Horst Dilling

Lebenszeitprävalenz psychischer Störungen in der erwachsenen Allgemeinbevölkerung Ergebnisse der TACOS-Studie

ZusammenfassungIm vorliegenden Beitrag werden Ergebnisse zur Lebenszeitprävalenz psychischer Störungen in der 18- bis 64-jährigen Allgemeinbevölkerung einer norddeutschen Region berichtet. 4.075 Personen einer zu 70,2% ausgeschöpften repräsentativen Einwohnermeldeamtsstichprobe wurden mit dem vollstandardisierten und computerisierten “Münchener Composite International Diagnostic Interview” (M-CIDI) in persönlichen Interviews untersucht. Die hier berichtete Klassifikation erfolgte auf Grundlage des DSM-IV. Störungen durch den Konsum psychotroper Substanzen stellten mit einer Lebenszeitprävalenz von 25,8% die häufigste Diagnosengruppe dar, gefolgt von Angststörungen (15,1%), somatoformen Störungen (12,9%), affektiven Störungen (12,3%) und Essstörungen (0,7%). Frauen waren dabei häufiger von nicht-substanzbezogenen psychischen Störungen betroffen und Männer häufiger von Substanzmissbrauch und -abhängigkeit. Es zeigt sich ein Trend zu geringerer psychiatrischer Morbidität bei Individuen mit höherer Schulbildung, höherem Einkommen, verheirateten Personen und Personen mit ländlichem Wohnsitz. 42% der Probanden mit einer Lebenszeitdiagnose erfüllten die Kriterien mindestens einer weiteren Störung. Die Ergebnisse werden im Kontext ausgewählter bisheriger Studien diskutiert.AbstractThe present paper reports lifetime prevalence rates of mental disorders in the 18- to 64-year-old general population of a northern German region. A representative random sample from registration office files of 4,075 individuals was examined in personal interviews using the fully standardized and computerised “Munich Composite International Diagnostic Interview” (M-CIDI). The response rate was 70.2%. Individuals were classified according to the DSM-IV. Substance use disorders were most frequent with 25.8% followed by anxiety (15.1%), somatoform (12.9%), affective (12.3%), and eating disorders (0.7%). Disorders other than substance use were more frequent in women and less frequent in men. A trend toward less psychiatric morbidity exists in individuals with higher educational level, higher income, and those who are married or reside in rural communities. Of all individuals affected by mental disorders, 42% fulfilled the criteria for at least one additional disorder. The results are discussed against the background of selected previous studies.

Prevalence, quality of life and psychosocial function in obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in northern Germany.

AbstractBackground: Despite the worldwide relevance of obsessive-compulsive disorder (OCD) there are considerable differences in prevalence rates and gender ratios between the studies and a substantial lack of prevalence data on subclinical OCD. Moreover, data on quality of life and on psychosocial function of subjects with OCD and subclinical OCD in the general population are missing to date. Methods: German versions of the DMS-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 persons aged 18–64 years living in a northern Germany region. Specific DSM-IV based criteria for subclinical OCD were used. Results: The life-time prevalence rates for OCD and subclinical OCD were 0.5% and 2%, respectively. Twelve month prevalence rates were 0.39% and 1.6%, respectively. The gender female:male ratio was 5.7 in OCD and 1.2 in subclinical OCD. In various measures of psychosocial function and quality of life, OCD and subclinical OCD were significantly impaired. However, subclinical OCD subjects did not visit mental health professionals more often than controls. Conclusion: Due to different epidemiological characteristics subclinical OCD might represent a syndrome distinct from OCD which is also associated with significant impairments in personal and interpersonal functions and in quality of life.

Prevalence of alcohol consumption, abuse and dependence in a country with high per capita consumption: findings from the German TACOS study

Background: The aim of the Transitions in Alcohol Consumption and Smoking (TACOS) project is to investigate substance use and use disorders in the adult general population in a region of the under-researched north of Germany, focussing on smoking and alcohol consumption. In this study, the design and quality assurance provisions of the baseline cross-section of the longitudinal project are described. Prevalence rates of alcohol use disorders, consumption pattern, and the nature of their association are also analysed with regard to preventive strategies. Method: A random sample of 4075 participants, aged 18 to 64 and drawn from residents registration office files, was interviewed with a DSM-IV adapted version of WHO CIDI. Fieldwork resulted in a response rate of 70.2% and an unbiased database with regard to demographic characteristics. Results: Low lifetime prevalence of alcohol use disorders (4.5% abuse, 3.8% dependence) and hazardous consumption (13.2% lifetime; 6.0% 12-month) was found compared to southern regions of Germany and US American data. In contrast, we found a comparatively high percentage of moderate alcohol uses. Male subjects are more affected by lifetime alcohol use disorders (abuse OR 8.3, 95% CI 5.3–13.2; dependence OR 4.3, 95% CI 2.8–6.4). The association between alcohol use disorders and alcohol consumption pattern revealed a weaker relation for alcohol abuse compared to dependence. Conclusion: National and regional drinking habits and norms have to be considered as a significant source of variance, supporting the need for European epidemiological research on substance use in addition to US American activities, and emphasising the advantages of community-based preventive measures. An evaluation of public recommendations for safe limits of alcohol consumption and prevention targets referring to average consumption is indicated. There is also a need for a clear distinction between alcohol abuse and dependence.

Lifetime-comorbidity of obsessive-compulsive disorder and subclinical obsessive-compulsive disorder in northern Germany

Objective Inspite of the worldwide relevance of obsessive-compulsive disorder (OCD), there is a substantial lack of data on comorbidity in OCD and subclinical OCD in the general population. Methods German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 persons aged 18–64 years, living in a northern German region. Results In both genders, high rates of comorbid depressive disorders were found in OCD and subclinical OCD, whereas somatoform pain disorder was only associated with OCD. In female subjects, OCD was additionally associated with social and specific phobias, alcohol, nicotine and sedative dependence, PTSD and atypical eating disorder. Conclusion Due to low comorbidity rates, subclinical OCD seems to represent an independent syndrome not restricted to the presence of other axis-I diagnoses. Comorbidity patterns show a disposition to anxiety and to depressive disorders in OCD and subclinical OCD. A broad association with obsessive-compulsive spectrum disorders could not be confirmed in our general population sample.

Somatoform Pain Disorder in the General Population

Background: Chronic pain disorder is assumed to represent a frequent and disabling condition. However, data on the prevalence of somatoform pain symptoms and somatoform pain disorder in the community are limited to date. Methods: German versions of the Composite International Diagnostic Interview were administered to a representative national sample of 4,075 people. Somatoform pain disorder was diagnosed by standardized diagnostic algorithm based on the DSM-III-R criteria (absence of adequate physical findings). One subgroup was identified as also meeting the DSM-IV criterion B for ‘significant distress or psychosocial impairment due to the somatoform pain’. Results: A lifetime prevalence rate of somatoform pain disorder according to DSM-III-R of 33.7% and a 6-month rate of 17.3% was found. When applying the DSM-IV B criterion, the prevalence rate dropped to 12.3 and 5.4%, respectively. In both groups more than 95% of the probands had contacted their doctor because of the pain. In 25% of the probands the pain was positively assigned to psychological factors. A female:male ratio of 2:1 was found. Conclusions: Somatoform pain disorder (DSM-III-R) is a frequent condition. However, only about one third of these subjects is severely distressed or impaired by the pain. A clear operationalized concept of the DSM-IV criterion C ‘psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance of the pain’ should be provided in the further development of the diagnosis ‘pain disorder’ in order to make this diagnosis suitable for general population surveys.

Use of the ICD-10 Classification in Psychiatry: An International Survey

On the background of some years of experience with ICD-10 psychiatric diagnoses in many countries of the world, an international comparison was performed to evaluate the frequency and use of the ICD-10 psychiatric diagnoses. For future revision of the ICD-10, it is important to know which diagnostic categories are either not used or are used possibly in an unspecific manner. Nineteen departments of psychiatry in 10 different countries took part in the study, presenting data on 33,857 treatment cases leading to a total of 25,470 ICD-10 main diagnoses. The analysis of data reveals that on a four-character level (Fxx.x), the 10 most often used diagnostic categories represent 40% of all main diagnoses, and 70% on a three-character level (Fxx.–). There are 32 specific diagnostic categories on a four-character level which are not used at all and 121 which are used less frequently than 0.1% in inpatient and outpatient treatment. The study shows that the ICD-10 classification is in use in a variety of treatment settings worldwide. Further results and limitations of this study are discussed against the background of transcultural differences.

KOSTEN-NUTZEN-ANALYSE KLINISCH-EVALUIERTER BEHANDLUNGSPROGRAMME : ERWEITERTE ENTZUGSTHERAPIE BEI ALKOHOLABHANGIGKEIT

ZusammenfassungKosten-Nutzen-Analysen neuer Therapieansätze ergänzen klinische Evaluationsstudien und erlauben eine bessere Gesamtabschätzung der Therapieeffizienz. Das Modell einer bereits klinisch evaluierten erweiterten Entzugsbehandlung Alkoholabhängiger (Entzug II) sollte unter Kosten-Nutzen-Gesichtspunkten überprüft werden. Es wurden 57 Patienten nach Entzug II und 37 nach konventioneller Entgiftung (Entzug I) untersucht. In einem retro- und prospektiven Ansatz wurden für 5 Jahre vor und nach Indextherapie Krankenversicherungsdaten zur Hospitalisierungshäufigkeit und -dauer, Arbeitsunfähigkeit und Krankengeldbezug erhoben. Entzug-II-Patienten wurden nach Indextherapie durchschnittlich seltener (3,5+4,4 vs. 7,3+11,3) und weniger lange (66+75 vs. 136+167) hospitalisiert und bezogen weniger lange Krankengeld (67+73 vs. 220+187) als Patienten nach Entzug I. Für den stationären Bereich ergaben sich bei Entzug-II-Patienten um ca. 50% geringere Gesamtbehandlungskosten (Indextherapie und Folgekosten). Insgesamt sprechen bei einer leichten klinischen Überlegenheit in den 12 Monaten nach Indextherapie (ca. 14% höhere Abstinenzrate) erheblich geringere Folgehospitalisierungen und Folgekosten für eine ausreichend hohe Effizienz der erweiterten Entzugstherapie Alkoholabhängiger.SummaryBackground: Cost-effectiveness analyses complete clinical evaluation studies and thereby support the a well based estimation of therapy efficiency. Aim: A qualified (extended) alcohol withdrawal treatment programme (II), which was previously described and evaluated by face-to-face follow-up studies, was analyzed with regard to cost-effectiveness. Sample: 57 alcohol-dependent patients, which had undergone programme II, were compared with 37 patients after a medical detoxification programme (I). Methods: Health insurance data (number and length of all hospitalisations, days of incapacity to work, days of financial substitution for incapacity to work) were assessed for the five years before and after index therapy and for each year, separateley. Results: While there were no substantial differences for the time before index therapy, programme II patients were hospitalized after index therapy (i) less frequently (3.5+4.4 vs. 7.3+11.3 times), (ii) for fewer days (66+75 vs. 136+167) than programme I patients, and they received financial support for fewer days (67±73 vs 220±187 days). Conclusion: Considering a somewhat better clinical outcome of programme II vs. programme I patients (14% greater abstinence rate within one year) the significantly lower rates and fewer days of follow-up hospitalisations support a sufficient efficiency of the extended alcohol withdrawal treatment programme.

The Lübeck General Hospital Study. I: Prevalence of psychiatric disorders in medical and surgical inpatients

The aim of the Lübeck General Hospital study was to assess the prevalence rates of psychiatric disorders in medical and surgical general hospital patients, as well as treatment needs. In a cross-sectional study, a total of 400 patients were interviewed, 200 each from medical and surgical departments. We used the standardized Composite International Diagnostic Interview (CIDI) and, in addition, a clinical interview. In the first of two articles, the prevalence rates of ICD-10 diagnoses, which had to be present within seven days before the interview, are described. Of the total sample, 35.5% of the patients received a CIDI diagnosis and 46.8% a clinical diagnosis. The most prominent disorders were organic mental disorders (CIDI, 18.3%; clinical, 16.5%), alcoholism (4.5% and 8.3%), and depression (8.3% and 15.3%). With regard to the spectrum of psychiatric diagnoses, no significant differences were found between the medical and the surgical sample. When compared to surveys of the general population in Germany, the prevalence rates of organic mental disorders, alcoholism and adjustment disorders were considerably higher in general hospital patients.

The multiaxial system of ICD-10 : Evaluation of a preliminary draft in a multicentric field trial

The multiaxial system (MAS) of ICD-10, chapter V (F) consists of three axes: axis I, clinical syndromes (psychiatric disorders including personality disorders and somatic diseases); axis II, disabilities; axis III, environmental/circumstantial and personal life-style/life management factors. Results of a multicentric field trial evaluating a preliminary draft of the MAS are presented. 45 raters in seven German centers made 488 ratings on 12 written case histories. With a mean kappa of 0.50 for 3-character diagnoses interrater reliability for axis I was moderate although lower than expected from previous field trials. On axis II the WHO Disability Diagnostic Scale (WHO-DDS) was compared to the Global Assessment of Functioning (GAF) used in DSM-III-R and DSM-IV. For both scales the intraclass correlation coefficient showed a moderate interrater reliability (WHO-DDS = 0.62; GAF = 0.65). On axis III the number of relevant psychosocial circumstances coded by the different raters varied greatly. Interrater reliability was very poor with kappa values ranging from 0.03 to 0.55 for the different categories and an overall kappa of 0.16.

Chapter 11: The Upper Bavarian Studies

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 130 132 137 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .