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The cross-national structure of mental disorders: results from the World Mental Health Surveys

  • Peter de Jonge (a1) (a2), Klaas J. Wardenaar (a2), Carmen C.W. Lim (a3) (a4) (a5), Sergio Aguilar-Gaxiola (a6), Jordi Alonso (a7) (a8) (a9), Laura Helena Andrade (a10), Brendan Bunting (a11), Somnath Chatterji (a12), Marius Ciutan (a13), Oye Gureje (a14), Elie G. Karam (a15) (a16), Sing Lee (a17), Maria Elena Medina-Mora (a18), Jacek Moskalewicz (a19), Fernando Navarro-Mateu (a20), Beth-Ellen Pennell (a21), Marina Piazza (a22) (a23), José Posada-Villa (a24), Yolanda Torres (a25), Ronald C. Kessler (a26) and Kate Scott (a3)...

Abstract

Background

The patterns of comorbidity among mental disorders have led researchers to model the underlying structure of psychopathology. While studies have suggested a structure including internalizing and externalizing disorders, less is known with regard to the cross-national stability of this model. Moreover, little data are available on the placement of eating disorders, bipolar disorder and psychotic experiences (PEs) in this structure.

Methods

We evaluated the structure of mental disorders with data from the World Health Organization Composite International Diagnostic Interview, including 15 lifetime mental disorders and six PEs. Respondents (n = 5478–15 499) were included from 10 high-, middle- and lower middle-income countries across the world aged 18 years or older. Confirmatory factor analyses (CFAs) were used to evaluate and compare the fit of different factor structures to the lifetime disorder data. Measurement invariance was evaluated with multigroup CFA (MG-CFA).

Results

A second-order model with internalizing and externalizing factors and fear and distress subfactors best described the structure of common mental disorders. MG-CFA showed that this model was stable across countries. Of the uncommon disorders, bipolar disorder and eating disorder were best grouped with the internalizing factor, and PEs with a separate factor.

Conclusions

These results indicate that cross-national patterns of lifetime common mental-disorder comorbidity can be explained with a second-order underlying structure that is stable across countries and can be extended to also cover less common mental disorders.

Copyright

Corresponding author

Author for correspondence: Peter de Jonge, E-mail: peter.de.jonge@rug.nl

Footnotes

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The WHO World Mental Health Survey collaborators are Sergio Aguilar-Gaxiola, MD, PhD, Ali Al-Hamzawi, MD, Mohammed Salih Al-Kaisy, MD, Jordi Alonso, MD, PhD, Laura Helena Andrade, MD, PhD, Corina Benjet, PhD, Guilherme Borges,ScD, Evelyn J. Bromet, PhD, Ronny Bruffaerts, PhD, Brendan Bunting, PhD, Jose Miguel Caldas de Almeida, MD, PhD, Graça Cardoso, MD, PhD, Somnath Chatterji, MD, Alfredo H. Cia, MD, Louisa Degenhardt, PhD, Koen Demyttenaere, MD, PhD, John Fayyad, MD, Silvia Florescu, MD, PhD, Giovanni de Girolamo, MD, Oye Gureje, MD, DSc, FRCPsych, Josep Maria Haro, MD, PhD, Yanling He, MD, Hristo Hinkov, MD, PhD, Chi-yi Hu, MD, PhD, Yueqin Huang, MD, MPH, PhD, Peter de Jonge, PhD, Aimee Nasser Karam, PhD, Elie G. Karam, MD, Norito Kawakami, MD, DMSc, Ronald C. Kessler, PhD, Andrzej Kiejna, MD, PhD, Viviane Kovess-Masfety, MD, PhD, Sing Lee, MB, BS, Jean-Pierre Lepine, MD, Daphna Levinson, PhD, John McGrath, MD, PhD, Maria Elena Medina-Mora, PhD, Jacek Moskalewicz, PhD, Fernando Navarro-Mateu, MD, PhD, Beth-Ellen Pennell, MA, Marina Piazza, MPH, ScD, Jose Posada-Villa, MD, Kate M. Scott, PhD, Tim Slade, PhD, Juan Carlos Stagnaro, MD, PhD, Dan J. Stein, FRCPC, PhD, Margreet ten Have, PhD, Yolanda Torres, MPH, Dra.HC, Maria Carmen Viana, MD, PhD, Harvey Whiteford, MBBS, PhD, David R. Williams, MPH, PhD, Bogdan Wojtyniak, ScD.

Footnotes

References

Hide All
Asparouhov, T (2005) Sampling weights in latent variable modeling. Structural Equation Modeling 12(3), 411434.
Bijl, RV, Ravelli, A and van Zessen, G (1998) Prevalence of psychiatric disorder in the general population: results of The Netherlands mental health survey and incidence study (NEMESIS). Social Psychiatry and Psychiatric Epidemiology 33(12), 587595.
Carragher, N, Krueger, RF, Eaton, NR and Slade, T (2015) Disorders without borders: current and future directions in the meta-structure of mental disorders. Social Psychiatry and Psychiatric Epidemiology 50(3), 339350.
Caspi, A, Houts, RM, Belsky, DW, Goldman-Mellor, SJ, Harrington, H, Israel, S et al. (2017) The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clinical Psychological Science 2(2), 119137.
Cheung, GW and Rensvold, RB (2002) Evaluating goodness-of-Fit indexes for testing measurement invariance. Structural Equation Modeling: A Multidisciplinary Journal 9, 233255.
Eaton, NR, Keyes, KM, Krueger, RF, Balsis, S, Skodol, AE, Markon, KE et al. (2012) An invariant dimensional liability model of gender differences in mental disorder prevalence: evidence from a national sample. Journal of Abnormal Psychology 121(1), 282288.
Eaton, NR, Keyes, KM, Krueger, RF, Noordhof, A, Skodol, AE, Markon, KE et al. (2013 b) Ethnicity and psychiatric comorbidity in a national sample: evidence for latent comorbidity factor invariance and connections with disorder prevalence. Social Psychiatry and Psychiatric Epidemiology 48(5), 701710.
Eaton, NR, Krueger, RF, Markon, KE, Keyes, KM, Skodol, AE, Wall, M et al. (2013 a) The structure and predictive validity of the internalizing disorders. Journal of Abnormal Psychology 122(1), 8692.
Eaton, NR, Krueger, RF and Oltmanns, TF (2011) Aging and the structure and long-term stability of the internalizing spectrum of personality and psychopathology. Psychology and Aging 26(4), 987993.
Eaton, NR, Rodriguez-Seijas, C, Carragher, N and Krueger, RF (2015) Transdiagnostic factors of psychopathology and substance use disorders: a review. Social Psychiatry and Psychiatric Epidemiology 50(2), 171182.
Eid, M, Geiser, C, Koch, T and Heene, M (in press) Anomalous results in g-factor models: explanations and alternatives. Psychological Methods 22(3), 541562
Farmer, RF, Seeley, JR, Kosty, DB and Lewinson, PM (2009) Refinements in the hierarchical structure of externalizing psychiatric disorders: patterns of lifetime liability from mid-adolescence through early adulthood. Journal of Abnormal Psychology 118(4), 699710.
Forbush, KT, South, SC, Krueger, RF, Iacono, WG, Clark, LA, Keel, PK et al. (2010) Locating eating pathology within an empirical diagnostic taxonomy: evidence from a community-based sample. Journal of Abnormal Psychology 119(2), 282292.
Forbush, KT and Watson, D (2013) The structure of common and uncommon mental disorders. Psychological Medicine 43(1), 97108.
Fusar-Poli, P, Bonoldi, I, Yung, AR, Borgwardt, S, Kempton, MJ, Valmaggia, L et al. (2012) Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives of General Psychiatry 69(3), 220.
Hasin, D and Kilcoyne, B (2012) Comorbidity of psychiatric and substance use disorders in the United States: current issues and findings from the NESARC. Current Opinions in Psychiatry 25(3), 165171.
Heeringa, SG, Wells, EJ and Hubbard, F (2008) Sample designs and sampling procedures. In: Kessler, RC, Üstun, TB, editors. The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders. New York, NY: Cambridge University Press, pp. 14–32.
Hicks, BM, Blonigen, DM, Kramer, MD, Krueger, RF, Patrick, CJ, Iacono, WG et al. (2007) Gender differences and developmental change in externalizing disorders from late adolescence to early adulthood: a longitudinal twin study. Journal of Abnormal Psychology 116(3), 433447.
Hu, L and Bentler, PM (1999) Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Structural Equation Modeling 6, 155.
Kendler, KS, Aggen, SH, Knudsen, GP, Røysamb, E, Neale, MC and Reichborn-Kjennerud, T (2011) The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV axis I and all axis II disorders. American Journal of Psychiatry 168(1), 2939.
Kessler, RC, Cox, BJ, Green, JG, Ormel, J, McLaughlin, KA, Merikangas, KR et al. (2011 a). The effects of latent variables in the development of comorbidity among common mental disorders. Depression and Anxiety 28(1), 2939.
Kessler, RC, McGonagle, KA, Zhao, S, Nelson, CB, Hughes, M, Eshleman, S et al. (1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry 51(1), 819.
Kessler, RC, Ormel, J, Petukhova, M, McLaughlin, KA, Green, JG, Russo, LJ et al. (2011 b) Development of lifetime comorbidity I the world health organization world mental health surveys. Archives of General Psychiatry 68(1), 90100.
Kessler, RC, Petukhova, M and Zaslavsky, AM (2011 c) The role of latent internalizing and externalizing predispositions in accounting for the development of comorbidity among common mental disorders. Current Opinions in Psychiatry 24(4), 307312.
Keyes, KM, Eaton, NR, Krueger, RF, Skodol, AE, Wall, MM, Grant, B et al. (2013) Thought disorder in the meta-structure of psychopathology. Psychological Medicine 43(8), 16731683.
Koch, T, Holtmann, J, Bohn, J and Eid, M (in press) Explaining general and specific factors in longitudinal, multimethod, and bifactor models: some caveats and recommendations. Psychological Methods. Advance online publication July 24. http://dx.doi.org/10.1037/met0000146
Kotov, R, Chang, SW, Fochtmann, LJ, Mojtabai, R, Carlson, GA, Sedler, MJ et al. (2011 a) Schizophrenia in the internalizing-externalizing framework: a third dimension? Schizophrenia Bulletin 37(6), 11681178.
Kotov, R, Krueger, RF, Watson, D, Achenbach, TM, Althoff, RR, Bagby, RM et al. (2017) The hierarchical taxonomy of psychopathology (HiTOP): a dimensional alternative to traditional nosologies. Journal of Abnormal Psychology 126(4), 454477.
Kotov, R, Perlman, G, Gámez, W and Watson, D (2015) The structure and short-term stability of the emotional disorders: a dimensional approach. Psychological Medicine 45(8), 16871698.
Kotov, R, Ruggero, CJ, Krueger, RF, Watson, D, Yuan, Q and Zimmerman, M (2011 b) New dimensions in the quantitative classification of mental illness. Archives of General Psychiatry 68(10), 10031011.
Kramer, MD, Krueger, RF and Hicks, BM (2007) The role of internalizing and externalizing liability factors in accounting for gender differences in the prevalence of common psychopathological syndromes. Psychological Medicine 38(1), 5161.
Krueger, RF (1999) The structure of common mental disorders. Archives of General Psychiatry 56(10), 921926.
Krueger, RF, Caspi, A, Moffitt, TE and Silva, PA (1998) The structure and stability of common mental disorders (DSM-III-R): a longitudinal-epidemiological study. Journal of Abnormal Psychology 107(2), 216227.
Krueger, RF, Chentsova-Dutton, YE, Markon, KE, Goldberg, D and Ormel, J (2003) A cross-cultural study of the structure of comorbidity among common psychopathological syndromes in the general health care setting. Journal of Abnormal Psychology 112(3), 437447.
Krueger, RF and Markon, KE (2006) Reinterpreting comorbidity: a model-based approach to understanding and classifying psychopathology. Annual Review of Clinical Psychology 2, 111133.
Krueger, RF, Markon, KE, Patrick, CJ, Benning, SD and Kramer, MD (2007) Linking antisocial behavior, substance use, and personality: an integrative quantitative model of the adult externalizing spectrum. Journal of Abnormal Psychology 116(4), 645666.
Krueger, RF, Markon, KE, Patrick, CJ and Iacono, WG (2005) Externalizing psychopathology in adulthood: a dimensional-spectrum conceptualization and its implications for DSM-V. Journal of Abnormal Psychology 114(4), 537550.
Lahey, BB, Krueger, RF, Rathouz, PJ, Waldman, ID and Zald, DH (2017) A hierarchical causal taxonomy of psychopathology across the life span. Psychological Bulletin 143(2), 142186.
Markon, KE (2010) Modeling psychopathology structure: a symptom-level analysis of Axis I and II disorders. Psychological Medicine 40(2), 273288.
Markon, KE and Krueger, RF (2005) Categorical and continuous models of liability to externalizing disorders: a direct comparison in NESARC. Archives of General Psychiatry 62(12), 13521359.
Miller, MW, Fogler, JM, Wolf, EJ, Kaloupek, DG and Keane, TM (2008) The internalizing and externalizing structure of psychiatric comorbidity in combat veterans. Journal of Traumatic Stress 21(1), 5865.
Mineka, S, Watson, D and Clark, LA (1998) Comorbidity of anxiety and unipolar mood disorders. Annual Review of Psychology 49, 377412.
Muthén, LK and Muthén, BO (1998–2012) Mplus User's Guide, 7th edn., Los Angeles, CA: Muthén & Muthén.
Pennell, B, Mneimneh, Z, Bowers, A, Chardoul, S, Wells, J, Viana, M et al. (2008) Implementation of the world mental health surveys. In Kessler, R and Üstün, T (eds). The WHO World Mental Health Surveys: Global Perspectives on the Epidemiology of Mental Disorders, pp. 3357. Cambridge University Press: Cambridge, UK.
Rössler, W, Hengartner, MP, Ajdacic-Gross, V, Haker, H and Angst, J (2011) Sub-clinical psychosis symptoms in young adults are risk factors for subsequent common mental disorders. Schizophrenia Research 131(1), 1823.
Røysamb, E, Kendler, KS, Tambs, K, Orstavik, RE, Neale, MC, Aggen, SH et al. (2010) The joint structure of DSM-IV axis I and axis II disorders. Journal of Abnormal Psychology 120(1), 198209.
Sher, KJ and Trull, TJ (1996) Methodological issues in psychopathology research. Annual Review of Psychology 47, 371400.
Slade, T and Watson, D (2006) The structure of common DSM-IV and ICD-10 mental disorders in the Australian general population. Psychological Medicine 36(11), 15931600.
South, SC and Jarnecke, AM (2017) Structural equation modeling of personality disorders and pathological personality traits. Personality Disorders: Theory, Research, and Treatment 8(2), 113129.
Teesson, M, Slade, T and Mills, K (2009) Comorbidity in Australia: findings of the 2007 national survey of mental health and wellbeing. Australian and New Zealand Journal of Psychiatry 43(7), 606614.
Vollebergh, WA, Iedema, J, Bijl, RV, de Graaf, R, Smit, F and Ormel, J (2001) The structure and stability of common mental disorders: the NEMESIS study. Archives of General Psychiatry 58(6), 597603.
Vrieze, SI, Perlman, G, Krueger, RF and Iacono, WG (2012) Is the continuity of externalizing psychopathology the same in adolescents and middle-aged adults? A test of the externalizing spectrum's developmental coherence. Journal of Abnormal Child Psychology 40(3), 459470.
The World Bank. (2009) Data and Statistics. Accessed May 12. http://go.worldbank.org/D7SN0B8YU0
Watson, D (2005) Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. Journal of Abnormal Psychology 114(4), 522536.
Werbeloff, N, Drukker, M, Dohrenwend, BP, Levav, I, Yoffe, R, van Os, J et al. (2012) Self-reported attenuated psychotic symptoms as forerunners of severe mental disorders later in life. Archives of General Psychiatry 69(5), 467475.
Widiger, TA and Clark, LA (2000) Toward DSM-V and the classification of psychopathology. Psychological Bulletin 126(6), 946963.
Wright, AG, Krueger, RF, Hobbs, MJ, Markon, KE, Eaton, NR and Slade, T (2013) The structure of psychopathology: toward an expanded quantitative empirical model. Journal of Abnormal Psychology 122(1), 281294.

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