settings has made it hard to compare longer-term outcomes in different settings. Information on the long-term outcomes of HIV-positive patients receiving ART in resource-limited countries is needed to guide the development of appropriate health systems and treatment regimens in these settings. In this collaborative analysis of prospective cohort studies, the researchers compare mortality up to 4 years on ART in South Africa, Europe, and North America. A prospective cohort study follows a group of individuals over time to see whether differences in specific characteristics at the start of the study affect subsequent outcomes. A collaborative analysis combines individual patient data from several studies.
What Did the Researchers Do and Find?
The researchers combined data from four South Africa cohorts of HIV-positive patients starting ART included in the International Epidemiologic Databases to Evaluate AIDS South African (IeDEA-SA) collaboration with data from six North American cohorts and nine European cohorts included in the ART Cohort Collaboration (ART-CC). The South African cohorts were chosen because unusually for studies undertaken in countries in sub-Saharan Africa the vital status of patients (whether they had died) who had been lost to follow-up in these cohorts could be obtained from the national population register. Patients in South Africa began treatment with more advanced disease (indicated by a lower average CD4 count) than patients in Europe or North America. Notably, high early mortality after starting ART in South Africa occurred mainly in patients starting ART with a CD4 count below 50 cells/mm3. The cumulative mortality after 4 years of ART was 16.6%, 4.7%, and 15.3% in South Africa, Europe, and North America, respectively. After adjusting for patient characteristics at ART initiation, the mortality rate among patients beginning ART was initially lower in Europe and North American than in South Africa. However, although the adjusted mortality rate in Europe remained lower than the rate in South Africa, the rate in North America was higher than that in South Africa between 24 and 48 months on ART.
What Do These Findings Mean?
Although the linkage to national vital registration systems (databases of births and deaths) undertaken in this collaborative analysis is likely to have greatly reduced bias due to under-ascertainment of mortality, the accuracy of these findings may still be limited by differences in how this linkage was undertaken in different settings. Nevertheless, these findings suggest that mortality among HIV-infected patients receiving ART in South Africa, although initially higher than in Europe and North America, rapidly declines with increasing duration on ART and, after 4 years of treatment, approaches the rate seen in high-income settings. Intriguingly, these findings also highlight the relatively higher late mortality in North America compared to either Europe or South Africa, a result that needs to be investigated to explore the extent to which differences in mortality ascertainment, patient characteristics and comorbidities, or health systems and treatment regimens contribute to variations in outcomes among HIV-positive patients in various settings.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Agnes Binagwaho and colleagues
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on universal access to ART, on HIV and AIDS in sub-Saharan Africa, and on HIV and AIDS in South Africa (in English and Spanish)
The World Health Organization provides information on all aspects of HIV/AIDS (in several languages); its 2013 Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infections: recommendations for a public health approach are available
The 2013 UNAIDS World AIDS Day Report provides up-to-date information about the AIDS epidemic and efforts to halt it
Information about the International Epidemiologic Databases to Evaluate AIDS South African (IeDEA-SA) collaboration and about the ART Cohort Collaboration is available
Personal stories about living with HIV/AIDS are available through Avert, Nam/aidsmap, and Healthtalkonline
PMCID: PMC4159124  PMID: 25203931
15.  Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study 
BMC Psychiatry  2013;13:182.
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.
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.
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.
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.
PMCID: PMC3716970  PMID: 23819543
Posttraumatic stress disorder; Trauma; South Africa
16.  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.
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.
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.
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.
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.
PMCID: PMC2847360  PMID: 17826169
Mental disorders; mental health service use; WMH surveys
17.  Health services utilization by school going Omani adolescents and youths with DSM IV mental disorders and barriers to service use 
Recent corpus of research suggests that psychiatric disorders amongst adolescents and youths are an emerging global challenge, but there is paucity of studies exploring health services utilization by this age group in Arab region.
This study focus on the health services utilization and the barriers among school going adolescents and youths with DSM IV disorders in the country Oman, whose population is predominantly youthful.
Representative sample of secondary school Omani adolescents and youths were concurrently interviewed for the (i) presence of DSM IV mental disorders using the face-to-face interview, World Mental Health-Composite International Diagnostic Interview (WMH-CIDI), (ii) tendency for health care utilization and (iii) predictors of utilization with clinical and demographic background.
The proportions of lifetime cases having ever made treatment contact are low, being 5.2% for any anxiety disorder and 13.2% for any mood disorder category. None of these anxiety cases made treatment contact in the year of onset of the disorder, and the median delay when they eventually made treatment contact is about 14 years. In any mood disorders category only 3.6% made contact within the 1st year of onset with the median delay in initial treatment contact is two years for the Bipolar disorder (broad), four years for Any Mood disorder and nine years for the Major Depressive Disorder group. Male gender is significantly associated with less likelihood of making treatment contact when suffering from Social phobia (p = 0.000), Major Depressive Disorder (p = 0.000) and Bipolar Disorder (p = 0.000). The younger cohorts of 14-16 years and 17-18 years of Social phobic made significantly less lifetime any treatment contact (p = 0.000). The 14-16 year olds were significantly less likely to make lifetime any treatment contact for Bipolar Mood disorder (p = 0.000), while the 17-18 group were 1.5 times more likely to do so. Over past 12 months only between 6 to 12% of those having some form of mental disorder avail of any treatment facility with utilization pattern nearly equal between the any healthcare and any non healthcare facilities. In the any healthcare services, more of those with anxiety disorders seek help from general medical doctors while those with Major Depressive Disorder and any Mood disorders are comparatively treated more by non allopathic services. Females were 13.5 times more likely to avail treatment(chi sq 7.1) as also those cases with increased severity of illness were 7 times more likely(chi sq 9.6). In the any treatment category for any 12 month disorder in general, the younger cohort of 14-16 years is 2.2 times more likely to receive any treatment over past 12 months (p = 0.042) while the situation shows marked reversal in the 17-18 age groups. Having any mood disorder is a significant predictor for the same (p = 0.040).
Present findings confer with other studies from elsewhere suggesting under utilization of health care services for those with mental illness. Since cultural teaching and traditional coping with mental illness are contributing significantly in furnishing mental health need for many in Oman, the findings are discussed within social-cultural context that forms the basis of the complex health care utilization in Oman. This could foster policies that help bridge the gap between allopathic and non-allopathic care services.
PMCID: PMC2761295  PMID: 19781054
18.  Disability and Treatment of Psychiatric and Physical Disorders in South Africa 
We aimed to compare disability rates associated with physical disorders versus psychiatric disorders and to establish treatment rates of both classes of disorder in the South African population. In a nationally representative survey of 4351 adults, treatment and prevalence rates of a range of physical and psychiatric disorders, and their associated morbidity during the previous 12 months were investigated. Physical illnesses were reported in 55.2% of the sample, 60.4% of whom received treatment for their disorder. Approximately 10% of the sample endorsed a mental illness with 6.1% having received treatment for their disorder. The prevalence of any mental illness reported was higher than that reported individually for asthma, cancer, diabetes and peptic ulcer. Mental disorders were consistently reported to be more disabling than physical disorders and the degree of disability increased as the number of comorbid disorders increased. Depression, in particular, was rated consistently higher across all domains than all physical disorders. Despite high rates of mental disorders and associated disability in South Africa, they are less likely to be treated than physical disorders.
PMCID: PMC3222919  PMID: 20061863
Disability; Mental Health; Physical Health; South Africa; Treatment
19.  Days out of role due to mental and physical illness in the South African stress and health study 
Both mental and physical disorders can result in role limitation, such as ‘days out of role’, which have an important impact on national productivity losses. This paper analyses data from the South African Stress and Health Study (SASH) on the association of both mental and physical disorders with days out of role.
Face-to-face interviews were conducted with a representative sample of 4,351 adult South Africans. The World Health Organization’s Composite International Diagnostic Interview (WHO-CIDI) was used to assess the presence of 21 mental and physical disorders that were grouped into 10 disorder categories for the analysis: major depressive disorder, any anxiety disorders, any substance abuse disorders, headaches or migraine, arthritis, chronic pain, cardiovascular, respiratory, diabetes and digestive disorders. Multiple regression techniques were used to explore associations between individual disorders, comorbid conditions, and annual days spent out of role. The estimated societal effects of the disorders [population attributable risk proportion (PARP)] were obtained.
The majority of respondents who reported a mental or physical disorder also reported another disorder (62.98 %). The average number of disorders reported by respondents who had at least one disorder was 2.3. Overall 12.4 % of respondents reported any days out of role due to mental or physical disorder. Anxiety disorders and depression were associated with highest days out of role (28.2 and 27.2, respectively) followed closely by arthritis and pain (24.7 and 21.7, respectively). Any mental disorder was associated with 23.6 days out of role, while any physical disorder was associated with 15.5 days out of role. Of the mental disorders, anxiety disorders had the highest PARP in relation to days out of role (9.0 %) followed by depression (4.8 %) and substance disorder (3.3. %). More than one-third (37.6 %) of days out of role are attributable to physical disorders and 16.1 % to mental disorders.
Comorbidity is common in both mental and physical disorders, and both are associated with substantial days out of role in South Africa. These data indicate substantial social and economic loss associated with these conditions, and emphasize the need to integrate health services to include common mental disorders in all basic packages of care and to assess for and manage comorbid conditions.
PMCID: PMC4322217  PMID: 25096982
Mental disorders; Physical disorders; South Africa; Days out of role; SASH
20.  Mental Disorders in Megacities: Findings from the São Paulo Megacity Mental Health Survey, Brazil 
PLoS ONE  2012;7(2):e31879.
World population growth is projected to be concentrated in megacities, with increases in social inequality and urbanization-associated stress. São Paulo Metropolitan Area (SPMA) provides a forewarning of the burden of mental disorders in urban settings in developing world. The aim of this study is to estimate prevalence, severity, and treatment of recently active DSM-IV mental disorders. We examined socio-demographic correlates, aspects of urban living such as internal migration, exposure to violence, and neighborhood-level social deprivation with 12-month mental disorders.
Methods and Results
A representative cross-sectional household sample of 5,037 adults was interviewed face-to-face using the WHO Composite International Diagnostic Interview (CIDI), to generate diagnoses of DSM-IV mental disorders within 12 months of interview, disorder severity, and treatment. Administrative data on neighborhood social deprivation were gathered. Multiple logistic regression was used to evaluate individual and contextual correlates of disorders, severity, and treatment. Around thirty percent of respondents reported a 12-month disorder, with an even distribution across severity levels. Anxiety disorders were the most common disorders (affecting 19.9%), followed by mood (11%), impulse-control (4.3%), and substance use (3.6%) disorders. Exposure to crime was associated with all four types of disorder. Migrants had low prevalence of all four types compared to stable residents. High urbanicity was associated with impulse-control disorders and high social deprivation with substance use disorders. Vulnerable subgroups were observed: women and migrant men living in most deprived areas. Only one-third of serious cases had received treatment in the previous year.
Adults living in São Paulo megacity had prevalence of mental disorders at greater levels than similar surveys conducted in other areas of the world. Integration of mental health promotion and care into the rapidly expanding Brazilian primary health system should be strengthened. This strategy might become a model for poorly resourced and highly populated developing countries.
PMCID: PMC3279422  PMID: 22348135
21.  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.
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.
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
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
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
PMCID: PMC2443200  PMID: 18597549
22.  Intermittent Explosive Disorder in the National Comorbidity Survey Replication Adolescent Supplement 
Archives of general psychiatry  2012;69(11):1131-1139.
Epidemiologic studies of adults show that DSM-IV intermittent explosive disorder (IED) is a highly prevalent and seriously impairing disorder. Although retrospective reports in these studies suggest that IED typically begins in childhood, no previous epidemiologic research has directly examined the prevalence or correlates of IED among youth.
To present epidemiologic data on the prevalence and correlates of IED among US adolescents in the National Comorbidity Survey Replication Adolescent Supplement.
United States survey of adolescent (age, 13–17 years) DSM-IV anxiety, mood, behavior, and substance disorders.
Dual-frame household-school samples.
A total of 6483 adolescents (interviews) and parents (questionnaires).
Main Outcome Measures
The DSM-IV disorders were assessed with the World Health Organization Composite International Diagnostic Interview (CIDI).
Nearly two-thirds of adolescents (63.3%) reported lifetime anger attacks that involved destroying property, threatening violence, or engaging in violence. Of these, 7.8% met DSM-IV/CIDI criteria for lifetime IED. Intermittent explosive disorder had an early age at onset (mean age, 12.0 years) and was highly persistent, as indicated by 80.1% of lifetime cases (6.2% of all respondents) meeting 12-month criteria for IED. Injuries related to IED requiring medical attention reportedly occurred 52.5 times per 100 lifetime cases. In addition, IED was significantly comorbid with a wide range of DSM-IV/CIDI mood, anxiety, and substance disorders, with 63.9% of lifetime cases meeting criteria for another such disorder. Although more than one-third (37.8%) of adolescents with 12-month IED received treatment for emotional problems in the year before the interview, only 6.5% of respondents with 12-month IED were treated specifically for anger.
Intermittent explosive disorder is a highly prevalent, persistent, and seriously impairing adolescent mental disorder that is both understudied and undertreated. Research is needed to uncover risk and protective factors for the disorder, develop strategies for screening and early detection, and identify effective treatments.
PMCID: PMC3637919  PMID: 22752056
23.  Mental illness and lost income among adult South Africans 
Little is known regarding the links between mental disorder and lost income in low- and middle-income countries. The purpose of this study was to investigate the association between mental disorder and lost income in the first nationally representative psychiatric epidemiology survey in South Africa.
A probability sample of South African adults was administered the World Health Organization Composite International Diagnostic Interview schedule to assess the presence of mental disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders, version IV.
The presence of severe depression or anxiety disorders was associated with a significant reduction in earnings in the previous 12 months among both employed and unemployed South African adults (p = 0.0043). In simulations of costs to individuals, the mean estimated lost income associated with severe depression and anxiety disorders was $4,798 per adult per year, after adjustment for age, gender, substance abuse, education, marital status, and household size. Projections of total annual cost to South Africans living with these disorders in lost earnings, extrapolated from the sample, were $3.6 billion. These data indicate either that mental illness has a major economic impact, through the effect of disability and stigma on earnings, or that people in lower income groups are at increased risk of mental illness. The indirect costs of severe depression and anxiety disorders stand in stark contrast with the direct costs of treatment in South Africa, as illustrated by annual government spending on mental health services, amounting to an estimated $59 million for adults.
The findings of this study support the economic argument for investing in mental health care as a means of mitigating indirect costs of mental illness.
PMCID: PMC3627034  PMID: 23007296
Income; Mental disorder; South Africa; Economics; Health policy
24.  The mental health impact of AIDS-related mortality in South Africa: a national study 
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.
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).
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.
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.
PMCID: PMC3203694  PMID: 19074926
25.  Life stress and mental disorders in the South African Stress and Health study 
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.
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.
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.
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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