Dissertations / Theses on the topic 'Psychische Störungen'

Im Rahmen einer Reanalyse von vier Erhebungen an jugendlichen und erwachsenen Probanden in den neuen und alten Bundesländern in den Jahren 1990 bis 1991/92 wurden Angaben zu Indikatoren für Depressivität, Angst/psychosomatische Beschwerden und Substanzgebrauch in Ost- und Westdeutschland verglichen. Zum Zeitpunkt der Untersuchungen gab es im Gegensatz zu der von einzelnen Autoren angeführten Erwartung keine eindeutigen Hinweise auf eine insgesamt erhöhte psychiatrische Morbidität in den neuen Bundesländern. Depressive Symptome und der Gebrauch von illegalen Drogen und Medikamenten sind durchgängig in den alten Bundesländern häufíger nachzuweisen als in den neuen Bundesländern. Allenfalls ergaben sich für die Stichproben Ost für einzelne depressionstypische sowie einzelne psychovegetative Symptome und für Alkoholgebrauch statistisch signifikant erhöhte Werte. Da keine Diagnosekriterien erhoben wurden, muβ die Aussagekraft der Daten dahingehend eingeschränkt werden, daβ lediglich Indikatoren für psychische Auffälligkeiten erhoben wurden.

Im Rahmen einer Reanalyse von vier Erhebungen an jugendlichen und erwachsenen Probanden in den neuen und alten Bundesländern in den Jahren 1990 bis 1991/92 wurden Angaben zu Indikatoren für Depressivität, Angst/psychosomatische Beschwerden und Substanzgebrauch in Ost- und Westdeutschland verglichen. Zum Zeitpunkt der Untersuchungen gab es im Gegensatz zu der von einzelnen Autoren angeführten Erwartung keine eindeutigen Hinweise auf eine insgesamt erhöhte psychiatrische Morbidität in den neuen Bundesländern. Depressive Symptome und der Gebrauch von illegalen Drogen und Medikamenten sind durchgängig in den alten Bundesländern häufíger nachzuweisen als in den neuen Bundesländern. Allenfalls ergaben sich für die Stichproben Ost für einzelne depressionstypische sowie einzelne psychovegetative Symptome und für Alkoholgebrauch statistisch signifikant erhöhte Werte. Da keine Diagnosekriterien erhoben wurden, muβ die Aussagekraft der Daten dahingehend eingeschränkt werden, daβ lediglich Indikatoren für psychische Auffälligkeiten erhoben wurden.

Nach Befunden des Bundes-Gesundheitssurveys 1998/99 (Zusatzsurvey „Psychische Störungen“) litten im Jahr der Erhebung 32% (=15,6 Millionen) der erwachsenen deutschen Bevölkerung im Alter von 18–65 unter einer oder mehreren psychischen Störungen. Jeder dritte Betroffene (36%) steht oder stand im Jahr vor der Erhebung wegen der psychischen Störung in Kontakt mit ambulanten oder stationären psychiatrisch/psychotherapeutischen Diensten oder seinem Hausarzt. Der Anteil von Betroffenen, die eine im weitesten Sinne adäquate Therapie nach modernen wissenschaftlichen Kriterien erhalten, kann konservativ auf ca.10% geschätzt werden. Die niedrige Versorgungsquote betrifft dabei nicht alle spezifischen Störungsgruppen in gleichem Ausmaß; niedrige Versorgungsraten ergaben sich insbesondere für somatoforme und Suchterkrankungen. Ferner ergaben sich zum Teil markante regionale Unterschiede (z.B. besonders schlechte Versorgungslage in Regionen, die weder über eine nahe Universität noch über psychotherapeutische Weiterbildungsinstitutionen verfügen).Ungeachtet unterschiedlich weiter oder enger Definitionen des Begriffs Behandlungsbedarf, zeigt sich eine gravierende Unterversorgung von Personen mit psychischen Erkrankungen. Quantitativ bedeutsame Hinweise auf eine Fehl- oder Überversorgung von Betroffenen lassen sich nicht aufzeigen
Data from the German Health Interview and Examination Survey, Mental Health Supplement (N=4181) reveal that 32% (15,6 million people) of the adult population between 18 and 65 years of age suffer from one or more mental disorders. Among those only 36% receive treatment which also varies in type, duration, and adequacy. The proportion of cases receiving “adequate evidence- based treatments” was estimated to be about 10%.Lowest treatment rates were found for somatoform disorders and substance abuses, highest for psychotic disorders, panic disorder, generalised anxiety disorder, and dysthymia. The data reveal substantial regional differences with regard to treatment rates (e.g. lower rates in regions without universities or institutions offering postgraduate mental health education).The paper concludes that, depending on the diagnosis, a considerable degree of unmet medical needs exist for the majority of people affected by mental disorders. No evidence was found for an excessive supply of health care for the patients suffering from mental disorders or for treatments without an existing clinical need

Hintergrund: Die Behandlung von Menschen mit psychischen Störungen stellt seit Jahrzehnten ein sowohl bedeutsames Versorgungssegment als auch Forschungsgebiet dar. Die im Gesundheitswesen in den letzten 20 Jahren aufkommende Haltung hin zu einer stärkeren Patientenorientierung rückt Patienten als Nutzer von Leistungen der Gesundheitsversorgung und „Experten in eigener Sache“ in den Mittelpunkt des Geschehens (Coulter & Magee, 2003). Damit wird den expertenbasierten Therapieleitlinien ein wichtiger Akteur, der Betroffene selbst, gegenübergestellt. Die Entwicklung bisheriger Leitlinien fußt auf der Beurteilung der methodischen Studienqualität sowie relevanter Therapieoutcomes, die ausschließlich von Experten vorgenommen wird. Patienteneinschätzungen werden dabei bisweilen nicht integriert, obwohl gerade durch der Einbezug von Präferenzen, Vorstellungen und Wünschen der Patienten eine wesentliche Grundlage für optimale klinische Therapieentscheidungen darstellt (Haynes, Devereaux & Guyatt, 2002). Eine verstärkt patientenorientierte Haltung hätte damit Auswirkungen auf a) die klinische Versorgungspraxis und b) die Forschung. Der Weg einer gleichberechtigten Kommunikation und gemeinsamen Entscheidungsfindung von Behandler und Patient über Behandlungsstrategien und die Auswahl von Therapieoptionen verbessert potentiell Compliance, Selbstmanagement und Zufriedenheit der Patienten. Fragestellungen: Die vorliegende kumulative Promotionsarbeit (drei peer-reviewed Publikationen) setzt den Kerngedanken der Patientenorientierung um, indem Methoden zur patientenorientierten Forschung erprobt, durchgeführt und hinsichtlich ihrer Nützlichkeit diskutiert sowie empirische Erkenntnisse zur Bedeutung von Patientenpräferenzen in der Gesundheitsversorgung beigesteuert werden. Drei Fragestellungen stehen dabei im Fokus: 1) Wie gut lassen sich Conjoint-Analysen zur patientenorientierten Forschung im Rahmen der Versorgung von psychischen Störungen einsetzen (Beitrag I)? 2) Welche Therapieziele sind bipolar Betroffenen in der Behandlung bipolarer Störungen besonders wichtig (Beitrag II)? 3) Kann mithilfe eines komprimierten achtsamkeitsorientierten Verfahrens ein Beitrag zur Verbesserung der Versorgung der Allgemeinbevölkerung sowie zur Überbrückung langer Wartezeiten auf eine ambulante Psychotherapie geleistet werden (Beitrag III)? Methode: Die methodische Umsetzung einer patientenorientierten Forschung wird anhand des Beispiels der Conjoint-Analyse zur Messung von Patientenpräferenzen für spezifische Therapieziele dargestellt. Die inhaltlichen Beiträge setzen sich aus zwei Studien zur Behandlung einer schweren chronischen psychischen Erkrankung (bipolare Störung) und einer Untersuchung zur Förderung der psychischen Gesundheit (Stressbewältigung, Depressivität, Lebensqualität) im Beratungssetting zusammen. Ergebnisse: Die vorliegende Arbeit stellt zum einen mit der Conjoint-Analyse einen innovativen Ansatz zur Messung von Patientenpräferenzen zu Therapiezielen im Rahmen der Versorgung psychischer Störungen dar (patientenorientierte Forschung). Dazu werden bisherige conjoint-analytische Untersuchungen mittels formaler, methodischer und inhaltlicher Merkmale systematisiert und hinsichtlich Nützlichkeit sowie möglichen Grenzen diskutiert. Zum zweiten liefert die Arbeit Erkenntnisse hinsichtlich der von Patienten eingeschätzten Relevanz und Präferenz von Therapiezielen in der Behandlung bipolarer Störungen. Dabei wird ausgewiesen, worin Unterschiede in den Einschätzungen bestehen und diskutiert, welche Relevanz sich für die Versorgung von Menschen mit bipolaren Störungen ergibt. Zum dritten werden Effekte (Verbesserung der Stressbewältigung, Verringerung der Depressivität, Steigerung der Lebensqualität) eines im Rahmen der psychosozialen Beratungsstelle der TU Chemnitz angewandten achtsamkeitsorientierten Stresstrainings (AST) dargestellt. Die mit einer achtsameren Haltung von Trainingsteilnehmern einhergehenden verbesserten Werte bezüglich Stressverarbeitung, Depressivität und Lebensqualität (patientennaher Endpunkt) deuten auf das Potential von AST hin, als niedrigschwelliges Angebot der psychosozialen Beratung bestehende Versorgungsangebote (Überbrückung von Therapiewartezeit) zu ergänzen. AST stellt einen Ansatz zur patientenorientierteren Ausrichtung von Wartezeitüberbrückung dar, da objektiv sehr lange Wartezeiten auf einen Psychotherapieplatz bestehen und Patienten selbst darin Versorgungsbarrieren sehen. Eine Überbrückung würde Patienten entlasten und psychische Gesundheit bereits vor dem Beginn der Psychotherapie stabilisieren. Diskussion: Patientenorientierte Forschung liefert Beiträge zur Ergänzung bisheriger Erkenntnisse in der Versorgung von Menschen mit psychischen Störungen. Die Befunde zeigen, dass Vorstellungen und Wünsche von Betroffenen nicht immer deckungsgleich mit Expertensichtweisen sind und im Rahmen von Prozessen des Shared Decision Makings Beachtung finden sollten, um eine individuell ausgerichtete Behandlung zu erzielen. Die Conjoint-Analyse als methodischer Ansatz zur Messung von Patientenpräferenzen weist sowohl Nutzen (hohe interne Validität der Messungen) als auch Grenzen auf (geringe externe Validität). Um eine möglichst hohe Generalisierbarkeit der Ergebnisse zu gewährleisten, ist notwendig, die untersuchten Zieldimensionen a priori nach klinischer Praxistauglichkeit auszuwählen. Patientenorientierte Forschung ermöglicht eine gemeinschaftlichere Basis sowohl auf Mikro- (Arzt-Patient-Kommunikation) als auch auf Mesoebene (patientennähere Leitlinien).

Hintergrund: Ein signifikanter Anteil der Patienten mit einer chronischen körperlichen Erkrankung weist eine komorbide psychische Störung auf. Ob und in welchem Ausmaß sich die Prävalenzraten psychischer Störungen bei Patienten mit einer chronischen Erkrankung von denen der Allgemeinbevölkerung unterscheiden, ist bislang noch kaum untersucht. Fragestellung: Die vorliegende epidemiologische Studie untersucht geschlechts- und altersadjustierte 4-Wochen, 12-Monats- und Lebenszeitprävalenzen psychischer Störungen bei Rehabilitationspatienten mit muskuloskelettalen und kardiovaskulären Erkrankungen im Vergleich zu Prävalenzraten der Allgemeinbevölkerung. Methode: Die Daten der drei Stichproben (N = 4192) basieren jeweils auf einem zweistufigen, epidemiologischen Untersuchungsansatz mit einer schriftlichen Befragung der Patienten bzw. Probanden zu ihrem psychischen Befinden (GHQ-12; M-CIDI-S) und einem anschließenden Interview (M-CIDI) bei einem randomisiert ausgewählten Teil der Gesamtstichprobe. Ergebnisse: Mit adjustierten Lebenszeitprävalenzen von 59.3 % (OR: 1.6) und 56.2 % (OR: 1.4) weisen die Patienten mit einer muskuloskelettalen und kardiovaskulären Erkrankung im Vergleich zur Allgemeinbevölkerung (47.9 %) eine deutlich erhöhte Prävalenz psychischer Störungen auf. Am häufigsten sind affektive Störungen (22.5 % bis 34.9%) und Angststörungen (18.4 % bis 33.8 %). Schlussfolgerung: Der im Vergleich zur Allgemeinbevölkerung deutliche Zusammenhang zwischen chronischen körperlichen Erkrankungen und psychischen Störungen verdeutlicht die Bedeutsamkeit einer verstärkten Diagnostik und Behandlung komorbider psychischer Störungen bei chronisch erkrankten Patienten
Background: A significant part of patients with chronic diseases have comorbid mental disorders. However, by now it is nearly unexplored if and to what extend the prevalence rates of mental disorders in patients with chronic diseases differ from the rates of the general population. Objective: The present epidemiologic study investigates sex- and age-adjusted 4-week, 12-months, and lifetime prevalence rates of mental disorders in inpatients with musculoskeletal and cardiovascular diseases compared to prevalence rates of the general population. Methods: In each sample (N = 4192), the data based on a two-stage epidemiologic design. The first stage entailed the use of a screening questionnaire for mental disorders (GHQ-12; M-CIDI-S). The second stage consisted of an interview (M-CIDI) of a randomised part of the sample. Results: The adjusted lifetime prevalence in both clinical samples (musculoskeletal: 59.3 %, OR 1.6; cardiovaskular: 56.2 %, OR 1.4) is high compared to the rate of the general population (47.9 %). Affective disorders (22.5 % to 34.9 %) and anxiety disorders (18.4% to 33.8 %) are the most common disorders. Conclusions: Compared to the general population there is a clear correlation between chronic diseases and mental disorders, that shows the importance of an improved diagnostic and treatment of patients suffering from comorbid mental disorders

Hintergrund: Ein signifikanter Anteil der Patienten mit einer chronischen körperlichen Erkrankung weist eine komorbide psychische Störung auf. Ob und in welchem Ausmaß sich die Prävalenzraten psychischer Störungen bei Patienten mit einer chronischen Erkrankung von denen der Allgemeinbevölkerung unterscheiden, ist bislang noch kaum untersucht. Fragestellung: Die vorliegende epidemiologische Studie untersucht geschlechts- und altersadjustierte 4-Wochen, 12-Monats- und Lebenszeitprävalenzen psychischer Störungen bei Rehabilitationspatienten mit muskuloskelettalen und kardiovaskulären Erkrankungen im Vergleich zu Prävalenzraten der Allgemeinbevölkerung. Methode: Die Daten der drei Stichproben (N = 4192) basieren jeweils auf einem zweistufigen, epidemiologischen Untersuchungsansatz mit einer schriftlichen Befragung der Patienten bzw. Probanden zu ihrem psychischen Befinden (GHQ-12; M-CIDI-S) und einem anschließenden Interview (M-CIDI) bei einem randomisiert ausgewählten Teil der Gesamtstichprobe. Ergebnisse: Mit adjustierten Lebenszeitprävalenzen von 59.3 % (OR: 1.6) und 56.2 % (OR: 1.4) weisen die Patienten mit einer muskuloskelettalen und kardiovaskulären Erkrankung im Vergleich zur Allgemeinbevölkerung (47.9 %) eine deutlich erhöhte Prävalenz psychischer Störungen auf. Am häufigsten sind affektive Störungen (22.5 % bis 34.9%) und Angststörungen (18.4 % bis 33.8 %). Schlussfolgerung: Der im Vergleich zur Allgemeinbevölkerung deutliche Zusammenhang zwischen chronischen körperlichen Erkrankungen und psychischen Störungen verdeutlicht die Bedeutsamkeit einer verstärkten Diagnostik und Behandlung komorbider psychischer Störungen bei chronisch erkrankten Patienten.
Background: A significant part of patients with chronic diseases have comorbid mental disorders. However, by now it is nearly unexplored if and to what extend the prevalence rates of mental disorders in patients with chronic diseases differ from the rates of the general population. Objective: The present epidemiologic study investigates sex- and age-adjusted 4-week, 12-months, and lifetime prevalence rates of mental disorders in inpatients with musculoskeletal and cardiovascular diseases compared to prevalence rates of the general population. Methods: In each sample (N = 4192), the data based on a two-stage epidemiologic design. The first stage entailed the use of a screening questionnaire for mental disorders (GHQ-12; M-CIDI-S). The second stage consisted of an interview (M-CIDI) of a randomised part of the sample. Results: The adjusted lifetime prevalence in both clinical samples (musculoskeletal: 59.3 %, OR 1.6; cardiovaskular: 56.2 %, OR 1.4) is high compared to the rate of the general population (47.9 %). Affective disorders (22.5 % to 34.9 %) and anxiety disorders (18.4% to 33.8 %) are the most common disorders. Conclusions: Compared to the general population there is a clear correlation between chronic diseases and mental disorders, that shows the importance of an improved diagnostic and treatment of patients suffering from comorbid mental disorders.

Background. As part of a longitudinal study, prevalence findings of DSM-IV disorders are presented for a random sample of 3021 respondents aged 14 to 24, with response rate 71%. Method. Assessment included various subtypes of disorders, subthreshold conditions and disorders that have only rarely been studied in other epidemiological surveys. The computer-assisted Munich-Composite International Diagnostic Interview (M-CIDI) was used to derive DSM-IV diagnoses. Results. Substance disorders were the most frequent (lifetime 17·7%; 12-month 11·4%), with abuse being considerably more frequent than dependence. Other mental disorders had a lifetime prevalence of 27·5% (12-month, 17·5%) with depressive disorders (16·8%) being more frequent than anxiety disorders (14·4%). Eating disorders (3·0%) and threshold somatoform disorders (1·2%) were rare disorders. Subthreshold anxiety and somatoform disorders, however, were more frequent than threshold disorders. Prevalence of disorders was equally high for males and females, although specific disorder prevalence varied significantly by gender. The co-occurrence of disorders (co-morbidity) was substantial and was significantly related to greater reductions in work productivity and increased rates of professional helpseeking behaviour. Conclusions. Findings underline that mental disorders in young adults are frequent and impairing, limiting work and education ability and social interaction. Given the fact that adolescents and young adults are in a key phase of socialization in terms of professional career and interpersonal relationships, our findings indicate a considerable risk potential for an accumulation of complicating factors and future chronicity. This paper is the first report of this ongoing longitudinal study about early developmental conditions of mental disorders.

Nach Befunden des Bundes-Gesundheitssurveys 1998/99 (Zusatzsurvey „Psychische Störungen“) litten im Jahr der Erhebung 32% (=15,6 Millionen) der erwachsenen deutschen Bevölkerung im Alter von 18–65 unter einer oder mehreren psychischen Störungen. Jeder dritte Betroffene (36%) steht oder stand im Jahr vor der Erhebung wegen der psychischen Störung in Kontakt mit ambulanten oder stationären psychiatrisch/psychotherapeutischen Diensten oder seinem Hausarzt. Der Anteil von Betroffenen, die eine im weitesten Sinne adäquate Therapie nach modernen wissenschaftlichen Kriterien erhalten, kann konservativ auf ca.10% geschätzt werden. Die niedrige Versorgungsquote betrifft dabei nicht alle spezifischen Störungsgruppen in gleichem Ausmaß; niedrige Versorgungsraten ergaben sich insbesondere für somatoforme und Suchterkrankungen. Ferner ergaben sich zum Teil markante regionale Unterschiede (z.B. besonders schlechte Versorgungslage in Regionen, die weder über eine nahe Universität noch über psychotherapeutische Weiterbildungsinstitutionen verfügen).Ungeachtet unterschiedlich weiter oder enger Definitionen des Begriffs Behandlungsbedarf, zeigt sich eine gravierende Unterversorgung von Personen mit psychischen Erkrankungen. Quantitativ bedeutsame Hinweise auf eine Fehl- oder Überversorgung von Betroffenen lassen sich nicht aufzeigen.
Data from the German Health Interview and Examination Survey, Mental Health Supplement (N=4181) reveal that 32% (15,6 million people) of the adult population between 18 and 65 years of age suffer from one or more mental disorders. Among those only 36% receive treatment which also varies in type, duration, and adequacy. The proportion of cases receiving “adequate evidence- based treatments” was estimated to be about 10%.Lowest treatment rates were found for somatoform disorders and substance abuses, highest for psychotic disorders, panic disorder, generalised anxiety disorder, and dysthymia. The data reveal substantial regional differences with regard to treatment rates (e.g. lower rates in regions without universities or institutions offering postgraduate mental health education).The paper concludes that, depending on the diagnosis, a considerable degree of unmet medical needs exist for the majority of people affected by mental disorders. No evidence was found for an excessive supply of health care for the patients suffering from mental disorders or for treatments without an existing clinical need.

Background. As part of a longitudinal study, prevalence findings of DSM-IV disorders are presented for a random sample of 3021 respondents aged 14 to 24, with response rate 71%. Method. Assessment included various subtypes of disorders, subthreshold conditions and disorders that have only rarely been studied in other epidemiological surveys. The computer-assisted Munich-Composite International Diagnostic Interview (M-CIDI) was used to derive DSM-IV diagnoses. Results. Substance disorders were the most frequent (lifetime 17·7%; 12-month 11·4%), with abuse being considerably more frequent than dependence. Other mental disorders had a lifetime prevalence of 27·5% (12-month, 17·5%) with depressive disorders (16·8%) being more frequent than anxiety disorders (14·4%). Eating disorders (3·0%) and threshold somatoform disorders (1·2%) were rare disorders. Subthreshold anxiety and somatoform disorders, however, were more frequent than threshold disorders. Prevalence of disorders was equally high for males and females, although specific disorder prevalence varied significantly by gender. The co-occurrence of disorders (co-morbidity) was substantial and was significantly related to greater reductions in work productivity and increased rates of professional helpseeking behaviour. Conclusions. Findings underline that mental disorders in young adults are frequent and impairing, limiting work and education ability and social interaction. Given the fact that adolescents and young adults are in a key phase of socialization in terms of professional career and interpersonal relationships, our findings indicate a considerable risk potential for an accumulation of complicating factors and future chronicity. This paper is the first report of this ongoing longitudinal study about early developmental conditions of mental disorders.

Background: Although positive effects of physical activity on mental health indicators have been reported, the relationship between physical activity and the development of specific mental disorders is unclear. Method: A cross-sectional (12-month) and prospective-longitudinal epidemiological study over 4 years in a community cohort of 2548 individuals, aged 14–24 years at outset of the study. Physical activity and mental disorders were assessed by the DSM-IV Composite International Diagnostic Interview (CIDI) with an embedded physical activity module. Multiple logistic regression analyses controlling for age, gender and educational status were used to determine the cross-sectional and prospective associations of mental disorders and physical activity. Results: Cross-sectionally, regular physical activity was associated with a decreased prevalence of any and co-morbid mental disorder, due to lower rates of substance use disorders, anxiety disorders and dysthymia. Prospectively, subjects with regular physical activity had a substantially lower overall incidence of any and co-morbid mental disorder, and also a lower incidence of anxiety, somatoform and dysthymic disorder. By contrast, the incidence of bipolar disorder was increased among those with regular physical activity at baseline. In terms of the population attributable fraction (PAF), the potential for preventive effects of physical activity was considerably higher for men than for women. Conclusions: Regular physical activity is associated with a substantially reduced risk for some, but not all, mental disorders and also seems to reduce the degree of co-morbidity. Further examination of the evidently complex mechanisms and pathways underlying these associations might reveal promising new research targets and procedures for targeted prevention.

Aus der Einleitung: "The authors of the seven meta-structure papers in this issue have to be applauded for their inspiring attempt to suggest and elaborate a new meta-structure of mental disorders consisting of five ‘ clusters ’. At first sight this proposal seems to be considerably simpler than the current diagnostic classifications structure used by DSM-IV-TR (17 categories ; APA, 2000) and, in some parts, more convergent with the ICD-10 (10 categories ; WHO, 1993). Against the background of dissatisfaction expressed with the current diagnostic classification structure for mental disorders and its principles, the authors provide a selective critical review of relevant research. In particular, evidence is examined to address the question of whether current individual mental disorders differ sufficiently from each other and whether the current more fine-graded distinction of specific mental disorders and their grouping in 10 major classes according to ICD-10 and 17 in DSM-IV-TR is justified. To help answer this question, a prioricriteria were chosen in the form of a wide range of ‘validators ’ grouped into so-called ‘causal’ risk factors (i.e. shared genetic risk factors, familiality, shared environmental risks, shared neural substrates, shared biomarkers, shared temperamental antecedents) and factors thought to be more likely to reflect the clinical picture itself (shared abnormalities of cognitive and emotional processing, symptom similarity, rates of co-morbidity, course, treatment response). The results of this impressive exploration are interpreted to suggest a substantial reduction of the current major classes to five clusters and a fairly large residual category of disorders not yet assigned. Particularly noteworthy examples for classificatory changes associated with the proposed meta-structure involve: the suggestion to group anxiety, somatoform and depressive disorders together under the term ‘emotional disorders ’ ; the allocation of bipolar disorders to the ‘psychotic cluster ’ ; and the formation of a broad externalizing cluster that comprises substance use disorders, some of the personality disorders and impulse control disorders. [...]"

This special issue was prepared within the framework of the European College of Neuropsychopharmacology (ECNP) Task Force on “Size and Burden of Mental Disorders in Europe”. The core aim of the Task Force was to describe the prevalence and the burden of treated and untreated mental disorders in all European member states and to highlight needs for further research. Ten state-of-theart epidemiological papers summarize the outcome of this project, making an attempt to provide for the first time ever prevalence estimates for a wide range of mental disorders, as well as for dementia and Parkinson’s disease in 28 European countries. These data also provide input for the European Brain Council (EBC, http://www.ebc-eurobrain. net) Initiative “Cost of Disorders of the Brain in Europe” aiming at estimating the cost of major classes of mental, neurological and neurosurgical disorders and conditions in Europe.

Background: The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people. Aims: To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country. Methods: The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27 + Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010. Results: The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US. Discussion: This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges. Recommendations: Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Theoretischer Hintergrund: Psychische Störungen in Schwangerschaft und Postpartalzeit sind mit 10-15% häufig und erhalten aufgrund ihrer weitreichenden negativen Konsequenzen für den Schwangerschaftsverlauf, die Geburt, die Mutter-Kind-Bindung und die kindliche Entwicklung eine besondere Bedeutung bei der Behandlung (Alder et al., 2007, Reck, 2012). Obwohl das Wissen um die negativen Auswirkungen mittlerweile gut belegt ist und sich daraus die Notwendigkeit einer spezialisierten und vor allem kurzfristigen Behandlung ergibt, bestehen dennoch verschiedene Grenzen und Problemfelder in der Versorgungslandschaft. Hierzu zählen ein objektiver Mangel an Behandlungsangeboten mit schnellem Zugang, vor allem in ländlichen Gebieten (Köllner, 2012), Unsicherheiten hinsichtlich psychotherapeutischer und/oder psychopharmakologischer Optionen bzw. des Settings (Mitnahme des Neugeborenen in die Therapie; Mutter-Kind-Therapie; Weidner et al., 2012) und eine geringe Inanspruchnahme professioneller Hilfe bei Frauen in Schwangerschaft und Postpartalzeit, was am ehesten mit Stigmatisierungsangst oder Angst vor Nebenwirkungen bzw. Wissen um Versorgungsengpässe sowie Organisationsprobleme begründet werden kann (Freed et al., 2012). Um dem Versorgungsdefizit zu begegnen, wurde in Dresden eine sektorenübergreifende multiprofessionelle Behandlung für betroffene Frauen etabliert. Ein bedeutsamer Teil dieses Behandlungsangebotes leistet die Spezialsprechstunde "Psychisch gesund für Zwei" an der Klinik für Psychotherapie und Psychosomatik des Universitätsklinikums Dresden. In der vorliegenden Dissertationsschrift wurde dieses spezialisierte Sprechstundenangebot evaluiert mit den Zielen, den Status quo darzulegen und Schwachstellen oder Versorgungslücken zu identifizieren, den objektiven Versorgungsbedarf und die Behandlungsinanspruchnahme gegenüberzustellen, Einflussfaktoren speziell für die Inanspruchnahme von Psychotherapie zu analysieren und die Psychopathologie im Verlauf in Abhängigkeit der Therapieinanspruchnahme zu beschreiben. Fragestellungen: Die Fragestellungen lauteten: (1) Wie sind die Frauen charakterisiert, die in die Sprechstunde kommen? (2) Wie wird die Spezialsprechstunde bewertet, wie ist der Zuweisungsmodus, die Wartezeit auf einen Ersttermin, wie viele Termine werden in Anspruch genommen und wie zufrieden sind die Patientinnen mit den Behandlungsempfehlungen sowie der Unterstützung bei der Weitervermittlung? (3) Wie häufig werden welche Behandlungs- und Unterstützungsangebote empfohlen und wie häufig werden diese im Zeitraum von t0 bis sechs Monate nach dem Erstgespräch umgesetzt? (4) Was sind Einflussfaktoren auf die Psychotherapieinanspruchnahme und (5) wie ist der Verlauf des psychischen Befindens in Abhängigkeit der Psychotherapieinanspruchnahme? Methoden: Es handelte sich um eine Versorgungsstichprobe mit zwei Messzeitpunkten. N=147 Frauen (49 schwanger, 98 postpartal; Alter: 29,9 Jahre, SD=5,3, 18-45 Jahre) wurden bei Erstvorstellung in der Spezialsprechstunde (t0) und sechs Monate später (t1) untersucht. Zu t0 wurden Informationen zu soziodemografischen, schwangerschafts- und geburtsspezifischen Merkmalen, zur Psychopathologie mittels SKID-I, BSI, EPDS und GAF-Skala, zu Persönlichkeitsstilen mittels PSSI, zur sozialen Unterstützung mittels F-SozU und zu Aspekten der Sprechstunde (Zuweisungsmodus, Zufriedenheit mit dem Sprechstundenangebot, Beziehungserleben im Erstkontakt) mittels selbstentwickeltem Fragebogen erfasst. Zu t1 wurden die Zufriedenheit mit den Behandlungsempfehlungen und der Weitervermittlung sowie die aktive Unterstützung durch den Therapeuten mittels selbstentwickeltem Fragebogen erhoben. Probandinnen, denen zu t0 eine Psychotherapie empfohlen worden war, wurden zu t1 zur Psychotherapie-Inanspruchnahme befragt. Zu t1 umfasste die Stichprobe 102 Frauen, was einer Teilnehmerquote von 69.4% entspricht. Ergebnisse: Frauen, die die Sprechstunde aufsuchten, verfügten über ein gutes Bildungsniveau, lebten überwiegend in einer festen Partnerschaft bzw. waren verheiratet und zwei Drittel der Probandinnen waren Erstgebärende. Frauen, die sich während der Schwangerschaft vorstellten, gaben häufiger eine ungeplante und ungewollte Schwangerschaft im Vergleich zu Frauen, die sich postpartal vorstellten an. Am häufigsten wurden die Kriterien für Angst- und depressive Störungen, gefolgt von Anpassungsstörungen erfüllt. Fast 75% berichteten psychische Störungen in der Vorgeschichte und zwei Drittel der Frauen gaben Schwangerschafts- und Geburtskomplikationen an. Die Bewertung der Sprechstunde durch die Patientinnen fiel sehr zufriedenstellend aus, bei kurzen Wartezeiten von durchschnittlich zwei Wochen und durchschnittlich 2-3 Therapeutenkontakten. Hauptzuweiser waren Frauenärzte, Hebammen und Psychotherapeuten. Hinsichtlich der erhaltenen Empfehlungen und Unterstützung bei der Suche nach einer geeigneten Weiterbehandlung bestand ebenfalls eine hohe Zufriedenheit. Von 102 Frauen erhielten 88 Frauen (86.3%) eine Psychotherapie-Empfehlung. 78.4% setzten die Empfehlung um. (Tendenziell) signifikante Einflussfaktoren auf die Therapieinanspruchnahme waren: psychische Komorbidität, psychische Störungen in der Vorgeschichte, geringes globales Funktionsniveau, ausgeprägte Zwanghaftigkeit und Ängstlichkeit, zurückhaltend-selbstunsicher-fürsorglicher Persönlichkeitsstil, positives Beziehungserleben im Erstgespräch und eine direkte Therapieanbahnung durch den Sprechstundentherapeuten. Die Psychopathologie verbesserte sich im Verlauf von sechs Monaten sowohl bei Frauen, mit und ohne Psychotherapie-Inanspruchnahme. Auch wenn kein statistisch signifikanter Interaktionseffekt für die Inanspruchnahme von Psychotherapie nachgewiesen werden konnte, wiesen die deskriptiven Daten dennoch auf eine allgemein stärker ausgeprägte psychische Belastung und höhere Krankheitsschwere zu t0 bei den Frauen mit Psychotherapieinanspruchnahme hin. Schlussfolgerungen: Die Spezialsprechstunde wird von Frauen mit peripartalen psychischen Belastungen gut angenommen und gibt innerhalb von wenigen Stunden die Möglichkeit für eine auf das jeweilige Anliegen angepassten Diagnostik, Problemanalyse, Krisenintervention, Kurzzeittherapie, Psychopharmakotherapie bzw. Vermittlung in weiterführende ambulante oder stationäre Psychotherapieangebote. Erstgebärende, Frauen mit Schwangerschafts- und Geburtskomplikationen und Frauen mit psychischen Störungen in der Vorgeschichte sollten über peripartale psychische Beschwerden, deren Behandelbarkeit und über verfügbare Versorgungsstrukturen im Rahmen der Geburtsvorbereitung und Nachsorge aufgeklärt werden. Ein Großteil der Patientinnen konnte in eine für sie geeignete Therapieform vermittelt werden, was für eine gute Netzwerkarbeit spricht. Dabei ließ sich die Psychotherapie-Inanspruchnahme durch konkrete Hilfestellung bei der Therapievermittlung durch den Sprechstundentherapeuten und einem positiven Beziehungserleben im Erstgespräch positiv beeinflussen. Die Ergebnisse zur Psychotherapieinanspruchnahme weisen auf eine Selbstselektion der Patientinnen hin: Frauen mit einer stärker ausgeprägten Psychopathologie konnten für die Inanspruchnahme von Psychotherapie motiviert werden; weniger stark psychisch belastete Frauen erfuhren durch die Kurzintervention innerhalb der Sprechstunde Stabilisierung und Entlastung. Patientinnen mit einem eher selbstsicheren Persönlichkeitsstil, einem guten globalen Funktionsniveau, einer geringen psychischen Komorbidität und ohne psychische Vorbelastung sollten frühzeitig herausgefiltert und für eine Kurzzeitpsychotherapie motiviert werden. Die Sprechstunde übernimmt als "Weichensteller" eine wichtige Funktion im Versorgungsnetz und leistet einen Beitrag zur Prävention von Mutter-Kind-Beziehungsstörungen und potentiell nachfolgenden Verhaltens- und emotionalen Problemen des heranwachsenden Kleinkindes. Die Verfügbarkeit dieses professionellen Hilfsangebotes hilft den potentiellen Zuweisern im Umgang mit ihren eigenen Unsicherheiten bzgl. der Behandlung und fördert somit in gewisser Weise erst das „Hinsehen“ und damit die adäquate Versorgung von Mutter und Kind
Background: Mental disorders during pregnancy and postpartum period have a high prevalence of 10 to 15%. Their treatment is of particular importance with respect to their far-reaching negative consequences for pregnancy, birth, mother-child-relationship, and child development (Alder et al., 2007, Reck, 2015). Although the knowledge about these negative consequences is well documented which results in the necessity of a specialized urgent care, different limits and problem areas can be identified within the care landscape. Firstly, there exists an objective lack of therapeutic services with fast access, particularly in rural areas (Köllner, 2012). Secondly, uncertainties on the side of the therapist concerning the psychotherapeutic and/or psychopharmacological treatments and the treatment setting (bringing the newborn to therapy, mother-child-treatment, Weidner et al., 2012) can be identified. Finally, women in pregnancy and postpartum period hardly seek professional help, which can be explained through fears of stigmatization or of possible side effects, knowledge about supply deficits in psychological health care, and problems with treatment organization (Freed et al., 2012). To overcome these deficits, a cross-sector multidisciplinary treatment for women with perinatal mental disorders was established in Dresden. A significant part of this treatment service is the special consultation hour called "Psychisch gesund für Zwei", offered by the Department of Psychotherapy and Psychosomatics at University Hospital Dresden. In the present work the special consultation was evaluated in order to show the status quo, identify supply gaps, compare objective treatment needs and treatment utilization, analyze influencing factors for psychotherapy use, as well as to analyze the psychopathology over time in relation to psychotherapy use. Objectives: The research questions included: (1) How are the women visiting the special consultation hour characterized? (2) The general evaluation of the consultation service: How is the assignment mode? How long do patients have to wait for their first contact? How many consultations are attended and how satisfied are the patients with the recommended treatments and the offered support concerning re-assignments? (3) What kind of treatment was how often recommended and utilized by the women within a period of six months? (4) Which factors influence the utilization of psychotherapy? (5) How does the mental condition change in the course of psychotherapy utilization? Methods: This research is based on a supply sample with two measurement time points: N=147 women (49 pregnant, 98 postpartal; mean age 29.9 ± 5.3 years SD; aged from 18 to 45 years) were interviewed at their first contact (t0) and 6 months later (t1). At t0, socio-demographic data, information concerning pregnancy and birth, psychopathology by SKID-I, BSI, EPDS and GAF-scale, style of personality by PSSI, social support by F-SozU, and evaluations of the special consultation hours (assignment mode, satisfaction with the special consultation, therapeutic relationship) were assessed with the help of a self-designed questionnaires. At t1, the degrees of satisfaction with treatment recommendations, transfer to an appropriate form of treatment and active support in seeking recommended treatment were also assessed by self-designed questionnaires. Women, to whom the utilization of psychotherapy had been recommended at t0, were interviewed regarding their psychotherapy utilization at t1. At t1, the sample size was 102 women which corresponds to a participation rate of 69,4%. Results: Women who attended the special consultation hours had a high level of education and were living together with a partner or were married. Two thirds of them were primiparae. Woman who joined the consultation service already during pregnancy were more likely to have an unplanned and unwanted pregnancy than women who were participating postpartum. Most frequently, anxiety and depressive disorders were diagnosed, followed by adjustment disorders. Almost 75% of women reported mental disorders in their personal medical history and 60% indicated pregnancy or birth complications. There was a high level of satisfaction with the consultation at short waiting periods and an average of 2-3 therapeutic contacts. Main assigning healthcare professionals were gynecologists, midwifes and psychotherapists. Altogether, patients were content with treatment recommendations and the support for acquiring further treatment possibilities. Out of 102 women, 88 women (86,3%) were recommended a psychotherapy. If recommended, psychotherapy was utilized in 78,4% of cases. Significant factors influencing the utilization of treatment were the comorbidity of mental disorders, mental disorders in personal medical history, low levels of global functioning, distinct compulsiveness and anxiety, restrained-avoidant-considerate personality traits, a positive therapeutic relationship at initial consultation and active support in seeking recommended psychotherapy. Psychopathology improved in the course of 6 months for both, women who utilized psychotherapy, as well as for those without psychotherapy. Although no statistically significant interaction effect for the utilization of psychotherapy could be proven, the descriptive data indicated a stronger severity of disease at t0 for women who utilized psychotherapy. Conclusions: The opportunity to attend the special consultation was received very well by women suffering from peripartal mental disorders. The consultations offered short-range adequate diagnosis, problem analysis, crisis intervention, short-term treatment, psychopharmacological therapy or the transferal to ambulatory and hospital psychotherapy. Primiparae, women with pregnancy or birth complications, and women with mental disorders in their medical history should be informed about peripartal mental symptoms, their treatability and available mental health services in the context of birth preparation and postnatal care. The majority of patients could be transferred successfully to an appropriate form of treatment, which indicates efficient networking activities among health professionals. The active support by healthcare professionals in seeking psychotherapy had a positive impact on the factual utilization of recommended psychotherapeutic treatments. With regard to the utilization of psychotherapy, the results suggest a self-selection of the patients: Women with increased severity of mental disorders could successfully be motivated to seek psychotherapy; less severe mentally strained women profited from short-term intervention within the consultation through stabilization and relief of strain. Patients with a confident personality, sufficient global level of functioning, slight mental comorbidity and without prior mental charge should be selected early and then motivated to seek short-term psychotherapy. The special consultation hours play an important role in the treatment of peripartal mental disorders and make an important contribution to prevent mother-child attachment disorders and potential behavioral and emotional problems of the growing child. The availability of this professional offer helps potentially re-assigning healthcare professionals to deal with their own uncertainties regarding adequate treatment and encourages them to pay closer attention to this topic, which eventually results in an adequate treatment for mother and child

Background: The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people. Aims: To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country. Methods: The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27 + Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010. Results: The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US. Discussion: This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges. Recommendations: Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Aims: To provide 12-month prevalence and disability burden estimates of a broad range of mental and neurological disorders in the European Union (EU) and to compare these findings to previous estimates. Referring to our previous 2005 review, improved up-to-date data for the enlarged EU on a broader range of disorders than previously covered are needed for basic, clinical and public health research and policy decisions and to inform about the estimated number of persons affected in the EU. Method: Stepwise multi-method approach, consisting of systematic literature reviews, reanalyses of existing data sets, national surveys and expert consultations. Studies and data from all member states of the European Union (EU-27) plus Switzerland, Iceland and Norway were included. Supplementary information about neurological disorders is provided, although methodological constraints prohibited the derivation of overall prevalence estimates for mental and neurological disorders. Disease burden was measured by disability adjusted life years (DALY). Results: Prevalence: It is estimated that each year 38.2% of the EU population suffers from a mental disorder. Adjusted for age and comorbidity, this corresponds to 164.8 million persons affected. Compared to 2005 (27.4%) this higher estimate is entirely due to the inclusion of 14 new disorders also covering childhood/adolescence as well as the elderly. The estimated higher number of persons affected (2011: 165 m vs. 2005: 82 m) is due to coverage of childhood and old age populations, new disorders and of new EU membership states. The most frequent disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%), somatoform (6.3%), alcohol and drug dependence (> 4%), ADHD (5%) in the young, and dementia (1–30%, depending on age). Except for substance use disorders and mental retardation, there were no substantial cultural or country variations. Although many sources, including national health insurance programs, reveal increases in sick leave, early retirement and treatment rates due to mental disorders, rates in the community have not increased with a few exceptions (i.e. dementia). There were also no consistent indications of improvements with regard to low treatment rates, delayed treatment provision and grossly inadequate treatment. Disability: Disorders of the brain and mental disorders in particular, contribute 26.6% of the total all cause burden, thus a greater proportion as compared to other regions of the world. The rank order of the most disabling diseases differs markedly by gender and age group; overall, the four most disabling single conditions were: depression, dementias, alcohol use disorders and stroke. Conclusion: In every year over a third of the total EU population suffers from mental disorders. The true size of “disorders of the brain” including neurological disorders is even considerably larger. Disorders of the brain are the largest contributor to the all cause morbidity burden as measured by DALY in the EU. No indications for increasing overall rates of mental disorders were found nor of improved care and treatment since 2005; less than one third of all cases receive any treatment, suggesting a considerable level of unmet needs. We conclude that the true size and burden of disorders of the brain in the EU was significantly underestimated in the past. Concerted priority action is needed at all levels, including substantially increased funding for basic, clinical and public health research in order to identify better strategies for improved prevention and treatment for disorders of the brain as the core health challenge of the 21st century.

The psychological sciences offer a large spectrum of theories, principles, and methodological approaches to understand mental health, normal and abnormal functions and behaviours, as well as mental disorders. Based on continued research progress, psychology has derived a wide range of effective interventions for behaviour change and the prevention, treatment and rehabilitation of mental disorders. Thus, psychology and clinical psychology in particular should be regarded as the ‘mother’ science for psychotherapy and psychotherapeutic practice. This paper provides a selective overview of the scope, strengths and gaps in psychological research to depict the advances needed to inform future research agendas on mental disorders and psychological interventions in the context of psychotherapy. Most maladaptive health behaviours and mental disorders can be conceptualised as the result of developmental dysfunctions of psychological functions and processes, and as associated neurobiological and genetic processes in interaction with behaviour and the environment. An integrative translational model, linking basic and experimental research with clinical research and population-based prospective longitudinal studies is proposed for improving identification of critical core vulnerability and risk factors and core pathogenic mechanisms. The proposed framework is expected to allow a more stringent delineation of targeted preventive and therapeutic psychological interventions and an optimisation and better understanding of cognitive-behavioural therapies and other psychological interventions. Based on a European consultation process, a ‘Science of Behaviour Change’ programme with the promise of improved diagnosis, treatment and prevention of both healthrisk behaviour constellations and mental disorders is proposed.
Psychologie als «Mutterwissenschaft» für Psychotherapie und psychische Gesundheit Psychologie als Wissenschaft bietet ein breites Spektrum an Theorien, Grundlagen und methodischen Ansätzen, um psychische Gesundheit, normale und gestörte Funktionen und Verhaltensweisen sowie psychische Störungen zu erforschen und zu «verstehen». Auf dieser Grundlage haben sich in der Klinischen Psychologie vielfältige effektive, psychologisch begründete Interventionen für die Prävention, Behandlung und Rehabilitation von psychischen Störungen ausdifferenziert. Damit ist die Psychologie als «Mutterwissenschaft » der Psychotherapie und psychotherapeutische Praxis anzusehen. Der Beitrag versucht auf der Grundlage einer Stärken-/Schwächen-Analyse der psychologischen Forschung diejenigen Themenbereiche zu definieren, die für Erkenntnisfortschritte bei psychischen Störungen und die psychotherapeutische Interventionsforschung besonders vielversprechend sein könnten. Dysfunktionale bzw. abweichende Verhaltensweisen wie auch psychische Störungen lassen sich als entwicklungsbezogene Störungen psychologischer Funktionen und Prozesse und damit assoziierter neurobiologischer und genetischer Prozesse konzeptualisieren. Für eine verbesserte Identifikation von zentralen Vulnerabilitäts- und Risikofaktoren sowie ätiologisch relevanten Schlüsselprozessen wird ein integratives translationales Modell vorgeschlagen, welches die Grundlagen- und experimentelle Forschung mit klinischer Forschung, Translation und Public-health-Implikationen verknüpft. Damit soll auf der einen Seite eine stringentere Ableitung gezielter Interventionen erleichtert werden, andererseits aber auch eine bessere Identifikation der zentralen Wirkfaktoren und Wirkprozesse psychologischer Therapien ermöglicht werden. Basierend auf einem europäischen Experten-Beratungsprozess wird ein EU-Programm ‘The science of behavior change’ angeregt.

Aims: To provide 12-month prevalence and disability burden estimates of a broad range of mental and neurological disorders in the European Union (EU) and to compare these findings to previous estimates. Referring to our previous 2005 review, improved up-to-date data for the enlarged EU on a broader range of disorders than previously covered are needed for basic, clinical and public health research and policy decisions and to inform about the estimated number of persons affected in the EU. Method: Stepwise multi-method approach, consisting of systematic literature reviews, reanalyses of existing data sets, national surveys and expert consultations. Studies and data from all member states of the European Union (EU-27) plus Switzerland, Iceland and Norway were included. Supplementary information about neurological disorders is provided, although methodological constraints prohibited the derivation of overall prevalence estimates for mental and neurological disorders. Disease burden was measured by disability adjusted life years (DALY). Results: Prevalence: It is estimated that each year 38.2% of the EU population suffers from a mental disorder. Adjusted for age and comorbidity, this corresponds to 164.8 million persons affected. Compared to 2005 (27.4%) this higher estimate is entirely due to the inclusion of 14 new disorders also covering childhood/adolescence as well as the elderly. The estimated higher number of persons affected (2011: 165 m vs. 2005: 82 m) is due to coverage of childhood and old age populations, new disorders and of new EU membership states. The most frequent disorders are anxiety disorders (14.0%), insomnia (7.0%), major depression (6.9%), somatoform (6.3%), alcohol and drug dependence (> 4%), ADHD (5%) in the young, and dementia (1–30%, depending on age). Except for substance use disorders and mental retardation, there were no substantial cultural or country variations. Although many sources, including national health insurance programs, reveal increases in sick leave, early retirement and treatment rates due to mental disorders, rates in the community have not increased with a few exceptions (i.e. dementia). There were also no consistent indications of improvements with regard to low treatment rates, delayed treatment provision and grossly inadequate treatment. Disability: Disorders of the brain and mental disorders in particular, contribute 26.6% of the total all cause burden, thus a greater proportion as compared to other regions of the world. The rank order of the most disabling diseases differs markedly by gender and age group; overall, the four most disabling single conditions were: depression, dementias, alcohol use disorders and stroke. Conclusion: In every year over a third of the total EU population suffers from mental disorders. The true size of “disorders of the brain” including neurological disorders is even considerably larger. Disorders of the brain are the largest contributor to the all cause morbidity burden as measured by DALY in the EU. No indications for increasing overall rates of mental disorders were found nor of improved care and treatment since 2005; less than one third of all cases receive any treatment, suggesting a considerable level of unmet needs. We conclude that the true size and burden of disorders of the brain in the EU was significantly underestimated in the past. Concerted priority action is needed at all levels, including substantially increased funding for basic, clinical and public health research in order to identify better strategies for improved prevention and treatment for disorders of the brain as the core health challenge of the 21st century.

This report presents an overview of the results of the US National Comorbidity Survey (NCS) (Kessler et al., 1994) and future directions based on these results. The NCS is a survey that was mandated by the US Congress to study the comorbidity of substance use disorders and nonsubstance psychiatric disorders in the general population of the US. (...)

The role of comorbidity as a risk for suicide attempts is investigated in a random sample of 3021 young adults aged 14–24 years. The M-CIDI, a fully standardized and modified version of the Composite International Diagnostic Interview, was used for the assessment of various DSM-IV lifetime and 12-month diagnoses as well as suicidal ideation and suicide attempts. Of all suicide attempters, 91% had at least one mental disorder, 79% were comorbid or multimorbid respectively and 45% had four or more diagnoses (only 5% in the total sample reached such high levels of comorbidity). Suicide attempters with more than three diagnoses were 18 times more likely (OR = 18.4) to attempt suicide than subjects with no diagnosis. Regarding specific diagnoses, multivariate comorbidity analyses indicated the highest risk for suicide attempt in those suffering from anxiety disorder (OR = 4.3), particularly posttraumatic stress disorder followed by substance disorder (OR = 2.2) and depressive disorder (OR = 2.1). Comorbidity, especially when anxiety disorders are involved, increases the risk for suicide attempts considerably more than any other individual DSM-IV diagnoses.

Background: Although positive effects of physical activity on mental health indicators have been reported, the relationship between physical activity and the development of specific mental disorders is unclear. Method: A cross-sectional (12-month) and prospective-longitudinal epidemiological study over 4 years in a community cohort of 2548 individuals, aged 14–24 years at outset of the study. Physical activity and mental disorders were assessed by the DSM-IV Composite International Diagnostic Interview (CIDI) with an embedded physical activity module. Multiple logistic regression analyses controlling for age, gender and educational status were used to determine the cross-sectional and prospective associations of mental disorders and physical activity. Results: Cross-sectionally, regular physical activity was associated with a decreased prevalence of any and co-morbid mental disorder, due to lower rates of substance use disorders, anxiety disorders and dysthymia. Prospectively, subjects with regular physical activity had a substantially lower overall incidence of any and co-morbid mental disorder, and also a lower incidence of anxiety, somatoform and dysthymic disorder. By contrast, the incidence of bipolar disorder was increased among those with regular physical activity at baseline. In terms of the population attributable fraction (PAF), the potential for preventive effects of physical activity was considerably higher for men than for women. Conclusions: Regular physical activity is associated with a substantially reduced risk for some, but not all, mental disorders and also seems to reduce the degree of co-morbidity. Further examination of the evidently complex mechanisms and pathways underlying these associations might reveal promising new research targets and procedures for targeted prevention.

Aus der Einleitung: "The authors of the seven meta-structure papers in this issue have to be applauded for their inspiring attempt to suggest and elaborate a new meta-structure of mental disorders consisting of five ‘ clusters ’. At first sight this proposal seems to be considerably simpler than the current diagnostic classifications structure used by DSM-IV-TR (17 categories ; APA, 2000) and, in some parts, more convergent with the ICD-10 (10 categories ; WHO, 1993). Against the background of dissatisfaction expressed with the current diagnostic classification structure for mental disorders and its principles, the authors provide a selective critical review of relevant research. In particular, evidence is examined to address the question of whether current individual mental disorders differ sufficiently from each other and whether the current more fine-graded distinction of specific mental disorders and their grouping in 10 major classes according to ICD-10 and 17 in DSM-IV-TR is justified. To help answer this question, a prioricriteria were chosen in the form of a wide range of ‘validators ’ grouped into so-called ‘causal’ risk factors (i.e. shared genetic risk factors, familiality, shared environmental risks, shared neural substrates, shared biomarkers, shared temperamental antecedents) and factors thought to be more likely to reflect the clinical picture itself (shared abnormalities of cognitive and emotional processing, symptom similarity, rates of co-morbidity, course, treatment response). The results of this impressive exploration are interpreted to suggest a substantial reduction of the current major classes to five clusters and a fairly large residual category of disorders not yet assigned. Particularly noteworthy examples for classificatory changes associated with the proposed meta-structure involve: the suggestion to group anxiety, somatoform and depressive disorders together under the term ‘emotional disorders ’ ; the allocation of bipolar disorders to the ‘psychotic cluster ’ ; and the formation of a broad externalizing cluster that comprises substance use disorders, some of the personality disorders and impulse control disorders. [...]"

This special issue was prepared within the framework of the European College of Neuropsychopharmacology (ECNP) Task Force on “Size and Burden of Mental Disorders in Europe”. The core aim of the Task Force was to describe the prevalence and the burden of treated and untreated mental disorders in all European member states and to highlight needs for further research. Ten state-of-theart epidemiological papers summarize the outcome of this project, making an attempt to provide for the first time ever prevalence estimates for a wide range of mental disorders, as well as for dementia and Parkinson’s disease in 28 European countries. These data also provide input for the European Brain Council (EBC, http://www.ebc-eurobrain. net) Initiative “Cost of Disorders of the Brain in Europe” aiming at estimating the cost of major classes of mental, neurological and neurosurgical disorders and conditions in Europe.

Background: Per definition, traumatic events include exposures to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Exposure to traumatic events is associated with persistent alterations in biological and psychological processes that are involved in the etiology of mental disorders. In fact, traumatic events are associated with a higher risk for various mental disorders such as posttraumatic stress disorder (PTSD) and substance use disorders, but also with treatment resistance. Thus, it is crucial to develop early interventions to prevent these adverse trauma-related outcomes. However, existing pharmacological and psychological early intervenions only have a limited efficacy so far. A major reason is that only a minority of trauma-exposed individuals actually develops adverse consequences making universally applied interventions ineffective. Thus, it is crucial to identify moderators of adverse responses to trauma exposure. Aims: This thesis aimed at (1) providing estimates on the prevelance of traumatic event exposure and trauma-related mental disorders for the general population and high-risk populations and (2) investigating moderators of adverse mental health consequences following traumatic event exposure. The following potential moderators were investigated: (i) the susceptibility to others‘ emotions, (ii) childhood traumas, (iii) biological stress markers and (iv) a specific genetic polymorphism involved in the degradation of monoamines (i.e. MAOA gene). These investigations were conducted with respect to differenct outcomes relevant in the processing of traumatic events including the initial affective and biological reaction, mental disorder symptoms (focusing on PTSD and alcohol use symptoms) and treatment response. Methods: To answer the research questions, different methods and designs were applied. First, epidemiological data from a national study program in German soldiers deployed to Afghanistan were used. These data included diagnostic interview data as well as biological markers. Second, an experimental study with a randomized trauma analogue design was used to investigate moderators of acute trauma responses. Third, a genetic moderator of trauma effects on treatment response was investigated using data from a multi-center trial of exposure-based cognitive behavioral therapy of panic and agoraphobia patients. Main results: Only a small minority of trauma-exposed individuals develops mental disorders. This also applies to populations with a high risk for multiple and/or severe trauma exposure. The investigations of potential moderators suggeted that individuals with a higher susceptibility to negative emotions of others show a higher stress reactivity after trauma exposure. Males with childhood traumas show a higher increase in alcohol craving after trauma exposure. Moreover, individuals with lower basal cortisol levels have a higher risk of increased PTSD symptoms and alcohol use following trauma exposure. Finally, a subgroup of traumatized female panic disorder patients with the low-active variant of the MAOA gene benefits less from exposure-based psychotherapy. Conclusions: These findings suggest novel targets for moderating factors and show the relevance of previously discovered moderators in novel contexts. Some of the identified moderators represent promising targets for risk markers before or in the direct aftermath of traumatic event exposure. Further research is needed to comfirm the suggested moderators and to investigate the exact mechanisms involved. Moreover, future studies should aim at integrating findings on different moderators and translate them into effective risk assessments and targeted early interventions.
Hintergrund: Traumatische Ereignisse sind definiert als Konfrontation mit tatsächlichem oder droghenden Tod, ernsthafter Verletzung oder sexueller Gewalt. Das Erleben traumatischer Ereignisse ist mit andauernder Veränderungen in biologischen und psychischen Prozesssen assoziiert, welche eine bedeutende Rolle in der Ätiologie psychischer Störungen spielen. Tatsächlich sind traumatische Ereignisse mit einem höheren Risiko für zahlreiche psychische Störungen assoziiert, darunter vor allem die Posttraumatische Belastungsstörung (PTBS) und Substanzstörungen. Zudem zeigen Personen mit traumatischen Erfahrungen häufiger ein schlechteres Ansprechen auf Behandlungen. Die Entwicklung möglichst früher Inteventionen zur Vermeidung dieser Traumafolgen ist somit von großer Bedeutung. Allerdings sind bestehende frühe Interventionen nach traumatischen Eriegnissen bislang nur sehr begrenzt effektiv. Ein wesentlicher Grund hierfür besteht darin, dass überhaupt nur ein kleiner Anteil von traumatisierten Personen negative Folgen entwickelt. Es ist demnach entscheidend, solche Faktoren zu identifizieren, die das Risiko negativer Folgen nach traumatischen Ereignissen moderieren. Ziele: (1) Darstellung der Prävalenz von traumatischen Ereignissen und trauma-bezogenen psychischen Störungen für die Allgemeinbevölkerung und für spezifische Risikopopulationen, sowie (2) die Untersuchung von Moderatoren negativer Traumafolgen, wobei folgende potenzielle Moderatoren untersucht wurden: (i) die Ansteckbarkeit für die Emotionen anderer, (ii) Kindheitstraumata, (iii) biologische Stressmarker und (iv) ein genetischer Polymorphismus, der beim Abbau von Monoaminen involviert ist (MAOA Gen). Diese Moderatoren wurden in Bezug auf unterschiedliche Outcomes untersucht, welche Aspekte der Verarbeitung traumatischer Ereignisse darstellen: die unmittelbare emotionale und biologische Reaktion, Symptome psychischer Störungen (mit Fokus auf PTBS und Alkoholkonsum) sowie das Ansprechen auf Behandlung. Methoden: Zur Beantwortung der Fragestellungen wurden verschiedene Methoden und Studiendesigns genutzt. Diese beinhalteten zum einen epidemiologische Daten eines bundesweiten Studienprogramms bei deutschen Soldaten mit Militäreinsatz in Afghanistan. Diese Daten umfassten diagnostische Interviews sowie biologische Stressmarker. Weiterhin wurde eine experimentelle randomisierte Analogstudie durchgeführt, um Moderatoren von initialen Traumareaktionen zu identifizieren. Schließlich wurden Daten einer Multi-Center Therapiestudie bei Patienten mit Paniskstörung und Agoraphobie verwendet, um die Moderation des Effekts vorangegangener Traumatisierung auf den Therapieerfolg durch einen genetischen Faktor (MAOA Gen) zu untersuchen. Hauptergebnisse: Nur ein geringer Anteil von Betroffenen entwickelt nach der Konfrontation mit einem trauamtischen Ereignis psychische Störungen. Dies gilt auch in Populationen mit einem erhöhten Risiko für multiple und schwere Traumata. Die durchgeführten Studien zur Identifikation von Moderatoren weisen darauf hin, dass Personen mit einer erhöhten Ansteckbarkeit für negative Emotionen anderer eine stärkere initiale Stressreaktion bei Traumaexposition aufweisen. Darüber hinaus zeigen Männer mit Traumatisierung in der Kindheit einen stärkeren Anstieg von Alkoholcraving nach der Konfrontation mit einem akuten Trauma. Weiterhin sind niedrige basale Cortisol Level mit einem höheren Risiko für einen Anstieg der PTBS Symptomatik sowie im Alkoholkonsum nach traumatischen Ereignissen assoziiert. Schließlich gibt es Hinweise auf geringere Therapieeffekte bei vorangegangener Traumatisierung bei einer Subgruppe von weiblichen Patientinnen mit Panikstörung mit der niedrig aktiven Variante des MAOA Gens. Schlussfolgerungen: Es konnten neue Kandidaten für mögliche Moderatoren identifiziert sowie die Relevanz bekannter Moderatoren in neuen Kontexten gezeigt werden. Einige dieser Moderatorvariablen stellen vielversprechende Ziele für Risikomarker vor und unmittelbar nach der Konfrontation mir traumatischen Ereignissen dar. Weitere Forschung ist nötig, um die hier identifizierten Moderatoren zu bestätigen und die zugrundeliegenden Mechanismen aufzudecken. Zudem sollte künftige Forschung die Befunde zu verschiedenen Moderatoren integrieren um daraus effektive Risikobewertungen und gezielte Frühinterventionen ableiten zu können.

The CIDI is a fully standardised diagnostic interview designed for assessing mental disorders based on the definitions and criteria of ICD-1Oand DSM-IlI-R. Field trials with the CIDI have been conducted in 18 centres around the world, to test the feasibility and reliability of the CIDI in different cultures and settings, as well as to test the inter-rater agreement for the different types of questions used. Of 590 subjects interviewed across all sites and rated by an interviewer and observer, 575 were eligible for analysis. The CIDI was judged to be acceptable for most subjects and was appropriate for use in different kinds of settings. Many subjects fulfilled criteria for more than one diagnosis (lifetime and six-month). The most frequent lifetime disorders were generalised anxiety, major depression, tobacco use disorders, and agoraphobia. Percentage agreements for all diagnoses were above 90% and the kappa values were all highly significant. No significant numbers of diagnostic disconcordances were found with lifetime, six-month, and four-week time frames.

Background: Psychological problems are common in cancer patients. For the purpose of planning psycho-oncological interventions and services tailored to the specific needs of different cancer patient populations, it is necessary to know to what extent psychological problems meet the criteria of mental disorders. The purpose of this study was to estimate the 12-month and lifetime prevalence rates of mental disorders in cancer patients. Methods: A representative sample of patients with different tumour entities and tumour stages (n = 2,141) in outpatient, inpatient and rehabilitation settings underwent the standardized computer-assisted Composite International Diagnostic Interview for mental disorders adapted for cancer patients (CIDI-O). Results: The overall 12-month prevalence for any mental disorder was 39.4% (95% CI: 37.3–41.5), that for anxiety disorders was 15.8% (95% CI: 14.4–17.4), 12.5% (95% CI: 11.3–14.0) for mood disorders, 9.5% (95% CI: 8.3–10.9) for somatoform disorders, 7.3% (95% CI: 6.2–8.5) for nicotine dependence, 3.7% (95% CI: 3.0–4.6) for disorders due to general medical condition, and 1.1% (95% CI: 0.7–1.6) for alcohol abuse or dependence. Lifetime prevalence for any mental disorder was 56.3% (95% CI 54.1–58.6), that for anxiety disorders was 24.1% (95% CI: 22.3–25.9), 20.5% (95% CI: 18.9–22.3) for mood disorders, 19.9% (95% CI: 18.3–21.7) for somatoform disorders, 18.2% (95% CI: 16.6–20.0) for nicotine dependence, 6.4% (95% CI: 5.4–7.6) for alcohol abuse or dependence, 4.6% (95% CI: 3.8–5.6) for disorders due to general medical condition, and 0.2% (95% CI: 0.1–0.6) for eating disorders. Conclusions: Mental disorders are highly prevalent in cancer patients, indicating the need for provision of continuous psycho-oncological support from inpatient to outpatient care, leading to an appropriate allocation of direct personnel and other resources.

This article reports the results of a cross-national investigation of patterns of comorbidity between substance use and psychiatric disorders in six studies participating in the International Consortium in Psychiatric Epidemiology. In general, there was a strong association between mood and anxiety disorders as well as conduct and antisocial personality disorder with substance disorders at all sites. The results also suggest that there is a continuum in the magnitude of comorbidity as a function of the spectrum of substance use category (use, problems, dependence), as well as a direct relationship between the number of comorbid disorders and increasing levels of severity of substance use disorders (which was particularly pronounced for drugs). Finally, whereas there was no specific temporal pattern of onset for mood disorders in relation to substance disorders, the onset of anxiety disorders was more likely to precede that of substance disorders in all countries. These results illustrate the contribution of cross-national data to understanding the patterns and risk factors for psychopathology and substance use disorders.

The role of comorbidity as a risk for suicide attempts is investigated in a random sample of 3021 young adults aged 14–24 years. The M-CIDI, a fully standardized and modified version of the Composite International Diagnostic Interview, was used for the assessment of various DSM-IV lifetime and 12-month diagnoses as well as suicidal ideation and suicide attempts. Of all suicide attempters, 91% had at least one mental disorder, 79% were comorbid or multimorbid respectively and 45% had four or more diagnoses (only 5% in the total sample reached such high levels of comorbidity). Suicide attempters with more than three diagnoses were 18 times more likely (OR = 18.4) to attempt suicide than subjects with no diagnosis. Regarding specific diagnoses, multivariate comorbidity analyses indicated the highest risk for suicide attempt in those suffering from anxiety disorder (OR = 4.3), particularly posttraumatic stress disorder followed by substance disorder (OR = 2.2) and depressive disorder (OR = 2.1). Comorbidity, especially when anxiety disorders are involved, increases the risk for suicide attempts considerably more than any other individual DSM-IV diagnoses.