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1.  Cross-National Comparisons of Sex Differences in Opportunities to Use Alcohol or Drugs, and the Transitions to Use 
Substance use & misuse  2011;46(9):1169-1178.
Sex differences in opportunities to use alcohol or drugs, and transition to use, were investigated in 15 surveys, in 2001–2004 (Europe 6; Americas 3; Africa 2, Asia 3; Oceania 1). The paper focuses on 18–29 year olds (N = 9,873). The World Mental Health Survey Initiative oversaw the surveys; each country obtained its own funding. A complex picture emerged with different results for alcohol and for drugs and for opportunity to use and the transition to use. Sex differences in opportunity to use alcohol were small except in Lebanon and Nigeria, whereas for drugs, the largest differences were in Mexico and Colombia.
doi:10.3109/10826084.2011.553659
PMCID: PMC4809203  PMID: 21417555
alcohol drinking; street drugs; sex factors; epidemiology; natural history; opportunity to use
2.  Sub-threshold Post Traumatic Stress Disorder in the WHO World Mental Health Surveys 
Biological psychiatry  2014;77(4):375-384.
Background
Although only a minority of people exposed to a traumatic event (TE) develops PTSD, symptoms not meeting full PTSD criteria are common and often clinically significant. Individuals with these symptoms have sometimes been characterized as having sub-threshold PTSD, but no consensus exists on the optimal definition of this term. Data from a large cross-national epidemiological survey are used to provide a principled basis for such a definition.
Methods
The WHO World Mental Health (WMH) Surveys administered fully-structured psychiatric diagnostic interviews to community samples in 13 countries containing assessments of PTSD associated with randomly selected TEs. Focusing on the 23,936 respondents reporting lifetime TE exposure, associations of approximated DSM-5 PTSD symptom profiles with six outcomes (distress-impairment, suicidality, comorbid fear-distress disorders, PTSD symptom duration) were examined to investigate implications of different sub-threshold definitions.
Results
Although consistently highest distress-impairment, suicidality, comorbidity, and symptom duration were observed among the 3.0% of respondents with DSM-5 PTSD than other symptom profiles, the additional 3.6% of respondents meeting two or three of DSM-5 Criteria BE also had significantly elevated scores for most outcomes. The proportion of cases with threshold versus sub-threshold PTSD varied depending on TE type, with threshold PTSD more common following interpersonal violence and sub-threshold PTSD more common following events happening to loved ones.
Conclusions
Sub-threshold DSM-5 PTSD is most usefully defined as meeting two or three of the DSM-5 Criteria B-E. Use of a consistent definition is critical to advance understanding of the prevalence, predictors, and clinical significance of sub-threshold PTSD.
doi:10.1016/j.biopsych.2014.03.028
PMCID: PMC4194258  PMID: 24842116
posttraumatic stress disorder; PTSD; partial PTSD; sub-threshold PTSD; nosology; epidemiology
3.  Proportion of patients without mental disorders being treated in mental health services worldwide 
The British Journal of Psychiatry  2015;206(2):101-109.
Background
Previous research suggests that many people receiving mental health treatment do not meet criteria for a mental disorder but are rather ‘the worried well’.
Aims
To examine the association of past-year mental health treatment with DSM-IV disorders.
Method
The World Health Organization’s World Mental Health (WMH) Surveys interviewed community samples of adults in 23 countries (n = 62 305) about DSM-IV disorders and treatment in the past 12 months for problems with emotions, alcohol or drugs.
Results
Roughly half (52%) of people who received treatment met criteria for a past-year DSM-IV disorder, an additional 18% for a lifetime disorder and an additional 13% for other indicators of need (multiple subthreshold disorders, recent stressors or suicidal behaviours). Dose-response associations were found between number of indicators of need and treatment.
Conclusions
The vast majority of treatment in the WMH countries goes to patients with mental disorders or other problems expected to benefit from treatment.
doi:10.1192/bjp.bp.113.141424
PMCID: PMC4312965  PMID: 25395690
4.  Same-sex sexuality and psychiatric disorders in the second Netherlands Mental Health Survey and Incidence Study (NEMESIS-2) 
LGBT health  2014;1(4):292-301.
Purpose
Sexual orientation has been shown to be a risk factor for psychiatric disorders. This study compared whether sexual orientation-related disparities in the prevalence of psychiatric disorders are similar based on homosexual behavior versus attraction and tested whether, with increased acceptance of homosexuality, these disparities have diminished over time.
Methods
The Composite International Diagnostic Interview 3.0 was administered with a total of 6,646 Dutch persons, aged 18 to 64 years.
Results
Between 2.0% and 2.5% of the participants reported same-sex sexual behavior in the preceding year or same-sex attraction. Homosexually active persons and persons with same-sex attraction reported a higher prevalence of disorders than heterosexual persons. There were more disparities in the prevalence of disorders based on sexual attraction than based on sexual behavior. Comparing these results with a previous study, showed that no significant changes over time have occurred in the pattern of health disparities.
Conclusions
Sexual orientation continues to be a risk factor for psychiatric disorders, stressing the need for understanding the origins of these disparities.
PMCID: PMC4655175  PMID: 26609539
Sexual orientation; mental disorders; epidemiology; health status disparities; Netherlands
5.  Medically Unexplained and Explained Physical Symptoms in the General Population: Association with Prevalent and Incident Mental Disorders 
PLoS ONE  2015;10(4):e0123274.
Background
Clinical studies have shown that Medically Unexplained Symptoms (MUS) are related to common mental disorders. It is unknown how often common mental disorders occur in subjects who have explained physical symptoms (PHY), MUS or both, in the general population, what the incidence rates are, and whether there is a difference between PHY and MUS in this respect.
Aim
To study the prevalence and incidence rates of mood, anxiety and substance use disorders in groups with PHY, MUS and combined MUS and PHY compared to a no-symptoms reference group in the general population.
Method
Data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face survey of the general population aged 18-64 years. We selected subjects with explained physical symptoms only (n=1952), with MUS only (n=177), with both MUS and PHY (n=209), and a reference group with no physical symptoms (n=4168). The assessment of common mental disorders was through the Composite International Diagnostic Interview 3.0. Multivariate logistic regression analyses were used to examine the association between group membership and the prevalence and first-incidence rates of comorbid mental disorders, adjusted for socio-demographic characteristics.
Results
MUS were associated with the highest prevalence rates of mood and anxiety disorders, and combined MUS and PHY with the highest prevalence rates of substance disorder. Combined MUS and PHY were associated with a higher incidence rate of mood disorder only (OR 2.9 (95%CI:1.27,6.74)).
Conclusion
In the general population, PHY, MUS and the combination of both are related to mood and anxiety disorder, but odds are highest for combined MUS and PHY in relation to substance use disorder. Combined MUS and PHY are related to a greater incidence of mood disorder. These findings warrant further research into possibilities to improve recognition and early intervention in subjects with combined MUS and PHY.
doi:10.1371/journal.pone.0123274
PMCID: PMC4390312  PMID: 25853676
6.  Psychopathological Mechanisms Linking Childhood Traumatic Experiences to Risk of Psychotic Symptoms: Analysis of a Large, Representative Population-Based Sample 
Schizophrenia Bulletin  2014;40(Suppl 2):S123-S130.
Background: Different psychological models of trauma-induced psychosis have been postulated, often based on the observation of “specific” associations between particular types of childhood trauma (CT) and particular psychotic symptoms or the co-occurrence of delusions and hallucinations. However, the actual specificity of these associations remains to be tested. Methods: In 2 population-based studies with comparable methodology (Netherlands Mental Health Survey and Incidence Study-1 [NEMESIS-1] and NEMESIS-2, N = 13 722), trained interviewers assessed CT, psychotic symptoms, and other psychopathology. Specificity of associations was assessed with mixed-effects regression models with multiple outcomes, a statistical method suitable to examine specificity of associations in case of multiple correlated outcomes. Results: Associations with CT were strong and significant across the entire range of psychotic symptoms, without evidence for specificity in the relationship between particular trauma variables and particular psychotic experiences (PEs). Abuse and neglect were both associated with PEs (ORabuse: 2.12, P < .001; ORneglect: 1.96, P < .001), with no large or significant difference in effect size. Intention-to-harm experiences showed stronger associations with psychosis than CT without intent (χ2 = 58.62, P < .001). Most trauma variables increased the likelihood of co-occurrence of delusions and hallucinations rather than either symptom in isolation. Discussion: Intention to harm is the key component linking childhood traumatic experiences to psychosis, most likely characterized by co-occurrence of hallucinations and delusions, indicating buildup of psychotic intensification, rather than specific psychotic symptoms in isolation. No evidence was found to support psychological theories regarding specific associations between particular types of CT and particular psychotic symptoms.
doi:10.1093/schbul/sbt150
PMCID: PMC3934395  PMID: 24562491
epidemiology; childhood adversity; psychosis
7.  Associations between mental disorders and subsequent onset of hypertension 
General hospital psychiatry  2013;36(2):142-149.
Background
Previous work has suggested significant associations between various psychological symptoms (e.g. depression, anxiety, anger, alcohol abuse) and hypertension. However, the presence and extent of associations between common mental disorders and subsequent adult onset of hypertension remains unclear. Further, there is little data available on how such associations vary by gender or over life course.
Methods
Data from the World Mental Health Surveys (comprising 19 countries, and 52,095 adults) were used. Survival analyses estimated associations between first onset of common mental disorders and subsequent onset of hypertension, with and without psychiatric comorbidity adjustment. Variations in the strength of associations by gender and by life course stage of onset of both the mental disorder and hypertension were investigated.
Results
After psychiatric comorbidity adjustment, depression, panic disorder, social phobia, specific phobia, binge eating disorder, bulimia nervosa, alcohol abuse, and drug abuse were significantly associated with subsequent diagnosis of hypertension (with ORs ranging from 1.1 to 1.6). Number of lifetime mental disorders was associated with subsequent hypertension in a dose-response fashion. For social phobia and alcohol abuse, associations with hypertension were stronger for males than females. For panic disorder, the association with hypertension was particularly apparent in earlier onset hypertension.
Conclusions
Depression, anxiety, impulsive eating disorders, and substance use disorders disorders were significantly associated with the subsequent diagnosis of hypertension. These data underscore the importance of early detection of mental disorders, and of physical health monitoring in people with these conditions..
doi:10.1016/j.genhosppsych.2013.11.002
PMCID: PMC3996437  PMID: 24342112
Hypertension; common mental disorders; World Mental Health Surveys
8.  A comparative analysis of role attainment and impairment in binge-eating disorder and bulimia nervosa: Results from the WHO World Mental Health Surveys 
Background
Cross-national population data from the WHO World Mental Health surveys are used to compare role attainments and role impairments associated with binge-eating disorder (BED) and bulimia nervosa (BN).
Methods
Community surveys assessed 23,000 adults across 12 countries for BED, BN, and 10 other DSM-IV mental disorders using the WHO Composite International Diagnostic Interview. Age-of-onset was assessed retrospectively. Ten physical disorders were assessed using standard conditions checklists. Analyses examined reciprocal time-lagged associations of eating disorders with education, associations of early-onset (i.e., prior to completing education) eating disorders with subsequent adult role attainments, and cross-sectional associations of current eating disorders with days of role impairment.
Results
BED and BN predicted significantly increased education (females). Student status predicted increased risk of subsequent BED and BN (females). Early-onset BED predicted reduced odds of current (at time of interview) marriage (females) and reduced odds of current employment (males). Early-onset BN predicted increased odds of current work disability (females and males). Current BED and BN were both associated with significantly increased days of role impairment (females and males). Significant BED and BN effects on adult role attainments and impairments were explained by controls for comorbid disorders.
Conclusions
Effects of BED on role attainments and impairments are comparable to those of BN. The most plausible interpretation of the fact that these associations are explained by comorbid disorders is that causal effects of eating disorders are mediated through secondary disorders. Controlled treatment effectiveness studies are needed to trace out long-term effects of BED-BN on secondary disorders.
doi:10.1017/S2045796013000516
PMCID: PMC4100465  PMID: 24054053
binge eating; bulimia nervosa; eating disorder; comorbidity; outcome; education; income; role impairment; achievement; epidemiology; WHO World Mental Health Surveys
9.  Emotional disorders among informal caregivers in the general population: target groups for prevention 
BMC Psychiatry  2015;15:23.
Background
There are indications that informal caregiving negatively impacts caregivers’ mental health, but this was hardly examined using diagnoses of mental disorders and most studies used convenience samples without including non-caregivers as reference group. We examine whether informal caregivers more often have any emotional disorder, i.e. mood or anxiety disorder, than non-caregivers. Identify key risk indicators for any emotional disorder among informal caregivers in the general population.
Methods
Data were used from the second wave of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2), a nationally representative face-to-face survey (n = 5,303; aged 21–68). Respondents were defined as informal caregiver when they provided unpaid care in the 12 months preceding the second wave to a family member, partner or friend who needed care because of physical or mental problems, or ageing. Twelve-month DSM-IV diagnoses of emotional disorders were assessed using the Composite International Diagnostic Interview 3.0. Key risk indicators were identified using the following aspects: prevalence, odds ratio, attributable risk proportion, and number needed to treat. Sociodemographic, caregiving-related and other characteristics were considered as risk indicators.
Results
In the past year, 31.1% of the respondents provided informal care, which ranged in time spent (8 or more hours/week: 32.1%) and duration (longer than 1 year: 48.7%). Informal caregiving was not associated with having any 12-month emotional disorder. Among caregivers, giving care to a first-degree relative, partner or close friend and giving emotional support increased the risk for any emotional disorder. Moreover, using all aspects, target groups were identified for prevention: caregivers without a job, living without a partner, and with a lack of social support.
Conclusions
Although informal caregivers do not have an increased risk of emotional disorders, key risk indicators were identified using four aspects. Especially informal caregivers with limited resources (unemployment, living without a partner, lack of social support) may benefit from targeted prevention whereas general prevention measures may be desirable for carers with a burdensome care situation (giving care to a close loved one or providing emotional support).
doi:10.1186/s12888-015-0406-0
PMCID: PMC4337323  PMID: 25884352
Informal care; Mood and anxiety disorders; Risk indicators; General population study
10.  Embarrassment When Illness Strikes A Close Relative: A World Mental Health Survey Consortium Multi-Site Study 
Psychological medicine  2013;43(10):2191-2202.
Background
This global study seeks to estimate the degree to which a family member might feel embarrassed when a close relative is suffering from an alcohol, drug, or mental health condition (ADMC) versus a general medical condition (GMC). To date, most studies have considered embarrassment and stigma in society and internalized by the afflicted individual, but have not assessed family embarrassment in a large scale study.
Method
In 16 sites of the World Mental Health Surveys (WMHS), standardized assessments were completed including items on family embarrassment. Site matching was used to constrain local socially shared determinants of stigma-related feelings, enabling a conditional logistic regression model that estimates the embarrassment close relatives may hold in relation to family members affected by an ADMC, GMC, or both conditions.
Results
There was a statistically robust association such that subgroups with an ADMC-affected relative were more likely to feel embarrassed as compared to subgroups with a relative affected by a GMC (p<0.001), even with covariate adjustments for age and sex.
Conclusions
The pattern of evidence from this research is consistent with conceptual models for interventions that target individual- and family-level stigma-related feelings of embarrassment as might be part of the obstacles to effective early intervention and treatment for ADMC conditions. Macro-level interventions are underway, but micro-level interventions also may be required among family members, along with care for each person with an ADMC.
doi:10.1017/S003329171200298X
PMCID: PMC4013530  PMID: 23298443
Family Embarrassment; Stigma; World Mental Health Surveys; Psychiatric Conditions
11.  Smoking estimates from around the world: data from the first 17 participating countries in the World Mental Health Survey Consortium 
Tobacco control  2009;19(1):65-74.
Objective
To contribute new multinational findings on basic descriptive features of smoking and cessation, based upon standardised community surveys of adults residing in seven low-income and middle-income countries and 10 higher-income countries from all regions of the world.
Methods
Data were collected using standardised interviews and community probability sample survey methods conducted as part of the WHO World Mental Health Surveys Initiative. Demographic and socioeconomic correlates of smoking are studied using cross-tabulation and logistic regression approaches. Within-country sample weights were applied with variance estimation appropriate for complex sample survey designs.
Results
Estimated prevalence of smoking experience (history of ever smoking) and current smoking varied across the countries under study. In all but four countries, one out of every four adults currently smoked. In higher-income countries, estimated proportions of former smokers (those who had quit) were roughly double the corresponding estimates for most low-income and middle-income countries. Characteristics of smokers varied within individual countries, and in relation to the World Bank's low-medium-high gradient of economic development. In stark contrast to a sturdy male-female difference in the uptake of smoking seen in each country, there is no consistent sex-associated pattern in the odds of remaining a smoker (versus quitting).
Conclusion
The World Mental Health Surveys estimates complement existing global tobacco monitoring efforts. The observed global diversity of associations with smoking and smoking cessation underscore reasons for implementation of the Framework Convention on Tobacco Control provisions and prompt local adaptation of prevention and control interventions.
doi:10.1136/tc.2009.032474
PMCID: PMC4124902  PMID: 19965796
12.  CUMULATIVE TRAUMAS AND RISK THRESHOLDS: 12-MONTH PTSD IN THE WORLD MENTAL HEALTH (WMH) SURVEYS 
Depression and anxiety  2013;31(2):130-142.
Background
Clinical research suggests that posttraumatic stress disorder (PTSD) patients exposed to multiple traumatic events (TEs) rather than a single TE have increased morbidity and dysfunction. Although epidemiological surveys in the United States and Europe also document high rates of multiple TE exposure, no population-based cross-national data have examined this issue.
Methods
Data were analyzed from 20 population surveys in the World Health Organization World Mental Health Survey Initiative (n 51,295 aged 18+). The Composite International Diagnostic Interview (3.0) assessed 12-month PTSD and other common DSM-IV disorders. Respondents with 12-month PTSD were assessed for single versus multiple TEs implicated in their symptoms. Associations were examined with age of onset (AOO), functional impairment, comorbidity, and PTSD symptom counts.
Results
19.8% of respondents with 12-month PTSD reported that their symptoms were associated with multiple TEs. Cases who associated their PTSD with four or more TEs had greater functional impairment, an earlier AOO, longer duration, higher comorbidity with mood and anxiety disorders, elevated hyper-arousal symptoms, higher proportional exposures to partner physical abuse and other types of physical assault, and lower proportional exposure to unexpected death of a loved one than cases with fewer associated TEs.
Conclusions
A risk threshold was observed in this large-scale cross-national database wherein cases who associated their PTSD with four or more TEs presented a more “complex” clinical picture with substantially greater functional impairment and greater morbidity than other cases of PTSD. PTSD cases associated with four or more TEs may merit specific and targeted intervention strategies. Depression and Anxiety 31:130–142, 2014.
doi:10.1002/da.22169
PMCID: PMC4085043  PMID: 23983056
PTSD; functional impairment; comorbidity; World Mental Health Surveys; epidemiology
13.  The prevalence and correlates of binge eating disorder in the WHO World Mental Health Surveys 
Biological psychiatry  2013;73(9):904-914.
Background
Little population-based data exist outside the United States on the epidemiology of binge eating disorder (BED). Cross-national data on BED are presented and compared to bulimia nervosa (BN) based on the WHO World Mental Health Surveys.
Methods
Community surveys with 24,124 respondents (ages 18+) across 14 mostly upper-middle and high income countries assessed lifetime and 12-month DSM-IV mental disorders with the WHO Composite International Diagnostic Interview. Physical disorders were assessed with a chronic conditions checklist.
Results
Country-specific lifetime prevalence estimates are consistently (median; inter-quartile range) higher for BED (1.4%;0.8–1.9%) than BN (0.8%;0.4–1.0%). Median age-of-onset is in the late teens to early 20s for both disorders but slightly younger for BN. Persistence is slightly higher for BN (6.5 years; 2.2–15.4) than BED (4.3 years; 1.0–11.7). Lifetime risk of both disorders is elevated for women and recent cohorts. Retrospective reports suggest that comorbid anxiety, mood, and disruptive behavior disorders predict subsequent onset of BN somewhat more strongly than BED and that BN predicts subsequent comorbid psychiatric disorders somewhat more strongly than does BED. Significant comorbidities with physical conditions are due almost entirely to BN and BED predicting subsequent onset of these conditions, again with BN somewhat stronger than BED. Role impairments are similar for BN and BED. Fewer than half of lifetime BN or BED cases receive treatment.
Conclusions
BED represents a public health problem at least equal to BN. Low treatment rates highlight the clinical importance of questioning patients about eating problems even when not included among presenting complaints.
doi:10.1016/j.biopsych.2012.11.020
PMCID: PMC3628997  PMID: 23290497
binge eating disorder; epidemiology; WHO World Mental Health Surveys; bulimia nervosa; comorbidity; treatment
14.  Disorder-specific cognitive profiles in major depressive disorder and generalized anxiety disorder 
BMC Psychiatry  2014;14:96.
Background
This investigation examines differences in cognitive profiles in subjects with major depressive disorder (MDD) and generalized anxiety disorder (GAD).
Methods
Data were used from subjects with current MDD (n = 655), GAD (n = 107) and comorbid MDD/GAD (n = 266) diagnosis from the Netherlands Study of Depression and Anxiety (NESDA). The Composite Interview Diagnostic Instrument was used to diagnose MDD and GAD. Cognitive profiles were measured using the Leiden Index of Depression Sensitivity, the Anxiety Sensitivity Index, and the Penn State Worry Questionnaire.
Results
Results showed that differences in cognitive profiles between single MDD and single GAD subjects were present: scores on hopelessness/suicidality and rumination were significantly higher in MDD than GAD, whereas anxiety sensitivity for physical concerns and pathological worry were higher in GAD than MDD. The cognitive profile of comorbid MDD/GAD showed more extreme depression cognitions compared to single disorders, and a similar anxiety profile compared to single GAD subjects.
Conclusions
Despite the commonalities in cognitive profiles in MDD and GAD, there are differences suggesting that MDD and GAD have disorder-specific cognitive profiles. Findings of this investigation give support for models like the cognitive content-specificity model and the tripartite model and could provide useful handles for treatment focus.
doi:10.1186/1471-244X-14-96
PMCID: PMC3975137  PMID: 24690413
Major depressive disorder; Generalized anxiety disorder; Cognitive profiles; Treatment; Classification
15.  An Updated Global Picture of Cigarette Smoking Persistence among Adults 
Background
Cross-national variance in smoking prevalence is relatively well documented. The aim of this study is to estimate levels of smoking persistence across 21 countries with a hypothesized inverse relationship between country income level and smoking persistence.
Methods
Data from the World Health Organization World Mental Health Survey Initiative were used to estimate cross-national differences in smoking persistence–the proportion of adults who started to smoke and persisted in smoking by the date of the survey.
Result
There is large variation in smoking persistence from 25% (Nigeria) to 85% (China), with a random-effects meta-analytic summary estimate of 55% with considerable cross-national variation. (Cochran's heterogeneity Q statistic=6,845; p<0.001). Meta-regressions indicated observed differences are not attributable to differences in country income level, age distribution of smokers, or how recent the onset of smoking began within each country.
Conclusion
While smoking should remain an important public health issue in any country where smokers are present, this report identifies several countries with higher levels of smoking persistence (namely, China and India).
doi:10.1016/j.jegh.2012.06.003
PMCID: PMC3635135  PMID: 23626929
16.  The Role of Study and Work in Cannabis Use and Dependence Trajectories among Young Adult Frequent Cannabis Users 
Life course theory considers events in study and work as potential turning points in deviance, including illicit drug use. This qualitative study explores the role of occupational life in cannabis use and dependence in young adults. Two and three years after the initial structured interview, 47 at baseline frequent cannabis users were interviewed in-depth about the dynamics underlying changes in their cannabis use and dependence. Overall, cannabis use and dependence declined, including interviewees who quit using cannabis completely, in particular with students, both during their study and after they got employed. Life course theory appeared to be a useful framework to explore how and why occupational life is related to cannabis use and dependence over time. Our study showed that life events in this realm are rather common in young adults and can have a strong impact on cannabis use. While sometimes changes in use are temporary, turning points can evolve from changes in educational and employment situations; an effect that seems to be related to the consequences of these changes in terms of amount of leisure time and agency (i.e., feelings of being in control).
doi:10.3389/fpsyt.2013.00085
PMCID: PMC3739012  PMID: 23950748
frequent cannabis use; cannabis dependence; young adults; qualitative research; life course approach; longitudinal study; education; employment
17.  Early-life mental disorders and adult household income in the World Mental Health Surveys 
Biological Psychiatry  2012;72(3):228-237.
Background
Better information on the human capital costs of early-onset mental disorders could increase sensitivity of policy-makers to the value of expanding initiatives for early detection-treatment. Data are presented on one important aspect of these costs: the associations of early-onset mental disorders with adult household income.
Methods
Data come from the WHO World Mental Health (WMH) Surveys in eleven high income, five upper-middle income, and six low/lower-middle income countries. Information about 15 lifetime DSM-IV mental disorders as of age of completing education, retrospectively assessed with the WHO Composite International Diagnostic Interview, was used to predict current household income among respondents ages 18-64 (n = 37,741) controlling for level of education. Gross associations were decomposed to evaluate mediating effects through major components of household income.
Results
Early-onset mental disorders are associated with significantly reduced household income in high and upper-middle income countries but not low/lower-middle income countries, with associations consistently stronger among women than men. Total associations are largely due to low personal earnings (increased unemployment, decreased earnings among the employed) and spouse earnings (decreased probabilities of marriage and, if married, spouse employment and low earnings of employed spouses). Individual-level effect sizes are equivalent to 16-33% of median within-country household income, while population-level effect sizes are in the range 1.0-1.4% of Gross Household Income.
Conclusions
Early mental disorders are associated with substantial decrements in income net of education at both individual and societal levels. Policy-makers should take these associations into consideration in making healthcare research and treatment resource allocation decisions.
doi:10.1016/j.biopsych.2012.03.009
PMCID: PMC3402018  PMID: 22521149
epidemiology; mental disorders; early-onset; income; cross-national; WHO World Mental Health (WMH)
18.  Functional disability as an explanation of the associations between chronic physical conditions and 12-month major depressive episode 
Journal of affective disorders  2009;124(0):38-44.
Background
The link between physical conditions and mental health is poorly understood. Functional disability could explain the association of physical conditions with major depressive episode (MDE) as an intermediary factor.
Methods
Data was analyzed from a subsample (N=8,796) of the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional general population survey. MDE during the last 12 months was assessed using a revision of the Composite International Diagnostic Interview (CIDI 3.0). Lifetime chronic physical conditions were assessed by self-report. Functional disability was measured using a version of the World Health Organization Disability Assessment Schedule (WHODAS). The associations of physical conditions with MDE and explanation by functional disability were quantified using logistic regression.
Results
All physical conditions were significantly associated with MDE. The increases in risk of MDE ranged from 30% for allergy to amply 100% for arthritis and heart disease. When adjusted for physical comorbidity, associations decreased and were no longer statistically significant for allergy and diabetes. Functional disability explained between 17 and 64% of these associations, most substantially for stomach or duodenum ulcer, arthritis and heart disease.
Limitations
Due to the cross-sectional nature of the study the temporal relationship of the variables could not be assessed and the amount of explanation can not simply be interpreted as the amount of mediation.
Conclusions
Our findings suggest that the association of chronic physical conditions with MDE is partly explained by functional disability. Such explanation is more pronounced for pain causing conditions and heart disease. Health professionals should be particularly aware of the increased risk of depressive disorder when patients experience disability from these conditions.
doi:10.1016/j.jad.2009.10.026
PMCID: PMC3659772  PMID: 19939461
Major depressive episode; chronic physical conditions; disability
19.  Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys 
The British Journal of Psychiatry  2012;200(4):290-299.
Background
Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity.
Aims
To examine the associations of parent with respondent disorders.
Method
Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews.
Results
Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle- than low-/lower-middle-income countries, and consistently higher for behaviour (11.0-19.9%) than other (7.1-14.0%) disorders.
Conclusions
Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.
doi:10.1192/bjp.bp.111.101253
PMCID: PMC3317036  PMID: 22403085
20.  Phenotypically Continuous With Clinical Psychosis, Discontinuous in Need for Care: Evidence for an Extended Psychosis Phenotype 
Schizophrenia Bulletin  2011;38(2):231-238.
Background:
Rates of self-reported psychotic experiences (SRPEs) in general population samples are high; however the reliability against interview-based assessments and the clinical significance of false-positive (FP) ratings remain unclear. Design: The second Netherlands Mental Health Survey and Incidence Study-2, a general population study.
Methods:
Trained lay interviewers administered a structured interview assessing psychopathology and psychosocial characteristics in 6646 participants. Participants with at least one SRPE (N = 1084) were reassessed by clinical telephone interview.
Results:
Thirty-six percent of participants with SRPEs were confirmed by clinical interview as true positive (TP). SPREs not confirmed by clinical interview (FP group) generated less help-seeking behavior and occurred less frequently compared with TP experiences (TP group). However, compared with controls without psychotic experiences, the FP group more often displayed mood disorder (relative risk [RR] 1.7, 1.4–2.2), substance use disorder (RR 2.0, 1.6–2.6), cannabis use (RR 1.5, 1.2–1.9), higher levels of neuroticism (RR 1.8, 1.5–2.2), affective dysregulation, and social dysfunction. The FP group also experienced more sexual (RR 2.0, 1.5–2.8) and psychological childhood trauma (RR 2.1, 1.7–2.6) as well as peer victimization (RR 1.5, 1.2–2.0) and recent life events (RR 2.0, 1.6–2.4) than controls without psychotic experiences. Differences between the FP group and the TP group across these domains were much smaller and less conclusive.
Discussion:
SRPEs not confirmed by clinical interview may epresent the softest expression of an extended psychosis phenotype that is phenotypically continuous with clinical psychosis but discontinuous in need for care.
doi:10.1093/schbul/sbr129
PMCID: PMC3283149  PMID: 21908795
diagnosis; schizophrenia; trauma; cannabis; epidemiology; false positive
21.  Treatment of suicidal people around the world † 
Background
Suicide is a leading cause of death worldwide; however, little information is available about the treatment of suicidal people, or about barriers to treatment.
Aims
To examine the receipt of mental health treatment and barriers to care among suicidal people around the world.
Method
Twenty-one nationally representative samples worldwide (n=55 302; age 18 years and over) from the World Health Organization’s World Mental Health Surveys were interviewed regarding past-year suicidal behaviour and past-year healthcare use. Suicidal respondents who had not used services in the past year were asked why they had not sought care.
Results
Two-fifths of the suicidal respondents had received treatment (from 17% in low-income countries to 56% in high-income countries), mostly from a general medical practitioner (22%), psychiatrist (15%) or non-psychiatrist (15%). Those who had actually attempted suicide were more likely to receive care. Low perceived need was the most important reason for not seeking help (58%), followed by attitudinal barriers such as the wish to handle the problem alone (40%) and structural barriers such as financial concerns (15%). Only 7% of respondents endorsed stigma as a reason for not seeking treatment.
Conclusions
Most people with suicide ideation, plans and attempts receive no treatment. This is a consistent and pervasive finding, especially in low-income countries. Improving the receipt of treatment worldwide will have to take into account culture-specific factors that may influence the process of help-seeking.
doi:10.1192/bjp.bp.110.084129
PMCID: PMC3167419  PMID: 21263012
22.  Parental Psychopathology and the Risk of Suicidal Behavior in their Offspring: Results from the World Mental Health Surveys 
Molecular psychiatry  2010;16(12):1221-1233.
Prior research suggests that parental psychopathology predicts suicidal behavior among offspring; however, the more fine-grained associations between specific parental disorders and distinct stages of the pathway to suicide are not well-understood. We set out to test the hypothesis that parental disorders associated with negative mood would predict offspring suicide ideation, whereas disorders characterized by impulsive-aggression (e,g., antisocial personality) and anxiety/agitation (e.g., panic disorder) would predict which offspring act on their suicide ideation and make a suicide attempt. Data were collected during face-to-face interviews conducted on nationally representative samples (N=55,299; age 18+) from 21 countries around the world. We tested the associations between a range of parental disorders and the onset and persistence over time (i.e., time-since-most-recent-episode controlling for age-of-onset and time-since-onset) of subsequent suicidal behavior (suicide ideation, plans, and attempts) among offspring. Analyses tested bivariate and multivariate associations between each parental disorder and distinct forms of suicidal behavior. Results revealed that each parental disorder examined increased the risk of suicide ideation among offspring, parental generalized anxiety and depression emerged as the only predictors of the onset and persistence (respectively) of suicide plans among offspring with ideation, whereas parental anti-social personality and anxiety disorders emerged as the only predictors of the onset and persistence of suicide attempts among ideators. A dose-response relation between parental disorders and respondent risk of suicide ideation and attempt also was found. Parental death by suicide was a particularly strong predictor of persistence of suicide attempts among offspring. These associations remained significant after controlling for comorbidity of parental disorders and for the presence of mental disorders among offspring. These findings should inform future explorations of the mechanisms of inter-generational transmission of suicidal behavior.
doi:10.1038/mp.2010.111
PMCID: PMC3142278  PMID: 21079606
suicide; parent and family history; intergenerational transmission
23.  Modifications to the WHODAS-II for the World Mental Health Surveys: Implications of Filter Items 
Journal of Clinical Epidemiology  2008;61(11):1132-1143.
Objective
The WHODAS-II was substantially modified for use in the World Mental Health Surveys. This paper considers the modified WHODAS-II’s psychometric properties and implications of filter items employed to reduce respondent burden.
Study design and setting
Seventeen surveys in 16 countries administered a modified WHODAS-II to population samples (N=38,934 adults). Modifications included introducing filter questions for four sub-scales and substituting questions on the number of days activity was limited for the Life Activities domain. We evaluated distributional properties, reliability, and validity of the modified WHODAS-II.
Results
Most respondents (77%–99%) had zero scores on filtered subscales. Lower bound estimates of internal consistency (alpha) for the filtered subscales were typically in the 0.70’s, but were higher for the Global scale. Loadings of subscale scores on a Global Disability factor were moderate-to-high. Correlations with the Sheehan Disability Scale were modest but consistently positive, while correlations with SF-12 Physical Component Summary were considerably higher. Cross-national variability in disability scores was observed, but was not readily explainable.
Conclusions
Internal consistency and validity of the modified WHODAS-II was generally supported, but use of filter questions impaired measurement properties. Group differences in modified WHODAS-II disability scores may be compared within, but not necessarily across, countries.
doi:10.1016/j.jclinepi.2007.12.009
PMCID: PMC3277915  PMID: 18619808
Disability; Measurement; Reliability; Validity; Survey; Epidemiology
24.  Development of lifetime comorbidity in the WHO World Mental Health (WMH) Surveys 
Archives of general psychiatry  2011;68(1):90-100.
CONTEXT
Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity.
OBJECTIVE
To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the WHO World Mental Health (WMH) surveys.
SETTING/PARTICIPANTS
Nationally or regionally representative community surveys in 14 countries with a total of 21,229 respondents.
MAIN OUTCOME MEASURES
First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the WHO Composite International Diagnostic Interview (CIDI).
RESULTS
Separate internalizing (anxiety and mood disorders) and externalizing (behavior and substance disorders) factors were found in exploratory factor analysis of lifetime disorders. Consistently significant positive time-lagged associations were found in survival analyses for virtually all temporally primary lifetime disorders predicting subsequent onset of other disorders. Within-domain (i.e., internalizing or externalizing) associations were generally stronger than between-domain associations. The vast majority of time-lagged associations were explained by a model that assumed the existence of mediating latent internalizing and externalizing variables. Specific phobia and obsessive-compulsive disorder (internalizing) and hyperactivity disorder and oppositional-defiant disorder (externalizing) were the most important predictors. A small number of residual associations remained significant after controlling the latent variables.
CONCLUSIONS
The good fit of the latent variable model suggests that common causal pathways account for most of the comorbidity among the disorders considered here. These common pathways should be the focus of future research on the development of comorbidity, although several important pair-wise associations that cannot be accounted for by latent variables also exist that warrant further focused study.
doi:10.1001/archgenpsychiatry.2010.180
PMCID: PMC3057480  PMID: 21199968
25.  The role of Criterion A2 in the DSM-IV diagnosis of post-traumatic stress disorder 
Biological psychiatry  2010;68(5):465-473.
Background
Controversy exists about the utility of DSM-IV post-traumatic stress disorder (PTSD) Criterion A2: that exposure to a potentially traumatic experience (PTE; PTSD Criterion A1) is accompanied by intense fear, helplessness, or horror.
Methods
Lifetime DSM-IV PTSD was assessed with the Composite International Diagnostic Interview in community surveys of 52,826 respondents across 21 countries in the World Mental Health Surveys.
Results
37.6% of 28,490 representative PTEs reported by respondents met Criterion A2, a proportion higher than the proportions meeting other criteria (B-F; 5.4-9.6%). Conditional prevalence of meeting all other criteria for a diagnosis of PTSD given a PTE was significantly higher in the presence (9.7%) than absence (0.1%) of A2. However, as only 1.4% of respondents who met all other criteria failed A2, the estimated prevalence of PTSD increased only slightly (from 3.64% to 3.69%) when A2 was not required for diagnosis. PTSD with or without Criterion A2 did not differ in persistence or predicted consequences (subsequent suicidal ideation or secondary disorders) depending on presence-absence of A2. Furthermore, as A2 was by far the most commonly reported symptom of PTSD, initial assessment of A2 would be much less efficient than screening other criteria in quickly ruling out a large proportion of non-cases.
Conclusion
Removal of A2 from the DSM-IV criterion set would reduce the complexity of diagnosing PTSD while not substantially increasing the number of people who qualify for diagnosis. A2 should consequently be reconceptualized as a risk factor for PTSD rather than as a diagnostic requirement.
doi:10.1016/j.biopsych.2010.04.032
PMCID: PMC3228599  PMID: 20599189
post-traumatic stress disorder (PTSD); potentially traumatic experience (PTE); Criterion A2; diagnosis; DSM-IV; Composite International Diagnostic Interview (CIDI); World Health Organization World Mental Health (WMH) Surveys

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