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1.  Embarrassment When Illness Strikes A Close Relative: A World Mental Health Survey Consortium Multi-Site Study 
Psychological medicine  2013;43(10):2191-2202.
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.
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.
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.
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.
PMCID: PMC4013530  PMID: 23298443
Family Embarrassment; Stigma; World Mental Health Surveys; Psychiatric Conditions
2.  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.
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.
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.
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).
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.
PMCID: PMC4124902  PMID: 19965796
Depression and anxiety  2013;31(2):130-142.
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.
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.
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.
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.
PMCID: PMC4085043  PMID: 23983056
PTSD; functional impairment; comorbidity; World Mental Health Surveys; epidemiology
4.  The prevalence and correlates of binge eating disorder in the WHO World Mental Health Surveys 
Biological psychiatry  2013;73(9):904-914.
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.
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.
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.
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.
PMCID: PMC3628997  PMID: 23290497
binge eating disorder; epidemiology; WHO World Mental Health Surveys; bulimia nervosa; comorbidity; treatment
5.  Disorder-specific cognitive profiles in major depressive disorder and generalized anxiety disorder 
BMC Psychiatry  2014;14:96.
This investigation examines differences in cognitive profiles in subjects with major depressive disorder (MDD) and generalized anxiety disorder (GAD).
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 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.
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.
PMCID: PMC3975137  PMID: 24690413
Major depressive disorder; Generalized anxiety disorder; Cognitive profiles; Treatment; Classification
6.  An Updated Global Picture of Cigarette Smoking Persistence among Adults 
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.
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.
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.
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).
PMCID: PMC3635135  PMID: 23626929
7.  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).
PMCID: PMC3739012  PMID: 23950748
frequent cannabis use; cannabis dependence; young adults; qualitative research; life course approach; longitudinal study; education; employment
8.  Early-life mental disorders and adult household income in the World Mental Health Surveys 
Biological Psychiatry  2012;72(3):228-237.
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.
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.
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.
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.
PMCID: PMC3402018  PMID: 22521149
epidemiology; mental disorders; early-onset; income; cross-national; WHO World Mental Health (WMH)
9.  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.
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.
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.
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.
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.
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.
PMCID: PMC3659772  PMID: 19939461
Major depressive episode; chronic physical conditions; disability
10.  Parent psychopathology and offspring mental disorders: results from the WHO World Mental Health Surveys 
The British Journal of Psychiatry  2012;200(4):290-299.
Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity.
To examine the associations of parent with respondent disorders.
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.
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.
Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.
PMCID: PMC3317036  PMID: 22403085
11.  Phenotypically Continuous With Clinical Psychosis, Discontinuous in Need for Care: Evidence for an Extended Psychosis Phenotype 
Schizophrenia Bulletin  2011;38(2):231-238.
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.
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.
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.
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.
PMCID: PMC3283149  PMID: 21908795
diagnosis; schizophrenia; trauma; cannabis; epidemiology; false positive
12.  Treatment of suicidal people around the world † 
Suicide is a leading cause of death worldwide; however, little information is available about the treatment of suicidal people, or about barriers to treatment.
To examine the receipt of mental health treatment and barriers to care among suicidal people around the world.
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.
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.
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.
PMCID: PMC3167419  PMID: 21263012
13.  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.
PMCID: PMC3142278  PMID: 21079606
suicide; parent and family history; intergenerational transmission
14.  Modifications to the WHODAS-II for the World Mental Health Surveys: Implications of Filter Items 
Journal of Clinical Epidemiology  2008;61(11):1132-1143.
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.
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.
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.
PMCID: PMC3277915  PMID: 18619808
Disability; Measurement; Reliability; Validity; Survey; Epidemiology
15.  Development of lifetime comorbidity in the WHO World Mental Health (WMH) Surveys 
Archives of general psychiatry  2011;68(1):90-100.
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.
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.
Nationally or regionally representative community surveys in 14 countries with a total of 21,229 respondents.
First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the WHO Composite International Diagnostic Interview (CIDI).
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.
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.
PMCID: PMC3057480  PMID: 21199968
16.  The role of Criterion A2 in the DSM-IV diagnosis of post-traumatic stress disorder 
Biological psychiatry  2010;68(5):465-473.
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.
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.
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.
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.
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
17.  Associations of serious mental illness with earnings: results from the WHO World Mental Health surveys 
The British Journal of Psychiatry  2010;197(2):114-121.
Burden-of-illness data, which are often used in setting healthcare policy-spending priorities, are unavailable for mental disorders in most countries.
To examine one central aspect of illness burden, the association of serious mental illness with earnings, in the World Health Organization (WHO) World Mental Health (WMH) Surveys.
The WMH Surveys were carried out in 10 high-income and 9 low- and middle-income countries. The associations of personal earnings with serious mental illness were estimated.
Respondents with serious mental illness earned on average a third less than median earnings, with no significant between-country differences (χ2(9) = 5.5–8.1, P = 0.52–0.79). These losses are equivalent to 0.3–0.8% of total national earnings. Reduced earnings among those with earnings and the increased probability of not earning are both important components of these associations.
These results add to a growing body of evidence that mental disorders have high societal costs. Decisions about healthcare resource allocation should take these costs into consideration.
PMCID: PMC2913273  PMID: 20679263
18.  Cross-national epidemiology of DSM-IV major depressive episode 
BMC Medicine  2011;9:90.
Major depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative.
Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults.
The average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed.
MDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.
PMCID: PMC3163615  PMID: 21791035
19.  Early Cannabis Use and Estimated Risk of Later Onset of Depression Spells: Epidemiologic Evidence From the Population-based World Health Organization World Mental Health Survey Initiative 
American Journal of Epidemiology  2010;172(2):149-159.
Early-onset cannabis use is widespread in many countries and might cause later onset of depression. Sound epidemiologic data across countries are missing. The authors estimated the suspected causal association that links early-onset (age <17 years) cannabis use with later-onset (age ≥17 years) risk of a depression spell, using data on 85,088 subjects from 17 countries participating in the population-based World Health Organization World Mental Health Survey Initiative (2001–2005). In all surveys, multistage household probability samples were evaluated with a fully structured diagnostic interview for assessment of psychiatric conditions. The association between early-onset cannabis use and later risk of a depression spell was studied using conditional logistic regression with local area matching of cases and controls, controlling for sex, age, tobacco use, and other mental health problems. The overall association was modest (controlled for sex and age, risk ratio = 1.5, 95% confidence interval: 1.4, 1.7), was statistically robust in 5 countries, and showed no sex difference. The association did not change appreciably with statistical adjustment for mental health problems, except for childhood conduct problems, which reduced the association to nonsignificance. This study did not allow differentiation of levels of cannabis use; this issue deserves consideration in future research.
PMCID: PMC2915487  PMID: 20534820
cannabis; depression; mental health; world health
20.  Childhood adversities as risk factors for onset and persistence of suicidal behaviour 
Suicide is a leading cause of death worldwide, but the precise effect of childhood adversities as risk factors for the onset and persistence of suicidal behaviour (suicide ideation, plans and attempts) are not well understood.
To examine the associations between childhood adversities as risk factors for the onset and persistence of suicidal behaviour across 21 countries worldwide.
Respondents from nationally representative samples (n = 55 299) were interviewed regarding childhood adversities that occurred before the age of 18 years and lifetime suicidal behaviour.
Childhood adversities were associated with an increased risk of suicide attempt and ideation in both bivariate and multivariate models (odds ratio range 1.2–5.7). The risk increased with the number of adversities experienced, but at a decreasing rate. Sexual and physical abuse were consistently the strongest risk factors for both the onset and persistence of suicidal behaviour, especially during adolescence. Associations remained similar after additional adjustment for respondents’ lifetime mental disorder status.
Childhood adversities (especially intrusive or aggressive adversities) are powerful predictors of the onset and persistence of suicidal behaviours.
PMCID: PMC2894980  PMID: 20592429
21.  Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys* 
Drug and alcohol dependence  2010;108(1-2):84-97.
It is unclear whether the normative sequence of drug use initiation, beginning with tobacco and alcohol, progressing to cannabis and then other illicit drugs, is due to causal effects of specific earlier drug use promoting progression, or to influences of other variables such as drug availability and attitudes. One way to investigate this is to see whether risk of later drug use in the sequence, conditional on use of drugs earlier in the sequence, changes according to time-space variation in use prevalence. We compared patterns and order of initiation of alcohol, tobacco, cannabis, and other illicit drug use across 17 countries with a wide range of drug use prevalence.
Analyses used data from World Health Organization (WHO) World Mental Health (WMH) Surveys, a series of parallel community epidemiological surveys using the same instruments and field procedures carried out in 17 countries throughout the world.
Initiation of “gateway” substances (i.e. alcohol, tobacco and cannabis) was differentially associated with subsequent onset of other illicit drug use based on background prevalence of gateway substance use. Cross-country differences in substance use prevalence also corresponded to differences in the likelihood of individuals reporting a non- normative sequence of substance initiation.
These results suggest the “gateway” pattern at least partially reflects unmeasured common causes rather than causal effects of specific drugs on subsequent use of others. This implies that successful efforts to prevent use of specific “gateway” drugs may not in themselves lead to major reductions in the use of later drugs.
PMCID: PMC2835832  PMID: 20060657
tobacco; alcohol; illicit drugs; gateway; WHO World Mental Health Surveys
22.  Subtyping Social Anxiety Disorder in Developed and Developing Countries 
Depression and anxiety  2010;27(4):390-403.
Although social anxiety disorder (SAD) is classified in DSM-IV into generalized and non-generalized subtypes, community surveys in Western countries find no evidence of disjunctions in the dose-response relationship between number of social fears and outcomes to support this distinction. We aimed to determine whether this holds across a broader set of developed and developing countries and whether subtyping according to number of performance versus interactional fears would be more useful.
The WHO World Mental Health (WMH) Survey Initiative undertook population epidemiological surveys in 11 developing and 9 developed countries using the Composite International Diagnostic Interview (CIDI) to assess DSM-IV disorders. Fourteen performance and interactional fears were assessed. Associations between number of social fears in SAD and numerous outcomes (age-of-onset, persistence, severity, comorbidity, treatment) were examined. Additional analyses examined associations with number of performance fears versus number of interactional fears.
Lifetime social fears are quite common in both developed (15.9%) and developing (14.3%) countries, but lifetime SAD is much more common in the former (6.1%) than latter (2.1%) countries. Among those with SAD, persistence, severity, comorbidity, and treatment all have dose-response relationships with number of social fears, with no clear nonlinearity in relationships that would support a distinction between generalized and non-generalized SAD. The distinction between performance fears and interactional fears is generally not important in predicting these same outcomes.
No evidence is found to support subtyping SAD on the basis of either number of social fears or number of performance fears versus number of interactional fears.
PMCID: PMC2851829  PMID: 20037919
23.  Health status of the advanced elderly in six european countries: results from a representative survey using EQ-5D and SF-12 
Due to demographic change, the advanced elderly represent the fastest growing population group in Europe. Health problems tend to be frequent and increasing with age within this cohort.
Aims of the study
To describe and compare health status of the elderly population in six European countries and to analyze the impact of socio-demographic variables on health.
In the European Study of the Epidemiology of Mental Disorders (ESEMeD), representative non-institutionalized population samples completed the EQ-5D and Short Form-12 (SF-12) questionnaires as part of personal computer-based home interviews in 2001-2003. This study is based on a subsample of 1659 respondents aged ≥ 75 years from Belgium (n = 194), France (n = 168), Germany (n = 244), Italy (n = 317), the Netherlands (n = 164) and Spain (n = 572). Descriptive statistics, bivariate- (chi-square tests) and multivariate methods (linear regressions) were used to examine differences in population health.
68.8% of respondents reported problems in one or more EQ-5D dimensions, most frequently pain/discomfort (55.2%), followed by mobility (50.0%), usual activities (36.6%), self-care (18.1%) and anxiety/depression (11.6%). The proportion of respondents reporting any problems increased significantly with age in bivariate analyses (age 75-79: 65.4%; age 80-84: 69.2%; age ≥ 85: 81.1%) and differed between countries, ranging from 58.7% in the Netherlands to 72.3% in Italy. The mean EQ VAS score was 61.9, decreasing with age (age 75-79: 64.1; age 80-84: 59.8; age ≥ 85: 56.7) and ranging from 60.0 in Italy to 72.9 in the Netherlands. SF-12 derived Physical Component Summary (PCS) and Mental Component Summary (MCS) scores varied little by age and country. Age and low educational level were associated with lower EQ VAS and PCS scores. After controlling for socio-demographic variables and reported EQ-5D health states, mean EQ VAS scores were significantly higher in the Netherlands and Belgium, and lower in Germany than the grand mean.
More than two thirds of the advanced elderly report impairment of health status. Impairment increases rapidly with age but differs considerably between countries. In all countries, health status is significantly associated with socio-demographic variables.
PMCID: PMC3009699  PMID: 21114833
24.  DSM-IV Personality Disorders in the WHO World Mental Health Surveys 
Little is known about the cross-national population prevalence or correlates of personality disorders (PDs).
To estimate prevalence and correlates of DSM-IV PD clusters in the WHO World Mental Health (WMH) Surveys.
International Personality Disorder Examination (IPDE) screening questions in 13 countries (n = 21,162) were calibrated to blinded IPDE clinical diagnoses. Prevalence and correlates were estimated using Multiple Imputation.
Prevalence estimates are 6.1% (2.4–7.9%) for any PD and 3.6% (1.1–5.3%), 1.5% (0.4–2.1%), and 2.7% (0.9–4.2%) for Clusters A–C, respectively. PDs are significantly elevated among males, the previously married (Cluster C), unemployed (Cluster C), the young (Clusters A and B) and the poorly education. PDs are highly comorbid with Axis I disorders. Impairments associated with PDs are only partially explained by comorbidity.
PDs are relatively common disorders that often co-occur with Axis I disorders and are associated with significant role impairments beyond those due to comorbidity.
PMCID: PMC2705873  PMID: 19567896
Comorbidity; Composite International Diagnostic Interview (CIDI); Epidemiology; International Personality Disorder Examination (IPDE); Personality disorders
25.  DSM–IV personality disorders in the WHO World Mental Health Surveys 
Little is known about the cross-national population prevalence or correlates of personality disorders.
To estimate prevalence and correlates of DSM–IV personality disorder clusters in the World Health Organization World Mental Health (WMH) Surveys.
International Personality Disorder Examination (IPDE) screening questions in 13 countries (n = 21 162) were calibrated to masked IPDE clinical diagnoses. Prevalence and correlates were estimated using multiple imputation.
Prevalence estimates are 6.1% (s.e. = 0.3) for any personality disorder and 3.6% (s.e. = 0.3), 1.5% (s.e. = 0.1) and 2.7% (s.e. = 0.2) for Clusters A, B and C respectively. Personality disorders are significantly elevated among males, the previously married (Cluster C), unemployed (Cluster C), the young (Clusters A and B) and the poorly educated. Personality disorders are highly comorbid with Axis I disorders. Impairments associated with personality disorders are only partially explained by comorbidity.
Personality disorders are relatively common disorders that often co-occur with Axis I disorders and are associated with significant role impairments beyond those due to comorbidity.
PMCID: PMC2705873  PMID: 19567896

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