5.5.1. Depression, mood/anxiety disorders
and suicides
5.5.1.1. Introduction
Mood disorders. Mood disorders, especially unipolar
depression are quite common. Lifetime prevalence of major depression is 13% in
Western and Southern EU Member States (Alonso et al, 2004a). Major depression
is much more common among women; in Europe, prevalence is 9% for adult men and
17% for adult women (Alonso et al., 2004a). Depression is more frequent in
young age groups (Alonso et al, 2004a). Major depression is highly co-morbid
with other mental disorders such as anxiety disorders (Kessler et al 1996) and
alcohol misuse (Sullivan et al, 2005), but is also associated with physical
chronic disease. Negative life-events, especially in childhood and adolescence
increase the risk for depression two to threefold (Fryers, 2007, Blakely et al,
2003) although there are other congenital and socio-economic predispositions
for depression.
Depression reduces significantly the quality of life to an
extent comparable to the reduction caused by serious physical illness (Saarni
et al, 2006). In addition, depression causes severe interference with normal
functions, even more than physical chronic conditions (Ormel et al, 2008).
Most the costs for mood disorders are indirect and include
loss of productivity due to sickness spells, absenteeism and early retirement
and also due to increased mortality for suicide. For example in 2004 the total
costs from depression were estimated to be euro 118 bn in EU and EFTA countries
(Sobocki et al 2006). The total costs of depression have doubled in ten years,
and most of the increase is due to indirect costs (Sobocki et al, 2007).
Undertreatment and underrecognition of depression are
common (Lecrubier, 2007). In Europe, only one third of those with mood
disorders have had a contact with formal health services in the previous year
(Alonso et al, 2004b). Of these, only about half receive adequate treatment
(Alonso et al., 2004b). the reasons for undertreatment can be due to stigma
associated with mental disorders (Thornicroft 2008), health service access
hurdles and under-recognition of depression by healthcare professionals
(Lecrubier, 2008).
Anxiety disorders. There are four types of anxiety
disorders: Obsessive-compulsive disorders, phobic anxiety disorders, other
anxiety disorders (e.g. panic disorder and generalised anxiety disorder), and
reaction to severe stress including adjustment disorders. Anxiety disorders are
often co-morbid with other anxiety disorders or mood disorders (Kessler, 2007).
Anxiety disorders are common; a WHO survey including six EU Member States found
lifetime prevalence of having any anxiety disorder to vary between 10-22% and
projected lifetime prevalence 13-26% in the participating EU member States
(Kessler et al., 2007). The onset of anxiety symptoms is often in childhood or
adolescence, but some anxiety disorders have a later onset in adulthood
(Kessler et al., 2007). Anxiety disorders are often chronic, even life-long.
Predisposing factors are both congenital and environmental. Stressful
and traumatic life-events as well as lack of social support increase the risk
of anxiety disorders (Fryers, 2007).
Anxiety disorders cause substantial impairment in
social and working life, causing loss of productivity. Use of formal
health services is low. About one person in four with any anxiety disorder has
been reported to contact health services (Alonso et al., 2004b).
Psychological distress. Although psychological distress
is obviously not a mental disease, its association with mood and anxiety
disorders is robust. Psychological distress refers to the presence of
symptoms of depression or anxiety, which do not fulfil the diagnostic criteria
for a mental disorder either because they are transient or because they are not
severe enough. Yet, psychological distress is significant as it is
common and causes decrease in quality of life and loss of productivity.
Suicide. 90% of completed suicides are associated with mental
disorders, especially with mood disorders but also with substance misuse (Mann
et al., 2005). Major depression is found in 60% of those who commit suicide.
Several factors interact to place an individual at higher risk of suicide
including psychiatric conditions, social exclusion at individual (e.g. Blakely
et al 2003) and even at community level (Berk et al., 2006) and genetic factors
(Currier et Mann, 2008).
Across the EU, about 59 000 citizens, 45 000 men and
14 000 women committed suicide in 2006 (Eurostat). This number is greater than
the annual death toll from road accidents of about 50 000 deaths
(Eurostat). The EU Member States differ from each other considerably in suicide
rates. Seven of the 27 EU Member States are among the global top 15 countries
in male suicide rates, and five in female suicide rates (WHO, most recent year
available as of 2007). Lithuania, Hungary and Latvia have the highest total
suicide rates (standardised death rate) in the EU.
In most Member States, suicide rates are higher for people
over 65 than for the other age groups (Eurostat statistics, available from
http://epp.eurostat.ec.europa.eu). Still, suicide is an important contributor
to life years lost because it frequently occurs among young people. In
addition, suicide is one of the leading causes of death in the 15-35 age group
for both sexes. Suicide methods vary from a country to another. In general, in Europe hanging, shooting and self-poisoning are the most used suicide means (Värnik et al.,
2008).
Mental disorders are estimated to be undertreated in as
much as 80% of cases of completed suicide. Furthermore, one study found over 50
percent of people who committed suicide had had health care within the month
prior to their death (Luoma et al., 2002).
The economic burden of suicides has a major impact on
European competitiveness through premature loss of life. One study estimated
that economic costs from suicide in Ireland at the beginning of the 2000s
amounted to almost 1% of Gross National Product of the country (Kennelly,
2007).
Non-fatal self-harm. Non-fatal self-harm is associated
to an increased risk for future suicidal behaviour and completed suicide (e.g.
Owens et al, 2002). The incidence of non-fatal self-harm is estimated to be
10–40 times more common than that of a completed suicide, especially among
women (1:9 for males, 1:42 for females) (Schmidtke et al, 2004).
5.5.1.2. Data sources
There are problems in European-wide comparability and
quality of mental health related register data. Problems include comparability
and validity of prevalence and incidence data when derived from hospital
discharge registers, not only because coding of diagnoses and coverage of
hospitalisation data vary, but also because of differences in organising mental
health services and in national health information systems. Also statistics on
mortality due to suicide are not totally reliable as Member States differ in
legal definition and process for determining suicide rates.
Routinely collected statistics on deaths related to mental
health problems or on morbidity based on hospital discharge rates do not
reflect the reality of population mental health. These statistics contain no
information on the large numbers of people who suffer from mental health
problems but neither die nor are hospitalised. Consequently, routine data
cannot be used to compare mental health morbidity between EU countries. There
are also some discrepancies between WHO-HFO and EUROSTAT due to different
definition of psychiatric beds ( Katschhnig ET AL., 2006).
·
WHO
databases
The WHO Health for All (HfA) –database includes seven
indicators related to mental health. Those relevant for mood and anxiety
disorders and suicides are presented below accordingly. For more information on
mental health data in HfA, see also the introductory Section 5.5.1.
Mood and anxiety disorders. There are no specific data in HfA
addressing mood or anxiety disorders only. HfA includes incidence of
mental disorders as total per 100 000 population for newly diagnosed
mental disorders. These data have been obtained from national routine reporting
systems of mental health establishments, annual data collections on mental
health and from health insurance data. In addition, the HfA includes prevalence
in %, as a cumulative number of all registered mental patients at the end
of a calendar year as registered by ICD-9/10. These data has been derived
nationally from hospital discharge registers and annual data collections on
mental health or relevant data sources. The incidence and prevalence data are
available in HfA for only about one third of the EU Member States. Due to
reason described above, international comparability of these data is heavily
compromised.
Suicide. HfA offers data on age-standardised death rate from
suicide and self-inflicted injury per 100 000 population. Age
standardisation delivers death rates which represent what the crude death rate
would have been if the population had the same age distribution as the European
standardised population. The HfA data is derived from national causes–of-death
statistics. It is available in age groups 0-64 years and all ages. The data
availability from the 27 European Member States varies according to the year.
·
Eurostat
Suicide. Eurostat contains annual information on causes of death,
grouped according to the European shortlist based on ICD-10, including suicide
and intentional self-harm. Suicide data is available for five year age cohorts,
for both sexes and as a total number and by region. Annual national data are
presented as absolute numbers, crude death rates and standardised death rates.
Data is available in principle from 1994 onwards. Most available national data
is from late 1990s and beginning of the 2000s. National differences are
possible due to differences in ICD interpretation regardless of attempts to
improve and harmonise coding.
·
OECD
The Organisation for Economic Co-Operation Development’s
OECD Health Data 2008 offers some mental health-related data for OECD
Member States. These include data on causes of mortality and potential years of
life lost from external cause, including intentional self-harm.
OECD Health Data 2008 includes also general mental health
indicators like mortality and potential years of life lost from mental and
behavioural disorders, number of psychiatric care beds, long term beds in
nursing homes and institutions and consumption and sales of different types of
pharmaceuticals. However, specific data concerning mood and anxiety disorders
cannot be derived from this data.
Lastly, it
should also be noted that some countries, e.g. Nordic Countries, currently
receive information on prscribed medicin3es on DDD levels per patient.
·
ESEMeD
The methods of the ESEMeD survey are presented in Chapter
5.5.1. Mental Disorders. The ESEMeD output include data on mood and anxiety
disorders, substance use disorders and suicidal ideations and attempts in six
EU Member States. The following areas are covered: prevalence, risk factors,
disability, health-related quality of life, use of treatment and healthcare
services. The survey data were gathered during 2001-3.
·
The
Eurobarometer Surveys
Eurobarometer
surveys are presented in detail in Chapter 5.5.1. Mental Disorders. Two
Eurobarometer surveys have included questions on psychological distress,
positive mental health and care-seeking behaviour.
The data derived from Eurobarometer surveys have certain
strengths and weaknesses. With respect to the strengths, the data come from
large randomly-selected samples, and use validated instruments used in the same
way in all countries. However, translation, even when validated, may be an
issue especially with respect to terms relating to psychological symptoms.
Acceptance of mental health problems varies between countries and this may
influence the frequency of positive answers. The number of non-participants was
relatively high, and the attrition may introduce a bias, even after careful
weighting. Thus, on European level, comparison of relative risks may be more
reliable than comparison of absolute prevalence rates. Reports of access to care
is influenced by differences between countries in the availability of resources
as well as in the stigma attached to mental disorders. The Eurobarometer data
do not include institutionalised patients and do not take into account the most
severe mental health disorders such as psychotic disorders.
·
Other
population surveys
Mood and
anxiety disorders.
ESEMeD and the Eurobarometers are the only two multi site
surveys using standardised mental health instruments that are available at the
present time. Nonetheless, some large multi site surveys have attempted to take
into account mental health or well-being by including questions on
psychological symptoms: E.g. the HBSC study, a large survey of schoolchildren,
and the
SHARE study, a collaborative European survey on people aged 50 and over in 13
EU Member States. They do not provide morbidity data derived from validated mental
health scales and interpretation of the data in terms of psychiatric diagnoses
would be difficult. HBSC and SHARE are presented in more detail in Chapter
5.5.1. Mood Disorders.
5.5.1.3. Data description and analysis
Lifetime prevalence of any mood disorder was found to be
15% in the ESEMeD countries. Lifetime prevalence of any anxiety disorder was
14%. Table 5.5.1.1 presents lifetime and 12 month prevalence rates (%) for mood
and anxiety disorders as the total in the six ESEMeD countries.
Table 5.5.1.1 Lifetime and 12 month prevalence
of mood and anxiety disorders in the six ESEMeD countries
About one third of those with any mood disorder and one
fourth of those with any anxiety disorder had contacted a formal health
service. About one third of the contacts were to General Practitioners (GP)
only.
Table 5.5.1.2. Level of care use (%)
among those with any mood or anxiety disorder or no mental disorder during 12
months, ESEMeD Study.
Anxiety and mood disorders were associated to considerable
lost productivity in the 6 ESEMED countries, a burden higher than that
attributable, for example, to heart diseases and diabetes.
Figure 5.5.1.1. Relative burden of some
mental health disorders and no disorder and some somatic disease as Work Days
Lost (WDL).
About one in three or four suffering from mood and/or
anxiety disorders had had suicidal thoughts. Lifetime suicide attempts were
higher among those with a generalised anxiety disorder.
Table 5.5.1.3. Lifetime suicidal behaviour
in some mood and anxiety disorders in the six ESEMeD countries
According to a Eurobarometer study, high psychological
distress concerns one person out of five although there is variation between
countries. Overall, 17% of the subjects interviewed presented a high level of
psychological distress. This percentage was higher in women (20%) than in men
(13%) and increased with age.
Table 5.5.1.4. Psychological distress
by gender and age
Logistic regression was used in order to control age,
gender, marital status, employment status, education and rural/urban living and
thus compare levels of psychological distress between countries, taking Germany as the reference. Three groups of countries could thus be distinguished:
1) those with a lower prevalence of psychological distress
than the reference country Germany: the Nordic countries and Ireland
2) those with a similar prevalence of psychological
distress to the reference country Germany: France, Belgium, Luxemburg, Austria, Great Britain. Spain, Malta, the Czech Republic, Slovenia and Slovakia.
3) those with a higher prevalence of psychological
distress than the reference country Germany : Most Mediterranean countries (Italy, Portugal, Greece, Cyprus and Turkey), as well as the Baltic countries (Estonia, Lithuania and Latvia) and some Central and Eastern European countries (Romania, Bulgaria, Poland, Hungary and Croatia).
Figure 5.5.1.2. Odds ratio (with 95%
confidence interval) for a score of MH<55 by country of residence
Logistic regression identified gender, age, marital
status, employment status, education, place of residence and place of birth as
important determinants of psychological distress.
Table 5.5.1.5. Odds Ratio for a score
MH5<55 by a number of Variables.
In all countries, psychological distress was more common
in women than in men. This was particularly the case for Portugal, France and Italy and less so for Denmark, Slovakia and Latvia.
Figure 5.5.1.3. Odds ratio (with 95%
confidence interval) for a score MH<55 in women with reference to men, by
country of residence.
In five countries (Portugal, Rumania, Austria, Netherlands and Poland) young people aged 15 to 24 presented lower risks than older adults.
In four countries (Sweden, Denmark, Great Britain, and Netherlands), the oldest age range (³65 years) have lower risk than younger adults.
Figure 5.5.1.4. Odds ratio (with 95%
confidence interval) for a score MH<55 in elderly (65+ year old) with
reference to 25-64 year old population, by country of residence.
The mortality rates for suicides and intentional self-harm
vary slightly between Eurostat and the WHO EURO databases due to differences in
presenting the data.
The mortality rate for suicide and intentional self-harm
vary considerably between the EU Member States. The Eurostat data indicate that
the highest mortality rates of suicide and intentional self-harm among the
Member States is found in Lithuania, Hungary, Latvia and Slovenia. Respectively the lowest rates have been observed in Cyprus, Greece, Malta and Italy (Figure 5.5.1.5).
Figure 5.5.1.5. Death due to suicide and
intentional self-harm per 100 000 whole population (standardized death
rate) in 1995 and 2005 in the EU. Source: Eurostat
The annual age adjusted mortality rates due to suicide and
self inflicted accidents per 100 000 people by country and gender in Europe are presented in Table 5.5.1.6.
Table 5.5.1.6. Annually age adjusted
mortality rates due to suicide and self inflicted accidents (per 100 000 people)
by gender in Europe
The stability of inter-country variations over
approximately 12 years is given in Table 5.5.1.7.
Table 5.5.1.7. Age adjusted mortality
rates and trends due to suicide and self inflicted accidents (per 100 000) in
Europe.
The changes in age-adjusted mortality rates in Belgium, Ireland, Spain, Luxembourg, Malta, Poland, Portugal, Romania and Iceland were not
significant. The countries that experienced the most impressive declines in
suicide and self inflicted accidents between the earlier and later time periods
were Estonia, Latvia and Denmark with a percentage of annual change estimated
at -6.1%(P<0.0001), –5.4%(P<0.0001) and –5.0%(P<0.0001) respectively.
In the 0-14 age group (Table 5.5.1.8) the suicide rates
were considerably low and very similar among all countries. In the 15-64 age
group the lowest suicide rates were found in Greece, Malta and Italy whereas the highest ones were in Lithuania, Hungary and Slovenia. In the 65+ age group the
highest rates were reported in Hungary, Slovenia, Lithuania and Croatia whereas the lowest suicide rates were in Greece, United Kingdom and Ireland.
Table 5.5.1.8. Number of deaths (N) and
average yearly age adjusted mortality rates (SMR) of the last 3 available years
for suicide and self inflicted accidents per age group and gender in Europe
As regards to the gender, in both 15-64 and 65+ age
groups, females in all countries have much lower suicide mortality rates
compared to men.
Mortality rates for suicide are higher in EU27 for both
men and female in Lithuania; for Lithuanian men the rate is the highest also at
global level, 70 per 100 000 and Lithuanian women have the fourth highest
rate of mortality for suicide in the world with 14 per 100 000 (WHO
statistics).
5.5.1.4. Control tools and policies
EU Mental Health Policies
Depression has been acknowledged by the European Council
recommendation already in 2001 as a risk factor for suicide.
A special report “Actions against depression” was prepared
in 2004 by the Commission. The expert group identified depression as one of the
most serious health problems in Europe in terms of severity of the disorder and
economic and mental burden. The report recognised depression as a treatable
disorder with effective interventions available. Under-recognition and low
accessibility to treatment were reported to be the hurdles in treatment of depression
(European Commission, 2004a)
The most recent mental health activity of the Commission
was the introduction of the Mental Health Pact in June 2008. The focus of the
Pact is on five themes, all relevant for mood and anxiety disorders and
suicides. These themes are mental health at schools, mental health at
workplace, mental health of older people, prevention of depression and suicide
and combating stigma (European Commission, 2008). The next steps of the
Commission will be based on both these themes and on the Mental Health Pact.
EU co-funded mental health projects from EU Public Health
Programmes concerning mental/mood disorders and suicide
The first mental health project co-funded from the EU was
conducted in 1997-98. This “Key Concepts” project defined and evaluated the
central concepts for mental health as well promoted and proposed priorities for
the EU, which included priority areas of action for mood and anxiety disorders
and suicides. Thus, several mental health programmes have been co-funded from
the EU Public Health Programmes. Several have been valuable for the promotion
of mental health and prevention of mood and anxiety disorders and suicides
(European Commission, 2004b):
Mental health projects co-funded by the European
Commission Public Health Programmes
·
Contribution
to mental health policy
General programmes targeted to
strengthen mental health policies in the EU.
o
Putting
Mental Health on the European Agenda (1998-2000).
o
Integrating
Mental health promotion Interventions into Countries’
Policies, Practice and the Health Care System (2002-4).
·
Promoting
mental health throughout the lifespan.
Different needs and targets
throughout lifespan are addressed through
these programmes.
o
Mental
health promotion for Children up to 6 years of
age(1997-99): Early years of life have a significant impact on mental health
through one’s life. The project developed strategies to promote mental health
of young children.
o
Supporting
Children in Substance Abuse Families (2002-3).
o
Mental
health promotion for Adolescents and Young People (2000-1)
included also interventions for schools.
o
Mental
health promotion Strategies for Coping with Anxiety,
Depression and Stress Related Disorders in Europe (2001-3) targeted people
belonging to different age groups, children and adolescence, those at working
age and older people.
o
Implementation
of Mental health promotion and Prevention Policies (2004- )
was especially targeted at promotion and prevention of stress, anxiety,
depression and suicide and related disorders.
·
Ensuring
relevant information on mental health
Reliable and comparable indicators
to monitor mental health are necessary to develop strategies and policies for
mental health promotion, prevention and services.
o
The
establishment of a Set of Mental Health Indicators for European Union
(1999-2001) provided indicators derived from statistical data and population
surveys, and consisted of indicators of health status, determinants of health
and health systems.
o
The
European Review of Suicide and Violence Epidemiology (1999-2003), evaluated the
quality of existing data and epidemiological trends.
o
The
Report of the State of Mental Health in the European Union (2002-4), included
also statistics on deaths from suicide and results from studies carried out in
several Member States.
o
Mental
Health Information and Determinants for the European level (2004-6), provided
final set of mental health indicators and proposed a system to analyse and
report all data.
EU activities other than in the Public Health Field with
relevance to mental/mood disorders and suicide
Several initiatives under the Community’s social and
employment policy have targeted the non discrimination of people with
mental disorders, the social inclusion of people with mental disabilities, and
the prevention of stress at workplaces.
5.5.1.5. Future developments
In spite of the differences and the increasing activity in
the prevention and promotion of mental health in many European countries, there
are still common challenges which should be addressed by a European strategy,
referring mainly to the lack of understanding and information on mental health
and the promotion of inter-sectoral approaches. The European Mental Health Pact
offers a base for future actions on mental health promotion
and prevention of mental disorders.
It is evident that better data should be offered for the
development of policy action for mental health. High quality and comparable
data need to be collected on mental health disorders through the use of surveys
conducted in the general population using a sound methodology and repeated at
regular intervals. Mental health surveys should also include measures of
psychological distress. Access to care should also be monitored.
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