Tom Fryers

Social inequalities and the common mental disorders - A systematic review of the evidence

Abstract.Background: Of two large-scale government-commissioned studies of common mental disorders in the UK, one found occupational social class to be the strongest marker of risk while the other showed no clear relationship. This study reviews the published evidence on the links between conventional markers of social position and the common mental disorders in developed countries. Methods: Inclusion criteria covered general population based studies with broad social class variation; samples of 3,000 or more adults of working age; identification of mental illness by validated instruments; social position identified by explicit standard markers; fieldwork undertaken since 1980; published output on key areas of interest. Incompatible study methods and concepts made statistical pooling of results invalid. Results: Of nine studies, eight provide evidence of an association between one or more markers of less privileged social position and higher prevalence of common mental disorders. For some individual indicators in particular studies, no clear trend was evident, but no study showed a contrary trend for any indicator. The more consistent associations were with unemployment, less education and low income or material standard of living. Occupational social class was the least consistent marker. Conclusions: Common mental disorders are significantly more frequent in socially disadvantaged populations. More precise indicators of education, employment and material circumstances are better markers of increased rates than occupational social class.

Size and burden of depressive disorders in Europe

We review epidemiological studies of depression in Europe. Community surveys are essential. Methodological differences in survey methods, instruments, nuances in language and translation limit comparability, but consistent findings are emerging. Western European countries show 1 year prevalence of major depression of around 5%, with two-fold variation, probably methodological, and higher prevalences in women, the middle-aged, less privileged groups, and those experiencing social adversity. There is high comorbidity with other psychiatric and physical disorders. Depression is a major cause of disability. Incidence has been less studied and lifetime incidence is not clear, with longitudinal studies required. There is pressing need for prevalence studies from Eastern Europe. The considerable differences in health care systems among European countries may impact on proportions of depressives receiving treatment and its adequacy, particularly in the key area of primary care, and require further study. There is a need for public health programmes aimed at improving treatment, reducing rates and consequences of depressive disorders.

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.

Childhood determinants of adult psychiatric disorder.

The aim of this project was to assess the current evidence from longitudinal studies for childhood determinants of adult mental illness. Because of the variable and often prolonged period between factors in childhood and the identification of mental illness in adults, prospective studies, particularly birth cohorts, offer the best chance of demonstrating associations in individuals. A review was undertaken in 2006 of the published literature from longitudinal studies, together with some large-scale retrospective studies and relevant reviews which provided supplementary evidence. The main focus was upon potentially ameliorable characteristics, experiences or situations of childhood; however, other factors, not determinants but pre-cursors, associated with later mental illness could not be left out. Seven major electronic data-bases of published research were interrogated with a range of key-words and the results supplemented from personal searches, enquiries and reference trails. In excess of 1,500 abstracts were read to select 250 papers for full review. The material was assessed in relation to ten factors: Psychological disturbance; Genetic Influences; Neurological Deviance; Neuroticism; Behaviour; School Performance; Adversity; Child Abuse or Neglect; Parenting and parent-child relationships; Disrupted and Disfunctional Families. In 2011 the search was repeated for the period 2006 to mid-2011, using the same search terms and supplemented in the same manner. Over 1,800 abstracts emerged and almost 200 papers selected for more detailed review. These were then integrated into the original text with modifications where necessary. The whole text was then revised and edited in January / February 2012. There is continuing evidence for the association with later mental ill-health for each of these ten factors, but with different degrees of conviction. The evidence for each is discussed in detail and weighed both separately and in relation to others. These are then summarised, and the research implications are considered. Finally, the implications for prevention are discussed together with the practical potential for preventive and health-promoting programmes.

Prevalence of psychiatric disorder in Europe: the potential and reality of meta–analysis

Abstract.Background:Within the European Mental Health Status Project, over 200 psychiatric surveys concerning members of the European Union (plus Norway) were examined for their potential for meta-analysis with regard to prevalence of psychiatric disorders and basic demographic and social variables. The diversity of samples, methods, analysis and presentation was such that only data derived from GHQ-12 and CIDI studies could be used, and those relating to sex differentials only.Methods:The statistical program ‘Stata’ was used to compute odds ratios (with confidence intervals) for individual studies, and to produce fixed and random effects estimates of the pooled odds ratio for all studies together, and a measure of heterogeneity. Forrest Plots were also produced.Results:Analysis of GHQ-12 data with a cut-off point of 4, indicating a current or recent ‘probable mental health problem’, showed, as expected, that women had higher prevalence rates than men. However, there was a relatively high heterogeneity score, suggesting that these studies may not be measuring the same thing. Analysis of CIDI results showed homogeneity for major depressive disorder within the last 12 months, with the risk for men about half of that for women.Conclusions:In terms of advancing epidemiological knowledge, the results are trivial, at most confirming what is already well known. However, the study shows the potential for pooled analysis, with much greater power in epidemiological investigation if consistency could be achieved in research. Various ways in which this might be done are discussed. It also shows the value of personal knowledge and personal networks in fields which are not well handled by electronic literature databases.

Psychosocial wellbeing and psychiatric care in the European Communities: analysis of macro indicators.

Abstract.Background:This paper reports the findings of an analytical comparison of several macro indicators collected routinely from institutional sources in Europe.Methods:We carried out a review of macro indicators capable of providing a synthetic description of mental health status and the availability of psychiatric care in European countries. These were collected routinely from sources such as WHO, OECD, EUROSTAT, and IMS. The evaluation of temporal trends in each nation permits subsequent comparisons between countries.Results:In all European countries, a decreased trend of suicides was observed in the period 1980–2000, with the exception of Ireland and (partially) of Spain. In Ireland, the increased trend was particularly strong, with a high risk in young and adult males. Portugal and Greece had respectively the highest and the lowest rates of undetermined causes of death. Most countries that were high consumers of alcohol in the initial period of observation had a rate above the national mean until 1980, after which consumption decreased. Most nations that were low consumers in 1960 had rates below the mean until 1980,when the rates progressively increased. However, a general decrease of alcohol-related deaths was apparent in all countries. Mortality associated with mental disorder increased, most clearly during the mid 1980s. The number of psychiatrists per 100,000 inhabitants ranged from 3.6 in Spain to 17.5 in Finland; of child psychiatrists, from 0.9 in Germany to 5.1 in Portugal. Psychiatric beds ranged from 0.4 per 1,000 inhabitants in Italy and Spain to 1.3 in Ireland. Nine countries showed a trend towards a reduction in psychiatric beds, whilst in a further five countries no change was observed. Rates of long-stay patients varied from 9.5 in the UK to 84 in Belgium, with a generally decreasing trend. The use of outpatient facilities differed markedly between countries, although there was a general increase over time. Official data were scarce in relation to the sale of psychotropic drugs. IMS data indicated increasing consumption in all European countries for antidepressant and antipsychotic medication.Conclusions:The official data resources available for European countries seem to indicate some discrepancies, probably relating to methods of recording. Better co-ordination in the collection of data about mental health status in the European Union and an improvement of the quality in available services is needed.

Work, identity and health

Arising from facing the challenges of retirement from work, a reflective article on the nature, purpose and role of work in modern western societies, and some of the psycho-social problems faced by those working, not working or unable to work, and some of the issues arising for society as a whole.

Social position and the common mental disorders with disability: estimates from the National Psychiatric Survey of Great Britain.

Abstract.Background: Published studies linking the common mental disorders with social disadvantage lack basic comparability. This project aimed to estimate effect sizes and independence of social position markers as risk factors for common mental disorders. Disorders with disability were examined to identify groups with high clinical and policy priority. Methods: Data from the 1993 household survey of psychiatric morbidity in Great Britain were analysed using logistic regression models, using traditional and more specific markers of social position. Results: Of those with a common mental disorder, 22 % reported difficulty doing at least one activity of daily living, linked to their mental symptoms. In comprehensive statistical analyses, having two or more physical illnesses was associated with an odds ratio of 6.42 (95 % CI 4.34–9.51) for common mental disorder with disability, while odds ratios of 3 or more were present for being economically inactive or having had two or more recent adverse life events. Occupational social class was not an independent marker of raised rates of disorder. Similar patterns of result were present for common mental disorders irrespective of disability, although odds ratios were smaller. Conclusions: Several specific markers of less privileged status are independently associated with raised rates of common mental disorders, with or without disability. There may be scope to target specific high-risk groups within comprehensive programmes to reduce mental health inequalities.

Epidemiological Thinking in Mental Retardation: Issues in Taxonomy and Population Frequency

Publisher Summary Epidemiology is the study of the distribution and determinants of health, disease, and disorder in human populations. It relies upon statistical methods. However, setting the objectives of study, deciding the methodology, interpreting the results, and drawing meaningful conclusions require knowledge of human, clinical, and pathological sciences concerned with individual experience and behavior and of demographic, cultural, organizational, economic, and environmental sciences. Epidemiological methods enable measuring and comparing the dimensions and characteristics of health-related phenomena in human communities. It also helps validate taxonomies, discriminate diagnostic or other categories, search for causes, and evaluate treatments and services. All require careful design, thorough implementation, accurate data, expert analysis, and creative interpretation. Above all, epidemiological research is dependent upon agreed, standardized categories, precise and consistent definitions, and accurate, reproducible measurements.

Access to medium secure psychiatric care in England and Wales. 3: The clinical needs of assessed patients

The needs of patients in medium secure psychiatric units are well documented, but little is known of the range of clinical and security needs of those assessed but put on waiting lists or not admitted. The aim of the study was to quantify needs for treatment and care of a nationally representative sample of patients assessed for admission to medium secure care. 34 units containing 98% of medium secure beds in England and Wales in 1999 participated. All assessments were logged. A random sub-sample was selected for detailed interviews with assessing clinicians. Higher sampling fractions were used in smaller units. Unit monthly waiting lists averaged 5 patients for each available bed. Common reasons for referral were aggressive behaviour, deteriorating mental state, need for diagnostic assessment, and non-compliance with treatment. 42 per cent of assessed patients needed medium secure care, one-third on a long-term basis. The assessing units refused some patients who needed medium secure care, and accepted some psychotic patients who did not require security. 4 weeks after assessment, 65% of waiting list patients had still not been admitted. The conclusion was that a substantial shortage in medium secure beds existed, especially for long-term placements. A third of those needing medium secure care required it on a long-term basis, but assessing units did not admit many of these patients. Further work is needed on the low levels of assessed need for interventions relating to substance abuse.