Robin E. McGee

Mortality in Mental Disorders and Global Disease Burden Implications: A Systematic Review and Meta-analysis

IMPORTANCE Despite the potential importance of understanding excess mortality among people with mental disorders, no comprehensive meta-analyses have been conducted quantifying mortality across mental disorders. OBJECTIVE To conduct a systematic review and meta-analysis of mortality among people with mental disorders and examine differences in mortality risks by type of death, diagnosis, and study characteristics. DATA SOURCES We searched EMBASE, MEDLINE, PsychINFO, and Web of Science from inception through May 7, 2014, including references of eligible articles. Our search strategy included terms for mental disorders (eg, mental disorders, serious mental illness, and severe mental illness), specific diagnoses (eg, schizophrenia, depression, anxiety, and bipolar disorder), and mortality. We also used Google Scholar to identify articles that cited eligible articles. STUDY SELECTION English-language cohort studies that reported a mortality estimate of mental disorders compared with a general population or controls from the same study setting without mental illness were included. Two reviewers independently reviewed the titles, abstracts, and articles. Of 2481 studies identified, 203 articles met the eligibility criteria and represented 29 countries in 6 continents. DATA EXTRACTION AND SYNTHESIS One reviewer conducted a full abstraction of all data, and 2 reviewers verified accuracy. MAIN OUTCOMES AND MEASURES Mortality estimates (eg, standardized mortality ratios, relative risks, hazard ratios, odds ratios, and years of potential life lost) comparing people with mental disorders and the general population or people without mental disorders. We used random-effects meta-analysis models to pool mortality ratios for all, natural, and unnatural causes of death. We also examined years of potential life lost and estimated the population attributable risk of mortality due to mental disorders. RESULTS For all-cause mortality, the pooled relative risk of mortality among those with mental disorders (from 148 studies) was 2.22 (95% CI, 2.12-2.33). Of these, 135 studies revealed that mortality was significantly higher among people with mental disorders than among the comparison population. A total of 67.3% of deaths among people with mental disorders were due to natural causes, 17.5% to unnatural causes, and the remainder to other or unknown causes. The median years of potential life lost was 10 years (n = 24 studies). We estimate that 14.3% of deaths worldwide, or approximately 8 million deaths each year, are attributable to mental disorders. CONCLUSIONS AND RELEVANCE These estimates suggest that mental disorders rank among the most substantial causes of death worldwide. Efforts to quantify and address the global burden of illness need to better consider the role of mental disorders in preventable mortality.

Knowledge about schizophrenia and social distance toward individuals with schizophrenia: A survey among predominantly low-income, urban, African American community members

This study surveyed 111 urban African American community members regarding their level of familiarity with mental illness, knowledge about schizophrenia, and social distance toward individuals with schizophrenia. The participants were predominantly Protestant, with relatively low educational attainment and low income. Knowledge and social distance scores were not significantly correlated. Independently significant predictors of knowledge about schizophrenia, which accounted for 49% of the variance in scores, included level of educational attainment, gender, having a friend with a history of psychiatric treatment, and having known someone with schizophrenia. Independent predictors of social distance scores included family history of psychiatric treatment and family history of schizophrenia, which accounted for 14% of variance in scores. Further research involving specific racial, ethnic, cultural, and socioeconomic groups is needed to better understand the complex associations underlying knowledge about schizophrenia and stigma.

Unemployment and depression among emerging adults in 12 states, Behavioral Risk Factor Surveillance System, 2010.

Introduction The high rate of unemployment among emerging adults (aged 18 to 25 years) is a public health concern. The risk of depression is higher among the unemployed than among the employed, but little is known about the relationship between unemployment and mental health among emerging adults. This secondary data analysis assessed the relationship between unemployment and depression among emerging adults. Methods Data from the 2010 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. Responses to the Patient Health Questionnaire-8 provided data about the prevalence of depression. Bivariate relationships were assessed using χ2 tests, and multivariable adjusted odds ratios were calculated with logistic regressions. Sociodemographic variables were sex, race/ethnicity, marital status, and education. In addition, logistic regression models adjusted for health insurance status, disability, smoking, and body mass index. The analyses were completed using SAS 9.3 survey procedures to account for the complex sampling design. Results Almost 12% of emerging adults were depressed (PHQ-8 ≥10) and about 23% were unemployed. Significantly more unemployed than employed emerging adults were classified with depression. In the final model, the odds of depression were about 3 times higher for unemployed than employed emerging adults. Conclusion The relationship between unemployment and depression is significant among emerging adults. With high rates of unemployment for this age group, this population may benefit from employment- and mental-health–focused interventions.

Race, Ethnicity, Substance Use, and Unwanted Sexual Intercourse among Adolescent Females in the United States

Introduction The purpose of this study was to examine racial/ethnic disparities in being forced to have sexual intercourse against ones will, and the effect of substance use on these disparities. Methods We analyzed data from adolescent women participating in the Youth Risk Behavior Survey. Bivariate associations and logistic regression models were assessed to examine associations among race/ethnicity, forced sex, and substance use behaviors. Results Being forced to have intercourse against ones will and substance use behaviors differed by race/ethnicity. African Americans had the highest prevalence of having been forced to have sexual intercourse (11.2%). Hispanic adolescent women were the most likely to drink (76.1%), Caucasians to binge drink (28.2%), and African Americans to use drugs (44.3%). When forced sexual intercourse was regressed onto both race/ethnicity and substance use behaviors, only substance use behaviors were significantly associated with forced sexual intercourse. Conclusion Differences in substance use behaviors account for the racial/ethnic differences in the likelihood of forced sexual intercourse. Future studies should explore the cultural and other roots of the racial/ethnic differences in substance use behavior as a step toward developing targeted interventions to prevent unwanted sexual experiences.

Development of the Adult Epilepsy Self-Management Measurement Instrument (AESMMI).

Epilepsy self-management is the total sum of steps that people perform to maximize seizure control, to minimize the impact of having a seizure disorder, and to maximize quality of life. As part of a phased approach to instrument development, we conducted descriptive analyses of data from epilepsy self-management items covering 10 domains of self-management gathered from 422 adults with epilepsy from multiple study sites. Participants most frequently reported performing sets of behaviors related to managing treatment and stigma, information seeking, managing symptoms, and communicating with providers. Behaviors reported with lower frequency were related to seeking social support and engaging in wellness behaviors. Significant differences for the domains were found for income, gender, and education levels but not for other different demographic variables. A subsequent analytic phase, reported in a companion article, will use factor analysis to identify and validate the subscale structure of the domains.

Factor analyses of an Adult Epilepsy Self-Management Measurement Instrument (AESMMI).

The purpose of this study was to test the psychometric properties of an enhanced Adult Epilepsy Self-Management Measurement Instrument (AESMMI). An instrument of 113 items, covering 10 a priori self-management domains, was generated through a multiphase process, based on a review of the literature, validated epilepsy and other chronic condition self-management scales and expert input. Reliability and exploratory factor analyses were conducted on data collected from 422 adults with epilepsy. The instrument was reduced to 65 items, converging on 11 factors: Health-care Communication, Coping, Treatment Management, Seizure Tracking, Social Support, Seizure Response, Wellness, Medication Adherence, Safety, Stress Management, and Proactivity. Exploratory factors supported the construct validity for 6 a priori domains, albeit with significant changes in the retained items or in their scope and 3 new factors. One a priori domain was split in 2 subscales pertaining to treatment. The configuration of the 11 factors provides additional insight into epilepsy self-management behaviors. Internal consistency reliability of the 65-item instrument was high (α=.935). Correlations with independent measures of health status, quality of life, depression, seizure severity, and life impact of epilepsy further validated the instrument. This instrument shows potential for use in research and clinical settings and for assessing intervention outcomes and self-management behaviors in adults with epilepsy.

Perspectives of Adults With Epilepsy and Their Support Persons on Self-Management Support:

Social support is an important mechanism for improving self-management, although little is known about its role in epilepsy self-management. We examined the type of support provided to people with epilepsy and its influence on self-management. We conducted in-depth interviews with 22 people with epilepsy and 16 support persons, representing 14 pairs and 10 unpaired individuals. We analyzed the data using principles of grounded theory. Supporters, who were mainly parents and spouses, aided people with epilepsy in every dimension of self-management. Support for self-management occurred along a continuum from person with epilepsy-led management to support person-led management. Where the pairs fell on the continuum depended on developmental stage, relationship type, and relationship dynamics. Seizure control shaped individuals’ experiences with self-management and support within each group. The self-management continuum provides a new aspect that can be integrated into existing models of self- and family management.

A dyadic model of living with epilepsy based on the perspectives of adults with epilepsy and their support persons.

Epilepsy is a chronic condition that significantly affects the lives of individuals with epilepsy and their support persons, though few studies have examined the experiences of both. To examine these experiences and explore the interpersonal relationships between dyad members, we conducted in-depth interviews with 22 persons with epilepsy and 16 support persons. Data analysis was guided by a grounded theory perspective. We developed a model that shows how epilepsy impacts the lives of both persons with epilepsy and their support persons and how the experiences of persons with epilepsy and supporters influence one another. The core model elements were seizure and treatment factors, relationship characteristics, self-management, seizure control, support provided, illness intrusiveness, and quality of life. Persons with epilepsy moved through the model in five trajectories depending on seizure control, relationship type, and gender. Support providers followed four trajectories based on seizure control, perception of burden, and support for themselves. Persons with epilepsy and their primary support providers have varied experiences in how epilepsy affects their lives. This model could serve as a basis for future research and intervention efforts focused on ways to reduce illness intrusiveness and improve quality of life for persons with epilepsy and their supporters.

Responding to a suicidal friend or family member: A qualitative study of college students

ABSTRACT The purpose of this qualitative study was to understand how college students have responded, at any point in their lifetime, to a suicidal friend or family member. College students completed an online survey in which they described, in their own words, what they have done when a friend or family member disclosed being suicidal. These responses included providing social support, information, telling someone, and crisis support. Future studies are needed to determine how common these responses are, identify factors that predict certain responses, and examine the impact responding to a suicidal person can have on college student wellbeing.

Distance Delivery of Mindfulness-Based Cognitive Therapy

Distance delivery of mindfulness-based cognitive therapy (MBCT) offers an innovative opportunity to provide therapy to people who would otherwise be unable to receive treatment for depression, anxiety, or other mental illnesses, particularly those with co-morbid chronic illness. Among other benefits, distance delivery by telephone or Internet can eliminate barriers to attending MBCT sessions that are related to transportation, mobility limitations, or stigma. However, distance delivery can also create challenges including technology issues, professional practice and confidentiality concerns, and limitations upon interpersonal communication. Studies suggest that distance delivery of cognitive behavioral therapy can be as effective as face-to-face delivery. Project UPLIFT is a distance-delivered intervention based in MBCT. In two randomized, controlled trials, Project UPLIFT was demonstrated to be effective for increasing mindfulness-based knowledge and skills, reducing depression, and increasing satisfaction with life among people with epilepsy. MBCT is particularly well-suited to distance delivery because many of the exercises are designed to be verbally led by the facilitator.