Mrcpsych Paper 2 Revision Epidemiology Answers & Lecture Notes May 2010

www.spmmpsychiatrycourse.
com © 2010 SPMM Course
CONTENTS
Introduction
Incidence and prevalence rates
Surveys across life span
Depression epidemiology
Biopolar epidemiology
Schizophrenia epidemiology
Anxiety disorders epidemiology
Suicidal ideas epidemiology
Adolescent suicides
Personality disorders
Unmet needs
Assessment instruments
MRCPsych Paper 2 Revision

Epidemiology
Answers & Lecture notes
May 2010
Epidemiology Answers 38
www.spmmpsychiatrycourse.com © 2010 SPMM Course
Introduction:
Psychiatric epidemiology deals with counting the frequency, risk factors and burden of
psychiatric diseases in specified human population in a specified period. The essence of
epidemiology is studying the distribution of disease using which causal attributions could be
drawn and health services could be organised. Descriptive epidemiology deals with
describing the pattern of diseases while analytical epidemiology attempts to make
associations of observed patterns in order to make inferences in a hypothesis driven manner.
A fast expanding branch of psychiatric epidemiology is genetic epidemiology. It is the
epidemiological evaluation of the role of inherited causes of disease in families and in
populations; Gene-gene and gene-environment interactions are also studied in genetic
epidemiology. Morton defined genetic epidemiology as ‗a science which deals with the
etiology, distribution, and control of disease in groups of relatives and with inherited causes
of disease in populations‘ (Morton NE. Outline of genetic epidemiology. Basel: S Karger,
1982.)
History of Psychiatric epidemiology:

To describe the development of psychiatric epidemiology, three ‗generations‘ of studies are
distinguished. Around 16 psychiatric–epidemiological studies carried out before World War 2
belongs to the first generation (includes Midtown Manhattan study). These studies focused
primarily on the health care agency registered prevalence of mental disorders in relation to
community characteristics. The 2nd generation of psychiatric epidemiological studies
followed an increased interest in the diagnostic criteria, classification and nomenclature of
psychiatric disorders after World War 2 where nearly 60 studies appeared. These were largely
mainly field surveys conducted in unstructured clinical interviews. Consequently the
reliability of these studies was low. The 3rd generation studies started around 1970 with more
effort into increasing the reliability of psychiatric diagnoses. A major objective of 3rd
generation studies is to obtain precise estimates of prevalence and incidence of specific
mental disorders, whereas 2nd generation studies focused on mental ill-health in general. It is
claimed that a fourth generation of psychiatric epidemiological studies is in the making. This
includes studies which include comprehensive sets of biologic markers including brain
imaging, cerebrospinal fluid examinations, blood sampling etc in the large scale cross-
sectional surveys e.g. H70 study (Skoog 2004).
Epidemic, endemic and pandemic:

The usual prevalence of a disease in a community is called as the baseline prevalence. If the
baseline is low to moderate level and continues without significant fluctuation, the disease is
said to be endemic in the community. A persistent but high level of baseline is called hyper
endemic occurrence. Most psychiatric disorders are low level endemic disorders (with
exceptions). An irregular pattern of significant fluctuation from baseline is called sporadic
occurrence. When the occurrence within an area clearly exceeds the expected level in a given
time period, it is called an epidemic. An epidemic can be slow and steady raising epidemic as
in the case of multifactorial chronic diseases or acute outbreaks as in infectious diseases. A
pandemic is an epidemic in wide geographical proportion e.g. HIV pandemic.
Levels of prevention:
Most psychiatric disorders are thought to have a biological or sociological aetiology which
produces the ‗hit‘ for later development of the disorder. For a time after this insult, the patient
may exhibit prodromal disturbances which are usually not picked up clinically. This
prodrome later develops into full blown disorder which is diagnosed clinically. This disorder
can have various outcomes: disability, death or recovery. This natural course of a disease
provides us with various nodes of intervention;
1. insult to prodrome node - averting a clinical disorder (primary)
2. prodrome to diagnosis node – early diagnosis (secondary)
3. diagnosis to outcome node - prevention of disability (tertiary)
Prevention psychiatry is the reduction of mental disorders and behavioral problems by

A) Identifying risk and protective factors, and
B) Applying evidence-based interventions.
Prevention could result in
Reduction of specific disorders: Reduced incidence and prevalence, delayed onset.
– E.g. Substance abuse, depression, PTSD
Reduction of risky behaviors
– E.g. Substance use, unsafe sex
Reduction of negative outcomes: This will minimize adverse psychosocial impact of
mental illnesses.
– E.g. Suicide, teen pregnancy, school dropout, delinquency
Promotion of mental health and wellness
In psychiatry currently as our knowledge of ‗insults‘ is limited, most prevention is tertiary.

Early intervention program in psychosis is an example of secondary prevention. Public health
initiatives such as eradication of poverty, maintaining healthy diet etc could prevent certain, at
least milder forms of mental illnesses – these could be termed as primary prevention
strategies. Interventions aimed at high risk groups are usually secondary preventions.
Rehabilitation is a tertiary prevention (reducing disabilities).
Primary Prevention
o Primary prevention is meant to reduce the incidence of the disease by preventing
the development of new cases.
o This is done through the elimination of aetiologic factors, increasing host
resistance, the reduction of risk factors, and blocking modes of disease
transmission. E.g vaccines
o The aetiologic factors in mental illnesses such as schizophrenia are not known
with sufficient certainty to make primary prevention possible
Secondary Prevention
o Early identification and prompt treatment of illness is the definition of secondary
prevention. The goal is to reduce the total number of existing cases by more rapid
effective intervention which shortens the duration of illness. This includes
screening programmes and early intervention, crisis support programmes.
Tertiary Prevention
o Tertiary prevention involves the reduction in the prevalence of residual defects or
disabilities that are consequences of the illness. It may not be possible to
eliminate fully the sequel of the illness, but the goal of tertiary prevention is for
individuals to reach their highest level of functioning.
o In the case of schizophrenia, tertiary prevention is rehabilitation.
o Relapse prevention si also a form of tertiary prevention.

o It is not appropriate to delay the initiation of rehabilitative techniques until acute
treatment is complete, because it is not always clear whether the symptoms being
treated are merely part of the acute process or will continue after acute treatment.
Risk factors:
 Risk factors predate the associated disorder; while some are easily identifiable and
are malleable via a preventive intervention, some may not be changeable.
 Biological risk factors include genetic vulnerability, adverse prenatal event
(traumatic, toxic, infectious)
 Psychological/Psychosocial risk factors include family discord, parenting skill
deficits
 Social/Environmental risk factors include availability of drugs and firearms, extreme
economic and social deprivation etc.
Protective factors:
 Protective factors predate the associated disorder; while some are easily identifiable
and are promotable via a preventive intervention, some may not be. Examples include
support from caring adults, good school performance, conflict resolution skills,
positive role models clear and consistent discipline in the family.
Institute of Medicine has classified preventive interventions as

 Universal preventive intervention: An intervention targeted to an entire population.
 Selective preventive intervention: An intervention targeted to members of a
population with higher than average risk factors.
 Indicated preventive intervention: An intervention targeted to members of a
population with subsyndromal symptoms of a disorder (or diagnosed with another
associated disorder).
(Maj & Sartorius, WPA series Evidence and experience in Psychiatry: Schizophrenia pp 249)
Incidence and prevalence rates:

Incidence:
Incidence of a disease is defined as the number of ‗new‘ cases diagnosed in a specified time
interval for a specified size of population at risk. This population size is usually determined
by mid-interval population. For example, if incidence of a disease in one year is calculated,
then the comparison will be made against mid-year population. In fact to be accurate, the
comparison must exclude those who are not risk, but this is generally not done for non
infectious, non epidemic diseases such as psychiatric illnesses. The essential criterion is that
the measure should indicate all new occurrences of a disease within the period of observation
in an area, irrespective of whether the newly diagnosed patients are cured or dead well within
the period of observation itself.
Number of newly diagnosed cases

Incidence = --------------------------------------------------------
(In year 2008) Mid 2008 population at an area
Incidence is a ratio measured against time. One month incidence will be invariably lower than
one year incidence. The most common measurement of incidence using the above formula is
also called as cumulative incidence. This is valid in cohort studies where attrition is low, but
not so useful when attrition is significant. This is because dropouts are excluded from being
counted as new cases, while the denominator population usually takes them into account. To
avoid this problem, incidence density (also called as incidence rate) is used. It expresses
number of new cases per person-year of observation. The unit of incidence rate is rather
bizarre, time-1. Hence incidence rate ratios are often used in reporting results that compare
two groups‘ incidence rates.
Prevalence:
Prevalence is defined as the number of ‗existing‘ cases in a specified population for a period
of observation (either cross-sectional observation – called point prevalence, or longitudinal
observation for a specified time – called period prevalence). The existing cases include all
new cases, all cases diagnosed before the observation but still suffering from the disease. But
existing cases exclude those who have been previously diagnosed but now cured or dead. The
essential criterion is that the cases must be found when observation is being carried out,
irrespective of when the diagnosis occurred. This is not possible if someone is dead or cured
well before the observation period.
Number of existing (both [new + old] – [dead + cured])

Point prevalence = ------------------------------------------------------------------
(On Jan 28, 2008) Cross sectional population at an area on Jan 28, 2008
Number of existing (both [new + old] – [dead + cured])

Period prevalence = -----------------------------------------------------------------
(2007 - 2008) Mid year population at an area
For illnesses which are significantly chronic (e.g. schizophrenia), prevalence will be higher
compared to those illnesses which are acute and short-lived (e.g. influenza), even if the
incidence rates are comparable. Hence a simple expression
Prevalence = incidence X duration of illness explains the relationship between incidence
and prevalence.
Certain factors can influence incidence and prevalence differently. For example, if a new
vaccine is developed for preventing an illness both incidence and prevalence may come
down. If a cure is developed for schizophrenia, incidence may not be affected, but prevalence
can drop. Similarly if interventions are introduced to reduce mortality in chronic
schizophrenia, then prevalence may paradoxically increase due to longevity of patients. This
may not affect incidence rates directly.
Lifetime prevalence is the proportion of individuals in the population who have ever
manifested a disorder, who are alive on a given day (ref: Saha). This is ascertained by
surveying a population cross-sectionally and finding out if they ever satisfied the criteria for a
disorder in the past or currently. As one can observe, this method though commonly used in
epidemiological surveys, is prone for recall bias.
Lifetime prevalence needs to be clearly distinguished from lifetime morbid risk (LMR).
LMR is the probability of a person developing the disorder during entire period (often a
specified period, defined by the life expectancy of the population studied) of their life. LMR
includes the entire lifetime of a birth cohort both past and future, and includes those deceased
at the time of the survey. For low-incidence disorders such as schizophrenia, summation of
age-specific incidence rates gives approximate LMR (Saha et al PLoSMed 2004)
Mortality rates:
Crude, specific and standardised rates: A crude rate is any rate applicable to whole
population e.g. crude birth rate, crude mortality rate etc. A specific rate is any rate applicable
to a subgroup of a population e.g. age specific mortality, disease specific mortality, cause
specific mortality rates etc. A standardized rate is a rate applicable to a hypothetical
population with an adjusted variable e.g. age. As population samples are heterogeneous, crude
rates from one population may not be comparable to another population. For example suicide
rates in inner London may not be comparable to rates in rural Yorkshire, as working age
population may be more in London, spuriously increasing suicide rates. Hence, standardized
hypothetical populations are used on which observed rates from a population are applied and
adjusted values are derived. These standardized values are easily comparable.
Crude mortality rate: Ratio between number of deaths due to all cause in a population and
total population size
Cause specific mortality rate: e.g. alcohol specific mortality. This refers to ratio between
number of deaths due to alcohol in a population and total population size.
Case fatality rate: Ratio between number of deaths due to a specific disease and number of
persons affected by the disease in a population. It is a measure of the fatal severity of the
disease studied. For example, 15 patients out of 100 with anorexia will die due to its
complications.
Proportionate mortality rate: It is a measure of contribution of a disease to societal mortality
burden. It is given by the ratio between deaths due to a specific cause and total number of
deaths in a population.
Years of Potential Life Lost (YPLL) is a measure of the impact of premature mortality on a
population. It is calculated as the sum of the differences between some predetermined end
point and the ages of death for those who died before that end point. The two most commonly
used end points are age 65 years and average life expectancy. Because of the way in which
YPLL is calculated, this measure gives more weight to a earlier deaths than later deaths.
Disability adjusted life years - The DALY is a health gap measure that extends the
concept of potential years of life lost due to premature death (PYLL) to include equivalent
years of 'healthy' life lost in states of less than full health, broadly termed disability. One
DALY represents the loss of one year of equivalent full health. Additionally, 3% time
discounting and non-uniform age weights which give less weight to years lived at young and
older ages were used in calculating DALYs.
DALYs for a particular disease is given by

DALY= YLL + YLD
YLL - years of life lost due to premature mortality in the population
YLD - years lost due to disability for cases.
YLL = N x LE
 Where N = number of deaths and
 LE = standard life expectancy at age of death in years
YLD = I X DW x LD
 I = number of incident cases
 DW = weight given to the disability
 LD = average duration of the case until remission or death (life until death in years)
For most of the above rates, total number of live births is the denominator.
Epidemiological surveys across lifespan:

Epidemiological catchment area study:
This investigation of the prevalence of psychiatric comorbidity was undertaken during 1976–
80 in five sites in the USA.19 More than 20 000 people were interviewed using the
Diagnostic Interview Schedule. It was criticised for its use of lifetime diagnoses, which may
be unreliable due to recollection bias. DIS was first lay person usable diagnostic instrument.
WHO used CIDI, more comprehensive structured instrument that includes elements of ICD
and DSM for second generation of cross national surveys from 1990. CIDI and DIS can
detect prevalence (frequency) but not severity of psychiatric conditions.
World Mental Health Survey Initiative:

WMH survey consortium was formed in 1998 in order to
1. Attempt broader coverage and
2. Assess impairment and severity by improvising CIDI version 3.0. (Kessler,
JAMA. 2004;291:2581-2590.)
28 countries were included in survey across different economical stages of development. It is
a multistage household probability survey wherein at the fist stage the diagnostic information
is collected and in the second stage all those who meet diagnostic criterion were sampled
again to collect secondary details. 25% of non-diagnosed sample from 1st part were also
subsampled in round 2. Three categories of severity – serious, moderate and mild were used.
Sheehan disability scale for specific disorder was employed with more than 1 sphere of role
disruption classed as serious. All bipolar 1 and substance dependence (physiological), any
history of suicide attempts were classed as serious. A list of professionals including religious
persons, natural and traditional healers was used to assess seeking treatment in last 12
months. Important findings are
1. prevalence varies widely across countries
2. anxiety disorder is the most common (except Ukraine), followed by mood
disorders (except Nigeria and Beijing where substance use caught up joint
second)
3. US has highest prevalence rate for any disorder
4. In all surveyed countries, severity was associated with treatment seeking.
Those in developed countries obtained more treatment still.
5. Interestingly a proportion of non-cases received treatment – more in
developed than less developed nations. This meant that most people receiving
treatment are either mild cases or non-cases.
6. Proportion of serious cases not receiving treatment is 35 to 50% in developed
countries and 75 to 85% in less developed countries
European study of epidemiology of mental disorders:

ESEMeD is the first major multicentre European psychiatric epidemiological study. It was not
conducted in UK. It used both CIDI version 3.0 (WHO) and SCID based clinical appraisal
(DSM 4 criteria). ESEMeD is a part of World Mental health survey initiative of WHO. 6
European countries were surveyed and 60% response rate was achieved. The results showed
that 1 in 4 adults had lifetime presence of a mental disorder and 1 in 10 had a mental disorder
in last 1 year. 14.7% had lifetime history of mood disorder (major depression only – 13%)
while 14% had anxiety (specific phobia only – 8%) and 5.2% had lifetime alcohol use
disorder. The highest rate of mental disorder was between the age group 18-24. Only 37% of
those with mood disorders and 21% of those with anxiety disorders sought help from health
care services. Only 21% of depressed patients received antidepressants in a year. One third of
identified cases have consulted their general practitioner in preceding 12 months while 21%
cases have seen a psychiatrist. Nearly one third of those who sought help, have never seen
any mental health professional. Nearly 21% remained untreated in spite of seeking help.
Comorbidity significantly influenced disability and functional impairment. Notably, while

NCS and NEMESIS excluded elderly population, ESEMed had nearly 1 in 2 respondents over
65 years of age. About six per cent of the ESEMeD sample was defined as being in need of
mental healthcare. Nearly half (48%) of these participants reported no formal healthcare use.
In total, 3.1% of the adult population had an unmet need for mental healthcare. About 13% of
visits to formal health services were made by individuals without any mental morbidity.
(Alonso et al, British Journal of Psychiatry (2007) 190: 299-306)
Comorbidity data from ESEMED: Of all respondents with a mood disorder, 41.7% also
had an anxiety or alcohol disorder. Among those with an anxiety disorder, 28.3% also had a
disorder from another broad category, whereas for alcohol disorder this figure was 22.8%.
Thus, mood disorder is the broad category most likely to be comorbid with another broad
category. Of the separate mood disorders, dysthymia had higher rates of comorbidity than
major depression (73.3% vs. 53.1%). In general, anxiety disorders were highly comorbid.
Agoraphobia (81.0%), GAD (69.4%) and panic disorder (63.8%) were the most comorbid
anxiety disorders; specific phobia (28.6%) and social phobia (49.1%) were the least. Alcohol
dependence was more frequently comorbid with other disorders (27.7%) than alcohol abuse
(20.8%). Alcohol abuse was the least comorbid of all the separate disorders. There were no
significant country differences in these data but two significant gender differences were
found: GAD and alcohol dependence were significantly more often comorbid in women.
Other European studies of epidemiology of mental disorders:
NEMESIS
The Netherlands Mental Health Survey and Incidence Study (NEMESIS study) is a large
general population study with three measurement points (baseline in 1996, first follow up in
1997 and subsequent follow up in 1999). Nearly 7000 individuals aged 18–64 years
participated in the baseline survey. Trained lay interviewers applied the Composite
International Diagnostic Interview for case ascertainment.
DEPRES Study
DEPRES (Depression Research in European Society) was the first large pan-European survey
of depression in the community. 78463 adults participated in screening interviews across six
countries and the 6-month prevalence of major depression was found to be nearly 7%. A
significant proportion of sufferers from depression (43%) failed to seek treatment for their
depressive symptoms. Of those who did seek help (57%), most consulted a primary care
physician, the frequency of consultation increasing with the severity of depression. Sufferers
from major depression made almost three times as many visits to their GP or family doctor as
non-sufferers, placing huge demands on the primary care. Only 31%of those who sought help
were given a drug therapy and among these, only 25% were given antidepressant drugs
(Lepine et al, International clinical psychopharmacology 1997 Jan;12(1):19-29).
Depression epidemiology:
Various studies including NCS and its replication NCS-R, NSEARC and ECA have
implicated that lifetime prevalence of depression is changing. But ECA was a subject of
differential recall bias as lifetime prevalence was recollected by subjects. NCS used DSMIIIR
(10.1% depression 12 month period prevalence) while its replication used DSMIV (8.7%
depression prevalence) with its clinical impairment and distress criteria making it possible
that less patients will be diagnosed with DSM IV. In fact it was later shown that if DSM IV
criteria were reapplied then prevalence of depression drops from 10.1% to 6.4% in NCS 1994.
Also NCS excluded all those above age 54 but included 15 to 17 age group (in contrast from
NCS-R), inadvertently choosing the most prevalent population that might have inflated the
prevalence value. These flaws were absent in NSEARC which showed nearly doubled point
prevalence estimate of depression from 3.3 to 7% (1992 to 2002).
Interestingly, the Stirling county study (cross-sectional samples 1952, 1970 and 1992)
revisited in 2000 (Murphy et al, 2000), showed that vernacular changes in semantic use of
terms like dysphoria can affect results of epidemiological survey. It also showed that lifetime
recall using DIS resulted in spuriously increased prevalence. Using the same diagnostic
system (called DPAX-1) in 1952 and 1970, no increases in point prevalence of depression
were noted. But when same criteria were employed in 1992 a drop in prevalence was noted.
This was due to a change in the use of term dysphoria in the studied population. By increasing
number of questions exploring the mood state and changing the diagnostic system (DPAX2)
similar prevalence rates were detected. It was noted that women and younger people were at
greater risk in 1992 than in 1970. Any historical trend in depression was a matter of
redistribution by sex and age, with a higher rate among younger women being of recent origin.
According to NESARC (National epidemiological survey of alcoholism and related

conditions. Hasin et al. Archives 2005; 62, 1097) mean age of onset of depression is 30years.
Mean number of episodes in patients with lifetime major depressive disorder is 5. The longest
duration was 24 weeks per episode. 60% get treated; women treated more than men 50.5% of
men received no treatment at all.. Mean age of treatment onset 33.5 years – lag 3 years.
Suicide attempted by 9%. Most common comorbidity was alcohol use (>40%) and anxiety
(>40%), 30% had Personality disorder. 1 yr prevalence was 5.3% while lifetime prevalence
was 13%. The highest risk was for age group greater than 30, as opposed to previous finding
of 19 to 29 age group. Cluster c PDs except anakastic PD show strong associations with
lifetime MDD.
Postpartum depression – Risk factors: 1. A history of depression in previous pregnancies

or postpartum period. 50% to 60% increased risk of recurrent episodes with subsequent
pregnancies. Women with a history of a mood disorder experienced during pregnancy are also
at a higher risk. 2. A previous history of depression. Up to 30% of women who have
experienced a major depressive episode prior to conception will develop postpartum
depression. 3. A history of depression in relatives. The risk even is greater if a relative
experienced a postpartum episode. 4. Psychosocial risk factors include poor social support,
adverse life events, marital instability, and ambivalence towards the pregnancy.
Bipolar epidemiology:
Consistently in large epidemiological studies, 1.5% prevalence is quoted for bipolar disorders.
It is unclear if there is an elevated estimation of depressive disorders and under-diagnosis of
bipolar type 2 disorder in these surveys. Hypomania, being positively appraised by patients
themselves, is often missed in structured, non-clinician interviews. Angst et al (Eur Arch
Psychiatry Clin Neurosci 2003, 253:236-240) observed in a 20 year long prospective study
that patients with depression and clinically undiagnosed subsyndromal hypomania have
similar risk factors, course and outcome compared to bipolar disorder type 2.
The kappa agreement between structured and clinical diagnostic techniques for mood
disorders is poor, ranging from 0.23 to 0.49 in ESEMED study. In the IOWA Study (a
prospective investigation of the hereditary nature of schizophrenia and bipolar disorders) the
prevalence of mania among relatives of patients affected by bipolar disorders, calculated
solely on the basis of diagnostic interviews, was 1.9%; however, when additional sources of
information such as clinical records and cross-interviewing of relatives were considered, the
rate increased to 5.3%.
In NCS-replication (part of WMH survey initiative), lifetime prevalence of bipolar 1 was

1.0%, bipolar 2 was 1.1% while subsyndromal bipolar spectrum was 2.4%. One year
prevalence was 0.6%, 0.8% and 1.4% respectively. NCS-R showed that mean age of onset for
BP-I was 18.2 while BP-II started around age 20. Subsyndromal BPD started around 22 years
of age. Clinical severity and role impairment were more common in BP-II than BP-I
(Merikangas et al; Arch Gen Psychiatry. 2007; 64:543-552). Among bipolar patients
diagnosed via such epidemiological surveys, it is shown that more patients receive only
antidepressants and no mood stabilisers for maintenance.
Suicide rate in bipolar disorder is 18 times higher than general population.
Schizophrenia epidemiology:
Incidence:
In 1986, WHO published results from 7 countries; ICD 9 schizophrenia was 16 to 42 per
100,000. Using narrow criteria it was 7 to 14 per 100,000. It showed considerable between
sites variation. But in spite of that it was concluded that schizophrenia showed remarkably
similar incidence across various countries. This led to an undervaluation of the potential role
of environmental factors on schizophrenia. McGrath et al has showed a five fold difference in
the incidence rates of schizophrenia across various sites. Being urban born increases the risk
of schizophrenia two-fold compared to rural born individuals. Living in the city is also noted
to increase incidence of schizophrenia. The incidence of schizophrenia is 3 to 5 times more
common in migrants than native population; this becomes 1.8 when considering prevalence
rates. Winter/spring birth increases the risk of schizophrenia to a small extent (RR 1.11); but
as prevalence of birth itself is common in winter/spring, 10.5% of all schizophrenia
incidences can be attributed to the seasonal birth. The winter/spring excess is positively
associated with latitude. Fluctuations in schizophrenia incidence have been reported over
many decades. This may be related to changing structure of the population. Irrespective of
broad or narrow definition, the incidence of schizophrenia has definitely increased in certain
urban areas over last 40 years. Boydell et al (BJP, 2003; 182, 45 -49) demonstrated a large
increase in Camberwell between 1965 and 1997 using case record analyses. The male: a
female difference in incidence of schizophrenia is estimated to be around 1.4:1, with more
males being diagnosed with the disease. The male excess persists even when factors such as
age range and diagnostic criteria are taken into account.
Prevalence:
The median prevalence of schizophrenia is estimated 4.6/1,000 for point prevalence,
3.3/1,000 for period prevalence, 4.0/1000 for lifetime prevalence (not 1% as quoted in DSM
IV manual) , and 7.2/1000 for lifetime morbid risk (Saha , McGrath et al PLoS Medicine
2004). There were no significant differences between males and females, or between urban,
rural, and mixed sites, although migrants and homeless people had higher rates of
schizophrenia and, not surprisingly, developing countries had lower prevalence rates (as
previously documented). As it is well known that outcome is better in developing nations,
point prevalence must be low as a corollary, as it was shown by Saha et al. Of note, catatonia
was 10% in developing vs. 1% in developed nations; hebephrenia was 13% in developed vs.
4% in developing nations
AESOP study - Migration and schizophrenia:

AESOP study concluded that all psychoses are more common in the black and minority ethnic
group compared to Whit population in Bristol, south-east London and Nottingham (crude
IRR, 3.6 [95% CI, 3.0-4.2]). Differences in age, sex, and study center accounted for
approximately a quarter of this effect (adjusted IRR, 2.9 [95% CI, 2.4-3.5]). The age-sex
standardized incidence rate for all psychoses was higher in Southeast London (IRR, 49.4 [95%
CI, 43.6-55.3]) than Nottingham (IRR, 23.9 [95% CI, 20.6-27.2]) or Bristol (IRR, 20.4 [95%
CI, 15.1-25.7]).
Determinants of DUP: AESOP also investigated the variables that determine long DUP. An
insidious mode of onset (psychotic symptoms appeared incrementally over a period of more
than 1 month since first noticeable behavioural change) was associated with a substantially
longer DUP compared with an acute onset, independent of other factors. Unemployment had a
similar, if less strong, effect. Conversely, family involvement in help-seeking was
independently associated with a shorter duration. There was a weak suggestion (not significant
on adjustment) that nonaffective psychosis was more associated with longer DUP than
affective psychosis.
MORGAN C et al., ―Clinical and social determinants of duration of untreated psychosis in the AeSOP first-
episode psychosis study,‖ The British Journal of Psychiatry 189, no. 5 (November 1, 2006): 446-452.
Urban birth and schizophrenia:

Urban birth is associated with increased risk of all psychoses (OR:1.61; CI: 1.4 – 1.8).
Marcelis et al. (1998) (Dutch National Psychiatric Register study) found that the effect of
urbanicity on all psychosis was greater for men than for women. The effect of urban birth was
greatest for individuals from the most recent birth cohorts and with early-onset disease even
after correcting for length of follow-up. Another study noted positive correlation between
admission rates for schizophrenia and degree of urbanization. There was a clear dose–
response relationship for urbanicity, in that the larger the town of birth, the greater the risk.
Outcome in schizophrenia:
In the Iowa 500 study, 186 persons with schizophrenia were followed for an average of 35
years. Excluding affective or schizoaffective disorder, 46% of those people with
schizophrenia had improved or recovered. The Bonn Hospital Study (Germany) followed 502
persons with schizophrenia for an average of 22.4 years. The results were that 22% of the
research participants had complete remission of symptoms, 43% had non-characteristic types
of remission (defined as involving non-psychotic symptoms only) and 35% experienced
characteristic schizophrenia residual syndromes. Therefore, 65% had a more favorable
outcome than would have been expected from clinical experience. With respect to social
functioning, 56% of all participants were judged to be ―fully recovered,‖ which was defined
in this study as full-time employment. At the last follow-up, 13.3% were permanently
hospitalized. In Chestnut Lodge study, 446 patients were followed for an average of 15 years.
One third (36%) were recovered (strict recovery criteria) or functioning adequately. In
Vermont longitudinal study, 68% of patients (n=269, follow up average 32 years) who
underwent a rehabilitation programme had good functioning as determined by GAF scale.
Males show more cognitive deficits while females have more depression at first episode.
Developing vs. developed nations:

International Study of Schizophrenia – WHO ISoS (1997) was a follow-up analysis that
included two major WHO incidence cohorts. The first cohort was part of IPSS – International
pilot study of schizophrenia while the second cohort was from the Determinants of Outcome
of Severe Mental Disorder and the reduction of disability study (DOSMeD) which followed
IPSS with more rigorous method and outcome measurement. IPSS assessed 1,202 persons
diagnosed with schizophrenia in nine countries. The results showed that persons with
schizophrenia in the ―developing‖ world (e.g., Columbia, India, Nigeria) had better outcomes
than persons in the ―developed‖ countries (e.g., Moscow, London, Washington, Prague,
Aarhus and Denmark). In total 52% of persons in the developing countries were assessed to
be in the ―best‖ outcome category (defined as a single episode only, followed by full or partial
recovery) compared with 39% in the developed countries. In a 5-year follow-up 73% of those
participants from the developing world were in the best outcome group compared with 52%
in the developed world. DOSMeD used more rigorous criteria and followed more than 1,300
patients in 10 countries and, similar to the IPSS, discovered that the highest rates of recovery
occurred in the developing world. At a 2-year follow-up, 56% of those in the developing
world were in the best outcome group compared to 39% of the participants from the
developed countries. DOSMeD excluded mode of onset being a confounding factor.

Differential follow-up rates, differential outcome measures, differential sex and age
distribution, diagnostic ambiguities did not confound the above results as proved later by
Hopper & Wanderling (Scz Bulletin 2000; 26, 835-46)
High risk prediction studies in schizophrenia:
It is thought that the individuals at enhanced genetic risk of schizophrenia (family history)
inherit a state of vulnerability characterised by transient and partial psychosis like symptoms;
but not all of these develop florid schizophrenia.
Edinburgh High Risk Study:
 According to Edinburgh High Risk Study, the 10% risk present in those with
high risk family history increases to nearly 50% in those subgroup who have
high score on schizotypal cognition and social withdrawal characterised by
introversion and anxiety.
 The EHRS population composed of non-help seekers i.e. identified as high
risk but not presenting themselves with symptoms.
 Measures of episodic memory are also proposed to be significantly
discriminating between those with high risk who develop schizophrenia from
those who do not; this is suggestive of temporal lobe dysfunction.
 It is also shown that temporal lobe volume deteriorate with the passage of
time in those with psychotic symptoms (this is controversial).
Johnstone EC, et al. Predicting schizophrenia—findings from the Edinburgh High-Risk Study.
Br J Psychiatry. 2005;186:18-25
Australian UHR – PACE clinic:

o In an Australian PACE clinic sample, twenty of 49 Ultra high risk subjects
(40.8%) developed a psychotic disorder within 12 months.
o Some highly significant predictors of psychosis were found: long duration of
prodromal symptoms, poor functioning at intake, low-grade psychotic
symptoms, depression and disorganization.
Klosterkotter’s Bonn Basic Symptoms:

 In German sample using Bonn Basic Symptoms criteria, a very high
conversion rate was seen in help seeking individuals in a long follow up
period of nearly 10 years.
 The Bonn Scale has 5 clusters.
 Cluster 1: thought, language, perception, and motor
disturbances;
 Cluster 2, impaired bodily sensations;
 Cluster 3, impaired tolerance to normal stress;
 Cluster 4, disorders of emotion and affect, including
impaired thought, energy, concentration, and memory;
 Cluster 5, increased emotional reactivity, impaired ability to
maintain or initiate social contacts, and disturbances in
nonverbal expression.
 Of these the cluster 1 (thought, language, perception, and motor disturbances)
showed a significantly greater predictive discrimination than any other
cluster.
Klosterkötter J, et al. Diagnosing schizophrenia in the initial prodromal phase. Arch Gen
Psychiatry. 2001;58(2):158-164
The NAPLS – North American Prodrome Longitudinal study:
 This is a blend of several individual North American cohorts representing a

pragmatic approximation of a prospectively designed cohort study.
 The key findings are that the ultrahigh risk UHR criteria using SIPS
(Structured interview for prodromal symptoms) predict an early transition to
psychosis (with a huge relative risk of 405 compared with the incident rate of
psychotic disorders in the general population).
 In this group the predictive power can probably be enhanced by the use of
key variables such as genetic risk, functional impairment, and higher levels of
psychopathology at baseline (especially odd beliefs and suspiciousness).
 Substance use also increased the predictive value, but the former 3 variables
together nearly doubled the predictive power. In multivariate analyses no
specific substance class of the 7 tested (ie, alcohol, hypnotics, cannabis,
amphetamines, opiates, cocaine, and hallucinogens) was significantly
associated with risk though as a whole a history of substance use was
predictive.
Cannon TD, et al. Prediction of psychosis in youth at high clinical risk: a multisite longitudinal
study in North America. Arch Gen Psychiatry. 2008;65(1):28-37.
Suicide and self harm in schizophrenia:

11.3% of those with first episode psychosis engage in self-harm between the onset of
psychotic symptoms and first presentation to services. The independent correlates of self-
harm were: male gender, belonging to social class I/II, depression and a prolonged period of
untreated psychosis. Increased insight was also associated with risk of self-harm (Harvey
2008 BJPsych 192:178-184).
The suicide rate in schizophrenia was thought to be 10% for a long time. But a recent
metaanalysis which included studies that were continued for at least 2 years with minimum
90% follow up rates concluded differently (Palmer, Arch Gen Psych 2005)
The estimate of lifetime suicide prevalence in those observed from first admission or illness
onset was 5.6% (95% confidence interval, 3.7%-8.5%). Mixed samples showed a rate of 1.8%
(95% confidence interval, 1.4%-2.3%). Case fatality rates showed no significant differences
when studies of patients diagnosed with the use of newer systems were compared with studies
of patients diagnosed under older criteria.
This concluded that 4.9% of schizophrenics will commit suicide during their lifetimes, usually
near illness onset.
In patients with schizophrenia, suicide is the major cause of death under the age of 35.
Suicide most commonly occurs in early stages or during exacerbations.
Delusional disorders epidemiology:

Delusional disorder
incidence 0.7 – 1.3 per 100 000
prevalence 24 – 30 per 100 000
Proportion of hospital first admission cases 1 -3%
Mean age of onset 39 years
Sex ratio 1.18 : 1 = M:F
From Kendler 1982 & Retterstol 1966
Anxiety disorders epidemiology:
15% of adults in UK at any time have broadly defined neurosis according to National
Psychiatric Morbidity Survey. In NPMS 1995 UK prevalence of anxiety disorder was higher
than depression (consistent with ECA and NCS USA), Phobic disorder the most common in
ECA & NCS but in NPMS – the most common anxiety disorder was mixed anxiety-
depression followed by GAD. 25% of all GP consultations are for anxiety related symptoms.
It is noted that with each generation, anxiety disorders are diagnosed at younger age than the
previous cohort. Considering the mean age of onset for various anxiety disorders, the
following pattern is noted; GAD – 30years, Panic disorder – 22 to 25 years, OCD – 20 years,
social phobia – 15 years, specific phobia – varies with individual categories – blood injury
injection or environmental types start around age 5 to 9 years while situational phobia starts
around 20 years of age.
The estimated lifetime prevalence of blood-injection-injury phobia is around 3.5%. The
median age of onset is around 5 to 6 years. Subjects with blood-injection-injury phobia have
higher lifetime histories of fainting and seizures. Prevalence was lower in the elderly and
higher in females and persons with less education. Patients with this phobia almost never seek
psychiatric help; but they have significantly higher than expected lifetime prevalences of
other psychiatric conditions, including substance use, depression, anxiety disorders and OCD.
Sex distribution of anxiety disorders is an important topic often tested by the College. As a
general rule, all anxiety disorders are common in women than men. Notable exceptions are
OCD which is more in boys than girls, but equally common in adult men and women. Also
men outnumber women in attending health care centres for social phobia.
Panic disorder epidemiology:

Panic can exist in different forms. Major classificatory systems recognise panic disorder,
agoraphobia and comorbid panic disorder with agoraphobia. DSM puts panic disorder as
primary dysfunction while ICD focuses on agoraphobia. To diagnose panic disorder there
must be frequent panic attacks within a specified time interval. It is increasingly being
realised that panic attacks can occur without fully satisfying panic disorder criteria. Patients
with such panic attacks have significant impairment, help seeking and medication
requirement. The NCS-R collected data on four composite groups: Isolated panic attacks (PA
only), Panic attacks with AG (PA-AG), Panic disorder (PD only), PD with AG (PD-AG).
Lifetime prevalence of PA only was 28% while 4.7% had lifetime PD only.1.1% had PD-AG
while 0.8% had lifetime PA-AG. Cued panic attacks are common in PD and AG compared to
isolated PA where non-cued out of blue panic is seen. Mean age of onset of any panic attack –
irrespective of diagnosis – is around 22 years.
Obsessive compulsive disorder epidemiology:

The prevalence of OCD is determined to be around 0.8% in adults and 0.25% in 5-15 year old
children (community samples), although earlier studies suggested rates as high as 1-3% in
adults and 1-2% in children and adolescents. It is the 4th most common psychiatric disorder in
the general population. The gender ratio of OCD in clinical samples is roughly equal, but
females predominate in community populations (~1.5:1), this may be because men have more
severe psychopathology. Males with OCD showed an earlier onset and a trend toward more
tics and poorer outcome than females. (Heyman et al, BMJ 2006;333:424-429 )
PTSD epidemiology:
The incidence varies across the world. Resilience to trauma is a dynamic factor and so
individuals who may not develop PTSD after one trauma may develop after another.
Males are more likely than females to be exposed to traumatic events (60% males vs. 50%
females). But females develop PTSD two times more frequently (12% vs 6% in NCS) even
after controlling the type of trauma. It is unclear if this is due to higher exposure to trauma or
greater vulnerability to develop PTSD. Molestation is more common in females than males.
Mugging is more common in males than females. But in both instances women develop more
PTSD. The only trauma where men develop more PTSD may be rape. PTSD is more common
in younger than older individuals; more common in those with higher anxiety response to
initial event and in those who perceive external locus of control (as opposed to internal locus).
Somatisation epidemiology:
Community surveys in the United States and Western Europe have found prevalence rates of
less than 1 per cent. Primary care surveys using structured interviews have found only a
slightly higher prevalence—typically 1 to 2 per cent. An analysis of follow-up data from the
World Health Organization multicentre primary care survey, however, indicates that recall
during structured interviews may significantly underestimate the lifetime prevalence of
somatization disorder and unexplained somatic symptoms. The prevalence of somatization
disorder and of less severe somatization syndromes is typically twice as high in women as
men. The survey also noted that approximately 20 per cent of primary care patients suffered
from persistent pain (one or more pain symptoms present for most of the last 6 months). Pain
syndromes are approximately twice as prevalent in women as in men
Surveys of psychotic symptoms in general population:

ONS 2000 Psychiatric morbidity survey obtained a nationally representative sample of 8580
adults aged 16–74 years living in private households in Great Britain. The respondents were
interviewed by lay interviewers in 2000 (Singleton et al, 2001) and classified according to
their score on the Clinical Interview Schedule – Revised. Psychosis Screening Questionnaire
(PSQ) was used in conjunction. 5.5% of respondents endorsed at least one psychosis item.
4.2% endorsed hallucination item (Johns, LC BJPsych 2004 185: 298-305) This 4.2% of the
sample said that there had been times when they heard or saw things that other people could
not, but only 0.7% reported hearing voices saying quite a few words or sentences when there
was no-one around that might account for it.
In a different study using ethnic census data, Four per cent of the White British sample
endorsed a hallucination question. Hallucinations were 2.5-fold higher in the Caribbean
sample and half as common in the South Asian sample. (Johns, LC et al, BJPsych 2002,
180:174-78)
Suicidal ideas - epidemiology:

(Nock et al, The British Journal of Psychiatry (2008) 192: 98-105) According to 17 countries
data as a part of WMH survey initiative, the cross-national lifetime prevalence of suicidal
ideation, plans, and attempts is 9.2%, 3.1% and 2.7% . Across all countries, 60% of
transitions from ideation to plan and attempt occur within the first year after ideation onset.
Consistent cross-national risk factors included being female, younger, less educated,
unmarried and having a mental disorder. Interestingly, the strongest diagnostic risk factors
were mood disorders in high-income countries but impulse control disorders in low- and
middle-income countries. Whereas studies in high-income countries suggest that >90% of
those who die by suicide have a diagnosable mental disorder and >60% have a mood disorder
in particular, rates in low- and middle-income countries have been suggested to be as low as
60% and 35% respectively.
Of NCS sample respondents, 13.5% reported lifetime ideation, 3.9% a plan, and 4.6% an
attempt. Cumulative probabilities were 34% for the transition from ideation to a plan, 72%
from a plan to an attempt, and 26% from ideation to an unplanned attempt. About 90% of
unplanned and 60% of planned first attempts occurred within 1 year of the onset of ideation.
All significant risk factors (female, previously married, age less than 25 years, in a recent
cohort, poorly educated, and having 1 or more of the DSM-III-R disorders assessed in the
survey) were more strongly related to ideation than to progression from ideation to a plan or
an attempt.
Kessler later concluded that despite a dramatic increase in treatment, no significant decrease
occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the
1990s, after analyzing NCS and NCS-R data between 1990-2000 (Kessler, JAMA. 2005; 293:
2487-2495.)
Note that males commit more suicides though females attempt more. Approximately 25
attempts of suicide are recorded for each recorded suicide. Diagnosis of any mental disorder
increases the risk of suicide. The most common method in UK is poisoning by overdose
(paracetamol or antidepressants). In US firearms top the list.
In depression risk factors such as panic attacks, anxiety symptoms, anhedonia, alcohol use,
and insomnia are regarded as short term modifiable risk factors for suicide. Long term factors
include hopelessness, suicidal attempt in the past and ongoing suicidal ideations. (Fawcett,
1990). No difference in suicide rates exist between melancholic and non-melancholic
depression.
Global suicide epidemiology:
♣ Highest suicide rates for both men and women – Eastern Europe (Estonia, Latvia,
Lithuania, Finland, Hungary and Russian Federation) followed by Sri Lanka and China.
♣ Island nations have higher suicide rates generally (Cuba, Japan, Mauritius and Sri Lanka)
♣ Lowest rates – Eastern Mediterranean Islamic nations and some central Asian (formerly
Soviet)
♣ Largest absolute number of suicides: Asia (due to population size)
♣ The male:female ratio is 3.5:1 for completed suicides globally. An exception is China
where females have higher or comparable rates to males. Number of suicides in China is
30% greater than that of whole Europe – due to the size of population.
♣ Globally suicide rates increase with age. In elderly, the rates are 6 – 8 times higher; but
in terms of absolute numbers, more young people are dying than the elderly. 55% of all
suicides fall within ages 5 and 44. (This was 40% in 1950 – the suicide rate in younger
people is increasing at faster pace than the elderly)
♣ Some Islamic countries have nearlyzero suicide rate – e.g. Kuwait. Predominantly Hindu
/ Christian nations have low to moderate rate (India: 10 per 100000 with male:female =
1.3:1 Italy 11.2 per 100000). Atheist nations have very high rates (China: 25.6 per
100000) and so does predominantly Buddhist countries (Sri Lanka, Japan 18 per 100000)
♣ WHO projection for 2020: nearly 1.53 million will die by suicide; 10-20times more will
attempt it. (i.e. one death every 20 seconds or one attempt every 1 -2 seconds)
J. M Bertolote and A. Fleischmann, ―A global perspective in the epidemiology of suicide.‖ Suicidology

2002; 7(2).
Suicide is generally a complication of a psychiatric disorder. More than 90% of suicide

victims have a diagnosable psychiatric illness (3–7), and most persons who attempt suicide
have a psychiatric disorder. The most common psychiatric conditions associated with suicide
or serious suicide attempt are mood disorders
Barraclough B, Bunch J, Nelson B, Sainsbury P. A hundred cases of suicide: clinical aspects. Br J Psychiatry.
1974;125:355-73.
Suicide statistics:
Description Rates
1. Global annual suicide rate 1 in 6000/year
2. Male:female 2-4:1
3. Most common age –15 to 24 females; 25 – 34 males.

> 65 declining, 15 – 24 increasing
4. Commonest methods Hanging, overdose

5. The most common psychiatric diagnoses in major depression (30–31%) & alcohol
suicide dependence (17–24%).
6. mental disorders without much increase in mental retardation and dementia
suicide rates OCD lesser than others – BUT ONLY IF NO
CLINICAL DEPRESSION
7. Suicides that have at least one recorded DSH 40 - 60%

attempt
8. Number that will repeat DSH within one 30%
year
9. In contact with mental health services within 25%
a year of death
10. Those on psychiatry outpatient registers 25%

Attempted suicides under alcohol influence 25% of all attempted suicides; 50% of has had
alcohol within the previous 6 hours.
11. Enhanced CPA cases Nearly 50%
12. Having seen by psychiatrist in previous 12.5%
week
13. Having seen health worker in last 3 weeks 33%
14. Having seen GP in last four weeks 66%

15. Having seen GP in last one week 40%
16. Inpatient suicide Hanging, belt, curtain rail. This is falling (first 14
days: highest risk) overall: 1 in 1000 to 1 in 500
17. Inpatient suicide in first week of admission 25% of all inpatient suicides
18. Inpatient suicides when under routine (not 80% of all inpatient suicides
constant or intermittent observations)
19. Noncompliant with medications 20% (nearly 1/3rd disengaged in last month)
20. Within 3 months of discharge from ward 25% suicides; 40% of these occurred before fist
follow up. In first 28 days after discharge, 1 in
500-1000 patients commit suicide.
21. Preventable suicides according to mental 22% (especially inpatient suicides)
health teams in England
22. Strongest risk factor of suicide DSH history
23. Risk of suicide within one year of DSH 0.7% (nearly 1 in 100); more in males 1.1%; 0.5%
in females. This is 66 x the general population
risk.
24. older patients who committed suicide that 20% on the same day as their suicide, 40% within
visited their primary care physician 1 week, and 70% within 1 month
Adolescent suicides:
Suicidal ideation (without deliberate self harm) in the past year was reported by 15.0% of an
adolescent cohort in UK (school pupils – self report). This was more common in females
(22%) than males (8.5%) (Odds ratio 3.1).
FACT FIGURE
Most common methods Paracetamol overdose and
cutting
One year prevalence of self-harm among 5-10 year- = 0.8%
olds without any mental health issues

olds diagnosed with an anxiety disorder
olds if the child had a conduct, hyperkinetic or less
common mental disorders

olds without any mental health issues

olds diagnosed with an anxiety disorder
One year prevalence of self-harm among 11-15year- = 8-13%
olds if the child had a conduct, hyperkinetic or less
common mental disorders
One year prevalence of self-harm among 11-15year- = 18.8%

olds if the child had depression
Proportion of DSH that receives hospital attention = less than 13%
One year prevalence of self harm in 15-16 year olds = 6.9%
Of all adolescents - Proportion of under16 group in = 5%

A&E attendees with self harm
Proportion that self harm at least once a week = 41%
Proportion that self harm at least once a week = 27%
There is no difference in prevalence between adolescents from the white or black or

ethnic minority communities.
Meltzer, H., Gatward, R., Goodman, R and Ford, T. (2000) The mental health of children and adolescents in
Great Britain: Summary Report, London: The Stationery Office
Hawton K., Rodham K., Evans E., Weatherall R. (2002). Deliberate self harm in adolescents: self report
survey in schools in England. British Medical Journal, 325 (7374), 1207-1211.
Risk factor for repeating self harm

Past self harm Antisocial PD
Psychiatric history Lack of cooperation with treatment
unemployment Hopelessness
Low social class High suicidal intent
Alcohol/drugs criminality
Risk factor for completing suicide

Past self harm Psychiatric history
Older age unemployment
male Poor physical health
Social isolation Access to means
Homicide Statistics:
 Around 50 homicides per year are committed by those in recent contact with mental health services;
this represents 9% of all homicides
 5% of homicide perpetrators have a diagnosis of schizophrenia
 Perpetrators with mental illness are less likely to kill strangers and the rate of ‘stranger homicides’ by
those with mental illness has not increased with national trends
 Alcohol and drug misuse contribute to homicide in 61% of cases
Personality disorders – epidemiology:

Personality disorders, as a group, are among the most frequent disorders treated by
psychiatrists (Zimmerman et al, Am J Psychiatry 162:1911-1918). Community studies of the
prevalence of unspecified personality disorder report prevalence figures ranging from 10-13%
(de Girolamo & Dotto, 2000). These studies have found that personality disorders are more
common in younger age groups (particularly the 25-44 year age group) and equally
distributed between males and females. (This is for all personality disorders. The sex ratio for
specific types of personality disorder is variable e.g. antisocial PD is commoner among
males).
The kappa agreement between raters for presence or absence of all inclusive ‗personality
disorder‘ itself is moderate to poor. Agreement on individual categories is still poorer.
People with personality disorders as a group are more likely to be separated, divorced, never
married, have more unemployment, frequent job changes, poorer social and interpersonal
functioning, and poorer occupational achievement. But as a group they are only rarely found
to be less well educated.
Personality disorder Median prevalence rate Weighted Prevalence in an

per 1000 in community prevalence per psychiatric outpatient
(from Oxford Textbook of 1000 in sample per 1000
Psychiatry, 2000)
community (Zimmerman et al
sample (from Coid 2005)
2006 BJPsych –
Great Britain data)
Paranoid 6 7 42
Schizoid 4 8 14
Schizotypal 6 0.6 6
Antisocial 19 6 36
Borderline 16 7 93
Histrionic 20 12 10
Narcissistic 2 8 23
Anankastic 17 19 87
Avoidant 7 8 147
Dependent 7 1 14
Passive aggressive 17 - No data
Cluster A = 1.6% Cluster A = 6%
Cluster B = 1.2% Cluster B = 13%
Cluster C = 2.6% Cluster C = 22%
Any PD = 4.4% Any PD = 46%
Epidemiological studies report that the prevalence of personality disorder in primary care
lies between 10 and 30% (Dilling et al, 1989; Casey & Tyrer 1990). In the community,
approximately 1 in 20 community residents in Britain have a personality disorder. The highest
prevalence occurs among GP patients with conspicuous psychiatric illness, although this may
be due to abnormalities of mental state biasing the assessment of personality. Patients with
Cluster C personality disorders are the commonest personality disorders to be encountered
among primary care attenders (Moran et al, 2000). When ICD diagnoses are considered
individually, anankastic personality is the most common type in primary care, followed by
impulsive (emotionally unstable) type.
In general, the prevalence of personality disorders among psychiatric outpatients and

inpatients is high, with many studies reporting a prevalence of greater than 50% of samples.
Borderline PD is generally the most prevalent (and certainly most heavily researched)
category in psychiatric settings. Personality disorders are particularly prevalent among
inpatients with drug, alcohol, and eating disorders. In these populations, prevalence figures
for personality disorder have been reported to be in excess of 70%.
Dissocial personality is the most prevalent category of personality disorder in prison settings.
A survey of a randomly selected sample of one in six prisoners in England and Wales, found
that the prevalence of any personality disorder was 78% for male remand, 64% for male
sentenced and 50% for female prisoners (Singleton et al, 1998). Antisocial personality
disorder had the highest prevalence of any category of personality disorder, with 63% of male
remand prisoners, 49% of sentenced prisoners and 31% of female prisoners. In Great Britain,
the prevalence of antisocial PD in general population is estimated at 0.6% (See Coid et al –
above table), with the rate in men (1%) five times that in women (0.2%). Surveys conducted
in other countries report prevalence rates for ASPD ranging from 0.2% to 4.1%. Higher
prevalence rates for personality disorders appear to be found in urban populations and this
may account for some of the range in reported prevalence (from NICE: The
ASPD draft scope [Post consultation 29/01/07] Page 5).
Paranoid personality:
 More in males , lower social class
 Common among relatives of probands with schizophrenia than among relatives of
controls.
Schizoid
 uncommon in clinical settings but is more prevalent in offender populations
 more common in males
 Demonstrate association with schizotypal personality disorder.
 might be better classified as a neurodevelopmental disorder than a personality
disorder possibly within the autistic spectrum
Schizotypal
 Schizotypal personality disorder is common in relatives of probands with

schizophrenia (15%)
 Studies of comorbidity have demonstrated associations with schizophrenia.
Avoidant
 In clinical samples, avoidant personality disorder is comorbid with dependent
personality disorder and phobic disorder, specifically social phobia
Obsessive—compulsive
 Has been described as a ‗high-functioning‘ category
 More common in white, male, highly educated, married and employed individuals.
Narcissistic
 Surveys tend to find a low prevalence of this condition.
 This Axis II construct is derived from psychodynamic theory
 It is diagnosed more frequently in males and is more common in forensic samples,
where it is comorbid with antisocial personality disorder.
Histrionic
 Earlier research suggested that histrionic personality disorder was more common in
women. More recent studies indicate that the gender ratio is similar.
 It is more common in divorced and separated persons, associated with parasuicide,
and associated in women with unexplained medical conditions and in men with
substance misuse.
Borderline
 Borderline personality disorder is seen in nearly 2% of general population, 10%
outpatients, 15-20% inpatients and 30-60% of all personality disorders in some
clinical samples.
 The estimated female:male ratio is 3:1.
 It is 5 times more common in first degree relatives of borderline patients. Lifetime
comorbid depression, and a raised prevalence of depression has been observed in the
relatives of borderline probands (association may be weak and non-specific)
 Borderline personality disorder is more prevalent in younger age groups (19-34
years), females and Whites
 Associated with poor work history and single marital status;
 Is more common in urban areas.
 Most severe in the mid-20s, with improvement noted in the late 30s
Longitudinal course of Borderline Personality:
** 2 important studies to date – McLean and CLPDS study.
** In McLean Study of Adult Development, the 24 symptoms of borderline personality disorder

studied were classified as acute and temperamental where acute symptoms are seen as akin to the
positive symptoms of schizophrenia (most dramatic, leads to service consumption but may resolve
relatively rapidly and are the best markers for the disorder), while the temperamental symptoms (innate
but not immutable, resolve more slowly, and are not specific to borderline personality disorder but
closely associated with ongoing psychosocial impairment) are seen as akin to negative symptoms.
Among the symptoms studied, the prevalence of five core borderline symptoms was found to decline
with particular rapidity: quasi-psychotic thought, self-mutilation, help-seeking suicide efforts,
treatment regressions, and countertransference problems. In contrast, feelings of depression, anger, and
loneliness/emptiness were the most stable symptoms.
** The 10 year follow up of McLean sample further clarified this. Affective instability, quasi-psychotic
thoughts, serious identity disturbance, specific impulsivity, substance abuse/dependence, promiscuity,
self-mutilation, and help-seeking suicide efforts, stormy relationships,
devaluation/manipulation/sadism, demandingness/entitlement, serious treatment regressions, and
countertransference problems/"special" treatment relationships remitted relatively rapidly. Chronic
dysphoria, intense anger, nondelusional paranoia, general impulsivity (disordered eating, spending
sprees, or reckless driving) remained relatively common after 10 years of prospective follow-up.
** In the Collaborative Longitudinal Personality Disorders Study, abandonment fears and physically
self-destructive acts were found to be the least stable (rapidly remitting).
John G. Gunderson, ―Borderline Personality Disorder: Ontogeny of a Diagnosis,‖ Am J Psychiatry 166, no.
5 (May 1, 2009): 530-539.
Antisocial
 Antisocial personality disorder has a prevalence of 2-3% in most Westernized
societies
 4-5 times more common in men than in women.
 The highest prevalence is in the 25- to 44-year age band.
 Associated with school drop-out, homelessness and raised mortality in early
adulthood.
 The prevalence is higher in inner-city populations and lower in rural areas.
 Diminish in middle age, but 20% still meet the criteria at 45 years of age.
Learning disabilities – epidemiology:

• According to the IQ normal distribution curve, 3% of population should fall below
the range defining intellectual disability. But surveys show only 1.5% of the
population to have learning disability. There is a 1.4:1 male :female ratio. 89% of
these have mild LD, 7% moderate and 4% severe.
• Population prevalence: 20 per 1000 for mild mental retardation and 3.8 per 1000 for
severe MR.
• Recurrence risk of MR is high among relatives of those with mild MR while those
with severe MR do not show this increased risk.
• A definite cause is most often found for severe MR (65%) vs. only 30% of mild MR.
• The point prevalence of schizophrenia in LD is reported as between 3% and
3.5% in most studies.
Specific reading disorders: In the UK (and the USA) it is generally recognized that between
4 to 7% of children have specific reading disorder - developmental dyslexia – at any given
time. However, it has been argued that dyslexia is far less prevalent in Japan or China because
these languages use logographic rather than alphabetic, phoneme based, scripts and do not
suffer the multiplicity of irregular spellings (such as yacht for ―yot‖) that characterize
English. Indeed some children have been found dyslexic in one language (often English) but
not in the other (Japanese), and in Kana, the Japanese phonetic script, but not in logographic
Kanji. But recent neurobiological studies have shown that developmental dyslexia results
from impaired development of auditory, visual, and motor aspects of basic brain function that
are likely to be as common in Japan as in the UK. Hence it is possible that the same brain
differences might manifest in rather different ways in children learning different languages.
The definitive review on cross-liguistic prevalence of dyslexia is the often quoted study of
Tarnapol & Tarnapol (1977). They reported surveys from 26 countries; the lowest prevalence
was in China and Japan (1%) while in Venezuela it was 33%. In Europe, Germany (5%) and
Italy reported lower rates than US.
Autism: The risk of autism was associated with breech presentation (risk ratio (RR) = 1.63),
low Apgar score at 5 minutes (RR = 1.89), gestational age at birth <35 weeks (RR = 2.45),
and parental psychiatric history (schizophrenia-like psychosis: RR = 3.44 & affective
disorder: RR = 2.91). Analyses showed no statistically significant association between risk of
autism and weight for gestational age, parity, number of antenatal visits, parental age, or
socioeconomic status. Results suggest that prenatal environmental factors and parental
psychopathology are associated with the risk of autism. These factors seem to act
independently. Childrearing practices have no impact on development of autism – in contrary
to earlier opinion (i.e. refrigerator mothers don‘t exist).
American Journal of Epidemiology 2005 161(10):916-925
Old Age Psychiatry - epidemiology:

Depression: When one excludes the comorbidity of physical illness and the dementias, the
prevalence of major depressive disorder is not higher in the elderly than in the young (1–3%).
Sub-threshold or minor depressive disorders have higher prevalence. ‗Caseness‘ ( A level of
severity of depression at which the majority of professionals would consider treatment) for
depression is seen in approximately 10–15% of community-living elderly, the prevalence
rising in those attending their general practitioners (GPs) (15–30%), and those in residential
(30–40%) or hospital (15–50%) care.
Paraphrenia: Howard suggested a prevalence rate of 1-2% over 65 (broadly 0.1 to 4%). It is
important to remember that in >65, 90% of those with schizophrenia are graduates i.e. have
onset before age 45 – only 10% constitute late onset group. The incidence of paraphrenia is
estimated to be 10-26 per 100 000 per year. People with late paraphrenia represent
approximately 10% of the elderly population of psychiatric hospitals. The point prevalence of
paranoid ideation in the general elderly population has been estimated to be 4%–6%, but most
of these patients will have dementia.
Dementia: The prevalence of dementia increases exponentially with age. About one third of
the population aged 85 and over has dementia, with prevalence ranging from 0.4% under 60
years to 45% at 95 years and over. The exponential doubling of prevalence rates after age 65
apparently slows down after age 90 in epidemiological studies, mostly due to reduced sample
size of observation in this age group. A 90+ study of n=911 reported 45% prevalence in
women and 28% prevalence in men with prevalence doubling every 5 years for women but
not men (Corrada et al).
Nearly 64% of those with dementia have Alzheimer‘s disease.
Age group Prevalence

65-69 1.5%
70-74 3.5%
75-79 6.8%
80-84 13.6%
85-89 22%
90-94 32%
>95 45%
Liddell et al (2001) Genetic risk of Alzheimer's disease: advising relatives. The British Journal of Psychiatry,
178, 7-11.
ADHD epidemiology:
The reported prevalence of ADHD in school age children worldwide varies from 1.7% to
17.8% depending on the criteria used. Most estimates lie between 5% and 10%. US estimates
have historically been higher than UK estimates, due presumably to the application of
narrower diagnostic criteria by UK authors. Three studies of English populations have shown
a prevalence rate of between 2% and 5%, depending on whether DSM-IV or ICD-10 criteria
were applied. A large sample of school children (n = 22,044) screened using DSM-IV teacher
rating scales showed a similar prevalence at school entry. The male to female ratio in ADHD
prevalence is at least 4 to 1.
http://www.sign.ac.uk/guidelines/fulltext/52/references.html#15
Unmet needs and healthcare utilization:

From pooled analysis of WMH surveys, median delays among cases eventually making
contact was estimated from 3.0 to 30.0 years for anxiety disorders, from 1.0 to 14.0 years for
mood disorders, and from 6.0 to 18.0 years for substance use disorders. Failure and delays in
treatment seeking were generally greater in developing countries, older cohorts, men, and
cases with earlier ages of onset. These results show that failure and delays in initial help
seeking are pervasive problems worldwide
Pathways to care:
Also called as filter model, this was developed by Goldberg and Huxley, to account for how
mental illness interacts with the healthcare system. Five levels of mental illness occurrence
were described: The community, the primary care attendees, the diagnosed primary care
attendees (in whom the mental illness has been recognised), the level of psychiatrist and that
at the level of psychiatric inpatient care.
Four filters explain the decreasing numbers of cases when going from the general population
to inpatient psychiatric care
1. At the level of the patient himself or herself (recognition)
2. At the level of the general practitioner (recognition, decision to treat, decision to refer),
3. At the outpatient level of the mental healthcare system and
4. At the inpatient admission level.
Common assessment instruments

Considerations for selecting a screening measure include
1. characteristics of the population to be screened,
2. psychometric properties of the instrument,
3. time required to complete the measure,
4. ease of use, and
5. cost of obtaining the measure
Self rated Observer rated

Beck‘s DI Dementia scales
Zung DI PANSS
Symptoms checklist SCL BPRS
GHQ HAMD
Lunser‘s (extrapyramidal) MADRS
Edinburgh postnatal depression scale YBOCS
SCID
General Health questionnaire:

 Goldberg introduced the General Health Questionnaire (GHQ)
 GHQ was developed as a screening tool to detect those likely to have or be at risk of
developing psychiatric disorders
 It is available in a variety of versions using 12, 28, 30 or 60 items, the 28-item version
is used most widely.
 Each item is scored as a 4 point Likert (0-3) allowing a total possible score on the
GHQ 28 of 0 to 84.
 Using alternative binary scoring method (with least symptomatic items scoring 0 and
the most symptomatic items scoring 1), the 28- and 30-item versions classify any
score exceeding the threshold value of 4 as achieving ‗psychiatric caseness‘. The
caseness threshold is 3 for the 12-item version. Psychiatric caseness is a probabilistic
term—whereby, if such respondents presented in general practice, they would be
likely to receive further attention.
 It should be noted that the GHQ is not usually used for predictive purposes.
 Reliability coefficients have ranged from 0.78 to 0.95 in various studies.
Jackson. C. The General Health Questionnaire. Occupational Medicine 2007 57(1):79;

Depression screening:
An affirmative response to the following two questions may be as effective as using longer
screening measures or may indicate the need for the use of more in-depth diagnostic tools:
(1) "Over the past two weeks, have you ever felt down, depressed, or hopeless?" and (2)
"Have you felt little interest or pleasure in doing things?"
Rating scales:
HAM_D/HDRS – Hamilton depression rating scale:

Observer rated.
17 – 21 items- 2 versions
Refers to last 1-2 weeks
More items for biological features
Remains a reference standard
MADRS – Montgomery-Asberg Depression rating scale:

10 items version
Most sensitive to change
Requires clinical interview like HDRS
BDI – Beck depression inventory:

Self rating
Lacks discriminatory power among very severely ill
Not very sensitive to change compared to MADRS
More psychological/cognitive factors included
Can be repeated at short intervals
Zung self rating scale:

20 items
Self rated
Avoids imbalance towards psychological factors seen in Beck‘s
Poor correlation with observer rating
Insensitive to change
Visual Analogue Scale (VAS)

Easiest way
10cm line where patient indicates the state of mood
Depression screening in children:

Depression screening for children and adolescents are generally appropriate in children who
are at least seven years of age.
Reynolds Child Depression Scale and the Children's Depression Inventory were developed
specifically for children and are written at lower reading levels.
Screening Measures for Depression in Children & Adolescents

Age appropriateness
Measure (approximate years)
Children's Depression Inventory (CDI) 7 to 17
Center for Epidemiological Studies-Depression
12 to 18
Scale for Children (CES-DC)15
Center for Epidemiological Studies-Depression
14 and older
Scale (CES-D)16
Reynolds Child Depression Scale12 8 to 12
13
Reynolds Adolescent Depression Scale 13 to 18
17
Beck Depression Inventory (BDI) 14 and older
Adapted from online version at www.aafp.org/afp/20020915/contents.html.
Advantages of the BDI and CES-D include ease of scoring, low cost, and comparable
psychometric properties.
o Perinatal depression:
The BDI, CES-D, and Edinburgh Postnatal Depression Scale (EPDS) have been used
to screen for depression in women during the antepartum and postpartum periods.
o The BDI and CES-D tend to produce higher scores and more false-positive results in
symptomatic pregnant women.
o Edinburgh Postnatal Depression Scale was specifically developed for assessing
postpartum depression and relies much less on somatic questions.
o Questions on the Edinburgh scale (10 items, can be self or clinician rated) are framed
within the "past seven days" and the response format is frequency-based.
o Routine use of EPDS during the postpartum period has been shown to increase the
detection of postpartum depression compared with usual care.
Cox JL, et al. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in postnatal
women. J Affect Disord 1996;39:185-9.
Geriatric depression:
o The GDS – Geriatric depression scale was specifically developed for use in geriatric
patients, and it contains fewer somatic items.
o Questions pertain to symptoms within the past week and responses require only a
"yes" or ‗no‘.
o In patients who have cognitive deficits, interviewer-administered instruments such as
the Cornell Scale for Depression in Dementia or the Hamilton Rating Scale for
Depression are preferred.
o The Cornell measure should be administered to the patient's primary caregiver.
Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use
in primary care settings. Am Fam Physician 2002;66: 1001-8.
Other scales in children & adolescents:

The Child & Adolescent Functional Assessment Scale:
 A rating scale to assess degree of impairment in functioning due to emotional,
behavioural, or psychiatric problems.
 It is completed by a clinical staff and takes about 10 minutes.
 It is useful for assessing outcome over time and for directing case management
activities.
It measures aggression and conduct problems especially in age between 7 to 17 years.
The Child Behavior Checklist (CBCL):

 It records the behavioural problems and competencies of children aged 4 through 16,
as reported by their parents or others (e.g teachers) who know the child well.
 The checklist is composed of 113 items in a Likert scale.
 The instrument provides three scores: a total score and scores on internalizing
behaviours (fearful, shy, anxious, and inhibited) and externalizing behaviours
 (Aggressive, antisocial, and under controlled).
 This instrument can either be self-administered or administered through an interview.
The CBCL can also be used to measure a child's change in behavior over time or
following a treatment.
 Teacher Report Forms, Youth Self-Reports and Direct Observation Forms are also
available for the Child Behavior Checklist.
 Two versions of this instrument exist: one for children ages 1 1/2 - 5 and another for
ages 6 - 18.
Achenbach, T. M. (1991). Manual for the Child Behavior Checklist/4-18 and 1991 Profile.
Burlington, VT: University of Vermont, Department of Psychiatry.
General Health Self-rated screening instrument for presence of psychiatric

Questionnaire illness (see below for further notes)
(GHQ)
Present State Clinician- Provides clinical diagnoses.
Examination (PSE) administered semi-

structured clinical
interview
Schedule for semi-structured Development of PSE.
Assessment in interview for use by
Neuropsychiatry trained clinicians
(SCAN)
Structured Clinical- Clinician- Use with patients in whom a psychiatric diagnosis is

Interview for DSM- administered semi- suspected. Non patient version available for
IV (SCID) structured epidemiology. SCID-II is available for axis 2
disorders.
Diagnostic Non-clinician- Used in ECA study, life time diagnoses made
Interview Schedule administered fully- initially; later time period specified. CIDI is an
(DIS) structured interview. improvised form with both ICD and DSM
diagnoses.
Global Assessment 100-item, self-report measuring overall psychosocial functioning.
of Functioning rating scale
Scale (GAF)
Health of the Nation For monitoring clinical recovery.

Outcome Scales
(HoNoS)
Hamilton Rating Interviewer ated, 17- 17 items scored according to severity, producing
Scale for item rating scale for total score.
Depression (HAM- depressive illness.
D) Not a diagnostic
instrument; used to
measure changes
(e.g. as a result of
drug treatment).
Self-rated Too high or too low scores may be falsified scores.

Beck Depression questionnaire
Inventory (BDI) containing 21
statements with four
possible responses
for each.
Montgomery- 10-item observer- Useful to measure change in depression especially
Asberg Depression rated scale during treatment trials.
Rating Scale
(MADRS)
Positive and Clinician- for assessment of severity and monitoring of change

Negative Symptom administered rating of symptoms in patients with a diagnosis of
Scale (PANSS) scale schizophrenia. 30 items covering positive
symptoms, negative symptoms, and general
psychopathology.
Yale-Brown Clinician- allowing rating of severity in patients with a pre-

Obsessive- administered semi- existing diagnosis of OCD.
Compulsive Scale structured interview

(Y-BOCS)
CAGE Brief screening test a score of 2 or more indicating the need for further
Questionnaire for alcohol problems assessment.
consisting of 4
yes/no questions,
Minnesota Results generate Self-report questionnaire consisting of 567
Multiphasic information useful questions covering 8 areas of psychopathology, 2
Personality for a broad range of additional areas of personality type, and 3 scales
Inventory (MMPI) clinical applications. assessing truthfulness. Results are compared with
normative data from non-clinical populations. NOT
A PROJECTIVE TEST.
International Semi-structured 67 standardised probe questions. 57-item true/false
Personality clinical interview for questionnaire also included for screening purposes.
Disorder use by clinicians
Examination producing ICD-10-
(IPDE) personality disorder
diagnosis.
References:
Brugha, T., Bebbington, P. E., Jenkins, R., et al (1999) Cross validation of a general population
survey diagnostic interview: a comparison of CIS-R with SCAN ICD-10 diagnostic categories.
Psychological Medicine, 5, 1029 -1042.
Johns, LC et al. Prevalence and correlates of self-reported psychotic symptoms in the British
population. The British Journal of Psychiatry 2004 185: 298-305
Bebbington, PE et al. Psychological Medicine (1997), 27: 821-834 Depression among older people
in Europe: the EURODEP studies
Johns, LC et al. Occurrence of hallucinatory experiences in a community sample and ethnic

variations. British Journal of Psychiatry 2002 180: 174-178
Kessler et al. Prevalence of and Risk Factors for Lifetime Suicide Attempts in the National
Comorbidity Survey. Arch Gen Psychiatry, 1999; 56: 617 - 626.
Murphy, JM., et al (2000) A 40-Year Perspective on the Prevalence of Depression: The Stirling
County Stud. Arch Gen Psychiatry.; 57:209-215.
Further reading: ANSWERS

1. C 40C EMI 1: 1.D 2.A
 Burger H, Neeleman J. A glossary on 2.C 41D 3.B 4.E
psychiatric epidemiology. J Epidemiol 3.A 42A
Community Health (2007) 61:185–89.
This article provides a very useful glossary of
4.A 43A EMI 2:
various terms commonly used in psychiatric 5.C 44E 1A 2A 3D
epidemiology. We feel it is very important that a 6.A 45E 4E
candidate familiarizes oneself with this article.
It is available through few trust Athens services. 7.B 46A
 BMJ. Basic notes on epidemiology – 8.B 47C EMI3: 1H 2D
collection of articles. 9.A 48D 3G
 Individual disease epidemiology from 10.A 49A
Oxford text book or new shorter Oxford 11.B 50C
book. The most reliable source is to keep
up to date with yellow journal and 12.A
landmark surveys in BMJ/Lancet (or 13.A
simply, the most recent SPMM notes!!). 14.B
15.A
Disclaimer: 16.C
These lecture notes are prepared by consulting various
published sources including peer reviewed journals and
17.B
books. These are acknowledged wherever possible; due to 18.E
the structure of this revision notes, acknowledgements 19.B
have not been possible for every passage/fact. We do not
check the accuracy of drug related information using 20.C
external sources; no part of these notes should be used as 21.B
prescribing information.
22.D
Lena Palaniyappan 23.D
May 2010 24.C
25.D
26.C
27.D
28.A
29.A
30.D
31.C
32A
33D
34A
35E
36C
37C
38D
39A

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Mrcpsych Paper 2 Revision Epidemiology Answers & Lecture Notes May 2010

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MRCPsych Paper 2 Revision

History of Psychiatric epidemiology:

Epidemic, endemic and pandemic:

Prevention psychiatry is the reduction of mental disorders and behavioral problems by

In psychiatry currently as our knowledge of ‗insults‘ is limited, most prevention is tertiary.

o Relapse prevention si also a form of tertiary prevention.

Institute of Medicine has classified preventive interventions as

Incidence and prevalence rates:

Number of newly diagnosed cases

Number of existing (both [new + old] – [dead + cured])

Number of existing (both [new + old] – [dead + cured])

DALYs for a particular disease is given by

Epidemiological surveys across lifespan:

World Mental Health Survey Initiative:

European study of epidemiology of mental disorders:

Comorbidity significantly influenced disability and functional impairment. Notably, while

Other European studies of epidemiology of mental disorders:

According to NESARC (National epidemiological survey of alcoholism and related

Postpartum depression – Risk factors: 1. A history of depression in previous pregnancies

In NCS-replication (part of WMH survey initiative), lifetime prevalence of bipolar 1 was

AESOP study - Migration and schizophrenia:

Urban birth and schizophrenia:

Developing vs. developed nations:

developed countries. DOSMeD excluded mode of onset being a confounding factor.

High risk prediction studies in schizophrenia:

Australian UHR – PACE clinic:

Klosterkotter’s Bonn Basic Symptoms:

The NAPLS – North American Prodrome Longitudinal study:

 This is a blend of several individual North American cohorts representing a

Suicide and self harm in schizophrenia:

Delusional disorders epidemiology:

Anxiety disorders epidemiology:

Panic disorder epidemiology:

Obsessive compulsive disorder epidemiology:

Surveys of psychotic symptoms in general population:

Suicidal ideas - epidemiology:

Global suicide epidemiology:

J. M Bertolote and A. Fleischmann, ―A global perspective in the epidemiology of suicide.‖ Suicidology

Suicide is generally a complication of a psychiatric disorder. More than 90% of suicide

3. Most common age –15 to 24 females; 25 – 34 males.

4. Commonest methods Hanging, overdose

7. Suicides that have at least one recorded DSH 40 - 60%

10. Those on psychiatry outpatient registers 25%

14. Having seen GP in last four weeks 66%

One year prevalence of self-harm among 5-10 year- = 6.2%

One year prevalence of self-harm among 11-15 year- = 1.2%

One year prevalence of self-harm among 11-15 year- = 9.4%

One year prevalence of self-harm among 11-15year- = 18.8%

Proportion of DSH that receives hospital attention = less than 13%

One year prevalence of self harm in 15-16 year olds = 6.9%

Of all adolescents - Proportion of under16 group in = 5%

Proportion that self harm at least once a week = 41%

Proportion that self harm at least once a week = 27%

There is no difference in prevalence between adolescents from the white or black or

Risk factor for repeating self harm

Risk factor for completing suicide

Personality disorders – epidemiology:

Personality disorder Median prevalence rate Weighted Prevalence in an

In general, the prevalence of personality disorders among psychiatric outpatients and

 Schizotypal personality disorder is common in relatives of probands with

Longitudinal course of Borderline Personality: