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Q What is the prevalence of mental disorders and comorbidity in German adults, and what are their associated factors and treatment rates?
Cross sectional study.
113 communities across Germany; June 1998 to October 1999.
4181 adults, aged 18–65 years, randomly drawn from population registries (113 randomly selected communities and 130 sampling units). People who were hospitalised for the entire recruitment period were excluded.
The Mental Health Supplement (GHS-MHS) was a subsection of the German National Health Interview and Examination Survey (GHSCS) (n = 7124). Individuals who screened positive in a 12 item questionnaire in the core survey, and 50% of those screening negative, were contacted for a structured clinical interview. Participants were assessed for a wide range of DSM-IV disorders, their comorbidity and correlation with other factors. Data were weighted for 50% negative response exclusion, sex, age, and community. Prevalence estimates and odds ratios (using logistical regression) were calculated.
Mental disorders (DSM-IV), including psychotic disorders, substance abuse, depression, bipolar mood disorder, anxiety disorders, and somatic and eating disorders. Subthreshold diagnoses were noted. Post-traumatic stress disorder and antisocial personality disorder were not assessed. Healthcare usage was assessed and reported as “at least minimal intervention”. Information was obtained via structured computer assisted clinical interviews (M-CIDI) by clinically trained personnel.
Follow up period:
The 12 month prevalence for any mental disorder was 31%. Anxiety, depression, and somatoform disorders were most common (any mood disorder: 11.9%; unipolar depression: 10.7%; any anxiety disorder: 14.5%; phobias: 12.6%; any somatoform disorder: 11.0%). Eating disorders, obsessive-compulsive disorder, and illegal drug abuse had the lowest rates (0.3%, 0.7%, and 0.7%). Prevalence of possible psychosis was 2.6%. Comorbidity rates ranged from 44% (alcohol abuse) to 94% (generalised anxiety), with 60.5% of individuals with mental disorders having a single diagnosis. Most disorders emerged at a young age (median age for lifetime disorders was 20 years); depression and psychosis started later (medians of 31 and 37 years). Increased rates of mental illness were associated with being female, single, low social class, or of poor health. Forty per cent of participants received “at least minimal intervention” and this rate depended on comorbidity (single disorder 30%, 76% for high comorbidity).
Mental disorders are highly prevalent in the adult German population with rates similar to other national studies. Disorders start early in life and are often comorbid.
Response rate of the GHSCS was 61.4% (n = 7124). After exclusion of subjects >65 years and 50% of screen negatives, the sample size for the GHS-MHS was 4773. A response rate of 87.6% resulted in a total of 4181 participants in the GHS-MHS. The paper also reported selected one month and lifetime prevalence rates.
This paper reports on a large German government sponsored survey of the prevalence of somatic and mental disorders in the general population, along the lines of the well known Epidemiologic Catchment Area Study in the United States.1 Particular strengths of the study were the concurrent screening for both psychiatric and somatic morbidities, the assessment of four week, 12 month, and lifetime prevalence, and the wide range of disorders considered, including many anxiety disorders, somatoform disorders, substance abuse disorders, and psychiatric disorders secondary to medical conditions. The results were similar to those found in other large studies. Twelve month prevalence of any DSM disorder was 31%, with female sex, low socioeconomic status, and medical comorbidities all associated with a higher prevalence of mental disorders. Mood, anxiety, and somatoform disorders predominated. Some prevalence findings were difficult to accept, such as the very low 0.3% prevalence of eating disorders.
There are a number of implications for clinical practice. Medical morbidity was strongly associated with mental disorders, with odds ratios of 1.9 to 4.0, suggesting that non-psychiatric clinicians should expect to see large numbers of these disorders in the medically ill population. Although the study was conducted in Germany, a country with a well established, largely socialised mental health system, utilisation rates were low compared with the USA, with only 40% of people with at least one current disorder receiving any intervention. This suggests that underutilisation may depend in part on factors such as stigma, lack of insight, or failure to screen for mental disorders, rather than access problems. In a striking and unfortunate omission, all people over the age of 65 were excluded from the study “because the psychometric properties of the CIDI, the interview used in the study, have not yet been satisfactorily established for use in older populations”. The authors missed a valuable opportunity to investigate phenomena such as late onset depression, or to explore medical/psychiatric comorbidity in the population likely to show the strongest associations.2 This limits the applicability of their findings to the whole population.
For correspondence: Dr Frank Jacobi, TU Dresden, Klinische Psychologie und Psychotherapie, Chemnitzer Str 46, D-01187 Dresden, Germany
Sources of funding: German Federal Ministry of Research, Education and Science.
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