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Sex-dependent differences in vulnerability to early risk factors for posttraumatic stress disorder: results from the AURORA study
- Stephanie Haering, Antonia V. Seligowski, Sarah D. Linnstaedt, Vasiliki Michopoulos, Stacey L. House, Francesca L. Beaudoin, Xinming An, Thomas C. Neylan, Gari D. Clifford, Laura T. Germine, Scott L. Rauch, John P. Haran, Alan B. Storrow, Christopher Lewandowski, Paul I. Musey, Jr., Phyllis L. Hendry, Sophia Sheikh, Christopher W. Jones, Brittany E. Punches, Robert A. Swor, Nina T. Gentile, Lauren A. Hudak, Jose L. Pascual, Mark J. Seamon, Claire Pearson, David A. Peak, Roland C. Merchant, Robert M. Domeier, Niels K. Rathlev, Brian J. O'Neil, Leon D. Sanchez, Steven E. Bruce, Steven E. Harte, Samuel A. McLean, Ronald C. Kessler, Karestan C. Koenen, Jennifer S. Stevens, Abigail Powers
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- Journal:
- Psychological Medicine , First View
- Published online by Cambridge University Press:
- 22 May 2024, pp. 1-11
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Background
Knowledge of sex differences in risk factors for posttraumatic stress disorder (PTSD) can contribute to the development of refined preventive interventions. Therefore, the aim of this study was to examine if women and men differ in their vulnerability to risk factors for PTSD.
MethodsAs part of the longitudinal AURORA study, 2924 patients seeking emergency department (ED) treatment in the acute aftermath of trauma provided self-report assessments of pre- peri- and post-traumatic risk factors, as well as 3-month PTSD severity. We systematically examined sex-dependent effects of 16 risk factors that have previously been hypothesized to show different associations with PTSD severity in women and men.
ResultsWomen reported higher PTSD severity at 3-months post-trauma. Z-score comparisons indicated that for five of the 16 examined risk factors the association with 3-month PTSD severity was stronger in men than in women. In multivariable models, interaction effects with sex were observed for pre-traumatic anxiety symptoms, and acute dissociative symptoms; both showed stronger associations with PTSD in men than in women. Subgroup analyses suggested trauma type-conditional effects.
ConclusionsOur findings indicate mechanisms to which men might be particularly vulnerable, demonstrating that known PTSD risk factors might behave differently in women and men. Analyses did not identify any risk factors to which women were more vulnerable than men, pointing toward further mechanisms to explain women's higher PTSD risk. Our study illustrates the need for a more systematic examination of sex differences in contributors to PTSD severity after trauma, which may inform refined preventive interventions.
Associations of alcohol and cannabis use with change in posttraumatic stress disorder and depression symptoms over time in recently trauma-exposed individuals
- Cecilia A. Hinojosa, Amanda Liew, Xinming An, Jennifer S. Stevens, Archana Basu, Sanne J. H. van Rooij, Stacey L. House, Francesca L. Beaudoin, Donglin Zeng, Thomas C. Neylan, Gari D. Clifford, Tanja Jovanovic, Sarah D. Linnstaedt, Laura T. Germine, Scott L. Rauch, John P. Haran, Alan B. Storrow, Christopher Lewandowski, Paul I. Musey, Phyllis L. Hendry, Sophia Sheikh, Christopher W. Jones, Brittany E. Punches, Michael C. Kurz, Robert A. Swor, Lauren A. Hudak, Jose L. Pascual, Mark J. Seamon, Elizabeth M. Datner, Anna M. Chang, Claire Pearson, David A. Peak, Roland C. Merchant, Robert M. Domeier, Niels K. Rathlev, Paulina Sergot, Leon D. Sanchez, Steven E. Bruce, Mark W. Miller, Robert H. Pietrzak, Jutta Joormann, Diego A. Pizzagalli, John F. Sheridan, Steven E. Harte, James M. Elliott, Ronald C. Kessler, Karestan C. Koenen, Samuel A. McLean, Kerry J. Ressler, Negar Fani
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- Journal:
- Psychological Medicine / Volume 54 / Issue 2 / January 2024
- Published online by Cambridge University Press:
- 13 June 2023, pp. 338-349
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Background
Several hypotheses may explain the association between substance use, posttraumatic stress disorder (PTSD), and depression. However, few studies have utilized a large multisite dataset to understand this complex relationship. Our study assessed the relationship between alcohol and cannabis use trajectories and PTSD and depression symptoms across 3 months in recently trauma-exposed civilians.
MethodsIn total, 1618 (1037 female) participants provided self-report data on past 30-day alcohol and cannabis use and PTSD and depression symptoms during their emergency department (baseline) visit. We reassessed participant's substance use and clinical symptoms 2, 8, and 12 weeks posttrauma. Latent class mixture modeling determined alcohol and cannabis use trajectories in the sample. Changes in PTSD and depression symptoms were assessed across alcohol and cannabis use trajectories via a mixed-model repeated-measures analysis of variance.
ResultsThree trajectory classes (low, high, increasing use) provided the best model fit for alcohol and cannabis use. The low alcohol use class exhibited lower PTSD symptoms at baseline than the high use class; the low cannabis use class exhibited lower PTSD and depression symptoms at baseline than the high and increasing use classes; these symptoms greatly increased at week 8 and declined at week 12. Participants who already use alcohol and cannabis exhibited greater PTSD and depression symptoms at baseline that increased at week 8 with a decrease in symptoms at week 12.
ConclusionsOur findings suggest that alcohol and cannabis use trajectories are associated with the intensity of posttrauma psychopathology. These findings could potentially inform the timing of therapeutic strategies.
Childhood adversities and risk of posttraumatic stress disorder and major depression following a motor vehicle collision in adulthood
- H. N. Ziobrowski, B. Holt-Gosselin, M. V. Petukhova, A. J. King, S. Lee, S. L. House, F. L. Beaudoin, X. An, J. S. Stevens, D. Zeng, T. C. Neylan, G. D. Clifford, S. D. Linnstaedt, L. T. Germine, K. A. Bollen, S. L. Rauch, J. P. Haran, A. B. Storrow, C. Lewandowski, P. I. Musey, P. L. Hendry, S. Sheikh, C. W. Jones, B. E. Punches, M. C. Kurz, R. A. Swor, L. A. Hudak, J. L. Pascual, M. J. Seamon, E. Harris, C. Pearson, R. C. Merchant, R. M. Domeier, N. K. Rathlev, B. J. O'Neil, P. Sergot, L. D. Sanchez, S. E. Bruce, M. W. Miller, R. H. Pietrzak, J. Joormann, D. M. Barch, D. A. Pizzagalli, S. E. Harte, J. M. Elliott, K. J. Ressler, S. A. McLean, K. C. Koenen, R. C. Kessler
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- Journal:
- Epidemiology and Psychiatric Sciences / Volume 32 / 2023
- Published online by Cambridge University Press:
- 10 January 2023, e1
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Aims
Childhood adversities (CAs) predict heightened risks of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) among people exposed to adult traumatic events. Identifying which CAs put individuals at greatest risk for these adverse posttraumatic neuropsychiatric sequelae (APNS) is important for targeting prevention interventions.
MethodsData came from n = 999 patients ages 18–75 presenting to 29 U.S. emergency departments after a motor vehicle collision (MVC) and followed for 3 months, the amount of time traditionally used to define chronic PTSD, in the Advancing Understanding of Recovery After Trauma (AURORA) study. Six CA types were self-reported at baseline: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect and bullying. Both dichotomous measures of ever experiencing each CA type and numeric measures of exposure frequency were included in the analysis. Risk ratios (RRs) of these CA measures as well as complex interactions among these measures were examined as predictors of APNS 3 months post-MVC. APNS was defined as meeting self-reported criteria for either PTSD based on the PTSD Checklist for DSM-5 and/or MDE based on the PROMIS Depression Short-Form 8b. We controlled for pre-MVC lifetime histories of PTSD and MDE. We also examined mediating effects through peritraumatic symptoms assessed in the emergency department and PTSD and MDE assessed in 2-week and 8-week follow-up surveys. Analyses were carried out with robust Poisson regression models.
ResultsMost participants (90.9%) reported at least rarely having experienced some CA. Ever experiencing each CA other than emotional neglect was univariably associated with 3-month APNS (RRs = 1.31–1.60). Each CA frequency was also univariably associated with 3-month APNS (RRs = 1.65–2.45). In multivariable models, joint associations of CAs with 3-month APNS were additive, with frequency of emotional abuse (RR = 2.03; 95% CI = 1.43–2.87) and bullying (RR = 1.44; 95% CI = 0.99–2.10) being the strongest predictors. Control variable analyses found that these associations were largely explained by pre-MVC histories of PTSD and MDE.
ConclusionsAlthough individuals who experience frequent emotional abuse and bullying in childhood have a heightened risk of experiencing APNS after an adult MVC, these associations are largely mediated by prior histories of PTSD and MDE.
Social network size and personality traits independently and prospectively predict distress disorders and suicidal behavior in U.S. Army soldiers
- Charles T. Taylor, Laura Campbell-Sills, Ronald C. Kessler, Xiaoying Sun, Matthew K. Nock, Robert J. Ursano, Sonia Jain, Murray B. Stein
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- Journal:
- Psychological Medicine / Volume 53 / Issue 11 / August 2023
- Published online by Cambridge University Press:
- 18 August 2022, pp. 5081-5090
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Background
Personality traits (e.g. neuroticism) and the social environment predict risk for internalizing disorders and suicidal behavior. Studying these characteristics together and prospectively within a population confronted with high stressor exposure (e.g. U.S. Army soldiers) has not been done, yet could uncover unique and interactive predictive effects that may inform prevention and early intervention efforts.
MethodsFive broad personality traits and social network size were assessed via self-administered questionnaires among experienced soldiers preparing for deployment (N = 4645) and new soldiers reporting for basic training (N = 6216). Predictive models examined associations of baseline personality and social network variables with recent distress disorders or suicidal behaviors assessed 3- and 9-months post-deployment and approximately 5 years following enlistment.
ResultsAmong the personality traits, elevated neuroticism was consistently associated with increased mental health risk following deployment. Small social networks were also associated with increased mental health risk following deployment, beyond the variance accounted for by personality. Limited support was found for social network size moderating the association between personality and mental health outcomes. Small social networks also predicted distress disorders and suicidal behavior 5 years following enlistment, whereas unique effects of personality traits on these more distal outcomes were rare.
ConclusionsHeightened neuroticism and small social networks predict a greater risk for negative mental health sequelae, especially following deployment. Social ties may mitigate adverse impacts of personality traits on psychopathology in some contexts. Early identification and targeted intervention for these distinct, modifiable factors may decrease the risk of distress disorders and suicidal behavior.
Mental impact of Covid-19 among Spanish healthcare workers. A large longitudinal survey
- J. Alonso, G. Vilagut, I. Alayo, M. Ferrer, F. Amigo, A. Aragón-Peña, E. Aragonès, M. Campos, I. del Cura-González, I. Urreta, M. Espuga, A. González Pinto, J. M. Haro, N. López Fresneña, A. Martínez de Salázar, J. D. Molina, R. M. Ortí Lucas, M. Parellada, J. M. Pelayo-Terán, A. Pérez Zapata, J. I. Pijoan, N. Plana, M. T. Puig, C. Rius, C. Rodriguez-Blazquez, F. Sanz, C. Serra, R. C. Kessler, R. Bruffaerts, E. Vieta, V. Pérez-Solá, P. Mortier, MINDCOVID Working group
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- Journal:
- Epidemiology and Psychiatric Sciences / Volume 31 / 2022
- Published online by Cambridge University Press:
- 29 April 2022, e28
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Aims
Longitudinal data on the mental health impact of the coronavirus disease 2019 (Covid-19) pandemic in healthcare workers is limited. We estimated prevalence, incidence and persistence of probable mental disorders in a cohort of Spanish healthcare workers (Covid-19 waves 1 and 2) -and identified associated risk factors.
Methods8996 healthcare workers evaluated on 5 May–7 September 2020 (baseline) were invited to a second web-based survey (October–December 2020). Major depressive disorder (PHQ-8 ≥ 10), generalised anxiety disorder (GAD-7 ≥ 10), panic attacks, post-traumatic stress disorder (PCL-5 ≥ 7), and alcohol use disorder (CAGE-AID ≥ 2) were assessed. Distal (pre-pandemic) and proximal (pandemic) risk factors were included. We estimated the incidence of probable mental disorders (among those without disorders at baseline) and persistence (among those with disorders at baseline). Logistic regression of individual-level [odds ratios (OR)] and population-level (population attributable risk proportions) associations were estimated, adjusting by all distal risk factors, health care centre and time of baseline interview.
Results4809 healthcare workers participated at four months follow-up (cooperation rate = 65.7%; mean = 120 days s.d. = 22 days from baseline assessment). Follow-up prevalence of any disorder was 41.5%, (v. 45.4% at baseline, p < 0.001); incidence, 19.7% (s.e. = 1.6) and persistence, 67.7% (s.e. = 2.3). Proximal factors showing significant bivariate-adjusted associations with incidence included: work-related factors [prioritising Covid-19 patients (OR = 1.62)], stress factors [personal health-related stress (OR = 1.61)], interpersonal stress (OR = 1.53) and financial factors [significant income loss (OR = 1.37)]. Risk factors associated with persistence were largely similar.
ConclusionsOur study indicates that the prevalence of probable mental disorders among Spanish healthcare workers during the second wave of the Covid-19 pandemic was similarly high to that after the first wave. This was in good part due to the persistence of mental disorders detected at the baseline, but with a relevant incidence of about 1 in 5 of HCWs without mental disorders during the first wave of the Covid-19 pandemic. Health-related factors, work-related factors and interpersonal stress are important risks of persistence of mental disorders and of incidence of mental disorders. Adequately addressing these factors might have prevented a considerable amount of mental health impact of the pandemic among this vulnerable population. Addressing health-related stress, work-related factors and interpersonal stress might reduce the prevalence of these disorders substantially. Study registration number: NCT04556565
Prior differences in previous trauma exposure primarily drive the observed racial/ethnic differences in posttrauma depression and anxiety following a recent trauma
- N. G. Harnett, N. M. Dumornay, M. Delity, L. D. Sanchez, K. Mohiuddin, P. I. Musey, Jr., M. J. Seamon, S. A. McLean, R. C. Kessler, K. C. Koenen, F. L. Beaudoin, L. A. M. Lebois, S. J. H. van Rooij, N. A. Sampson, V. Michopoulos, J. L. Maples-Keller, J. P. Haran, A. B. Storrow, C. Lewandowski, P. L. Hendry, S. Sheikh, C. W. Jones, B. E. Punches, M. C. Kurz, R. A. Swor, M. E. McGrath, L. A. Hudak, J. L. Pascual, S. L. House, X. An, J. S. Stevens, T. C. Neylan, T. Jovanovic, S. D. Linnstaedt, L. T. Germine, E. M. Datner, A. M. Chang, C. Pearson, D. A. Peak, R. C. Merchant, R. M. Domeier, N. K. Rathlev, B. J. O'Neil, P. Sergot, S. E. Bruce, M. W. Miller, R. H. Pietrzak, J. Joormann, D. M. Barch, D. A. Pizzagalli, J. F. Sheridan, J. W. Smoller, B. Luna, S. E. Harte, J. M. Elliott, K. J. Ressler
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- Journal:
- Psychological Medicine / Volume 53 / Issue 6 / April 2023
- Published online by Cambridge University Press:
- 31 January 2022, pp. 2553-2562
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Background
Racial and ethnic groups in the USA differ in the prevalence of posttraumatic stress disorder (PTSD). Recent research however has not observed consistent racial/ethnic differences in posttraumatic stress in the early aftermath of trauma, suggesting that such differences in chronic PTSD rates may be related to differences in recovery over time.
MethodsAs part of the multisite, longitudinal AURORA study, we investigated racial/ethnic differences in PTSD and related outcomes within 3 months after trauma. Participants (n = 930) were recruited from emergency departments across the USA and provided periodic (2 weeks, 8 weeks, and 3 months after trauma) self-report assessments of PTSD, depression, dissociation, anxiety, and resilience. Linear models were completed to investigate racial/ethnic differences in posttraumatic dysfunction with subsequent follow-up models assessing potential effects of prior life stressors.
ResultsRacial/ethnic groups did not differ in symptoms over time; however, Black participants showed reduced posttraumatic depression and anxiety symptoms overall compared to Hispanic participants and White participants. Racial/ethnic differences were not attenuated after accounting for differences in sociodemographic factors. However, racial/ethnic differences in depression and anxiety were no longer significant after accounting for greater prior trauma exposure and childhood emotional abuse in White participants.
ConclusionsThe present findings suggest prior differences in previous trauma exposure partially mediate the observed racial/ethnic differences in posttraumatic depression and anxiety symptoms following a recent trauma. Our findings further demonstrate that racial/ethnic groups show similar rates of symptom recovery over time. Future work utilizing longer time-scale data is needed to elucidate potential racial/ethnic differences in long-term symptom trajectories.
Antidepressant use in low- middle- and high-income countries: a World Mental Health Surveys report
- Alan E. Kazdin, Chi-Shin Wu, Irving Hwang, Victor Puac-Polanco, Nancy A. Sampson, Ali Al-Hamzawi, Jordi Alonso, Laura Helena Andrade, Corina Benjet, José-Miguel Caldas-de-Almeida, Giovanni de Girolamo, Peter de Jonge, Silvia Florescu, Oye Gureje, Josep M. Haro, Meredith G. Harris, Elie G. Karam, Georges Karam, Viviane Kovess-Masfety, Sing Lee, John J. McGrath, Fernando Navarro-Mateu, Daisuke Nishi, Bibilola D. Oladeji, José Posada-Villa, Dan J. Stein, T. Bedirhan Üstün, Daniel V. Vigo, Zahari Zarkov, Alan M. Zaslavsky, Ronald C. Kessler, the WHO World Mental Health Survey collaborators
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- Journal:
- Psychological Medicine / Volume 53 / Issue 4 / March 2023
- Published online by Cambridge University Press:
- 23 September 2021, pp. 1583-1591
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Background
The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries.
MethodsFace-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents.
Results3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2–4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness.
ConclusionADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.
Role of age, gender and marital status in prognosis for adults with depression: An individual patient data meta-analysis
- J. E. J. Buckman, R. Saunders, J. Stott, L.-L. Arundell, C. O'Driscoll, M. R. Davies, T. C. Eley, S. D. Hollon, T. Kendrick, G. Ambler, Z. D. Cohen, E. Watkins, S. Gilbody, N. Wiles, D. Kessler, D. Richards, S. Brabyn, E. Littlewood, R. J. DeRubeis, G. Lewis, S. Pilling
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- Journal:
- Epidemiology and Psychiatric Sciences / Volume 30 / 2021
- Published online by Cambridge University Press:
- 04 June 2021, e42
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Aims
To determine whether age, gender and marital status are associated with prognosis for adults with depression who sought treatment in primary care.
MethodsMedline, Embase, PsycINFO and Cochrane Central were searched from inception to 1st December 2020 for randomised controlled trials (RCTs) of adults seeking treatment for depression from their general practitioners, that used the Revised Clinical Interview Schedule so that there was uniformity in the measurement of clinical prognostic factors, and that reported on age, gender and marital status. Individual participant data were gathered from all nine eligible RCTs (N = 4864). Two-stage random-effects meta-analyses were conducted to ascertain the independent association between: (i) age, (ii) gender and (iii) marital status, and depressive symptoms at 3–4, 6–8,<Vinod: Please carry out the deletion of serial commas throughout the article> and 9–12 months post-baseline and remission at 3–4 months. Risk of bias was evaluated using QUIPS and quality was assessed using GRADE. PROSPERO registration: CRD42019129512. Pre-registered protocol https://osf.io/e5zup/.
ResultsThere was no evidence of an association between age and prognosis before or after adjusting for depressive ‘disorder characteristics’ that are associated with prognosis (symptom severity, durations of depression and anxiety, comorbid panic disorderand a history of antidepressant treatment). Difference in mean depressive symptom score at 3–4 months post-baseline per-5-year increase in age = 0(95% CI: −0.02 to 0.02). There was no evidence for a difference in prognoses for men and women at 3–4 months or 9–12 months post-baseline, but men had worse prognoses at 6–8 months (percentage difference in depressive symptoms for men compared to women: 15.08% (95% CI: 4.82 to 26.35)). However, this was largely driven by a single study that contributed data at 6–8 months and not the other time points. Further, there was little evidence for an association after adjusting for depressive ‘disorder characteristics’ and employment status (12.23% (−1.69 to 28.12)). Participants that were either single (percentage difference in depressive symptoms for single participants: 9.25% (95% CI: 2.78 to 16.13) or no longer married (8.02% (95% CI: 1.31 to 15.18)) had worse prognoses than those that were married, even after adjusting for depressive ‘disorder characteristics’ and all available confounders.
ConclusionClinicians and researchers will continue to routinely record age and gender, but despite their importance for incidence and prevalence of depression, they appear to offer little information regarding prognosis. Patients that are single or no longer married may be expected to have slightly worse prognoses than those that are married. Ensuring this is recorded routinely alongside depressive ‘disorder characteristics’ in clinic may be important.
Predicting prognosis for adults with depression using individual symptom data: a comparison of modelling approaches
- J. E. J. Buckman, Z. D. Cohen, C. O'Driscoll, E. I. Fried, R. Saunders, G. Ambler, R. J. DeRubeis, S. Gilbody, S. D. Hollon, T. Kendrick, E. Watkins, T.C. Eley, A. J. Peel, C. Rayner, D. Kessler, N. Wiles, G. Lewis, S. Pilling
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- Journal:
- Psychological Medicine / Volume 53 / Issue 2 / January 2023
- Published online by Cambridge University Press:
- 06 May 2021, pp. 408-418
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Background
This study aimed to develop, validate and compare the performance of models predicting post-treatment outcomes for depressed adults based on pre-treatment data.
MethodsIndividual patient data from all six eligible randomised controlled trials were used to develop (k = 3, n = 1722) and test (k = 3, n = 918) nine models. Predictors included depressive and anxiety symptoms, social support, life events and alcohol use. Weighted sum scores were developed using coefficient weights derived from network centrality statistics (models 1–3) and factor loadings from a confirmatory factor analysis (model 4). Unweighted sum score models were tested using elastic net regularised (ENR) and ordinary least squares (OLS) regression (models 5 and 6). Individual items were then included in ENR and OLS (models 7 and 8). All models were compared to one another and to a null model (mean post-baseline Beck Depression Inventory Second Edition (BDI-II) score in the training data: model 9). Primary outcome: BDI-II scores at 3–4 months.
ResultsModels 1–7 all outperformed the null model and model 8. Model performance was very similar across models 1–6, meaning that differential weights applied to the baseline sum scores had little impact.
ConclusionsAny of the modelling techniques (models 1–7) could be used to inform prognostic predictions for depressed adults with differences in the proportions of patients reaching remission based on the predicted severity of depressive symptoms post-treatment. However, the majority of variance in prognosis remained unexplained. It may be necessary to include a broader range of biopsychosocial variables to better adjudicate between competing models, and to derive models with greater clinical utility for treatment-seeking adults with depression.
Socio-demographic and trauma-related predictors of depression within eight weeks of motor vehicle collision in the AURORA study
- Jutta Joormann, Samuel A. McLean, Francesca L. Beaudoin, Xinming An, Jennifer S. Stevens, Donglin Zeng, Thomas C. Neylan, Gari Clifford, Sarah D. Linnstaedt, Laura T. Germine, Scott L. Rauch, Paul I. Musey, Phyllis L. Hendry, Sophia Sheikh, Christopher W. Jones, Brittany E. Punches, Gregory Fermann, Lauren A. Hudak, Kamran Mohiuddin, Vishnu Murty, Meghan E. McGrath, John P. Haran, Jose Pascual, Mark Seamon, David A. Peak, Claire Pearson, Robert M. Domeier, Paulina Sergot, Roland Merchant, Leon D. Sanchez, Niels K. Rathlev, William F. Peacock, Steven E. Bruce, Deanna Barch, Diego A. Pizzagalli, Beatriz Luna, Steven E. Harte, Irving Hwang, Sue Lee, Nancy Sampson, Karestan C. Koenen, Kerry J. Ressler, Ronald C. Kessler
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- Journal:
- Psychological Medicine / Volume 52 / Issue 10 / July 2022
- Published online by Cambridge University Press:
- 29 October 2020, pp. 1934-1947
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Background
This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.
MethodsWe focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.
ResultsEight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.
ConclusionsThese observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.
Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys
- S. Evans-Lacko, S. Aguilar-Gaxiola, A. Al-Hamzawi, J. Alonso, C. Benjet, R. Bruffaerts, W. T. Chiu, S. Florescu, G. de Girolamo, O. Gureje, J. M. Haro, Y. He, C. Hu, E. G. Karam, N. Kawakami, S. Lee, C. Lund, V. Kovess-Masfety, D. Levinson, F. Navarro-Mateu, B. E. Pennell, N. A. Sampson, K. M. Scott, H. Tachimori, M. ten Have, M. C. Viana, D. R. Williams, B. J. Wojtyniak, Z. Zarkov, R. C. Kessler, S. Chatterji, G. Thornicroft
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- Journal:
- Psychological Medicine / Volume 48 / Issue 9 / July 2018
- Published online by Cambridge University Press:
- 27 November 2017, pp. 1560-1571
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Background
The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data.
MethodsData come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI).
ResultsOnly 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes).
ConclusionsThe modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.
Using self-report surveys at the beginning of service to develop multi-outcome risk models for new soldiers in the U.S. Army
- A. J. Rosellini, M. B. Stein, D. M. Benedek, P. D. Bliese, W. T. Chiu, I. Hwang, J. Monahan, M. K. Nock, M. V. Petukhova, N. A. Sampson, A. E. Street, A. M. Zaslavsky, R. J. Ursano, R.C. Kessler,
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- Journal:
- Psychological Medicine / Volume 47 / Issue 13 / October 2017
- Published online by Cambridge University Press:
- 04 April 2017, pp. 2275-2287
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Background
The U.S. Army uses universal preventives interventions for several negative outcomes (e.g. suicide, violence, sexual assault) with especially high risks in the early years of service. More intensive interventions exist, but would be cost-effective only if targeted at high-risk soldiers. We report results of efforts to develop models for such targeting from self-report surveys administered at the beginning of Army service.
Methods21 832 new soldiers completed a self-administered questionnaire (SAQ) in 2011–2012 and consented to link administrative data to SAQ responses. Penalized regression models were developed for 12 administratively-recorded outcomes occurring by December 2013: suicide attempt, mental hospitalization, positive drug test, traumatic brain injury (TBI), other severe injury, several types of violence perpetration and victimization, demotion, and attrition.
ResultsThe best-performing models were for TBI (AUC = 0.80), major physical violence perpetration (AUC = 0.78), sexual assault perpetration (AUC = 0.78), and suicide attempt (AUC = 0.74). Although predicted risk scores were significantly correlated across outcomes, prediction was not improved by including risk scores for other outcomes in models. Of particular note: 40.5% of suicide attempts occurred among the 10% of new soldiers with highest predicted risk, 57.2% of male sexual assault perpetrations among the 15% with highest predicted risk, and 35.5% of female sexual assault victimizations among the 10% with highest predicted risk.
ConclusionsData collected at the beginning of service in self-report surveys could be used to develop risk models that define small proportions of new soldiers accounting for high proportions of negative outcomes over the first few years of service.
The cross-national epidemiology of specific phobia in the World Mental Health Surveys
- K. J. Wardenaar, C. C. W. Lim, A. O. Al-Hamzawi, J. Alonso, L. H. Andrade, C. Benjet, B. Bunting, G. de Girolamo, K. Demyttenaere, S. E. Florescu, O. Gureje, T. Hisateru, C. Hu, Y. Huang, E. Karam, A. Kiejna, J. P. Lepine, F. Navarro-Mateu, M. Oakley Browne, M. Piazza, J. Posada-Villa, M. L. ten Have, Y. Torres, M. Xavier, Z. Zarkov, R. C. Kessler, K. M. Scott, P. de Jonge
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- Journal:
- Psychological Medicine / Volume 47 / Issue 10 / July 2017
- Published online by Cambridge University Press:
- 22 February 2017, pp. 1744-1760
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Background
Although specific phobia is highly prevalent, associated with impairment, and an important risk factor for the development of other mental disorders, cross-national epidemiological data are scarce, especially from low- and middle-income countries. This paper presents epidemiological data from 22 low-, lower-middle-, upper-middle- and high-income countries.
MethodData came from 25 representative population-based surveys conducted in 22 countries (2001–2011) as part of the World Health Organization World Mental Health Surveys initiative (n = 124 902). The presence of specific phobia as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition was evaluated using the World Health Organization Composite International Diagnostic Interview.
ResultsThe cross-national lifetime and 12-month prevalence rates of specific phobia were, respectively, 7.4% and 5.5%, being higher in females (9.8 and 7.7%) than in males (4.9% and 3.3%) and higher in high- and higher-middle-income countries than in low-/lower-middle-income countries. The median age of onset was young (8 years). Of the 12-month patients, 18.7% reported severe role impairment (13.3–21.9% across income groups) and 23.1% reported any treatment (9.6–30.1% across income groups). Lifetime co-morbidity was observed in 60.5% of those with lifetime specific phobia, with the onset of specific phobia preceding the other disorder in most cases (72.6%). Interestingly, rates of impairment, treatment use and co-morbidity increased with the number of fear subtypes.
ConclusionsSpecific phobia is common and associated with impairment in a considerable percentage of cases. Importantly, specific phobia often precedes the onset of other mental disorders, making it a possible early-life indicator of psychopathology vulnerability.
Post-traumatic stress disorder associated with natural and human-made disasters in the World Mental Health Surveys
- E. J. Bromet, L. Atwoli, N. Kawakami, F. Navarro-Mateu, P. Piotrowski, A. J. King, S. Aguilar-Gaxiola, J. Alonso, B. Bunting, K. Demyttenaere, S. Florescu, G. de Girolamo, S. Gluzman, J. M. Haro, P. de Jonge, E. G. Karam, S. Lee, V. Kovess-Masfety, M. E. Medina-Mora, Z. Mneimneh, B.-E. Pennell, J. Posada-Villa, D. Salmerón, T. Takeshima, R. C. Kessler
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- Journal:
- Psychological Medicine / Volume 47 / Issue 2 / January 2017
- Published online by Cambridge University Press:
- 30 August 2016, pp. 227-241
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Background
Research on post-traumatic stress disorder (PTSD) following natural and human-made disasters has been undertaken for more than three decades. Although PTSD prevalence estimates vary widely, most are in the 20–40% range in disaster-focused studies but considerably lower (3–5%) in the few general population epidemiological surveys that evaluated disaster-related PTSD as part of a broader clinical assessment. The World Mental Health (WMH) Surveys provide an opportunity to examine disaster-related PTSD in representative general population surveys across a much wider range of sites than in previous studies.
MethodAlthough disaster-related PTSD was evaluated in 18 WMH surveys, only six in high-income countries had enough respondents for a risk factor analysis. Predictors considered were socio-demographics, disaster characteristics, and pre-disaster vulnerability factors (childhood family adversities, prior traumatic experiences, and prior mental disorders).
ResultsDisaster-related PTSD prevalence was 0.0–3.8% among adult (ages 18+) WMH respondents and was significantly related to high education, serious injury or death of someone close, forced displacement from home, and pre-existing vulnerabilities (prior childhood family adversities, other traumas, and mental disorders). Of PTSD cases 44.5% were among the 5% of respondents classified by the model as having highest PTSD risk.
ConclusionDisaster-related PTSD is uncommon in high-income WMH countries. Risk factors are consistent with prior research: severity of exposure, history of prior stress exposure, and pre-existing mental disorders. The high concentration of PTSD among respondents with high predicted risk in our model supports the focus of screening assessments that identify disaster survivors most in need of preventive interventions.
The cross-national epidemiology of DSM-IV intermittent explosive disorder
- K. M. Scott, C. C. W. Lim, I. Hwang, T. Adamowski, A. Al-Hamzawi, E. Bromet, B. Bunting, M. P. Ferrand, S. Florescu, O. Gureje, H. Hinkov, C. Hu, E. Karam, S. Lee, J. Posada-Villa, D. Stein, H. Tachimori, M. C. Viana, M. Xavier, R. C. Kessler
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- Journal:
- Psychological Medicine / Volume 46 / Issue 15 / November 2016
- Published online by Cambridge University Press:
- 30 August 2016, pp. 3161-3172
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Background
This is the first cross-national study of intermittent explosive disorder (IED).
MethodA total of 17 face-to-face cross-sectional household surveys of adults were conducted in 16 countries (n = 88 063) as part of the World Mental Health Surveys initiative. The World Health Organization Composite International Diagnostic Interview (CIDI 3.0) assessed DSM-IV IED, using a conservative definition.
ResultsLifetime prevalence of IED ranged across countries from 0.1 to 2.7% with a weighted average of 0.8%; 0.4 and 0.3% met criteria for 12-month and 30-day prevalence, respectively. Sociodemographic correlates of lifetime risk of IED were being male, young, unemployed, divorced or separated, and having less education. The median age of onset of IED was 17 years with an interquartile range across countries of 13–23 years. The vast majority (81.7%) of those with lifetime IED met criteria for at least one other lifetime disorder; co-morbidity was highest with alcohol abuse and depression. Of those with 12-month IED, 39% reported severe impairment in at least one domain, most commonly social or relationship functioning. Prior traumatic experiences involving physical (non-combat) or sexual violence were associated with increased risk of IED onset.
ConclusionsConservatively defined, IED is a low prevalence disorder but this belies the true societal costs of IED in terms of the effects of explosive anger attacks on families and relationships. IED is more common among males, the young, the socially disadvantaged and among those with prior exposure to violence, especially in childhood.
LO042: Sonography in Hypotension and Cardiac Arrest (SHoC) - Hypotension: derivation of an evidence-based consensus algorithm for the integration of point of care ultrasound into resuscitation of hypotensive patients
- P. Atkinson, J. Bowra, J. Milne, M. Lambert, B. Jarman, V. Noble, H. Lamprecht, D. Lewis, T. Harris, R. Gangahar, Advisory panel members , M. Stander, C. Muhr, J. Connolly, R. Gaspari, R. Kessler, C. Raio, P. Sierzenski, B. Hoffmann, C. Pham, M. Woo, P. Olszynski, R. Henneberry, O. Frenkel, J. Chenkin, G. Hall, L. Rang, M. Valois, C. Wurster, M. Tutschka, R. Arntfield, J. Fischer, M. Tessaro
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S44
- Print publication:
- May 2016
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Introduction: Point of care ultrasound has become an established tool in the initial management of patients with undifferentiated hypotension. Current established protocols (RUSH, ACES, etc) were developed by expert user opinion, rather than objective, prospective data. We wished to use reported disease incidence to develop an informed approach to PoCUS in hypotension using a “4 F’s” approach: Fluid; Form; Function; Filling. Methods: We summarized the incidence of PoCUS findings from an international multicentre RCT, and using a modified Delphi approach incorporating this data we obtained the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. The modified Delphi tool was developed to reach an international consensus on how to integrate PoCUS for hypotensive emergency department patients. Results: Rates of abnormal PoCUS findings from 151 patients with undifferentiated hypotension included left ventricular dynamic changes (43%), IVC abnormalities (27%), pericardial effusion (16%), and pleural fluid (8%). Abdominal pathology was rare (fluid 5%, AAA 2%). After two rounds of the survey, using majority consensus, agreement was reached on a SHoC-hypotension protocol comprising: A. Core: 1. Cardiac views (Sub-xiphoid and parasternal windows for pericardial fluid, cardiac form and ventricular function); 2. Lung views for pleural fluid and B-lines for filling status; and 3. IVC views for filling status; B. Supplementary: Additional cardiac views; and C. Additional views (when indicated) including peritoneal fluid, aorta, pelvic for IUP, and proximal leg veins for DVT. Conclusion: An international consensus process based on prospectively collected disease incidence has led to a proposed SHoC-hypotension PoCUS protocol comprising a stepwise clinical-indication based approach of Core, Supplementary and Additional PoCUS views.
LO045: Sonography in Hypotension and Cardiac Arrest (SHoC) - Cardiac Arrest: A consensus on the integration of point of care ultrasound into advanced cardiac life support during cardiac arrest
- P. Atkinson, J. Bowra, J. Milne, M. Lambert, B. Jarman, V. Noble, H. Lamprecht, D. Lewis, T. Harris, R. Gangahar, Advisory panel members , S. Bomann, A. Goudie, H. Poncia, A. Bystrzycki, G. Blecher, M. Rose, S. Dass, O. Doran, R. Large, A. Salter, J. Sadewasser, A. Murray, M. Rawson, M. Stander, C. Muhr, J. Connolly, R. Gaspari, R. Kessler, C. Raio, P. Sierzenski, B. Hoffmann, C. Pham, M. Woo, P. Olszynski, R. Henneberry, O. Frenkel, J. Chenkin, G. Hall, L. Rang, M. Valois, C. Wurster, M. Tutschka, R. Arntfield, J. Fischer, M. Tessaro
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, pp. S45-S46
- Print publication:
- May 2016
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Introduction: Point of care ultrasound (PoCUS) provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We consider that a consensus-based priority checklist using a “4 F’s” approach (Fluid; Form; Function; Filling), would provide a better algorithm during ACLS. Methods: The ultrasound subcommittee of the Australasian College for Emergency Medicine (ACEM) drafted a checklist incorporating PoCUS into the ACLS algorithm. This was further developed using the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. A modified Delphi tool was developed to reach an international consensus on how to integrate ultrasound into cardiac arrest algorithms for emergency department patients. Results: Consensus was reached following 3 rounds. The agreed protocol focuses on the timing of PoCUS as well as the specific clinical questions. Core cardiac windows performed during the rhythm check pause in chest compressions are the sub-xiphoid and parasternal cardiac views. Either view should be used to detect pericardial fluid, as well as examining ventricular form (e.g. right heart strain) and function, (e.g. asystole versus organized cardiac activity). Supplementary views include lung views (for absent lung sliding in pneumothorax and for pleural fluid), and IVC views for filling. Additional ultrasound applications are for endotracheal tube confirmation, proximal leg veins for DVT, or for sources of blood loss (AAA, peritoneal/pelvic fluid). Conclusion: The authors hope that this process will lead to a consensus-based SHoC-cardiac arrest guideline on incorporating PoCUS into the ACLS algorithm.
The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium
- C. Benjet, E. Bromet, E. G. Karam, R. C. Kessler, K. A. McLaughlin, A. M. Ruscio, V. Shahly, D. J. Stein, M. Petukhova, E. Hill, J. Alonso, L. Atwoli, B. Bunting, R. Bruffaerts, J. M. Caldas-de-Almeida, G. de Girolamo, S. Florescu, O. Gureje, Y. Huang, J. P. Lepine, N. Kawakami, Viviane Kovess-Masfety, M. E. Medina-Mora, F. Navarro-Mateu, M. Piazza, J. Posada-Villa, K. M. Scott, A. Shalev, T. Slade, M. ten Have, Y. Torres, M. C. Viana, Z. Zarkov, K. C. Koenen
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- Journal:
- Psychological Medicine / Volume 46 / Issue 2 / January 2016
- Published online by Cambridge University Press:
- 29 October 2015, pp. 327-343
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Background
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.
MethodGeneral 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.
ResultsOver 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.
ConclusionsGiven 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.
Occupational differences in US Army suicide rates
- R. C. Kessler, M. B. Stein, P. D. Bliese, E. J. Bromet, W. T. Chiu, K. L. Cox, L. J. Colpe, C. S. Fullerton, S. E. Gilman, M. J. Gruber, S. G. Heeringa, L. Lewandowski-Romps, A. Millikan-Bell, J. A. Naifeh, M. K. Nock, M. V. Petukhova, A. J. Rosellini, N. A. Sampson, M. Schoenbaum, A. M. Zaslavsky, R. J. Ursano
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- Journal:
- Psychological Medicine / Volume 45 / Issue 15 / November 2015
- Published online by Cambridge University Press:
- 20 July 2015, pp. 3293-3304
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Background
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.
MethodThe 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.
ResultsThere 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.
ConclusionsEfforts are needed to elucidate the causal mechanisms underlying this interaction to guide preventive interventions for soldiers at high suicide risk.
Anxious and non-anxious major depressive disorder in the World Health Organization World Mental Health Surveys
- R. C. Kessler, N. A. Sampson, P. Berglund, M. J. Gruber, A. Al-Hamzawi, L. Andrade, B. Bunting, K. Demyttenaere, S. Florescu, G. de Girolamo, O. Gureje, Y. He, C. Hu, Y. Huang, E. Karam, V. Kovess-Masfety, S Lee, D. Levinson, M. E. Medina Mora, J. Moskalewicz, Y. Nakamura, F. Navarro-Mateu, M. A. Oakley Browne, M. Piazza, J. Posada-Villa, T. Slade, M. ten Have, Y. Torres, G. Vilagut, M. Xavier, Z. Zarkov, V. Shahly, M. A. Wilcox
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- Journal:
- Epidemiology and Psychiatric Sciences / Volume 24 / Issue 3 / June 2015
- Published online by Cambridge University Press:
- 27 February 2015, pp. 210-226
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Background.
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).
Method.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).
Results.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 (AOO) of their first anxiety disorder than their MDD, while 13.5% reported an earlier AOO of MDD and the remaining 18.5% reported the same AOO 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 v. 46.0%; χ21 = 187.0, p < 0.001) and suicide ideation (19.5 v. 8.9%; χ21 = 71.6, p < 0.001). 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 v. 45.4%; χ21 = 108.8, p < 0.001) than low/middle-income countries (30.3 v. 20.6%; χ21 = 11.7, p < 0.001).
Conclusions.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 v. 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.