EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

5. HEALTH IMPACTS OF NON COMMUNICABLE DISEASES AND RELATED TIME-TRENDS

5.5. Mental and brain diseases and disorders

5.5.1. Depression, mood/anxiety disorders and suicides

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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 1040 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

 

 

5.5.1.2.1. Registers

 

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 causesof-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.

 

5.5.1.2.2. Data from population surveys

 

 

·          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

 

Prevalence, incidence, access to treatment and work days lost in mood and anxiety disorders

 

The ESEMeD study is based on a sample of 21,425 non-institutionalized adults, collected during 2001-3. It represents a population of more than 212 million from Belgium, France, Germany, Italy, the Netherlands, and Spain.

 

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

 

Psychological distress

 

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.

 

Suicides

 

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 reportActions 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 Conceptsproject 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 CountriesPolicies, 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.

 

5.5.1.6. References

 

Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS, Bryson H (2004a). Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand (suppl 420): 21-27.

 

Alonso J, Angermeyer M, Bernert S, Bruffaerts R, Brugha TS, Bryson H, de Girolamo G, Graaf R, Demyttenaere K, Gasquet I, Haro JM, Katz SJ, Kessler RC, Kovess V, Lépine JP, Ormel J, Polidori G, Russo LJ, Vilagut G, Almansa J, Arbabzadeh-Bouchez S, Autonell J, Bernal M, Buist-Bouwman MA, Codony M, Domingo-Salvany A, Ferrer M, Joo SS, Martínez-Alonso M, Matschinger H, Mazzi F, Morgan Z, Morosini P, Palacín C, Romera B, Taub N, Vollebergh WA; ESEMeD/MHEDEA 2000 Investigators, European Study of the Epidemiology of Mental Disorders (ESEMeD) Project (2004b). Use of mental health services in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand 109 (suppl 420):47-54.

 

Alonso J, Lépine JP (2007). Overview of key data from the European Study of the Epidemiology of Mentl Disorders (ESEMeD). J Clin Psychiatry 68(suppl 2): 3-9.

 

Berk M, Dodd S, Henry M (2006). The effect of macroeconomic variables on suicide. Psychol Med 36(2):181-9.

 

Blakely TA, Collings SC, Atkinson J (2003). Unemployment and suicide. Evidence for a causal association? J Epidemiol Community Health 57(8):594-600.

 

Currier D, Mann JJ (2008). Stress, genes and the biology of suicidal behaviour. Psychiatr Clin North Am. 31(2):247-69.

 

European Commission (2008). European Pact for mental Health. Brussels: European Commission, 2008. Available at: http://ec.europa.eu/health/ph_determinants/life_style/mental/docs/pact_en.pdf.

 

European Commission (2004a). Action for Mental Health. Activities co-funded from the European Community Public Health Programmes 1997-2004). Luxembourg: European Communities and STAKES, 2004.

 

European Commission (2004b). Actions against depression. European Communities, 2004. Also available online at: http://ec.europa.eu/health/ph_determinants/life_style/mental/pubs_mental_health_en.htm

 

Fryers T (2007). Childhood determinants of adult psychiatric disorder. Research reports. Stakes, Helsinki.

 

Haro JM, Bernal M, Bernert S, Brugha T, de Graaf R, Bruffaerts R, Lépine JP, de Girolamo G, Vilagut G, Gasquet I, Torres JV, Kovess V, Kessler RC, Alonso J and the ESEMED/MHEDEA Investigators (2006). Risk factors for suicidality in Europe: results from the ESEMED study. Journal of Affective Disorders, epub online.

 

International Longevity Center.(2006). Ageism in America. New York: International Longevity Center.

 

Kennelly B (2007). The economic cost of suicide in Ireland. Crisis 28(2):89-94.

 

Kessler RC, Angermeyer M, Anthony JC, DE Graaf R, Demyttenaere K, Gasquet I, De Girolamo G, Gluzman S, Gureje O, Haro JM, Kawakami N, Karam A, Levinson D, Medina Mora ME, Oakley Browne MA, Posada-Villa J, Stein DJ, Adley Tsang CH, Aguilar-Gaxiola S, Alonso J, Lee S, Heeringa S, Pennell BE, Berglund P, Gruber MJ, Petukhova M, Chatterji S, Ustün TB (2007): Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's World Mental Health Survey Initiative. World Psychiatry 6(3):168-76.

 

Kessler R, Nelson C, McGonagle K, Liu J, Swartz M, Blazer DG (1996): Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey. Br J Psychiatry 168(Suppl. 30):1730.

 

Kovess-Masféty V, Alonso J, Brugha TS, Angermeyer MC, Haro JM, Sevilla-Dedieu C, the ESEMeD/MHEDEA 2000 Investigators (2007). Differences in lifetime use of services for mental health problems in six European countries. Psychiatric Services 58: 213-220.

 

Lecrubier Y. (2007). Widespread under-recognition and undertreatment of anxiety and mood disorders: results from 3 European studies. J Clin Psychiatry 68(Suppl 2):36-41.

 

Luoma JB, Martin CE, Pearson JL. (2002). Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 159(6):909-16.

 

Ormel J, Petukhova M, Chaterji S, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Bromet EJ, Burger H, Demyttenaere K, de Girolamo G, Haro JM, Hwang I, Karam E, Kawakami N, Lépine JP, Medina-Mora ME, Posada-Villa J, Sampson N, Scott K, Ustün TB, Von Korff M, Williams DR, Zhang M, Kessler RC (2008). Disability and treatment of specific mental and physical disorders across the world: Result from the WHO World Mental Health Surveys. Br J Psychiatry 192(5):368-75.

 

Owens D, Horrocks J, House A (2002). Fatal and non-fatal repetition of self-harm. Systematic review. Bri J Psychiatry 181:193-9.

 

Thornicroft G (2008). Stigma and discrimination limit access to mental health care. Epidemiol Psichiatr Soc 17(1):14-9.

 

Saarni SI, Härkänen T, Sintonen H et al. (2006). The impact of 29 chronic conditions on health-related quality of life: a general population survey in Finland using 15D and EQ-5D. Qual Life Res 15(8):1403-14.

 

Schmidtke A., Bille-Brahe U, De Leo D et al. (2004). Suicidal behaviour in Europe - Results from the WHO/EURO Multicentre Study on Suicidal Behaviour. Göttingen: Hogrefe and Huber.

 

Sobocki P, Jönsson B, Angst J, Rehnberg C (2006). Cost of depression in Europe. J Mental Health Policy Econ 9(2):87-98.

 

Sobocki P, Lekander I, Borgström F et al. (2007). The economic burden of depression in Sweden from 1997 to 2005. Eur Psychiatry 22(3):146-52.

 

Sullivan LE, Fiellin DA, O'Connor PG (2005). The prevalence and impact of alcohol problems in major depression: a systematic review. Am J Med 118(4):330-41.

 

Värnik A, Kölves K, van der Feltz-Cornelius CM, Marusic A, Oskarsson H, Palmer A, Reisch T, Scheerder G, Arensman E, Aromaa E, Giupponi G, Gusmäo R, Maxwell M, Pull C, Szekely A, Sola VP, Hegerl U, (2008). Suicide methods in Europe: a gender-specific analysis of countries participating in the "European Alliance Against Depression". J Epidemiol Community Health. 62(6):545-51.