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1.  Lifetime and 12-month prevalence, severity and unmet need for treatment of common mental disorders in Japan: results from the final dataset of World Mental Health Japan Survey 
The aim of this study is to estimate the lifetime and 12-month prevalence, severity, and treatment of Diagnostic and Statistical Manual of Mental Disorders 4th ed. (DSM-IV) mental disorders in Japan based on the final data set of the World Mental Health Japan Survey conducted in 2002–2006.
Face-to-face household interviews of 4,130 respondents who were randomly selected from Japanese-speaking residents aged 20 years or older were conducted from 2002 to 2006 in 11 community populations in Japan (overall response rate, 56%). The World Mental Health version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay administered psychiatric diagnostic interview, was used for diagnostic assessment.
Lifetime/12-month prevalence of any DSM-IV common mental disorders in Japan was estimated to be 20.3/7.6%. Rank-order of four classes of mental disorders was anxiety disorders (8.1/4.9%), substance disorders (7.4/1.0%), mood disorders (6.5/2.3%), and impulse control disorders (2.0/0.7%). The most common individual disorders were alcohol abuse/dependence (7.3/0.9%), major depressive disorder (6.1/2.2%), specific phobia (3.4/2.3%), and generalized anxiety disorder (2.6/1.3%). While the lifetime prevalence of any mental disorder was greater for males and the middle-aged, the persistence (proportion of 12-month cases among lifetime cases) of any mental disorder was greater for females and younger respondents. Among those with any 12-month disorder, 15.3% were classified as severe, 44.1% moderate, and 40.6% mild. Although a strong association between severity and service use was found, only 21.9% of respondents with any 12-month disorder sought treatment within the last 12 months; only 37.0% of severe cases received medical care. The mental health specialty sector was the most common resource used in Japan. Although the prevalence of mental disorders were quite low, mental disorders were the second most prevalent cause of severe role impairment among chronic physical and mental disorders.
These results suggest lower prevalence of mental disorders in Japan than that in Western countries, although the general pattern of disorders, risk factors, and unmet need for treatment were similar to those in other countries. Greater lifetime prevalence for males and greater persistence for females seem a unique feature of Japan, suggesting a cultural difference in gender-related etiology and course of disorders. The treatment rate in Japan was lower than that in most other high-income countries in WMH surveys.
PMCID: PMC5144586  PMID: 26148821
2.  Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys 
To examine cross-national patterns and correlates of lifetime and 12-month comorbid DSM-IV anxiety disorders among people with lifetime and 12-month DSM-IV major depressive disorder (MDD).
Nationally or regionally representative epidemiological interviews were administered to 74,045 adults in 27 surveys across 24 countries in the WHO World Mental Health (WMH) Surveys. DSM-IV MDD, a wide range of comorbid DSM-IV anxiety disorders, and a number of correlates were assessed with the WHO Composite International Diagnostic Interview (CIDI).
45.7% of respondents with lifetime MDD (32.0–46.5% inter-quartile range [IQR] across surveys) had one of more lifetime anxiety disorders. A slightly higher proportion of respondents with 12-month MDD had lifetime anxiety disorders (51.7%, 37.8–54.0% IQR) and only slightly lower proportions of respondents with 12-month MDD had 12-month anxiety disorders (41.6%, 29.9–47.2% IQR). Two-thirds (68%) of respondents with lifetime comorbid anxiety disorders and MDD reported an earlier age-of-onset of their first anxiety disorder than their MDD, while 13.5% reported an earlier age-of-onset of MDD and the remaining 18.5% reported the same age-of-onset of both disorders. Women and previously married people had consistently elevated rates of lifetime and 12-month MDD as well as comorbid anxiety disorders. Consistently higher proportions of respondents with 12-month anxious than non-anxious MDD reported severe role impairment (64.4% vs. 46.0%; χ21=187.0, p<.001) and suicide ideation (19.5% vs. 8.9%; χ21=71.6, p<.001). Significantly more respondents with 12-month anxious than non-anxious MDD received treatment for their depression in the 12 months before interview, but this difference was more pronounced in high income countries (68.8% vs. 45.4%; χ21=108.8, p<.001) than low/middle income countries (30.3% vs. 20.6%; χ21=11.7, p<.001).
Patterns and correlates of comorbid DSM-IV anxiety disorders among people with DSM-IV MDD are similar across WMH countries. The narrow IQR of the proportion of respondents with temporally prior AOO of anxiety disorders than comorbid MDD (69.6–74.7%) is especially noteworthy. However, the fact that these proportions are not higher among respondents with 12-month than lifetime comorbidity means that temporal priority between lifetime anxiety disorders and MDD is not related to MDD persistence among people with anxious MDD. This, in turn, raises complex questions about the relative importance of temporally primary anxiety disorders as risk markers versus causal risk factors for subsequent MDD onset and persistence, including the possibility that anxiety disorders might primarily be risk markers for MDD onset and causal risk factors for MDD persistence.
PMCID: PMC5129607  PMID: 25720357
anxious depression; comorbidity; epidemiology
3.  Understanding the elevated suicide risk of female soldiers during deployments 
Psychological medicine  2014;45(4):717-726.
The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment.
Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004–2009 (n = 975 057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier’s occupation, the proportion of same-gender soldiers in each soldier’s unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier’s pre-deployment history of treated mental/behavioral disorders.
The suicide rate of currently deployed women (14.0/100 000 person-years) was 3.1–3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100 000 person-years) was 0.9–1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1–6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9–2.8) after adjusting for the hypothesized explanatory variables.
These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.
PMCID: PMC4869515  PMID: 25359554
Army; Army STARRS; epidemiology; gender; military; risk factors; suicide
4.  Occupational differences in US Army suicide rates 
Psychological medicine  2015;45(15):3293-3304.
Civilian suicide rates vary by occupation in ways related to occupational stress exposure. Comparable military research finds suicide rates elevated in combat arms occupations. However, no research has evaluated variation in this pattern by deployment history, the indicator of occupation stress widely considered responsible for the recent rise in the military suicide rate.
The joint associations of Army occupation and deployment history in predicting suicides were analysed in an administrative dataset for the 729 337 male enlisted Regular Army soldiers in the US Army between 2004 and 2009.
There were 496 suicides over the study period (22.4/100 000 person-years). Only two occupational categories, both in combat arms, had significantly elevated suicide rates: infantrymen (37.2/100 000 person-years) and combat engineers (38.2/100 000 person-years). However, the suicide rates in these two categories were significantly lower when currently deployed (30.6/100 000 person-years) than never deployed or previously deployed (41.2–39.1/100 000 person-years), whereas the suicide rate of other soldiers was significantly higher when currently deployed and previously deployed (20.2–22.4/100 000 person-years) than never deployed (14.5/100 000 person-years), resulting in the adjusted suicide rate of infantrymen and combat engineers being most elevated when never deployed [odds ratio (OR) 2.9, 95% confidence interval (CI) 2.1–4.1], less so when previously deployed (OR 1.6, 95% CI 1.1–2.1), and not at all when currently deployed (OR 1.2, 95% CI 0.8–1.8). Adjustment for a differential ‘healthy warrior effect’ cannot explain this variation in the relative suicide rates of never-deployed infantrymen and combat engineers by deployment status.
Efforts are needed to elucidate the causal mechanisms underlying this interaction to guide preventive interventions for soldiers at high suicide risk.
PMCID: PMC4860903  PMID: 26190760
Army; Army STARRS; deployment; resiliency factors; suicide
5.  The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium 
Psychological medicine  2015;46(2):327-343.
Considerable research has documented that exposure to traumatic events has negative effects on physical and mental health. Much less research has examined the predictors of traumatic event exposure. Increased understanding of risk factors for exposure to traumatic events could be of considerable value in targeting preventive interventions and anticipating service needs.
General population surveys in 24 countries with a combined sample of 68 894 adult respondents across six continents assessed exposure to 29 traumatic event types. Differences in prevalence were examined with cross-tabulations. Exploratory factor analysis was conducted to determine whether traumatic event types clustered into interpretable factors. Survival analysis was carried out to examine associations of sociodemographic characteristics and prior traumatic events with subsequent exposure.
Over 70% of respondents reported a traumatic event; 30.5% were exposed to four or more. Five types – witnessing death or serious injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury – accounted for over half of all exposures. Exposure varied by country, sociodemographics and history of prior traumatic events. Being married was the most consistent protective factor. Exposure to interpersonal violence had the strongest associations with subsequent traumatic events.
Given the near ubiquity of exposure, limited resources may best be dedicated to those that are more likely to be further exposed such as victims of interpersonal violence. Identifying mechanisms that account for the associations of prior interpersonal violence with subsequent trauma is critical to develop interventions to prevent revictimization.
PMCID: PMC4869975  PMID: 26511595
Disasters; epidemiology; injury; revictimization; trauma; violence
6.  The impact of lifetime suicidality on academic performance in college freshmen 
Journal of affective disorders  2015;186:254-260.
While suicidal thoughts and behaviors (STB) among college students are common, the associations between STB and academic performance are not well understood.
As part of the World Mental Health Surveys International College Student project, web-based self-reported STB of KU Leuven (Leuven, Belgium) incoming freshmen (N=4921; response rate=65.4%) was collected, as well as academic year percentage (AYP), and the departments to which students belong. Single- and multilevel multivariate analyses were conducted, adjusted for gender, age, parental educational level, and comorbid lifetime emotional problems.
Lifetime suicide plan and attempt upon college entrance were associated with significant decreases in AYP (3.6% and 7.9%, respectively). A significant interaction was found with average departmental AYP, with STB more strongly associated with reduced AYP in departments with lower than higher average AYP.
Limited sample size precluded further investigation of interactions between department-level and student-level variables. No information was available on freshman secondary school academic performance.
Lifetime STB has a strong negative association with academic performance in college. Our study suggests a potential role for the college environment as target for treatment and prevention interventions.
PMCID: PMC4708078  PMID: 26254617
College student; Suicide attempt; Suicide plan; Grade point average; Academic performance
7.  Association between traumatic events and post-traumatic stress disorder: results from the ESEMeD-Spain study 
The relative importance of traumatic events (TEs) in accounting for the social burden of post-traumatic stress disorder (PTSD) could vary according to cross-cultural factors. In that sense, no such studies have yet been conducted in the Spanish general population. The present study aims to determine the epidemiology of trauma and PTSD in a Spanish community sample using the randomly selected TEs method.
The European Study of the Epidemiology of Mental Disorders (ESEMeD)-Spain is a cross-sectional household survey of a representative sample of adult population. Lifetime prevalence of self-reported TEs and lifetime and 12-month prevalence of PTSD were evaluated using the World Health Organization (WHO) Composite International Diagnostic Interview. Reports of PTSD associated with randomly selected TEs were weighted by the individual-level probabilities of TE selection to generate estimates of population-level PTSD risk associated with each TE.
Road accident was the most commonly self-reported TE (14.1%). Sexual assault had the highest conditional risk of PTSD (16.5%). The TEs that contributed most to societal PTSD burden were unexpected death of a loved one (36.4% of all cases) and sexual assault (17.2%). Being female and having a low educational level were associated with low risk of overall TE exposure and being previously married was related to higher risk. Being female was related to high risk of PTSD after experiencing a TE.
Having an accident is commonly reported among Spanish adults, but two TE are responsible for the highest burden associated with PTSD: the unexpected death of someone close and sexual assault. These results can help designing public health interventions to reduce the societal PTSD burden.
PMCID: PMC4143480  PMID: 24565167
Epidemiology; post-traumatic stress disorder; PTSD burden; traumatic event
8.  The effects of comorbidity in defining major depression subtypes associated with long-term course and severity 
Psychological medicine  2014;44(15):3289-3302.
Although variation in long-term course of major depressive disorder (MDD) is not strongly predicted by existing symptom subtype distinctions, recent research suggests that prediction can be improved by using machine learning methods. However, it is not known whether these distinctions can be refined by added information about comorbid conditions. The current report presents results on this question.
Data come from 8,261 respondents with lifetime DSM-IV MDD in the WHO World Mental Health (WMH) Surveys. Outcomes include four retrospectively-reported measures of persistence-severity of course (years in episode; years in chronic episodes, hospitalization for MDD; disability due to MDD). Machine learning methods (regression tree analysis; lasso, ridge, and elastic net penalized regression) followed by k-means cluster analysis were used to augment previously-detected subtypes with information about prior comorbidity to predict these outcomes.
Predicted values were strongly correlated across outcomes. Cluster analysis of predicted values found 3 clusters with consistently high, intermediate, or low values. The high-risk cluster (32.4% of cases) accounted for 56.6–72.9% of high persistence, high chronicity, hospitalization, and disability. This high-risk cluster had both higher sensitivity and likelihood-ratio positive (relative proportions of cases in the high-risk cluster versus other clusters having the adverse outcomes) than in a parallel analysis that excluded measures of comorbidity as predictors.
Although results using the retrospective data reported here suggest that useful MDD subtyping distinctions can be made with machine learning and clustering across multiple indicators of illness persistence-severity, replication is need with prospective data to confirm this preliminary conclusion.
PMCID: PMC4180779  PMID: 25066141
Comorbidity; data mining; depression subtypes; depression symptom profiles; elastic net; machine learning; predictive modeling; risk assessment
9.  Sociodemographic and career history predictors of suicide mortality in the United States Army 2004–2009 
Psychological medicine  2014;44(12):2579-2592.
The US Army suicide rate has increased sharply in recent years. Identifying significant predictors of Army suicides in Army and Department of Defense (DoD) administrative records might help focus prevention efforts and guide intervention content. Previous studies of administrative data, although documenting significant predictors, were based on limited samples and models. A career history perspective is used here to develop more textured models.
The analysis was carried out as part of the Historical Administrative Data Study (HADS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). De-identified data were combined across numerous Army and DoD administrative data systems for all Regular Army soldiers on active duty in 2004–2009. Multivariate associations of sociodemographics and Army career variables with suicide were examined in subgroups defined by time in service, rank and deployment history.
Several novel results were found that could have intervention implications. The most notable of these were significantly elevated suicide rates (69.6–80.0 suicides per 100000 person-years compared with 18.5 suicides per 100000 person-years in the total Army) among enlisted soldiers deployed either during their first year of service or with less than expected (based on time in service) junior enlisted rank; a substantially greater rise in suicide among women than men during deployment; and a protective effect of marriage against suicide only during deployment.
A career history approach produces several actionable insights missed in less textured analyses of administrative data predictors. Expansion of analyses to a richer set of predictors might help refine understanding of intervention implications.
PMCID: PMC4113022  PMID: 25055175
Army; Army STARRS; epidemiology; military; risk factors; suicide
10.  The effects of temporally secondary co-morbid mental disorders on the associations of DSM-IV ADHD with adverse outcomes in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A) 
Psychological medicine  2013;44(8):1779-1792.
Although DSM-IV attention deficit hyperactivity disorder (ADHD) is known to be associated with numerous adverse outcomes, uncertainties exist about how much these associations are mediated temporally by secondary co-morbid disorders.
The US National Comorbidity Survey Replication Adolescent Supplement (NCS-A), a national survey of adolescents aged 13–17 years (n = 6483 adolescent–parent pairs), assessed DSM-IV disorders with the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Statistical decomposition was used to compare direct effects of ADHD with indirect effects of ADHD through temporally secondary mental disorders (anxiety, mood, disruptive behavior, substance disorders) in predicting poor educational performance (suspension, repeating a grade, below-average grades), suicidality (ideation, plans, attempts) and parent perceptions of adolescent functioning (physical and mental health, interference with role functioning and distress due to emotional problems).
ADHD had significant gross associations with all outcomes. Direct effects of ADHD explained most (51.9–67.6%) of these associations with repeating a grade in school, perceived physical and mental health (only girls), interference with role functioning and distress, and significant components (34.5–44.6%) of the associations with school suspension and perceived mental health (only boys). Indirect effects of ADHD on educational outcomes were predominantly through disruptive behavior disorders (26.9–52.5%) whereas indirect effects on suicidality were predominantly through mood disorders (42.8–59.1%). Indirect effects on most other outcomes were through both mood (19.8–31.2%) and disruptive behavior (20.1–24.5%) disorders, with anxiety and substance disorders less consistently important. Most associations were comparable for girls and boys.
Interventions aimed at reducing the adverse effects of ADHD might profitably target prevention or treatment of temporally secondary co-morbid disorders.
PMCID: PMC4124915  PMID: 24103255
Adolescence; attention deficit hyperactivity disorder (ADHD); co-morbidity; DSM-IV; epidemiology; National Comorbidity Survey Replication Adolescent Supplement (NCS-A); prevalence
11.  Barriers to Mental Health Treatment: Results from the WHO World Mental Health (WMH) Surveys 
Psychological medicine  2013;44(6):1303-1317.
To examine barriers to initiation and continuation of mental health treatment among individuals with common mental disorders.
Data are from the WHO World Mental Health (WMH) Surveys. Representative household samples were interviewed face-to-face in 24 countries. Reasons to initiate and continue treatment were examined in a subsample (n= 63,678) and analyzed at different levels of clinical severity.
Among those with a DSM-IV disorder in the past twelve months, low perceived need was the most common reason for not initiating treatment and more common among moderate and mild than severe cases. Women and younger people with disorders were more likely to recognize a need for treatment. Desire to handle the problem on one’s own was the most common barrier among respondents with a disorder who perceived a need for treatment (63.8%). Attitudinal barriers were much more important than structural barriers both to initiating and continuing treatment. However, attitudinal barriers dominated for mild-moderate cases and structural barriers for severe cases. Perceived ineffectiveness of treatment was the most commonly reported reason for treatment dropout (39.3%) followed by negative experiences with treatment providers (26.9% of respondents with severe disorders).
Low perceived need and attitudinal barriers are the major barriers to seeking and staying in treatment among individuals with common mental disorders worldwide. Apart from targeting structural barriers, mainly in countries with poor resources, increasing population mental health literacy is an important endeavor worldwide.
PMCID: PMC4100460  PMID: 23931656
mental healthcare; treatment seeking; continuity
12.  War and first onset of suicidality: the role of mental disorders 
Psychological medicine  2012;42(10):2109-2118.
Suicide rates increase following periods of war; however, the mechanism through which this occurs is not known. The aim of this paper is to shed some light on the associations of war exposure, mental disorders, and subsequent suicidal behavior.
A national sample of Lebanese adults was administered the Composite International Diagnostic Interview to collect data on lifetime prevalence and age of onset of suicide ideation, plan, and attempt, and mental disorders, in addition to information about exposure to stressors associated with the 1975–1989 Lebanon war.
The onset of suicide ideation, plan, and attempt was associated with female gender, younger age, post-war period, major depression, impulse-control disorders, and social phobia. The effect of post-war period on each type of suicide outcome was largely explained by the post-war onset of mental disorders. Finally, the conjunction of having a prior impulse-control disorder and either being a civilian in a terror region or witnessing war-related stressors was associated with especially high risk of suicide attempt.
The association of war with increased risk of suicidality appears to be partially explained by the emergence of mental disorders in the context of war. Exposure to war may exacerbate disinhibition among those who have prior impulse-control disorders, thus magnifying the association of mental disorders with suicidality.
PMCID: PMC4100459  PMID: 22370047
Mental disorders; suicide; war
13.  Cross-national differences in the prevalence and correlates of burden among older family caregivers in the WHO World Mental Health (WMH) Surveys 
Psychological medicine  2012;43(4):865-879.
Current trends in population aging affect both recipients and providers of informal family caregiving, as the pool of family caregivers is shrinking while demand is increasing. Epidemiologic research has not yet examined the implications of these trends for burdens experienced by aging family caregivers.
Cross-sectional community surveys in 20 countries asked 13,892 respondents ages 50+ about the objective (time, financial) and subjective (distress, embarrassment) burdens they experience in providing care to first-degree relatives with 12 broadly-defined serious physical and mental conditions. Differential burden was examined by country income category, kinship status, and type of condition.
Among the 26.9-42.5% respondents in high, upper-middle, and low/lower-middle income countries reporting serious relative health conditions, 35.7-42.5% reported burden. Of those, 25.2-29.0% spent time and 13.5-19.4% money, while 24.4-30.6% felt distress and 6.4-21.7% embarrassment. Mean caregiving hours/week given any was 16.6-23.6 (169.9-205.8 hours/week/100 people ages 50+). Burden in low/lower-middle income countries was 2-3-fold higher than in higher income countries, with financial burden given any averaging 14.3% of median family income in high, 17.7% in upper-middle, and 39.8% in low/lower-middle income countries. Higher burden was reported by women than men and for conditions of spouses and children than parents or siblings.
Uncompensated family caregiving is an important societal asset that offsets rising formal healthcare costs. However, the substantial burdens experienced by aging caregivers across multiple family health conditions and geographic regions threaten the continued integrity of their caregiving capacity. Initiatives supporting older family caregivers are consequently needed, especially in low/lower-middle income countries.
PMCID: PMC4045502  PMID: 22877824
family burden; cross-national; caregivers; epidemiology; mental health
14.  A multinational study of mental disorders, marriage, and divorce 
Acta psychiatrica Scandinavica  2011;124(6):474-486.
Estimate predictive associations of mental disorders with marriage and divorce in a cross-national sample.
Population surveys of mental disorders included assessment of age at first marriage in 19 countries (n = 46 128) and age at first divorce in a subset of 12 countries (n = 30 729). Associations between mental disorders and subsequent marriage and divorce were estimated in discrete time survival models.
Fourteen of 18 premarital mental disorders are associated with lower likelihood of ever marrying (odds ratios ranging from 0.6 to 0.9), but these associations vary across ages of marriage. Associations between premarital mental disorders and marriage are generally null for early marriage (age 17 or younger), but negative associations come to predominate at later ages. All 18 mental disorders are positively associated with divorce (odds ratios ranging from 1.2 to 1.8). Three disorders, specific phobia, major depression, and alcohol abuse, are associated with the largest population attributable risk proportions for both marriage and divorce.
This evidence adds to research demonstrating adverse effects of mental disorders on life course altering events across a diverse range of socioeconomic and cultural settings. These effects should be included in considerations of public health investments in preventing and treating mental disorders.
PMCID: PMC4011132  PMID: 21534936
mental disorders; marriage; divorce
15.  Lifetime comorbidity of DSM-IV disorders in the NCS-R Adolescent Supplement (NCS-A) 
Psychological medicine  2012;42(9):1997-2010.
Research on the structure of comorbidity among common mental disorders has largely focused on current prevalence rather than on the development of comorbidity. This report presents preliminary results of the latter type of analysis based on the National Comorbidity Survey Replication Adolescent Supplement (NCS-A).
A national survey was carried out of adolescent mental disorders. DSM-IV diagnoses were based on the Composite International Diagnostic Interview administered to adolescents and questionnaires self-administered to parents. Factor analysis examined comorbidity among 15 lifetime DSM-IV disorders. Discrete-time survival analysis was used to predict first onset of each disorder from information about prior history of the other 14 disorders.
Factor analysis found four factors representing fear, distress, behavior, and substance disorders. Associations of temporally primary disorders with the subsequent onset of other disorders (dated using retrospective age-of-onset reports) were almost entirely positive. Within-class associations (e.g., distress disorders predicting subsequent onset of other distress disorders) were more consistently significant (63.2%) than between-class associations (33.0%). Strength of associations decreased as comorbidity among disorders increased. The percent of lifetime disorders explained (in a predictive rather than causal sense) by temporally prior disorders was in the range 3.7-6.9% for earliest-onset disorders (specific phobia and attention-deficit/hyperactivity disorder) and much higher (23.1-64.3%) for later-onset disorders. Fear disorders were the strongest predictors of most other subsequent disorders.
Adolescent mental disorders are highly comorbid. The strong associations of temporally primary fear disorders with many other later-onset disorders suggest that fear disorders might be promising targets for early interventions.
PMCID: PMC3448706  PMID: 22273480
NCS-A; adolescence; epidemiology; lifetime prevalence; lifetime comorbidity; mental disorders
16.  The importance of secondary trauma exposure for post-disaster mental disorder 
Interventions to treat mental disorders after natural disasters are important both for humanitarian reasons and also for successful post-disaster physical reconstruction that depends on the psychological functioning of the affected population. A major difficulty in developing such interventions, however, is that large between-disaster variation exists in the prevalence of post-disaster mental disorders, making it difficult to estimate need for services in designing interventions without carrying out a post-disaster mental health needs assessment survey. One of the daunting methodological challenges in implementing such surveys is that secondary stressors unique to the disaster often need to be discovered to understand the magnitude, type, and population segments most affected by post-disaster mental disorders.
This problem is examined in the current commentary by analyzing data from the WHO World Mental Health (WMH) Surveys. We analyze the extent to which people exposed to natural disasters throughout the world also experienced secondary stressors and the extent to which the mental disorders associated with disasters were more proximally due to these secondary stressors than to the disasters themselves.
Lifetime exposure to natural disasters was found to be high across countries (4.4–7.5%). 10.7–11.4% of those exposed to natural disasters reported the occurrence of other related stressors (e.g. death of a loved one and destruction of property). A monotonic relationship was found between the number of additional stressors and the subsequent onset of mental disorders
These results document the importance of secondary stressors in accounting for the effects of natural disasters on mental disorders. Implications for intervention planning are discussed.
PMCID: PMC3465701  PMID: 22670411
Natural disasters; needs assessment; post-disaster intervention planning
17.  The prevalence of family childhood adversities and their association with first onset of DSM-IV disorders in metropolitan China 
Psychological medicine  2010;41(1):85-96.
The prevalence of family childhood adversities (FCAs) and their joint effects on the first onset of subsequent mental disorders throughout the life course are rarely examined, especially in Asian communities.
Face-to-face household interviews of 5201 people aged 18–70 years in Beijing and Shanghai were conducted by a multi-stage household probability sampling method. The first onsets of four broad groups of mental disorders and six categories of FCAs were assessed using The World Mental Health Composite International Diagnostic Interview (WMH-CIDI). Joint effects of FCAs were analyzed by the best fitting of several competitive multivariate models.
FCAs were highly prevalent and inter-correlated. Half of them were in a family-dysfunction cluster. The best-fitting model included each of six types of FCA (with family-dysfunction FCAs being the strongest predictors), number of family-dysfunction FCAs, and number of other FCAs. Family-dysfunction FCAs had a significant subadditive association with subsequent disorders. Little specificity was found for the effects of particular FCAs with particular disorders. Predictive effects of FCAs reached the highest in ages 13–24 compared to ages 4–12 and ⩾25. Estimates of population-attributable risk proportions indicated that all FCAs together explained 38.5% of all first-onset disorders.
Chinese children were exposed to a broad spectrum of inter-related FCAs, as found in Western countries. FCAs related to family dysfunction were especially associated with subsequent mental disorders. Biological and/or environmental factors that mediate these long-term effects should be studied in prospective research on broad groups of FCAs.
PMCID: PMC3040101  PMID: 20367892
Childhood adversity (CA); China; family; first onset; mental disorders
18.  Mental disorders and termination of education in high-income and low- and middle-income countries: epidemiological study 
The British Journal of Psychiatry  2009;194(5):411-417.
Studies of the impact of mental disorders on educational attainment are rare in both high-income and low- and middle-income (LAMI) countries.
To examine the association between early-onset mental disorder and subsequent termination of education.
Sixteen countries taking part in the World Health Organization World Mental Health Survey Initiative were surveyed with the Composite International Diagnostic Interview (n=41 688). Survival models were used to estimate associations between DSM–IV mental disorders and subsequent non-attainment of educational milestones.
In high-income countries, prior substance use disorders were associated with non-completion at all stages of education (OR 1.4–15.2). Anxiety disorders (OR=1.3), mood disorders (OR=1.4) and impulse control disorders (OR=2.2) were associated with early termination of secondary education. In LAMI countries, impulse control disorders (OR=1.3) and substance use disorders (OR=1.5) were associated with early termination of secondary education.
Onset of mental disorder and subsequent non-completion of education are consistently associated in both high-income and LAMI countries.
PMCID: PMC2801820  PMID: 19407270
19.  The Epidemiology of Obsessive-Compulsive Disorder in the National Comorbidity Survey Replication 
Molecular psychiatry  2008;15(1):53-63.
Despite significant advances in the study of obsessive-compulsive disorder (OCD), important questions remain about the disorder's public health significance, appropriate diagnostic classification, and clinical heterogeneity. These issues were explored using data from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of U.S. adults. A subsample of 2073 respondents was assessed for lifetime DSM-IV OCD. More than one-quarter of respondents reported experiencing obsessions or compulsions at some time in their lives. While conditional probability of OCD was strongly associated with the number of obsessions and compulsions reported, only small proportions of respondents met full DSM-IV criteria for lifetime (2.3%) or 12-month (1.2%) OCD. OCD is associated with substantial comorbidity, not only with anxiety and mood disorders but also with impulse-control and substance use disorders. Severity of OCD, assessed by an adapted version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), is associated with poor insight, high comorbidity, high role impairment, and high probability of seeking treatment. The high prevalence of subthreshold OCD symptoms may help explain past inconsistencies in prevalence estimates across surveys and suggests that the public health burden of OCD may be greater than its low prevalence implies. Evidence of a preponderance of early-onset cases in males, high comorbidity with a wide range of disorders, and reliable associations between disorder severity and key outcomes may have implications for how OCD is classified in DSM-V.
PMCID: PMC2797569  PMID: 18725912
epidemiology; obsessive behavior; compulsive behavior; obsessive-compulsive behavior; National Comorbidity Survey-Replication
20.  The epidemiology of depression in metropolitan China 
Psychological medicine  2008;39(5):735-747.
Previous surveys on depression in China focused on prevalence estimates without providing a detailed epidemiological profile.
Face-to-face household interviews were conducted with a multi-stage household probability sample of 2633 adults (age ≥18 years) in Beijing and 2568 in Shanghai between November 2001 and February 2002. The World Health Organization Composite International Diagnostic Interview (CIDI) was used to assess major depressive episode (MDE) according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria.
The lifetime prevalence and 1-year prevalence estimates of DSM-IV/CIDI MDE were 3.6 % [95 % confidence interval (CI) 2.8-4.4 %] and 1.8 % (95 % CI 1.2-2.4 %) respectively. No significant gender difference was found in these estimates. Respondents born in 1967 or later were at elevated lifetime risk compared with respondents born in earlier cohorts. The mean age of onset was 30.3 years. Among those reporting 1-year MDE, 15.7, 51.8, 25.3 and 6.4 % reported mild, moderate, severe and very severe symptoms respectively; 4.8, 2.6 and 3.2 % reported suicidal ideation, plans, and recent attempts in the same year respectively. Respondents with 1-year MDE reported a mean of 27.5 days out of role owing to their depression in the year before interview. Significant co-morbidity was found between MDE and other mental disorders [odds ratio (OR) 22.0] and chronic physical disorders (OR 3.2). Only 22.7 % of respondents with 1-year MDE sought treatment.
The low prevalence and insignificant gender difference, but not patterns of onset, course, co-morbidity, and impairment, distinguish the epidemiological profile of MDE in metropolitan China from those in other countries.
PMCID: PMC2681248  PMID: 18713484
Co-morbidity; epidemiology; major depression; metropolitan China; suicide; treatment
21.  Does the ‘gateway’ matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication 
Psychological medicine  2008;39(1):157-167.
The ‘gateway’ pattern of drug initiation describes a normative sequence, beginning with alcohol and tobacco use, followed by cannabis, then other illicit drugs. Previous work has suggested that ‘violations’ of this sequence may be predictors of later problems but other determinants were not considered. We have examined the role of pre-existing mental disorders and sociodemographics in explaining the predictive effects of violations using data from the US National Comorbidity Survey Replication (NCS-R).
The NCS-R is a nationally representative face-to-face household survey of 9282 English-speaking respondents aged 18 years and older that used the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) to assess DSM-IV mental and substance disorders. Drug initiation was estimated using retrospective age-of-onset reports and ‘violations’ defined as inconsistent with the normative initiation order. Predictors of violations were examined using multivariable logistic regressions. Discrete-time survival analysis was used to see whether violations predicted progression to dependence.
Gateway violations were largely unrelated to later dependence risk, with the exception of small increases in risk of alcohol and other illicit drug dependence for those who initiated use of other illicit drugs before cannabis. Early-onset internalizing disorders were predictors of gateway violations, and both internalizing and externalizing disorders increased the risks of dependence among users of all drugs.
Drug use initiation follows a strong normative pattern, deviations from which are not strongly predictive of later problems. By contrast, adolescents who have already developed mental health problems are at risk for deviations from the normative sequence of drug initiation and for the development of dependence.
PMCID: PMC2653272  PMID: 18466664
Alcohol; cannabis; dependence; gateway; illicit drugs; National Comorbidity Survey Replication; tobacco
22.  Mental–physical co-morbidity and its relationship with disability: results from the World Mental Health Surveys 
Psychological medicine  2008;39(1):33-43.
The relationship between mental and physical disorders is well established, but there is less consensus as to the nature of their joint association with disability, in part because additive and interactive models of co-morbidity have not always been clearly differentiated in prior research.
Eighteen general population surveys were carried out among adults as part of the World Mental Health (WMH) Survey Initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). Chronic physical conditions (arthritis, heart disease, respiratory disease, chronic back/neck pain, chronic headache, and diabetes) were ascertained using a standard checklist. Severe disability was defined as on or above the 90th percentile of the WMH version of the World Health Organization Disability Assessment Schedule (WHODAS-II).
The odds of severe disability among those with both mental disorder and each of the physical conditions (with the exception of heart disease) were significantly greater than the sum of the odds of the single conditions. The evidence for synergy was model dependent: it was observed in the additive interaction models but not in models assessing multiplicative interactions. Mental disorders were more likely to be associated with severe disability than were the chronic physical conditions.
This first cross-national study of the joint effect of mental and physical conditions on the probability of severe disability finds that co-morbidity exerts modest synergistic effects. Clinicians need to accord both mental and physical conditions equal priority, in order for co-morbidity to be adequately managed and disability reduced.
PMCID: PMC2637813  PMID: 18366819
Co-morbidity; disability; interaction; mental; physical
23.  Age patterns in the prevalence of DSM-IV depressive/anxiety disorders with and without physical co-morbidity 
Psychological medicine  2008;38(11):1659-1669.
Physical morbidity is a potent risk factor for depression onset and clearly increases with age, yet prior research has often found depressive disorders to decrease with age. This study tests the possibility that the relationship between age and mental disorders differs as a function of physical co-morbidity.
Eighteen general population surveys were carried out among household-residing adults as part of the World Mental Health (WMH) surveys initiative (n=42 697). DSM-IV disorders were assessed using face-to-face interviews with the Composite International Diagnostic Interview (CIDI 3.0). The effect of age was estimated for 12-month depressive and/or anxiety disorders with and without physical or pain co-morbidity, and for physical and/or pain conditions without mental co-morbidity.
Depressive and anxiety disorders decreased with age, a result that cannot be explained by organic exclusion criteria. No significant difference was found in the relationship between mental disorders and age as a function of physical/pain co-morbidity. The majority of older persons have chronic physical or pain conditions without co-morbid mental disorders; by contrast, the majority of those with mental disorders have physical/pain co-morbidity, particularly among the older age groups.
CIDI-diagnosed depressive and anxiety disorders in the general population decrease with age, despite greatly increasing physical morbidity with age. Physical morbidity among persons with mental disorder is the norm, particularly in older populations. Health professionals, including mental health professionals, need to address barriers to the management of physical co-morbidity among those with mental disorders.
PMCID: PMC2637812  PMID: 18485262
Age; anxiety disorder; co-morbidity; depressive disorder; physical
24.  Twelve-month mental disorders in South Africa: prevalence, service use and demographic correlates in the population-based South African Stress and Health Study 
Psychological medicine  2007;38(2):211-220.
South Africa’s history and current social conditions suggest that mental disorders are likely to be a major contributor to disease burden, but there has been no national study using standardized assessment tools.
The South African Stress and Health Study was a nationally representative in-person psychiatric epidemiological survey of 4351 adults (aged ≥18 years) that was conducted as part of the WHO World Mental Health (WMH) Survey Initiative between January 2002 and June 2004. Twelve-month prevalence and severity of DSM-IV disorders, treatment, and sociodemographic correlates were assessed with Version 3.0 of the WHO Composite International Diagnostic Interview (CIDI 3.0).
The 12-month prevalence of any DSM-IV/CIDI disorder was 16.5%, with 26.2% of respondents with disorder classified as severe cases and an additional 31.1% as moderately severe cases. The most common disorders were agoraphobia (4.8 %), major depressive disorder (4.9%) and alcohol abuse or dependence (4.5 %). Twenty-eight percent of adults with a severe or moderately severe disorder received treatment compared to 24.4% of mild cases. Some 13.8% of persons with no disorder received treatment. Treatment was mostly provided by the general medical sector with few people receiving treatment from mental health providers.
Psychiatric disorders are much higher in South Africa than in Nigeria and there is a high level of unmet need among persons with severe and moderately severe disorders.
PMCID: PMC2718686  PMID: 17903333
Mental disorders; mental health services; South Africa
25.  Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys 
Molecular Psychiatry  2010;16(12):1234-1246.
Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity.
PMCID: PMC3223313  PMID: 20938433
mental disorders; chronic disease; disability; productivity loss; prevalence; burden of disease

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