Ricardo Araya

Education and income: which is more important for mental health?

Study objective: To assess which indicators of socioeconomic status are associated with an increased prevalence of common mental disorders. Design: Cross sectional household survey. Setting: Santiago, Chile. Participants: Random sample of adults aged 16–65 residing in private households. Main results: Less education (odds ratio 2.44, 95% confidence intervals 1.50 to 3.97), a recent income decrease (odds ratio 2.14, 1.70 to 2.70), and poor housing (odds ratio 1.53, 1.05 to 2.23), were the only socioeconomic status variables that remained significantly associated with an increased prevalence of common mental disorders after adjustments. The prevalence of common mental disorders was also higher among people with manual unskilled occupations, overcrowded housing, and lower per capita income but these associations disappeared after adjustment for other explanatory and confounding variables. Conclusions: There is a strong, inverse, and independent association between education and common mental disorders. However, income was not associated with the prevalence of common mental disorders, after adjusting for other socioeconomic variables. Similar results have been found in other Latin American studies but British studies tend to find the opposite, that income but not education is associated with common mental disorders. Understanding the impact of socioeconomic factors on mental health requires research in poor as well as rich countries.

Comparison of two self administered psychiatric questionnaires (GHQ-12 and SRQ-20) in primary care in Chile.

SummaryThe General Health Questionnaire (GHQ-12) and the Self Report Questionaire (SRQ-20) were simultaneously validated against the criterion of the Revised Clinical Interview Schedule (CIS-R) in a primary care clinic in Santiago, Chile. A Relative Operating Characteristic (ROC) analaysis was used to determine the optimal threshold point for case definition and to compare the performance of these two questionnaires. The validation coefficients for the GHQ-12 and the SRQ-20 were, respectively: sensitivity 76% and 74%; specificity 73% and 77%; overall misclassification rate: 26% and 25%. Misclassification by these questionnaires was significantly associated with education and sex, males being more likely than females to be misclassified as false negatives and poorly educated respondents as false positives. The symptom response profile of both questionnaires showed that the most prevalent items were psychological complaints of anxiety and depression. Both instruments seem to have a similar ability to identify minor psychiatric disorders in primary care in Chile.

The comparison of latent variable models of non-psychotic psychiatric morbidity in four culturally diverse populations.

BACKGROUND Factor analysis has been employed to identify latent variables that are unifying constructs and that parsimoniously describe correlations among a related group of variables. Confirmatory factor analysis is used to test hypothesized factor structures for a set of variables; it can also, as in this paper be used to model data from two or more groups simultaneously to determine whether they have the same factor structure. METHOD Non-psychotic psychiatric morbidity, elicited by the Revised Clinical Interview Schedule (CIS-R), from four culturally diverse populations was compared. Confirmatory factor analysis was employed to compare the factor structures of CIS-R data sets from Santiago, Harare, Rotherhithe and Ealing. These structures were compared with hypothetical one and two factor (depression-anxiety) models. RESULTS The models fitted well with the different data sets. The depression-anxiety model was marginally superior to the one factor model as judged by various statistical measures of fit. The two factors in depression-anxiety model were, however, highly correlated. CONCLUSIONS The findings suggest that symptoms of emotional distress seem to have the same factor structure across cultures.

Cross-cultural patterns of the association between varying levels of alcohol consumption and the common mental disorders of depression and anxiety: Secondary analysis of the WHO Collaborative Study on Psychological Problems in General Health Care

BACKGROUND Alcohol consumption is associated with several complications of both physical and mental health. Light or moderate alcohol consumption may have beneficial effects on physical or mental health but this effect is still controversial and research in the mental health field is relatively scarce. Our aim was to investigate the association between varying levels of alcohol consumption and the common mental disorders of depression and anxiety in a large international primary care sample. METHODS The sample consisted of 5438 primary care attenders from 14 countries who participated in the WHO Collaborative Study of Psychological Problems in General Health Care. Alcohol use was assessed using Alcohol Use Disorders Identification Test (AUDIT) and the mental disorders were assessed with the Composite International Diagnostic Interview (CIDI). RESULTS Light to moderate alcohol consumption was associated with a lower prevalence of depression and generalized anxiety disorder compared to abstinence while excessive alcohol consumption was associated with a higher prevalence of depression. This non-linear association was not substantially affected after adjustment for a range of possible confounding variables, including the presence of chronic disease and the current physical status of participants and was evident in different drinking cultures. CONCLUSION The study confirms that excessive drinking is associated with an increased prevalence of depression, but also raises the possibility that light/moderate drinking may be associated with a reduced prevalence of both depression and anxiety. Any causal interpretation of this association is difficult in the context of this cross-sectional study and further longitudinal studies are needed.

Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial

BACKGROUND Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression. DESIGN Cluster randomised controlled trial. SETTING UK primary care practices (n = 51) in three UK primary care districts. PARTICIPANTS A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. INTERVENTIONS Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice. MAIN OUTCOME MEASURES Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. RESULTS In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. CONCLUSIONS Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se. TRIAL REGISTRATION Current Controlled Trials ISRCTN32829227. FUNDING This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.

Do depressed and anxious men do groups? What works and what are the barriers to help seeking?

AIM To map the availability and types of depression and anxiety groups, to examine mens experiences and perception of this support as well as the role of health professionals in accessing support. BACKGROUND The best ways to support men with depression and anxiety in primary care are not well understood. Group-based interventions are sometimes offered but it is unknown whether this type of support is acceptable to men. METHODS Interviews with 17 men experiencing depression or anxiety. A further 12 interviews were conducted with staff who worked with depressed men (half of whom also experienced depression or anxiety themselves). There were detailed observations of four mental health groups and a mapping exercise of groups in a single English city (Bristol). FINDINGS Some men attend groups for support with depression and anxiety. There was a strong theme of isolated men, some reluctant to discuss problems with their close family and friends but attending groups. Peer support, reduced stigma and opportunities for leadership were some of the identified benefits of groups. The different types of groups may relate to different potential member audiences. For example, unemployed men with greater mental health and support needs attended a professionally led group whereas men with milder mental health problems attended peer-led groups. Barriers to help seeking were commonly reported, many of which related to cultural norms about how men should behave. General practitioners played a key role in helping men to acknowledge their experiences of depression and anxiety, listening and providing information on the range of support options, including groups. Men with depression and anxiety do go to groups and appear to be well supported by them. Groups may potentially be low cost and offer additional advantages for some men. Health professionals could do more to identify and promote local groups.