School of Psychiatry, University of New South Wales, Sydney, Australia
Dunedin Multidisciplinary Health and Development Research Unit,University of Otago, Dunedin, New Zealand
Department of Psychiatry, Sahlgrenska University Hospital, Goteborg, Sweden
Correspondence: Professor Gavin Andrews, School of Psychiatry, UNSW at St Vincents Hospital, Sydney, Australia 2010. E-mail: gavina{at}unsw.edu.au
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ABSTRACT |
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INTRODUCTION |
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CAN CROSS-SECTIONAL SURVEYS INFORM? |
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The US National Comorbidity Survey used the Composite International Diagnostic Interview (CIDI) to determine a history of symptoms that matched DSMIIIR major depressive disorder (Blazer et al, 1994). The lifetime risk was 17.1%. Rates were higher in females and younger respondents. Respondents were aged 1554 (mean 34), so no one interviewed had survived their full period of risk. Similar surveys were conducted in ten developed countries under the aegis of the International Consortium of Psychiatric Epidemiology (Andrade et al, 2003). Lifetime risk of hierarchy free DSMIIIR/DSMIV major depressive episode varied widely, from 3% in Japan (surveys in Asian countries routinely report low rates of depression) to 16.9% in the USA, with the majority in the range of 8% to 12%. Again, the lifetime risk was higher in females and in younger respondents.
Waraich et al (2004) conducted a systematic review of the literature for the 21 years, 19802000. They reported on 15 studies of major depressive disorder that mostly used the CIDI/DSMIIIR. Their best estimate was 6.7% (95% CI 4.210.1) with lower rates in Taiwan and Korea and a very high rate with a telephone survey in Montreal, Canada. Rates in women were double those in men but they found little evidence of an overall age effect. They argued that the prevalence of depression in these high-quality studies was lower than the rates commonly reported in the literature and that the burden of this disease should therefore be revised downward. They did not address the issues of recall bias or of period of risk yet to come.
Because the lifetime risk of depression is biased by recall problems and by the age of those being interviewed it was estimated indirectly for two countries by Kruijshaar et al (2005). They used a microsimulation model to generate population-based measures of depression. The two national surveys were the Netherlands Mental Health Survey and Incidence study (Bijl et al, 1998) and the Australian National Survey of Mental Health and Well-Being (Andrews et al, 2001). Based on the 1 month and 12 month prevalence data from those surveys it was estimated that approximately 30% of men and 40% of women would suffer from one or more episodes of major depression during their life. Lifetime rates observed in cross-sectional surveys are, as noted above, much lower than this, first because these surveys cannot identify cases that become incident after the survey, and second because of recall bias. That the true lifetime risk could be three times that estimated by the cross-sectional surveys is a matter of concern, but to a certain extent explains why depression is such an important public health problem.
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PROSPECTIVE STUDIES SHOULD BE BETTER |
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Reviews suggest that well-being increases with age (Jorm, 2000), but few epidemiological studies have included people over the age of 70. There is a prospective study of first-onset DSMIIIR depression in a representative sample of 70-year-olds followed for 15 years and interviewed six times by psychiatrists. Palsson et al (2001) found that rates were considerable, and that the prevalence rose in the very old, affecting 13% of those aged 85. The investigators combined the clinical information on the total cohort with that from clinical records for the years prior to these individuals entering the study and concluded that the lifetime risk of depression in these people who were healthy enough to survive to old age was 23% in men and 45% in women (Palsson et al, 2001). The ability to identify ambulatory care episodes of depression in this cohort born at the beginning of the last century must be poor, but already the investigators have found evidence of being treated for depression in 30% of these elderly people who said they had never been troubled by depression. Genetic studies, as Palsson et al note, will be compromised by people with the phenotype being included in the control group. The total lifetime risk must be higher than the figures in these two prospective studies, and certainly much more than that reported in the cross-sectional studies.
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CONCLUSION |
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REFERENCES |
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Received for publication April 1, 2005. Revision received May 3, 2005. Accepted for publication May 20, 2005.
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