- Email: [email protected]
Global Burden of Disease
HERE
IN THIS ISSUE
F
rom internalizing to externalizing disorders, this issue of the Journal brings valuable information on mental health problems that impose a considerable burden to children and adolescents. Two of these articles focus on preschool children, expanding our knowledge on features associated with anxiety disorders and irritability symptoms early in life; another study shows promising results for tackling aggressive behavior in children with attention-deficit/hyperactivity disorder (ADHD). In an article on the prevalence and comorbidity of preschool anxiety disorders in primary care, Franz and colleagues (p. 1294) present evidence supporting the idea that these conditions are already present and common in the first years of life. The Duke Preschool Anxiety Study screened 3,433 children 2 to 5 years old and selected for further assessment all children who scored high (n ¼ 944) and a random subsample of those with low scores (n ¼ 189). Using the Preschool Age Psychiatric Assessment to interview eligible parents, the investigators found prevalence rates of 8.6% for generalized anxiety disorder, 10.5% for separation anxiety disorder, and 7.5% for social phobia. Overall, 19.4% of preschool children assessed in primary care presented at least 1 of these disorders. Interestingly, comorbidity patterns for young children exhibited some differences from those usually observed in late adolescence and adulthood: the disorder with the highest comorbidity— generalized anxiety—tended to co-occur more frequently with separation anxiety disorder (odds ratio [OR] 4.1), social phobia (OR 6.4), and disruptive behavior disorders (OR 5.1) than with depression (OR 3.7). Irritability is a common symptom in child and adolescent psychopathology that has received increasing attention from the scientific literature. In this issue, Dougherty and colleagues (p. 1304) extend previous studies by focusing on the roots of irritable symptoms in preschool children from 3 to 6 years old. A total
of 531 parents were interviewed at baseline and then 462 3 years later. Irritability was concurrently associated with depressive, anxiety, ADHD, and oppositional defiant disorders at 3 years old and with all these except anxiety at 6 years. Longitudinal analyses showed baseline irritability to be a predictor of depression (OR 1.96) and oppositional defiant disorder (OR 1.54) at the end of the study using categorical and dimensional measurements. These associations remained statistically significant after adjustment for potential confounders, including the effect of item overlap between irritability and disorder-specific scales. Irritability at 3 years also prospectively predicted higher ratings of impairment and lower global assessment of functioning scores at follow-up at 6 years. Aggressive behavior frequently starts in childhood, and there is evidence suggesting that pharmacologic treatment for ADHD can decrease associated aggressive behavior. Whether this decrease is limited to impulsive, reactive aggression or extends to proactive acts is an unsolved issue in the literature. Callous and unemotional (CU) characteristics (such as diminished empathy, lack of remorse, and insincerity) might contribute to proactive aggression. An article by Blader and colleagues (p. 1281) examines whether baseline proactive aggression and CU traits moderate changes in behavioral outcomes in 160 children with ADHD who underwent stimulant treatment (concurrent psychological intervention using behaviorally oriented techniques also was offered to families). The effectiveness of treatment in decreasing aggressive behavior, however, was not decreased by elevated baseline CU traits, proactive aggression, or the by the interaction of these factors: for the 82 children who had remission of aggressive behavior, neither of these factors predicted normalization. In fact, in those children whose overall aggression remitted, significant decreases in CU traits (effect size 0.38) and proactive aggression (effect size 0.46) were observed.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 12 DECEMBER 2013
www.jaacap.org
1243
THERE
ABSTRACT THINKING Global Burden of Disease oung individuals are disproportionally affected by mental health problems compared with other medical conditions, as highlighted in recent reports of the 2010 Global Burden of Disease Study (GBDS).1,2 They updated and extended the landmark 1990 report, evaluating the impact of 291 diseases on 20 age groups across 187 countries. Although less frequently associated with premature death compared with diseases in other areas of medicine, psychiatric disorders impose a substantial decrease in the quality of life in affected individuals. The development of the disability-adjusted life year (DALY) methodology allowed for the combination of years of life lost and years lived with disability (YLDs) measurements into a single statistic that aggregates the 2 constructs. Disability weights are generated with values ranging from 0 (perfect health) to 1 (death) for each disease state. By merging years of life lost with YLDs, 1 DALY represents the loss of the equivalent of 1 year of full health. This rationale not only allows for a fair comparison between mental and other medical conditions but also reinforces the notion that there can be no health without mental health. Data from the GBDS clearly highlight the relevance of mental and substance use disorders: together, they account for 7.4% of DALYs around the globe (compared with 12% for cardiovascular diseases and 7.6% for cancer). The relative importance of mental health conditions is even greater for quality of life, representing 22.9% of YLDs worldwide. These numbers are even higher in youth: mental disorders account for as much as 16% of the DALYs and 27% of the YLDs from 10 to 14 years of age, figures that increase up to 17% and 34% for individuals 15 to 19 years old. During late adolescence, leading causes of burden are unipolar depressive
Y
REFERENCES
1. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-2223.
disorders (6.8% of DALYs) and followed by anxiety (3.3%) and behavioral disorders (ADHD and conduct disorder, 2%; included for the first time in the survey). The inclusion of disorders that usually affected children in the 2010 study was especially relevant to recognize the burden in regions of the world where children constitute large proportions of the population (e.g., some countries in Africa). In addition, to confirm the huge burden imposed by mental disorders worldwide, a detailed analysis of the GBDS results show the lack of robust data for most mental disorders— especially in low- and middle-income countries and at early stages in life. To generate burden estimates, a series of imputations had to be performed, including iterations to infer burden in regions for which no information is currently available. Such calculations rely heavily on the reliability and validity of studies that quantified prevalence and risks associated with these conditions. Further studies assessing the longitudinal course of mental disorders, including their roots in the first decades of life and the lifelong consequences of their early onset, will be required to strengthen the bases of such estimates. Christian Kieling,
The author gratefully acknowledges Argyris Stringaris, M.D., Ph.D, M.R.C.Psych., for his editorial input. Disclosure: Dr. Kieling has received support from Brazilian governmental research funding agencies (Conselho Nacional de Desen~o de volvimento Cientıfico e Tecnol ogico [CNPq], Coordenac¸a Aperfeic¸oamento de Pessoal de Nıvel Superior [CAPES], and ~o de Amparo a Pesquisa do Estado do Rio Grande do Sul Fundac¸a [Fapergs]). http://dx.doi.org/10.1016/j.jaac.2013.09.012
2. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. http://dx. doi.org/10.1016/S0140-6736(13)61611-6.
JOURNAL 1244
www.jaacap.org
M.D., Ph.D.
[email protected] Hospital de Clınicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 12 DECEMBER 2013
IN THIS ISSUE
F
rom internalizing to externalizing disorders, this issue of the Journal brings valuable information on mental health problems that impose a considerable burden to children and adolescents. Two of these articles focus on preschool children, expanding our knowledge on features associated with anxiety disorders and irritability symptoms early in life; another study shows promising results for tackling aggressive behavior in children with attention-deficit/hyperactivity disorder (ADHD). In an article on the prevalence and comorbidity of preschool anxiety disorders in primary care, Franz and colleagues (p. 1294) present evidence supporting the idea that these conditions are already present and common in the first years of life. The Duke Preschool Anxiety Study screened 3,433 children 2 to 5 years old and selected for further assessment all children who scored high (n ¼ 944) and a random subsample of those with low scores (n ¼ 189). Using the Preschool Age Psychiatric Assessment to interview eligible parents, the investigators found prevalence rates of 8.6% for generalized anxiety disorder, 10.5% for separation anxiety disorder, and 7.5% for social phobia. Overall, 19.4% of preschool children assessed in primary care presented at least 1 of these disorders. Interestingly, comorbidity patterns for young children exhibited some differences from those usually observed in late adolescence and adulthood: the disorder with the highest comorbidity— generalized anxiety—tended to co-occur more frequently with separation anxiety disorder (odds ratio [OR] 4.1), social phobia (OR 6.4), and disruptive behavior disorders (OR 5.1) than with depression (OR 3.7). Irritability is a common symptom in child and adolescent psychopathology that has received increasing attention from the scientific literature. In this issue, Dougherty and colleagues (p. 1304) extend previous studies by focusing on the roots of irritable symptoms in preschool children from 3 to 6 years old. A total
of 531 parents were interviewed at baseline and then 462 3 years later. Irritability was concurrently associated with depressive, anxiety, ADHD, and oppositional defiant disorders at 3 years old and with all these except anxiety at 6 years. Longitudinal analyses showed baseline irritability to be a predictor of depression (OR 1.96) and oppositional defiant disorder (OR 1.54) at the end of the study using categorical and dimensional measurements. These associations remained statistically significant after adjustment for potential confounders, including the effect of item overlap between irritability and disorder-specific scales. Irritability at 3 years also prospectively predicted higher ratings of impairment and lower global assessment of functioning scores at follow-up at 6 years. Aggressive behavior frequently starts in childhood, and there is evidence suggesting that pharmacologic treatment for ADHD can decrease associated aggressive behavior. Whether this decrease is limited to impulsive, reactive aggression or extends to proactive acts is an unsolved issue in the literature. Callous and unemotional (CU) characteristics (such as diminished empathy, lack of remorse, and insincerity) might contribute to proactive aggression. An article by Blader and colleagues (p. 1281) examines whether baseline proactive aggression and CU traits moderate changes in behavioral outcomes in 160 children with ADHD who underwent stimulant treatment (concurrent psychological intervention using behaviorally oriented techniques also was offered to families). The effectiveness of treatment in decreasing aggressive behavior, however, was not decreased by elevated baseline CU traits, proactive aggression, or the by the interaction of these factors: for the 82 children who had remission of aggressive behavior, neither of these factors predicted normalization. In fact, in those children whose overall aggression remitted, significant decreases in CU traits (effect size 0.38) and proactive aggression (effect size 0.46) were observed.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 12 DECEMBER 2013
www.jaacap.org
1243
THERE
ABSTRACT THINKING Global Burden of Disease oung individuals are disproportionally affected by mental health problems compared with other medical conditions, as highlighted in recent reports of the 2010 Global Burden of Disease Study (GBDS).1,2 They updated and extended the landmark 1990 report, evaluating the impact of 291 diseases on 20 age groups across 187 countries. Although less frequently associated with premature death compared with diseases in other areas of medicine, psychiatric disorders impose a substantial decrease in the quality of life in affected individuals. The development of the disability-adjusted life year (DALY) methodology allowed for the combination of years of life lost and years lived with disability (YLDs) measurements into a single statistic that aggregates the 2 constructs. Disability weights are generated with values ranging from 0 (perfect health) to 1 (death) for each disease state. By merging years of life lost with YLDs, 1 DALY represents the loss of the equivalent of 1 year of full health. This rationale not only allows for a fair comparison between mental and other medical conditions but also reinforces the notion that there can be no health without mental health. Data from the GBDS clearly highlight the relevance of mental and substance use disorders: together, they account for 7.4% of DALYs around the globe (compared with 12% for cardiovascular diseases and 7.6% for cancer). The relative importance of mental health conditions is even greater for quality of life, representing 22.9% of YLDs worldwide. These numbers are even higher in youth: mental disorders account for as much as 16% of the DALYs and 27% of the YLDs from 10 to 14 years of age, figures that increase up to 17% and 34% for individuals 15 to 19 years old. During late adolescence, leading causes of burden are unipolar depressive
Y
REFERENCES
1. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-2223.
disorders (6.8% of DALYs) and followed by anxiety (3.3%) and behavioral disorders (ADHD and conduct disorder, 2%; included for the first time in the survey). The inclusion of disorders that usually affected children in the 2010 study was especially relevant to recognize the burden in regions of the world where children constitute large proportions of the population (e.g., some countries in Africa). In addition, to confirm the huge burden imposed by mental disorders worldwide, a detailed analysis of the GBDS results show the lack of robust data for most mental disorders— especially in low- and middle-income countries and at early stages in life. To generate burden estimates, a series of imputations had to be performed, including iterations to infer burden in regions for which no information is currently available. Such calculations rely heavily on the reliability and validity of studies that quantified prevalence and risks associated with these conditions. Further studies assessing the longitudinal course of mental disorders, including their roots in the first decades of life and the lifelong consequences of their early onset, will be required to strengthen the bases of such estimates. Christian Kieling,
The author gratefully acknowledges Argyris Stringaris, M.D., Ph.D, M.R.C.Psych., for his editorial input. Disclosure: Dr. Kieling has received support from Brazilian governmental research funding agencies (Conselho Nacional de Desen~o de volvimento Cientıfico e Tecnol ogico [CNPq], Coordenac¸a Aperfeic¸oamento de Pessoal de Nıvel Superior [CAPES], and ~o de Amparo a Pesquisa do Estado do Rio Grande do Sul Fundac¸a [Fapergs]). http://dx.doi.org/10.1016/j.jaac.2013.09.012
2. Whiteford HA, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet. http://dx. doi.org/10.1016/S0140-6736(13)61611-6.
JOURNAL 1244
www.jaacap.org
M.D., Ph.D.
[email protected] Hospital de Clınicas de Porto Alegre Universidade Federal do Rio Grande do Sul Porto Alegre, Brazil
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 52 NUMBER 12 DECEMBER 2013