Screening for serious mental illness in the general population

BACKGROUND: Public Law 102-321 established a block grant for adults with "serious mental illness" (SMI) and required the Substance Abuse and Mental Health Services Administration (SAMHSA) to develop a method to estimate the prevalence of SMI. METHODS: Three SMI screening scales were developed for possible use in the SAMHSA National Household Survey on Drug Abuse: the Composite International Diagnostic Interview Short-Form (CIDI-SF) scale, the K10/K6 nonspecific distress scales, and the World Health Organization Disability Assessment Schedule (WHO-DAS). An enriched convenience sample of 155 respondents was administered all screening scales followed by the 12-month Structured Clinical Interview for DSM-IV and the Global Assessment of Functioning (GAF). We defined SMI as any 12-month DSM-IV disorder, other than a substance use disorder, with a GAF score of less than 60. RESULTS: All screening scales were significantly related to SMI. However, neither the CIDI-SF nor the WHO-DAS improved prediction significantly over the K10 or K6 scales. The area under the receiver operating characteristic curve of SMI was 0.854 for K10 and 0.865 for K6. The most efficient screening scale, K6, had a sensitivity (SE) of 0.36 (0.08) and a specificity of 0.96 (0.02) in predicting SMI. CONCLUSIONS: The brevity and accuracy of the K6 and K10 scales make them attractive screens for SMI. Routine inclusion of either scale in clinical studies would create an important, and heretofore missing, crosswalk between community and clinical epidemiology.     

Pre-marital predictors of marital violence in the WHO World Mental Health (WMH) Surveys

Social Psychiatry and Psychiatric Epidemiology - Intimate partner violence (IPV) is a pervasive public health problem. Existing research has focused on reports from victims and few studies have...     

The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)

This paper presents an overview of the World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) and a discussion of the methodological research on which the development of the instrument was based. The WMH-CIDI includes a screening module and 40 sections that focus on diagnoses (22 sections), functioning (four sections), treatment (two sections), risk factors (four sections), socio-demographic correlates (seven sections), and methodological factors (two sections). Innovations compared to earlier versions of the CIDI include expansion of the diagnostic sections, a focus on 12-month as well as lifetime disorders in the same interview, detailed assessment of clinical severity, and inclusion of information on treatment, risk factors, and consequences. A computer-assisted version of the interview is available along with a direct data entry software system that can be used to keypunch responses to the paper-and-pencil version of the interview. Computer programs that generate diagnoses are also available based on both ICD-10 and DSM-IV criteria. Elaborate CD-ROM-based training materials are available to teach interviewers how to administer the interview as well as to teach supervisors how to monitor the quality of data collection.     

Clinical calibration of DSM-IV diagnoses in the World Mental Health (WMH) version of the World Health Organization (WHO) Composite International Diagnostic Interview (WMHCIDI)

An overview is presented of the rationale, design, and analysis plan for the WMH-CIDI clinical calibration studies. As no clinical gold standard assessment is available for the DSM-IV disorders assessed in the WMH-CIDI, we adopted the goal of calibration rather than validation; that is, we asked whether WMH-CIDI diagnoses are 'consistent' with diagnoses based on a state-of-the-art clinical research diagnostic interview (SCID; Structured Clinical Interview for DSM-IV) rather than whether they are 'correct'. Consistency is evaluated both at the aggregate level (consistency of WMH-CIDI and SCID prevalence estimates) and at the individual level (consistency of WMH-CIDI and SCID diagnostic classifications). Although conventional statistics (sensitivity, specificity, Cohen's kappa) are used to describe diagnostic consistency, an argument is made for considering the area under the receiver operator curve (AUC) to be a more useful general-purpose measure of consistency. In addition, more detailed analyses are used to evaluate consistency on a substantive level. These analyses begin by estimating prediction equations in a clinical calibration subsample, with WMH-CIDI symptom-level data used to predict SCID diagnoses, and using the coefficients from these equations to assign predicted probabilities of SCID diagnoses to each respondent in the remainder of the sample. Substantive analyses then investigate whether estimates of prevalence and associations when based on WMH-CIDI diagnoses are consistent with those based on predicted SCID diagnoses. Multiple imputation is used to adjust estimated standard errors for the imprecision introduced by SCID diagnoses being imputed under a model rather than measured directly. A brief illustration of this approach is presented in comparing the precision of SCID and predicted SCID estimates of prevalence and correlates under varying sample designs.     

Days out of role due to common physical and mental conditions: results from the WHO World Mental Health surveys

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.     

Introduction to the special issue: The WHO World Mental Health International College Student (WMH‐ICS) initiative

Most mental disorders have their first onset in early adulthood. Epidemiological research, as well as research on preventive and early interventions, is therefore very important. This thematic issue focuses on one of the first systematic attempts to develop such services for college students. The WHO World Mental Health International College Student (WMH‐ICS) initiative is based on the largest and continuously growing epidemiological dataset ever collected in college students. Based on these results, the initiative has now started to implement internet‐based interventions for common mental disorders and emotional problems. In this special issue, a general paper about the initiative is presented, as well as a paper on the implementation of the WMH‐ICS initiative in low and middle income countries. It also includes several papers with core epidemiological results of the initiative, a meta‐analysis of internet‐based interventions for mental health problems in college students and the first results of trials conducted as part of the initiative. Taken together, the papers in this special issue show that WMH‐ICS is on its way to becoming a major initiative in addressing the problem of unmet need for treatment of mental health problems among college students.     

Health outcomes for people with serious mental illness: a case study

PURPOSE: To describe outcomes of clients with serious mental illnesses who used regional public mental health services; and what the public mental health system did well or needed to change to better satisfy clients' needs. METHODS: A modal case study analysis method was used with 15 clients. Participants were interviewed three times. FINDINGS: Participants reported dissatisfaction with their social functioning and general health, and unmet needs for case management services, social/recreational activities, and vocational rehabilitation. CONCLUSIONS: The case study method is an effective way for nurses to evaluate public mental health systems and to determine areas for system intervention.     

Performance of the 6-item Kessler scale for measuring serious mental illness in Hong Kong

BackgroundThe 6-item Kessler scale (K6) promises to be a valuable epidemiological tool for assessing serious mental illness (SMI) in communities with limited resources for psychiatric research and treatment. Its performance in Chinese community has not been studied with reference to clinically assessed SMI.MethodFrom a representative telephone-based population survey (n = 3014) that administered the K6, 153 participants were readministered the K6 and, on the same day, interviewed face-to-face by clinicians using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition, Axis I Disorder. Predictive indicators such as McNemar χ², area under receiver operating characteristic curve and stratum-specific likelihood ratios were used to investigate the concordance between the K6 and clinical status of SMI, individual-level predicted probabilities of having SMI, and the weighted prevalence of SMI in the community.ResultThe K6 exhibited high internal consistency and test-retest reliability. Factor analysis revealed 2 correlating components composed of depression and anxiety. Matching of K6 caseness and SMI status showed that at the cutoff of 12/13, the area under receiver operating characteristic curve was moderate (0.69). The K6 had high specificity and was a stronger screen-out than screen-in tool for SMI. The weighted prevalence estimate of SMI in Hong Kong was 6.5%. A person scoring 13 or above on the K6 has a probability of at least 22.2% of having SMI.ConclusionThe Chinese K6 is reliable and generates the likelihood of SMI with substantial concordance with face-to-face clinical interviews in Hong Kong. It is a valuable tool for screening SMI, behavioral risk factor surveillance, and community epidemiological surveys.     

Mental disorders among adults with asthma: results from the World Mental Health Survey

OBJECTIVE: Our objectives were (a) to determine which common mental disorders are associated with asthma in the general population after controlling for age and sex, and (b) to assess whether the associations of mental disorders with asthma are consistent across diverse countries. METHOD: Eighteen population surveys of household-residing adults were carried out in 17 countries (N=85,088). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0, a fully structured diagnostic interview. The disorders considered here are 12-month anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, posttraumatic stress disorder and social phobia), depressive disorders (dysthymia and major depressive disorder) and alcohol use disorders (abuse and dependence). Asthma was ascertained by self-reports of lifetime diagnosis among a subsample (n=42,697). RESULTS: Pooled estimates of age-adjusted and sex-adjusted odds of mental disorders among persons with asthma relative to those without asthma were 1.6 [95% confidence interval (95% CI)=1.4, 1.8] for depressive disorders, 1.5 (95% CI=1.4, 1.7) for anxiety disorders and 1.7 (95% CI=1.4, 2.1) for alcohol use disorders. CONCLUSION: This first cross-national study of the relationship between asthma and mental disorders confirms that a range of common mental disorders occurs with greater frequency among persons with asthma. These results attest to the importance of clinicians in diverse settings being alert to the co-occurrence of these conditions.     

Civilians in World War II and DSM-IV mental disorders: results from the World Mental Health Survey Initiative

Purpose

Understanding the effects of war on mental disorders is important for developing effective post-conflict recovery policies and programs. The current study uses cross-sectional, retrospectively reported data collected as part of the World Mental Health (WMH) Survey Initiative to examine the associations of being a civilian in a war zone/region of terror in World War II with a range of DSM-IV mental disorders.

Methods

Adults (n?=?3370) who lived in countries directly involved in World War II in Europe and Japan were administered structured diagnostic interviews of lifetime DSM-IV mental disorders. The associations of war-related traumas with subsequent disorder onset-persistence were assessed with discrete-time survival analysis (lifetime prevalence) and conditional logistic regression (12-month prevalence).

Results

Respondents who were civilians in a war zone/region of terror had higher lifetime risks than other respondents of major depressive disorder (MDD; OR 1.5, 95% CI 1.1, 1.9) and anxiety disorder (OR 1.5, 95% CI 1.1, 2.0). The association of war exposure with MDD was strongest in the early years after the war, whereas the association with anxiety disorders increased over time. Among lifetime cases, war exposure was associated with lower past year risk of anxiety disorders (OR 0.4, 95% CI 0.2, 0.7).

Conclusions

Exposure to war in World War II was associated with higher lifetime risk of some mental disorders. Whether comparable patterns will be found among civilians living through more recent wars remains to be seen, but should be recognized as a possibility by those projecting future needs for treatment of mental disorders.

     

Preliminary results from an Australian psychosocial rehabilitation program for people with serious mental illness

Psychosocial rehabilitation, for those with a serious mental illness, is of significant importance due to both its frequency and cost to government. This paper describes the implementation and preliminary assessments of a new psychosocial rehabilitation program in New South Wales. Of particular urgency was the requirement to establish baseline measures for ongoing service evaluation at the unit. An extensive array of assessment tools (Brief Psychiatric Rating Scale, BPRS; Scale for the Assessment of Negative Symptoms, SANS; Quality Of Life Scale, QOLS) was applied to determine the functioning of clients prior to the program. Following the initial assessments, subsequent measures were undertaken on completion of the program and then at 1 year follow-up. It was hypothesized that the clients would demonstrate significant improvements on these measures with a reduction in their psychopathology as assessed by the BPRS, improvement in their quality-of-life as measured by the QOLS and improvement in their negative symptoms as measured by the SANS. The final outcome demonstrated improvement in the assessment scores by 34%. A positive correlation to the above results showed a 54% reduction in the re-admission rate of clients and length of stay in hospital. The paper describes further developments regarding this psychosocial rehabilitation unit and suggests other psychosocial rehabilitation initiatives.     

The 6-item Kessler psychological distress scale to survey serious mental illness among Chinese undergraduates: Psychometric properties and prevalence estimate

ObjectiveTo evaluate the psychometric properties of the 6-item Kessler psychological distress scale (K6) in screening for serious mental illness (SMI) among undergraduates in a major comprehensive university in China.MethodThe K6 was self-completed by 8289 randomly sampled participants. A group of them (n = 222) were re-assessed using K6 and interviewed using the Chinese version of Composite International Diagnostic Interview 3.1 (CIDI-3.1).ResultsThe test–retest reliability of the K6 scale was 0.79, the Cronbach's alpha was 0.84, and its area under the receiver operating curve (AUC) for diagnosing CIDI-3.1 SMI was 0.85 (95% CI = 0.80–0.90). For the optimal cut-off of K6 (12/13), the sensitivity (SEN), specificity (SPE), positive predictive value (PPV), negative predictive value (NPV), and classification accuracy (AC) were 0.83, 0.79, 0.60, 0.93, and 0.80, respectively. The 12-month prevalence of SMI was estimated as 3.97% using this optimal cut-off. Binary logistic regression analysis (including gender, ethnicity, grade, number of siblings and family residency location) showed that only family residency location in rural areas compared to urban areas was significantly associated with more SMI.ConclusionsThis study documented the value of using the K6 for detecting SMI in Chinese undergraduate populations and supported its cross-cultural reliability and validity.     

Social inequalities in mental health: results from the EU contribution to the World Mental Health Surveys Initiative

Purpose

The objective of the present study was to provide updated data from nine European countries about the impact of social inequalities in the prevalence of common mental disorders.

Methods

Cross-sectional household survey of a representative sample of the adult general population of Belgium, Bulgaria, Germany, Italy, The Netherlands, Northern Ireland, Portugal, Romania and Spain. In total, 34,395 individuals were included. Social inequalities in 12-month mood, anxiety and alcohol-related disorders were evaluated.

Results

In Europe, income seems not to be related to the prevalence of mental disorders. Unemployment and disablement are associated with mental disorders. Lower educational level augments the risk for mood disorders. Living in small (rural) areas decreases the risk for mood disorders and living in urban settings increases it. Northern Ireland, Portugal and Belgium are the countries with the highest risks for mental disorders.

Conclusions

Despite some contradictions with previous literature, in Europe there are social inequalities in the prevalence of mental disorders. However, income showed not to be associated with inequalities in mental health. Being younger, unemployed or disabled, with no education or incomplete primary studies, living in urban settings, and in Northern Ireland, Portugal or Belgium were associated to an augmented prevalence of mental disorders. Policy makers could focus on mental health promotion and mental disorders prevention programmes for risk groups such as unemployed/disabled individuals. Support to vulnerable groups (unemployed or those with less education) and mental health literacy can improve European citizens’ mental health.     

Perceived helpfulness of treatment for social anxiety disorder: findings from the WHO World Mental Health Surveys

Purpose

To investigate the prevalence and predictors of perceived helpfulness of treatment in persons with a history of DSM-IV social anxiety disorder (SAD), using a worldwide population-based sample.

Methods

The World Health Organization World Mental Health Surveys is a coordinated series of community epidemiological surveys of non-institutionalized adults; 27 surveys in 24 countries (16 in high-income; 11 in low/middle-income countries; N = 117,856) included people with a lifetime history of treated SAD.

Results

In respondents with lifetime SAD, approximately one in five ever obtained treatment. Among these (n = 1322), cumulative probability of receiving treatment they regarded as helpful after seeing up to seven professionals was 92.2%. However, only 30.2% persisted this long, resulting in 65.1% ever receiving treatment perceived as helpful. Perceiving treatment as helpful was more common in female respondents, those currently married, more highly educated, and treated in non-formal health-care settings. Persistence in seeking treatment for SAD was higher among those with shorter delays in seeking treatment, in those receiving medication from a mental health specialist, and those with more than two lifetime anxiety disorders.

Conclusions

The vast majority of individuals with SAD do not receive any treatment. Among those who do, the probability that people treated for SAD obtain treatment they consider helpful increases considerably if they persisted in help-seeking after earlier unhelpful treatments.