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The PART Study A Population Based Study of Mental Health in the Stockholm County: Study Design. Phase l (1998-2000)

Tore Hällström Kerstin Damström Thakker Yvonne Forsell Ingvar Lundberg Petter Tinghög

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© Copyright The PART Study Group Rapport 2003:1

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The PART Study Group -

Tore Hällström, M.D., PhD., Professor emeritus 1 Kerstin Damström Thakker, PhD 2 Yvonne Forsell, M.D., PhD., Associate Professor 3 Ingvar Lundberg, M.D., PhD., Professor 4

NEUROTEC, Section of Psychiatry, Karolinska Institutet Postal address: Huddinge University Hospital, M98, SE-141 86 Stockholm Phone: +46 8 585 857 84 Fax: +46 8 585 857 85 E-mail: [email protected] 1

Stockholm Center of Public Health, Department of Alcohol and Drug Prevention Postal address: Box 175 33, SE-118 91 Stockholm, Sweden Phone: +46 8 517 781 86 Fax: +46 8 517 780 05 E-mail: [email protected]

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Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet Postal address: Norrbacka, Karolinska Hospital, SE-171 76 Stockholm, Sweden Phone: +46 8 517 781 23 Fax: +46 8 517 781 55 E-mail: [email protected]

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National Institute for Working Life, Department for Work and Health Postal address: SE-113 91 Stockholm, Sweden Phone: +46 8 619 69 48 Fax: +46 8 619 68 96 E-mail: [email protected]

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PREFACE This is a report of the study design of phase l of the PART Study. A Population Based Study of Mental Health in the Stockholm County. In this report we present: The problem areas and their relation to earlier research. The aims of the PART Study. The selection of the study population. The various dimensions and screening instruments used in the questionnaire, the definitions of screening positive and screening negative respondents, the response rate and the attrition analysis. The instrument used in the psychiatric interview, the attrition analysis, the diagnoses made, the assessments made of treatment need and the cognitive tests used. Characteristics of the participants based on data from the questionnaire and the interviews. Phase ll of the PART Study was carried out from 2001 to 2003. December 2003 The PART Study Group

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CONTENTS PREFACE ..........................................................................................................4 INTRODUCTION ............................................................................................7 Problem areas............................................................................................7 Relation to earlier research......................................................................8 Theoretical framework.....................................................................8 Individual vulnerability...................................................................9 Negative life events (stressors) .......................................................9 Social support....................................................................................9 Coping ..............................................................................................10 Concept of illness............................................................................10 Illness behaviour.............................................................................11 Quality of life...................................................................................11 Gender aspects ................................................................................11 Treatment service interventions ...................................................12 References ........................................................................................14 GRANTS..........................................................................................................16 CHIEF INVESTIGATORS .............................................................................17 THE AIMS OF THE PART STUDY .............................................................18 STUDY POPULATION .................................................................................19 QUESTIONNAIRE.........................................................................................20 Risk and protective factors for mental ill-health ........................20 Screening instruments....................................................................21 Screening positive and screening negative respondents ..........23 Response rate ..................................................................................24 Attrition analysis for response to the questionnaire..................25 References ........................................................................................27 PSYCHIATRIC INTERVIEW........................................................................29 Attrition analysis for participation in the psychiatric interview ..........................................................................................30 Diagnoses.........................................................................................30 Treatment need ...............................................................................31 Blood samples .................................................................................31 Cognitive tests.................................................................................32 References ........................................................................................33

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CHARACTERISTICS OF THE PARTICIPANTS BASED ON DATA FROM THE QUESTIONNAIRE AND THE INTERVIEWS ........35 Appendix 1: Data from the questionnaire: Background characteristics of the participants.........................................................36 Appendix 2: Data from the questionnaire: Outcome of the screening instruments............................................................................43 Appendix 3: Data from the interviews: Previous treatment and treatment need for mental health problems .......................................48

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INTRODUCTION Problem areas There is a high incidence of mental disorders in the population and taken together they constitute the most common reason for early retirement. This is thus a public health problem involving significant costs for society. The psychiatric illness panorama is in certain respects a reflection of developments in both society and the culture. One example is the greatly increased incidence of depressive syndromes and eating disturbances. The psychiatric population studies that have been conducted earlier in Sweden are now quite ancient. Studies assessing unmet treatment needs in the population are rare even internationally. The 1999 Public Health Report for the County of Stockholm states that mental ill health is the largest public health problem, measured in terms of disability-adjusted life years (DALYs). For women, "depression and neurosis" take first place amongst all types of illness/injury, in terms of burden of disease in the population. Among men, "depression and neurosis" take second place (after coronary diseases). Alcohol dependence comes third amongst men and self-inflicted injuries take fifth place. Mental ill health as a problem area has come increasingly to the fore in Stockholm, as the proportion of the population with impaired mental health has increased somewhat since 1990. This is particularly the case for women in the age group 20-44 (Stockholm County Council, 1999). The national investigations of living conditions conducted by Statistics Sweden also show that the proportion of the population with mental problems increased during the 1990s. This demonstrates the need for increased knowledge about both the causes of mental ill health and its effects in the form of social disability. It is also necessary to analyse the treatment system's (primary care and psychiatry) capacity to meet the increased needs of the population, from the perspective of the major diagnostic groups. National reports and overviews of psychiatry from recent years have focused almost exclusively on the situation of the chronic mentally ill. In the Public Health Report for the County of Stockholm (1999), the conclusion is drawn that changed conditions in society, such as greater unemployment, increased financial stress and greater work demands can explain about a third of the increase in mental problems. The major part of this increase thus remains unexplained, which further emphasises the importance of deeper studies of the area. The most prevalent psychiatric symptoms and syndromes (depression, anxiety, alcohol dependence/abuse and eating disturbances) show a clear association with socio-demographic factors (poor education, low income, female gender, single status, unemployment). A fundamental question is 7

how the effect of socio-demographic factors is mediated by more specific risk and protective factors. Examples of such factors are negative events during formative years, negative events later in life, functioning of the social network, work conditions etc. An increased understanding of these associations makes it necessary to be able to distinguish between cause and effect, which methodologically necessitates a longitudinal project design. The most common mental disorders exhibit significant gender differences with regard to prevalence. Depression, most of the anxiety syndromes and eating disturbances are most common amongst women; alcohol dependence/abuse are most common amongst men. Very little of substance is known about the reasons for these gender differences.

Relation to earlier research Theoretical framework The vulnerability-stress-support model provides an overall approach as to how mental ill health arises. Conditions in society

Stressors

Living conditions

Social support

Coping

Symptoms, illness behaviour

Primary care, psychiatry

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Individual resources, vulnerability

Individual vulnerability The resources/vulnerability of the individual develop early in life in interplay between biological conditions and social surroundings. Vulnerability can be of a genetic nature, depend on pre-, peri, or postnatal brain damage, or be connected to unfavourable childhood conditions (Tennant, 1991). A childhood characterised by lack of affection and/or love, control, insecurity or sexual abuse increases vulnerability for depression and suicidal tendencies later in life (Bifulco et al., 1991; Mullen et al., 1993). In such cases, the child develops an uncertain bond with the parents, which is the central theoretical concept (Bowlby, 1977). The past decades have seen many improvements in children's living conditions, which have become more characterised by equality. At the same time, the divorce rate has increased, although the understanding of the child's needs in family crises has improved. There are no current population-based Swedish studies of the association between childhood conditions and mental health in adult years.

Negative life events (stressors) Negative life events can be serious (e.g. death in the family) and increase the risk of depressive and anxiety syndromes over a long period, or less serious and only have a short-term triggering effect (Paykel, 1978). Certain strains cannot be described as events (Brown & Harris, 1978) but exist over a long period (major difficulties according to the sociologist George Brown's terminology); e.g. that someone in the family has a severe chronic mental illness. In working life, great demands in association with little control over the work situation constitute a risk factor. Brain damage sustained later in life can also increase vulnerability for psychosocial stressors or be the direct cause of a mental disorder. What determines the degree of the negative consequences of such events is primarily that they are unwanted and unpredictable, outside the control of the individual. The degree of loss or threatening danger is also very important.

Social support Social support in the form of a functioning network and feelings of belonging has been shown to be of importance for mental health (Cohen & Syme, 1985). It can be enough to have a single intimate relationship. The size of the network is less important and among women appears to have a negative effect; i.e. the larger the network the greater the risk of negative events. However, this finding needs to be confirmed and specified.

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Social support is provided by the informal network; family, friends, colleagues etc. The formal social network encompasses health care services, school, and social services. The informal network can be described in terms of structure and function (Cohen & Wills, 1985). Both networks are surveyed in PART. Structural characteristics appear essentially to have direct effects regardless of strains. The network's functional effects are observed for the most part in association with the appearance of strain (the buffer hypothesis). In PART, it is possible to analyse both the effects of structure and function in the network.

Coping The effects of stress/support are affected by coping. Coping can be understood as a mobilisation to manage external and internal demands and conflicts between various demands (Lazarus, Folkman, 1984). The concept of coping is limited to stressful situations that exceed the everyday demands of more routine adjustment. Certain personality factors affect coping behaviour, such as sensation seeking and optimistic/pessimistic attitudes to life. In PART, data are collected about both coping and personality characteristics.

Concept of illness A mental illness or disorder involves a psychological and/or behavioural change in the individual that means that the person in question has painful symptoms and/or functions less well socially. All aspects of mental life may be affected, including thinking, feelings and impulse control. Problems with relations or an impaired work capacity are the rule. ICD-10 (WHO, 1992) and DSM-IV (APA, 1994) are the internationally recognised standard rules for how mental disorders are defined. Psychological dysfunctions, which are usually matched by subjective experiences, are taken into consideration in the definitions. These definitions are fundamentally only descriptive, which makes them useable for empirically investigating causes, treatment effects and prognoses. The aetiology of practically all forms of mental disorders is multifactorial (i.e. socio-cultural, psychological and biological factors play a role). It is essential that the diagnostic systems be developed continually on empirical grounds. One of the problems is that the boundary between illness and health is vague. The so-called non-specific mental disorders, which do not completely meet the standardised diagnostic criteria, are poorly described regarding symptom constellations, causal patterns, degree of social disability, treatability and prognosis. These so-called subsyndromal disorders probably constitute heterogeneous groups, in which, 10

in certain cases there is a great tendency for self-healing, whereas in other cases there is a major risk of long-term social disability. The PART study provides great opportunities to illuminate such issues.

Illness behaviour Illness behaviour is the ill person's way of managing his/her illness. Illness behaviour is just as important a concept in mental disorders as it is with regard to somatic illness. Illness behaviour is determined by the sociocultural, psychological and situational factors that make people aware of symptoms, the cognitive schemata they use to interpret them, as well as the way in which treatment is made available (organisation, funding etc.) in order to govern treatment-seeking behaviour. The extent to which socio-economic conditions influence illness behaviour and treatment, as well as how this can lead to treatment needs, arising from mental ill health in different groups, being met in varying degrees, is an important but little studied area. During the past decade in Sweden, the patient's freedom to choose treatment has been increasingly emphasised. Psychiatric outpatient care and primary care have been made more and more accessible, as well as psychotherapy (in the cities). The preferences of the population in these matters are, apart from the experiences of the treatment providers, not known. Thus, more information is needed on e.g. attitudes to support from relatives and alternative treatment versus officially recognised treatment, primary care versus specialist psychiatry, national health service versus private treatment, as well as medication versus psychotherapy.

Quality of life The concept of health-focused quality of life in association with somatic illness generally encompasses only the subjective component of well being. With regard to mental ill health it is important to include also the components of social ability and living conditions, partly because they can both later include risk factors for mental ill health as well as its consequences, partly because subjective well-being is to a significant extent a reflection of the degree of depressivity in the individual (Mechanic et al, 1994; Katschnig & Angermeyer, 1997).

Gender aspects There are significant gender differences (Hällström, 1996) in the incidence of the most common mental disorders (depression, anxiety syndromes and alcohol dependence/abuse). Depression, most of the anxiety syndromes as well as eating disturbances are the most common amongst women; alcohol dependence/abuse is most common amongst men. Very little is known about the reasons for these gender differences. There is an association with 11

socio-demographic factors (poor education, low income, unemployment, single status). Unemployment is a known risk factor for, amongst other things, depression in both genders. The degree of gender dominance at the work place appears to play a role for being put on the sick list with a psychiatric diagnosis. For both genders, sick list frequency is highest in groups that are extremely male or female dominated and lowest at work places with an even gender distribution (Hensing et al., 1995). How this association is to be interpreted is increasingly unclear. Conflicting demands, reorganisation and lack of social support at work increase the risk for mental problems (Stansfeld et al., 1995; Niedhammer et al., 1998). Professions that involve management, control and planning probably have an inbuilt protection against depression. Whether or not this is due to the content of the work or underlying factors can be discussed. It can be noted that the association between working conditions and mental ill health has only been studied to a small extent. Quite vague outcome measures, with unclear clinical relevance, have usually been used in the research that has been carried out. The psychosocial work environment, measured as the proportion of the work force engaged in highly stressful work (mentally taxing work in which there is little scope for own decision making), has deteriorated in Sweden since the 1980s, especially for women (Krantz, 1994; Lundberg, 1995). This further emphasises the urgency for further research in this area. The majority of the population studies that illuminate the association between social factors and mental ill health do not have a longitudinal design, which greatly limits the conclusions that can be drawn. Almost all such studies focus upon depression amongst women or alcohol dependence/abuse amongst men, or use various more diffuse indices of mental ill health, the validity of which it is often difficult to interpret. Studies addressing defined anxiety syndromes or eating disturbances are downright rare. In the PART study we shall be able to analyse a number of urgent questions within these areas that concern both genders.

Treatment service interventions Two of the most important issues from a public health perspective are to assess the treatment needs due to mental ill health and to determine the extent of unmet needs. This concerns issues of equality, cost effectiveness and priorities. Uncertainty about the effectiveness of treatment has given rise to controversies about how treatment needs are to be confirmed (Klerman et al., 1992). This has lead to the emphasis being placed on the demand of treatment, i.e. the consumer perspective rather than the need, the latter being the perspective of the treatment provider or professional. Both perspectives must obviously be taken into consideration. 12

The ECA study in the USA showed that only 22 % of individuals with a mental disorder, according to the DSM-lll-R criteria had been treated within psychiatry or primary care during the past year. The percentage was higher, 54 and 64 % respectively, for persons with major depression or schizophrenia (Robins & Regier, 1991). Swedish studies have shown that a third of the patients in primary care with mental ill health received a psychiatric diagnosis (Swartling et al., 1987; Westerling 1988). However, specific information about unmet treatment needs is not available. Without such information it is not possible to make population-based, health economic calculations. However, studies on treatment costs are now beginning to appear (Jönsson & Rosenbaum, 1993).

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References APA: Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Fourth Edition. (1994) Washington, DC: American Psychiatric Association. Bifulco, A., Brown, G.W., Adler, Z. (1991). Early sexual abuse and clinical depression in adult life. Br J Psychiatry, 159, 115-22. Bowlby, J. (1977). The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory. Br J Psychiatry, 130, 201-210. Brown, G., Harris, T. (1978). Social origin of depression: a study of psychiatric disorder in women. London: Tavistock. Cohen, S., Syme, S.L. (1985). Social support and health. Orlando: Academic Press. Cohen, S., Wills, T.A. (1985). Stress, social symtoms and the buffering hypothesis. Psychol Bull, 98, 310-357. Hensing, G., Alexanderson, K., Åkerlind, I., Bjurulf, P. (1995). Sick-leave due to minor psychiatric morbidity: role of sex integration. Soc Psychiatry Psychiatr Epidemiol, 30, 39-43. Hällström, T. (1996). Mental ill-health - gender differences. In Östlin, P., Danielsson, M., Didrichsen, F., Härenstam, A., Lindberg, G., eds. Gender and ill-health: an anthology on gender differences from a public health perspective (in Swedish). Lund; Studentlitteratur. Jönsson, B., Rosenbaum, J., eds. (1993). Health economics of depression. Chichester: Wiley. Katschnig, H., Angermeyer, M.C. (1997). Quality of life in depression. In Katschnig, H. et al, ed. Quality of Life in Mental Disorders. New York: John Wiley & Sons. Klerman, G.L., Olfson, M., Leon, A.C., Weissman, M.M. (1992). Measuring the need for mental health care. Health Affairs, 11, 23-33. Krantz, G. (1994). Health developments for Scandinavian women (in Swedish). Nord Med, 109, 284-287. Lazarus, R.S., Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer Publishing Company. Lundberg, O. (1995). Living conditions among women today. In Women´s (ill-)health, edited by Swedish Medical Association and Swedish Institute for Health Services Development (in Swedish). Stockholm: Spris förlag. Mechanic, D., McAlpine, D., Rosenfield, S., Davis, D. (1994) Effects of illness attribution and depression on the quality of life among persons with serious mental illness. Soc Sci Med, 39, 155-164.

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Mullen, P.E,. Martin, J.L., Anderson, J.C., Romans, S.E,, Herbison, G.P. (1993). Childhood sexual abuse and mental health in adult life. Br J Psychiatry; 163, 721-732. Niedhammer, I., Goldberg, M., Leclerc, A., Bugel, I., David, S. (1998). Psychosocial factors at work and subsequent depressive symptoms in the Gazel cohort. Scand J Work Environ Health, 24, 197-205. Paykel, E.S. (1978). Contribution of life events to causation of psychiatric illness. Psychol Med, 8, 245-253. Robins, L.N., Regier, D.A., eds. (1991). Psychiatric disorders in America: the Epidemiologic Catchment Area study. New York: Free Press. Stansfeld, S.A., North, F.M., White, I., Marmot, M.G. (1995). Work characteristics and psychiatric disorder in civil servants in London. J Epidemiol Community Health, 49, 48-53. Stockholm County Council. (1999). Public health report. On the development of health in the Stockholm County (in Swedish). Stockholm: Stockholm County Council. Swartling, P.G., Kebbon, L., Smedby, B. (1987). Mental health problems in primary health care as seen by doctors. Scand J Prim Health Care, 5, 201204. Tennant, T. (1991). Parental loss in childhood: it´s effect in adult life. In Bebbington, P.E., ed. Social psychiatry. Theory, methodology and practice. New Brunswick: Transaction Publishers. Westerling, R. (1988). Diagnoses associated with the prescription of psychotropic drugs at a Swedish health centre. Scand J Prim Health Care, 6, 93-8. WHO: International statistical classification of diseases and related health problems. 10 th revision. (1992). Geneva: World Health Organization.

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GRANTS Phase l of the PART Study was supported by grants from the Stockholm County Council, Psychiatric Research and Development, Department of Psychiatry at Huddinge University Hospital, Department of Occupational Health at the Stockholm Center of Public Health, Swedish Medical Research Council, Swedish Council for Work Life Research, National Institute of Public Health and Alcohol Research Council of the Swedish Alcohol Retailing Monopoly.

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CHIEF INVESTIGATORS In phase l the chief investigators were Tore Hällström, M.D., PhD., Professor emeritus1,2, Kerstin Damström Thakker, PhD1,3, Yvonne Forsell, M.D., PhD., Associated Professor4,5, and Ingvar Lundberg, M.D., PhD., Professor6,7. 1 NEUROTEC,

Section of Psychiatry, Karolinska Institutet, Stockholm,

Sweden 2

Psychiatric Research and Development, Department of Psychiatry, Huddinge University Hospital, Stockholm, Sweden

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Stockholm Center of Public Health, Department of Alcohol and Drug Prevention, Stockholm, Sweden

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Department of Public Health Sciences, Division of Social Medicine, Karolinska Institutet, Stockholm, Sweden

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Stockholm Center of Public Health, Department of Epidemiology, Psychiatric Epidemiology, Stockholm, Sweden

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Department of Public Health Sciences, Division of Occupational Medicine, Karolinska Institutet, Stockholm, Sweden

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National Institute for Working Life and Health, Department of Work and Health, Stockholm, Sweden

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THE AIMS OF THE PART STUDY •

To describe risk and protective factors for mental ill-health in the adult (20-64 years old) population of the Stockholm County.

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To analyse the association between social, somatic, cognitive and mental ill-health.

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To validate screening instruments for assessment of mental ill-health.

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To analyse factors associated with meetable need of psychiatric, psychological and social services.

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To analyse consequences of mental ill-health.

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To analyse the outcome of both treated and untreated mental ill-health.

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To describe the frequency of the most common axis I psychiatric symptoms and syndromes in the adult population.

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STUDY POPULATION The study population includes 19 742 randomly selected Swedish citizens aged 20-64 years and residing in the Stockholm County in 1998-2000. Potential participants were identified in the Population register of the Stockholm County at five occasions. The samples were of approximately equal size and drawn at regular intervals. To minimise lingual problems only Swedish citizens were included. The age-limits were set since the present study focused on mental health in the wage-earning ages. Since most of the interviews were expected to take place in the premises of the study, people living in some remote municipalities with poor access to public transportation were excluded. In 1998-2000 there were approximately 858 000 inhabitants in the Stockholm County fulfilling the sampling criteria. The PART Study was approved by the Ethical Committee at Karolinska Institutet as being in accordance with ethical standards (Dnr 96-260 and 97-313).

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QUESTIONNAIRE In a pilot study in 1997 the preliminary version of the questionnaire was mailed to 300 randomly selected Swedish citizens aged 20-65 years residing in one of the municipalities in the Stockholm County. After evaluating the results some questions were removed, a few were modified or added and the cut off for one of the screening instruments was modified (see below). It took about one hour to fill in the final version of the questionnaire. The Swedish version of the questionnaire is available from the PART Study Group. For addresses to the members of the PART Study Group, see page 3.

Risk and protective factors for mental ill-health The first part of the questionnaire covered demographic data and circumstances reported to be either risk or protective factors for mental illhealth: -

Own and parents country of birth (Questions A1-A3), family background (A4-A7), marital and housing conditions (section B), education and financial resources (section C).

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Social network, both qualitative and quantitative (section D). From a Swedish modification of the Interview Schedule for Social Interaction (ISSI; Henderson et al, 1980; Undén, Orth-Gomér, 1984) 6 questions on Availability of social integration (AVSI; D1-D4, D8-D9) and 3 questions on Availability of attachment (AVAT; D5-D7) were used.

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Strong feeling of affinity with the area in which the respondent lives (D10) and with his/her family (D11) were included in the Stockholm County Public Health Questionnaire 1998 (Stockholm County Council, 1999a).

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Contacts with official institutions, e.g. medical and social services, the employment agency, the public insurance office and the police as well as satisfaction with services provided (D12).

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Coping strategies when facing problems and difficulties in life (section E). An instrument developed by Aronsson, Strömberg (1993) was used.

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The occurrence of a number of life events during the past 12 months (section F), such as the death of a spouse, a traumatic accident, a child having a serious problem or severe conflict at work. There were also questions on the emotional influence on the respondent of some of these events (F2). Most of these questions have been used in previous Swedish studies (e.g. Theorell et al., 1975).

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There were questions on occupation (G1), socio-economic status at present (G2) and during the past 5 years (G3), unemployment during 20

the past 5 years (G4) and unemployment by a cohabiting person during the past year (G5). Questions G1-G2 and G4-G5 were included in the Stockholm County Public Health Questionnaire 1998 (Stockholm County Council, 1999a) while questions G1 and G3 were used in the EIRA Study (Stolt et al, 2003). Questions G1, G3-G4 are slightly modified versions of the original questions. -

Those who were employed were asked about a broad range of working conditions (section H). Questions on type of employment (H1), doing overtime (H3), feelings of being excluded by managers or colleagues (H10-H11) and notice of redundancy (H14) were included in the Stockholm County Public Health Questionnaire 1998 (Stockholm County Council, 1999a). The question on association between work demand, knowledge and skills (H5) were used in the EIRA Study (Stolt et al, 2003). The questions concerning work demand and control (H6) were developed by Karasek, Theorell (1990) while the questions on workplace social support (H8) were developed by Johnson (1986). The question on occurrence of violence or threats at work (H9) was used in the MUSIC Study (Vingård et al, 2000; Wigaeus et al., 2001). Questions on changing working conditions (H12-H13) were used in a follow-up of the Stockholm County Public Health Study 1994 (Stockholm County Council, 1999b).

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Those who were unemployed were asked about length of unemployment (I1) and last employment (I2), efforts to find a new job (I3) and experiences of being unemployed (I4-I10).

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The question on self-assessed health status (J1) was the same as the one used in e.g. the Stockholm County Public Health Questionnaire 1998 (Stockholm County Council, 1999a).

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The occurrence of a number of common somatic disorders (25 questions) and of psychiatric disorders/mental ill-health (one question). Only disorders treated by a physician or involving hospitalisation were to be considered. Present and previous disorders were to be reported separately (J2).

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Number of days with sickness absence during the past 30 days (J3).

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Medications taken at present. The name of the drug, dosage and reason for taking it was asked for. Use of psychotropic drugs was recorded separately (J4).

Screening instruments The second part of the questionnaire included a scale on psychological well-being and screening instruments for psychiatric symptoms, harmful alcohol use, illicit drug use and social disability due to psychiatric or psychological symptoms. 21

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Psychological well-being during the past week (section K) was assessed with the WHO (Ten) Well-Being Index (Bech et al., 1996) which is based on the WHO (Bradley) Subjective Well-Being Inventory Index (Bradley, 1994). The higher the score the lower the well-being.

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Symptoms of anxiety during the past 30 days (section L) were assessed with a slightly revised version of the Sheehan Patient-Rated (Panic) Anxiety Scale (Sheehan, 1983). Only symptoms covering DSM-lV criteria for panic syndrome were used. Moreover, a question on how anxious the respondent was that the symptoms would recur was added. The full PART instrument (20 questions) was used to screen for any symptoms of anxiety and one of it´s questions was also used to screen specifically for panic attacks.

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Symptoms of social phobia and agoraphobia (section M) were assessed with questions from the avoidance part of an instrument developed by Marks & Matthews (1979). Based on clinical experience and results from the pilot study indicating that they were too unspecific in a population sample four questions were removed. Two of them referred to agoraphobia ("Walking alone in busy streets" and "Going alone far from home") and two to social phobia ("Talking to people in authority" and "Being criticised"). The PART questionnaire thus included 3 of the 5 original questions on both agoraphobia and social phobia as well as the original question concerning avoidance of other situations.

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Symptoms of obsessive-compulsive disorders during the past 30 days (section N) were assessed with 3 screening questions suggested by The Swedish Psychiatric Association & The Swedish Institute for Health Services Development (1997). In accordance with DSM-lV-criteria a question measuring severity of social impairment due to the symptoms was added.

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Depressive symptoms during the past 14 days (section O) were assessed with a slightly modified version of the Major (ICD-10) Depression Inventory, MDI (Bech & Wermuth, 1998). To make the PART scale correspond to the criteria of a major depressive episode in DSM-lV some symptom questions were modified or added: The question "Have you felt either very restless or rather subdued" was divided into two separate questions. The questions "Have you had trouble sleeping at night" and "Have you suffered from reduced appetite" were supplemented by the questions "Have you needed to sleep more than usual" and "Have you had increased appetite or increased in weight recently". When analysing the data the questions on sleep and appetite will be considered in combination. One question was added: "Have you felt as if you wanted to take your life". Moreover, also questions on severity of social impairment due to the symptoms and duration of the symptoms were added. The full PART instrument was used to screen

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for any symptoms of depression while one of the questions was also used to screen specifically for suicidal thoughts. -

Symptoms of eating disorders during the past 30 days (section P) were assessed with an abbreviated version of a case-finding questionnaire developed by Beglin and Fairburn (1992). A question on length was added. Since the pilot study indicated that the questions on use of laxatives and diuretics were too unspecific in a population sample they were excluded.

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The Alcohol Use Disorders Identification Test (AUDIT; section Q) was used to screen for harmful alcohol consumption (Saunders et al., 1993; Bergman et al., 1998). AUDIT was developed by WHO to enable early detection of hazardous and harmful alcohol use in primary health care settings. In PART only those who had drunk at least one glass of alcohol during the past 12 months were asked to answer the AUDIT questions. As a consequence, the question on drinking frequency was coded 1-4, the following 7 questions 0-4 and the last 2 questions 0, 2 and 4. As in the original version the range of the total score on the AUDIT was thus 0-40.

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Use of illicit drugs ever was asked for. When relevant it was also asked when drugs were last used and which types of illicit drugs that had ever been used (section R).

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Social disability due to psychiatric or psychological symptoms during the past 30 days (section S) was assessed with items 2-6 and 7 of the WHO´s Brief Disability Questionnarie (BDQ; Ormel et al, 1999) which is based on WHO's Short Disability Assessment Schedule (WHO DAS-S; Janca et al, 1996). Items 2-6 the BDQ corresponds to the Role Disability scale and item 6 to the number of days the subject had not been able to carry out his/her usual activities.

Screening positive and screening negative respondents A respondent was defined as screening positive for suspected mental disorders if at least one of the following criteria were met: -

Report of psychiatric disorder/mental ill-health at present.

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Report of use of psychotropic drugs at present.

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Being "Extremely" or "Markedly" bothered by at least 6 symptoms of anxiety during the past 30 days.

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Being "Extremely" or "Markedly" bothered by at least one symptom of panic attacks during the past 30 days.

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Symptoms of agoraphobia: "Very often" or "Always" avoiding at least one agoraphobic situation due to fear of anxiety. 23

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Symptoms of social phobia: "Very often" or "Always" avoiding at least one social phobic situation due to fear of anxiety.

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At least one obsessive compulsive symptom and suffering due to this.

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At least 5 symptoms of depression "Most of the time" or "All the time" over the past 2 weeks and disability due to this.

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Suicidal thoughts “Some of the time” or more often over the past 2 weeks. Due to ethical reasons all persons with suicidal thoughts were invited to participate in an interview.

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Symptoms of eating disorders: Preoccupation with food for ≥16 of the past 30 days, feeling guilt about eating more often than every second time and self-induced vomiting during the past 30 days.

-

Symptoms of harmful alcohol consumption: An AUDIT score ≥11 for both men and women. Saunders et al (1993) recommended ≥8 points as cut off in primary care settings. Since a pilot study indicated that the WHO cut off identified a high proportion of cases as being screening positive only because of harmful alcohol consumption it was decided to use a higher and more conservative cut off in this population study of overall mental health.

-

Use of illicit drugs during the past 12 months.

-

"Often" or "More frequently" troubled by at least one symptom of some form of social disability due to psychiatric or psychological problems or unable to perform usual responsibilities due to such symptoms during the past 30 days.

The reliability and validity of the screening instruments will be reported in separate publication.

Response rate When the study population was first contacted they received a letter of introduction, an information brochure, the questionnaire and an envelope with prepaid postage. In the letter it was mentioned that participation was voluntary and confidentiality for information provided was assured. It was also mentioned that some of the respondents might later on be invited to participate in an interview. The non-respondents received up to four reminders, after 2 and 6 weeks by mail and after 4 and 8 weeks by telephone. Persons without known telephone numbers received all four reminders by mail. Totally 10 441 of the 19 742 persons randomly selected for the study participated. Of the respondents 4 643 were men and 5 798 were women (see Table 1). The overall response rate was thus 53 % and it was higher among women than men (58 and 47 % respectively). Participation was 24

higher among 50-64-year old men than among 20-34 and 35-49 year old men (56 and 43-45 % respectively). Also among women was the response rate the highest in the oldest age-group (60 %) but it was only slightly higher than in the two younger age-groups (57-58 %). Table 1: Participation rate by gender and age-group. Per cent (numbers). Men

Participation rate n

Women

20-34 years

Age-group 35-49 50-64 years years

20-34 years

Age-group 35-49 50-64 years Years

Total

Total

44.7%

43.1%

56.1%

47.4%

58.2%

57.0%

60.1%

58.3%

1 620

1 470

1 553

4 643

2 128

1 897

1 773

5 798 N=10 441

After four reminders 28 % of the total study population informed us that they would not participate. Another 18 % never returned the questionnaire and only 1 % had an unknown address. Men were more often than women both active (31 and 25 % respectively) and passive (20 and 15 % respectively) non-responders. The net response rate — considering only persons with a known address — was 54 %, 48 % among men and 59 % among women. Internal non-response was low since respondents who did not answer all questions were again contacted by telephone and asked to give supplementary information.

Attrition analysis for response to the questionnaire Thus, almost half of those selected for the study did not answer the questionnaire despite our efforts to increase the participation. This prompted an evaluation of the importance of the non-participation based on two questions: 1.

Which were the determinants of non-participation and how could they affect estimates of the occurrence of different living conditions and outcomes such as well-being, depressive symptoms and social disability?

2.

To what extent could the non-participation distort relationships found between living conditions and mental ill-health.

In order to answer these questions the entire material was linked to a number of national population registers, i.e. the Register on income and 25

wealth 1998 (for total income in 1998, country of origin and level of education), the Register on sickness allowance 1992-August 2000 (for periods of sickness-allowance lasting more than 14 days), the Hospital discharge register for diagnoses in in-patient care 1987-1998, the Register of diagnoses for granting disability pension 1971-August 2000 and the Census of 1990 (for socio-economic group among those born before 1965). Our analyses yielded the following answers to the two questions: 1.

Male gender, being below 50 years of age, low income, low education and country of birth outside the Nordic countries were strong determinants of non-participation (also in multivariate analysis with all the variables controlled for each other). However, having been treated because of a primary diagnosis of psychosis — but not being treated because of other primary psychiatric diagnoses — remained as a determinant in multivariate analyses (controlling for all other variables). A disability pension granted because of any of the primary psychiatric diagnoses combined remained as a significant determinant in multivariate analyses while primary somatic diagnoses combined did not.

2.

Odds ratios for all psychiatric diagnoses combined, for psychosis, for substance use disorders or for all other psychiatric diagnoses than psychosis or substance use disorders were remarkably similar among participants and non-participants when related to gender, age, income, education, country of birth, number of days with sickness-allowance or socio-economic group.

Thus, there are two main conclusions: First, it is highly probable that prevalences of psychiatric disorders combined based only on participants in psychiatric epidemiological studies will be marked underestimations. Secondly, that it is also highly probable that relationships between living conditions and psychiatric disorders will be depicted rather correctly. A separate publication on the analysis of non-participation is under way (Lundberg, et al).

26

References Aronsson, G., Strömberg, A. (1993). Coping with malfunctions of computer aided equipment from a stress perspective. In Smith MJ, Salvendy G (Eds.) Human-computer interaction: Applications and case studies (pp 804808). Amsterdam: Elsevier. Bech, P., Gudex, C., Staehr Johansen, K. (1996). The WHO (Ten) Well-Being Index: Validation in Diabetes. Psychother Psychosom, 65, 183-190. Bech, P., Wermuth, L. (1998). Applicability and validity of the Major Depression Inventory in patients with Parkinson´s disease. Nord J Psychiatry, 52, 305-309. Beglin, S. J., Fairburn, C. G. (1992). Evaluation of a new instrument for the detection of eating disorders in community samples. Psychiatry Research, 44, 191-201. Bergman, H., Källmén, H., Rydberg, U., Sandahl, C. (1998). A 10-item questionnaire identifying alcohol problems (in Swedish). Läkartidningen, 95, 4731-4735. Bradley, C. (1994). The Well-Being Questionnaire. In Bradley C, ed. Handbook of Psychology and Diabetes (pp 89-109). Amsterdam: Harwood Academic Publishers. Henderson, S., Duncan-Jones, P., Byrne, D. (1980). Measuring social relationships. The interview schedule for social interaction. Psychol Med, 10, 723-734. Janca, A., Kastrup, M., Katschnig, H., Lopez-Ibor, J. J., Mezzich, J. E., Sartorius, N. (1996). The World Health Organization Short Disability Assessment Schedule (WHO DAS-S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders. Soc Psychiatry Psychiatr Epidemiol, 31, 6, 349-354. Johnson, J. (1986). The impact of workplace social support, job demands and work control upon cardiovascular disease in Sweden. Stockholm: Department of Psychology, University of Stockholm. Dissertation. Karasek, R., Theorell, T. (1990). Healthy work. Stress, productivity and the reconstruction of working life. New York: Basic Books. Marks, I. M., Mathews, A. M. (1979). Brief standard self-rating for phobic patients. Behav Res Therapy, 17, 263-267. Ormel, J., Vonkorff, M., Oldehinkel, A.J., Simon, G., Tiemens, B.G., Üstün T.B. (1999). Onset of disability in depressed and non-depressed primary care patients. Psychological Medicine, 29, 847-853.

27

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption — ll. Addiction, 88, 791-804. Sheehan, D. V. (1983). The anxiety disease (pp 124-129). New York: Charles Scribners Sons. Stockholm County Council. (1999 a). Public health report. On the development of health in the Stockholm County (in Swedish). Stockholm: Stockholm County Council. Stockholm County Council. (1999 b). Report on working related health. On the association between working conditions and ill-health in the Stockholm County (in Swedish). Stockholm: Stockholm County Council. Stolt, P., Bengtsson, C., Nordmark, B., Lindblad, S., Lundberg, I., Klareskog, L., Alfredsson, L., EIRA Study Group. (2003). Quantification of the influence of cigarette smoking on rheumatoid arthritis: results from a population based case-control study, using incident cases. Ann Rheum Dis, 62, 835-841. Swedish Psychiatric Association and Swedish Institute for Health Services Development. (1997). Anxiety syndromes — clinical guidelines for assessment and treatment (pp 28; in Swedish). Stockholm: Spris förlag. Theorell, T., Lind, E., Flodérus, B. (1975). The relationship of disturbing lifechanges and emotions to the early development of myocardial infarction and other serious illnesses. Int J Epidemiol, 4, 281-293. Undén, A-L., Orth-Gomér, K. (1984). Social support and health. Report No. 2. Development of a survey method to measure social support in population studies (in Swedish). Stress Research Report No. 178, Karolinska Institute. Vingård, E., Alfredsson, L., Hagberg, M., Kilbom, Å., Theorell, T., Waldenström, M., Wigaeus-Hjelm, E., Wiktorin, C., Hogstedt, C., and the MUSIC — Norrtälje Study Group. (2000). To what extent do current and past physical and psychosocial occupational factors explain careseeking for low back pain in a working population - results from the musculoskeletal intervention center — Norrtälje Study? Spine, 25, 493500. Wigaeus Tornqvist, E., Kilbom, Å., Vingård, E., Alfredsson, L., Hagberg, M., Theorell, T., Waldenström, M., Wiktorin, C., Hogstedt, C, and the MUSIC — Norrtälje Study Group. (2001).The influence of seeking care due to neck and shoulder disorders from work-related exposure among men and women in a Swedish general population — results from the MUSIC — Norrtälje Study. Epidemiology, 12, 537-545.

28

PSYCHIATRIC INTERVIEW Random samples of both screening positive and screening negative participants were invited to the psychiatric interview. Altogether 1 093 participants were interviewed, 884 who were screening positive (27 % of all screening positive respondents; 60 % women) and 209 who were screening negative (49 % women). Table 2: Proportion of interviewees who were screening positive by gender and agegroup. Per cent (numbers). Men 20-34 years Screening positive 78.4% interviewees n 109

Women

Age-group 35-49 50-64 Years years

Total

20-34 years

Age-group 35-49 50-64 years Years

Total

79.1%

73.8%

76.9%

84.9%

82.2%

84.1%

83.8%

117

124

350

197

152

185

534 N=1 093

Among both men and women approximately 1/10 of the respondents were interviewed. Table 3: Proportion of participants interviewed by gender and age-group. Per cent (numbers). Men 20-34 years Respondents 8.6% interviewed n 139

Women


20-34 years


Total

Total

10.1%

10.8%

9.8%

10.9%

9.8%

12.5%

11.0%

148

168

455

232

185

221

638 N=10 441

The instrument used was Schedules for Clinical Assessment in Neuropsychiatry (SCAN, version 2.1, 1998) which is a semi-structured clinical interview schedule designed for clinician´s assessment of the symptoms and course of adult mental disorders. SCAN was developed from the Present State Examination (PSE) by Wing et al (1977) and later revised by the World Health Organisation (Wing et al., 1990). Part l contains sections concerned with worries, anxiety and depressive symptoms, eating and substance abuse disorders and a screening module 29

for part ll. Part ll contains psychotic symptoms and was only performed if the screening module was positive. The period for which symptoms was rated in SCAN was the past 30 days though for substance abuse disorders the entire past year was considered. All interviewers were clinically experienced, most of them were psychiatrists and one was a psychologist. All interviewers had an initial one-week introductory course in the use of SCAN led by one of the WHO designated trainers. Later on they also had regular supervision by an assistant professor in psychiatry with a long experience of tutoring. Interrater reliability was tested using videotaped interviews. Two of the interviewers become designated WHO-trainers. The interview took 1.5-3 hours and almost all interviews were performed in the premises of the study. No treatment was offered but to those interested information was given of available treatment services.

Attrition analysis for participation in the psychiatric interview The same data from official registers that were used for the attrition analysis for response to the questionnaire were used in an analysis for participation in the psychiatric interview. No statistically significant differences were found between those randomly selected for interview who participated and those who did not participate.

Diagnoses DSM-IV diagnostic criteria for Axis I disorders were strictly followed and diagnoses according to appendix B, criteria sets and axes provided for further study were included (APA, 1994). Diagnoses were first made by the interviewer and then by a senior psychiatrist. In case of disagreement the senior psychiatrist had the final word. The SCAN algorithm was used but diagnoses was also allowed for persons having an ongoing successful treatment and appendix B diagnoses. The following diagnoses were made: -

Anxiety: Panic syndrome with agoraphobia 300.21, Agoraphobia without panic syndrome 300.22, Social phobia 300.23, Obsessive compulsive disorder 300.3, Panic syndrome without agoraphobia 300.01, Anxiety syndrome due to somatic cause 293.89, Specific phobia 300.29, Posttraumatic stress syndrome 309.81, General anxiety disorder 330.02, Acute stress syndrome 308.3.

-

Depressive disorders: Major depression 292.x, Dysthymia 300.4, Bipolar syndromes 296.

30

-

Sleep disorders: Night mare disorders 307.47, Primary hypersomnia 307.44, Primary insomnia 307.42.

-

Alcohol use disorders: Alcohol dependence 303.90x and Alcohol abuse 305.00.

-

Substance use disorders other than alcohol use disorders: Abuse of cannabis (305.20), amphetamine (305.70), hallucinogenes (305.30), opiates (305.50) and sedatives (305.40); Dependence of cannabis (304.30), amphetamine (304.40), cocain (304.20), opiates (304.00) and sedatives (304.10).

-

Others: Undifferentiated Somatoform disorder 300.81, Sexual disorders UNS 302.70, Adjustment disorder 309.9, Buliminia 307.1.

-

Appendix B diagnoses: Mixed Anxiety-depressive disorder and Minor depression.

The prevalences of mental disorders will be reported in separate publication.

Treatment need The participants were asked about present and previous use of treatment due to psychiatric symptoms. They were also asked to specify type of treatment provider and the current use of psychotropic drugs. Moreover, they were asked about preference of treatment for psychiatric problems (Mangen, Brewin, 1991; Thornicroft et al., 1992). Meetable need of treatment was assessed both by the interviewer and the participant. Both of them were also to state whether the observed need of care was satisfied by the treatment provided. In both cases a four-degree scale was used (Yes, absolutely; Yes, probably; Probably not and Absolutely not). Both the interviewer and the participant also assessed the presence of significant psychiatric problems. Also in this case a four-degree scale was used (Yes, absolutely; Yes, probably; Probably not and Absolutely not). There were also two open-ended questions concerning possible reasons for not seeking treatment for psychiatric problems and on the use of self-care strategies when experiencing psychological distress.

Blood samples Altogether 958 of the 1 093 interviewees agreed to provide a fingertip blood sample. Genetical analyses will be performed at a later time. Before these analyses can be made ethical approval is required. 31

Cognitive tests The following cognitive tests were used: -

Episodic memory: The episodic information to-be-remembered consisted of 32 words. The words belonged to 8 taxonomic categories (e.g., vehicles, toys, kitchen utensils) with four subordinates each (e.g., train, doll, spoon). The items used were highly typical of their category, according to norms established by Nilsson (1973). Subjects were instructed to remember as many words as possible but were not informed about the possibility to organize the words.

-

Verbal fluency: The Word Association Test was used as a test of letter fluency (Benton, Hamsher, 1989). The test consists of three wordfinding trials, using the letters F, A, and S. The subjects were instructed to produce as many words as possible in one minute, beginning with each of the target letters.

-

Perceptual-motor speed: The trail-making test was used to assess perceptual motor speed (Reitan, 1959; Reitan, Davidson, 1974). The test was given in two parts, A and B. For both parts, subjects were presented with a white sheet of paper on which circles were distributed. In part A, the circles were numbered from 1 to 25 and participants were asked to draw lines to connect the 25 circles in correct order (i.e., 1-2-3...25). In part B, the circles contained numbers from 1 to 13 and letters from A to L. The subjects were instructed to connect the consecutively numbered and alphabetically lettered circles, by alternating between the two sequences (i.e., 1-A-2-B....L-13). In both tests, subjects were told to connect the circles as fast as they could. The first error observed was immediately pointed out by the examiner, and the subject was required to correct the error. Thereafter the subject could continue in the proper sequence. From the second error onward the subject was not corrected and performance time was unlimited. For both parts, accuracy scores and completion time were recorded by the examiner.

The cognitive test battery was administered by trained co-workers at the data collection center for the PART-study. The test battery was always administered before the SCAN-interview. All participants were tested individually in one session that took approximately 25 minutes to complete. The test session started with a questionnaire concerning health status. The examiner gathered information regarding sensory functioning (vision and hearing), neurological diseases, migraine, sleep apnea, concussion of the brain, epilepsy, meningitis, and tick born encephalitis (TBE). Information regarding drug intake and mother tongue was also collected.

32

This was followed by the verbal fluency test (FAS). After completion of this test, the participants were presented with the episodic memory test. The examiner read the entire list of 32 words aloud at the rate of one word every 3-sec. Following presentation of the last item in the list, participants received an immediate free recall test. Participants recalled orally during a period of 3 minutes. The examiner recorded each subjects unique recall order verbatim. This task was followed by a cued recall test. In this test, the 8 taxonomic names were provided as retrieval cues. The examiner read each category name aloud, one by one, and subjects were asked to recall as many words as possible belonging to each category. Twenty seconds per category were allowed and the responses were recorded by the examiner. Finally the perceptual-motor speed tests (TMT-A and TMT-B) were administered. Four different test orders were created and approximately 250 subjects were randomly assigned to each presentation order. In addition, for the episodic memory task four different and scrambled orders of the 32 nouns were prepared, yielding four unique word lists, which were counterbalanced across test order. The category names provided in the cued recall test were presented in two different orders and counterbalanced across test order as well. Free text was allowed at the end of the form. The interviewer wrote down additional information.

References APA: Diagnostic and Statistical Manual of Mental Disorders, DSM-IV. Fourth Edition. (1994) Washington, DC: American Psychiatric Association. Benton, L., Hamsher, K. D. (1989). Multilingual Aphasia Examination. Iowa City, Iowa: AJA Associates. Mangen, S., Brewin, C. R. (1991).The measurement of need. In Bebbington, P. E., ed. Social Psychiatry. Theory, methodology and practice. New Brunswick: Transaction Publishers. Nilsson, L-G. (1973). Category norms for verbal material (Technical Report No135) Uppsala: University of Uppsala, Department of Psychology. Reitan, R. M. (1959). Manual for Administration of Neuropsychological Test Batteries for Adults and Children. .. Indianapolis, Indiana. Reitan, R. M., Davidson, L. A. (1974). Clinical neuropsychology: Current Status and Applications. New York: John Wiley. Thornicroft, G., Brewin, C. R., Wing, J., eds. (1992). Measuring mental health needs. London: Gaskell.

33

Wing, J. K., Babor, T., Brugha, T., Burke, J., Cooper, J. E., Giel, R., Jablenski, A., Regier, D., Sartorius, N. (1990). SCAN. Schedules for Clinical Assessment in Neuropsychiatry. Arch Gen Psychiatry, 47, 6, 589-593. Wing, J. K., Nixon, J. M., Mann, S. A., Leff, J. P. (1977). Reliability of the PSE (ninth edition) used in a population study. Psychological Medicine, 7, 3, 505-516.

34

CHARACTERISTICS OF THE PARTICIPANTS BASED ON DATA FROM THE QUESTIONNAIRE AND THE INTERVIEWS On the basis of responses to the questionnaire some of the background characteristics of the participants are presented in Appendix 1. Data are reported on both their own and their parents country of birth (Tables 1-2), their present family situation (Tables 3-4), education and financial situation (Tables 5-7) and occupation and socio-economic status (Tables 8-9). Data are also presented on their health status (Tables 10-11) and their contacts with the medical services and satisfaction with treatment provided (Tables 12-13). In Appendix 2 the proportions of screeening positive cases according to each of the screening instruments used in the questionnaire (Tables 14-26) as well as according to all the screening instruments combined (Table 27) are presented. In Appendix 3 previous medical treatment for mental health problems (Tables 28-30) as well as preferences for different kinds of treatment and confidence in the ability of the medical profession to provide help for mental health problems (Tables 31-33) are reported. Finally, assessments by both interviewees and the interviewers on treatment need and whether treatment need has essentially been met is presented (Tables 34-37). All tables are presented by gender and age-group.

35

Appendix 1: Data from the questionnaire: Background characteristics of the participants Data are reported on the following background characteristics of the participants: Both the participants and their parents country of birth (Tables 1-2). Present family situation (Tables 3-4), education and financial situation (Tables 5-7), occupation and socio-economic status (Tables 8-9). Self-reported health status (Tables 10-11). Contacts with the medical services and satisfaction with treatment provided (Tables 12-13). In the title of each table both the section and number within the section of each variable in the questionnaire is presented. As an illustration: A1 in table 1 refers to section A and question 1 in the questionnaire.

Table 1/A1: Respondents born outside Sweden, by gender and age-group. Per cent (numbers).

20-34 years

Men Age-group 35-49 50-64 years years

7.8 (126)

12.5 (184)

11.9 (184)

Total

20-34 years

Women Age-group 35-49 50-64 years years

10.7 (494)

7.4 (158)

13.8 (262)

11.6 (206)

Total 10.8 (626)

N=10 431 Missing=10

Table 2/A3a-c: Respondents with parents born outside Sweden, by gender and age-group. Per cent (numbers). Men

Women

Age-group

Age-group

20-34 years

35-49 years

50-64 years

Total

20-34 years

35-49 years

50-64 years

Total

18.4 (293)

14.2 (205)

6.0 (91)

13.0 (589)

16.2 (337)

16.5 (307)

5.7 (99)

13.1 (743)

N=10 205 Missing=236

36

Table 3/B1: Respondents having children of their own, by gender and age-group. Per cent (numbers).

20-34 years


24.0 (388)

72.4 84.7 59.6 (1 062) (1 311) (2 761)

Total

20-34 years


32.9 (699)

81.7 87.7 65.6 (1 546) (1 548) (3 793)

Total

N=10 413 Missing=28

Table 4/ B2: Respondents living together with other adult/adults, by gender and age-group. Per cent (numbers).

20-34 years


No

36.1 (582)

25.8 (378)

Yes, with partner or husband/wife

50.5 (815)

Yes, with other (s)

13.4 (217)

20.4 (317)

Total

20-34 years


27.6 (1 277)

31.1 (659)

28.6 (541)

32.0 (566)

Total 30.6 (1 766)

71.1 76.9 65.9 58.5 68.5 65.8 64 (1 041) (1 194) (3 050) (1 239) (1 294) (1 164) (3 697) 3.1 (45)

2.6 (41)

6.6 (303)

10.4 (221)

2.9 (55)

2.3 (40)

5.5 (316) N=10 409 Missing=32

37

Table 5/C1: Respondents' highest completed level of education, by gender and age-group. Per cent (numbers).

20-34 years


Total

20-34 years


1-9 years of education

23.4 (379)

28.0 (410)

41.0 (640)

30.9 (1 429)

18.4 (390)

26.5 (502)

46.4 (819)

29.6 (1 711)

10-12 years of education

39.0 (631)

24.5 (359)

12.0 (186)

25.4 (1 176)

39.0 (828)

21.7 (410)

8.5 (150)

24.0 (1 388)

13 years or more of education

36.7 (594)

45,3 (664)

43.9 (679)

41.8 (1 937)

41.8 (887)

50.1 (947)

42.7 (753)

44.8 (2 587)

Total

N =10 409 Missing=32

Table 6/C2: Total annual income before tax and subsidies in the respondents' household, by gender and age group. Per cent (numbers).

20-34 years


Total

20-34 years


Total

Less than 100 00 SCr

14.2 (229)

4.3 (63)

2.6 (40)

7.2 (332)

14.7 (310)

4.4 (83)

3.6 (64)

7.9 (457)

100 000–149 000 SCr

6.8 (109)

4.6 (68)

4.1 (64)

5.2 (241)

9.5 (202)

7.5 (141)

7.5 (132)

8.2 (475)

150 000–199 000 SCr

12.4 (200)

8.2 (120)

7.8 (120)

9.5 (440)

16.0 (338)

11.1 (210)

12.2 (214)

13.2 (762)

200 000–299 000 SCr

21.9 (354)

18.2 (267)

19.6 (303)

20.0 (924)

18.8 (398)

21.7 (409)

23.1 (406)

21.1 (1 213)

More than 300 000 SCr

44.7 (722)

64.6 (946)

41.0 (868)

55.4 (1 046)

53.5 (940)

49.5 (2 854)

65.9 58.1 (1 020) (2 690)

N=10 386 Missing=55

38

Table 7/C3: Respondents abel to obtain 14 000 SCr within a week in case of an unforeseen and sudden situation, by gender and age-group. Per cent (numbers).

20-34 years


Yes, definitely

64.1 (1 038)

65.1 (955)

Yes, probably

23.0 (373)

20.5 (301)

12.3 (190)

18.6 (864)

29.4 (624)

24.9 (472)

17.1 (303)

24.2 (1 399)

No, probably not

8.3 (135)

7.8 (115)

4.7 (73)

7.0 (323)

11.7 (248)

9.1 (173)

6.2 (109)

9.2 (530)

No

4.5 (73)

6.5 (96)

4.0 (62)

5.0 (231)

7.9 (168)

9.3 (176)

7.1 (125)

8.1 (469)

Total

20-34 years


Total

79.0 69.4 51.0 56.6 69.7 58.6 (1 226) (3 219) (1 083) (1 071) (1 234) (3 388)

N=10 423 Missing=18

39

Table 8/G1: Respondents´ present occupation*, by gender and age-group. Per cent (numbers).

Employment Full-time Part-time Self-employed Full-time Part-time Leave of absence ** Full-time Part-time Student Full-time Part-time Unemployment Full-time Part-time Labour market measures Full time

Men Age-group 20-34 35-49 50-64 years years years 66.4 72.2 60.6 (1 077) (1 060) (940) 8.4 5.4 4.9 (136) (80) (76) 7.0 15.9 15.2 (113) (233) (235) 4.7 6.2 5.6 (76) (91) (87) 1.8 0.9 0.1 (29) (13) (2) 0.5 0.7 0.3 (8) (11) (5) 16.8 1.9 0.3 (273) (28) (4) 4.8 1.8 1.2 (78) (26) (18) 3.6 4.8 4.8 (58) (71) (74) 0.8 1.4 0.8 (13) (20) (13) 1.0 (16) 0.4 (6) 0.6 (9) 0.1 (2)

Women Age-group Total 20-34 35-49 50-64 years years years 66.3 55.4 56.8 56.4 (3 077) (1 175) (1 075) (998) 6.3 16.5 23.7 15.9 (294) (351) (449) (282) 12.5 3.2 5.5 4.7 (581) (68) (105) (84) 5.5 2.5 5.8 3.8 (256) (53) (110) (67) 0.9 10.3 4.1 0.7 (44) (219) (78) (13) 0.6 1.7 2.0 0.5 (26) (37) (38) (9) 6.6 19.4 4.0 0.6 (305) (412) (75) (10) 2.7 4.3 4.3 0.8 (124) (92) (81) (14) 4.4 3.9 4.0 3.4 (203) (82) (76) (60) 1.0 1.4 1.5 1.1 (48) (30) (29) (19)

Total 56.1 (3 248) 18.7 (1 084) 4.4 (257) 4.0 (232) 5.4 (310) 1.5 (86) 8.6 (497) 3.3 (189) 3.8 (218) 1.4 (80)

1.7 1.6 1.4 1.0 1.0 0.5 0.9 (25) (25) (66) (22) (19) (9) (50) 0.6 0.4 0.5 0.2 0.7 0.6 0.5 Part-time (9) (6) (23) (4) (14) (10) (30) Disability pension 1.9 7.7 3.4 0.5 2.0 9.3 3.7 Full-time (28) (119) (156) (11) (38) (164) (213) 1.0 2.3 1.2 0.1 2.0 4.2 2.0 Part-time (14) (36) (54) (2) (38) (75) (117) Old age pension 0.1 6.1 2.1 5.7 1.8 Full-time (1) (94) (97) (101) (102) 0.3 0.4 0.3 0.4 0.9 0.4 Part-time (4) (6) (12) (7) (16) (24) Sick leave*** 0.7 1.8 2.8 1.8 1.7 3.1 3.8 2.8 Full-time (12) (26) (44) (84) (36) (59) (68) (163) 0.1 1.0 1.1 0.8 0.6 1.7 2.2 1.5 Part-time (2) (15) (17) (36) (13) (32) (39) (84) Other 1.7 0.7 2.5 1.6 2.4 2.3 3.6 2.7 Full-time (27) (10) (38) (75) (51) (43) (63) (157) 2.1 1.8 1.4 1.8 2.2 2.3 1.6 2.1 Part-time (33) (27) (22) (84) (46) (44) (29) (120) * Respondents could report several alternatives N=10 423 ** Including respondents on maternity/paternity leave or on leave for studies Missing=18 *** Since more than 30 days

40

Table 9/G2: Respondents´ socio-economic status (SEI), by gender and age-group. Per cent (numbers).*. **

Unskilled and semiskilled workers Skilled workers

20-34 years 15.4 (193) 13.5 (169) 12.2 (153) 24.6 (309)

Men Age-group 35-49 50-64 years years 11.6 9.2 (153) (115) 8.8 7.9 (116) (99) 9.4 8.4 (124) (105) 21.0 20.4 (277) (254)

Total 12.1 (461) 10.0 (384) 10.0 (382) 22.0 (840)

20-34 years 20.3 (312) 6.4 (99) 21.6 (333) 28.6 (441)

Assistant non-manual workers Intermediate non-manual employees Employed and self-employed professionals, higher civil 27.0 36.1 39.8 34.3 19.1 servants and executives (338) (477) (496) (1 311) (294) Self-employed (others than 7.3 13.2 14.2 11.6 4.0 professionals) (92) (174) (177) (443) (61) * If respondents are employed, self-employed or on leave of absence, full or part time according to Table 8/G1. ** If a respondent have more than one occupation, the main occupation is taken into account.

Women Age-group 35-49 50-64 years years 11.0 10.9 (178) (148) 5.3 3.8 (86) (51) 19.9 23.3 (321) (316) 31.3 29.7 (504) (404) 26.2 (422) 6.3 (101)

Total 14.1 (638) 5.2 (236) 21.5 (970) 29.9 (1 349)

26.8 (364) 5.5 (75)

23.9 (1 080) 5.3 (237) N=8 331 Missing=430

Table 10/J1: Respondents’ self-assessed present health, by gender and age-group. Per cent (numbers).

Very good Rather good Neither good nor bad Rather poor Very poor

20-34 years 38.5 (618) 46.6 (749) 10.1 (163) 4.0 (64) 0.7 (12)

Men Age-group 35-49 50-64 years years 31.3 32.6 (456) (499) 47.4 43.3 (690) (662) 13.7 14.8 (199) (227) 6.3 7.5 (92) (115) 1.3 1.8 (19) (27)

41

Total 34.3 (1 573) 45.8 (2 102) 12.8 (589) 5.9 (271) 1.3 (58)

20-34 years 35.4 (741) 45.8 (959) 12.4 (262) 5.4 (113) 1.0 (21)

Women Age-group 35-49 50-64 years years 30.1 26.4 (564) (458) 47.1 46.5 (883) (807) 13.7 15.7 (257) (273) 7.8 9.5 (147) (165) 1.3 2.0 (24) (34)

Total

30.9 (1 763) 46.4 (2 649) 13.9 (792) 7.4 (425) 1.4 (79) N=10 300 Missing=141

Table 11/J3: Respondents being on sick leave full-time or parttime during the last 30 days, by gender and age-group. Per cent (numbers).

20-34 years


11.1 (179)

12.5 (182)

10.1 (155)

Total

20-34 years


11.2 (516)

14.2 (300)

17.0 (320)

15.9 (279)

Total 15.6 (899)

N=10 363 Missing=78

Table 12/D12-1a: Respondents who had contact with the medical services during the last 12 months, by gender and age-group. Per cent (numbers).

20-34 years


Total

20-34 years


Total

67.9 68.3 69.2 68.4 84.9 82.6 83.1 83.6 (1 097) (1 000) (1 074) (3 171) (1 801) (1 564) (1 471) (4 836) N=10 419 Missing=23

Table 13/D12-1b: Respondents´ satisfaction with treatment provided by the medical services, by gender and age group. Per cent (numbers).

20-34 years


I got the information, support or help I needed

72.0 (778)

76.4 (757)

85.2 (897)

I got some information, support or help

26.1 (282)

21.6 (214)

14.1 (148)

20.6 (644)

27.8 (497)

22.4 (347)

18.9 (273)

23.4 (1 117)

I did not get any information, support or help

1.9 (20)

2. (20)

0.8 (8)

1.5 (48)

2.2 (39)

1.4 (22)

1.0 (14)

1.6 (75)

Total

20-34 years


Total

77,8 70.0 76.2 80.1 75.1 (2 438) (1 252) (1 180) (1 157) (3 591)

N=7 905 Missing=102

42

Appendix 2: Data from the questionnaire: Outcome of the screening instruments Data from the questionnaire on the proportion of screeening positive cases according to each of the screening instruments used in the questionnaire (Tables 14-26) as well as according to all the screening instruments combined (Table 27) are presented below. In the title of each table both the section - and when relevant, the number of the question within the section — of each screening scale is presented. As an illustration: J2 in table 14 refers to section J and question 2 while L in table 16 refers to the entire section L which is the screening scale for symptoms of anxiety. Table 14/J2: Respondents reporting being treated by a doctor or in hospital for psychiatric disorders or mental health problems at present, by gender and age-group. Per cent (numbers).

20-34 years 2.2 (35) *

Men Age-group 35-49 50-64 years years 3.8 (56)

3.8 (59)

Total

20-34 years

3.2 (150)

3.2 (68)

Women Age-group 35-49 50-64 years years 4.7 (89)

3.8 (59)

Only affirmative answers were recorded. Internal non-response is thus unknown.

Total 4.6 (267) N=10 441*

Table 15/J4: Respondents reporting using psychotropic drugs at present, by gender and age-group. Per cent (numbers).

20-34 years 3.1 (50) *


8.1 (126)

Total

20-34 years

5.1 (237)

3.7 (79)

Only affirmative answers were recorded. Internal non-response is thus unknown.

43


12.4 (220)

Total 7.1 (411) N=10 441*

Table 16/L: Respondents with symptoms of anxiety, by gender and age-group. Per cent (numbers).

20-34 years ≥6 symptoms

1.9 (30)


3.0 (46)

Total

20-34 years

2.8 (131)

4.5 (96)


5.1 (91)

Total 4.7 (269)

N=10 377 Missing=64

Table 17/L17: Respondents with sudden and unexpected attacks of intense worries or panic, by gender and age group. Per cent (numbers).

20-34 years ≥ 1 symptom

2.0 (33)


3.4 (52)

Total

20-34 years

3.2 (147)

5.1 (108)


3.8 (67)

Total 4.4 (252)

N=10 397 Missing=44

Table 18/ M1-3: Respondents with agoraphobic symptoms, by gender and age-group. Per cent (numbers).

20-34 years ≥1 symptom

0.9 (14)


1.4 (22)

Total

20-34 years

1.1 (49)

0.7 (14)


2.2 (39)

Total 1.6 (92)

N=10 366 Missing=75

44

Table 19/M4-6: Respondents with symptoms of social phobia, by gender and age-group. Per cent (numbers).


1.6 (26)


1.2 (18)

Total

20-34 years

1.5 (68)

2.0 (42)


2.2 (38)

Total 2.0 (116)

N=10 382 Missing=59

Table 20/N: Respondents with symptoms of obsessive compulsive character, by gender and age-group. Per cent (numbers).


6.0 (97)


3.9 (61)

Total

20-34 years


5.5 (254)

6.7 (143)

6.8 (129)

6.0 (107)

Total 6.5 (379)

N=10 412 Missing =29

Table 21/O: Respondents with symptoms of depression, by gender and age-group. Per cent (numbers).

20-34 years ≥5 symptoms

3.5 (57)


4.0 (62)

Total

20-34 years


4.1 (188)

6.5 (137)

7.0 (132)

6.4 (114)

Total 6.6 (383)

N=10 418 Missing=23

45

Table 22/ O7: Respondents with suicidal thoughts, by gender and age-group. Per cent (numbers).

20-34 years 4.7 (76)


4.2 (65)

Total

20-34 years

4.5 (208)

5.6 (118)


5.0 (88)

Total 5.2 (300)

N=10 406 Missing=35

Table 23/P: Respondents with symptoms of eating disturbances, by gender and age-group. Per cent (numbers).

20-34 years 3.3 (53)


3.7 (58)

Total

20-34 years


3.7 (173)

14.3 (304)

11.8 (223)

9.5 (168)

Total 12.0 (695)

N=10 403 Missing=38

Table 24/Q: Respondents with symptoms of harmful alcohol consumption, by gender and age-group. Per cent (numbers).

AUDIT score ≥11

20-34 years


16.4 (264)

9.7 (141)

9.1 (140)

Total

20-34 years

11.8 (545)

4.5 (95)


2.5 (45)

Total 3.6 (206)

N=10 390 Missing=51

46

Table 25/ R: Respondents reporting use of illicit drugs during the last 12 months, by gender and age-group. Per cent (numbers).

20-34 years 7.9 (128)


0.4 (6)

Total

20-34 years

3.6 (166)

4.2 (90)


0.2 (3)

Total 1.8 (102)

N=10 395 Missing=46

Table 26/ S: Respondents with symptoms of social disability due to psychiatric or psychological problems, by gender and age-group. Per cent (numbers).

≥1 symptom

20-34 years


13.0 (209)

14.1 (205)

12.6 (194)

Total

20-34 years


13.2 (608)

19.6 (413)

17.8 (334)

16.8 (295)

Total 18.1 (1 042)

N=10 352 Missing=89

Table 27: Respondents who were screening positive for some type of psychiatríc disorders, by gender and age-group. Per cent (numbers).

20-34 years


35.2 (560)

30.0 (434)

27.5 (418)

Total

20-34 years


31.0 (1 412)

40.2 (834)

35.6 (662)

35.1 (613)

Total 37.1 (2 109)

N=10 243 Missing=198

47

Appendix 3: Data from the interviews: Previous treatment and treatment need for mental health problems Data on previous medical treatment for mental health problems (Tables 28-30), preferences for different kinds of treatment and confidence in the ability of the medical profession to provide help for mental health problems (Tables 31-33) are reported. Also assessments by both interviewees and the interviewers of treatment need and whether treatment need has essentially been met is presented (Tables 34-37). In the title of each table the number of each variable in the questionnaire on treatment contacts and treatment need — which was filled in by the interviewer during the interview — is reported. As an illustration: v1 in table 28 refers to question 1 in the questionnaire. Table 28/v1: Interviewees who have received medical treatment for mental health problems, by gender and age-group. Numbers.

20-34 years


Total

20-34 years


Total

During the last 3 months

21

27

28

76

43

39

65

147

Earlier

21

46

48

115

74

68

81

223

N=1 068 Missing=25

Table 29/v2-8a: Interviewees who have been treated for mental health problems during the last 3 months by kind of medical professional providing treatment, by gender and age-group. Numbers.

20-34 years


Total

20-34 years


Total

Psychiatrist

7

14

15

36

13

16

25

54

Psychologist/ psychotherapist

8

7

4

19

24

15

19

58

General practitioner

5

7

10

22

6

10

24

40

2

5

4

11

7

8

13

28

Other medical/ psychological treatment

N=221-226

48

Table 30/v2-8b: Interviewees who have been treated for mental health problems more than 3 months ago by kind of medical professional providing treatment, by gender and age-group. Numbers.

20-34 years


Total

20-34 years


Total

Psychiatrist

17

32

48

97

34

47

78

159

Psychologist/ Psychotherapist

21

32

25

78

73

64

74

211

General practitioner

7

26

23

56

23

33

60

116

6

15

13

34

13

19

29

61

Other medical/ psychological treatment

N=517-523

Table 31/v10: Interviewees’ preference for different kinds of treatment for mental health problems, by gender and age-group. Numbers.

20-34 years


Total

20-34 years


Total

Medication

3

7

9

19

4

7

6

17

Counselling/ therapy/ psychotherapy

22

29

26

77

86

52

58

196

9

23

21

53

18

37

63

118

5

4

9

18

5

5

8

18

Medication and counselling/ therapy/ psychotherapy are equally important Other

N=516 Missing=45

49

Table 32/v19: Interviewees’ confidence in the ability of medical professionals to provide help in case of mental health problems, by gender and age-group. Numbers.

20-34 years


Total

20-34 years


Total

Confident

92

97

112

301

157

136

147

440

Not confident

17

17

12

46

16

16

24

56

Do not know

22

26

12

85

46

28

37

111 N=1 039 Missing=54

Table 33/v20: Interviewees’ preference for type of medical professional to provide help in case of mental health problems,* by gender and age-group. Numbers.

20-34 years General practitioner employed by county council


Total

20-34 years


Total

5

15

33

53

20

19

41

80

5

4

8

17

6

4

9

19

15

19

20

54

19

20

31

70

17

15

18

50

17

23

16

56

Psychologist/ Psychotherapist employed by the county council

26

16

10

52

46

37

21

102

Psychologist/ psychotherapist, private clinic

22

18

13

53

51

30

18

99

Other

18

15

20

53

23

25

20

68

Ranking is not applicable. The nature of the problems decide

14

22

16

52

24

23

24

71

Medical doctor, private clinic Psychiatrist employed by county council Psychiatrist, private clinic

* If the interviewee was "Confident" according to Table 32.

50

N=722 Missing=19

Table 34/v23a: Interviewees’ assessment of their own treatment need for mental health problems, by gender and age-group. Numbers. Men Age-group

Women Age-group

20-34 years

35-49 years

50-64 years

Total

20-34 years

35-49 years

50-64 years

Total

Yes, absolutely

16

19

22

57

32

24

45

101

Yes, probably

30

35

24

89

53

38

47

138

Probably not

17

26

22

65

40

34

29

103

Absolutely not

57

53

81

191

76

64

71

211

N=955 Missing=138

Table 35/v23b: Interviewer’s assessment of treatment need for mental health problems, by gender and age-group. Numbers. Men Age-group

Women Age-group

20-34 years

35-49 years

50-64 years

Total

20-34 years

35-49 years

50-64 years

Total

Yes, absolutely

19

31

34

84

40

34

61

135

Yes, probably

44

36

28

108

51

36

48

135

Probably not

19

25

39

83

59

35

44

138

Absolutely not

41

40

55

136

57

54

49

160

N=979 Missing=114

51

Table 36/v24a: Interviewees’ assessment of whether their own treatment need for mental health problems has essentially been met*, by gender and Age group. Numbers. Men Age-group

Women Age-group

20-34 years

35-49 years

50-64 years

Total

20-34 years

35-49 years

50-64 years

Total

Yes, absolutely

2

5

7

14

6

7

16

29

Yes, probably

7

7

7

21

13

8

18

39

Probably not

13

16

15

44

17

19

22

58

Absolutely no

15

17

13

45

29

16

22

67

* If the interviewee answered "Yes, absolutely" or "Yes, probably" according to Table 34.

N=317 Missing=68

Table 37/v1124b: Interviewer’s assessment of whether the treatment need for mental health problems has essentially been met*, by gender and age group. Numbers. Men Age-group

Women Age-group

20-34 years

35-49 years

50-64 years

Total

20-34 years

35-49 years

50-64 years

Total

Yes, absolutely

1

3

4

8

5

3

10

18

Yes, probably

6

10

7

23

13

14

24

51

Probably not

24

16

19

59

28

21

31

80

Absolutely no

26

28

23

77

30

21

36

87

* If the interviewer answered "Yes, absolutely" or "Yes, probably" according to Table 35.

52

N=403 Missing=59