Epidémiologie des Troubles Anxieux et Dépressifs Jean-Pierre Lépine INSERM U705 - CNRS UMR 7157 Université Paris Diderot Hôpital Lariboisière Fernand Widal Assistance Publique Hôpitaux de Paris

Prévalence Incidence Facteurs de risque Epidémiologie Prévalence Incidence Facteurs de risque

Prévalence sur la vie du Trouble Anxiété Sociale (DSM-III) ECA Puerto Rico Edmonton Paris Zurich Munich Florence Christchurch Seoul Taïwan 2.7 1.6 1.7 4.1 3.8 2.5 1.0 3.5 0.5 0.4-0.6

Prévalence sur la vie du Trouble Anxiété Sociale DSM-III-R NCS 13.3

Définition du cas a case for what ? What is a case ? The problem of definition in psychiatric community surveys JK Wing, P Bebbington & LN Robins 1981 Grant McIntyre , London a case for what ?

maladie - syndrome modèle hiérarchique critères diagnostiques entretiens diagnostiques structurés

Validité du Diagnostic Establishment of diagnostic validity in psychiatric illness : its application to schizophrenia Eli Robins, Samuel B Guze American Journal of Psychiatry, 1970, 126,107-111 Cinq phases - description clinique - études de laboratoires - différenciation des autres troubles - étude de suivi - études familiales

Signes Symptômes Critères Syndrome

Critères diagnostiques explicites et précis possibles interprétations "implicites" pour le clinicien

Entretien diagnostique Classification diagnostique

Jugement clinique versus Règles strictes des algorithmes

Qualité du recueil de données Référence aux critères diagnostiques

Instruments Diagnostiques Recueil de données Critères Algorithmes

Cliniciens Non cliniciens Intervieweurs Cliniciens Non cliniciens

Connaissances requises Manuel d'utilisation Formation

libellé des questions précision des questions codage des réponses instructions de saut algorithmes

SADS SCID SCAN - PSE ADIS DIGS MINI

Diagnostic Interview Schedule Composite International Diagnostic Interview

CIDI 1.0 ... 2.0 CIDI - PPGHC UM - CIDI M - CIDI CIDI - 2000

Comparaison des classifications

Diagnostic grammar and assessment : Translating criteria into questions Lee N Robins The validity of psychiatric diagnosis, LN Robins, JE Barrett (1989)

Traduction des Critères en Questions Pluriel au moins 2 Souvent, fréquemment au moins 3 fois

Pouvez-vous vous rappeler quel âge précis vous aviez, quand pour la toute première fois ? Environ quel âge aviez-vous ? Quel est l'âge dont vous pouvez précisément vous rappeler ?

Seuils de sévérité évaluation dimensionnelle handicap retentissement

Fidélité inter-cotateurs test - retest stabilité temporelle

Validité des Instruments Comparative Diagnostic standard

LEAD Longitudinal observations made by Expert clinicians utilizing All Data available (Spitzer, 1983)

Comparabilité des études

Annual Prevalence of Major Depression, Ages 18 to 64 Years Annual Prevalence of Major Depression, Ages 18 to 64 Years* (Cross National Study) United States Edmonton, Alberta Puerto Rico Paris, France West Germany*** Florence, Italy** Beirut, Lebanon** Taiwan Korea Christchurch, New Zealand Rate/100 * Figures standardized to US age and sex distribution ** Data not available *** Data from former Federal Republic of Germany (West Germany) based on ages 26 to 64 years from Weissman et al, 1996

Lifetime Prevalence of Major Depression by Sex, Ages 18 to 64 Years* United States Edmonton, Alberta Puerto Rico Paris, France West Germany*** Florence, Italy Beirut, Lebanon Taiwan Korea Christchurch, New Zealand Rate/100 * Figures standardized to US age and sex distribution ** Data from former Federal Republic of Germany (West Germany) based on ages 26 to 64 years from Weissman et al, 1996

Cross National Collaborative Study

Trouble Panique: prévalence annuelle (%) USA Edmonton Puerto Rico Paris Munich Florence Beirut Taiwan Korea New Zealand

Trouble Panique: Prévalence sur la vie en fonction du sexe (%) USA Edmonton Puerto Rico Paris Munich Florence Beirut Taiwan Korea New Zealand

Prévalence sur la vie de la dépression majeure en fonction du sexe, sujets de 18 à 64 ans* Etats Unis Edmonton, Alberta Porto Rico Paris, France Allemagne** Florence, Italie Beyrouth, Liban Taiwan Corée Christchurch, Nlle Zélande Taux/100 * Figures standardisées à la distribution par age et sexe des EU ** Données de l’ancienne Allemagne de l’Ouest (sujets de 26 à 64 ans) d’après Weissman et al, JAMA, 1996

The World Health Organization World Mental Health Survey Initiative

Participating Countries Sample Type National Probability Sample Regional Probability Sample

Data Collection Status Completed In progress To be completed

ESEMeD/MHEDEA 2000 Background Few comparative studies in Europe Different methodology Lack of comprehensive information Majority of epidemiological studies in Europe have: been limited to a single country population, studied different populations eg general population vs GP based surveys studied different age ranges (eg >18 vs 18-54) assessed different prevalence rates eg 6m vs 12m or lifetime utilised different methodologies eg different diagnostic instruments (ICD 10/DSM III/IV) different sampling methodologies different assessment instruments different methods of data collection All of the above make it difficult to compare data with previous studies and across populations. Previous surveys have also been limited by lack of comprehensive information eg only mood disorders or single anxiety disorders assessed assessment of care needs extremely limited assessment of disease burden eg disability and QOL limited

ESEMeD/MHEDEA 2000 Objectives Prevalence of mental disorders Associated risk factors Health-related quality of life impact Services use, including use of psychotropic medication Unmet needs for care ESEMeD will assess prevalence rates and severity of mental disorders (both singly and in combination) in a general non-institutionalised population, aged 18 years or older, who are not suffering from severe cognitive deficits The following mental disorders were assessed in the preliminary analysis: Mood disorders (Major Depression, and Dysthymia); Anxiety disorders (GAD, Simple Phobia, Social Phobia/Social Anxiety Disorder, PTSD, Panic Disorder, Agoraphobia); Substance use disorders (alcohol/drug abuse, dependence). Questions on these disorders were asked to all respondents. Other disorders were also screened and will be included in the final assessment – Minor Depression, OCD, Pre-Menstrual Dysphoric Disorder, eating disorders, childhood disorders, psychoses and personality disorders, separation anxiety disorders, ADHD and Oppositional-Defiant Disorder. Limitations in budget and the complexity of the study meant that it was not possible to screen for all mental disorders. However, ESEMeD is still the most comprehensive epidemiological survey ever conducted in Europe. The ESEMeD survey will rigorously assess and evaluate the impact of mental disorders on the level of disability and Quality of life (QoL) using validated assessment tools eg Sheehan Disability Scale; SF 12, EuroQol 5D, WHO DAS. The ESEMeD survey will describe and evaluate across selected countries the use of treatment and care services in the general population and their adequacy and better assess unmet care needs

ESEMeD/MHEDEA 2000 Methods Cross-sectional, home interview Non-institutionalised general population (18+ years of age) Computer-Assisted Personal Interview (CAPI) Composite International Diagnostic Interview (CIDI 2000) Standardised severity and QoL scales Cross-sectional survey- assessed at a point in time. Not longitudinal data Innovative methodology. Standardised data collection by trained interviewers using the Computer-Assisted Personal Interview (CAPI) provides a unique combined dataset across the countries use of validated scales use of DSM IV and ICD10 diagnostic tools use of CIDI -2000 (composite international diagnostic interview), designed to measure the prevalence of mood and anxiety disorders and QOL. Validated in collaboration with the WHO. Will be utilised by WHO as part of mental health initiative 2000 enabling comparability across the globe. in a proportion of cases spouses will also be interviewed Quality control procedures trained interviewers clinical validation (psychiatrists)

ESEMeD/MHEDEA-2000 CIDI-2000 More disorders assessed DSM-IV and ICD-10 criteria Clinical severity Disability/use of services Longer, improved screening section Computerised version

Methodology CIDI 2000 Comprehensive, fully structured, diagnostic interview developed by the WHO DSM-IV and ICD-10 criteria Computerised Broader range of mental disorders assessed mood disorders anxiety disorders substance use others (eating disorders, childhood disorders, etc.) Data on 12m and lifetime prevalence are presented here. The CIDI 2000 collects data on; Demographics Age, gender , education, marital status, employment, living situation - urban, alone etc Physical and Mental Condition Symptoms = disorder characterisation, mood disorders, anxiety disorders, substance use, other (eating, childhood etc) prevalence of disorders - life-time, one year, 1 month Co-morbidity - pattern, severity and persistence, Diagnosis - physical and mental Psychotropic drug use AD, Anti-Psychotics,Anxiolytics, Mood stabilisers - named drug recorded (booklet provided to enable drugs to be identified\) Quality of life - Short Form-12 Physical Health Component Mental Health Component - WHO Disability Assessment Schedule II General disability factor Work loss days Health care utilisation - Assessment of use of resources : consulting any formal health servicefor emotions or mental health Level of care used and type of service received - both assessed use for mental conditions and some specific chronic physical conditions i.e. diabetes

Sample characteristics Europe Country Sample Size Response Rate (%) Belgium 2419 50.6 France 2894 45.9 Germany 3555 57.8 Italy 4712 71.3 Netherlands 2372 56.4 Spain 5473 78.6 Ukraine 4725 78.3

ESEMeD/MHEDEA 2000 Sampling frames Country Belgium France Germany Italy The Netherlands Spain Sampling frame National registry Telephone listing Community registries Local electoral census Local postal registries Household enumeration Random sampling of a representative sample of the non-institutionalised general population aged 18 yrs or older. Individuals were randomly selected throughout each country. Sampling sources (frame) varied by country. Individuals were excluded if they were under 18 years, severely cognitively impaired, unable to understand the language of the survey (not first language). How did you convince individuals to participate in the survey? Letters explaining the aims and requirements of the survey were sent to randomly selected individuals on behalf of of local/international institutions. The letters also highlighted the involvement of the key opinion leaders, GSK and EU in this initiative. In order to ensure responses from a representative sample and to reduce bias, relevant and limited incentives were provided eg vouchers. Another important feature of this study is that substitutions for non-respondents were not accepted. In addition, efforts to compare available information from respondents and non-respondents are ongoing. In the preliminary dataset weights were added to ensure that the sample within each country was representative of that country. However, each country has a similar impact on the results regardless of the population size. This will be addressed in the final dataset

Sample characteristics Americas Country Sample Size Response Rate (%) Colombia 4544 87.7 Mexico 5782 76.6 United States 9282 70.9

Sample characteristics Middle East/Africa Country Sample Size Response Rate (%) Lebanon 2856 70.0 Nigeria 4984 79.9

Sample characteristics Asia Country Sample Size Response Rate (%) Japan 1663 56.4 PRC Beijing 2633 74.8 PRC Shanghai 2568 74.6

Twelve-month (12-mo) prevalence of WMH-CIDI/DSM-IV disorders Any Disorder United States Ukraine France Colombia Lebanon Netherlands Mexico Belgium Spain PRC Beijing Germany Japan Italy Nigeria PRC Shanghai Prevalence

Twelve-month (12-mo) prevalence of WMH-CIDI/DSM-IV disorders Mood Disorders United States Ukraine France Netherlands Colombia Lebanon Belgium Spain Mexico Italy Germany Japan PRC Beijing PRC Shanghai Nigeria Prevalence

Twelve-month (12-mo) prevalence of WMH-CIDI/DSM-IV disorders Anxiety Disorders Prevalence

Twelve-month (12-mo) prevalence of WMH-CIDI/DSM-IV disorders Substance Disorders Ukraine United States Netherlands Colombia PRC Beijing Mexico Japan Lebanon Belgium Germany Nigeria France PRC Shanghai Spain Italy Prevalence

Prevalence of anxiety disorders (%) 12-month Lifetime Total Anxiety Disorders 7.4 16.4 GAD 1.3 3.8 SAD 3.3 7.7 Specific Phobia 0.9 2.1 PTSD 1 2.6 PD 1.3 3.7 Ag 0.9 2.8 PD+Ag Total anxiety disorders GAD SAD Specific Phobia PTSD PD Ag PD + Ag GAD=Generalised Anxiety Disorder; SAD=Social Phobia/Social Anxiety Disorder; PTSD=Posttraumatic Stress Disorder; PD=Panic Disorder; Ag=Agoraphobia

Associated factors: age Unadjusted odds ratios Odds ratio

Associated factors: marital status Odds ratio Reference group Odds Ratios (OR) definition. OR is significant if 1 is included Reference Group - Married Preliminary results based on the analysis of the first 14,078 interviews completed by 1 April 2002 Fieldwork in Germany started August 2002 Unadjusted odds ratios Preliminary results based on the analysis of the first 14,078 interviews completed by 1 April 2002 Fieldwork in Germany started August 2002

Associated factors: employment status Unadjusted odds ratios Odds ratio

Order of Occurrence of Anxiety and Affective Disorders Simple phobia Social phobia Agoraphobia PD GAD OCD

Standardized mortality ratios by age at first admission in unipolar patients in Sweden (1973-1995) Controlled for sex, age at admission, and calendar period (Osby et al, 2001)

Standardized mortality ratios by time at first admission in unipolar patients in Sweden (1973-1995) N° of years of Follow-up Controlled for sex, age at admission, and calendar period (Osby et al, 2001)

Five year risk of cardiac mortality in relation to initial BDI during hospitalization (Lespérance et al, 2002)