Jayati Das-Munshi

Prevalence of mental health conditions in cancer patients in acute care—a meta-analysis

BACKGROUND To what extent is professional psychosocial care of cancer patients in acute hospitals necessary? In a previous meta-analysis, prevalence of psychological sequelae was found to be the same as in the general population. New studies with advanced methodology have been published since; therefore, an updated meta-analysis was needed. METHODS We systematically reviewed studies assessing the prevalence of mental health conditions in acute care hospitals with comprehensive structured clinical interviews. RESULTS Of 46 retrieved manuscripts, eight were deemed eligible for this meta-analysis. Within the studies, 1448 cancer patients had been assessed, whereby 456 were diagnosed having a mental health disorder. The prevalence rates ranged from 23% (breast cancer patients in Turkey) to 53% (elderly cancer patients in Uganda). The combined prevalence estimate is 32% (95% confidence interval 27% to 37%). CONCLUSION One-third of the cancer patients in acute care hospitals is suffering from mental health disorders and need appropriate treatment.

Diabetes, common mental disorders, and disability: Findings from the UK National Psychiatric Morbidity Survey

Objectives: To determine a) the associations between diabetes and common mental disorders in a nationally representative sample and the effect of key covariates on such associations and b) the association of comorbid common mental disorders on the quality of life and diabetes self-care indicators. Methods: In a cross-sectional survey, people with diabetes were identified from a sample of 8580 individuals aged 16 to 74 years, drawn from the 2000 UK National Psychiatric Morbidity Survey. Diabetes was ascertained by self-report and prescribed medications. Psychiatric morbidity was assessed using the Revised Clinical Interview Schedule. Quality of life was measured using the Short Form-12, and questions were asked regarding diabetes self-care and functioning. Results: A total of 249 individuals were identified with diabetes. People with diabetes were more likely to suffer from common mental disorders (odds ratio (OR) = 1.5; 95% Confidence Interval (CI): 1.1–2.2; p < .05), and in particular mixed anxiety and depression (OR: 1.7; 95% CI: 1.1–2.6; p < .05), after controlling for age, gender, ethnicity, and socioeconomic status. The increased risk was uniform across diabetes subtypes. Among people with diabetes, common mental disorders were significantly associated with impaired health-related quality of life, more days off work, nonadherence, and difficulties with diabetes self-care. Conclusions: People with diabetes are more likely to suffer from common mental disorders, a finding which is highly relevant, given that psychiatric comorbidity in people with diabetes is also associated with higher levels of functional impairment, impaired quality of life, and difficulties with diabetes self-care. UK NPMS = United Kingdom National Psychiatric Morbidity Survey; ICD-10 = International Classification of Diseases-10; CIS-R = Clinical Interview Schedule-Revised; OCD = obsessive compulsive disorder; GAD = generalized anxiety disorder; MADD = mixed anxiety and depression disorder; ADLs = activities of daily living; SF-12 = Short Form-12 (Health-Related Quality of Life).

Understanding the effect of ethnic density on mental health: multi-level investigation of survey data from England

Objectives To determine if living in areas where higher proportions of people of the same ethnicity reside is protective for common mental disorders, and associated with a reduced exposure to discrimination and improved social support. Finally, to determine if any protective ethnic density effects are mediated by reduced exposure to racism and improved social support. Design Multi-level logistic regression analysis of national survey data, with area-level, own-group ethnic density modelled as the main exposure. Participants and setting 4281 participants of Irish, black Caribbean, Indian, Pakistani, Bangladeshi, and white British ethnicity, aged 16–74 years, randomly sampled from 892 “middle layer super output areas” in England. Main outcome measures Common mental disorders (assessed via structured interviews); discrimination (assessed via structured questionnaire); and social support and social networks (assessed via structured questionnaire). Results Although the most ethnically dense areas were also the poorest, for each 10 percentage point increase in own-group ethnic density, there was evidence of a decreased risk of common mental disorders, for the full ethnic minority sample (odds ratio 0.94 (95% confidence interval 0.89 to 0.99); P=0.02, trend), for the Irish group (odds ratio 0.21 (0.06 to 0.74); P=0.01, trend), and for the Bangladeshi group (odds ratio 0.75 (0.62 to 0.91); P=0.005, trend), after adjusting for a priori confounders. For some groups, living in areas of higher own-group density was associated with a reduction in the reporting of discrimination and with improved social support and improved social networks. However, none of these factors mediated ethnic density effects. Conclusions A protective effect of living in areas of higher own-group ethnic density was present for common mental disorders for some minority groups. People living in areas of higher own-group density may report improved social support and less discrimination, but these associations did not fully account for density effects.

Migration, social mobility and common mental disorders: critical review of the literature and meta-analysis.

Objective. Changes in socio-economic position in people who migrate may have adverse associations with mental health. The main objective of this review was to assess the association of social mobility with common mental disorders in migrant and second-generation groups, to inform future research. Design. Systematic review and meta-analysis of English-language studies assessing the association of social mobility in migrant or second-generation groups with common mental disorders. Approaches to operationalise ‘social mobility’ were reviewed. Results. Twelve studies (n=18,548) met criteria for retrieval. Very few included second-generation groups, and most studies were cross-sectional in design. Approaches to operationalise ‘social mobility’ varied between studies. Downward intragenerational social mobility was associated with migration in the majority of studies. Random effects meta-analysis (n=5179) suggested that migrants to higher income countries who experienced downward mobility or underemployment were more likely to screen positive for common mental disorders, relative to migrants who were upwardly mobile or experienced no changes to socio-economic position. Conclusions on second-generation groups were limited by the lack of research highlighted for these groups. Downward intragenerational mobility associated with migration may be associated with vulnerability to common mental disorders in some migrant groups. Conclusion. Given the increasing scale of global migration, further research is needed to clarify how changes to socio-economic position associated with international migration may impact on the mental health of migrants, and in their children.

Ethnicity and excess mortality in severe mental illness: a cohort study

Summary Background Excess mortality in severe mental illness (defined here as schizophrenia, schizoaffective disorders, and bipolar affective disorders) is well described, but little is known about this inequality in ethnic minorities. We aimed to estimate excess mortality for people with severe mental illness for five ethnic groups (white British, black Caribbean, black African, south Asian, and Irish) and to assess the association of ethnicity with mortality risk. Methods We conducted a longitudinal cohort study of individuals with a valid diagnosis of severe mental illness between Jan 1, 2007, and Dec 31, 2014, from the case registry of the South London and Maudsley Trust (London, UK). We linked mortality data from the UK Office for National Statistics for the general population in England and Wales to our cohort, and determined all-cause and cause-specific mortality by ethnicity, standardised by age and sex to this population in 2011. We used Cox proportional hazards regression to estimate hazard ratios and a modified Cox regression, taking into account competing risks to derive sub-hazard ratios, for the association of ethnicity with all-cause and cause-specific mortality. Findings We identified 18 201 individuals with a valid diagnosis of severe mental illness (median follow-up 6·36 years, IQR 3·26–9·92), of whom 1767 died. Compared with the general population, age-and-sex-standardised mortality ratios (SMRs) in people with severe mental illness were increased for a range of causes, including suicides (7·65, 95% CI 6·43–9·04), non-suicide unnatural causes (4·01, 3·34–4·78), respiratory disease (3·38, 3·04–3·74), cardiovascular disease (2·65, 2·45–2·86), and cancers (1·45, 1·32–1·60). SMRs were broadly similar in different ethnic groups with severe mental illness, although the south Asian group had a reduced SMR for cancer mortality (0·49, 0·21–0·96). Within the cohort with severe mental illness, hazard ratios for all-cause mortality and sub-hazard ratios for natural-cause and unnatural-cause mortality were lower in most ethnic minority groups relative to the white British group. Interpretation People with severe mental illness have excess mortality relative to the general population irrespective of ethnicity. Among those with severe mental illness, some ethnic minorities have lower mortality than the white British group, for which the reasons deserve further investigation. Funding UK Health Foundation and UK Academy of Medical Sciences.

Mental Health Inequalities in Adolescents Growing Up in Post-Apartheid South Africa: Cross-Sectional Survey, SHaW Study

Background South Africa is one of the most ‘unequal’ societies in the world. Despite apartheid ending more than 20 years ago, material inequalities remain interwoven with ethnic/racial inequalities. There is limited research on the prevalence/predictors of common mental disorders (CMD) among young people. Adolescence is a unique time-point during which intervention may lead to improved mental health and reduced social problems later. The study objective was to assess mental health disparities in a representative sample of adolescents growing up in South Africa. Methods Cross-sectional associations of race/ethnicity and material disadvantage with CMD and Post Traumatic Stress Disorder (PTSD) were assessed in a stratified random sample representative of school-attendees, aged 14–15 years, in a large metropolitan area of Cape Town. Validated instruments assessed mental disorders; these included: Harvard Trauma Questionnaire (PTSD); Short Moods and Feelings Questionnaire (depression); Zung self-rated anxiety scale (anxiety). Self-ascribed ethnicity was determined using procedures similar to the South African census and previous national surveys. Results Response rate was 88% (1034 of 1169 individuals). Adolescents experienced a high prevalence of depression (41%), anxiety (16%) and PTSD (21%). A gradient between material disadvantage and CMD/ PTSD was evident across all ethnic/racial groups. Respondents self-identifying as ‘black’ or ‘coloured’ were disadvantaged across most indicators. After adjusting for confounders, relative to white children, relative risk (RR) of CMD in black children was 2.27 (95% CI:1.24, 4.15) and for PTSD was RR: 2.21 (95% CI:1.73, 2.83). Relative risk of CMD was elevated in children self-identifying as ‘coloured’ (RR: 1.73, 95% CI:1.11, 2.70). Putative mediators (violence, racially motivated bullying, social support, self-esteem) partially accounted for differences in CMD and fully for PTSD. Conclusions Adolescent mental health inequalities in Cape Town are associated with material disadvantage and self-identification with historically disadvantaged groups.

Ethnic density, health care seeking behaviour and expected discrimination from health services among ethnic minority people in England

The health of ethnic minority people is reported to be poorer in areas of lower ethnic density. Based on this literature, higher rates of health seeking behaviours would be expected among ethnic minorities resident in neighbourhoods of lower ethnic density. Should health seeking not increase in areas of lower ethnic density, a possible explanation might be that ethnic minority people resident in these neighbourhoods are not accessing services for fear of racial discrimination. The present study examined this hypothesis using two nationally-representative surveys from England. Health seeking behaviour did not vary by ethnic density. Lower ethnic density was associated with increased reports of expected discrimination from services, but also with increased satisfaction with services.

Does childhood adversity account for poorer mental and physical health in second-generation Irish people living in Britain? Birth cohort study from Britain (NCDS)

Objectives Worldwide, the Irish diaspora experience elevated mortality and morbidity across generations, not accounted for through socioeconomic position. The main objective of the present study was to assess if childhood disadvantage accounts for poorer mental and physical health in adulthood, in second-generation Irish people. Design Analysis of prospectively collected birth cohort data, with participants followed to midlife. Setting England, Scotland and Wales. Participants Approximately 17 000 babies born in a single week in 1958. Six per cent of the cohort were of second-generation Irish descent. Outcomes Primary outcomes were common mental disorders assessed at age 44/45 and self-rated health at age 42. Secondary outcomes were those assessed at ages 23 and 33. Results Relative to the rest of the cohort, second-generation Irish children grew up in marked material and social disadvantage, which tracked into early adulthood. By midlife, parity was reached between second-generation Irish cohort members and the rest of the sample on most disadvantage indicators. At age 23, Irish cohort members were more likely to screen positive for common mental disorders (OR 1.44; 95% CI 1.06 to 1.94). This had reduced slightly by midlife (OR 1.27; 95% CI 0.96 to 1.69). Although at age 23 second-generation cohort members were just as likely to report poorer self-rated health (OR 1.06; 95% CI 0.79 to 1.43), by midlife this difference had increased (OR 1.25; 95% CI 0.98 to 1.60). Adjustment for childhood and early adulthood adversity fully attenuated differences in adult health disadvantages. Conclusions Social and material disadvantage experienced in childhood continues to have long-range adverse effects on physical and mental health at midlife, in second-generation Irish cohort members. This suggests important mechanisms over the life-course, which may have important policy implications in the settlement of migrant families.

Does depression diagnosis and antidepressant prescribing vary by location? Analysis of ethnic density associations using a large primary care dataset

Background Studies have linked ethnic differences in depression rates with neighbourhood ethnic density although results have not been conclusive. We looked at this using a novel approach analysing whole population data covering just over one million GP patients in four London boroughs. Method Using a dataset of GP records for all patients registered in Lambeth, Hackney, Tower Hamlets and Newham in 2013 we investigated new diagnoses of depression and antidepressant use for: Indian, Pakistani, Bangladeshi, black Caribbean and black African patients. Neighbourhood effects were assessed independently of GP practice using a cross-classified multilevel model. Results Black and minority ethnic groups are up to four times less likely to be newly diagnosed with depression or prescribed antidepressants compared to white British patients. We found an inverse relationship between neighbourhood ethnic density and new depression diagnosis for some groups, where an increase of 10% own-ethnic density was associated with a statistically significant (p < 0.05) reduced odds of depression for Pakistani [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.70–0.93], Indian (OR 0.88, CI 0.81–0.95), African (OR 0.88, CI 0.78–0.99) and Bangladeshi (OR 0.94, CI 0.90–0.99) patients. Black Caribbean patients, however, showed the opposite effect (OR 1.26, CI 1.09–1.46). The results for antidepressant use were very similar although the corresponding effect for black Caribbeans was no longer statistically significant (p = 0.07). Conclusion New depression diagnosis and antidepressant use was shown to be less likely in areas of higher own-ethnic density for some, but not all, ethnic groups.

Minority status and mental distress: a comparison of group density effects.

Background It has been observed that mental disorders, such as psychosis, are more common for people in some ethnic groups in areas where their ethnic group is less common. We set out to test whether this ethnic density effect reflects minority status in general, by looking at three situations where individual characteristics differ from what is usual in a locality. Method Using data from the South East London Community Health study (n = 1698) we investigated associations between minority status (defined by: ethnicity, household status and occupational social class) and risk of psychotic experiences, common mental disorders and parasuicide. We used a multilevel logistic model to examine cross-level interactions between minority status at individual and neighbourhood levels. Results Being Black in an area where this was less common (10%) was associated with higher odds of psychotic experiences [odds ratio (OR) 1.34 95% confidence interval (CI) 1.07–1.67], and attempted suicide (OR 1.84 95% CI 1.19–2.85). Living alone where this was less usual (10% less) was associated with increased odds of psychotic experiences (OR 2.18 95% CI 0.91–5.26), while being in a disadvantaged social class where this was less usual (10% less) was associated with increased odds of attempted suicide (OR 1.33 95% CI 1.03–1.71). We found no evidence for an association with common mental disorders. Conclusions The relationship between minority status and mental distress was most apparent when defined in terms of broad ethnic group but was also observed for individual household status and occupational social class.