Scott Weich

The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation

BackgroundThere is increasing international interest in the concept of mental well-being and its contribution to all aspects of human life. Demand for instruments to monitor mental well-being at a population level and evaluate mental health promotion initiatives is growing. This article describes the development and validation of a new scale, comprised only of positively worded items relating to different aspects of positive mental health: the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS).MethodsWEMWBS was developed by an expert panel drawing on current academic literature, qualitative research with focus groups, and psychometric testing of an existing scale. It was validated on a student and representative population sample. Content validity was assessed by reviewing the frequency of complete responses and the distribution of responses to each item. Confirmatory factor analysis was used to test the hypothesis that the scale measured a single construct. Internal consistency was assessed using Cronbachs alpha. Criterion validity was explored in terms of correlations between WEMWBS and other scales and by testing whether the scale discriminated between population groups in line with pre-specified hypotheses. Test-retest reliability was assessed at one week using intra-class correlation coefficients. Susceptibility to bias was measured using the Balanced Inventory of Desired Responding.ResultsWEMWBS showed good content validity. Confirmatory factor analysis supported the single factor hypothesis. A Cronbachs alpha score of 0.89 (student sample) and 0.91 (population sample) suggests some item redundancy in the scale. WEMWBS showed high correlations with other mental health and well-being scales and lower correlations with scales measuring overall health. Its distribution was near normal and the scale did not show ceiling effects in a population sample. It discriminated between population groups in a way that is largely consistent with the results of other population surveys. Test-retest reliability at one week was high (0.83). Social desirability bias was lower or similar to that of other comparable scales.ConclusionWEMWBS is a measure of mental well-being focusing entirely on positive aspects of mental health. As a short and psychometrically robust scale, with no ceiling effects in a population sample, it offers promise as a tool for monitoring mental well-being at a population level. Whilst WEMWBS should appeal to those evaluating mental health promotion initiatives, it is important that the scales sensitivity to change is established before it is recommended in this context.

Social capital and mental health

Evidence for inequalities in morbidity and mortality by occupational social class and material standard of living has become irrefutable ([Acheson, 1998][1]). Attention has now turned to the effects of social context ([MacIntyre et al , 1993][2]; [MacIntyre, 1997][3]; [Ecob & MacIntyre, 2000][4]; [

Poverty, unemployment, and common mental disorders: population based cohort study.

Abstract Objective: To determine whether poverty and unemployment increase the likelihood of or delay recovery from common mental disorders, and whether these associations could be explained by subjective financial strain. Design: Prospective cohort study. Setting: England, Wales, and Scotland. Subjects: 7726 adults aged 16-75 living in private households. Main outcome measures: Common mental disorders were assessed using the general health questionnaire, a self assessed measure of psychiatric morbidity. Results: Poverty and unemployment (odds ratio 1.86, 95% confidence interval 1.18 to 2.94) were associated with the maintenance but not onset of episodes of common mental disorders. Associations between poverty and employment and maintenance of common mental disorders, however, were much smaller than those of cross sectional studies. Financial strain at baseline was independently associated with both onset (1.57, 1.19 to 2.07) and maintenance (1.86, 1.36 to 2.53) even after adjusting for objective indices of standard of living. Conclusions: Poverty and unemployment increased the duration of episodes of common mental disorders but not the likelihood of their onset. Financial strain was a better predictor of future psychiatric morbidity than either of these more objective risk factors though the nature of this risk factor and its relation with poverty and unemployment remain unclear. Key messages The prevalence of the most common mental disorders, anxiety and depression, has been shown to be consistently associated with unemployment and measures of poverty, independent of occupational social class Unemployment and poverty were associated with the maintenance of episodes of most common mental disorders but not their onset Financial strain was a powerful independent predictor of both the onset and maintenance of episodes of common mental disorders, even after adjusting for more objective measures of standard of living Over 12 months poverty and financial strain, but not unemployment, were associated with significant increases in psychiatric morbidity; the effect of poverty increased with the level of baseline morbidity Further research is needed to better understand the nature of financial strain and its relation with unemployment and objective measures of standard of living

Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial

BACKGROUND Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care. METHODS In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578. FINDINGS 113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2.39, 95% CI 1.23-4.67; p=0.011), and 46 (42%) versus 26 (26%) at 8 months (2.07, 1.11-3.87; p=0.023). INTERPRETATION CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT. FUNDING BUPA Foundation.

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

BACKGROUND There is evidence that the prevalence of common mental disorders varies across Europe. AIMS To compare prevalence of common mental disorders in general practice attendees in six European countries. METHOD Unselected 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. RESULTS Prevalence 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. CONCLUSIONS These 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.

Debt, income and mental disorder in the general population

BACKGROUND The association between poor mental health and poverty is well known but its mechanism is not fully understood. This study tests the hypothesis that the association between low income and mental disorder is mediated by debt and its attendant financial hardship. METHOD The study is a cross-sectional nationally representative survey of private households in England, Scotland and Wales, which assessed 8580 participants aged 16-74 years living in general households. Psychosis, neurosis, alcohol abuse and drug abuse were identified by the Clinical Interview Schedule--Revised, the Schedule for Assessment in Neuropsychiatry (SCAN), the Alcohol Use Disorder Identification Test (AUDIT) and other measures. Detailed questions were asked about income, debt and financial hardship. RESULTS Those with low income were more likely to have mental disorder [odds ratio (OR) 2.09, 95% confidence interval (CI) 1.68-2.59] but this relationship was attenuated after adjustment for debt (OR 1.58, 95% CI 1.25-1.97) and vanished when other sociodemographic variables were also controlled (OR 1.07, 95% CI 0.77-1.48). Of those with mental disorder, 23% were in debt (compared with 8% of those without disorder), and 10% had had a utility disconnected (compared with 3%). The more debts people had, the more likely they were to have some form of mental disorder, even after adjustment for income and other sociodemographic variables. People with six or more separate debts had a six-fold increase in mental disorder after adjustment for income (OR 6.0, 95% CI 3.5-10.3). CONCLUSIONS Both low income and debt are associated with mental illness, but the effect of income appears to be mediated largely by debt.

Material standard of living, social class, and the prevalence of the common mental disorders in Great Britain.

STUDY OBJECTIVE: To test the hypothesis that poor material standard of living is independently associated with the prevalence of the common mental disorders after adjusting for occupational social class, and to estimate the population impact of poor material standard of living on the prevalence of these disorders. DESIGN: Cross sectional survey. Prevalence of the common mental disorders was assessed using the General Health Questionnaire, a self administered measure of psychiatric morbidity. PARTICIPANTS: 9064 adults aged 16-75 living in private households in England, Wales, and Scotland. MAIN RESULTS: The common mental disorders were significantly associated with poor material standard of living, including low household income (OR 1.24, 95% CI 1.00, 1.54) and not saving from income (OR 1.29, 95% CI 1.15, 1.45), after adjusting for occupational social class and other potential confounders. An independent association was also found with occupational social class of the head of household among women, but not men, after adjusting for material standard of living. The adjusted population attributable fraction for poor material standard of living (using a five item index) was 24.0%. CONCLUSIONS: Like mortality and physical morbidity, common mental disorders are associated with a poor material standard of living, independent of occupational social class. These findings support the view that recent widening of inequalities in material standards of living in the United Kingdom pose a substantial threat to health.

Family relationships in childhood and common psychiatric disorders in later life: systematic review of prospective studies

BACKGROUND Most evidence for associations between childhood adversity and adult mental illness is retrospective. AIMS To evaluate prospective evidence of associations between poor parent-child relationships and common psychiatric disorders in later life. METHOD Systematic review of studies published between 1970 and 2008 including: (a) more than 100 participants; (b) measures of relationships in the home during childhood; (c) at least 10 years between assessment of exposures; and (d) measures of anxiety, depression, suicide, suicidal ideation or post-traumatic stress disorder (PTSD). Analysis was by narrative synthesis. RESULTS Twenty-three papers were identified reporting data from 16 cohorts. Abusive relationships predicted depression, anxiety and PTSD. Maternal emotional unavailability in early life predicted suicide attempts in adolescence. Results of studies investigating less severe relationship problems were suggestive but not conclusive of causal association, due partly to methodological heterogeneity. CONCLUSIONS Given the prevalence and disabling nature of common psychiatric problems, these studies highlight the need to minimise harm associated with dysfunctional parent-child relationships.

Racial/Ethnic Discrimination and Common Mental Disorders Among Workers: Findings From the EMPIRIC Study of Ethnic Minority Groups in the United Kingdom?

OBJECTIVES We measured perceived discrimination and its association with common mental disorders among workers in the United Kingdom. METHODS We conducted a secondary analysis of a national sample of 6 ethnic groups (n=2054). Discrimination was measured as reports of insults; unfair treatment at work; or job denial stemming from race, religion, or language. The outcome assessed was presence of common mental disorders. RESULTS The risk of mental disorders was highest among ethnic minority individuals reporting unfair treatment (odds ratio [OR]=2.0; 95% confidence interval [CI]=1.2, 3.2) and racial insults (OR=2.3; 95% CI=1.4, 3.6). The overall greatest risks were observed among Black Caribbeans exposed to unfair treatment at work (OR=2.9; 95% CI=1.2, 7.3) and Indian (OR=3.1; 95% CI=1.4, 7.2), Bangladeshi (OR=32.9; 95% CI=2.5, 436.0), and Irish (OR=2.9; 95% CI=1.1, 7.6) individuals reporting insults. CONCLUSIONS Racial/ethnic discrimination shows strong associations with common mental disorders.

Racism, psychosis and common mental disorder among ethnic minority groups in England.

BACKGROUND The aim of this study was to explore the relationship between risk of psychosis, common mental disorder (CMD) and indicators of racism among ethnic minority groups in England and how this relationship may vary by particular ethnic groups. METHOD A multivariate analysis was carried out of quantitative, cross-sectional data from a nationally representative community sample of people aged between 16 and 74 years from the largest ethnic minority groups in England: those of Caribbean, Indian, Pakistani, Bangladeshi and Irish origin. RESULTS Experience of interpersonal racism and perceiving racism in the wider society each have independent effects on the risk of CMD and psychosis, after controlling for the effects of gender, age and socio-economic status. There was some variation in the findings when they were conducted for separate ethnic and gender groups. CONCLUSIONS An understanding of the relationship between racism and mental health may go some way towards explaining the ethnic variations found in both CMD and, particularly, psychosis.