Correlates of mental disorder and harmful substance use in an indigenous Australian urban sample: an analysis of data from the Queensland Urban Indigenous Mental Health Survey.

PURPOSE: Limited data exists on the relationship between sociodemographic and cultural variables and the prevalence of specific mental and substance use disorders (MSDs) among Indigenous Australians, using diagnostic prevalence data. This paper utilises data from the Queensland Urban Indigenous Mental Health Survey (QUIMHS), a population-level diagnostic mental health survey, to identify socioeconomic and cultural correlates of psychological distress and specific MSDs in an urban Indigenous Australian sample. METHODS: Using a mixture of household sampling (door-knocking) and snowball sampling (promotion of the survey in the community), 406 participants aged 18 to 89 were recruited across key locations in Southeast Queensland. The study investigated various demographic, socioeconomic, and cultural factors as predictors of psychological distress (measured by the Kessler-5) and MSD diagnoses (utilising the Composite International Diagnostic Interview, CIDI 3.0) using a series of univariate logistic regressions. RESULTS: Individuals in unstable housing (homeless, sleeping rough) and those reporting financial distress were more likely to experience an MSD in the past 12 months and throughout their lifetime. Individuals reporting lower levels of connection and belonging, limited participation in cultural events, and lower empowerment were more likely to have a lifetime mental disorder. CONCLUSION: This data emphasises the importance of addressing systemic and social determinants of health when designing and delivering community mental health services and underscores the need for holistic approaches when working with Indigenous communities.

Los trastornos mentales en México 1990-2021. Resultados del estudio Global Burden of Disease 2021 / Mental disorders in Mexico 1990-2021. Results from the Global Burden of Disease 2021 study

Resumen Antecedentes: Los trastornos mentales constituyen una de las principales causas de años vividos con discapacidad, si bien no se dispone de estimaciones recientes sobre su magnitud. Objetivo: Reportar las tendencias de prevalencia de trastornos mentales, los años vividos con discapacidad y los años de vida saludables perdidos por sexo, edad y entidad federativa de México. Material y métodos: Se utilizó la base de datos para México del Global Burden of Disease. Resultados: Se calcularon 18.1 millones de personas con algún trastorno mental en 2021, que representaron un incremento de 15.4 % respecto a 2019. Los trastornos depresivos y de ansiedad aumentaron de manera notable entre 2019 y 2021, lo cual posiblemente esté relacionado con COVID-19, el confinamiento y los duelos vividos durante la pandemia. Conclusiones: Los trastornos mentales se han incrementado considerablemente desde la única encuesta nacional de salud mental que utilizó criterios diagnósticos para evaluar las prevalencias. Es importante invertir en estudios epidemiológicos, prevención y atención de los trastornos mentales, los cuales se encuentran entre las primeras causas de años vividos con discapacidad en el país.

Abstract Background: Mental disorders are one of the main causes of years lived with disability, although there is a lack of recent estimates of their magnitude. Objective: To report the trends of mental disorders prevalence, years lived with disability and years of healthy life lost by sex, age and state in Mexico. Material and methods: The Global Burden of Disease database for Mexico was used. Results: There were an estimated 18.1 million persons with some mental disorder in 2021, which represented an increase of 15.4% in comparison with 2019. Depressive and anxiety disorders did significantly increase between 2019 and 2021, which is possibly related to COVID-19, the confinement and the situations of grief experienced during the pandemic. Conclusions: Mental disorders have considerably increased since the only national mental health survey that used diagnostic criteria to evaluate their prevalence. It is important to invest in epidemiological studies, prevention and care of mental disorders, which are among the leading causes of years lived with disability in the country.

Grading disorder severity and averted burden by access to treatment within the GBD framework: a case study with anxiety disorders.

BACKGROUND: The Global Burden of Disease Study (GBD) estimates burden by cause with major relevance for resource allocators globally. Non-fatal burden estimates are influenced by disorder severity. However, for many disorders, global severity is sourced from a single high-income country survey. We aimed to estimate severity distributions that vary by Healthcare Access Quality Index (HAQI) using anxiety disorders as a case study and present the usefulness of this method in simulating averted and avoidable burden globally. METHODS: In this case study, we estimated treatment use among respondents with anxiety disorder in the 1997 Australian National Survey of Mental Health and Wellbeing (NSMHWB), the source used to estimate severity of anxiety disorders in GBD. Treatment effects were sourced from the Cochrane Database of Systematic Reviews and pooled via network meta-analysis. Severity distribution was established via a meta-regression of their disability weights, derived from 12-item short form survey scores. We simulated the shift in severity across scenarios without access to treatment and with full access to optimal treatment (cognitive behavioural therapy and antidepressants). We interpolated this shift linearly along the HAQI, extrapolated country-specific severity from HAQI scores, and calculated averted and avoidable burden. FINDINGS: The database review sourced 56 reviews, of which eight were eligible for inclusion. These eight reviews reported on 156 randomised controlled trials, with 194 treatment effects. Respondents to the 1997 NSMHWB consisted of 5936 women (55·8%) and 4705 (44·2%) men aged 18 years or older (mean age and ethnicity data not available). The survey-weighted treatment effect size was -0·28 (95% uncertainty interval -0·45 to -0·12). The pooled treatment effect for full coverage optimal treatment was -1·07 (-1·47 to -0·64). The sequela-weighted disability weight among people with anxiety disorder in the NSMHWB was 0·141 (0·042 to 0·275). The estimated disability weight was 0·188 (0·070 to 0·341) after removing the benefits of treatment and 0·056 (0·013 to 0·140) after providing all people with anxiety disorder access to optimal treatment. Globally, 12·5% (4·6 to 21·5) of anxiety disorder burden was averted because of available treatment. However, 71·1% (46·2 to 87·6) of global anxiety disorder burden could be averted if all people with anxiety disorders had access to optimal treatment. INTERPRETATION: Because it is based on guidance from a single survey done in one high-income country, the burden of anxiety disorders in low-income and middle-income countries is probably underestimated by GBD. Despite the availability of effective treatments, low use of these treatments means that most burden is still avoidable. Most of the burden could be averted if all people with anxiety disorders had access to optimal treatment, highlighting the importance of public promotion and referral pathways of treatment for anxiety disorders. Location-specific severity distributions in GBD would greatly increase precision in burden estimates and highlight avertable burden to clinicians, public health practitioners, and policy makers. FUNDING: Queensland Health and Bill & Melinda Gates Foundation.

Diagnostic accuracy of the Composite International Diagnostic Interview (CIDI 3.0) in an urban Indigenous Australian sample.

OBJECTIVE: The Composite International Diagnostic Interview 3.0 is a standardised diagnostic interview commonly used in population-based mental health surveys, but has not been used in community-residing Indigenous Australians. This paper seeks to determine whether the Composite International Diagnostic Interview 3.0 can produce valid diagnostic information when compared with a diagnostic interview in an urban Indigenous Australian sample. METHOD: This research was conducted over 10 weeks with adult Indigenous clients of two participating Aboriginal Medical Services in South-East Queensland. Using a cross-sectional, repeated-measures design, participants were administered the Composite International Diagnostic Interview 3.0 by an Indigenous interviewer and within 2 weeks attended a second appointment with an Indigenous clinical psychologist, who produced a diagnostic summary. The Composite International Diagnostic Interview 3.0 diagnoses were compared with the diagnostic summaries and clinical concordance between the two measures was calculated. RESULTS: The diagnostic accuracy of the Composite International Diagnostic Interview 3.0 differed by module. The Post-traumatic Stress Disorder and Major Depression modules had good utility in diagnosing post-traumatic stress disorder and major depressive episodes, respectively; however, the Mania module that provides diagnoses of bipolar disorder was found to be unsuitable for this population. Although there were no identified contraindications for the use of the Generalised Anxiety and Alcohol Use Disorder modules, further research on the diagnostic accuracy of these modules is warranted. CONCLUSIONS: The Composite International Diagnostic Interview 3.0 can accurately diagnose some common mental disorders in an Indigenous Australian population, but was found to be unsuitable for others. Given these findings, care should be taken when using the Composite International Diagnostic Interview 3.0 in epidemiological prevalence studies with Indigenous Australian populations.

Mental disorders in Mexico 1990-2021. Results from the Global Burden of Disease 2021 study.

BACKGROUND: Mental disorders are one of the main causes of years lived with disability, although there is a lack of recent estimates of their magnitude. OBJECTIVE: To report the trends of mental disorders prevalence, years lived with disability and years of healthy life lost by sex, age and state in Mexico. MATERIAL AND METHODS: The Global Burden of Disease database for Mexico was used. RESULTS: There were an estimated 18.1 million persons with some mental disorder in 2021, which represented an increase of 15.4% in comparison with 2019. Depressive and anxiety disorders did significantly increase between 2019 and 2021, which is possibly related to COVID-19, the confinement and the situations of grief experienced during the pandemic. CONCLUSIONS: Mental disorders have considerably increased since the only national mental health survey that used diagnostic criteria to evaluate their prevalence. It is important to invest in epidemiological studies, prevention and care of mental disorders, which are among the leading causes of years lived with disability in the country.

ANTECEDENTES: Los trastornos mentales constituyen una de las principales causas de años vividos con discapacidad, si bien no se dispone de estimaciones recientes sobre su magnitud. OBJETIVO: Reportar las tendencias de prevalencia de trastornos mentales, los años vividos con discapacidad y los años de vida saludables perdidos por sexo, edad y entidad federativa de México. MATERIAL Y MÉTODOS: Se utilizó la base de datos para México del Global Burden of Disease. RESULTADOS: Se calcularon 18.1 millones de personas con algún trastorno mental en 2021, que representaron un incremento de 15.4 % respecto a 2019. Los trastornos depresivos y de ansiedad aumentaron de manera notable entre 2019 y 2021, lo cual posiblemente esté relacionado con COVID-19, el confinamiento y los duelos vividos durante la pandemia. CONCLUSIONES: Los trastornos mentales se han incrementado considerablemente desde la única encuesta nacional de salud mental que utilizó criterios diagnósticos para evaluar las prevalencias. Es importante invertir en estudios epidemiológicos, prevención y atención de los trastornos mentales, los cuales se encuentran entre las primeras causas de años vividos con discapacidad en el país.

The Burden of Proof studies: assessing the evidence of risk.

Exposure to risks throughout life results in a wide variety of outcomes. Objectively judging the relative impact of these risks on personal and population health is fundamental to individual survival and societal prosperity. Existing mechanisms to quantify and rank the magnitude of these myriad effects and the uncertainty in their estimation are largely subjective, leaving room for interpretation that can fuel academic controversy and add to confusion when communicating risk. We present a new suite of meta-analyses-termed the Burden of Proof studies-designed specifically to help evaluate these methodological issues objectively and quantitatively. Through this data-driven approach that complements existing systems, including GRADE and Cochrane Reviews, we aim to aggregate evidence across multiple studies and enable a quantitative comparison of risk-outcome pairs. We introduce the burden of proof risk function (BPRF), which estimates the level of risk closest to the null hypothesis that is consistent with available data. Here we illustrate the BPRF methodology for the evaluation of four exemplar risk-outcome pairs: smoking and lung cancer, systolic blood pressure and ischemic heart disease, vegetable consumption and ischemic heart disease, and unprocessed red meat consumption and ischemic heart disease. The strength of evidence for each relationship is assessed by computing and summarizing the BPRF, and then translating the summary to a simple star rating. The Burden of Proof methodology provides a consistent way to understand, evaluate and summarize evidence of risk across different risk-outcome pairs, and informs risk analysis conducted as part of the Global Burden of Diseases, Injuries, and Risk Factors Study.

The contribution of general medical conditions to the non-fatal burden of mental disorders: register-based cohort study in Denmark.

BACKGROUND: General medical conditions (GMCs) often co-occur with mental and substance use disorders (MSDs). AIMS: To explore the contribution of GMCs to the burden of disease in people with MSDs, and investigate how this varied by age. METHOD: A population-based cohort of 6 988 507 persons living in Denmark during 2000-2015 followed for up to 16 years. Danish health registers were used to identify people with MSDs and GMCs. For each MSD, years lived with disability and health loss proportion (HeLP) were estimated for comorbid MSDs and GMCs, using a multiplicative model for disability weights. RESULTS: Those with any MSD lost the equivalent of 43% of healthy life (HeLP = 0.43, 95% CI 0.40-0.44) after including information on GMCs, which was an increase from 25% before including GMCs (HeLP = 0.25, 95% CI 0.23-0.27). Schizophrenia was associated with the highest burden of disease (HeLP = 0.77, 95% CI 0.68-0.85). However, within each disorder, the relative contribution of MSDs and GMCs varied. For example, in those diagnosed with schizophrenia, MSDs and GMCs accounted for 86% and 14% of the total health loss; in contrast, in those with anxiety disorders, the same proportions were 59% and 41%. In general, HeLP increased with age, and was mainly associated with increasing rates of pulmonary, musculoskeletal and circulatory diseases. CONCLUSIONS: In those with mental disorders, the relative contribution of comorbid GMCs to the non-fatal burden of disease increases with age. GMCs contribute substantially to the non-fatal burden of disease in those with MSDs.

Excess mortality in severe mental disorders: A systematic review and meta-regression.

The excess mortality observed in people with severe mental disorders (SMD) has not improved over time and is not captured in estimates of disease burden. This study aimed to improve upon previous analytic approaches to account for potential sources of heterogeneity in pooled mortality estimates. A systematic review of studies examining excess mortality in people with psychotic disorders and bipolar disorder was conducted. PubMed, EMBASE and PsycINFO were searched from January 1, 1980 to 31/12/20. Studies were eligible if they were longitudinal; the study population was diagnosed according to established criteria, not restricted to subgroups and the disorder was primary and not acute or transient; and mortality was reported in comparison to the general population or a control group without SMD. Meta-regression models were used to calculate pooled relative risks (RRs) of all-cause and cause-specific mortality adjusted for study- and population-level covariates. Risk of bias was assessed using an adaptation of the Newcastle-Ottawa scale. A total of 76 studies were included in the analyses. Covariates incorporated into the final models included age, sex, population type and mid-year. The adjusted RR for all-cause mortality in schizophrenia was 2.89 (95% CI 2.50 to 3.34) and 2.51 (95%CI 2.10 to 3.00) for bipolar disorder. There were larger RRs for broader categories of psychotic disorders. Mortality was elevated in each cause of death examined. Most of the heterogeneity between studies could not be accounted for. Future research should investigate underlying causal pathways and find ways to incorporate the excess mortality associated with SMD into global health estimates.

The global gap in treatment coverage for major depressive disorder in 84 countries from 2000-2019: A systematic review and Bayesian meta-regression analysis.

BACKGROUND: The treatment coverage for major depressive disorder (MDD) is low in many parts of the world despite MDD being a major contributor to disability globally. Most existing reviews of MDD treatment coverage do not account for potential sources of study-level heterogeneity that contribute to variation in reported treatment rates. This study aims to provide a comprehensive review of the evidence and analytically quantify sources of heterogeneity to report updated estimates of MDD treatment coverage and gaps by location and treatment type between 2000 and 2019. METHODS AND FINDINGS: A systematic review of the literature was conducted to identify relevant studies that provided data on treatment rates for MDD between January 1, 2000, and November 26, 2021, from 2 online scholarly databases PubMed and Embase. Cohort and cross-sectional studies were included if treatment rates pertaining to the last 12 months or less were reported directly or if sufficient information was available to calculate this along with 95% uncertainty intervals (UIs). Studies were included if they made use of population-based surveys that were representative of communities, countries, or regions under study. Studies were included if they used established diagnostic criteria to diagnose cases of MDD. Sample and methodological characteristics were extracted from selected studies. Treatment rates were modeled using a Bayesian meta-regression approach and adjusted for select covariates that quantified heterogeneity in the data. These covariates included age, sex, treatment type, location, and choice of MDD assessment tool. A total of 149 studies were included for quantitative analysis. Treatment coverage for health service use ranged from 51% [95% UI 20%, 82%] in high-income locations to 20% [95% UI 1%, 53%] in low- and lower middle-income locations. Treatment coverage for mental health service use ranged from 33% [95% UI 8%, 66%] in high-income locations to 8% [95% UI <1%, 36%] in low- and lower middle-income countries. Minimally adequate treatment (MAT) rates ranged from 23% [95% UI 2%, 55%] in high-income countries to 3% [95% UI <1%, 25%]) in low- and lower middle-income countries. A primary methodological limitation was the lack of sufficient data from low- and lower middle-income countries, which precluded our ability to provide more detailed treatment rate estimates. CONCLUSIONS: In this study, we observed that the treatment coverage for MDD continues to be low in many parts of the world and in particular in low- and lower middle-income countries. There is a continued need for routine data collection that will help obtain more accurate estimates of treatment coverage globally.

How do Japanese rate the severity of different diseases and injuries?-an assessment of disability weights for 231 health states by 37,318 Japanese respondents.

BACKGROUND: Disability weights (DWs) are weight factors that reflect the severity of health states for estimates of disability-adjusted life years. A new set of global DWs was published for the Global Burden of Diseases and Injuries (GBD) 2013 study, which relied on sampling from various world regions, but included little data for countries in East Asia. This study aimed to measure DWs in Japan using comparable methods, and compare the results with previous estimates from the GBD 2013 DW study. METHODS: We conducted a web-based survey in 2019 to estimate DWs for 231 health states for the Japanese population. The survey included five new health states but otherwise followed the method of the GBD DW measurement study. The survey consisted of 15 paired comparison (PC) questions and 3 population health equivalence questions (PHE) per respondent. We analyzed PC data using probit regression and rescaled results to DW units between 0 (equivalent to full health) and 1 (equivalent to death). FINDINGS: We considered 37,318 nationally representative respondents. The values of the resulting DWs ranged from 0.707 (95% uncertainty interval (UI) 0.527-0.842) for spinal cord injury at neck level (untreated) to 0.004 (UI 0.001-0.009) for mild anemia. High correlation between Japanese DW and GBD 2013 DW was observed, but there was considerable disagreement. Out of 226 comparable health states, 55 (24.3%) showed more than a factor-of-two difference, of which 41 (74.6%) had a higher value in Japanese DW. Many of the health states with higher DW in the Japan study were injuries, including amputation and fracture, and hearing and vision loss, while mental, behavioral, and substance use disorders generally tended to be lower. CONCLUSIONS: This study has created an empirical basis for assessment of Japanese DWs of health status. The findings from this study based on the Japanese population suggest that there might be contextual differences in rating the severity of health states compared to previous surveys conducted elsewhere.

Register-based metrics of years lived with disability associated with mental and substance use disorders: a register-based cohort study in Denmark.

BACKGROUND: Mental disorders account for a substantial proportion of the years lived with disability (YLDs) globally. These estimates have generally been calculated top down based on summary statistics. The aim for this study was to calculate YLDs and a novel related measure, Health Loss Proportion (HeLP), for 18 mental and substance use disorders, based on person-level register data (bottom up). METHODS: A cohort of 6 989 627 Danish residents (5·9% had a diagnosis of a mental or substance use disorder registered in the Danish Psychiatric Central Research Register) was investigated. YLDs (the duration of disease multiplied by a disability weight) were calculated for the disorder of interest and for comorbid mental and substance use disorders. HeLPs were estimated as YLDs associated with an index disorder and comorbid mental and substance use disorders divided by person-years at risk in persons with the index disorder. All analyses were adjusted for mental and substance use comorbidity using a multiplicative model of disability weights. FINDINGS: Major depressive disorder was the most prevalent disorder, although schizophrenia was the leading cause of YLDs in both sexes combined (YLDs 273·3 [95 % CI 232·3-313·6] per 100 000 person-years). People diagnosed with schizophrenia lost the equivalent of 73% (63-83%) of healthy life per year due to mental and substance use disorders, the largest HeLP of all mental and substance use disorders. Comorbidity of mental and substance use disorders accounted for 69-83% of HeLPs in people with either cannabis use disorders, other drug use disorder and ADHD. By contrast, comorbidity explained 11-23% of the HeLPs in people with autism spectrum disorders, conduct disorder, and schizophrenia. INTERPRETATION: Substantial variation in disability was observed across age, sex, and disorders. The new HeLP metric provides novel details of the contribution of comorbidity to the disability associated with mental and substance use disorders. FUNDING: The Danish National Research Foundation, Queensland Government Department of Health, European Union's Horizon 2020, Lundbeck Foundation, Stanley Medical Research Institute. TRANSLATION: For the Danish translation of the abstract see Supplementary Materials section.

Estimating the risk of suicide associated with mental disorders: A systematic review and meta-regression analysis.

BACKGROUND: Mental disorders (MDs) are known risk factors for suicide. This systematic review updates the evidence base for this association and improves upon analytic approaches by incorporating study-level and methodological variables to account for measurement error in pooled suicide risk estimates. METHODS: A systematic review was conducted to review studies on MDs as risk factors for suicide. Relevant studies were searched using PubMed, Embase, PsychINFO, and existing reviews from 2010 to 19. Studies were eligible if they were longitudinal/case-control studies, representative of the general population, used diagnostic instruments, and quantified suicide risk. The outcome assessed was relative risks (RRs) for suicide due to MDs. A multi-level meta-regression approach was used to obtain pooled RRs adjusted for covariates and between-study effects. FINDINGS: We identified 20 eligible studies yielding 69 RRs. Disorder type, age, sex, use of psychological autopsy, study design, and adjustment for confounders were tested as predictors of pooled suicide risk. Overall, all disorders were significant predictors of suicide with predicted adjusted RRs ranging from 4·11 [2·09, 8·09] for dysthymia to 7·64 [4·3, 13·58] for major depressive disorder. INTERPRETATION: Our results indicate that MDs are important risk factors for suicide. This systematic review provides pooled RRs that have been adjusted for methodological sources of bias. Findings from our paper may inform suicide prevention strategies as part of national health agendas.

The hidden burden of eating disorders: an extension of estimates from the Global Burden of Disease Study 2019.

BACKGROUND: Anorexia nervosa and bulimia nervosa are the only eating disorders included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, yet binge-eating disorder and other specified feeding or eating disorder (OSFED) are more prevalent. This study sought to estimate the prevalence and burden of binge-eating disorder and OSFED globally and present a case for their inclusion in GBD. METHODS: We sourced studies from the GBD 2019 anorexia nervosa and bulimia nervosa epidemiological databases, two systematic reviews that included studies with epidemiological estimates of binge-eating disorder and OSFED, and experts in the field. Studies, published between Jan 1, 1998, and March 1, 2019, were included if they reported non-zero prevalence of two or more eating disorders (anorexia nervosa, bulimia nervosa, binge-eating disorder, or OSFED) and diagnosed cases according to DSM-IV or DSM-5. The proportions of total eating disorder cases that met diagnostic criteria for each individual eating disorder were estimated via network meta-regression and simulation using studies reporting eating disorder prevalence. The global cases unrepresented in GBD 2019 were estimated using the proportions from the simulation and the GBD 2019 eating disorder prevalence. Disability weights for binge-eating disorder and OSFED were then estimated along with disability-adjusted life-years (DALYs). Estimates are presented with 95% uncertainty intervals (UIs). FINDINGS: 54 studies, of which 36 were from high-income countries, were included in the analysis. The number of global eating disorder cases in 2019 that were unrepresented in GBD 2019 was 41·9 million (95% UI 27·9-59·0), and consisted of 17·3 million (11·3-24·9) people with binge-eating disorder and 24·6 million (14·7-39·7) people with OSFED (vs 13·6 million [10·2-17·5] people with eating disorders in GBD 2019). Together, binge-eating disorder and OSFED caused 3·7 million (95% UI 2·0-6·5) DALYs globally, bringing the total eating disorder DALYs to 6·6 million (3·8-10·6) in 2019. INTERPRETATION: Binge-eating disorder and OSFED accounted for the majority of eating disorder cases and DALYs globally. These findings warrant the inclusion of binge-eating disorder and OSFED in future iterations of GBD, which will bring the burden experienced by people living with these disorders to the attention of policy makers with the means to target this burden. FUNDING: Queensland Health, Australian National Health and Medical Research Council, and Bill & Melinda Gates Foundation.

Service demand for psychological interventions among Australian adults: a population perspective.

BACKGROUND: Psychological interventions (PIs) are good practice treatment for both subthreshold and diagnosed mental disorders. Australia has implemented major reforms to expand the provision of subsidised psychological services for individuals with a diagnosed mental disorder. But there are gaps in knowledge about demand for PIs (i.e., use of and perceived need for PIs) across the population. This study uses nationally representative survey data from the 2007 Australian National Survey of Mental Health and Wellbeing to analyse demand for PIs. It also provides a method for analysing survey data to estimate demand for PIs when new survey data becomes available, along with suggestions to inform future survey development. METHODS: Nationally representative community survey respondents (n = 8841, 16-85 years) indicated their perceived need for nine types of help for mental health problems in the past 12 months, including three PIs (cognitive behavioural therapy, psychotherapy, and counselling), and whether these needs were unmet, partially met, or fully met. Types of help were grouped as: PIs only; PIs plus other; and other only. Chi-square analyses were used to examine the association between type of intervention, sociodemographic and clinical factors, and type of professional consulted; multinomial logistic regression models were used to examine predictors of type of intervention(s) received. RESULTS: 7.9% (95%CI: 7.2-8.6) received PIs. Receipt of PIs was positively associated with higher education and consulting a mental health specialist. Twice as many respondents received PIs plus medication as compared to PIs only (4.2% vs. 2.0%). Almost half (45.4, 95%CI 36.5-54.6) incurred out-of-pocket costs for treatment. The most common reason for partially met need for PIs was cost (24.8, 95%CI 17.2-34.3); for unmet need, it was preference for self-management (33.9, 95%CI 21.2-49.5). Perceived unmet need for PIs only (3.1, 95%CI 2.1-4.6) or PIs plus other interventions (5.2, 95%CI 3.9-6.9%) was lower than for other interventions only (22.8, 95%CI 18.7-27.6). CONCLUSIONS: Continued reforms in Australia means that on-going monitoring of demand for PIs, using nationally representative data, is required. This study provides a baseline for comparison of the long-term effects of these reforms; this comparison may be undertaken using data from the third iteration of Australia's NSMHWB, due for completion in 2021-22.

All-cause and cause-specific mortality among people with regular or problematic cocaine use: a systematic review and meta-analysis.

AIMS: To estimate pooled all-cause and cause-specific mortality risk for people with regular or problematic cocaine use. METHODS: Systematic review and meta-analysis of prospective or retrospective cohort studies or clinical trials (n ≥30) of people with regular or problematic cocaine use with data on all-cause or cause-specific mortality. Of 2808 papers, 28 were eligible and reported on 21 cohorts, with a total 170 019 individuals. Cohorts identified based on acute care for drug poisoning or other severe health presentation were excluded. Title/abstract screening was conducted by one reviewer; a second reviewer independently checked 10% of excluded studies. Two reviewers conducted full-text screening. Data were extracted by one reviewer and checked by a second. A customized review-specific study reporting quality/risk of bias tool was used. Data on crude mortality rates (CMR) and standardized mortality ratios were extracted for both all-cause and cause-specific mortality. Standardized mortality ratios were imputed where not provided by the author using extracted data and information from the Global Burden of Disease Study 2017. Data were pooled using a random-effects model. RESULTS: The pooled all-cause crude mortality rate was 1.24 per 100 person-years [95% confidence interval (CI) = 0.86, 1.78; n = 16 cohorts], but with considerable heterogeneity (I2  = 98.8%). The pooled all-cause standardized mortality ratio (SMR) was 6.13 (95% CI = 4.15, 9.05; n = 16 cohorts). Suicide (SMR = 6.26, 95% CI = 2.84, 13.80), accidental injury (SMR = 6.36, 95% CI = 4.18, 9.68), homicide (SMR = 9.38, 95% CI 3.45-25.48) and AIDS-related mortality (SMR = 23.12, 95% CI = 11.30, 47.31) were all elevated compared with age and sex peers in the general population. CONCLUSIONS: There are elevated rates of mortality among people with regular or problematic cocaine use for traumatic deaths and deaths attributable to infectious disease.

Nature and prevalence of combinations of mental disorders and their association with excess mortality in a population-based cohort study.

The nature and prevalence of combinations of mental disorders and their associations with premature mortality have never been reported in a comprehensive way. We describe the most common combinations of mental disorders and estimate excess mortality associated with these combinations. We designed a population-based cohort study including all 7,505,576 persons living in Denmark at some point between January 1, 1995 and December 31, 2016. Information on mental disorders and mortality was obtained from national registers. A total of 546,090 individuals (10.5%) living in Denmark on January 1, 1995 were diagnosed with at least one mental disorder during the 22-year follow-up period. The overall crude rate of diagnosis of mental disorders was 9.28 (95% CI: 9.26-9.30) per 1,000 person-years. The rate of diagnosis of additional mental disorders was 70.01 (95% CI: 69.80-70.26) per 1,000 person-years for individuals with one disorder already diagnosed. At the end of follow-up, two out of five individuals with mental disorders were diagnosed with two or more disorder types. The most prevalent were neurotic/stress-related/somatoform disorders (ICD-10 F40-F48) and mood disorders (ICD-10 F30-F39), which - alone or in combination with other disorders - were present in 64.8% of individuals diagnosed with any mental disorder. Mortality rates were higher for people with mental disorders compared to those without mental disorders. The highest mortality rate ratio was 5.97 (95% CI: 5.52-6.45) for the combination of schizophrenia (ICD-10 F20-F29), neurotic/stress-related/somatoform disorders and substance use disorders (ICD-10 F10-F19). Any combination of mental disorders was associated with a shorter life expectancy compared to the general Danish population, with differences in remaining life expectancy ranging from 5.06 years (95% CI: 5.01-5.11) to 17.46 years (95% CI: 16.86-18.03). The largest excess mortality was observed for combinations that included substance use disorders. This study reports novel estimates related to the "force of comorbidity" and provides new insights into the contribution of substance use disorders to premature mortality in those with comorbid mental disorders.

All-Cause and Overdose Mortality Risk Among People Prescribed Opioids: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate all-cause and overdose crude mortality rates and standardized mortality ratios among people prescribed opioids for chronic noncancer pain and risk of overdose death in this population relative to people with similar clinical profiles but not prescribed opioids. DESIGN: Systematic review and meta-analysis. METHODS: Medline, Embase, and PsycINFO were searched in February 2018 and October 2019 for articles published beginning 2009. Due to limitations in published studies, we revised our inclusion criteria to include cohort studies of people prescribed opioids, excluding those studies where people were explicitly prescribed opioids for the treatment of opioid use disorder or acute cancer or palliative pain. We estimated pooled all-cause and overdose crude mortality rates using random effects meta-analysis models. No studies reported standardized mortality ratios or relative risks. RESULTS: We included 13 cohorts with 6,029,810 participants. The pooled all-cause crude mortality rate, based on 10 cohorts, was 28.8 per 1000 person-years (95% CI = 17.9-46.4), with substantial heterogeneity (I2 = 99.9%). The pooled overdose crude mortality rate, based on six cohorts, was 1.1 per 1000 person-years (95% CI = 0.4-3.4), with substantial heterogeneity (I2 = 99.5%), but indications for opioid prescribing and opioid exposure were poorly ascertained. We were unable to estimate mortality in this population relative to clinically similar populations not prescribed opioids. CONCLUSIONS: Methodological limitations in the identified literature complicate efforts to determine the overdose mortality risk of people prescribed opioids. There is a need for large-scale clinical trials to assess adverse outcomes in opioid prescribing, especially for chronic noncancer pain.

Association of Specific Mental Disorders With Premature Mortality in the Danish Population Using Alternative Measurement Methods.

Importance: The association of mental disorders with premature mortality published in the Global Burden of Disease (GBD) studies has been underestimated because these analyses have recommended using only a small number of mental disorders as causes of death to estimate years of life lost (YLL). Alternative methods have been introduced, such as estimating life-years lost (LYL), to compare individuals with mental disorders with the general population. Objectives: To generate register-based YLL and LYL estimates and to use these measurement methods to assess the association of specific mental disorders with premature mortality. Design, Setting, and Participants: This population-based cohort study included all persons with and without mental disorders aged 0 to 94 years who were living in Denmark between January 1, 2000, and December 31, 2015. Data were analyzed from January to December 2019. Main Outcomes and Measures: Danish health registers were used to identify mental disorder diagnoses, dates of death, and causes of death. The YLLs were estimated for the set of mental health-associated causes of death, and all-cause and cause-specific LYLs were estimated for 18 specific mental disorders and 3 broad categories of mental disorders that were recommended for use in the GBD studies. The association between the number of comorbid mental disorders (divided into categories of persons with ≥1 type of disorder, ≥2 types of disorders, ≥3 types of disorders, and ≥4 types of disorders) and LYL estimates was also examined. Results: A total of 6 989 627 individuals (3 481 219 male persons [49.8%] and 3 508 408 female persons [50.2%]; mean [SD] age at study enrollment, 32.2 [24.4] years) were followed up for a total of 85 911 461 person-years. The YLL rates per 100 000 person-years were highest for alcohol use disorder (for male individuals, 568.7 [95% CI, 564.4-572.7]; for female individuals, 155.5 [95% CI, 153.5-157.9]) and suicide (for male individuals, 590.1 [95% CI, 583.8-596.5]; for female individuals, 202.3 [95% CI, 198.5-206.4]). Although only 3 of 18 mental and substance use disorders could be associated with YLL, all mental disorders were associated with shorter life expectancies when LYL was used for measurement. Male and female individuals diagnosed with any mental disorder had life expectancies that were shorter by 11.2 years (95% CI, 11.1-11.3 years) and 7.9 years (95% CI, 7.8-8.0 years), respectively, and remaining life expectancy decreased further among those with comorbid mental disorders. Drug use disorders were associated with the highest excess LYL estimates; however, common mental disorders, such as depressive and anxiety disorders, were also associated with substantial premature mortality. Conclusions and Relevance: Mental disorders were observed to be associated with reductions in life expectancy. This finding provides a foundation for future intervention programs designed to reduce the differential mortality gap associated with mental disorders. Register-based studies allow the calculation of precise individual-level YLLs and LYLs, and both measurement methods are informative for health care planning. Compared with YLL, the novel LYL measurement approach may more precisely capture the association of mental disorders with premature mortality and facilitates the exploration of comorbidity and specific causes of death in individuals with mental disorders.

All-Cause and Cause-Specific Mortality Among People Using Extramedical Opioids: A Systematic Review and Meta-analysis.

Importance: Extramedical opioid use has escalated in recent years. A better understanding of cause-specific mortality in this population is needed to inform comprehensive responses. Objective: To estimate all-cause and cause-specific crude mortality rates (CMRs) and standardized mortality ratios (SMRs) among people using extramedical opioids, including age- and sex-specific estimates when possible. Data Sources: For this systematic review and meta-analysis, MEDLINE, PsycINFO, and Embase were searched for studies published from January 1, 2009, to October 3, 2019, and an earlier systematic review on this topic published in 2011. Study Selection: Cohort studies of people using extramedical opioids and reporting mortality outcomes were screened for inclusion independently by 2 team members. Data Extraction and Synthesis: Data were extracted by a team member and checked by another team member. Study quality was assessed using a custom set of items that examined risk of bias and quality of reporting. Data were pooled using random-effects meta-analysis models. Heterogeneity was assessed using stratified meta-analyses and meta-regression. Main Outcomes and Measures: Outcome measures were all-cause and cause-specific CMRs and SMRs among people using extramedical opioids compared with the general population of the same age and sex. Results: Of 8683 identified studies, 124 were included in this analysis (100 primary studies and 24 studies providing additional data for primary studies). The pooled all-cause CMR, based on 99 cohorts of 1 262 592 people, was 1.6 per 100 person-years (95% CI, 1.4-1.8 per 100 person-years), with substantial heterogeneity (I2 = 99.7%). Heterogeneity was associated with the proportion of the study sample that injected opioids or was living with HIV infection or hepatitis C. The pooled all-cause SMR, based on 43 cohorts, was 10.0 (95% CI, 7.6-13.2). Excess mortality was observed across a range of causes, including overdose, injuries, and infectious and noncommunicable diseases. Conclusions and Relevance: The findings suggest that people using extramedical opioids experience significant excess mortality, much of which is preventable. The range of causes for which excess mortality was observed highlights the multiplicity of risk exposures experienced by this population and the need for comprehensive responses to address these. Better data on cause-specific mortality in this population in several world regions appear to be needed.