Hui G. Cheng

The burden of mental, neurological, and substance use disorders in China and India: a systematic analysis of community representative epidemiological studies.

BACKGROUND China and India jointly account for 38% of the world population, so understanding the burden attributed to mental, neurological, and substance use disorders within these two countries is essential. As part of the Lancet/Lancet Psychiatry China-India Mental Health Alliance Series, we aim to provide estimates of the burden of mental, neurological, and substance use disorders for China and India from the Global Burden of Disease Study 2013 (GBD 2013). METHODS In this systematic analysis for community representative epidemiological studies, we conducted systematic reviews in line with PRISMA guidelines for community representative epidemiological studies. We extracted estimates of prevalence, incidence, remission and duration, and mortality along with associated uncertainty intervals from GBD 2013. Using these data as primary inputs, DisMod-MR 2.0, a Bayesian meta-regression instrument, used a log rate and incidence-prevalence-mortality mathematical model to develop internally consistent epidemiological models. Disability-adjusted life-year (DALY) changes between 1990 and 2013 were decomposed to quantify change attributable to population growth and ageing. We projected DALYs from 2013 to 2025 for mental, neurological, and substance use disorders using United Nations population data. FINDINGS Around a third of global DALYs attributable to mental, neurological, and substance use disorders were found in China and India (66 million DALYs), a number greater than all developed countries combined (50 million DALYs). Disease burden profiles differed; India showed similarities with other developing countries (around 50% of DALYs attributable to non-communicable disease), whereas China more closely resembled developed countries (around 80% of DALYs attributable to non-communicable disease). The overall population growth in India explains a greater proportion of the increase in mental, neurological, and substance use disorder burden from 1990 to 2013 (44%) than in China (20%). The burden of mental, neurological, and substance use disorders is estimated to increase by 10% in China and 23% in India between 2013 and 2025. INTERPRETATION The current and projected burden of mental, neurological, and substance use disorders in China and India warrants the urgent prioritisation of programmes focused on targeted prevention, early identification, and effective treatment. FUNDING China Medical Board, Bill & Melinda Gates Foundation.

Smoking estimates from around the world: data from the first 17 participating countries in the World Mental Health Survey Consortium

Objective To contribute new multinational findings on basic descriptive features of smoking and cessation, based upon standardised community surveys of adults residing in seven low-income and middle-income countries and 10 higher-income countries from all regions of the world. Methods Data were collected using standardised interviews and community probability sample survey methods conducted as part of the WHO World Mental Health Surveys Initiative. Demographic and socioeconomic correlates of smoking are studied using cross-tabulation and logistic regression approaches. Within-country sample weights were applied with variance estimation appropriate for complex sample survey designs. Results Estimated prevalence of smoking experience (history of ever smoking) and current smoking varied across the countries under study. In all but four countries, one out of every four adults currently smoked. In higher-income countries, estimated proportions of former smokers (those who had quit) were roughly double the corresponding estimates for most low-income and middle-income countries. Characteristics of smokers varied within individual countries, and in relation to the World Banks low-medium-high gradient of economic development. In stark contrast to a sturdy male-female difference in the uptake of smoking seen in each country, there is no consistent sex-associated pattern in the odds of remaining a smoker (versus quitting). Conclusion The World Mental Health Surveys estimates complement existing global tobacco monitoring efforts. The observed global diversity of associations with smoking and smoking cessation underscore reasons for implementation of the Framework Convention on Tobacco Control provisions and prompt local adaptation of prevention and control interventions.

Prevalence of alcohol use disorders in mainland China: a systematic review

Abstract Aims To identify studies about the prevalence of alcohol use disorder (AUD) in mainland China, evaluate the quality of these studies and conduct a meta‐analysis of the prevalence of AUD in Chinas adult population and in population subgroups defined by sex, age and urban versus rural residency. Methods Relevant studies published prior to January 2014 were identified from the following databases: China Knowledge Resource Integrated (CNKI), Wanfang, Pubmed, EmBase and Web of Science. A 16‐item quality assessment inventory for epidemiological studies in mainland China was constructed to evaluate the methodological rigor of the studies. A total of 38 studies including 1 304 354 individuals were identified. Outcomes included current and life‐time prevalence of AUD, alcohol dependence and alcohol abuse. Results The pooled life‐time and current prevalence of alcohol dependence were 1.4% [95% confidence interval (CI) = 1.3, 1.5] and 1.5% (95% CI = 1.2, 1.9). For males, pooled estimates of the current prevalence of alcohol dependence, alcohol abuse and AUD were 4.4 (95% CI = 3.1, 5.7), 4.0 (95% CI = 2.2, 5.7) and 10.1% (95% CI = 4.7, 15.4), respectively; the corresponding values for females were all below 0.2, 0.1, and 0.1%. There was large between‐study heterogeneity in the prevalence measures that was associated with sample size, the use of key informants and the use of substitute respondents. The quality of included studies was generally low. Higher‐quality studies reported higher prevalence. Conclusions Alcohol use disorder is an urgent public health problem in China, especially among males. When using high‐quality studies, current and life‐time prevalence estimates of alcohol dependence in China measure 2.2% and 3.7%, respectively, approaching those of the Netherlands, United States and other western countries.

Secondary analysis of existing data: opportunities and implementation

Summary The secondary analysis of existing data has become an increasingly popular method of enhancing the overall efficiency of the health research enterprise. But this effort depends on governments, funding agencies, and researchers making the data collected in primary research studies and in health-related registry systems available to qualified researchers who were not involved in the original research or in the creation and maintenance of the registry systems. The benefits of doing this are clear but the barriers are many, so the effort of increasing access to such material has been slow, particularly in low- and middleincome countries. This article introduces the rationale and concept of the secondary analysis of existing data, describes several sources of publicly available datasets, provides general guidelines for conducting secondary analyses of existing data, and discusses the advantages and disadvantages of analyzing existing data.

Cross-National Comparisons of Sex Differences in Opportunities to Use Alcohol or Drugs, and the Transitions to Use

Sex differences in opportunities to use alcohol or drugs, and transition to use, were investigated in 15 surveys, in 2001–2004 (Europe 6; Americas 3; Africa 2, Asia 3; Oceania 1). The paper focuses on 18–29 year olds (N = 9,873). The World Mental Health Survey Initiative oversaw the surveys; each country obtained its own funding. A complex picture emerged with different results for alcohol and for drugs and for opportunity to use and the transition to use. Sex differences in opportunity to use alcohol were small except in Lebanon and Nigeria, whereas for drugs, the largest differences were in Mexico and Colombia.

The epidemiological profile of alcohol and other drug use in metropolitan China.

PurposeThere is evidence that alcohol, tobacco, and other drug use may be rising in China, but epidemiological studies that examine several drugs simultaneously and the transition from initial try to current use are limited. The present study provides an epidemiological profile of drug use in contemporary metropolitan China.MethodsA multistage probability sampling method was used to select household-dwelling adults in Beijing and Shanghai. Standard face-to-face interviews with 5,201 participants were completed during 2002–2003.ResultsAn estimated 70–76% had used any type of drug: alcohol and tobacco were the most commonly used drugs (alcohol, 67%; tobacco, 39%). Regarding extra-medical use of internationally regulated drugs, sedatives and analgesics were most common and illegal drug use was rare. The majority of tobacco users used it recently (82.5%), especially young adults. Male–female differences were observed in lifetime tobacco use, but not for recent use. Concurrent use of alcohol and tobacco was very common.ConclusionPsychoactive drug use is common in metropolitan China. Public health policies and prevention initiatives may be needed to address associated problems that may increase following the country’s rapid socioeconomic change.

Prospective relationship of depressive symptoms, drinking, and tobacco smoking among middle-aged and elderly community-dwelling adults: results from the China Health and Retirement Longitudinal Study (CHARLS)

BACKGROUND Previous studies in Western countries have consistently documented positive associations of smoking and heavy drinking with depressive symptoms but a prospective analysis of these relationships among middle-aged and elderly community members in China have not previously been reported. METHODS Using data from the China Health and Retirement Longitudinal Study, a two-wave nationally representative survey conducted in 15,628 adults 45 years of age and older, we estimated the prospective association between depressive symptoms and an array of smoking and drinking behaviors. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) short form. RESULTS Inverse associations were the dominant pattern of association. For the population as a whole, individuals with baseline depressive symptoms were less likely to start drinking (OR=0.7, 95% CI=0.5, 0.9) or smoking (OR=0.6, 95% CI=0.4, 0.8). Similarly, baseline drinkers and smokers were less likely to develop depressive symptoms (ORdrinkers=0.6, 95% CI=0.5, 0.7; ORsmokers=0.7, 95% CJ=0.6, 0.9). No evidence was found for an increased incidence or persistence of depressive symptoms among high-frequency drinkers or heavy smokers or vice versa. Males who had never smoked prior to the onset of depressive symptoms tended to have more rapid onset of tobacco dependence compared to those without such symptoms. Males and females had different association patterns. LIMITATIONS The study is observational in nature and provides limited evidence for causality. DISCUSSION The results are inconsistent with previous findings in Western countries, throwing into question the presumed universality of the association between alcohol drinking or tobacco use and depression among middle-aged and elderly adults.

Relationship between knowledge about the harms of smoking and smoking status in the 2010 Global Adult Tobacco China Survey

Background This analysis estimates the association between smoking-related knowledge and smoking behaviour in a Chinese context. To identify the specific knowledge most directly related to smoking status, we used a novel latent variable analysis approach to adjust for the high correlations between different measures of knowledge about tobacco smoking. Method Data are from the Global Adult Tobacco China Survey, a nationally representative sample of 13 354 household-dwelling individuals 15 years of age or older. Multinomial logistic regressions estimated the association between smoking status (ie, never smoked, current smoker or past smoker) and four smoking-related beliefs: whether or not smoking causes lung cancer, heart attack and stroke, and whether or not low-tar cigarettes are less harmful. A latent variable approach reassessed these associations while taking into account the general level of knowledge about smoking. Results After demographic variables and general knowledge about smoking had been controlled for, the belief that low-tar cigarettes are not less harmful was more prevalent in persons who had never smoked than in current smokers (OR=1.3 (95% CI 1.0 to 1.7) in men and OR=2.8 (95% CI 1.3 to 5.9) in women); this association was even stronger when past smokers and current smokers were compared (OR=2.1 (95% CI 1.5 to 3.0) in men and OR=5.0 (95% CI 1.3 to 20.1) in women). Conclusions Compared with those who have never smoked and those who have ceased smoking, current smokers in China are more likely to believe that low-tar cigarettes are less harmful than regular cigarettes.

Harsh physical punishment as a specific childhood adversity linked to adult drinking consequences: evidence from China

AIMS The aim of the current study is to estimate the association between childhood physical punishment (CPP) and level of alcohol use disorder (AUD), using two different approaches to take other childhood adversities into account. DESIGN AND SETTING Population survey using face-to-face interviews to a representative sample of non-institutionalized adult residents of Beijing and Shanghai, China. PARTICIPANTS A total of 5201 participants aged 18-70 years. MEASUREMENTS A version of the World Mental Health Composite International Diagnostic Interview was used. Standardized assessments covered early life experiences of childhood physical punishment, other childhood adversities, parental drinking problems, childhood conduct problems and clinical features of AUD. FINDINGS A robust association linking CPP and level of AUD was found, holding other childhood adversities constant (probit coefficient = 0.70, 95% CI = 0.40, 1.00) via covariate terms in structural equations modeling. Furthermore, there was evidence that CPP might exert an additional influence on level of AUD over and above a generally noxious family environment (probit coefficient = 0.20, 95% CI = 0.02, 0.38). CONCLUSIONS There appears to be a robust association between reports of harsh punishment in childhood and alcohol dependence in adulthood adjusting for a range of possible confounding factors. Whether the association is causal or whether both are related to a common underlying factor or recall bias needs to be investigated further.

Social correlates of mental, neurological, and substance use disorders in China and India: a review

Understanding the epidemiological profiles of mental, neurological, and substance use disorders provides opportunities for the identification of high-risk population subgroups and for the development of effective country-specific prevention and intervention strategies. Guided by the Conceptual Framework for Action on the Social Determinants of Health by WHO we reviewed the literature to examine the association between a range of social correlates (eg, sex, age, education, income, urbanicity, marital status, and regional differences) and mental, neurological, and substance use disorders in China and India, the most populous countries in the world. We looked for papers on mental, neurological, and substance use disorders with location identifiers and socioeconomic correlates published between 1990 and 2015 and our search found 65 relevant studies from China and 29 from India. Several association patterns between social correlates and mental, neurological, and substance use disorders were not consistent with those reported in high-income countries, including a high concentration of middle-aged men with alcohol use disorders in China and to a lesser extent in India, and a positive association between being married and depression among women in India. Consistent with previous global reports, low education and poverty were associated with higher occurrence of dementia in both China and India, although there is evidence of an interaction between education and income in the risk for dementia in China. Large variations across regions and ethnic groups were consistently documented in China. These unique correlation patterns for mental, neurological, and substance use disorders identified in China and India emphasise the importance of understanding the local social context when planning targeted strategies to reduce the burden of these disorders. High-quality, up-to-date information about the constantly changing pattern of societal factors correlated with mental, neurological, and substance use disorders is urgently needed to help reduce the large and increasing negative social and economic effects that these conditions are having in China, India, and other low-income and middle-income countries.