FACULTY OF CLINICAL SCIENCES
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Item Patterns and correlates of patient-reported helpfulness of treatment for common mental and substance use disorders in the WHO World Mental Health Surveys(Elsevier Srl, 2022) Kessler, R. C.; Kazdin, A. E.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Alonso, J.; Altwaijri, Y. A.; Andrade, L. H.; Benjet, C.; Bharat, C.; Borges, G.; Bruffaerts, R.; Bunting, B.; Caldas de Almeida, J. M.; Cardoso, G.; Chiu, W. T.; Cía, A.; Ciutan, M.; Degenhardt, L.; de Girolamo, G.; de Jonge, P.; de Vries, Y. A.; Florescu, S.; Gureje, O.; Haro, J. M.; Harris, M. G.,; Hu, C.; Karam, A. N.; Karam, E. G.; Karam, G.; Kawakami, N.; Kiejna, A.; Kovess-Masfety, V.; Lee, S.; Makanjuola, V.; McGrath, J. J.; Medina-Mora, M. E.; Moskalewicz, J.; Navarro-Mateu, F.; Nierenberg, A. A.; Nishi, D.; Ojagbemi, A.; Oladeji, B. D.; O’Neill, S.; Posada-Villa, J.; Puac-Polanco, V.; Rapsey, C.; Ruscio, A. M.; Sampson, N. A.; Scott, K. M.; Slade, T.; Stagnaro, J. C.; Stein, D. J.; Tachimori, H.; ten Have, M.; Torres, Y.; Viana, M. C.; Vigo, D. V.; Williams, D. R.; Wojtyniak, B.; Xavier, M.; Zarkov, Z.; Ziobrowski, H. N.; WHO WMH survey collaboratorsPatient-reported helpfulness of treatment is an important indicator of quality in patient-centered care. We examined its pathways and predictors among respondents to household surveys who reported ever receiving treatment for major depression, generalized anxiety disorder, social phobia, specific phobia, post-traumatic stress disorder, bipolar disorder, or alcohol use disorder. Data came from 30 community epidemiological surveys –17 in high-income countries (HICs) and 13 in low- and middle-income countries (LMICs) – carried out as part of the World Health Organization (WHO)’s World Mental Health (WMH) Surveys. Respondents were asked whether treatment of each disorder was ever helpful and, if so, the number of professionals seen before receiving helpful treatment. Across all surveys and diagnostic categories, 26.1% of patients (N=10,035) reported being helped by the very first professional they saw. Persisting to a second professional after a first unhelpful treatment brought the cumulative probability of receiving helpful treatment to 51.2%. If patients persisted with up through eight professionals, the cumulative probability rose to 90.6%. However, only an estimated 22.8% of patients would have persisted in seeing these many professionals after repeatedly receiving treatments they considered not helpful. Although the proportion of individuals with disorders who sought treatment was higher and they were more persistent in HICs than LMICs, proportional helpfulness among treated cases was no different between HICs and LMICs. A wide range of predictors of perceived treatment helpfulness were found, some of them consistent across diagnostic categories and others unique to specific disorders. These results provide novel information about patient evaluations of treatment across diagnoses and countries varying in income level, and suggest that a critical issue in improving the quality of care for mental disorders should be fostering persistence in professional help-seeking if earlier treatments are not helpful.Item Antidepressant use in low- middle- and high-income countries: a world mental health surveys report(Cambridge University Press, 2021) Kadzin, A. E.; Wu, C.; Hwang, I.; Puac-Polanco, V.; Sampson, N. A.; Al-Hamzawi, A.; Alonso, J.; Andrade, L. H.; Benjet, C.; Caldas-de-Almeida, J.; de Girolamo, G.; de Jonge, P.; Florescu, S.; Gureje, O.; Haro, J. M.; Harris, M. G.; Karam, E. G.; Karam, G.; Kovess-Masfety, V.; Lee, S.; McGrath, J. J.; Navarro-Mateu, F.; Nishi, D.; Oladeji, B. D.; Posada-Villa, J.; Stein, D. J.; Üstün, T. B.; Vigo, D. V.; Zarkov, Z.; Zaslavsky, A. M.; Kessler, R. C.; WHO World Mental Health Survey collaboratorsBackground. The most common treatment for major depressive disorder (MDD) is antidepressant medication (ADM). Results are reported on frequency of ADM use, reasons for use, and perceived effectiveness of use in general population surveys across 20 countries. Methods. Face-to-face interviews with community samples totaling n = 49 919 respondents in the World Health Organization (WHO) World Mental Health (WMH) Surveys asked about ADM use anytime in the prior 12 months in conjunction with validated fully structured diagnostic interviews. Treatment questions were administered independently of diagnoses and asked of all respondents. Results. 3.1% of respondents reported ADM use within the past 12 months. In high-income countries (HICs), depression (49.2%) and anxiety (36.4%) were the most common reasons for use. In low- and middle-income countries (LMICs), depression (38.4%) and sleep problems (31.9%) were the most common reasons for use. Prevalence of use was 2–4 times as high in HICs as LMICs across all examined diagnoses. Newer ADMs were proportionally used more often in HICs than LMICs. Across all conditions, ADMs were reported as very effective by 58.8% of users and somewhat effective by an additional 28.3% of users, with both proportions higher in LMICs than HICs. Neither ADM class nor reason for use was a significant predictor of perceived effectiveness. Conclusion. ADMs are in widespread use and for a variety of conditions including but going beyond depression and anxiety. In a general population sample from multiple LMICs and HICs, ADMs were widely perceived to be either very or somewhat effective by the people who use them.Item Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment and suicidality(Cambridge University Press, 2020) Scott, K. M.; de Vries, Y. A.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Alonso, J.; Bromet, E. J.; Bunting, B.; Caldas-de-Almeida, J. M.; Cía, A.; Florescu, S.; Gureje, O.; Hu, C. Y.; Karam, E. G.; Karam, A.; Kawakami, N.; Kessler, R. C.; Lee, S.; McGrath, J.; Oladeji, B.; Posada-Villa, J.; Stein, D. J.; Zarkov, Z.; de Jonge, P.Aims. Intermittent explosive disorder (IED) is characterised by impulsive anger attacks that vary greatly across individuals in severity and consequence. Understanding IED subtypes has been limited by lack of large, general population datasets including assessment of IED. Using the 17-country World Mental Health surveys dataset, this study examined whether behavioural subtypes of IED are associated with differing patterns of comorbidity, suicidality and functional impairment. Methods. IED was assessed using the Composite International Diagnostic Interview in the World Mental Health surveys (n = 45 266). Five behavioural subtypes were created based on type of anger attack. Logistic regression assessed association of these subtypes with lifetime comorbidity, lifetime suicidality and 12-month functional impairment. Results. The lifetime prevalence of IED in all countries was 0.8% (S.E.: 0.0). The two subtypes involving anger attacks that harmed people (‘hurt people only’ and ‘destroy property and hurt people’), collectively comprising 73% of those with IED, were characterised by high rates of externalising comorbid disorders. The remaining three subtypes involving anger attacks that destroyed property only, destroyed property and threatened people, and threatened people only, were characterized by higher rates of internalising than externalising comorbid disorders. Suicidal behaviour did not vary across the five behavioural subtypes but was higher among those with (v. those without) comorbid disorders, and among those who perpetrated more violent assaults. Conclusions. The most common IED behavioural subtypes in these general population samples are associated with high rates of externalising disorders. This contrasts with the findings from clinical studies of IED, which observe a preponderance of internalising disorder comorbidity. This disparity in findings across population and clinical studies, together with the marked heterogeneity that characterizes the diagnostic entity of IED, suggests that it is a disorder that requires much greater research.Item Findings from world mental health surveys of the perceived helpfulness of treatment for patients with major depressive disorder(American Medical Association, 2020-05) Harris, M. G.; Kazdin, A. E.; Chiu, W. T.; Sampson, N. A.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Alonso, J.; Altwaijri, Y.; Andrade, L. H.; Cardoso, G.; Cía A.; Florescu, S.; Gureje, O.; Hu, C.; Karam, E. G.; Karam, G.; Mneimneh, Z.; Navarro-Mateu, F.; Oladeji, B. D.; O'Neill, S.; Scott, K.; Slade, T.; Torres, Y.; Vigo, D.; Wojtyniak, B.; Zarkov, Z.; Ziv, Y.; Kessler, R. C.; WHO World Mental Health Survey CollaboratorsIMPORTANCE The perceived helpfulness of treatment is an important patient-centered measure that is a joint function of whether treatment professionals are perceived as helpful and whether patients persist in help-seeking after previous unhelpful treatments. OBJECTIVE To examine the prevalence and factors associated with the 2 main components of perceived helpfulness of treatment in a representative sample of individuals with a lifetime history of DSM-IV major depressive disorder (MDD). DESIGN, SETTING, AND PARTICIPANTS This study examined the results of a coordinated series of community epidemiologic surveys of noninstitutionalized adults using theWorld Health OrganizationWorld Mental Health surveys. Seventeen surveys were conducted in 16 countries (8 surveys in high-income countries and 9 in low- and middle-income countries). The dates of data collection ranged from 2002 to 2003 (Lebanon) to 2016 to 2017 (Bulgaria). Participants included those with a lifetime history of treated MDD. Data analyses were conducted from April 2019 to January 2020. Data on socioeconomic characteristics, lifetime comorbid conditions (eg, anxiety and substance use disorders), treatment type, treatment timing, and country income level were collected. MAIN OUTCOMES AND MEASURES Conditional probabilities of helpful treatment after seeing between 1 and 5 professionals; persistence in help-seeking after between 1 and 4 unhelpful treatments; and ever obtaining helpful treatment regardless of number of professionals seen. RESULTS Survey response rates ranged from 50.4%(Poland) to 97.2%(Medellín, Columbia), with a pooled response rate of 68.3%(n = 117 616) across surveys. Mean (SE) age at first depression treatment was 34.8 (0.3) years, and 69.4%were female. Of 2726 people with a lifetime history of treatment of MDD, the cumulative probability (SE) of all respondents pooled across countries of helpful treatment after seeing up to 10 professionals was 93.9% (1.2%), but only 21.5%(3.2%) of patients persisted that long (ie, beyond 9 unhelpful treatments), resulting in 68.2%(1.1%) of patients ever receiving treatment that they perceived as helpful. The probability of perceiving treatment as helpful increased in association with 4 factors: older age at initiating treatment (adjusted odds ratio [AOR], 1.02; 95%CI, 1.01-1.03), higher educational level (low: AOR, 0.48; 95%CI, 0.33-0.70; low-average: AOR, 0.62; 95%CI, 0.44-0.89; high average: AOR, 0.67; 95%CI, 0.49-0.91 vs high educational level), shorter delay in initiating treatment after first onset (AOR, 0.98; 95%CI, 0.97-0.99), and medication received from a mental health specialist (AOR, 2.91; 95%CI, 2.04-4.15). Decomposition analysis showed that the first 2 of these 4 factors were associated with only the conditional probability of an individual treatment professional being perceived as helpful (age at first depression treatment: AOR, 1.02; 95%CI, 1.01-1.02; educational level: low: AOR, 0.48; 95%CI, 0.33-0.70; low-average: AOR, 0.62; 95%CI, 0.44-0.89; high-average: AOR, 0.67; 95%CI, 0.49-0.91 vs high educational level), whereas the latter 2 factors were associated with only persistence (treatment delay: AOR, 0.98; 95%CI, 0.97-0.99; treatment type: AOR, 3.43; 95%CI, 2.51-4.70). CONCLUSIONS AND RELEVANCE The probability that patients with MDD obtain treatment that they consider helpful might increase, perhaps markedly, if they persisted in help-seeking after unhelpful treatments with up to 9 prior professionals.Item Childhood generalized specific phobia as an early marker of internalizing psychopathology across the lifespan: results from the World Mental Health Surveys(BioMed Central (BMC), 2019) de Vries, Y. A.; Al-Hamzawi, A.; Alonso, J.; Borges, G.; Bruffaerts, R.; Bunting, B.; Caldas-de-Almeida, J. M.; Cia, A. H.; De Girolamo, G.; Dinolova, R. V.; Esan, O. B.; Florescu, S.; Gureje, O.; Haro, J. M.; Hu, C.; Karam, E. G.; Karam, A.; Kawakami, N.; Kiejna, A.; Kovess-Masfety, V.; WHO World Mental Health Survey CollaboratorsBackground: Specific phobia (SP) is a relatively common disorder associated with high levels of psychiatric comorbidity. Because of its early onset, SP may be a useful early marker of internalizing psychopathology, especially if generalized to multiple situations. This study aimed to evaluate the association of childhood generalized SP with comorbid internalizing disorders. Methods: We conducted retrospective analyses of the cross-sectional population-based World Mental Health Surveys using the Composite International Diagnostic Interview. Outcomes were lifetime prevalence, age of onset, and persistence of internalizing disorders; past-month disability; lifetime suicidality; and 12-month serious mental illness. Logistic and linear regressions were used to assess the association of these outcomes with the number of subtypes of childhood-onset (< 13 years) SP. Results: Among 123,628 respondents from 25 countries, retrospectively reported prevalence of childhood SP was 5.9%, 56% of whom reported one, 25% two, 10% three, and 8% four or more subtypes. Lifetime prevalence of internalizing disorders increased from 18.2% among those without childhood SP to 46.3% among those with one and 75.6% those with 4+ subtypes (OR=2.4, 95% CI 2.3–2.5, p< 0.001). Conclusions: This large international study shows that childhood-onset generalized SP is related to adverse outcomes in the internalizing domain throughout the life course. Comorbidity, persistence, and severity of internalizing disorders all increased with the number of childhood SP subtypes. Although our study cannot establish whether SP is causally associated with these poor outcomes or whether other factors, such as a shared underlying vulnerability, explain the association, our findings clearly show that childhood generalized SP identifies an important target group for early intervention.Item The association between psychotic experiences and health-related quality of life. A cross-national analysis based on World Mental Health Surveys(Elsevier, 2018) Alonso, J.; Saha, S.; Lim, C. C. W.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Benjet, C.; Bromet, E. J.; Degenhardt, L.; de Girolamo, G.; Esan, O.B.; Florescu, S.; Gureje, O.; Haro, J. M.; Hu, C.; Karam, E. G.; Karam, G.; Kovess- Masfety, V.; Lepine, J. P.; Lee, S.; Mneimneh, Z.; WHO World Mental Health Survey CollaboratorsPsychotic experiences (PEs)are associated with arrange of mental and physical disorders, and disability, but little is known about the association between PEs and aspects of health-related quality of life (HRQoL). We aimed to investigate the association between PEs and five HRQoL indicators with various adjustments. Using data from the WHO World Mental Health surveys (n = 33,370 adult respondents from 19 countries), we assessed for PEs and five HRQoL indicators (self-rated physical or mental health, perceived level of stigma (embarrassment and discrimination), and social network burden). Logistic regression models that adjusted for socio-demographic characteristics, 21 DSM-IV mental disorders, and 14 general medical conditions were used to investigate the associations between the variables of interest. We also investigated dose-response relationships between PE related metrics (number of types and frequency of episodes) and the HRQoL indicators. Those with a history of PEs had increased odds of poor perceived mental (OR = 1.5, 95% CI = 1.2–1.9) and physical health (OR = 1.3, 95% CI =1.0–1.7) after adjustment for the presence of any mental or general medical conditions. Higher levels of perceived stigma and social network burden were also associated with PEs in the adjusted models. Dose response associations between PE type and frequency metrics and subjective physical and mental health were non-significant, except those with more PE types had increased odds of reporting higher discrimination (OR=2.2,95%CI=1.3–3.5). Our findings provide novel insights into how those with PEs perceive their health status.Item The association between childhood adversities and subsequent first onset of psychotic experiences: a cross- national analysis of 23 998 respondents from 17 countries(Cambridge University Press, 2017) McGrath, J.J.; McLaughlin, K.A.; Saha, S.; Aguilar-Gaxiola, S.; Al-Hamzawi, A.; Alonso, J.; Bruffaerts, R.; de Girolamo, G.; de Jonge, P.; Esan, O.B.; Florescu, S.; Gureje, O.; Haro, J.M.; Hu, C.; Karam, E.G.; Kovess-Masfety, V.; Lee, S.; Lepine, J.P.; Lim, C.C.; Medina-Mora, M.E.; Mneimneh, Z.; Pennell, B. E.; Pennell, B. E.; Piazza, M.; Posada-Villa, J.; Sampson, N.; Viana, M.C.; Xavier, M.; Bromet, E.J.; Kendler, K.S.; Kessler, R.C.Background—Although there is robust evidence linking childhood adversities (CAs) and an increased risk for psychotic experiences (PEs), little is known about whether these associations vary across the life-course and whether mental disorders that emerge prior to PEs explain these associations. Methods—We assessed CAs, PEs and DSM-IV mental disorders in 23,998 adults in the WHO World Mental Health Surveys. Discrete-time survival analysis was used to investigate the associations between CAs and PEs, and the influence of mental disorders on these associations using multivariate logistic models. Results—Exposure to CAs was common, and those who experienced any CAs had increased odds of later PEs (OR =2.3, 95%CI=1.9–2.6). CAs reflecting maladaptive family functioning (MFF), including abuse, neglect, and parent maladjustment, exhibited the strongest associations with PE onset in all life-course stages. Sexual abuse exhibited a strong association with PE onset during childhood (OR= 8.5, 95%CI=3.6–20.2), whereas other CA types were associated with PE onset in adolescence. Associations of Other CAs with PEs disappeared in adolescence after adjustment for prior-onset mental disorders. The population attributable risk proportion (PARP) for PEs associated with all CAs was 31% (24% for MFF). Conclusions—Exposure to CAs is associated with PE onset throughout the life-course, although sexual abuse is most strongly associated with childhood onset PEs. The presence of mental disorders prior to the onset of PEs does not fully explain these associations. The large PARPs suggest that preventing CAs could lead to a meaningful reduction in PEs in the population.