Jan Neeleman

Prevalence of common mental disorders in general practice attendees across Europe.

BACKGROUNDnThere is evidence that the prevalence of common mental disorders varies across Europe.nnnAIMSnTo compare prevalence of common mental disorders in general practice attendees in six European countries.nnnMETHODnUnselected attendees to general practices in the UK, Spain, Portugal, Slovenia, Estonia and The Netherlands were assessed for major depression, panic syndrome and other anxiety syndrome. Prevalence of DSM-IV major depression, other anxiety syndrome and panic syndrome was compared between the UK and other countries after taking account of differences in demographic factors and practice consultation rates.nnnRESULTSnPrevalence was estimated in 2,344 men and 4,865 women. The highest prevalence for all disorders occurred in the UK and Spain, and lowest in Slovenia and The Netherlands. Men aged 30-50 and women aged 18-30 had the highest prevalence of major depression; men aged 40-60 had the highest prevalence of anxiety, and men and women aged 40-50 had the highest prevalence of panic syndrome. Demographic factors accounted for the variance between the UK and Spain but otherwise had little impact on the significance of observed country differences.nnnCONCLUSIONSnThese results add to the evidence for real differences between European countries in prevalence of psychological disorders and show that the burden of care on general practitioners varies markedly between countries.

Tolerance of suicide, religion and suicide rates: an ecological and individual study in 19 Western countries

BACKGROUNDnNegative associations between religion and suicide, in individuals and countries, may be mediated by the degree to which suicide is tolerated.nnnMETHODSnLinear regression was used to examine ecological associations between suicide tolerance, religion and suicide rates in 19 Western countries in 1989/90. Logistic regression was used to study associations between suicide tolerance and strength of religious belief in 28085 individuals in these countries. The concept of effect modifying function was used to examine whether the strength of the association between suicide tolerance and religious belief in individuals depended on the extent of religious belief in their country.nnnRESULTSnHigher female suicide rates were associated with lower aggregate levels of religious belief and, less strongly, religious attendance. These associations were mostly attributable to the association between higher tolerance of suicide and higher suicide rates. In the 28085 subjects suicide tolerance and the strength of religious belief were negatively associated even after adjustment for other religious and sociodemographic variables and general tolerance levels (odds ratios: men 0.74 (95% CI 0.58-0.94), women 0.72 (95% CI 0.60-0.86)). This negative individual-level association was more pronounced in more highly religious countries but this modifying effect of the religious context was apparent for men only.nnnCONCLUSIONSnEcological associations between religious variables and suicide rates are stronger for women than men, stronger for measures of belief than observance and mediated by tolerance of suicide. In individuals, stronger religious beliefs are associated with lower tolerance of suicide. Personal religious beliefs and, for men, exposure to a religious environment, may protect against suicide by reducing its acceptability.

Ethnic minority suicide : a small area geographical study in south London

BACKGROUNDnThe relationship between ethnicity and suicide risk is ill-understood. It is unclear whether, and if so, how, the ethnic mix of local areas affects risk in local individuals.nnnMETHODSnCoroners records of 329 suicides were used to obtain ethnic (White, Afro-Caribbean, Asian) suicide rates in South London (population 902,008) for 1991-3. Geographical variation and associations of ethnic suicide rates with small area (mean population 8274) ethnic densities (proportion of residents of given ethnic groups) and deprivation, were examined with random effects Poisson regression.nnnRESULTSnAdjusted for deprivation, age and gender, suicide rates in wards with larger minority groups were higher among Whites (relative rate (RR) per standard deviation (S.D.) increase in minority density 1.18; 95% CI 1.02-1.37) but lower among minority groups (RR 0.75 (0.59-0.96)) (LR-test for interaction chi2 = 9.2 (df = 1); P = 0.003). Similar patterns were also apparent for Afro-Caribbeans and Asians separately. With White suicide rates as baseline, ethnic minority status is a risk factor for suicide in wards with small, but a protective factor in neighbourhoods with large minority populations. The RR of minority versus White suicide declines with a factor (relative RR) 0.67 (0.51-0.87) per S.D. increase in local minority density.nnnCONCLUSIONSnMinority suicide rates are higher in areas where minority groups are smaller. This effect is ethnic-specific and not due to confounding by gender, age, deprivation or unbalanced migration. Dependent on address, a suicide risk factor for a White individual may protect an ethnic minority individual and vice versa. This has implications for research and prevention.

Development and Validation of an International Risk Prediction Algorithm for Episodes of Major Depression in General Practice Attendees The PredictD Study

CONTEXTnStrategies for prevention of depression are hindered by lack of evidence about the combined predictive effect of known risk factors.nnnOBJECTIVESnTo develop a risk algorithm for onset of major depression.nnnDESIGNnCohort of adult general practice attendees followed up at 6 and 12 months. We measured 39 known risk factors to construct a risk model for onset of major depression using stepwise logistic regression. We corrected the model for overfitting and tested it in an external population.nnnSETTINGnGeneral practices in 6 European countries and in Chile.nnnPARTICIPANTSnIn Europe and Chile, 10 045 attendees were recruited April 2003 to February 2005. The algorithm was developed in 5216 European attendees who were not depressed at recruitment and had follow-up data on depression status. It was tested in 1732 patients in Chile who were not depressed at recruitment. Main Outcome Measure DSM-IV major depression.nnnRESULTSnSixty-six percent of people approached participated, of whom 89.5% participated again at 6 months and 85.9%, at 12 months. Nine of the 10 factors in the risk algorithm were age, sex, educational level achieved, results of lifetime screen for depression, family history of psychological difficulties, physical health and mental health subscale scores on the Short Form 12, unsupported difficulties in paid or unpaid work, and experiences of discrimination. Country was the tenth factor. The algorithms average C index across countries was 0.790 (95% confidence interval [CI], 0.767-0.813). Effect size for difference in predicted log odds of depression between European attendees who became depressed and those who did not was 1.28 (95% CI, 1.17-1.40). Application of the algorithm in Chilean attendees resulted in a C index of 0.710 (95% CI, 0.670-0.749).nnnCONCLUSIONnThis first risk algorithm for onset of major depression functions as well as similar risk algorithms for cardiovascular events and may be useful in prevention of depression.

Ethnic density and deliberate self harm; a small area study in south east London

STUDY OBJECTIVE Relative risks are frequently used to convey how strongly outcomes like mental illness and suicidal behaviour are associated with personal characteristics like ethnic background. This study examined whether RRs for deliberate self harm (DSH) in ethnic groups vary between small areas according to their ethnic mix. DESIGN Small area study of DSH rates in ethnic groups, by local ethnic density, using negative binomial regression. SETTING 73 south London electoral wards, 1994–1997. SUBJECTS 1643 people attending casualty after DSH. MAIN RESULTS African-Caribbean and Asian DSH rates, relative to the white population, varied between wards. A linear model indicated a decline by factors (relative rate ratios) 0.76 (95% confidence intervals (CI) 0.64 to 0.90) and 0.59 (95% CI 0.36 to 0.97) respectively per SD increase in the local size of these minority populations. However, for both groups, an inverted U shaped curve provided a better fit for the link between the relative DSH rate in these groups and their local population density. CONCLUSIONS The DSH rate of minority groups relative to the white group is low (suggesting protection) in some areas, and high (suggesting risk) elsewhere. This has implications for management of suicidal behaviour in ethnic groups but also for interpretation, and policy implementation, of research on risk for suicidal behaviour, and, probably, many other outcomes. Relative risks or rates are not stable indicators of association in psychiatric epidemiology.

Predictors of suicide, accidental death, and premature natural death in a general-population birth cohort

BACKGROUNDnWhether putative suicide risk factors, such as conduct and emotional disorders, are specific to suicide or are general associations of a continuum between subintentional and intentional self-destruction is not clear. We undertook an investigation of this issue in a UK population-based birth cohort.nnnMETHODSnUsing competing-risks analysis, we examined links between prospectively collected childhood and adolescent temperamental and behavioural variables and the risk of natural, accidental, and suicidal death, occurring between the ages of 16 and 50 years. Of the 5362 members of the cohort, full data were available for 3591. A panel of psychiatrists scored deaths on likely suicidal intention. These scores were used in a weighted logistic regression to examine independence of risk factors for (sub)intentional self-destruction.nnnFINDINGSnThere were 167 deaths among the risk-set between the 16th and 50th birthdays. 120 were due to natural causes; of the other 47, the panel of psychiatrists judged that 36 were accidental deaths and 11 were suicides (certainty rating > or = 51%). Adolescent emotional instability and conduct problems had different associations with the various causes of premature death, being lowest for natural death (odds ratio 1.0 [95% CI 0.8-1.2] and 1.2 [1.0-1.5]), intermediate for accidental death (1.1 [0.8-1.5] and 1.3 [1.0-1.7]), and highest for suicidal death (2.0 [1.2-3.6] and 1.8 [1.3-2.5]). Emotional instability (boys 1.3 [1.0-1.7], girls 1.4 [1.0-1.9]) increased risk for subintentional or intentional self-destruction, as did low anxiety in adolescence (1.7 [1.3-2.5]) and nocturnal enuresis at age 4 (1.4 [1.2-1.7]) in boys, and conduct problems in girls (1.4 [1.0-2.0]).nnnINTERPRETATIONnSuicide shares important risk factors with other causes of premature death. These findings suggest an aetiological continuum of self-destruction from subintentional to intentional. Research on premature mortality associated with psychological disorder should include all causes of death.

Suicide acceptability in African- and white Americans: The role of religion

Rates of suicidal behavior are lower among African- than white Americans. We analyzed the association of suicide acceptability with religious, sociodemographic, and emotional variables in representative samples of African- and white Americans (1990). Adjusted for ethnic response bias, the former were less accepting of suicide than the latter (odds ratio .60; 95% confidence interval .41, .88). Orthodox religious beliefs and personal devotion predicted rejection of suicide best; this effect was equally strong in both groups. The comparatively low level of suicide acceptability among African-Americans was mostly attributable to their relatively high levels of orthodox religious beliefs and devotion, as opposed to practice and affiliation, although sociodemographic and emotional differences contributed as well. These results are interpreted using the cognitive dissonance model. Given rapid secularization among the young in the United States, these findings may help explain the rising suicide rates among white and, especially, African-American young people.

Changes in classification of suicide in England and Wales: Time trends and associations with coroners' professional backgrounds

BACKGROUNDnThe legal definition of suicide in England and Wales (E & W) gives rise to a high proportion of open verdicts and an underestimated suicide rate. We examined whether the ratio between open and suicide verdicts in E & W has changed between 1974 and 1991 and whether it varies according to coroners qualifications.nnnMETHODSnTemporal changes of the ratio of open and suicide verdicts were examined using logistic regression adjusting for confounders such as changing age and gender distributions of suicide victims and the methods they use.nnnRESULTSnAdjusted for age at death and suicide method, the ratio between open and suicide verdicts had, over successive 3-year time periods, increased with a factor 1.21 (95% CI 1.20-1.23) for male and 1.15 (95% CI 1.14-1.17) for female deaths. Medical coroners were 1.25 (1.08-1.44) times more likely than non-medical coroners to return open rather than suicide verdicts.nnnCONCLUSIONSnAs a likely result of factors in the death registration system, the ratio between open and suicide verdicts has increased substantially in E & W since the early 70s. In 1990 it was higher than in any other comparable country. This has important implications for comparisons of time trends in suicide between E & W and other countries.

Suicide, religion, and socioeconomic conditions. An ecological study in 26 countries, 1990

STUDY OBJECTIVE: Relative risks are frequently assumed to be stable across populations but this may not apply in psychiatric epidemiology where sociocultural context may modify them. Such ecological effect modification will give curved associations between aggregated risk factor and outcome. This was examined in connection with the ecological association between suicide rates and an aggregate index of religiosity. DESIGN: Ecological study of associations between suicide rates and an index of religiosity, adjusted for socioeconomic variation. The effect of stratification of the study sample according to levels of religiosity, was examined. SETTING: 26 European and American countries. SUBJECTS: Interview data from 37,688 people aggregated by country. OUTCOME MEASURES: Age and sex specific (1986-1990) suicide rates. MAIN RESULT: Adjusted for socioeconomic variation, negative associations of male suicide rates with religiosity were apparent in the 13 least religious countries only (test for interaction F (1, 25) = 5.6; p = 0.026). Associations between religiosity and female suicide rates did not vary across countries. CONCLUSION: The bent ecological association was apparent only after adjustment for socioeconomic variation suggesting that, rather than confounding, ecological modification of individual level links between religion and male (but not female) suicide risk is the responsible mechanism. This concurs with micro-level findings suggesting that suicide acceptance depends not only on personal but also on contextual levels of religious belief, and that men are more sensitive to this phenomenon than women. In psychiatric epidemiology, relative risks vary with the exposures prevalence. This has important implications for research and prevention.

Prediction of depression in European general practice attendees: the PREDICT study

BackgroundPrevention of depression must address multiple risk factors. Estimating overall risk across a range of putative risk factors is fundamental to prevention of depression. However, we lack reliable and valid methods of risk estimation. This protocol paper introduces PREDICT, an international research study to address this risk estimation.Methods/designThis is a prospective study in which consecutive general practice attendees in six European countries are recruited and followed up after six and 12 months. Prevalence of depression is assessed at baseline and each follow-up point. Consecutive attendees between April 2003 and September 2004 who were aged 18 to 75 were asked to take part. The possibility of a depressive episode was assessed using the Depression Section of the Composite International Diagnostic Interview. A selection of presumed risk factors was based on our previous work and a systematic review of the literature. It was necessary to evaluate the test-retest reliability of a number of risk factor questions that were developed specifically, or adapted, for the PREDICT study. In a separate reliability study conducted between January and November 2003, consecutive general practice attendees in the six participating European countries completed the risk factor items on two occasions, two weeks apart. The overall response rate at entry to the study was 69%. We exceeded our expected recruitment rate, achieving a total of 10,048 people in all. Reliability coefficients were generally good to excellent.DiscussionResponse rate to follow-up in all countries was uniformly high, which suggests that prediction will be based on almost a full cohort. The results of our reliability analysis are encouraging and suggest that data collected during the course of PREDICT will have a satisfactory level of stability. The development of a multi-factor risk score for depression will lay the foundation for future research on risk reduction in primary care. Our data will also provide the necessary evidence base on which to develop and evaluate interventions to reduce the prevalence of depression.