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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.
Previous work has identified associations between psychotic experiences (PEs) and general medical conditions (GMCs), but their temporal direction remains unclear as does the extent to which they are independent of comorbid mental disorders.
In total, 28 002 adults in 16 countries from the WHO World Mental Health (WMH) Surveys were assessed for PEs, GMCs and 21 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) mental disorders. Discrete-time survival analyses were used to estimate the associations between PEs and GMCs with various adjustments.
After adjustment for comorbid mental disorders, temporally prior PEs were significantly associated with subsequent onset of 8/12 GMCs (arthritis, back or neck pain, frequent or severe headache, other chronic pain, heart disease, high blood pressure, diabetes and peptic ulcer) with odds ratios (ORs) ranging from 1.3 [95% confidence interval (CI) 1.1–1.5] to 1.9 (95% CI 1.4–2.4). In contrast, only three GMCs (frequent or severe headache, other chronic pain and asthma) were significantly associated with subsequent onset of PEs after adjustment for comorbid GMCs and mental disorders, with ORs ranging from 1.5 (95% CI 1.2–1.9) to 1.7 (95% CI 1.2–2.4).
PEs were associated with the subsequent onset of a wide range of GMCs, independent of comorbid mental disorders. There were also associations between some medical conditions (particularly those involving chronic pain) and subsequent PEs. Although these findings will need to be confirmed in prospective studies, clinicians should be aware that psychotic symptoms may be risk markers for a wide range of adverse health outcomes. Whether PEs are causal risk factors will require further research.
The humanitarian tragedy of large-scale armed conflict continues to be part of human experience leaving a tremendous demographic, social, economic, and health impact on societies. Investigating the impact of such conflicts, assessing the community’s needs, and guiding and evaluating interventions require collecting reliable information on the affected population. Survey research provides tools for collecting such information, but the obstacles to successful survey data collection in these circumstances are substantial. We argue that conducting surveys in armed conflict settings is difficult, but can be done and done well by following a few design and implementation principles. We begin this chapter by summarizing these principles and discuss them further in the remaining sections of the chapter. These principles are derived from the authors’ experiences conducting surveys in such settings and reports from the literature and are based on observational rather than experimental evidence, but reflect the forefront of research on these topics. The first principle is to maintain an adaptive (flexible) approach at all phases of the survey allowing researchers to adjust the study protocols to such volatile circumstances. Second, mixed method approaches can be used to maximize that flexibility and minimize the weaknesses in a survey data collection design by capitalizing on the strengths of supplementary methods. Third, recruitment and training of interviewers require unconventional approaches such as: maintaining political neutrality during recruitment and training, and adding training components on psychological preparation, the art of politically neutral interactions, and handling conversations with respondents about the conflict. The fourth principle is to tailor data collection methods to deal with specific armed conflict challenges. Examples include: tailoring approaches to minimize refusals and noncontact, special efforts to secure interview privacy, and unconventional monitoring. Fifth, data collection in armed conflict settings often raises major ethical considerations that need to be carefully addressed. Overall, most good survey practice in armed conflict settings is no different from good general survey practice. But the challenges associated with these settings demand new mixes of existing approaches and flexibility to address the specific local conditions.
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