Prevalence and treatment of common mental disorders in the English national population, 1993-2007.

BACKGROUND: The National Psychiatric Morbidity Surveys include English cross-sectional household samples surveyed in 1993, 2000 and 2007. AIMS: To evaluate frequency of common mental disorders (CMDs), service contact and treatment. METHOD: Common mental disorders were identified with the Clinical Interview Schedule - Revised (CIS-R). Service contact and treatment were established in structured interviews. RESULTS: There were 8615, 6126 and 5385 participants aged 16-64. Prevalence of CMDs was consistent (1993: 14.3%; 2000: 16.0%; 2007: 16.0%), as was past-year primary care physician contact for psychological problems (1993: 11.3%; 2000: 12.0%; 2007: 11.7%). Antidepressant receipt in people with CMDs more than doubled between 1993 (5.7%) and 2000 (14.5%), with little further increase by 2007 (15.9%). Psychological treatments increased in successive surveys. Many with CMDs received no treatment. CONCLUSIONS: Reduction in prevalence did not follow increased treatment uptake, and may require universal public health measures together with individual pharmacological, psychological and computer-based interventions.

Why are suicidal thoughts less prevalent in older age groups? Age differences in the correlates of suicidal thoughts in the English Adult Psychiatric Morbidity Survey 2007.

BACKGROUND: Suicidal ideation is more strongly associated with suicidal intent in later life, so risk factors may also differ by age. We investigated whether the relationship between suicidal ideation and established correlates varied by age in a representative population. METHODS: We used data from the 2007 Adult Psychiatric Morbidity Survey of England to assess the relationship between age and suicidal thoughts across 20-year age bands, using logistic regression, adjusted for survey weights. We used mediation analyses to assess the extent to which other factors mediate the relationship between suicidal thoughts and age. RESULTS: Reports of previous-year suicidal thoughts decreased with age. This was partly explained by (1) lower rates of reported child abuse (in those aged 75+), of depression, and of anxiety symptoms (in those aged 55+), factors all strongly associated with suicidal thoughts, and (2) higher rates of protective factors in people aged 35+, specifically homeownership and cohabitation. Rates of phobias, irritability and compulsions also decreased with age, and the association of these symptoms with suicidal thoughts was particularly strong in the youngest (16-34) age group. People who reported experiencing childhood abuse in all age groups reported more suicidal thoughts, suggesting abuse has lifelong negative effects on suicidal ideation. LIMITATIONS: The response rate was 57%. Older people may be less likely to recall childhood abuse. CONCLUSIONS: Sexual and physical abuse in childhood are associated with suicidal ideas throughout the lifespan, so screening for suicidal ideas in younger and older people should be routine and vigorous, and cover experiences in early life: management may require appropriate psychological interventions.

How do child and adolescent mental health problems influence public sector costs? Interindividual variations in a nationally representative British sample.

BACKGROUND: Policy and practice guidelines emphasize that responses to children and young people with poor mental health should be tailored to needs, but little is known about the impact on costs. We investigated variations in service-related public sector costs for a nationally representative sample of children in Britain, focusing on the impact of mental health problems. METHODS: Analysis of service uses data and associated costs for 2461 children aged 5-15 from the British Child and Adolescent Mental Health Surveys. Multivariate statistical analyses, including two-part models, examined factors potentially associated with interindividual differences in service use related to emotional or behavioural problems and cost. We categorized service use into primary care, specialist mental health services, frontline education, special education and social care. RESULTS: Marked interindividual variations in utilization and costs were observed. Impairment, reading attainment, child age, gender and ethnicity, maternal age, parental anxiety and depression, social class, family size and functioning were significantly associated with utilization and/or costs. CONCLUSIONS: Unexplained variation in costs could indicate poor targeting, inequality and inefficiency in the way that mental health, education and social care systems respond to emotional and behavioural problems.

Physical illness in looked-after children: a cross-sectional study.

OBJECTIVE: To compare the reported point prevalence of chronic physical illness among children looked after by local authorities with those living in their own homes. DESIGN: Cross-sectional study, using questionnaire data from a national survey. SETTING: The UK. PARTICIPANTS: Random samples of children aged 5-15 years. Children looked after were selected from Department of Health databases, stratified according to placement type. The child benefit register was the sampling frame for children in their own homes, weighted to match the child population demographic and compensate for response variability. MAIN OUTCOME: Carer-reported prevalence of 10 physical illnesses. RESULTS: Data were collected on 1253 looked-after children and 10 438 children in their own homes. There were lower rates of asthma, eczema and hay fever reported among looked-after children compared with children at home (ORs, adjusted for age, gender and ethnicity, were 0.63, 0.61 and 0.36, respectively). Epilepsy, cystic fibrosis and cerebral palsy were more commonly reported in looked-after children (adjusted ORs 4.13, 4.2 and 7.26, respectively). There was no difference in the proportions of children in the two groups reporting glue ear, diabetes mellitus, spina bifida or cancer. CONCLUSIONS: Looked-after children have an increased prevalence of some physical illnesses. The results also suggest that there may be significant unmet need, with health professionals and carers failing to identify other illnesses. The lower reported prevalence of atopic conditions may reflect a truly lower occurrence of such diseases in looked-after children; this requires further work to explore.

The structure of paranoia in the general population.

BACKGROUND: Psychotic phenomena appear to form a continuum with normal experience and beliefs, and may build on common emotional interpersonal concerns. AIMS: We tested predictions that paranoid ideation is exponentially distributed and hierarchically arranged in the general population, and that persecutory ideas build on more common cognitions of mistrust, interpersonal sensitivity and ideas of reference. METHOD: Items were chosen from the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II) questionnaire and the Psychosis Screening Questionnaire in the second British National Survey of Psychiatric Morbidity (n = 8580), to test a putative hierarchy of paranoid development using confirmatory factor analysis, latent class analysis and factor mixture modelling analysis. RESULTS: Different types of paranoid ideation ranged in frequency from less than 2% to nearly 30%. Total scores on these items followed an almost perfect exponential distribution (r = 0.99). Our four a priori first-order factors were corroborated (interpersonal sensitivity; mistrust; ideas of reference; ideas of persecution). These mapped onto four classes of individual respondents: a rare, severe, persecutory class with high endorsement of all item factors, including persecutory ideation; a quasi-normal class with infrequent endorsement of interpersonal sensitivity, mistrust and ideas of reference, and no ideas of persecution; and two intermediate classes, characterised respectively by relatively high endorsement of items relating to mistrust and to ideas of reference. CONCLUSIONS: The paranoia continuum has implications for the aetiology, mechanisms and treatment of psychotic disorders, while confirming the lack of a clear distinction from normal experiences and processes.

Influence of problematic child-teacher relationships on future psychiatric disorder: population survey with 3-year follow-up.

BACKGROUND: Teacher-pupil relationships have been found to mediate behavioural, social and psychological outcomes for children at different ages according to teacher and child report, but most studies have been small. AIMS: To explore later psychiatric disorder among children with problematic teacher-pupil relationships. METHOD: Secondary analysis of a population-based cross-sectional survey of children aged 5-16 with a 3-year follow-up. RESULTS: Of the 3799 primary-school pupils assessed, 2.5% of parents reported problematic teacher-pupil relationships; for secondary-school pupils (n = 3817) this rose to 6.6%. Among secondary-school pupils, even when children with psychiatric disorder at baseline were excluded and we adjusted for baseline psychopathology score, problematic teacher-pupil relationships were statistically significantly related to higher levels of psychiatric disorder at 3-year follow-up (odds ratio (OR) = 1.93, 95% CI 1.07-3.51 for any psychiatric disorder, OR = 3.00, 95% CI 1.37-6.58 for conduct disorder). Results for primary-school pupils were similar but non-significant at this level of adjustment. CONCLUSIONS: This study underlines the need to support teachers and schools to develop positive relationships with their pupils.

Economic impact of childhood psychiatric disorder on public sector services in Britain: estimates from national survey data.

BACKGROUND: Approximately one in ten children aged 5-15 in Britain has a conduct, hyperactivity or emotional disorder. METHODS: The British Child and Adolescent Mental Health Surveys (BCAMHS) identified children aged 5-15 with a psychiatric disorder, and their use of health, education and social care services. Service costs were estimated for each child and weighted to estimate the overall economic impact at national level. RESULTS: Additional health, social care and education costs associated with child psychiatric disorders totalled £1.47bn in 2008. The lion's share of the costs falls to frontline education and special education services. CONCLUSIONS: There are huge costs to the public sector associated with child psychiatric disorder, particularly the education system. There is a pressing need to explore ways to reduce these costs while improving health and well-being.

Ethnic inequalities in the use of health services for common mental disorders in England.

PURPOSE: The purpose of this study is to investigate whether minority ethnic people were less likely to receive treatment for mental health problems than the white population were, controlling for symptom severity. METHOD: We analysed data from 23,917 participants in the 1993, 2000 and 2007 National Psychiatric Morbidity Surveys. Survey response rates were 79, 69 and 57 %, respectively. The revised Clinical Interview Schedule was used to adjust for symptom severity. RESULTS: Black people were less likely to be taking antidepressants than their white counterparts were (Odds ratio 0.4; 95 % confidence interval 0.2-0.9) after controlling for symptom severity. After controlling for symptom severity and socioeconomic status, people from black (0.7; 0.5-0.97) and South Asian (0.5; 0.3-0.8) ethnic groups were less likely to have contacted a GP about their mental health in the last year. CONCLUSIONS: Interventions to reduce these inequalities are needed to ensure that NHS health care is delivered fairly according to need to all ethnic groups.

The relationship between personal debt and specific common mental disorders.

BACKGROUND: Personal debt is now recognized as one of the many factors associated with common mental disorders (CMD). We aim to estimate the prevalence of 'specific' mental disorders based on ICD-10 research diagnostic criteria by type of debt and quantify the additional influence of addictive behaviours. METHOD: A random probability sample comprising 7461 respondents were interviewed for the third national survey of psychiatric morbidity of adults in England carried out in 2007. The prevalence of CMD was estimated from the administration of the CIS-R. Respondents were asked about sources of debt and their borrowing choices. RESULTS: In 2007, 8.5% of adults were in arrears. Adults in debt were three times more likely than those not in debt to have CMD. The increased likelihood of CMD among those in arrears was found for all CMD and was irrespective of source of debt--housing, utilities and purchases on credit. The situation was exacerbated among those with addictive behaviours--alcohol or drug dependence or problem gambling. Those with multiple sources of debt and who had to obtain money from pawnbrokers and moneylenders had the highest rate of CMD, ≈ 50%. CONCLUSIONS: Debt is one of the major risk factors for CMD. This has practical implications for both health services and financial services, which both need to be alert to the association and adapt and train their respective services accordingly so that people in debt can access help for mental disorders and people with mental disorders can access help for debt.

Religion, spirituality and mental health: results from a national study of English households.

BACKGROUND: Religious participation or belief may predict better mental health but most research is American and measures of spirituality are often conflated with well-being. AIMS: To examine associations between a spiritual or religious understanding of life and psychiatric symptoms and diagnoses. METHOD: We analysed data collected from interviews with 7403 people who participated in the third National Psychiatric Morbidity Study in England. RESULTS: Of the participants 35% had a religious understanding of life, 19% were spiritual but not religious and 46% were neither religious nor spiritual. Religious people were similar to those who were neither religious nor spiritual with regard to the prevalence of mental disorders, except that the former were less likely to have ever used drugs (odds ratio (OR) = 0.73, 95% CI 0.60-0.88) or be a hazardous drinker (OR = 0.81, 95% CI 0.69-0.96). Spiritual people were more likely than those who were neither religious nor spiritual to have ever used (OR = 1.24, 95% CI 1.02-1.49) or be dependent on drugs (OR = 1.77, 95% CI 1.20-2.61), and to have abnormal eating attitudes (OR = 1.46, 95% CI 1.10-1.94), generalised anxiety disorder (OR = 1.50, 95% CI 1.09-2.06), any phobia (OR = 1.72, 95% CI 1.07-2.77) or any neurotic disorder (OR = 1.37, 95% CI 1.12-1.68). They were also more likely to be taking psychotropic medication (OR = 1.40, 95% CI 1.05-1.86). CONCLUSIONS: People who have a spiritual understanding of life in the absence of a religious framework are vulnerable to mental disorder.

Feelings of loneliness among adults with mental disorder.

PURPOSE: Loneliness can affect people at any time and for some it can be an overwhelming feeling leading to negative thoughts and feelings. The current study, based on the Adult Psychiatric Morbidity Survey in England, 2007, quantified the association of loneliness with a range of specific mental disorders and tested whether the relationship was influenced by formal and informal social participation and perceived social support.Methods Using a random probability sample design,7,461 adults were interviewed in a cross-sectional national survey in England in 2007. Common Mental Disorders were assessed using the revised Clinical Interview Schedule;the diagnosis of psychosis was based on the administration of the Schedules of the Clinical Assessment of Neuropsychiatry, while loneliness was derived from an item in the Social Functioning Questionnaire.Results Feelings of loneliness were more prevalent in women (OR = 1.34, 95 % CI 1.20­1.50, P\0.001) as well as in those who were single (OR = 2.24, 95 % C I1.96­2.55, P<0.001), widowed, divorced or separated(OR = 2.78, 95 % CI 2.38­3.23, P<0.001), economically inactive (OR = 1.24, 95 % CI 1.11­1.44,P = 0.007), living in rented accommodation (OR = 1.73,95 % CI 1.53­1.95, P<0.001) or in debt (OR = 2.47,95 % CI 2.07­1.50, P<0.001). Loneliness was associated with all mental disorders, especially depression [corrected].

Children who run away from home: risks for suicidal behavior and substance misuse.

PURPOSE: The primary aim of this study is to examine the extent to which running away from home as a child is associated with behavioral problems and victimization during childhood and with suicidal behavior and substance abuse during early adulthood. METHODS: A random probability sample comprising 7,461 respondents was interviewed for the 2007 survey of psychiatric morbidity of adults in England. A subsample of 16- to 34-year-old individuals was selected for secondary analysis (N = 2,247). All survey respondents were asked whether they had run away from home and asked specific questions on being physically, emotionally and sexually abused as children. They were also asked about suicidal behavior and alcohol and drug dependence in early adulthood. RESULTS: Approximately 7% of 16- to 34-year-old individuals reported running away from home before the age of 16 years, with higher rates in women than in men (9.8% compared with 5.3%). Overall, 45.3% reported being bullied, 25.3% experienced violence at home, and 8.8% reported unwanted sexual intercourse. Runaways were far more likely than other children to have suffered victimization and family difficulties and to exhibit behavioral problems. Adults who reported running away from home were three times more likely than other adults to have thought about or attempted suicide, but the relationship with substance abuse was far less pronounced. CONCLUSIONS: Sexual, physical, and emotional abuse, along with family difficulties, can all impact children who run away from home. Running away from home was strongly associated with suicidal behavior in adulthood, regardless of other childhood adversities.

Physical ill health, disability, dependence and depression: results from the 2007 national survey of psychiatric morbidity among adults in England.

BACKGROUND: The relationship between physical ill health, disability, and depression is not straightforward. Both cross-sectional and longitudinal studies have clearly shown that medical illness and physical disability are strongly associated with depression. OBJECTIVE: To test the hypothesis that disability is associated with an increased prevalence of depression irrespective of physical health problems and that this is proportionate to the severity of disability (measured in terms of the number of difficulties in daily activities and the degree of dependence on others). METHODS: Using a random probability sample design, 7460 respondents were interviewed for the third national survey of psychiatric morbidity of adults in the private household population in England. Fieldwork was carried out throughout 2007. The prevalence of depression was established by the administration of the revised Clinical Interview Schedule (CIS-R), while disability was measured by reported difficulties in activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS: Disability was associated with depression even after adjustment for physical ill health. The number of ADL/IADL difficulties was directly related to the likelihood of respondents having depression. Dependence on others was not associated with depression once severity of disability had been accounted for. CONCLUSION: All ADL/IADL limitations are significantly associated with depression and there seems to be a cumulative effect irrespective of whether the limitation is in personal care or in instrumental activities such as mobility problems.

Increased prevalence of insomnia and changes in hypnotics use in England over 15 years: analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys.

STUDY OBJECTIVES: To investigate changes over 15 years in the prevalence of insomnia and its association with demographic characteristics and hypnotic medication use. DESIGN: Analysis of 3 cross-sectional national mental health surveys carried out in 1993, 2000, and 2007, which used comparable sampling methods and identical insomnia assessments. SETTING: Adults living in private households in England. PATIENTS OR PARTICIPANTS: 20,503 people aged 16-64 years. MEASUREMENTS AND RESULTS: Insomnia was defined according to 4 different criteria, using relevant questions from the revised Clinical Interview Schedule. Modest increases in insomnia prevalence were found over the survey periods (any symptoms increasing from 35.0% in 1993 to 38.6% in 2007; insomnia diagnosis from 3.1% to 5.8%, respectively). In all 3 surveys, similar strengths of association in relation to all criteria were found, with female gender, increased age, lower educational attainment, depression, unemployment, economic inactivity, and widowed, divorced, or separated status. Prevalence of hypnotic use was double in 2000 (0.8%) compared to 1993 (0.4%); from limited information on selected medications, there was no such increase between 2000 and 2007. The reasons reported for any sleep disturbance over the last month were generally similar across surveys, the most marked change being illness/discomfort increasing as an explanation from 14.3% to 17.4% to 19.0%. CONCLUSIONS: In the English general population, insomnia (by any definition) showed a modest but steady increase in prevalence over a 15-year period. Strengths of associations with demographic factors and self-reported reasons for sleep disturbance remained reasonably stable over this period.

Insomnia, worry, anxiety and depression as predictors of the occurrence and persistence of paranoid thinking.

PURPOSE: Our theoretical model proposes that insomnia, worry, and negative affect are important determinants of paranoid thinking. Anxiety produces anticipation of threat, depression increases the sense of vulnerability, worry leads to implausible ideas, and insomnia exacerbates negative affect and creates an altered perceptual state. The study objective was to examine for the first time these factors as predictors of the onset of new paranoid thinking and of the persistence of existing paranoid thinking. METHOD: A total of 2,382 participants in the 2000 British National Psychiatric Morbidity Survey were followed-up 18 months after their first assessment. Baseline assessments were used to predict the development and persistence of paranoid thinking at follow-up. Data were weighted to be representative of the general household population. RESULTS: Insomnia, worry, anxiety, depression and depressive ideas were each substantial predictors both of new inceptions of paranoia and of the persistence of existing paranoid thinking. Worry and insomnia were the strongest predictors. For example, insomnia at the first assessment led to a more than threefold increase in later inceptions of paranoid thinking. CONCLUSIONS: The study indicates that insomnia, worry, anxiety and depression are potential risk factors for new inceptions of paranoid thinking. The results also corroborate an emerging literature indicating that anxiety, worry and depression may encourage the persistence of paranoid thinking. The study provides the first longitudinal evidence linking insomnia and paranoia. The important clinical implication is that the use of interventions for common mental health difficulties in people with psychosis may have the additional benefit of reducing paranoia.

The meaning of reporting forgetfulness: a cross-sectional study of adults in the English 2007 Adult Psychiatric Morbidity Survey.

OBJECTIVES: we measured subjective memory impairment (SMI) across the whole adult age range in a representative, national survey. Age is the strongest risk factor for dementia and SMI may be a precursor of objective cognitive impairment. We therefore hypothesised that SMI prevalence would rise with age in a non-demented population. METHOD: we analysed data from the English 2007 Adult Psychiatric Morbidity Survey, representative of people in private households. Participants were asked whether they had noticed problems with forgetting in the last month, or forgotten anything important in the last week; and completed the modified Telephone Interview for Cognitive Status. RESULTS: of those contacted, 7,461 (57%) participated. After excluding participants screening positive for dementia, 2,168 (31.7%) reported forgetfulness in the last month, while 449 (6.4%) had forgotten something important in the last week. Reporting forgetfulness was not associated with age. In a multivariate analysis including cognition and age, the only significant associates of reporting forgetfulness were anxiety, depressive and somatic symptoms. CONCLUSIONS: our hypothesis that subjective forgetfulness prevalence would rise with age in a non-demented population was not supported. Although subjective forgetfulness can be an early symptom of future or mild dementia, it is common and non-specific and-at population level-is more likely to be related to mood than to be an early symptom of dementia. Asking those presenting with subjective forgetfulness additional questions about memory and functional decline and objective forgetfulness is likely to help clinicians to detect those at risk of dementia.

Age and birth cohort differences in the prevalence of common mental disorder in England: National Psychiatric Morbidity Surveys 1993-2007.

BACKGROUND: There are concerns that the prevalence of mental disorder is increasing. AIMS: To determine whether the prevalence of common adult mental disorders has increased over time, using age-period-cohort analysis. METHOD: The study consisted of a pseudocohort analysis of a sequence of three cross-sectional surveys of the English household population. The main outcome was common mental disorder, indicated by a score of 12 or above on the Revised Clinical Interview Schedule (CIS-R). Secondary outcomes were neurotic symptoms likely to require treatment, indicated by a CIS-R score of 18 or over, and individual subscale scores for fatigue, sleep problems, irritability and worry. RESULTS: There were 8670 participants in the 1993 survey, 6977 in the 2000 survey and 6815 in the 2007 survey. In men a significant increase in common mental disorder occurred between the cohort born in 1943-9 and that born in 1950-6 (odds ratio 1.4, 95% CI 1.1-1.9) but prevalence in subsequent cohorts remained largely stable. More extended increases in prevalence of sleep problems and mental disorders were observed in women, but not consistently across cohorts or measures. CONCLUSIONS: We found little evidence that the prevalence of common mental disorder is increasing.

Psychiatric morbidity in prisoners with intellectual disabilities: analysis of prison survey data for England and Wales.

A substantial number of prisoners have intellectual disabilities. We analysed data on a sample drawn from all prisons in England and Wales. Intellectual disability was defined as Quick Test scores equivalent to an IQ of ≤65. We found a significantly higher prevalence of probable psychosis, attempted suicide and cannabis use in prisoners with intellectual disabilities. Presence of intellectual disability was twice as likely to be associated with probable psychosis but the relationship was fully mediated by self-rated health status. It is important to identify this group as early as possible in order to provide timely interventions to cope in adverse environments and manage substance misuse.

Epidemiology of autism spectrum disorders in adults in the community in England.

CONTEXT: To our knowledge, there is no published information on the epidemiology of autism spectrum disorders (ASDs) in adults. If the prevalence of autism is increasing, rates in older adults would be expected to be lower than rates among younger adults. OBJECTIVE: To estimate the prevalence and characteristics of adults with ASD living in the community in England. DESIGN: A stratified, multiphase random sample was used in the third national survey of psychiatric morbidity in adults in England in 2007. Survey data were weighted to take account of study design and nonresponse so that the results were representative of the household population. SETTING: General community (ie, private households) in England. PARTICIPANTS: Adults (people 16 years or older). MAIN OUTCOME MEASURES: Autism Diagnostic Observation Schedule, Module 4 in phase 2 validated against the Autism Diagnostic Interview-Revised and Diagnostic Interview for Social and Communication Disorders in phase 3. A 20-item subset of the Autism-Spectrum Quotient self-completion questionnaire was used in phase 1 to select respondents for phase 2. Respondents also provided information on sociodemographics and their use of mental health services. RESULTS: Of 7461 adult participants who provided a complete phase 1 interview, 618 completed phase 2 diagnostic assessments. The weighted prevalence of ASD in adults was estimated to be 9.8 per 1000 (95% confidence interval, 3.0-16.5). Prevalence was not related to the respondent's age. Rates were higher in men, those without educational qualifications, and those living in rented social (government-financed) housing. There was no evidence of increased use of services for mental health problems. CONCLUSIONS: Conducting epidemiologic research on ASD in adults is feasible. The prevalence of ASD in this population is similar to that found in children. The lack of an association with age is consistent with there having been no increase in prevalence and with its causes being temporally constant. Adults with ASD living in the community are socially disadvantaged and tend to be unrecognized.