The aims of this paper are to investigate the change in prevalence of psychological distress (PD), to investigate the cumulative incidence of the psychological distress and to indicate are there any differences between genders and various age groups in Croatian adult population. Psychological distress status was measured by the five-item Mental Health Scale (MHI-5) of the Short Form questionnaire (SF-36). Psychological distress was present in 28.5% (95% CI 25.7%–31.2%) of men and 32.1% (95% CI 30.1%–34.0%) of women in 2003. In 2008 PD was present in 33.0% (95% CI 30.1%–35.9%) of men and 34.1% (95% CI 32.1%–36.0%) of women. The highest incidence of PD, both for men and women, was in the oldest age group (>65 years). Results of this study demonstrating the fact that every third adult men and woman in Croatia are in psychological distress, the fact that there is an increase in PD prevalence for men and women should be taken into account in the future mental health policy planning

Aleksandar Džakula

Bjanka Vuksan Ćusa

Hana Fazlić

Ognjen Brborović

Tea Vukušić Rukavina

English

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Coll. Antropol. 36 (2012) Suppl. 1: 109–112Original scientific paperPrevalence and Five-Year Cumulative Incidenceof Psychological Distress: the CroHort studyTea Vuku{i} Rukavina1, Ognjen Brborovi}1, Hana Fazli}1, Aleksandar D`akula1 andBjanka Vuksan ]usa21 University of Zagreb, School of Medicine, »Andrija [tampar« School of Public Health, Zagreb, Croatia2 Zagreb University Hospital Center, Department of Psychiatry, Zagreb, CroatiaA B S T R A C TThe aims of this paper are to investigate the change in prevalence of psychological distress (PD), to investigate the cu-mulative incidence of the psychological distress and to indicate are there any differences between genders and various agegroups in Croatian adult population. Psychological distress status was measured by the five-item Mental Health Scale(MHI-5) of the Short Form questionnaire (SF-36). Psychological distress was present in 28.5% (95% CI 25.7%–31.2%) ofmen and 32.1% (95% CI 30.1%–34.0%) of women in 2003. In 2008 PD was present in 33.0% (95% CI 30.1%–35.9%) ofmen and 34.1% (95% CI 32.1%–36.0%) of women. The highest incidence of PD, both for men and women, was in the oldestage group (>65 years). Results of this study demonstrating the fact that every third adult men and woman in Croatia are inpsychological distress, the fact that there is an increase in PD prevalence for men and women should be taken into accountin the future mental health policy planning.Key words: psychological distress, prevalence, cumulative incidence, CroHortIntroductionThe public health significance of mental and behav-ioral disorders is demonstrated by the fact that they areamong the most important causes of morbidity in pri-mary care settings and produce considerable disability1,2.According to the World Health Organization’s GlobalBurden of Disease project in 20011, one third of the yearslived with disability are due to neuropsychiatric disor-ders and a further 2.1% are associated with intentionalinjuries. Four of the six leading causes of years lived withdisability are due to neuropsychiatric disorders (depres-sion, alcohol use disorders, schizophrenia and bipolardisorders). Depression alone causes over 12% of the yearslived with disability globally, and ranks as the third lead-ing contributor to the global burden of disease. Morethan 150 million persons suffer from depression at anypoint in time. About 25 million suffer from schizophreniaand more than 90 million suffer from an alcohol or drugrelated problem. In 2000, more than 1.8 million deathswere attributed to alcohol related risks and 205,000deaths were attributed to illicit drug use3.General population surveys are extremely importantwhen it comes to collecting mental health morbiditydata. This is because routinely collected statistics ondeaths related to mental health problems do not reflectthe reality of mental health. Nor do hospital dischargedata. These statistics contain no information on the largenumbers of people who suffer from mental health prob-lems but neither die nor are hospitalized as a result4.Some instruments measure more generic factors suchas 'psychological distress' by recording the presence orabsence of some symptoms, such as those of anxiety ordepression. This type of instrument produces a mentalhealth score, and for some of them cut-off points can beused to categorize people into groups such as 'probablecases' with mental health disorders. Instruments in thiscategory include the General Health Questionnaire(GHQ) and the five-item Mental Health Scale of theSF-36 (MHI-5) which is a sub-scale of a widely used ge-neric instrument, the Short-Form 36 (SF-36).Psychological distress (PD) is a non-specific dimen-sion of psychopathology, indicating that something iswrong but does not yield diagnostic assessment, com-prised usually of anxiety and depression related distressstates5. These symptoms are usually measured by 'check-109Received for publication September 1, 2011lists' which produce a score by adding up the answers tothe various questions. Psychological distress is, there-fore, a continuous dimension. The symptoms are rathercommon and could be transient, for example, following anegative or stressful life event. However, most of thetime the person does not fit into a psychiatric diagnosticcategory and probably never will. Those who are definedas having psychiatric disorders, however, do usually alsoscore highly on the psychological distress checklist.The aims of this paper are to investigate the change inprevalence of PD in a follow up study, to investigate thecumulative incidence of the psychological distress in Cro-atian adult population and to indicate are there any dif-ferences between genders and various age groups.Materials and MethodsThis study was a part of the Croatian Adult CohortHealth Study (CroHort), a repeated cross-sectional sur-vey of adults aimed at providing a comprehensive com-munity health assessment of Croats, including their ac-cess to and use of health care services, health status, anddeterminants of health such as nutrition, physical activ-ity, smoking and alcohol consumption. The sample wasfirst examined in the 2003 CAHS study6 and re-examinedin the 2008 Croatian Adult Cohort Health Study7. Thesample of this study consisted of 3,229 respondents (1,015male and 2,214 female) who participated in both Croa-tian Adult Health Survey 2003 and the follow-up Croa-tian Adult Health Cohort Study (CroHort) in 2008. Theywere 18 years or older at the time of the first survey.Psychological distress status was measured by thefive-item Mental Health Scale of the SF-36 (MHI-5)8,9.MHI-5 is a well validated and reliable measure of mentalhealth status10. MHI-5 has been used to identify mentaldisorders in the community11 and clinical samples12–16.The 5-item mental health index (MHI-5) of the SF-36 hasbeen reported to correlate highly with the GHQ-12-ques-tionnaire which is a well-established indicator of psychicdistress17,18 as well as with different versions of the SCLquestionnaire19. With regard to assumed validity, theMHI-5 is equal to a longer version, MHI-18 and anotherquestionnaire GHQ-30 in detecting the mental disordersdiagnosed with an established and standardized DIS-in-terview schedule20.The MHI-5 used in CroHort is part of the SF-36 ver-sion 2 and comprises five questions relating to the pastfour weeks: 'Have you been very nervous?' 'Have you feltso down in the dumps that nothing could cheer you up?''Have you felt calm and peaceful?' 'Have you felt down--hearted and depressed?' 'Have you been happy?' Each ofthe five questions has five response categories which arescored from 1 to 5: 'all of the time' 1; 'most of the time' 2;'some of the time' 3; 'a little of the time' 4; or 'none of thetime' 5. Response scores were transformed and imputedmissing data to a scale of range 0 to 100 using the stan-dard method of the SF Health Outcomes Scoring Soft-ware Ver.1.0.1.9. Lower scores on MHI-5 indicate lowermental health status. Psychological distress was deter-mined when MHI-5 score was less or equal to 5221–23.The analysis included calculations of the prevalenceof PD with 95% confidence intervals (CI). Presence of PDwas calculated regarding gender and age group. Pear-son’s c2-test was used for comparison of frequencies. Pvalues less than 0.05 were considered statistically signifi-cant. All statistical analyses were carried out with theSAS statistical package ver. 9.1.ResultsPsychological distress was present in 28.5% (95% CI25.7%–31.2%) of men and 32.1% (95% CI 30.1%–34.0%)of women in 2003, and although observed, the increase inthe prevalence was insignificant; in 33.0% (95% CI30.1%–35.9%) of men and 34.1% (95% CI 32.1%–36.0%)of women PD was present in 2008.In 2003 there were 693 men without PD; out of them,in 2008, 235 have PD. Out of the male population withPD in 2003, 222 men do not have PD in 2008 and 100 re-mained in the status of having PD. There is no statisti-cally significant difference between age groups regardingthe number of new PD cases (c2=1.185, p=0.276), sameas for those who ceased having PD in 2008 (c2=0.84,p=0.35, Table 1).Table 2 presents results of the five year cumulativeincidence of PD for men. The highest incidence is in theage group of elderly men, two folds higher than in theyoungest age group.In 2003 there were 1537 women without PD, out ofthem, in 2008, 516 have PD. Out of the female populationwith PD in 2003, 439 women do not have PD in 2008 and238 remained in the status of having PD. There is no stati-stically significant difference between age groups regard-ing the number of new PD cases (c2=1.056, p=0.304),same as for those who ceased having PD in 2008 (c2=0.465,p=0.495, Table 3).T. Vuku{i} Rukavina et al.: Psychological Distress 2003–2008, Coll. Antropol. 36 (2012) Suppl. 1: 109–112110TABLE 1NUMBER OF MEN WITHOUT PD AND WITH PD IN RELATIONTO PD STATUS IN 20032003 does not have PDN/%2003 have PDN/%Agegroup2008 doesnot have PD2008 havePD2008 doesnot have PD2008 havePD18–34 52/80.0% 13/20.0% 25/89.3% 3/10.7%35–65 265/67.4% 128/32.6% 120/71.4% 48/28.6%>65 141/60.0% 94/40.0% 77/61.1% 49/38.9%TABLE 2FIVE YEAR INCIDENCE COUNTED PER 1000 INHABITANTS –MENAgegroupNewcasesTotal population forincidence calculation5 year incidence/1000inhabitants18–34 13 65 20035–65 128 393 326>65 94 235 400Table 4 presents results of the five year cumulativeincidence of PD for women. The highest incidence is inthe age group of elderly women, two and a half foldshigher than in the youngest age group.DiscussionSurvey results based on measures of psychologicaldistress show higher levels of psychological distress, andhigher probability of mental ill-health, in women than inmen in most countries4. Our study shows similar find-ings demonstrating estimated prevalence of psychologi-cal distress (PD) of 33.0% for men and 34.1% for womenin general population of adults in Croatia.The Eurobarometer survey conducted in 17 Europeancountries, which included a measure of psychological dis-tress using the MHI-5 scale, allows for calculation ofprobable cases of mental ill-health and to compare therisk by gender4. In each country except three – Nether-lands, Austria and Luxembourg – females have higherrisk than males, also confirmed with this study. Resultsof the PD prevalence for men in Croatia are the highestwhen compared to other European countries which canbe explained by study’s sample limitation and cohort de-sign thus persons with PD were more motivated to par-ticipate in the follow-up. Results of the PD prevalence forwomen in Croatia are also among the highest when com-pared to the Eurobarometer survey (Portugal, Italy andGreat Britain have higher prevalences of PD for women).Similar findings are reported for Ireland24 but small sam-ple size and low response rate limit the generalization ofthat study’s findings. The fact that every third adult menand woman in Croatia are in psychological distress canbe explained by post-transitional era along with the be-ginning of the global recession influencing the socio-eco-nomic status at the time of interviewing respondents.The highest incidence of PD, both for men and women,is in the oldest age group, with 5 year cumulative inci-dence being 2,8 folds higher for older women and twofolds higher for older men when compared to the youn-gest age group (18–34 years).It is estimated that the proportion of the Europeanpopulation over 65 will rise from 22% in 2000 to 30% in202525. The number of oldest old will increase dispropor-tionately. With these changes underway, aging and thespecial circumstances of older people are taking an in-creasingly central place in public health. Mental disor-ders in old age are common, especially when consideringlife changing events (retirement, potential loss of a part-ner, social isolation, etc.) that influence mental healthwell-being. The most serious threats to mental health inold age are posed by depression and dementia26,27.These results should be interpreted with acknowl-edged limitation of the follow-up sample where respon-dents were significantly older than non-respondents7which might influence the results. Also sample of CroHortwas not weighted, therefore data from CroHort should beconsidered informative and analyzed only on nationallevel. Another limitation of this study is that instrumentused to assess PD prevalence does not have validated cutoff point to differentiate the levels of the PD (e.g. severpsychological distress) that would enable more detailedanalysis of the population that are having psychiatricdisorders.ConclusionResults of this study demonstrating the fact that ev-ery third adult men and woman in Croatia are in psycho-logical distress, the fact that there is an increase in PDprevalence for men and women should be taken into ac-count in the future mental health policy planning by therelevant decision makers.Although, for the most part, those who will experi-ence psychological distress will not require any mentalhealth services, it is still important to have supportsavailable to them to prevent any further deteriorationthat may at a later date require more intensive serviceprovision. Recent findings show that even mild psycho-logical distress may be associated with more long-termdisability than previously acknowledged and its publichealth importance may be underestimated28. The WHO29recommends the provision of most mental health ser-vices via primary care, especially in low and middle-re-sourced countries. However, it is recommended that oncereasonably well-resourced countries have developed ro-bust primary care services they should then developmainstream mental health services that liaise effectivelywith these primary care services30.AcknowledgementsThis study was supported by the Croatian Ministry ofScience, Education and Sport, grant number 108-1080135--0264.T. Vuku{i} Rukavina et al.: Psychological Distress 2003–2008, Coll. Antropol. 36 (2012) Suppl. 1: 109–112111TABLE 3NUMBER OF WOMEN WITHOUT PD AND WITH PD INRELATION TO PD STATUS IN 20032003 does not have PDN/%2003 have PDN/%Agegroup2008 doesnot have PD2008 havePD2008 doesnot have PD2008 havePD18–34 152/82.6% 32/17.4% 76/77.6% 22/22.4%35–65 608/71.7% 240/28.3% 249/69.7% 108/30.3%>65 261/51.7% 244/48.3% 114/51.4% 108/48.6%TABLE 4FIVE YEAR INCIDENCE COUNTED PER 1000 INHABITANTS –WOMENAgegroupNewcasesTotal population forincidence calculation5 year incidence/1000inhabitants18–34 32 184 17435–65 240 848 283>65 244 505 483R E F E R E N C E S1. The world health report 2001 – Mental health: new understanding,new hope. Geneva: World Health Organization; 2001. — 2. ORMEL J,VON KORFF, M., USTUN, T.B., PINI, S., KORTEN, A., OLDEHINKEL,T., JAMA, 272 (1994). — 3. Investing in Mental Health. Geneva: WorldHealth Organization; 2003. — 4. The state of mental health in the Euro-pean Union: World Health Organization; 2005. — 5. 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MCCABE CJ, THOMAS KJ, BRAZIER JE, CO-LEMAN P, Br J Psychiatry, 169 (1996). — 18. AYUSO-MATEOS JL, LASAL, VAZQUEZ-BARQUERO JL, OVIEDO A, DIEZ-MANRIQUE JF, ActaPsychiatr Scand, 99 (1999). — 19. STRAND BH, DALGARD OS, TAMBSK, ROGNERUD M, Nord J Psychiatry, 57 (2003). — 20. WEINSTEINMC, BERWICK DM, GOLDMAN PA, MURPHY JM, BARSKY AJ, MedCare, 27 (1989). — 21. HOLMES WC, Med Care, 36 (1998). — 22. KO-VESS V. The State of Mental Health in European Union. Luxembourg:European Commission, Directorate General for Health and ConsumerProtection; 2004. — 23. (EORG) TEORG. Eurobarometer 58.2. The men-tal health status of the European population; 2003. — 24. HUGHES M,BYRNE, M., SYNNOTT, J., Clinical Psychology Forum, 206 (2010). — 25.LUTZ W S, S., First probabilistic population projections for the EuropeanUnion. In: Lutz W, ed. Kompendium der Familienforschung in Österreich(Schriftenreihe des ÖIF Nr.7, Vienna, 1999). — 26. DUNHAM NC, SA-GER, M.A., Arch Fam Med 3(1994). — 27. GANZINI L, SMITH, D.M.,FENN, D.S., LEE, M.A., J Am Geriatr Soc 45 (1997). — 28. RAI D, KOSI-DOU K, LUNDBERG M, ARAYA R, LEWIS G, MAGNUSSON C, J Epide-miol Community Health, (2011). — 29. What are the arguments for com-munity-based mental health care? Copenhagen: World Health Organisa-tion; 2003. — 30. THORNICROFT G, TANSELLA M, The mental healthmatrix: A manual to improve services. (Cambridge University Press, Cam-bridge, 1999).T. Vuku{i} RukavinaUniversity of Zagreb, School of Medicine, »Andrija [tampar« School of Public Health, Rockefellerova 4,10 000 Zagreb, Croatiae-mail: tvukusic@snz.hrPREVALENCIJA I PETOGODI[NJA KUMULATIVNA INCIDENCIJA PSIHOLO[KE PATNJE:CroHort STUDIJAS A @ E T A KCiljevi ovog istra`ivanja bili su istra`iti promjene u prevalenciji psiholo{ke patnje (PP) te istra`iti spolne i dobne raz-like u kumulativnoj incidenciji PP u odrasloj populaciji Hrvatske. Podaci su dobiveni iz Hrvatske zdravstvene ankete pro-vedene 2003. te ponovljene 2008. godine, a uzorak je ^inila kohorta od 3229 ispitanika. Postojanje PP procijenjeno je teme-ljem Skale mentalnog zdravlja koja je dio SF-36 upitnika. Psiholo{ka patnja utvr|ena je u 28,5% (95% CI 25,7%–31,2%)mu{karaca i 32,1% (95% CI 30,1%–34,0%) `ena za 2003.g. Za 2008.g. PP utvr|ena je u 33,0% (95% CI 30,1%–35,9%)mu{karaca i 34,1% (95% CI 32,1%–36,0%) `ena. Rezultati su pokazali najve}u petogodi{nju kumulativna incidencijuPP, i za mu{karce i za `ene, u najstarijoj dobnoj skupini (>65 g.). Rezultati ovog istra`ivanja koji pokazuju da svakatre}a `ena i svaki tre}i mu{karac u Hrvatskoj imaju PP te da postoji porast prevalencije PP trebaju poslu`iti nadle`niminstitucijama kao osnova za budu}e planiranje politike du{evnog zdravlja.T. Vuku{i} Rukavina et al.: Psychological Distress 2003–2008, Coll. Antropol. 36 (2012) Suppl. 1: 109–112112

Prevalence and Five-Year Cumulative Incidence of Psychological Distress: the CroHort study

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