Institut National de la Santé et de la Recherche Médicale (INSERM), E 0361 Pathologies of the Nervous System, Montpellier, France
INSERM E 0361, and Section of Old Age Psychiatry, Institute of Psychiatry, London, UK
INSERM E 0361, and University Department of Biochemistry, Hôpital Lapeyronie, Montpellier, France
INSERM E 3061, and Department of Psychiatry, University of Geneva, Switzerland
INSERM E 0361, and University La Colombière, Montpellier, France
Correspondence: Dr Karen Ritchie, INSERM E 0361 Pathologies of the Nervous System, Hôpital La Colombière, 39 avenue Charles Flahault, 34093 Montpellier Cedex 5, France. Tel: 04 99 61 45 60; fax: 04 99 61 45 79
Funding detailed in Acknowledgements.
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ABSTRACT |
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Aims To describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder.
Method A study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM IV criteria were re-examined by a clinical panel.
Results Forty-six per cent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis.
Conclusions Results show veryhigh rates of lifetime but not current major depression. Rates of currentphobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.
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INTRODUCTION |
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METHOD |
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Participants were asked to attend a half-day examination at the Gui de Chauliac Neurology Hospital (with taxi transport where necessary), to undergo the assessments described below. Housebound participants were examined at home by a nurse and neurologist with training in psychogeriatrics. In each case the neurologist contacted the person's general practitioner, permitting verification of information where necessary. This paper reports results obtained from the psychiatric examination only.
Health interview
A standardised health interview covered present state of health; individual
and family medical history; medication use (participants were asked to bring
their medication to the centre); past and present hormonal therapy for women;
exposure to adverse environmental factors (including pesticides,
electromagnetic fields, anaesthesia, adverse life events); and sleep
disorders. Exposure to adverse life events was assessed using the Gospel Oak
questionnaire (Harwood et al,
1998). The Activities of Daily Living (ADL;
Katz et al, 1963),
Instrumental Activities of Daily Living (IADL;
Lawton, 1988) and the Rosow
& Breslau (1966) scales
were completed for assessment of disabilities.
Neurological examination
A standardised neurological examination based on ICD-10 criteria
(World Health Organization,
1992) was used to detect possible organic causes of behavioural
disorder. The examination also included measures of sitting and standing blood
pressure and a cognitive examination.
Psychiatric interview
A standardised psychiatric interview was used to investigate lifetime and
current psychiatric disorder; this was the Mini International Neuropsychiatric
Interview (MINI, French version 5.00), previously validated within the general
population setting (Lecrubier et
al, 1997). This interview, which has been widely used in many
clinical and research settings in France, provides an extensive
symptomatological examination. Diagnostic algorithms may then be applied to
assess caseness. The interviewers (nurses or psychologists) were
trained using video recordings of interviews by the clinicians responsible for
the development of the French version of the MINI. Following training, the
interviewers administered the examination over a 1-month period under the
supervision of psychiatrists in the department of adult psychiatry at
Montpellier University. Regular meetings were conducted with clinicians to
discuss problems, and dual interviews were randomly conducted to minimise
interviewer drif. Cases detected by the MINI, i.e. those meeting
DSM-IV criteria (American Psychiatric
Association, 1994), were reviewed at the research site by an
international panel of three psychiatrists and a psychologist, taking into
account the observations of the neurologist and the participant's medication
and medical history, in order to validate the initial diagnosis. The MINI
explores lifetime and current DSM-IV Axis I psychiatric disorders, and a pilot
study conducted on 20 persons by two of the ESPRIT interviewers within a
geriatric hospital showed it to be well accepted, even by extremely old and
frail people and by those with mild cognitive impairment. In the case of mild
cognitive or sensory difficulties the MINI is administered with the assistance
of a close relative or carer. The MINI does not use a hierarchical approach
and comorbidity was recorded under each disorder. Severity of anxiety and
depressive symptoms was examined using the State and Trait versions of the
Spielberger Anxiety Scales (Spielberger,
1983) and the Center for Epidemiologic Studies - Depression (CESD)
scale (Radloff, 1977).
Interviews were occasionally conducted in tandem to reduce drift.
Biological measures
Stress reactivity was measured by cortisol levels taken over 2 days, one
stressful and one non-stressful, and blood samples were taken at home on the
day after the clinical examination to constitute a specimen (serum, plasma,
DNA). The results of these analyses are not reported here.
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RESULTS |
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Table 2 gives current and lifetime prevalence rates and confidence intervals for each DSM-IV disorder in men and women. Overall, 45.7% of the population sampled had experienced at least one psychiatric disorder in their lifetime and 17.4% were currently suffering from such a disorder. Anxiety disorders were the most frequent, with a lifetime prevalence of 29.4%, and a lifetime history of mood disorders was reported by 26.5% of the sample. Comorbidity rates are given in Table 3.
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Mood disorders
The prevalence of current (during the past 15 days) depressive illness in
the Montpellier district was 3.1% and the lifetime prevalence of major
depression was 26.5%. Both lifetime and current prevalence were twice as high
in women than in men. Around 10% admitted to current suicidal ideation (during
the past month) and 3.7% had made at least one suicide attempt.
Table 4 shows the mean age at
first-reported episode for each psychiatric disorder. In order to distinguish
between late-onset and early-onset disorders, prevalence rates are also given
according to the period of onset (under 20 years, 21-40 years, 41-60 years, 61
years and over) roughly corresponding to periods of childhood and adolescence,
young adulthood, old adulthood and old age.
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Mean age at first major depressive episode was 44.8 years, and was similar for men and women. There is a progressive increase in the proportion of first episodes of major depression up to age 60 years. In more than 76% of the diagnosed cases of major depression, the age of onset was 21-60 years; however, late episodes are not uncommon, since 16.8% of first episodes occurred after age 60 years. The current prevalence rate for manic episodes is 0.4%, and 1.2% of participants had experienced an episode during their lifetime. Prevalence rates in men were 2.6 and 8 times higher than those in women for current and lifetime episodes, respectively. For both men and women, the mean age at first manic episode was 33.2 years and first onset of mania appeared more frequently before age 40 years (only one case of mania was reported after age 60, in a man).
Anxiety disorders
The prevalence of all anxiety disorders in the cohort has been estimated to
be 14.2% and 29.4% for current (during the past month) prevalence. Phobia was
the most prevalent anxiety disorder, currently affecting 10.7% of the cohort
(1.2% of these phobias were classified as social phobia). The lifetime
prevalence of phobia was 21.6% (social phobia 6%). The prevalence of current
generalised anxiety disorder in the cohort has been estimated at 4.6%.
Lifetime generalised anxiety disorder accounted for 10.8% of total psychiatric
disorders. Generalised anxiety and phobia states are seen to be almost twice
as common in women than in men for both current and lifetime prevalence.
Obsessive-compulsive disorders were diagnosed in 0.5% of the population;
lifetime prevalence was 1%, with a slightly higher prevalence in men (1.3%)
than in women (0.8%). Current panic attacks were found in 0.3% of the cohort,
principally in women, and the lifetime prevalence rate for panic disorder was
2%. All anxiety disorders had their mean age of onset primarily before the age
of 50 years in this population (mean age at first episode is generally 31-42
years). Earlier median ages at illness onset are found only for social phobia
(16.3 years), which occurs much earlier than other phobias (31.1 years). The
first episode generally occurred at the same age or slightly earlier for women
than for men except for social phobia. Irrespective of the type of phobia, for
both men and women there was a gradual decline with age in the proportion of
first episodes. Regarding social phobia, most of the episodes (73.2%) occurred
before age 20 years, and after age 60 years there was no case of social phobia
onset, whereas a significant proportion of agoraphobia (14.5%) occurred after
age 60 years. Generalised anxiety disorder follows a different pattern: there
is roughly the same proportion (around 30%) of first episodes in each of the
age ranges 20, 20-40 years and 40-60 years, and only 6.8% of onset occurs
after age 60 years. For obsessive-compulsive disorder, the first episode
occurred later in women (35.1 years) than in men (25.1 years) and half of the
participants experienced their first episode before the age of 20 years. In
contrast, irrespective of gender, 61% of panic first episodes occurred between
the ages of 21 years and 60 years, and a large proportion (22%) occurred after
age 60 years.
Psychosis
Psychosis as defined by the MINI refers to the presence of delusions,
hallucinations and thought disorder, permitting a DSM-IV diagnosis of
schizophrenia and mood disorder with psychotic features. The lifetime
prevalence of psychosis in the Montpellier study was 4.7%, and 1.7% of the
study sample currently suffered from this disorder. A slightly higher
prevalence was observed for men than for women (differing by less than
1.4-fold). The mean age at onset was 24 years, with an earlier onset for men
than for women (21 years v. 26.9 years). Most of the participants
(especially men) had their onset primarily before the age of 20 years, and
after age 60 years there was only one case of first onset (male).
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DISCUSSION |
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Mood disorders
Major depression is the most frequent mood disorder reported by other
studies in Western cultures, with variable lifetime prevalence rates ranging
from 3-7% using the DSM-III version of the Diagnostic Interview Schedule (DIS;
Robins et al, 1984)
to 15-19% using DSM-III-R and the Composite International Diagnostic Interview
(CIDI; Lepine et al,
1989; Kessler et al,
1994). Using DSM-IV criteria for depression, Forsell et
al (1995) reported a 7.9%
prevalence of major depressive episode in Swedish nonagenarians. In the
Montpellier district (using DSM-IV criteria) we noted a significantly higher
lifetime prevalence of major depression: 26.5%. The current prevalence rate of
3.1% is, however, comparable with rates reported elsewhere in Europe, which
range between 2% and 4.3%, and also in the USA (1-3.8%).
There are few reports of the prevalence of manic disorder in elderly people. It has been estimated that episodes of mania occur in less than 2% of the elderly population (0-2.2%) (Robins et al, 1984; Kessler et al, 1994; Angst, 1995) with no reported gender differences (Kessler et al, 1994). In our study the current prevalence rate was in the same range (0.4%), with a higher prevalence in men than in women, although the numbers are too small to draw conclusions on this point. First onset of mania appeared more frequently before age 40 years, and after age 60 years only one case of mania was diagnosed (a man).
Suicide attempts and suicidal ideation
Seventy-six per cent of the diagnosed cases of major depression had their
onset between the ages of 21 and 60 years. Given the relatively higher rates
of suicide, especially among older men in France, it is possible that the
lifetime prevalence of major depression at higher ages reported here are
underestimates due to suicide-related mortality. The suicide rates in the
Languedoc-Roussillon region of France where this study was conducted (3.9% for
men and 1% for women) are twice the national rates (2% and 0.6%). Our study
shows a high rate of current suicidal ideation - 9.8% compared with the
estimated 0.7-1.2% reported from the USA by Callahan et al
(1996). In Sweden, Skoog et
al (1996) noted an
increase of suicidal ideation in people aged over 85 years (9.6% in men and
18.7% in women). Findings in our Montpellier sample were similar, with rates
of suicidal ideation over the past month in people aged over 80 years of 11.3%
for men and 21.4% for women. During their lifetime, 3.7% of our cohort had
made at least one suicide attempt, and this was 2.8 times more frequent for
women than for men. This gender difference may be due to a survival effect, as
men make attempts that are more seriously life-threatening.
Anxiety disorders
Anxiety disorders are the most common psychiatric disorders in this elderly
population. In the present study, the prevalence of all anxiety disorders has
been estimated at 14.2% and 29.4% for current and lifetime prevalence,
respectively. Other epidemiological surveys also reveal that up to 30% of
individuals will experience an anxiety disorder in their lifetime
(Robins et al, 1984;
Kessler et al, 1994).
In our sample, phobias were the most common anxiety disorder, generalised
anxiety disorder was relatively common and obsessive-compulsive disorder and
panic were quite rare. The MINI only deals with agoraphobia and social phobia.
The differential diagnosis between agoraphobia and specific phobia is
sometimes difficult to establish, and we have thus not distinguished between
these disorders, although social phobia was estimated separately. The lifetime
prevalence for phobia was 21.6% with 6% corresponding to social phobia. Around
11% of participants were currently experiencing phobias.
Previously reported prevalences for phobic disorders are highly variable - from 0.7% to 12% for current rates (Krasucki et al, 1998) - essentially because of the use of different diagnostic systems, through different hierarchical diagnostic rules and severity criteria (Lindesay & Banerjee, 1993; Krasucki et al, 1998). More specifically, estimates of prevalence for agoraphobia vary from 1% to 8% (Robins et al, 1984; Kessler et al, 1994; Manela et al, 1996). The lowest prevalence figures probably result from the combination of the use of DSM-III hierarchical exclusion criteria in the DIS, which require that agoraphobia not be diagnosed in the presence of major depressive disorder, and a different threshold for caseness resulting from the use of different anxiety instruments. On the other hand, the agoraphobia dimension on the Anxiety Disorder Scale includes two items - fear of being with and fear of meeting other people - that could be construed as establishing the presence of social phobia rather than agoraphobia (Krasucki et al, 1998).
There is also considerable variation in prevalence findings for social phobia, from fairly low rates of 2-3% (Robins et al, 1984) to considerably higher estimates (13-16%; Kessler et al, 1994; Manela et al, 1996; Lecrubier et al, 2000). The lowest estimates, notably found in the ECA study (0.6%), are probably an underestimation due to the use of the DSM-III version of the DIS, which assessed only a limited range of social fears as part of the simple phobia section. This problem has been corrected in the World Health Organization's CIDI, and the lifetime prevalence of social phobia in the general population is estimated to be at least 7% (Lecrubier et al, 2000). Unfortunately, as yet there are few (if any) exhaustive epidemiological studies using DSM-IV diagnostic criteria.
In our survey, lifetime generalised anxiety disorder accounted for 10.8% of total psychiatric disorders, which is higher than the 4-6% generally reported (Robins et al, 1984; Kessler et al, 1994). We estimated the prevalence of current generalised anxiety disorder at 4.6%, which corresponds to the highest rates reported elsewhere (generally between 1% and 4.7%; see for review Krasucki et al, 1998). Obsessive-compulsive disorder was diagnosed in 0.5% of our population and its lifetime prevalence was 1%. Other European and US studies report comparable rates for current (0.1-1.5%) and lifetime 1-3% prevalence (Robins et al, 1984; Copeland et al, 1987; Bland et al, 1988). Current panic attacks were found in 0.3% of the cohort. The lifetime prevalence for panic disorder was 2%, which is in the 0.1-3.5% range reported by other epidemiological studies (Robins et al, 1984; Copeland et al, 1987; Bland et al, 1988; Lepine et al, 1989; Kessler et al, 1994; Krasucki et al, 1998).
Generalised anxiety disorder is generally reported to be rare in adolescence and early adulthood and more common in older adults, especially women aged 50-79 years (Krasucki et al, 1998; Pigott, 1999). The peak incidence for panic disorder generally occurs in men aged 18-44 years, and slightly later in women (30-64 years), whereas in those aged over 65 years, no new case has been reported (Krasucki et al, 1998). This contrasts with our population, in whom an equal distribution (around 30%) of onset of the disorder was observed in the 0-20, 21-40 and 41-60 year age groups, and in whom a constant sustained rate for panic disorder was observed even after age 60 years. This could result from the fact that this elderly population had been exposed to several successive wars between 1914 and 1962: the First World War for the oldest, the Second World War for all of them, the war in Indochina for a small proportion, and for more than a quarter of our population, the Algerian conflict. This could also explain the high lifetime prevalence rates observed for most mood and anxiety disorders in this population. Unfortunately, regional statistics do not record the proportion of the population resettled from postwar Algeria, and thus it is not known to what extent this might constitute a risk factor specific to this region. In subsequent waves of the study, detailed information was obtained on war exposure, early life events and immigration, which may help us to determine the relative weight of such risk factors in disease onset. In our sample we observed similar rates for mood and anxiety disorders (around 30%); however, point prevalence rates were quite different, with 5% of participants currently manifesting mood disorders and 15% currently suffering from anxiety disorders. This might be due to differential attrition rates in depression across the life span (in particular through suicide), and/or more successful current treatment of depression.
Psychosis
The lifetime and current prevalence rates for psychosis are 1.7% and 4.7%
respectively, and in 70% of cases onset was before the age of 40 years. Little
information is available concerning the prevalence of psychotic episodes in
elderly people. These rates are much higher than the 0.6% found in the ECA
study (Robins & Regier,
1991). Training sessions with the MINI suggested that the module
concerning psychoses caused the most problems. Although in some cases indirect
validation was possible by reference to treatment, these questions posed the
most difficulty for the interviewees. The clinical panel found that most
people reporting psychotic symptoms were also classified by the neurological
examination as having mild cognitive impairment (a pre-dementia syndrome).
Follow-up of these individuals will allow us to determine whether the current
psychotic symptoms recorded by interviewers on the MINI were in fact
dementia-related neuropsychiatric signs.
Gender differences
In our sample there was a general trend for a female predominance in
depression (but not in mania) and in anxiety disorders (except
obsessive-compulsive disorder), which has also been reported in US and
European studies (Robins et al,
1984; Lepine et al,
1989; Kessler et al,
1994; Krasucki et al,
1998), and an age-related decline for some anxiety disorders
(especially phobia). This downward age-related trend could be due to an excess
anxiety-related mortality (for example from suicide, or from cardiovascular or
cerebrovascular causes) and could possibly contribute to the lower prevalence
in men than in women (Krasucki et
al, 1998). Numbers are too small to examine gender
differences in psychotic disorder.
Study limitations and future research
The study has a number of shortcomings which might have led us to
underestimate the true prevalence: institutionalised elderly people were not
included; registration on the electoral roll is voluntary, and no information
is available on non-registered populations (which may include a large number
of residents who have moved to the region, and illegal immigrants); and there
was undersampling of the oldest age group, in which suicide rates are highest.
Although costly cross-sectional population studies are now considered to add
little to current knowledge, longitudinal observations of mental disorder are
still undertaken in almost all European countries to permit monitoring of
changes in prevalence, to develop dynamic models of disease onset, establish
causality, describe patterns of care utilisation and to assess the impact of
therapeutic innovations (Ritchie &
Mann, 2001). This first French prospective epidemiological study
of psychiatric disorders in elderly people shows a very high lifetime
prevalence of major depression, and relatively high rates of current
generalised anxiety disorder and phobia. Longitudinal follow-up of this
population will permit the construction of aetiological hypotheses concerning
the causes of psychiatric disorder in elderly people, to determine whether
these high rates of morbidity may be attributed to biological determinants,
environmental exposures or differences in clinical management.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication April 8, 2003. Revision received August 29, 2003. Accepted for publication October 2, 2003.
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