Frank Jacobi

Size and burden of mental disorders in Europe—a critical review and appraisal of 27 studies

Epidemiological data on a wide range of mental disorders from community studies conducted in European countries are presented to determine the availability and consistency of prevalence, disability and treatment findings for the EU. Using a stepwise multimethod approach, 27 eligible studies with quite variable designs and methods including over 150,000 subjects from 16 European countries were identified. Prevalence: On the basis of meta-analytic techniques as well as on reanalyses of selected data sets, it is estimated that about 27% (equals 82.7 million; 95% CI: 78.5-87.1) of the adult EU population, 18-65 of age, is or has been affected by at least one mental disorder in the past 12 months. Taking into account the considerable degree of comorbidity (about one third had more than one disorder), the most frequent disorders are anxiety disorders, depressive, somatoform and substance dependence disorders. When taking into account design, sampling and other methodological differences between studies, little evidence seems to exist for considerable cultural or country variation. Disability and treatment: despite very divergent and fairly crude assessment strategies, the available data consistently demonstrate (a) an association of all mental disorders with a considerable disability burden in terms of number of work days lost (WLD) and (b) generally low utilization and treatment rates. Only 26% of all cases had any consultation with professional health care services, a finding suggesting a considerable degree of unmet need. The paper highlights considerable future research needs for coordinated EU studies across all disorders and age groups. As prevalence estimates could not simply be equated with defined treatment needs, such studies should determine the degree of met and unmet needs for services by taking into account severity, disability and comorbidity. These needs are most pronounced for the new EU member states as well as more generally for adolescent and older populations.

Die Versorgungssituation psychischer Störungen in Deutschland

ZusammenfassungNach Befunden des Bundes-Gesundheitssurveys 1998/99 (Zusatzsurvey “Psychische Störungen”) litten im Jahr der Erhebung 32% (=15,6 Millionen) der erwachsenen deutschen Bevölkerung im Alter von 18–65 unter einer oder mehreren psychischen Störungen. Jeder dritte Betroffene (36%) steht oder stand im Jahr vor der Erhebung wegen der psychischen Störung in Kontakt mit ambulanten oder stationären psychiatrisch/psychotherapeutischen Diensten oder seinem Hausarzt. Der Anteil von Betroffenen, die eine im weitesten Sinne adäquate Therapie nach modernen wissenschaftlichen Kriterien erhalten, kann konservativ auf ca. 10% geschätzt werden. Die niedrige Versorgungsquote betrifft dabei nicht alle spezifischen Störungsgruppen in gleichem Ausmaß; niedrige Versorgungsraten ergaben sich insbesondere für somatoforme und Suchterkrankungen. Ferner ergaben sich zum Teil markante regionale Unterschiede (z. B. besonders schlechte Versorgungslage in Regionen, die weder über eine nahe Universität noch über psychotherapeutische Weiterbildungsinstitutionen verfügen). Ungeachtet unterschiedlich weiter oder enger Definitionen des Begriffs Behandlungsbedarf, zeigt sich eine gravierende Unterversorgung von Personen mit psychischen Erkrankungen. Quantitativ bedeutsame Hinweise auf eine Fehl- oder Überversorgung von Betroffenen lassen sich nicht aufzeigen.AbstractData from the German Health Interview and Examination Survey, Mental Health Supplement (N=4181) reveal that 32% (15,6 million people) of the adult population between 18 and 65 years of age suffer from one or more mental disorders. Among those only 36% receive treatment which also varies in type, duration, and adequacy. The proportion of cases receiving “adequate evidence- based treatments” was estimated to be about 10%. Lowest treatment rates were found for somatoform disorders and substance abuses, highest for psychotic disorders, panic disorder, generalised anxiety disorder, and dysthymia. The data reveal substantial regional differences with regard to treatment rates (e.g. lower rates in regions without universities or institutions offering postgraduate mental health education). The paper concludes that, depending on the diagnosis, a considerable degree of unmet medical needs exist for the majority of people affected by mental disorders. No evidence was found for an excessive supply of health care for the patients suffering from mental disorders or for treatments without an existing clinical need.

Increased 12-Month Prevalence Rates of Mental Disorders in Patients with Chronic Somatic Diseases

Background: Although it is well established that chronic somatic diseases are significantly associated with a wide range of psychopathology, it remains unclear to what extent subjects with chronic somatic diseases are at increased risk of experiencing mental disorders. The present epidemiological study investigates age- and sex-adjusted 12-month prevalence rates of mental disorders in patients with cancer, and musculoskeletal, cardiovascular and respiratory tract diseases, based on comprehensive physicians’ diagnoses and compared with physically healthy probands. Methods: Prevalence rates were calculated from two large epidemiological surveys. These studies investigated inpatients and patients from the general population with cancer (n = 174) and musculoskeletal (n = 1,416), cardiovascular (n = 915) and respiratory tract diseases (n = 453) as well as healthy controls (n = 1,083). The prevalence rates were based on the Munich Composite International Diagnostic Interview, a standardized interview for the assessment of mental disorders. Results: Prevalence rates were very similar for inpatients (43.7%) and patients from the general population (42.2%). The adjusted odds ratios (OR) of patients with chronic somatic diseases were significantly elevated for mental disorders in comparison with healthy probands (OR: 2.2). Mood, anxiety and somatoform disorders were most frequent. The prevalence rates did not differ significantly between the somatic index diseases. The number of somatic diseases per patient had a higher association with mental disorders. Conclusions: There is a strong relationship between chronic somatic diseases and mental disorders. A future task is to improve the care of mental disorders in patients with chronic physical illness, specifically with multimorbid conditions.

Alcohol use disorders in EU countries and Norway: An overview of the epidemiology

Based on a systematic literature search and an expert survey, publications after 1990 on prevalence of alcohol use disorders (AUD) in EU countries and Norway were reviewed. The search was restricted to studies using the DSM-IIIR or DSM-IV, or ICD-10, plus validated instruments to assess AUD. Using only representative general population surveys, the weighted median estimates for 12-month prevalence rates for dependence alone are 6.1% for males (arithmetic mean 5.0%; interquartile range 0.4% to 7.5%) and 1.1% for females (arithmetic mean 1.4%; interquartile range 0.1% to 2.1%). Results thus showed, that AUD constitute a high burden of disease in Europe, but there was high variability of prevalence. Men have higher prevalence rates of AUD than women. No clear pictures emerged with respect to age and AUD prevalence, or with respect to urban vs. rural and AUD prevalence. The discussion highlights potential explanations for the high variability of prevalence between countries, and the fact, that AUD constitute only a small part of all alcohol-related harm.

Social anxiety disorder above and below the diagnostic threshold: prevalence, comorbidity and impairment in the general population

BackgroundThere is a lack of data systematically describing subthreshold expressions of social anxiety disorder (SAD) with regard to prevalence, comorbidity, and impairment.MethodsThis analysis was based on data from the German Health Survey (GHS) and its Mental Health Supplement (GHS-MHS). Social anxiety disorder and its syndromes as well as other mental disorders were assessed with a standardized diagnostic interview (M-CIDI) in 4,174 adults.ResultsThe 12-month prevalence rate for threshold SAD was 2.0%, subthreshold and symptomatic social anxiety (one DSM-IV criterion missing/two or more criteria missing) was found in 3.0 and 7.5% of the participants, respectively. As expected, threshold SAD was characterized by an elevated risk for comorbid disorders and associated with impairment in diverse areas of life. However, this was also true for the two subthreshold expressions of social anxiety, which were also significantly associated with higher comorbidity and greater impairment compared to the control group.ConclusionsOur results suggest that social anxiety below the diagnostic threshold is clearly associated with adverse outcomes. Prospective designs should examine the exact temporal and possible causal pathways of this burden in order to inform prevention and early intervention programs.

Twelve-month prevalence, comorbidity and correlates of mental disorders in Germany: the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1-MH)

This paper provides up to date prevalence estimates of mental disorders in Germany derived from a national survey (German Health Interview and Examination Survey for Adults, Mental Health Module [DEGS1‐MH]). A nationally representative sample (N = 5318) of the adult (18–79) population was examined by clinically trained interviewers with a modified version of the Composite International Diagnostic Interview (DEGS‐CIDI) to assess symptoms, syndromes and diagnoses according to DSM‐IV‐TR (25 diagnoses covered). Of the participants 27.7% met criteria for at least one mental disorder during the past 12 months, among them 44% with more than one disorder and 22% with three or more diagnoses. Most frequent were anxiety (15.3%), mood (9.3%) and substance use disorders (5.7%). Overall rates for mental disorders were substantially higher in women (33% versus 22% in men), younger age group (18–34: 37% versus 20% in age group 65–79), when living without a partner (37% versus 26% with partnership) or with low (38%) versus high socio‐economic status (22%). High degree of urbanization (> 500,000 inhabitants versus < 20,000) was associated with elevated rates of psychotic (5.2% versus 2.5%) and mood disorders (13.9% versus 7.8%). The findings confirm that almost one third of the general population is affected by mental disorders and inform about subsets in the population who are particularly affected. Copyright

Can gender differences in the prevalence of mental disorders be explained by sociodemographic factors

SummaryBackground and aims: Epidemiological studies throughout the world consistently reported higher rates of depression and anxiety disorders in women, whereas men consistently show higher rates of substance and antisocial disorders. The present study examined factors potentially contributing to these gender differences using general population data. Methods: The sample was drawn from population registries (N=4181) and can be regarded as representative for the adult German population aged 18–65. Mental disorders (DSM-IV) were assessed with a diagnostic interview (CIDI) carried out by clinically trained interviewers. A range of sociodemographic variables was analysed within men, within women, and between genders. Results: The prevalence of common mental disorders (mood, anxiety, substance use and somatoform disorders) is higher among females, with the exception of substance use disorders. Young age was related to substance disorders both in women and in men. Not being married and being unemployed were associated with increased rates of mental disorders in both sexes, but in men stronger than in women. Being retired was associated with depression only in women, whereas belonging to a higher social class, working fulltime and having children appeared to be protective factors for men only. Other sociodemographic factors (concerning education, employment and family status) were not associated with increased rates of mental disorders both in women and men. Conclusion: Overall the emotional advantages or disadvantages of marital status, employment status, number of children, parenthood and social class apply equally to men and women. We cannot explain the female preponderance in most mental disorders by detecting specific unfavourable patterns of sociodemographic correlates, suggesting that determinants of gender differences in common mental disorders are still far from being understood.

Relationship of anxiety disorders, sleep quality, and functional impairment in a community sample

BACKGROUND Anxiety disorders and insomnia are each prevalent, impairing, and highly comorbid. However, little is known about whether specific types of sleep complaints are associated with specific anxiety disorders, and whether poor sleep has an additive effect on functional impairment in anxiety disorders. METHOD Data from the German Health Survey (GHS; N = 4181; ages 18-65) were utilized to examine relationships among anxiety disorders, sleep quality (assessed by the Pittsburgh Sleep Quality Inventory; PSQI), and functional impairment (assessed by the Medical Outcomes Scale Short Form; SF-36; and past-month disability days due to physical and emotional problems, respectively). RESULTS Most anxiety disorders were significantly associated with global PSQI scores. Social phobia (AOR 3.95, 95% CI 1.73-9.04) and GAD (AOR 3.94, 95% CI 1.66-9.34) had the strongest relationships with global PSQI scores. Daytime dysfunction was the PSQI subscale most strongly associated with anxiety disorders, particularly GAD. Having a comorbid anxiety disorder and poor sleep was associated with significantly lower Mental Component Scores on the SF-36 than having an anxiety disorder alone (40.87 versus 43.87, p = .011) and with increased odds of one or more disability days due to emotional problems (AOR 2.72, 95% CI 1.35-5.48), even after controlling for sociodemographic factors and past-month mood and substance use disorders. CONCLUSIONS Most anxiety disorders are moderately associated with reduced sleep quality. Individuals with anxiety disorders and poor sleep experience significantly worse mental health-related quality of life and increased disability relative to those with anxiety disorders alone.

Self-reported utilization of mental health services in the adult German population - evidence for unmet needs? Results of the DEGS1-Mental Health Module (DEGS1-MH)

This paper provides up‐to‐date data on service use for mental health problems and disorders among adults aged 18‐79 years in Germany derived from the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1‐MH; N=4483). Data are based exclusively on self‐report. Respondents were examined by clinically trained interviewers with a modified version of the Composite International Diagnostic Interview DIA‐X/M‐CIDI to assess diagnoses according to the criteria of DSM‐IV‐TR. Service use, i.e. contact to mental health care services, due to mental health problems was assessed for the past 12 months and lifetime, by type of sector and type of institution. Among respondents with a 12‐month diagnosis of a mental disorder, 23.5% of the women and 11.6% of the men reported any service use in the past 12 months. Service use depends on type of diagnosis, comorbidity and socio‐demographic characteristics. Lowest 12‐month utilization rates were found for substance use disorders (15.6%; lifetime use 37.3%), highest for psychotic disorders (40.5%; lifetime 72.1%). Further, a considerable time lap was found between disorder onset and subsequent service use among the majority of cases with anxiety and mood disorders. This paper provides self‐reported epidemiological data on mental health service use in Germany, complementing administrative statistics and the predecessor mental health module of the German Health Interview and Examination Survey (GHS‐MHS) from 1998. Despite considerable changes in the mental health field in Germany and the existence of a comprehensive mental health care system without major financial barriers, we find no indications of substantially higher utilization rates for mental disorders as compared to other comparable European countries. Further, no indications of major overall changes in utilization rates are apparent. To pinpoint areas with unmet needs, more detailed analyses of the data are needed taking into account type, frequency, and adequacy of service use and treatment of mental disorders. Appropriately matched comparisons with the GHS‐MHS are needed to identify changes in patterns of utilization and interventions by type of disorder. Copyright

DSM-IV pain disorder in the general population. An exploration of the structure and threshold of medically unexplained pain symptoms.

BackgroundDespite an abundance of questionnaire data, the prevalence of clinically significant and medically unexplained pain syndromes in the general population has rarely been examined with a rigid personal–interview methodology.ObjectiveTo examine the prevalence of pain syndromes and DSM–IV pain disorder in the general population and the association with other mental disorders, as well as effects on disability and health–care utilization.MethodsAnalyses were based on a community sample of 4.181 participants 18–65 years old; diagnostic variables were assessed with a standardized diagnostic interview (M–CIDI).ResultsThe 12–month prevalence for DSM–IV pain disorder in the general population was 8.1%; more than 53% showed concurrent anxiety and mood disorders. Subjects with pain disorder revealed significantly poorer quality of life, greater disability, and higher health–care utilization rates compared to cases with pain below the diagnostic threshold. The majority had more than one type of pain, with excessive headache being the most frequent type.ConclusionsEven when stringent diagnostic criteria are used, pain disorder ranks among the most prevalent conditions in the community. The joint effects of high prevalence in all age groups, substantial disability, and increased health services utilization result in a substantial total burden, exceeding that of depression and anxiety.