Irving Hwang

Cross-national epidemiology of DSM-IV major depressive episode.

BackgroundMajor depression is one of the leading causes of disability worldwide, yet epidemiologic data are not available for many countries, particularly low- to middle-income countries. In this paper, we present data on the prevalence, impairment and demographic correlates of depression from 18 high and low- to middle-income countries in the World Mental Health Survey Initiative.MethodsMajor depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults.ResultsThe average lifetime and 12-month prevalence estimates of DSM-IV MDE were 14.6% and 5.5% in the ten high-income and 11.1% and 5.9% in the eight low- to middle-income countries. The average age of onset ascertained retrospectively was 25.7 in the high-income and 24.0 in low- to middle-income countries. Functional impairment was associated with recency of MDE. The female: male ratio was about 2:1. In high-income countries, younger age was associated with higher 12-month prevalence; by contrast, in several low- to middle-income countries, older age was associated with greater likelihood of MDE. The strongest demographic correlate in high-income countries was being separated from a partner, and in low- to middle-income countries, was being divorced or widowed.ConclusionsMDE is a significant public-health concern across all regions of the world and is strongly linked to social conditions. Future research is needed to investigate the combination of demographic risk factors that are most strongly associated with MDE in the specific countries included in the WMH.

DSM-IV pathological gambling in the National Comorbidity Survey Replication

BACKGROUND Little is known about the prevalence or correlates of DSM-IV pathological gambling (PG). METHOD Data from the US National Comorbidity Survey Replication (NCS-R), a nationally representative US household survey, were used to assess lifetime gambling symptoms and PG along with other DSM-IV disorders. Age of onset (AOO) of each lifetime disorder was assessed retrospectively. AOO reports were used to study associations between temporally primary disorders and the subsequent risk of secondary disorders. RESULTS Most respondents (78.4%) reported lifetime gambling. Lifetime problem gambling (at least one Criterion A symptom of PG) (2.3%) and PG (0.6%) were much less common. PG was significantly associated with being young, male, and Non-Hispanic Black. People with PG reported first gambling significantly earlier than non-problem gamblers (mean age 16.7 v. 23.9 years, z=12.7, p<0.001), with gambling problems typically beginning during the mid-20s and persisting for an average of 9.4 years. During this time the largest annual gambling losses averaged US

Mental Disorders, Comorbidity and Suicidal Behavior: Results from the National Comorbidity Survey Replication

4800. Onset and persistence of PG were predicted by a variety of prior DSM-IV anxiety, mood, impulse-control and substance use disorders. PG also predicted the subsequent onset of generalized anxiety disorder, post-traumatic stress disorder (PTSD) and substance dependence. Although none of the NCS-R respondents with PG ever received treatment for gambling problems, 49.0% were treated at some time for other mental disorders. CONCLUSIONS DSM-IV PG is a comparatively rare, seriously impairing, and undertreated disorder whose symptoms typically start during early adulthood and is frequently secondary to other mental or substance disorders that are associated with both PG onset and persistence.

Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents: Results From the National Comorbidity Survey Replication Adolescent Supplement

Mental disorders are among the strongest predictors of suicide attempts. However, little is known regarding which disorders that are uniquely associated with suicidal behavior because of high levels of psychiatric comorbidity. We examined the unique associations between individual disorders and subsequent suicidal behavior (suicide ideation, plans and attempts) using data from the National Comorbidity Survey Replication, a nationally representative household survey of 9282 US adults. Results revealed that approximately 80% of suicide attempters in the United States have a temporally prior mental disorder. Anxiety, mood, impulse-control and substance use disorders all significantly predict subsequent suicide attempts in bivariate analyses (odds ratios (OR)=2.7–6.7); however, these associations decrease substantially in multivariate analyses controlling for comorbidity (OR=1.5–2.3) but remain statistically significant in most cases. Disaggregation of the observed effects reveals that depression predicts suicide ideation, but not suicide plans or attempts among those with ideation. Instead, disorders characterized by severe anxiety/agitation (for example, post-traumatic stress disorder) and poor impulse control (for example, conduct disorder, substance use disorders) predict which suicide ideators who go on to make a plan or attempt. These results advance understanding of the unique associations between mental disorders and different forms of suicidal behavior. Future research must further delineate the mechanisms through which people come to think about suicide and progress from suicidal thoughts to attempts.

Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys.

CONTEXT Although suicide is the third leading cause of death among US adolescents, little is known about the prevalence, correlates, or treatment of its immediate precursors, adolescent suicidal behaviors (ie, suicide ideation, plans, and attempts). OBJECTIVES To estimate the lifetime prevalence of suicidal behaviors among US adolescents and the associations of retrospectively reported, temporally primary DSM-IV disorders with the subsequent onset of suicidal behaviors. DESIGN Dual-frame national sample of adolescents from the National Comorbidity Survey Replication Adolescent Supplement. SETTING Face-to-face household interviews with adolescents and questionnaires for parents. PARTICIPANTS A total of 6483 adolescents 13 to 18 years of age and their parents. MAIN OUTCOME MEASURES Lifetime suicide ideation, plans, and attempts. RESULTS The estimated lifetime prevalences of suicide ideation, plans, and attempts among the respondents are 12.1%, 4.0%, and 4.1%, respectively. The vast majority of adolescents with these behaviors meet lifetime criteria for at least one DSM-IV mental disorder assessed in the survey. Most temporally primary (based on retrospective age-of-onset reports) fear/anger, distress, disruptive behavior, and substance disorders significantly predict elevated odds of subsequent suicidal behaviors in bivariate models. The most consistently significant associations of these disorders are with suicide ideation, although a number of disorders are also predictors of plans and both planned and unplanned attempts among ideators. Most suicidal adolescents (>80%) receive some form of mental health treatment. In most cases (>55%), treatment starts prior to onset of suicidal behaviors but fails to prevent these behaviors from occurring. CONCLUSIONS Suicidal behaviors are common among US adolescents, with rates that approach those of adults. The vast majority of youth with suicidal behaviors have preexisting mental disorders. The disorders most powerfully predicting ideation, though, are different from those most powerfully predicting conditional transitions from ideation to plans and attempts. These differences suggest that distinct prediction and prevention strategies are needed for ideation, plans among ideators, planned attempts, and unplanned attempts.

Twelve-Month Prevalence of and Risk Factors for Suicide Attempts in the World Health Organization World Mental Health Surveys

Using data from over 100,000 individuals in 21 countries participating in the WHO World Mental Health Surveys, Matthew Nock and colleagues investigate which mental health disorders increase the odds of experiencing suicidal thoughts and actual suicide attempts, and how these relationships differ across developed and developing countries.

Age differences in major depression: results from the National Comorbidity Survey Replication (NCS-R)

OBJECTIVE Although suicide is a leading cause of death worldwide, clinicians and researchers lack a data-driven method to assess the risk of suicide attempts. This study reports the results of an analysis of a large cross-national epidemiologic survey database that estimates the 12-month prevalence of suicidal behaviors, identifies risk factors for suicide attempts, and combines these factors to create a risk index for 12-month suicide attempts separately for developed and developing countries. METHOD Data come from the World Health Organization (WHO) World Mental Health (WMH) Surveys (conducted 2001-2007), in which 108,705 adults from 21 countries were interviewed using the WHO Composite International Diagnostic Interview. The survey assessed suicidal behaviors and potential risk factors across multiple domains, including sociodemographic characteristics, parent psychopathology, childhood adversities, DSM-IV disorders, and history of suicidal behavior. RESULTS Twelve-month prevalence estimates of suicide ideation, plans, and attempts are 2.0%, 0.6%, and 0.3%, respectively, for developed countries and 2.1%, 0.7%, and 0.4%, respectively, for developing countries. Risk factors for suicidal behaviors in both developed and developing countries include female sex, younger age, lower education and income, unmarried status, unemployment, parent psychopathology, childhood adversities, and presence of diverse 12-month DSM-IV mental disorders. Combining risk factors from multiple domains produced risk indices that accurately predicted 12-month suicide attempts in both developed and developing countries (area under the receiver operating characteristic curve = 0.74-0.80). CONCLUSIONS Suicidal behaviors occur at similar rates in both developed and developing countries. Risk indices assessing multiple domains can predict suicide attempts with fairly good accuracy and may be useful in aiding clinicians in the prediction of these behaviors.

Co-morbid major depression and generalized anxiety disorders in the National Comorbidity Survey follow-up.

BACKGROUND Although depression appears to decrease in late life, this could be due to misattribution of depressive symptom to physical disorders that increase in late life. METHOD We studied age differences in major depressive episodes (MDE) in the National Comorbidity Survey Replication, a national survey of the US household population. DSM-IV MDE was defined without organic exclusions or diagnostic hierarchy rules to facilitate analysis of co-morbidity. Physical disorders were assessed with a standard chronic conditions checklist and mental disorders with the WHO Composite International Diagnostic Interview (CIDI) version 3.0. RESULTS Lifetime and recent DSM-IV/CIDI MDE were significantly less prevalent among respondents aged 65 years than among younger adults. Recent episode severity, but not duration, was also lower among the elderly. Despite prevalence of mental disorders decreasing with age, co-morbidity of hierarchy-free MDE with these disorders was either highest among the elderly or unrelated to age. Co-morbidity of MDE with physical disorders, in comparison, generally decreased with age despite prevalence of co-morbid physical disorders usually increasing. Somewhat more than half of respondents with 12-month MDE received past-year treatment, but the percentage in treatment was lowest and most concentrated in the general medical sector among the elderly. CONCLUSIONS Given that physical disorders increase with age independent of depression, their lower associations with MDE in old age argue that causal effects of physical disorders on MDE weaken in old age. This result argues against the suggestion that the low estimated prevalence of MDE among the elderly is due to increased confounding with physical disorders.

Disability and treatment of specific mental and physical disorders across the world

BACKGROUND Although generalized anxiety disorder (GAD) and major depressive episode (MDE) are known to be highly co-morbid, little prospective research has examined whether these two disorders predict the subsequent first onset or persistence of the other or the extent to which other predictors explain the time-lagged associations between GAD and MDE. METHOD Data were analyzed from the nationally representative two-wave panel sample of 5001 respondents who participated in the 1990-1992 National Comorbidity Survey (NCS) and the 2001-2003 NCS follow-up survey. Both surveys assessed GAD and MDE. The baseline NCS also assessed three sets of risk factors that are considered here: childhood adversities, parental history of mental-substance disorders, and respondent personality. RESULTS Baseline MDE significantly predicted subsequent GAD onset but not persistence. Baseline GAD significantly predicted subsequent MDE onset and persistence. The associations of each disorder with the subsequent onset of the other attenuated with time since onset of the temporally primary disorder, but remained significant for over a decade after this onset. The risk factors predicted onset more than persistence. Meaningful variation was found in the strength and consistency of associations between risk factors and the two disorders. Controls for risk factors did not substantially reduce the net cross-lagged associations of the disorders with each other. CONCLUSIONS The existence of differences in risk factors for GAD and MDE argues against the view that the two disorders are merely different manifestations of a single underlying internalizing syndrome or that GAD is merely a prodrome, residual, or severity marker of MDE.

AGE DIFFERENCES IN THE PREVALENCE AND CO-MORBIDITY OF DSM-IV MAJOR DEPRESSIVE EPISODES : RESULTS FROM THE WHO WORLD MENTAL HEALTH SURVEY INITIATIVE

BACKGROUND Advocates of expanded mental health treatment assert that mental disorders are as disabling as physical disorders, but little evidence supports this assertion. AIMS To establish the disability and treatment of specific mental and physical disorders in high-income and low- and middle-income countries. METHOD Community epidemiological surveys were administered in 15 countries through the World Health Organization World Mental Health (WMH) Survey Initiative. RESULTS Respondents in both high-income and low- and middle-income countries attributed higher disability to mental disorders than to the commonly occurring physical disorders included in the surveys. This pattern held for all disorders and also for treated disorders. Disaggregation showed that the higher disability of mental than physical disorders was limited to disability in social and personal role functioning, whereas disability in productive role functioning was generally comparable for mental and physical disorders. CONCLUSIONS Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and in low- and middle-income countries.