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The present article aims to highlight methodological aspects related to understanding and conceptualising social capital for the purposes of population research as well as describing the key challenges in the harmonisation process of indicators of social capital. The study was conducted in the frame of the Ageing Trajectories of Health: Longitudinal Opportunities and Synergies (ATHLOS) project. After a review of social capital theories developed in social science and a subsequent review of the documentation of 18 international cohorts, decision trees of the harmonisation of social variables were developed. The known-group validity was verified. The results focused on generalised trust, civic engagement and social participation are presented. The summary of the availability of any indicators of these concepts is classified in seven domains (generalised trust, political participation, religious participation, senior-specific participation, participation in sport groups, participation in volunteer/charity group activities, any participation) across surveys. The results of the analysis for known-group validity support the construct validity of the harmonised variables.
Major depressive disorder (MDD) is characterised by a recurrent course and high comorbidity rates. A lifespan perspective may therefore provide important information regarding health outcomes. The aim of the present study is to examine mental disorders that preceded 12-month MDD diagnosis and the impact of these disorders on depression outcomes.
Data came from 29 cross-sectional community epidemiological surveys of adults in 27 countries (n = 80 190). The Composite International Diagnostic Interview (CIDI) was used to assess 12-month MDD and lifetime DSM-IV disorders with onset prior to the respondent's age at interview. Disorders were grouped into depressive distress disorders, non-depressive
distress disorders, fear disorders and externalising disorders. Depression outcomes included 12-month suicidality, days out of role and impairment in role functioning.
Among respondents with 12-month MDD, 94.9% (s.e. = 0.4) had at least one prior disorder (including previous MDD), and 64.6% (s.e. = 0.9) had at least one prior, non-MDD disorder. Previous non-depressive distress, fear and externalising disorders, but not depressive distress disorders, predicted higher impairment (OR = 1.4–1.6) and suicidality (OR = 1.5–2.5), after adjustment for sociodemographic variables. Further adjustment for MDD characteristics weakened, but did not eliminate, these associations. Associations were largely driven by current comorbidities, but both remitted and current externalising disorders predicted suicidality among respondents with 12-month MDD.
These results illustrate the importance of careful psychiatric history taking regarding current anxiety disorders and lifetime externalising disorders in individuals with MDD.
Depressive and anxiety disorders are highly comorbid, which has been theorized to be due to an underlying internalizing vulnerability. We aimed to identify groups of participants with differing vulnerabilities by examining the course of internalizing psychopathology up to age 45.
We used data from 24158 participants (aged 45+) in 23 population-based cross-sectional World Mental Health Surveys. Internalizing disorders were assessed with the Composite International Diagnostic Interview (CIDI). We applied latent class growth analysis (LCGA) and investigated the characteristics of identified classes using logistic or linear regression.
The best-fitting LCGA solution identified eight classes: a healthy class (81.9%), three childhood-onset classes with mild (3.7%), moderate (2.0%), or severe (1.1%) internalizing comorbidity, two puberty-onset classes with mild (4.0%) or moderate (1.4%) comorbidity, and two adult-onset classes with mild comorbidity (2.7% and 3.2%). The childhood-onset severe class had particularly unfavorable sociodemographic outcomes compared to the healthy class, with increased risks of being never or previously married (OR = 2.2 and 2.0, p < 0.001), not being employed (OR = 3.5, p < 0.001), and having a low/low-average income (OR = 2.2, p < 0.001). Moderate or severe (v. mild) comorbidity was associated with 12-month internalizing disorders (OR = 1.9 and 4.8, p < 0.001), disability (B = 1.1–2.3, p < 0.001), and suicidal ideation (OR = 4.2, p < 0.001 for severe comorbidity only). Adult (v. childhood) onset was associated with lower rates of 12-month internalizing disorders (OR = 0.2, p < 0.001).
We identified eight transdiagnostic trajectories of internalizing psychopathology. Unfavorable outcomes were concentrated in the 1% of participants with childhood onset and severe comorbidity. Early identification of this group may offer opportunities for preventive interventions.
Major depressive disorder (MDD) is a leading cause of morbidity and mortality. Shortfalls in treatment quantity and quality are well-established, but the specific gaps in pharmacotherapy and psychotherapy are poorly understood. This paper analyzes the gap in treatment coverage for MDD and identifies critical bottlenecks.
Seventeen surveys were conducted across 15 countries by the World Health Organization-World Mental Health Surveys Initiative. Of 35 012 respondents, 3341 met DSM-IV criteria for 12-month MDD. The following components of effective treatment coverage were analyzed: (a) any mental health service utilization; (b) adequate pharmacotherapy; (c) adequate psychotherapy; and (d) adequate severity-specific combination of both.
MDD prevalence was 4.8% (s.e., 0.2). A total of 41.8% (s.e., 1.1) received any mental health services, 23.2% (s.e., 1.5) of which was deemed effective. This 90% gap in effective treatment is due to lack of utilization (58%) and inadequate quality or adherence (32%). Critical bottlenecks are underutilization of psychotherapy (26 percentage-points reduction in coverage), underutilization of psychopharmacology (13-point reduction), inadequate physician monitoring (13-point reduction), and inadequate drug-type (10-point reduction). High-income countries double low-income countries in any mental health service utilization, adequate pharmacotherapy, adequate psychotherapy, and adequate combination of both. Severe cases are more likely than mild-moderate cases to receive either adequate pharmacotherapy or psychotherapy, but less likely to receive an adequate combination.
Decision-makers need to increase the utilization and quality of pharmacotherapy and psychotherapy. Innovations such as telehealth for training and supervision plus non-specialist or community resources to deliver pharmacotherapy and psychotherapy could address these bottlenecks.
This study aims to generate country-specific norms for two episodic memory tasks and a verbal fluency test among middle-aged and older adults using nationally representative data from nine low-, middle-, and high-income countries.
Data from nine countries in Africa, Asia, Europe, and Latin America were analyzed (n = 42,116; aged 50 years or older). Episodic memory was assessed with the word list memory (three trials of immediate recall) and word list recall (delayed recall). Verbal fluency was measured through the animal naming task. Multiple linear regression models with country-specific adjustments for gender, age, education, and residential area were carried out.
Both age and education showed high influence on test performance (i.e. lower cognitive performance with increasing age and decreasing years of education, respectively), while the effect of sex and residential area on cognitive function was neither homogeneous across countries nor across cognitive tasks.
Our study provided sex-, age-, education-, and residential area-specific regression-based norms that were obtained from one of the largest normative study worldwide on verbal recall and fluency tests to date. Findings derived from this study will be especially useful for clinicians and researchers based at countries where cognitive norms are limited.
Only a few studies have analyzed the effects of physical and psychiatric conditions on the risk of chronic fatigue syndrome (CFS). Therefore, the goal of this exploratory case-control study was to investigate the associations of physical and psychiatric conditions with CFS in almost 19 800 adults from Germany.
This study included patients diagnosed for the first time with CFS in one of 1238 general practices in Germany between 2010 and 2017 (index date). Controls without CFS were matched (1:1) to cases with CFS by sex, age, index year, and practice. Physical and psychiatric conditions diagnosed in the year prior to the index date were included if they were present in at least 3% of patients with CFS. Associations between physical and psychiatric conditions (33 potential independent variables) and CFS (dependent variable) were analyzed in an adjusted conditional logistic regression model, and physical and psychiatric disorders were included in the model using forward stepwise selection.
This study included 9896 cases with CFS and 9896 controls without CFS [65.1% women; mean (standard deviation) age 49.5 (18.3) years]. Seven conditions were associated with CFS in the adjusted regression model. The disorders displaying the strongest relationship with CFS were cancer [odds ratio (OR) = 2.57, 95% confidence interval (CI) = 2.24–2.95], sleep disorders (OR = 1.88, 95% CI = 1.66–2.12) and depression (OR = 1.77, 95% CI = 1.61–1.95).
Cancer, sleep disorders, and depression were strongly and positively associated with CFS. Additional studies are needed to gain a better understanding of the mechanisms underlying these relationships.
There is a substantial proportion of patients who drop out of treatment before they receive minimally adequate care. They tend to have worse health outcomes than those who complete treatment. Our main goal is to describe the frequency and determinants of dropout from treatment for mental disorders in low-, middle-, and high-income countries.
Respondents from 13 low- or middle-income countries (N = 60 224) and 15 in high-income countries (N = 77 303) were screened for mental and substance use disorders. Cross-tabulations were used to examine the distribution of treatment and dropout rates for those who screened positive. The timing of dropout was examined using Kaplan–Meier curves. Predictors of dropout were examined with survival analysis using a logistic link function.
Dropout rates are high, both in high-income (30%) and low/middle-income (45%) countries. Dropout mostly occurs during the first two visits. It is higher in general medical rather than in specialist settings (nearly 60% v. 20% in lower income settings). It is also higher for mild and moderate than for severe presentations. The lack of financial protection for mental health services is associated with overall increased dropout from care.
Extending financial protection and coverage for mental disorders may reduce dropout. Efficiency can be improved by managing the milder clinical presentations at the entry point to the mental health system, providing adequate training, support and specialist supervision for non-specialists, and streamlining referral to psychiatrists for more severe cases.
Psychopathological heterogeneity in manic syndromes may in part reflect underlying latent classes with characteristic outcome patterns. Differential treatment course and outcome after 12 weeks of treatment were examined for three distinct classes of patients with acute mania in bipolar disorder.
Subjects and methods
Three thousand four hundred and twenty-five patients with acute mania were divided into three distinct mania classes: ‘Typical’, ‘Psychotic’ and ‘Dual’ (i.e. comorbid substance use) mania. Persistence of class differences and social outcomes were examined, using multilevel regression analyses and odds ratios.
The three classes showed substantial stability post-baseline in the pattern of associations with class-characteristic variables. Psychotic and Dual mania predicted poorer outcome in terms of psychosis comorbidity and overall bipolar and mania severity, while Dual mania additionally predicted poorer outcome of alcohol and substance abuse. Worse social outcomes were observed for both Dual and Psychotic mania.
The identified distinct classes are stable and associated with differential treatment outcome. Overall, Dual and Psychotic mania show less favourable outcomes compared to Typical mania. These findings additionally give rise to concern on the generalisability of randomized clinical trials RCTs.
Antipsychotic medication maintenance and the factors influencing it were analyzed using data from the SOHO study, a large observational study of the outcomes of antipsychotic treatment for schizophrenia in Europe. A total of 7186 adult patients in the outpatient setting who were initiating or changing their antipsychotic medication and who were prescribed only one antipsychotic after the baseline visit were analyzed. Medication maintenance at 12 months varied with the type of antipsychotic prescribed, being highest with clozapine (79.5%) and olanzapine (77.0%), and lowest with quetiapine (51.4%) and amisulpride (58.2%). Multiple logistic regression analysis demonstrated that the type of antipsychotic prescribed at baseline was the most important predictor of medication maintenance. Alcohol dependency, taking mood stabilizers, compulsory admission or arrest in the previous 6 months, greater clinical severity, and changing antipsychotic medication due to lack of effectiveness at baseline predicted a higher frequency of medication discontinuation in the subsequent 12 months. In contrast, medication maintenance was higher among patients who were treatment naïve at baseline, socially active or who had loss of libido at baseline. The findings from this study should be interpreted conservatively because of its non-randomized observational design.
This article presents the long-term results in terms of antipsychotic medication maintenance and factors influencing it in a representative sample of patients with schizophrenia recruited in the SOHO study within Spain.
The SOHO was a prospective, 3-year observational study of the outcomes of schizophrenia treatment in outpatients who initiated therapy or changed to a new antipsychotic performed in 10 European countries with a focus on olanzapine. The Kaplan–Meier method was used to analyse the time to treatment discontinuation and the Cox proportional hazards model to investigate correlates of discontinuation.
Results and conclusions
In total, 1688 patients were included in the analyses. Medication maintenance at 3 years varied with the antipsychotic prescribed, being highest with clozapine (57.6%, 95% CI 39.2–74.5), followed by olanzapine (48.3%, 95% CI 45.1–51.5); and lowest with quetiapine (19.0%, 95% CI 13.0–26.3). Treatment discontinuation was significantly less frequent with olanzapine than with risperidone (p = 0.015), depot typical (p = 0.001), oral typical antipsychotics (p < 0.001) or quetiapine (p < 0.001); but not than with clozapine (p = 0.309). Longer maintenance was also associated with higher social abilities and better cognitive status at baseline; in contrast, a shorter time to discontinuation was associated with the need for mood stabilisers during follow-up. This study emphasises the different value of antipsychotics in day-to-day clinical practice, as some of them were associated with longer medication maintenance periods than others. This study has some limitations because of possible selection and information biases derived from the non-systematic, non-randomised allocation to treatments and the existence of unobserved covariates that may influence the outcome.
Non-heterosexual individuals are at high risk for a variety of factors associated with the emergence of psychotic experiences (PEs) (e.g. common mental disorders, substance use, and stress). However, there is a scarcity of data on the association between sexual orientation and PEs. Therefore, the aim of this study was to examine the sexual orientation-PE relationship, and to identify potential mediators in this relationship.
This study used nationally representative cross-sectional data from the 2007 Adult Psychiatric Morbidity Survey. Sexual orientation was dichotomized into heterosexual and non-heterosexual. Past 12-month PE was assessed with the Psychosis Screening Questionnaire. Regression and mediation analyses were conducted to analyze the association between sexual orientation and PEs, and to identify potential mediators involved in this relationship.
The final sample consisted of 7275 individuals aged ⩾16 years. The prevalence of non-heterosexual orientation and any PE was 7.1% and 5.5%, respectively. After adjusting for sex, age, and ethnicity, non-heterosexual orientation was positively associated with any PE (odds ratio 1.99, 95% confidence interval 1.34–2.93). The strongest mediators involved in this relationship were borderline personality disorder (BPD) traits (mediated percentage = 33.5%), loneliness (29.1%), and stressful life events (25.4%).
These findings suggest that there is a positive relationship between sexual orientation and PEs in the general population in England, and that underlying mechanisms may involve BPD traits, loneliness, and stressful life events. Future studies with a longitudinal design are warranted to shed more light on how these factors are implicated in the association between sexual orientation and PEs.
To identify, in caregivers of patients with Alzheimer’s disease (AD) dementia, factors associated with subjective (personal, physical, emotional, and social) and objective (informal caregiver time and costs) caregiver burden.
Prospective longitudinal European observational study: post-hoc analysis.
Community-dwelling patients in France and Germany aged ≥ 55 years (n = 969) with probable AD and their informal caregivers.
Mini-Mental State Examination (MMSE), Alzheimer’s Disease Cooperative Study—Activities of Daily Living (ADCS-ADL), 12-item Neuropsychiatric Inventory (NPI-12), Zarit Burden Interview (ZBI), informal caregiver basic and instrumental ADL hours (Resource Utilization in Dementia instrument), and informal caregiver costs. Mixed-effect models of repeated measures (MMRM) were run, including baseline and time-dependent covariates (change from baseline [CFB] to 18 months in MMSE, ADCS-ADL, and NPI-12 scores) associated with CFB in ZBI score/informal caregiver time over 36 months (analyzed using linear regression models) and informal caregiver costs over 36 months (analyzed using generalized linear models).
Greater decline in patient function (ADCS-ADL) over 18 months was associated with increased subjective caregiver burden (ZBI), hours, and costs over 36 months. Increased behavioral problems (NPI-12) over 18 months also negatively impacted ZBI. Cognitive decline (MMSE) over 18 months did not affect change in caregiver burden.
Long-term informal caregiver burden was driven by worsening functional abilities and behavioral symptoms but not cognitive decline, over 18 months in community-dwelling patients with AD dementia. Identifying the drivers of caregiver burden could highlight areas in which interventions may benefit both caregivers and patients.
Data on the relationship between intelligence quotient (IQ) and violence perpetration are scarce and nationally representative data from the UK adult population is lacking. Therefore, our goal was to examine the relationship between IQ and violence perpetration using nationally representative community-based data from the UK.
We analyzed cross-sectional data from the 2007 Adult Psychiatric Morbidity Survey. IQ was estimated using the National Adult Reading Test (NART). Violence perpetration referred to being in a physical fight or having deliberately hit anyone in the past 5 years. We conducted logistic regression analysis to assess the association between IQ (exposure variable) and violence perpetration (outcome variable).
There were 6872 participants aged ⩾16 years included in this study. The prevalence of violence perpetration decreased linearly with increasing IQ [16.3% (IQ 70–79) v. 2.9% (IQ 120–129)]. After adjusting for demographic and behavioral factors, childhood adversity, and psychiatric morbidity, compared with those with IQ 120–129, IQ scores of 110–119, 100–109, 90–99, 80–89, and 70–79 were associated with 1.07 [95% confidence interval (CI) 0.63–1.84], 1.90 (95% CI 1.12–3.22), 1.80 (95% CI 1.05–3.13), 2.36 (95% CI 1.32–4.22), and 2.25 (95% CI 1.26–4.01) times higher odds for violence perpetration, respectively.
Lower IQ was associated with violence perpetration in the UK general population. Further studies are warranted to assess how low IQ can lead to violence perpetration, and whether interventions are possible for this high-risk group.
It is well known that negative ageing perceptions have various detrimental effects on indicators of successful ageing, but less is known about the role of social support networks and loneliness in ageing perceptions. The objective of this study was therefore to assess the association of social networks, relationship quality and loneliness with negative ageing perceptions in late life. Cross-sectional data on 6,912 adults aged ⩾50 years from the first wave of the Irish Longitudinal Study on Ageing (TILDA) were analysed. Ageing perceptions were assessed with the Brief Ageing Perceptions Questionnaire. Information on social support networks, loneliness and socio-demographics were obtained using standard questions. Depressive symptoms were assessed with the Center for Epidemiologic Studies Depression scale. Multivariable linear regression was conducted to assess the associations. Social isolation, poor relationship quality (with spouse, children, other family members or friends) and loneliness were all significantly associated with negative ageing perceptions even after adjustment for all potential confounders including depressive symptoms. Our study indicates that targeting integration into social support networks and improving relationship quality may potentially reduce the extent to which older individuals adopt negative ageing perceptions. Future studies with prospective design are warranted to understand the temporal direction and causal association of social support networks and loneliness with negative ageing perceptions.
Traumatic events are associated with increased risk of psychotic experiences, but it is unclear whether this association is explained by mental disorders prior to psychotic experience onset.
To investigate the associations between traumatic events and subsequent psychotic experience onset after adjusting for post-traumatic stress disorder and other mental disorders.
We assessed 29 traumatic event types and psychotic experiences from the World Mental Health surveys and examined the associations of traumatic events with subsequent psychotic experience onset with and without adjustments for mental disorders.
Respondents with any traumatic events had three times the odds of other respondents of subsequently developing psychotic experiences (OR=3.1, 95% CI 2.7–3.7), with variability in strength of association across traumatic event types. These associations persisted after adjustment for mental disorders.
Exposure to traumatic events predicts subsequent onset of psychotic experiences even after adjusting for comorbid mental disorders.
Major depressive disorder (MDD) is a leading cause of disability worldwide.
To examine the: (a) 12-month prevalence of DSM-IV MDD; (b) proportion aware that they have a problem needing treatment and who want care; (c) proportion of the latter receiving treatment; and (d) proportion of such treatment meeting minimal standards.
Representative community household surveys from 21 countries as part of the World Health Organization World Mental Health Surveys.
Of 51 547 respondents, 4.6% met 12-month criteria for DSM-IV MDD and of these 56.7% reported needing treatment. Among those who recognised their need for treatment, most (71.1%) made at least one visit to a service provider. Among those who received treatment, only 41.0% received treatment that met minimal standards. This resulted in only 16.5% of all individuals with 12-month MDD receiving minimally adequate treatment.
Only a minority of participants with MDD received minimally adequate treatment: 1 in 5 people in high-income and 1 in 27 in low-/lower-middle-income countries. Scaling up care for MDD requires fundamental transformations in community education and outreach, supply of treatment and quality of services.
We assessed specificity protein 1 (SP1) and 4 (SP4) transcription factor levels in peripheral blood mononuclear cells and conducted a voxel-based morphometry analysis on brain structural magnetic resonance images from 11 patients with first-episode psychosis and 14 healthy controls. We found lower SP1 and SP4 levels in patients, which correlated positively with right hippocampal volume. These results extend previous evidence showing that such transcription factors may constitute a molecular pathway to the development of psychosis.
We aimed to obtain a better understanding of how different aspects of patient functioning affect key cost and caregiver outcomes in Alzheimer's disease (AD).
Baseline data from a prospective observational study of community-living AD patients (GERAS) were used. Functioning was assessed using the Alzheimer's Disease Cooperative Study – Activities of Daily Living Scale. Generalized linear models were conducted to analyze the relationship between scores for total activities of daily living (ADL), basic ADL (BADL), instrumental ADL (IADL), ADL subdomains (confirmed through factor analysis) and individual ADL questions, and total societal costs, patient healthcare and social care costs, total and supervision caregiver time, and caregiver burden.
Four distinct ADL subdomains were confirmed: basic activities, domestic/household activities, communication, and outside activities. Higher total societal costs were associated with impairments in all aspects of ADL, including all subdomains; patient costs were associated with total ADL and BADL, and basic activities subdomain scores. Both total and supervision caregiver hours were associated with total ADL and IADL scores, and domestic/household and outside activities subdomain scores (greater hours associated with greater functional impairments). There was no association between caregiver burden and BADL or basic activities subdomain scores. The relationship between total ADL, IADL, and the outside activities subdomain and outcomes differed between patients with mild and moderate-to-severe AD.
Identification of ADL subdomains may lead to a better understanding of the association between patient function and costs and caregiver outcomes at different stages of AD, in particular the outside activities subdomain within mild AD.