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Instituto Nacional de Psiquiatría Ramón de la Fuente
Instituto Nacional de Psiquiatría Ramón de la Fuente and Universidad Autonóma Metropolitana, Xochimilco
Instituto Nacional de Psiquiatría Ramón de la Fuente, Mexico
Department of Epidemiology and Biostatistics, Michigan State University, Ann Arbor, Michigan, USA
Correspondence: Correspondence: Professor Guilherme Borges, Investigaciones Epidemiologicas, Instituto Nacional de Psiquiatría and Universidad Autónoma Metropolitana, Calzada México Xochimilco No. 101, Col. San Lorenzo Huipulco C.P.10610, México DF, México. Email: guibor{at}imp.edu.mx
Declaration of interest None. Funding detailed in Acknowledgements.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Aims To present data on lifetime prevalence and projected lifetime risk, age at onset and demographic correlates of DSM–IV psychiatric disorders assessed in the Mexican National Comorbidity Survey.
Method The survey was based on a multistage area probability sample of non-institutionalised people aged 18–65 years in urban Mexico. The World Mental Health Survey version of the Composite International Diagnostic Interview was administered by lay interviewers.
Results Of those surveyed, 26.1% had experienced at least one psychiatric disorder in their life and 36.4% of Mexicans will eventually experience one of these disorders. Half of the population who present with a psychiatric disorder do so by the age of 21 and younger cohorts are at greater risk for most disorders.
Conclusions Our results suggest an urgent need to re-evaluate the resources allocated for the detection and treatment of psychiatric illnesses in Mexico.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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In a previous study of the 12-month prevalence, severity and demographic correlates of 16 DSM–IV psychiatric disorders and service utilisation in Mexico (Medina-Mora et al, 2005), we showed that although psychiatric disorders are common, with a 12-month prevalence of 12.1%, very severe mental disorders are less common (prevalence of 3.7%); moreover, there was extreme under-utilisation of mental health services, with only 24% of those more severely affected using any services at all. The most common disorders were specific phobia (4.0%), major depressive disorder (3.7%) and alcohol abuse or dependence (2.2%). Income was associated with severity of illness, with people of low and low–average incomes more likely to report a 12-month disorder. Females were more likely to report a mood and anxiety disorder but less likely to report a substance use disorder.
In this paper, we report the lifetime prevalence and the projected lifetime risk of DSM–IV psychiatric disorders in the Mexican population. We expand prior analyses of age at onset of major depression in Mexico (Benjet et al, 2004) to other psychiatric disorders which are now more common among youths in Mexico, and investigate whether new cohorts are at an increased risk, especially for substance use disorders (Villatoro et al, 2005).
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METHOD |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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All interviews were conducted at the respondent’s home after providing a careful description of the study goals and obtaining informed consent. No financial incentive was given for respondents’ participation. All recruitment and consent procedures were approved by the ethics committee of the National Institute of Psychiatry.
Diagnostic assessment
A laptop computer version (CAPI) of the WHO World Mental Health Survey
Initiative version of the CIDI (WMH–CIDI;
Kessler & Ustun, 2004) was
administered in face-to-face interviews and yielded DSM–IV diagnoses
(American Psychiatric Association,
1994). Adequate interrater reliability
(Wittchen et al,
1991; Wittchen,
1994), test–retest reliability
(Wacker et al, 1990)
and validity (Farmer et al,
1987; Janca et al,
1992) of earlier versions of the CIDI have been documented
(Andrews & Peters, 1998).
These instruments have shown good performance in studies in Mexico (Caraveo
et al, 1991,
1998) and other
Spanish-speaking communities (Vega et
al, 1998). The translation of the WMH–CIDI into Spanish
was carried out according to WHO recommendations, utilising material currently
in use in Spanish, such as the ICD–10
(World Health Organization,
1993), DSM–IV, and SF–36
(Duran-Arenas et al,
2004), with back-translation of selected items and terms of the
clinical sections.
The disorders are grouped into the following categories: mood disorders (major depressive disorder, dysthymia with hierarchy and bipolar disorder I and II); anxiety disorders (panic disorder, generalised anxiety disorder, social phobia, specific phobia, agoraphobia without panic disorder, separation anxiety disorder and post-traumatic stress disorder); substance use disorders (alcohol and drug misuse and dependence); and impulse-control disorders (oppositional-defiant disorder, conduct disorder and attention-deficit hyperactivity disorder). These three disorders were assessed only in respondents in the 18- to 44-year age group because of concerns about recall bias among older respondents. With the exception of substance use disorders, all disorders used organic exclusions rules as well as hierarchy rules.
Retrospective ages at onset were obtained from the WMH–CIDI using a series of questions designed to avoid implausible response patterns sometimes reported using the standard CIDI age at onset question (Simon & VonKorff, 1995; Kessler et al, 2005). First, a question is posed which aims to obtain the exact age when the syndrome started. If the respondent is unable to report the exact age, subsequent questions probe for approximate ages in ascending order, using anchoring events or stages such as ‘Was it before you first started school?’ or ‘Was it before you became a teenager?’
Analysis
The data analysed in this study were obtained from a stratified multistage
sample and were subsequently weighted to adjust for differential probabilities
of selection and non-response. Post-stratification to the total Mexican
population according to the year 2000 Census in the target age range and of
the corresponding gender was also performed. The interview schedule consisted
of two parts. All respondents completed part 1, which contained core
diagnostic assessments, and those meeting criteria for any of these core
disorders plus a probability subsample of other respondents were administered
part 2, which assessed disorders of secondary interest and a wide range of
correlates. Data from part 1 were weighted to adjust for differential
probabilities of selection within and between households and to match sample
distributions to population distributions for socio-demographic and geographic
data. The part 2 sample was also weighted for the undersampling of part 1
respondents without core disorders.
As a result of this complex sample design and weighting, estimates of standard errors for proportions were obtained by the Taylor series linearisation method using the Sudaan release 8.0.1 for Windows (http://www.rti.org/sudaan). Lifetime prevalence was estimated as the proportion of respondents who ever had a given disorder up to their age at the time of the interview. Age at onset and projected lifetime risk (the estimated proportion of the population who will have the disorder by the end of their life) as of age 65 were estimated using a two-part actuarial method implemented in SAS version 8.2 for Windows. Socio-demographic predictors were examined using discrete time survival analyses with person-year as the unit of analysis (Efron, 1988). Statistical significance was evaluated using two-sided design-based tests at the 0.05 level of probability. Standard errors of lifetime risk estimates were obtained using the jackknife repeated replication method implemented in an SAS macro (Berglund, 2002: pp. 1–5).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Age at onset and lifetime risk
The distribution of age at onset is presented in
Table 2. The median age at
onset (50th percentile) for any psychiatric disorder in Mexico was 21 years,
ranging from 9 years for impulse-control disorders, rising to 14 for anxiety
disorders, 26 for substance use disorders and 41 for mood disorders. The young
age at onset for anxiety disorders is primarily a result of the specific and
social phobias which make up 61% of all anxiety disorders. The disorder with
the lowest age at onset was attention-deficit disorder (8 years) and that with
the highest generalised anxiety disorder (47 years). With the exception of
impulse-control disorders, there was a large interquartile range (IQR) for age
of onset (IQR=28 years for any disorder).
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Table 2 also presents the projected lifetime risk of psychiatric disorders in Mexico. According to these estimates, approximately 36.4% of Mexicans will develop a psychiatric disorder by age 65, 20.4% will develop a mood disorder, 17.8% will develop an anxiety disorder and 11.9% will develop a substance use disorder. The projected lifetime risk for any disorder is larger than the prevalence estimate reported in Table 1 (36.4 v. 26.1%). The greatest increase in lifetime risk was found for the mood disorders (20.4 v. 9.2%), which is mainly owing to the late age at onset for this group.
Cohort effects
Dummy variables defining age groups 18–29, 30–44, 45–54
and 
55 years were used to predict lifetime disorders using discrete time
survival analysis (Table 3).
The cohorts were significant predictors for all classes of disorders, except
impulse-control disorders which had a narrow age range in our survey. Younger
cohorts (18–29 years) had larger odds ratios when compared with the
older cohort (55 years) for most groups of disorders and for
‘any’ disorder. There was a dose–response relationship such
that the younger the cohort the greater the odds of having a lifetime
disorder. For example, in the any disorder group, respondents of 18–29
years were 2.7 times more likely to have a lifetime disorder compared with the
cohort of 55, those aged 30–44 years had 2 times the risk and the
cohort aged 45–54 years had 1.4 times higher risk.
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Predictors of disorders
Table 4 shows discrete time
survival analyses for the impact of education (time-varying predictor), gender
and age on the lifetime risk of DSM–IV disorders. Educational level was
associated with mood disorders (with current students less likely to report
mood disorders than respondents with high-school or a higher level of
education) and with substance use disorders (with current students less likely
to report substance use disorders, and all other educational groups more
likely than respondents with high-school or a higher level of education).
Anxiety and mood disorders were more likely among females and impulse-control
and substance use disorders more likely to be reported by males. With the
exception of any impulsive disorder, which had a narrow age range in our
survey, age was strongly related to psychiatric disorders; all age groups had
increased risks compared with those over 55, with the youngest (18–29
years) showing the largest increases in risk.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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As in other countries (Kessler et al, 1994; Bromet et al, 2005), psychiatric disorders have early ages at onset in Mexico. Half of the population who present with a psychiatric disorder do so by the age of 21, thus the disorder affects the population throughout a large portion of their life. Early ages at onset may have far-reaching repercussions given the important developmental tasks of the first decades of life, which include educational attainment, career choice, selection of romantic partners and development of sexual identity. Adolescents with depression, have been found to have significantly more social, work and family impairment 9–10 years later as adults compared with their peers without depression (Weissman et al, 1999). Early ages at onset may also have a deleterious impact upon service utilisation because psychiatric symptoms must first be identified by a parent, teacher or other relevant adult. In Mexico, those with early-onset depression were less likely to receive treatment and reported greater treatment delays than those with adult-onset depression (Benjet et al, 2004). Further complicating the early ages at onset for psychiatric disorders is the greater availability and consumption of drugs at ever younger ages. However, in marked contrast to the USA where ages at onset are concentrated in the first two decades of life (Kessler et al, 2005), in Mexico there is considerably more variation for any disorder (IQR=11–39 years). This contributes to the increase from the prevalence estimates (26.1%) to the projected lifetime risk (36.4%).
The median age at onset was much higher for most disorders in Mexico compared with the USA (with the exception of impulse-control disorders) and also higher for mood and alcohol use disorders in Mexico (but not for any anxiety disorder) than in the Ukraine. Reasons for differences are largely speculative but it is possible that in the USA social factors have led to a sharp increase in the prevalence of psychiatric disorders (e.g. substance use disorders) among younger cohorts. This is supported by the consistently higher odds ratios for lifetime psychiatric disorders in the USA than in Mexico. For example, the youngest cohort in the USA has a fourfold likelihood of any disorder compared with the oldest cohort whereas in Mexico the corresponding figure is 2.7 (Kessler et al, 2005). If this trend continues, Mexico will have increasingly younger ages at onset in the future. Also youths leave home earlier in the USA (often at the age of 18) and are expected to live independently, whereas in Mexico they generally live with their family of origin for much longer, often not leaving until they form families of their own. This probably provides an extended period of family support and thus a more gradual transition into independence, which may contribute to a later onset of psychiatric disorder.
The socio-demographic predictors of lifetime psychopathology are consistent with findings from other countries: being female is related to a greater risk for anxiety and mood disorders and lesser risk for impulse-control and substance use disorders, younger cohorts are at greater risk for most disorders and those who are less educated are at a greater risk for substance use disorders (Abou-Saleh et al, 2001; Alonso et al, 2004; Kessler et al, 2005). Interestingly, current students are at reduced risk of substance use and mood disorders. Whether this is owing to the protection afforded by the educational environment or a reflection of impairment caused by substance use and mood disorders preventing those affected from being able to carry out their studies cannot be determined. Other research in Latin-American countries has evaluated the impact of socio-demographic variables (Araya et al, 2001) and has found an independent inverse association between education and the 1-week prevalence of ‘common mental disorders’ (Araya et al, 2003). Differences in the impact of education on psychiatric disorders in Chile and Mexico could be attributed to differences in the time frames employed (1 week in the Chilean survey and lifetime presented here for Mexico). It is noteworthy that a similar survey in Nigeria (Gureje et al, 2006) and a more recent survey in Chile (Vicente et al, 2006) also did not find education to be related to life-time prevalence of psychiatric disorders. A more detailed investigation of the social determinants of psychiatric disorders in the context of the World Mental Health Surveys, including Mexico, is ongoing.
Study limitations
One limitation of this study is that diagnosis is based on a single
structured interview administered by lay interviewers. In order to survey such
a large and geographically disperse sample, we sacrificed some diagnostic
precision that might have been obtained by using clinical interviewers,
multiple interviews or additional sources of information. In addition,
although evidence of reliability and validity of different versions of the
CIDI has been documented in other countries
(Farmer et al, 1987;
Wacker et al, 1990;
Janca et al, 1992)
and previous versions of the CIDI have shown good performance in Mexico
(Caraveo et al, 1991)
and other Spanish-speaking communities
(Vega et al, 1998),
the reliability and validity of the Spanish language version of the CIDI used
in this survey have not been established.
However, studies of validity of the WMH–CIDI are currently underway (Demyttenaere et al, 2004) in major regions of the world, including other non-Western countries participating in the World Mental Health Survey Initiative (Bromet et al, 2005; Gureje et al, 2006; Karam et al, 2006). Specific analyses of sub-threshold cases in the World Mental Health Survey Initiative have also helped to shed light on validity issues, especially those related to low prevalences found in some sites (Gureje et al, 2006; Shen et al, 2006).
Bias in respondents’ ability to recall events or symptoms as well as willingness to disclose them are also potential limitations. Longitudinal studies might help to evaluate the magnitude of recall bias. One such study which evaluated the recall of key depressive symptoms at age 25 compared with reports between the ages of 15 and 21 found that 4% of those without any previous symptoms of depression recalled symptoms, whereas of those who had a diagnosis of major depression up to age 21, only 44% recalled symptoms (Wells & Horwood, 2004). This suggests that recall bias leads to major underestimation of the lifetime prevalence of depression. Reports of age at onset may be particularly subject to errors in recall, possibly as a function of age at interview. Despite improvements in the reporting of age at onset estimates in the US National Comorbidity Study (Knauper et al, 1999), some recall bias most probably remains.
Moreover we might have underestimated the prevalence of psychiatric disorders because the disorders assessed were only a subset of those in DSM–IV and because those that did not participate might be more likely to have a psychiatric disorder (Lundberg et al, 2005). We tried to compensate for possible imbalances in the age and gender distribution of those that participated with a weighting scheme that adjusted for differential probabilities of selection and non-response (Kessler et al, 2004; Hofler et al, 2005). Finally, our sample does not include people without a fixed residence, those who are institutionalised, those without sufficient proficiency in Spanish and those from rural areas with less than 2500 inhabitants. Local surveys conducted among rural populations in Mexico have documented lower prevalence rates of psychiatric disorders, with the exception of alcohol abuse and dependence which is higher. Rates of service utilisation are also considerably lower in rural areas (Salgado de Snyder & Díaz-Pérez, 1999; Berenzon et al, 2003). However, homeless and institutionalised people might be assumed to have a higher prevalence of psychiatric disorder. Taken together these limitations suggest that bias has probably led to underestimation of the lifetime prevalence of disorders.
Implications
We project that one in three Mexicans will experience a psychiatric
disorder by the end of their life. This, in conjunction with the increasing
prevalence in younger cohorts, suggests an important challenge for the Mexican
health system in the present and the near future, especially since most mental
health speciality services are concentrated in Mexico City and are poorly
distributed throughout the rest of the country
(World Health Organization,
2005). Although not all psychiatric disorders necessarily require
specialised attention, other results of this survey reported previously
(Medina-Mora et al,
2005) suggest that among those with a 12-month disorder, one-third
are classified as serious, one-third as moderate and one-third as mild. Even
among those most severely affected, current treatment rates are low
(Borges et al,
2006).
Projected lifetime risks for psychiatric disorders can be of enormous benefit to policy makers in Mexico, where no such estimates have previously aided optimal allocation of constrained resources. We hope this survey can also serve as evidence of feasibility and an impetus for comparable efforts in other low- and middle-income countries. Although the lifetime prevalence estimates of psychiatric disorders for Mexico are not as high as in some countries the number of associated disability-adjusted life years (Murray & Lopez, 1996; Frenk et al, 1999) and the projected lifetime risk suggest an urgent need to reevaluate the resources allocated for the detection and treatment of these disorders in Mexico, particularly for major depression and alcohol misuse.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Received for publication May 3, 2006. Revision received November 8, 2006. Accepted for publication December 1, 2006.
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