Robert Kohn

The treatment gap in mental health care

Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.

Intimate Partner Violence and Long-Term Psychosocial Functioning in a National Sample of American Women

Using a nationally representative sample of American married or cohabiting women, this prospective study examined women who reported or denied intimate partner violence (IPV) at wave 1 and compared them on a range of psychosocial outcomes at a 5-year follow-up. This study also examined the rate of divorce or separation during the 5-year interval among women who reported IPV at wave 1 and explored whether certain predictors were related to ending an abusive relationship with an intimate partner during the period. Women with IPV at wave 1, compared to women without IPV, were significantly more likely to experience a greater degree of depressive symptoms and functional impairment and less self-esteem and life satisfaction at the 5-year follow-up. Also, nearly half of the women in an abusive relationship left the relationship within the period. Leaving the abusive relationship was associated with lower individual income and more social support at wave 1.

MRI and neuropsychological differences in early- and late-life-onset geriatric depression

We sought to determine whether geriatric patients with late-life-onset major depression have more subcortical hyperintensities on MRI and greater cognitive impairment than age-matched geriatric patients with early-life-onset major depression, suggesting that subcortical disease may be etiologic in late-life depression. Most negative studies of the clinical significance of subcortical hyperintensities on MRI in geriatric patients have sampled from a restricted range of subjects, have employed limited batteries of neuropsychological tests, or have not quantified MRI changes; the present study attempted to address these limitations. Thirty subjects from a geriatric psychiatry inpatient service who were over 60 years of age and presented with major depression were divided into groups with onset of first depression after age 60 (mean = 72.4 years, 15 women, 0 men), and onset of first depression before age 60 (mean = 35.8 years, 12 women, 3 men). Quantitative analysis of MRI yielded the volume of: periventricular hyperintensities (PVH) and deep white-matter hyperintensities (DWMH). Subjects were administered a neuropsychological battery and measures of depression by raters blind to age of onset. The late-onset group had significantly more PVH and DWMH. They were also more impaired on executive and verbal and nonverbal memory tasks. Discriminant function analysis using the severity of subcortical signal hyperintensities on MRI, cognitive index, and depression scores correctly predicted late versus early onset of depression in 87% of the early-onset group and 80% of the late-onset group. These findings suggest that late-life-onset depression may be associated with an increased severity of subcortical vascular disease and greater impairment of cognitive performance. NEUROLOGY 1996;46: 1567-1574

Prevalence of mood, anxiety, and substance-abuse disorders for older Americans in the national comorbidity survey-replication.

OBJECTIVES Current information on the prevalence of psychiatric disorders among older adults in the United States is lacking. Prevalence of anxiety, mood, and substance disorders was examined by age (18-44, 45-64, 65-74, and 75 years and older) and sex. Covariates of disorders for older adults (65 years and older) were explored. DESIGN Cross-sectional epidemiologic study, using data from the National Comorbidity Survey-Replication. SETTING Community-based epidemiologic survey. PARTICIPANTS Representative national sample of community-dwelling adults in the United States. MEASUREMENTS The World Health Organization Composite International Diagnostic Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders. RESULTS Prevalence of 12-month and lifetime mood, anxiety, and substance-use disorders was lower for older adults (65 years and older) than younger age groups: 2.6% for mood disorder, 7.0% for anxiety disorder, 0 for any substance-use disorder, and 8.5% for any of these disorders (for any disorder, 18-44 years = 27.6%, 45-64 years = 22.4%). Among older adults, presence of a 12-month anxiety disorder was associated with female sex, lower education, being unmarried, and three or more chronic conditions. Presence of a 12-month mood disorder was associated with disability. Similar patterns were noted for lifetime disorders (any disorder: 18-44 years = 46.4%, 45-64 years = 43.7%, and 65 years and older = 20.9%). CONCLUSIONS This study documents the continued pattern of lower rates of formal diagnoses for elders. These rates likely underestimate the burden of late-life psychiatric disorders, given the potential for underdiagnosis, clinical significance of subthreshold symptoms, and lack of representation from high-risk older adults (e.g., medically ill, long-term care residents).

Los trastornos mentales en América Latina y el Caribe: asunto prioritario para la salud pública

OBJETIVO: La creciente carga de trastornos mentales que afecta a las poblaciones de America Latina y el Caribe es demasiado grande para hacer caso omiso de ella. Por lo tanto, es una necesidad impostergable conocer la prevalencia de los trastornos mentales y la brecha de tratamiento, que esta dada por la diferencia entre las tasas de prevalencia verdadera y las de las personas que han sido tratadas, que en algunos casos es grande pese a la existencia de tratamientos eficaces. Si se dispone de mayor informacion, se hace mas factible 1) abogar mejor por los intereses de las personas que necesitan atencion, 2) adoptar politicas mas eficaces, 3) formular programas de intervencion innovadores y 4) adjudicar recursos en conformidad con las necesidades observadas. METODOS: Los datos se obtuvieron de estudios comunitarios publicados en America Latina y el Caribe entre 1980 y 2004. En esas investigaciones epidemiologicas se usaron instrumentos diagnosticos estructurados y se estimaron tasas de prevalencia. Las tasas brutas de diversos trastornos psiquiatricos en America Latina y el Caribe se estimaron a partir de las tasas media y mediana extraidas de los estudios, desglosadas por sexo. Tambien se extrajeron los datos correspondientes al uso de servicios de salud mental para poder calcular la brecha en el tratamiento segun trastornos especificos. RESULTADOS: Las psicosis no afectivas (entre ellas la esquizofrenia) tuvieron una prevalencia media estimada durante el ano precedente de 1,0%; la depresion mayor, de 4,9%; y el abuso o la dependencia del alcohol, de 5,7%. Mas de la tercera parte de las personas afectadas por psicosis no afectivas, mas de la mitad de las afectadas por trastornos de ansiedad, y cerca de tres cuartas partes de las que abusaban o dependian del alcohol no habian recibido tratamiento psiquiatrico alguno, sea en un servicio especializado o en uno de tipo general. CONCLUSIONES: La actual brecha en el tratamiento de los trastornos mentales en America Latina y el Caribe sigue siendo abrumadora. Ademas, las tasas actuales probablemente subestiman el numero de personas sin atencion. La transicion epidemiologica y los cambios en la composicion poblacional acentuaran aun mas la brecha en la atencion en America Latina y el Caribe, a no ser que se formulen nuevas politicas de salud mental o que se actualicen las existentes, procurando incluir en ellas la extension de los programas y servicios.

The relationship between quality of interpersonal relationships and major depressive disorder: findings from the National Comorbidity Survey.

BACKGROUND The current study compared the quality of interpersonal relationships in individuals with major depressive disorder to individuals with dysthymia, comorbid depression, nonaffective disorders, and no psychiatric disorders. METHODS Using data from the National Comorbidity Study, a series of logistic regressions, controlling for demographic variables, were conducted to examine the strength of the association between a major depressive disorder and interpersonal dysfunction (positive and negative interactions) in contrast to other psychiatric disorders. RESULTS Respondents with current major depressive disorder reported significantly fewer positive interactions and more negative interactions with their spouse or live-in partner than those with nonaffective disorders, and than those with no psychiatric disorders. There were no significant differences in quality of interpersonal relationships between respondents with major depressive disorder and those with dysthymia. Among those with major depressive disorder, comorbidity or treatment-seeking behavior did not significantly contribute to degree of interpersonal difficulties. The strength of the association between interpersonal dysfunction and depression were, in general, comparable for men and women with major depressive disorder. LIMITATIONS The cross-sectional design of this report precludes inferences regarding causality between quality of interpersonal relationship and current major depressive disorder. CONCLUSIONS The results of this study indicate that, relative to psychiatric illness in general, poor intimate relationships are characteristic of a current major depressive disorder.

Estudio chileno de prevalencia de patología psiquiátrica (DSM-III-R/CIDI) (ECPP)

Background: The Diagnostic and Statistic Manual (DSM) solved the problem of diagnostic criteria for psychiatric diseases. Highly structured interviews such as Composite International Diagnostic Interview (CIDI) allow the evaluation of psychiatric disorders in large samples, whith great accuracy. Aim: To report the prevalence rates of psychiatric disorders in a representative sample of Chilean individuals. Material and methods: The CIDI was administered to 2978 Chilean individuals coming form four provinces. Lifetime and prevalence rates of psychiatric disorders, based in the third revision of the DSM, were calculated. Results: Thirty six percent of the population had a psychiatric disorder at least once in their lifetime and 23% had a disorder in the last six months. The most common lifetime diagnoses were agoraphobia in 11%, major depressive disorders in 9%, dysthymia in 8% and alcohol dependence in 6%. Only 49% of those with a psychiatric disorder sought medical care, while 4% of those individuals considered devoid of psychiatric illnesses, consulted in a mental health facility. Conclusions: The prevalence of psychiatric disorders in the Chilean population is similar to that of other Spanish speaking populations in Latin or North America (Rev Med Chile 2002; 130: 527-36)

Cancer incidence and survival following bereavement

OBJECTIVES This study investigated the effect of parental bereavement on cancer incidence and survival. METHODS A cohort of 6284 Jewish Israelis who lost an adult son in the Yom Kippur War or in an accident between 1970 and 1977 was followed for 20 years. We compared the incidence of cancer in this cohort with that among nonbereaved members of the population by logistic regression analysis. The survival of bereaved parents with cancer was compared with that of matched controls with cancer. RESULTS Increased incidence was found for lymphatic and hematopoietic malignancies among the parents of accident victims (odds ratio [OR] = 2.01; 95% confidence interval [CI] = 1.30, 3.11) and among war-bereaved parents (OR = 1.47; 95% CI = 1.13, 1.92), as well as for melanomas (OR = 4.62 [95% CI = 1.93, 11.06] and 1.71 [95% CI = 1.06, 2.76], respectively). Accident-bereaved parents also had an increased risk of respiratory cancer (OR = 1.50; 95% CI = 1.07, 2.11). The survival study showed that the risk of death was increased by bereavement if the cancer had been diagnosed before the loss, but not after. CONCLUSIONS This study showed an effect of stress on the incidence of malignancies for selected sites and accelerated demise among parents bereaved following a diagnosis of cancer, but not among those bereaved before such a diagnosis.

Epidemiology of trauma, post-traumatic stress disorder (PTSD) and co-morbid disorders in Chile.

BACKGROUND In this study we examined the prevalence rates of post-traumatic stress disorder (PTSD), types of trauma most often associated with PTSD, the co-morbidity of PTSD with other lifetime psychiatric disorders, which disorders preceded PTSD, and gender differences in PTSD and trauma exposure in a representative sample of Chileans. METHOD The DSM-III-R PTSD and antisocial personality disorder modules from the Diagnostic Interview Schedule (DIS) and modules for a range of DSM-III-R diagnoses from the Composite International Diagnostic Interview (CIDI) were administered to a representative sample of 2390 persons aged 15 to over 64 years in three cities in Chile. RESULTS The lifetime prevalence of PTSD was 4.4% (2.5% for men and 6.2% for women). Among persons exposed to trauma, rape was most strongly associated with PTSD. Onset of PTSD significantly increased the risk of developing each of the 10 other tested disorders. Among those exposed to trauma, women were significantly more likely to develop PTSD, after controlling for assaultive violence. CONCLUSIONS This study highlights the importance of investigating the prevalence of PTSD, patterns of co-morbidity of PTSD, and gender differences in PTSD in non-English-speaking countries.

Comorbidity of Depressive and Anxiety Disorders for Older Americans in the National Comorbidity Survey-Replication

OBJECTIVE To identify age differences in the 12-month and lifetime comorbidity of depressive and anxiety disorders for adults (18-64 years) compared with older adults (65 years and older) in a nationally representative sample of community-dwelling adults in the United States. DESIGN Cross-sectional epidemiologic study, using data from the National Comorbidity Survey-Replication public use dataset. SETTING Community-based epidemiologic survey. PARTICIPANTS Representative national sample of community-dwelling adults in the United States. MEASUREMENTS The World Health Organization Composite International Diagnostic Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition psychiatric disorders. RESULTS More than half of respondents with a 12-month major depressive disorder (MDD) had a comorbid anxiety disorder or dysthymia (18-64 years = 60.6%; 65 years and older = 51.8%). High rates of MDD were also found for those with anxiety disorders across both age groups, highest in the 18-64 years group for generalized anxiety disorder (28.5%) and highest in the 65 years and older group for panic disorder (36.7%). Age group did not predict 12-month diagnosis of a comorbid anxiety disorder among those with a depressive disorder in multivariate logistic regression. Onset of anxiety disorders preceded onset of depressive disorders for most older adults (77.6%). CONCLUSIONS Depressive and anxiety disorders frequently cooccurred in this representative sample of community-dwelling adults. Older adults experienced comorbidity to a similar extent as younger adults, suggesting high rates of comorbidity across the lifespan.