The influence of social factors on common mental disorders. Destabilisation and restitution

Neuroticism and common mental disorders: meaning and utility of a complex relationship

Neuroticism's prospective association with common mental disorders (CMDs) has fueled the assumption that neuroticism is an independent etiologically informative risk factor. This vulnerability model postulates that neuroticism sets in motion processes that lead to CMDs. However, four other models seek to explain the association, including the spectrum model (manifestations of the same process), common cause model (shared determinants), state and scar models (CMD episode adds temporary/permanent neuroticism). To examine their validity we reviewed literature on confounding, operational overlap, stability and change, determinants, and treatment effects. None of the models is able to account for (virtually) all findings. The state and scar model cannot explain the prospective association. The spectrum model has some relevance, especially for internalizing disorders. Common causes are most important but the vulnerability model cannot be excluded although confounding of the prospective association by baseline symptoms and psychiatric history is substantial. In fact, some of the findings, such as interactions with stress and the small decay of neuroticism's effect over time, are consistent with the vulnerability model. We describe research designs that discriminate the remaining models and plea for deconstruction of neuroticism. Neuroticism is etiologically not informative yet but useful as an efficient marker of non-specified general risk.

Women's and doctors' accounts of their experiences of depression in primary care: the influence of social and moral reasoning on patients' and doctors' decisions

BACKGROUND

Little is known about how general practitioners (GPs) manage depression within everyday clinical practice, particularly in relation to the issue of 'problem definition'. In addition, there has been relatively little research on the patients' perspective of depression and its management in primary care.

METHODS

Qualitative interviews explored women's and GPs' experiences of recognizing depression and their experiences of the management of depression. Thirty-seven women and 20 GPs were recruited from practices in four National Health Service Board areas of Scotland. Each participant was interviewed at the start of the study, and 30 women and 19 GPs were revisited approximately 9-12 months later so that the process of care could be reviewed.

RESULTS

The findings demonstrate the social and moral reasoning that lies behind women's decisions to seek help and to subsequently accept their GPs' explanation and advice, and that the acceptance of antidepressants created a moral dilemma for the women. For GPs, the diagnosis and management of depression led to contemplating the boundaries of their professional role, and social and moral reasoning was also evident in their decision-making processes.

DISCUSSION

The implication is that, for the majority of women, a chronic-disease model for the management for depression in primary care would be likely to increase rather than reduce the moral dilemma. In addition, the management of depression is not solely based on clinical decisions, so the applicability of a chronic-disease model to primary care requires further consideration.

Establishing a set of mental health indicators for Europe

AIMS

This review presents the background work for developing a set of mental health indicators as part of a comprehensive health monitoring system in the European Union. The review focuses on the appraisal of mental health at population level with special emphasis on assessments that could be useful for mental health promotion.

METHODS

A functional model of mental health is used to delineate variables important for a set of mental health indicators. Variables that are not possible to monitor at population level are not discussed here. Literature searches were conducted through the MEDLINE, PSYCHLIT, and SOCIOLOGICAL ABSTRACTS databases and available textbooks.

RESULTS

The review presents findings from research seeking associations between mental health and ill health and different individual, social, economic, ecological, and service-related characteristics. Specific domains as key starting points in establishing a set of mental health indicators are outlined according to the research findings.

CONCLUSION

A set of mental health indicators can enhance the visibility of mental health issues in the European context. Ultimately the indicators could be used in estimating how the targets set for health policies are met, and whether there has been a measurable decrease in disability, suffering, and disease.

Systematic review of the role of gender as a health determinant of hospitalization for depression

Objectives:To conduct a systematic review of selected health determinants, including gender, and their impact on hospitalization rates for depression. Depression includes both depressive and bipolar disorders. Selected health determinants were gender, age, sex, family structure, education, and socioeconomic status.

Methods:Systematic search of conventional and fugitive literature sources. All reports of primary data, systematic reviews, and meta-analysis of primary data were included if they focused on hospitalization for depression and reported data by one or more of the selected health determinants. Two researchers independently evaluated each citation for inclusion and extracted data from the included studies.

Results:There is an important underreporting of health determinants data in studies of hospitalization for depression. No studies examined the role of gender. Age and sex were reported in 83 percent and 80 percent of the 110 included studies. Women showed a higher rate of hospitalization for depression than men (p<.05). Age and diagnosis had different effects in men and women. Adult women were significantly more likely than men to report a depressive disorder, whereas men were more likely to report a bipolar disorder (p<.05). Little can be concluded on the other health determinants.

Conclusions:The importance of reporting hospitalization data and conducting hospital utilization analysis by sex and health determinants, including gender, must be emphasized.

Vulnerability, destabilization and restitution in anxious depression

OBJECTIVE

To summarize what is known about vulnerability and resilience to common mental disorders, and the psychosocial factors associated with speed of recovery.

METHOD

Recent genetic factors are summarized, and taken together with known facts about social factors encouraging or reducing likelihood of an episode.

RESULTS

Multiple genes are likely, controlling both vulnerability and resilience, with the manifestation in phenotype modified by environmental factors. Restitution must be thought of separately from vulnerability.

CONCLUSION

Instead of specific genes causing specific mental disorders, we need a more complex model.

High prevalence of mental disorders in primary care

OBJECTIVE

To determine the prevalence of common mental disorders in an adult primary care population.

DESIGN

Cross-sectional survey in randomly selected subjects, using the PRIME-MD questionnaire.

SETTING

Eighty-six general practices in Belgium.

SUBJECTS

A total of 2316 randomly selected patients, aged 18 years or older and consulting their general practitioner for other than administrative reasons alone, with slightly more women (58.1%) than men (41.3%). MAIN OUTCOME RESULT: Prevalence rates of mental disorders most commonly seen in primary care practice (mood, anxiety, somatoform, eating and alcohol disorders).

METHODS

To facilitate data collection and processing, the entire PRIME-MD questionnaire was programmed on a handheld computer. Patient answers and physician assessments were immediately electronically recorded during the interview. All investigators were trained on the use of the PRIME-MD. The recruitment period lasted 6 weeks: from 15 February to 25 March 1999, and patients were randomly selected for the interview based on a computerized procedure.

RESULTS

Although only 5.4% of all patients consulted for a psychiatric reason, a threshold/subthreshold psychiatric disorder was detected in 42.5% of all patients. Most commonly detected disorders were mood disorders in 31.0% (major depressive disorder, 13.9% and dysthymia, 12.6%), anxiety disorders in 19.0% (generalized anxiety disorder, 10.3%), somatoform disorders in 18.0% and probable alcohol abuse/dependence in 10.1%. The results also showed the important rate of comorbidity between these disorders.

CONCLUSION

The present study confirms the high prevalence of mental disorders in a general practice setting, and their frequent association. Prevalence rates of our study are even higher than those obtained in previously conducted trials. Our study also demonstrates the utility of the PRIME-MD as a screening tool for mental disorders in primary care. In addition the use of the handheld computer software version of the PRIME-MD allowed us to screen for mental disorders in patients who are unable to attend the GP office and are seen during 'home' visits.

Depressive symptoms in intellectual disability: does gender play a role?

BACKGROUND

Gender issues remain largely unaddressed in the dual diagnosis arena, even in the area of depression where there is a 2:1 female to male ratio in the general population. This paper argues that women with intellectual disability (ID) report higher levels of depressive symptoms than men with ID and that risk factors for depression identified for women in the general population are relevant to this group.

METHOD

Findings are based on structured interviews with 99 men and women with ID, with corroborative information provided from caregivers and casebook reviews.

RESULTS

Overall, women reported higher levels of depression than men. Individuals with higher depression scores were more lonely and had higher stress levels than individuals with lower scores. Women with higher depression scores were more likely to report coming from abusive situations, to have poor social support from family and to be unemployed when compared to women with lower scores, but similar differences were not found when comparing men with higher and lower depression scores.

CONCLUSION

Men and women who report experiencing these psychosocial correlates of depression should be a target group for future prevention efforts, taking gender specific concerns into consideration.

Primary care options to prevent mental illness

The common mental disorders, mainly anxiety and depression, constitute a major public health problem, incurring considerable costs in terms of use of health services and time lost from work. Risk factors include low socioeconomic status, poverty and poor housing, as well as stressful life events and difficulties such as demanding child care, separation or divorce, bereavement, loss of employment and caring for a dependant relative. Population approaches are probably necessary to reduce significantly the burden of such mental health problems, but health care measures are far from negligible. Primary care professionals have regular opportunities to identify people at risk of mental health problems and refer them to welfare and social support services (primary prevention). A number of interventions among high-risk groups have been shown to be effective, including problem-solving training and cognitive-behavioural approaches. The most important tasks in primary care are to identify people with depression, alcohol and drug misuse and eating disorders as early as possible in the course of their illness and to institute effective treatment (secondary prevention). Primary care teams should also join in shared care arrangements for patients with chronic disabling mental illnesses, in order to prevent recurrences and relapses (tertiary prevention).

Strategies for the prevention of psychiatric disorder in primary care in south London

STUDY OBJECTIVE

To compare the potential impact of high risk and population based approaches to the prevention of psychiatric disorder, using a representative sample of general practice attenders as the target population.

DESIGN

This was a prospective cohort study.

SETTING

A health centre in south London.

PARTICIPANTS

Three hundred and seven consecutive attenders aged 16-65, recruited at randomly selected general practice surgeries.

MAIN RESULTS

A linear association was found between the number of different types of socioeconomic adversity reported at recruitment (T1) and the prevalence of psychiatric disorder one year later (T2). The population attributable fraction (PAF) for socioeconomic adversity at T1 was 37.4%. In theory, social interventions for high risk individuals at T1 would reduce the prevalence of psychiatric disorder at T2 by 9% at most, compared with a reduction of 18% if just one item of socioeconomic adversity were eliminated among those with any socioeconomic risk factors.

CONCLUSIONS

Social interventions targeted at individuals at highest risk of the most common mental disorders are likely to be extremely limited in their capacity to reduce the prevalence of these conditions. A population based risk reduction strategy, modified according to individual risk, represents a potentially feasible and effective alternative.

DSM-III mental disorders in general medical sector: predictors of outcome

In 1987, a multicentric research was carried out in Emilia-Romagna, an administrative area in northern Italy. Nine hundred and forty one people in the general medical sector were contacted to enter a two-stage procedure to identify DSM-III cases. Cases were recontacted for 3-month, 1-year and 2-year follow-ups. Eighty cases completing at least the one-year follow-up were analysed. The sample was split into "still-cases" and "no longer-cases" depending on the persistence of a DSM-III diagnosis at the last follow-up. Both clinical and social features proved to be predictors of the outcome. A disorder lasting one year or longer, past recurrences, Axis I comorbidity, older age, being married and having children were the features which at the first assessment predicted an unfavourable outcome. Having children and past episodes proved to be the best predictors of remaining a case in a stratified logistic regression model. The persistence of major difficulties during the follow-up period was also correlated to a "still-case" status.

In the shadow of adversity: the evolution and resolution of anxiety and depressive disorder

BACKGROUND

It was proposed to explore the longitudinal relationship between adverse experience and mental health; in particular, whether particular adverse experiences influence the form of subsequent expression of morbidity.

METHOD

Three groups of women were selected: 64 whose marital partner had recently died, 143 whose husbands had recently experienced a myocardial infarction and a third group of 32 women who had sought protection in a Women's Aid refuge. An initial interview assessed psychiatric status according to the RDC for the six months before the event and up to the time of interview, and a second interview was completed four months after the event had occurred. The course was assessed using the Longitudinal Interval Follow-up Evaluation.

RESULTS

For the coronary group, the prevalence of psychiatric disorder doubled following the experience of the event, and was most pronounced for anxiety disorder. For the bereaved, rates increased over eight times for major depressive disorder and more than twice for anxiety disorder, following the loss; for the refuge group, prevalence rates were lower after entering the refuge than those before. Analyses that took account of the timing of the onset of disorders showed that in almost half of those experienced by the coronary group, and about 40% of the bereaved group, onset pre-dated the timing of the event.

CONCLUSIONS

The results further advance knowledge of the evolution and form of psychiatric conditions following the experience of severe adversity.

Aetiology of anxiety and depressive disorders in an inner-city population. 2. Comorbidity and adversity

An earlier paper documented that adverse experiences in childhood and adolescence considerably raise risk of both depressive and anxiety conditions (with the exception of mild agoraphobia and simple phobia) in adult life. This paper deals with the same inner-city women with children at home. Consideration of adverse experiences throughout adulthood as a whole (excluding the period just before onset) particularly involving major prior losses suggests that rather different aetiological processes may be involved. Depression appears to be often linked to experiences of major loss in adulthood as a whole and to be particularly susceptible to shortcomings in the quality of ongoing social support. For anxiety only early adverse experiences appeared to be critical. (However, the onset of both conditions is often provoked by a severely threatening event in the most recent period--particularly 'loss' in depression, and 'danger' in anxiety.) Finally the critical role of early experience for both anxiety and depression explains to a considerable extent why they so often occur together; and social factors not studied in the present enquiry may account for some of the remaining unexplained comorbidity.

The effects of physical illness on psychiatric disorder

Somatic symptoms of both organic and non-organic causes are associated with an increase in psychiatric morbidity irrespective of setting; patients with chronic medical conditions are approximately twice as likely to report psychiatric disorder as controls. This increase cannot be entirely explained in terms of help-seeking behaviour, recognition rates by treating doctors or treatment outcome. The detection and treatment of coincident psychiatric disorder in this group of patients needs further clarification.

The NH & MRC Social Psychiatry Research Unit, at the Australian National University, Canberra, 1975-90

In 1974, the National Health and Medical Research Council (NH & MRC) in Australia reviewed what initiatives might be undertaken to promote medical research relevant to the needs of the population. It noted that Australia had contributed with distinction in some areas, such as the neurosciences and immunology, whereas fields such as epidemiology and psychiatry were much less developed scientifically. As the principal source of funding for medical research, the NH & MRC had hitherto supported projects, individuals and a small number of institutions (e.g. the Walter and Eliza Hall, the Florey and the Baker Institutes). The initiative adopted in 1974, as an additional commitment, was to establish some research units in areas of major relevance for public health. These were intended to become centres of excellence in fields where more expertise was needed at a national level.