Adult Mental Disorders Research Articles

Gender differences in mental health expectancies in early- and midlife in six European countries

Health expectancies, taking into account both quality and quantity of life, have generally been based on disability and physical functioning. To compare mental health expectancies at age 25 and 55 based on common mental disorders both across countries and between males and females. Mental health expectancies were calculated by combining mortality data from population life tables and the age-specific prevalence of selected common mental disorders obtained from the European Study of the Epidemiology of Mental Disorders (ESEMeD). For the male population aged 25 (all countries combined) life expectancy was 52 years and life expectancy spent with a common mental disorder was 1.8 years (95% CI 0.7-2.9), 3.4% of overall life expectancy. In comparison, for the female population life expectancy at age 25 was higher (57.9 years) as was life expectancy spent with a common mental disorder (5.1 years, 95% CI 3.6-6.6) and as a proportion of overall life expectancy, 8.8%. By age 55 life expectancy spent with a common mental disorder had reduced to 0.7 years (males) and 2.3 years (females). Age and gender differences underpin our understanding of years spent with common mental disorders in adulthood. Greater age does not mean living relatively more years with common mental disorder. However, the female population spends more years with common mental disorders and a greater proportion of their longer life expectancy with them (and with each studied separate mental disorder).

Adult mental health disorders and their age at onset

The study of age at onset of mental health disorders is technically and conceptually difficult. It is important to consider these age distributions in order to understand causes and mechanisms of illness and to intervene at an appropriate juncture for primary and secondary prevention. This article reviews some of the approaches to studying age at onset, sets out the evidence to support the assertion that adult mental disorders begin in adolescence, and finds that perhaps half of all adult mental health disorders have begun by the teenage years. The paper then discusses whether this fits what is known about the developmental neurobiology of the brain and introduces the implications for mental health services.

946 – Education modulates the effect of childhood adversity on lifetime suicidal behavior and major depression

Introduction Childhood adversity is a major risk factor for life-time various psychiatric disorders. The vulnerability for psychiatric disorders appears to be modulated by cognitive reserve (CR). Objectives We wanted to examine the impact of childhood adversity on lifetime suicidal behavior and major depression and its modulation by education, a CR proxy. Method 1494 non-institutionalized individuals without dementia from a cohort of community-dwelling persons aged over 65 years (the ESPRIT study) were randomly selected from electoral rolls and rated for childhood adversity (e.g., emotional abuse and neglect). Life-time major depression and suicidal behavior were assessed according to DSM-IV criteria. Results Exposure to adversity in childhood increased the risk of life-time suicidal behavior and major depression (p Conclusion Our results suggest high education level as a protective factor to counteract the effects of childhood adversity on the onset of mental disorders in adulthood.

Childhood maltreatment and DSM-IV adult mental disorders: comparison of prospective and retrospective findings

Childhood maltreatment and DSM-IV adult mental disorders: comparison of prospective and retrospective findings

Collaborative Care for the Treatment of Depression in Primary Care With a Low-Income, Spanish-Speaking Population

This study sought to (1) evaluate the effectiveness of a collaborative care model with a predominantly Hispanic, low-income population in a primary care setting and (2) examine depression outcomes with a subpopulation of preferentially Spanish-speaking patients compared with non-Hispanic white participants. The data were collected from September 2006 through September 2009 at the study site, the People's Community Clinic, Austin, Texas. Data collection was part of an evaluation of the Integrated Behavioral Health program, a collaborative care model of identifying and treating mild-to-moderate mental disorders in adults in a primary care setting. A bilingual care manager provided supportive counseling and patient education and systematically tracked patient progress in a patient registry. A consulting psychiatrist evaluated patients with diagnostic or treatment concerns. The study retrospectively examined changes in depression scores among 269 subjects as measured by the Patient Health Questionnaire (PHQ-9), the primary outcome measure. The PHQ-9 is a self-report of frequency of symptoms for each of the 9 DSM-IV criteria for depression. Logistic regression models compared race/ethnicity and language group combinations on their odds of achieving clinically meaningful depression improvement when background characteristics were controlled for. Spanish-speaking Hispanic patients had significantly greater odds of achieving a clinically meaningful improvement in depression at 3-month follow-up (odds ratio [OR] = 2.45, P = .013) compared to non-Hispanic whites. The finding for greater improvement in the Spanish-speaking population remained after controlling for age, sex, medical comorbidities, prior treatment, and baseline depression scores. The results suggest a model of care that is effective for a population at great risk for marginal mental health care, non-English-speaking Hispanics. Attention to patient preferences in primary care is essential to improve quality of depression treatment and may improve outcomes. In light of previous research that demonstrates insufficient evidence-based guidelines for patients with limited English proficiency and evidence that evaluation of patients in their nonprimary language or through an interpreter can lead to inaccurate mental health assessments, this study suggests an opportunity to improve the quality of mental health care for non-English-speaking Hispanics in the United States.

Is there a general factor of prevalent psychopathology during adulthood?

The patterns of comorbidity among prevalent mental disorders in adults lead them to load on "externalizing," "distress," and "fears" factors. These factors are themselves robustly correlated, but little attention has been paid to this fact. As a first step in studying the implications of these interfactor correlations, we conducted confirmatory factor analyses on diagnoses of 11 prevalent Diagnostic and Statistical Manual of Mental Disorders (4th ed.) mental disorders in a nationally representative sample. A model specifying correlated externalizing, distress, and fears factors fit well, but an alternative model was tested in which a "general" bifactor was added to capture what these disorders share in common. There was a modest but significant improvement in fit for the bifactor model relative to the 3-factor oblique model, with all disorders loading strongly on the bifactor. Tests of external validity revealed that the fears, distress, and externalizing factors were differentially associated with measures of functioning and potential risk factors. Nonetheless, the general bifactor accounted for significant independent variance in future psychopathology, functioning, and other criteria over and above the fears, distress, and externalizing factors. These findings support the hypothesis that these prevalent forms of psychopathology have both important common and unique features. Future studies should determine whether this is because they share elements of their etiology and neurobiological mechanisms. If so, the existence of common features across diverse forms of prevalent psychopathology could have important implications for understanding the nature, etiology, and outcomes of psychopathology.

Studies impacting the clinical world in the European Child and Adolescent Psychiatry

One of the most promising areas in medicine is the so called personalized medicine where pharmacogenetic approach has a clear role [4]. However, the developments in the pharmacogenetic field of psychiatric disorders have not been as quick as in other areas of medicine. This scenario is even slower for child and adolescents mental disorders. In this issue of the journal, Blazquez et al. [1] present an extensive review of the literature describing how certain genes are involved in the pharmacodynamics and pharmacokinetics of fluoxetine in children and adolescents. Initial exciting findings seem to suggest a potential role for polymorphisms in several genes like SLC6A4, HTR1A and MAO-A as moderators of response to fluoxetine in depression. Nevertheless, the authors clearly document the scarcity of studies and the diversity of methodology in the investigations hampering any chance of a major step in defining a more personalized treatment for this disorder at the present moment. Other relevant research areas in child mental health with impact on clinical work are: (1) the role of environmental factors in child mental disorders, specially smoking during pregnancy in ADHD; and (2) the need of developing friendly non-pharmacological interventions that can help individuals with mental disorders dealing with the impact of symptoms in their daily lives. There is an unresolved debate in the literature on the real role of smoking during pregnancy in the etiology of ADHD with several authors suggesting that the association found might be solely a product of not controlled confounding variables like the genetic predisposition for ADHD (see Motlagh et al. [6] and Thapar et al. [7]). In this issue of the journal, Ellis et al. [5] add interesting findings for this discussion. In a community sample of 995 4-year olds from Norway, they found increased odds for both ADHD and ODD in offspring of mothers that smoked during pregnancy, even after adjusting for potential confounding variables by using the propensity score. Obviously, if a real association exists between smoking during pregnancy and externalizing disorders in children, the implications for public mental health are enormous. Developmental psychopathology has emphasized the intimate relation between child and adult mental disorders. Pharmacological interventions are key tools for treating core symptoms of some mental disorders like ADHD [2]. However, clinicians are left without many evidence-based options for helping their patients to deal with increasing environmental demands, even more when they grow up entering adulthood. Thus, there is a clear need to test potential interventions in the real world addressing this shortcoming. In this context, Wentz et al. [9] applied a user-centered design to develop a model for internet-based support and coaching for adolescents and adults with ADHD and ASD. The intervention is a mix of support sessions via internet (chat) and two additional in-person meetings. It was designed to last 8 weeks and the model was validated in a pilot study with ten individuals with ASD and/or ADHD. Since quality of life seems to be seriously impaired by ADHD (see Danckaerts et al. [3]), one reassuring finding was an improvement in subjective quality of life at follow-up. Although replication is needed before any firm conclusion on the efficacy of the intervention might be defined, the field certainly welcomes this kind of initiatives. Finally, but yet in the context of developmental psychopathology, roads from certain temperamental aspects L. A. Rohde (&) Department of Psychiatry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil e-mail: lrohde@terra.com.br

Low intake of B-vitamins is associated with poor adolescent mental health and behaviour

ObjectiveThe current prevalence of mental health problems in Western populations is approximately 20% and half of all adult mental health disorders are estimated to originate in adolescence. Diet plays an important role in modulating psychological wellbeing and B-vitamins are vital for the synthesis of neurotransmitters such as serotonin. We aimed to examine the relationship between B-group vitamins and adolescent mental health and behaviour. MethodsThis is a cross-sectional analysis of the West Australian Pregnancy Cohort (Raine) Study. The 17-year follow-up included collection of a food frequency questionnaire allowing B-vitamin intake calculation. Mental health was assessed using the Youth Self Report (YSR) which measures total, internalising (withdrawn/depressed) and externalising (aggressive/delinquent) behaviour scores. Multiple linear regression was used to analyse associations between B-vitamins and mental health with adjustment for relevant confounders (n=709). ResultsLower intake of vitamins B1, B2, B3, B5, B6, and folate was associated with higher externalising behaviour scores (p≤0.05). Reduced intake of vitamin B6 and folate was associated with higher internalising behaviour scores (p≤0.05). ConclusionsPoor nutrition may contribute to the pathogenesis of mental health problems in adolescence. The role of B-vitamins requires further investigation in randomised controlled trials.

Relation of Childhood Malnutrition to Adult Mental Disorders

Relation of Childhood Malnutrition to Adult Mental Disorders

Caudate Gray Matter Volume in Obsessive-Compulsive Disorder Is Influenced by Adverse Childhood Experiences and Ongoing Drug Treatment

Exposure to adverse childhood experiences (ACE) increases the risk of adult physical and mental health disorders, including obsessive-compulsive disorder (OCD), and influences adult cortical neural responses and gray matter (GM) volumes. Robust neuroimaging findings associated OCD with corticostriatal dysfunction and with abnormal morphology and metabolism of cortical areas and basal ganglia. We explored the GM correlates of ACE in 40 patients with OCD (15 drug-naive and 25 drug-treated patients) with magnetic resonance imaging voxel-based morphometry at 3.0 T. Regional GM volumes were the dependent variable, and drug treatment (naive vs treated) and breadth of exposure to ACE (high vs low) were the factors of interest. Sex, duration of illness, and handedness were considered as nuisance covariates. Whole brain statistical threshold was P < 0.05 familywise error corrected for multiple comparisons. Patients with higher levels of exposure to ACE showed increased GM volume in the head of the left caudate nucleus. Ongoing drug treatment was associated with reduced GM volume in the same area. Earlier age at onset of OCD, need for medication treatment, and mixed handedness were correlated with higher levels of ACE. Exposure to ACE increased, and ongoing drug treatment decreased, caudate GM in OCD. Increased volume and metabolism of the caudate nucleus have been consistently associated with OCD. Our findings suggest a detrimental effect of ACE on the brain underpinnings of OCD, with an opposite effect of medications.

Prognostic significance of functional somatic symptoms in adolescence: a 15-year community-based follow-up study of adolescents with depression compared with healthy peers

BackgroundThere is a lack of population-based long-term longitudinal research on mental health status and functional physical/somatic symptoms. Little is known about the long-term mental health outcomes associated with somatic symptoms or the temporal relationship between depression and such symptoms. This 15-year study followed up adolescents with depression and matched controls, screened from a population-based sample, who reported different numbers of somatic symptoms.MethodsThe total population of 16–17-year-olds in Uppsala, Sweden, was screened for depression in 1991–1993. Adolescents who screened positive and an equal number of healthy controls took part in a semi-structured diagnostic interview. In addition, 21 different self-rated somatic symptoms were assessed. Sixty-four percent of those adolescents participated in a follow-up structured interview 15 years later.ResultsSomatic symptoms in adolescence predicted depression and other adult mental disorders regardless of the presence of adolescent depression. In adolescents with depression, the number of functional somatic symptoms predicted, in a dose response relationship, suicidal behavior, bipolar episodes, and psychotic episodes as well as chronic and recurrent depression. Contrary to expectations, the somatic symptoms of abdominal pain and perspiration without exertion better predicted depression than all DSM-IV depressive symptoms. Abdominal pain persisted as an independent strong predictor of depression and anxiety, even after controlling for other important confounders.ConclusionsSomatic symptoms in adolescence can predict severe adult mental health disorders. The number of somatic symptoms concurrent with adolescent depression is, in a stepwise manner, linked to suicidal attempts, bipolar disorders, psychotic disorders, and recurrent and chronic depression. These findings can be useful in developing treatment guidelines for patients with somatic symptoms.

Impact of ethnic density on adult mental disorders: narrative review

The 'ethnic density hypothesis' is a proposition that members of ethnic minority groups may have better mental health when they live in areas with higher proportions of people of the same ethnicity. Investigations into this hypothesis have resulted in a complex and sometimes disparate literature. To systematically identify relevant studies, summarise their findings and discuss potential explanations of the associations found between ethnic density and mental disorders. A narrative review of studies published up to January 2011, identified through a systematic search strategy. Studies included have a defined ethnic minority sample; some measure of ethnic density defined at a geographical scale smaller than a nation or a US state; and a measure ascertaining mental health or disorder. A total of 34 papers from 29 data-sets were identified. Protective associations between ethnic density and diagnosis of mental disorders were most consistent in older US ecological studies of admission rates. Among more recent multilevel studies, there was some evidence of ethnic density being protective against depression and anxiety for African American people and Hispanic adults in the USA. However, Hispanic, Asian-American and Canadian 'visible minority' adolescents have higher levels of depression at higher ethnic densities. Studies in the UK showed mixed results, with evidence for protective associations most consistent for psychoses. The most consistent associations with ethnic density are found for psychoses. Ethnic density may also protect against other mental disorders, but presently, as most studies of ethnic density have limited statistical power, and given the heterogeneity of their study designs, our conclusions can only be tentative.

Childhood maltreatment and DSM-IV adult mental disorders: Comparison of prospective and retrospective findings

Prior research reports stronger associations between childhood maltreatment and adult psychopathology when maltreatment is assessed retrospectively compared with prospectively, casting doubt on the mental health risk conferred by maltreatment and on the validity of retrospective reports. To investigate associations of psychopathology with prospective v. retrospective maltreatment ascertainment. A nationally representative sample of respondents aged 16-27 years (n = 1413) in New Zealand completed a retrospective assessment of maltreatment and DSM-IV mental disorders. Survey data were linked with a national child protection database to identify respondents with maltreatment records (prospective ascertainment). Childhood maltreatment was associated with elevated odds of mood, anxiety and drug disorders (odds ratios = 2.1-4.1), with no difference in association strength between prospective and retrospective groups. Prospectively ascertained maltreatment predicted unfavourable depression course involving early onset, chronicity and impairment. Prospectively and retrospectively assessed maltreatment elevated the risk of psychopathology to a similar degree. Prospectively ascertained maltreatment predicted a more unfavourable depression course.

Parental death during childhood and psychopathology in adulthood

We examined the association between parental death during childhood and lifetime and 12-month psychopathology, age of onset, incidence of mental health problems, use of mental health services during adulthood and functional limitations during adulthood.We conducted a longitudinal, population-based epidemiological study in adults aged 18–64years (N=7076). Mental disorders were assessed with a standardized diagnostic interview (Composite International Diagnostic Interview (CIDI)). Few indications were found that there was a significant increase in mental disorders in adulthood among people who had lost a parent before the age of 16 (N=541). Parental death was not associated with mental disorders (12months; lifetime), age of onset, incidence of mental disorders, functional limitations or use of mental health services. The majority of children overcome the loss of a parent during childhood without experiencing increased mental health problems, reduced functional limitations or a greater need for mental health services during adulthood.

Maternal mental disorders in pregnancy and the puerperium and risks to infant health.

Prenatal and postnatal period presents the highest prevalence of mental disorders in women's lives and depression is the most frequent one, affecting approximately one in every five mothers. The aggravating factor here is that during this period psychiatric symptoms affect not only women's health and well-being but may also interfere in the infant's intra and extra-uterine development. Although the causes of the relationship between maternal mental disorders and possible risks to a child's health and development remain unknown, it is suspected that these risks may be related to the use of psychotropic drugs during pregnancy, to substance abuse and the mother's lifestyle. Moreover, after delivery, maternal mental disorders may also impair the ties of affection (bonding) with the newborn and the maternal capacity of caring in the post-partum period thus increasing the risk for infant infection and malnutrition, impaired child growth that is expressed in low weight and height for age, and even behavioral problems and vulnerability to presenting mental disorders in adulthood. Generally speaking, research on this theme can be divided into the type of mental disorder analyzed: studies that research minor mental disorders during pregnancy such as depression and anxiety find an association between these maternal disorders and obstetric complications such as prematurity and low birth weight, whereas studies that evaluate severe maternal mental disorders such as schizophrenia and bipolar disorder have found not only an association with general obstetric complications as well as with congenital malformations and perinatal mortality. Therefore, the success of infant growth care programs also depends on the mother's mental well being. Such findings have led to the need for new public policies in the field of maternal-infant care geared toward the population of mothers. However, more research is necessary so as to confirm the association between all factors with greater scientific rigor.

Overview of Intellectual/Developmental Disabilities

Patients with intellectual/developmental disabilities (IDD) present many challenges to mental health professionals. The capacity to work with such patients requires a working knowledge of IDD as well as an awareness and understanding of the factors that affect the clinical presentation of mental health disorders across the spectrum of IDD.

Placental Source for 5-HT that Tunes Fetal Brain Development

Deciphering the influences of fetal programming on adult mental disorders causality depends on the identification of specific molecular pathways involved in their etiology. New insights will provide the means for reducing developmentally based disorder risk, and new therapeutic targets for treatments in adulthood. For example, our recent discovery of maternal–placental–fetal interactions that may influence brain development leads to new hypotheses regarding the mechanisms by which fetal programming of adult mental disorders may occur. A tryptophan (the precursor of serotonin—5-HT) metabolic pathway in the placenta (Bonnin et al, 2011) reflects the potential importance of extra-embryonically derived 5-HT in modulating developmental processes such as brain circuit wiring, thus affecting long-term brain function. This concept is consistent with classic genetic (5-HT1A knockout) and pharmacological (SSRI exposure) studies showing that disruption of 5-HT signaling transiently, during a restricted period of pre- or postnatal development, results in long-term behavioral abnormalities, such as increased anxiety in adulthood (Ansorge et al, 2008; Oberlander et al, 2009). Because many 5-HT receptors are expressed early and in complex temporal and spatial patterns during brain development (Bonnin et al, 2006), the full extent of the mechanisms through which disruption of 5-HT signaling leads to adult phenotypes is not yet understood. One possible route through which it could occur is the disruption of the modulatory activity of 5-HT signaling on fetal forebrain wiring. This was demonstrated in vitro via the modulation of netrin-1 axon guidance activity by 5-HT, and in vivo by simultaneous, targeted disruption of two 5-HT receptors (5-HT1B/1D) (Bonnin et al, 2007). Altered 5-HT signaling in the forebrain could preferentially influence wiring in this brain region in utero (Bonnin et al, 2007; Bonnin et al, 2011), ultimately leading to long-term dysfunction of circuits underlying mood and emotion. Control of 5-HT signaling, through the number and/or type of 5-HT receptors activated, may thus be critical for normal brain development.

Long-Lasting Effects of Maternal Separation on an Animal Model of Post-Traumatic Stress Disorder: Effects on Memory and Hippocampal Oxidative Stress

Adverse early life events, such as periodic maternal separation, may alter the normal pattern of brain development and subsequently the vulnerability to a variety of mental disorders in adulthood. Patients with a history of early adversities show higher frequency of post-traumatic stress disorder (PTSD). This study was undertaken to verify if repeated long-term separation of pups from dams would affect memory and oxidative stress parameters after exposure to an animal model of PTSD. Nests of Wistar rats were divided into intact and subjected to maternal separation (incubator at 32°C, 3h/day) during post-natal days 1-10. When adults, the animals were subdivided into exposed or not to a PTSD model consisting of exposure to inescapable footshock, followed by situational reminders. One month after exposure to the shock, the animals were exposed to a memory task (Morris water maze) and another month later animals were sacrificed and DNA breaks and antioxidant enzymes activities were measured in the hippocampus. Rats exposed to shock or maternal separation plus shock showed long-lasting effects on spatial memory, spending more time in the opposite quadrant of the water maze. This effect was higher in animals subjected to both maternal separation and shock. Both shock and maternal separation induced a higher score of DNA breaks in the hippocampus. No differences were observed on antioxidant enzymes activities. In conclusion, periodic maternal separation may increase the susceptibility to the effects of a stressor applied in adulthood on performance in the water maze. Increased DNA breaks in hippocampus was induced by both, maternal separation and exposure to shock.

Prevalence of autism-caused disability among Chinese children: A national population-based survey

Few articles in English have discussed the prevalence of autism in China. The work described here was aimed at estimating the prevalence rate of autism-caused disability among Chinese children and exploring family environmental factors associated with autism based on a national population sample. Data for this study were derived from the Second China National Sample Survey on Disability. A weighted number of 77,301 disabled children affected by autism were identified, yielding a prevalence rate of 2.38/10,000. A history of mental disorders in adults was strongly associated with autism. The prevalence of autism in Chinese children was underestimated, and the lack of qualified professionals able to identify and diagnose autism was the main reason. Countermeasures are warranted to obtain a more precise overview of autism in China.

Fetal, maternal, and placental sources of serotonin and new implications for developmental programming of the brain

In addition to its role in neurotransmission, embryonic serotonin (5-HT) has been implicated in the regulation of neurodevelopmental processes. For example, we recently showed that a subset of 5-HT1-receptors expressed in the fetal forebrain mediate a serotonergic modulation of thalamocortical axons response to axon guidance cues, both in vitro and in vivo. This influence of 5-HT signaling on fetal brain wiring raised important questions regarding the source of the ligand during pregnancy. Until recently, it was thought that 5-HT sources impacting brain development arose from maternal transport to the fetus, or from raphe neurons in the brainstem of the fetus. Using genetic mouse models, we uncovered previously unknown differences in 5-HT accumulation between the fore- and hindbrain during early and late fetal stages, through an exogenous source of 5-HT. Using additional genetic strategies, a new technology for studying placental biology ex vivo, and direct manipulation of placental neosynthesis, we investigated the nature of this exogenous source and uncovered a placental 5-HT synthetic pathway from a maternal tryptophan precursor, in both mice and humans. These results implicate a new, direct role for placental metabolic pathways in modulating fetal brain development and suggest an important role for maternal-placental-fetal interactions and 5-HT in the fetal programming of adult mental disorders.