Context Uncertainties exist about prevalence and correlates of major depressive
Objective To present nationally representative data on prevalence and correlates
of MDD by Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) criteria, and on study
patterns and correlates of treatment and treatment adequacy from the recently
completed National Comorbidity Survey Replication (NCS-R).
Design Face-to-face household survey conducted from February 2001 to December
Setting The 48 contiguous United States.
Participants Household residents ages 18 years or older (N = 9090) who responded
to the NCS-R survey.
Main Outcome Measures Prevalence and correlates of MDD using the World Health Organization's
(WHO) Composite International Diagnostic Interview (CIDI), 12-month severity
with the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR),
the Sheehan Disability Scale (SDS), and the WHO disability assessment scale
(WHO-DAS). Clinical reinterviews used the Structured Clinical Interview for DSM-IV.
Results The prevalence of CIDI MDD for lifetime was 16.2% (95% confidence interval
[CI], 15.1-17.3) (32.6-35.1 million US adults) and for 12-month was 6.6% (95%
CI, 5.9-7.3) (13.1-14.2 million US adults). Virtually all CIDI 12-month cases
were independently classified as clinically significant using the QIDS-SR,
with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9% very severe. Mean
episode duration was 16 weeks (95% CI, 15.1-17.3). Role impairment as measured
by SDS was substantial as indicated by 59.3% of 12-month cases with severe
or very severe role impairment. Most lifetime (72.1%) and 12-month (78.5%)
cases had comorbid CIDI/DSM-IV disorders, with MDD
only rarely primary. Although 51.6% (95% CI, 46.1-57.2) of 12-month cases
received health care treatment for MDD, treatment was adequate in only 41.9%
(95% CI, 35.9-47.9) of these cases, resulting in 21.7% (95% CI, 18.1-25.2)
of 12-month MDD being adequately treated. Sociodemographic correlates of treatment
were far less numerous than those of prevalence.
Conclusions Major depressive disorder is a common disorder, widely distributed in
the population, and usually associated with substantial symptom severity and
role impairment. While the recent increase in treatment is encouraging, inadequate
treatment is a serious concern. Emphasis on screening and expansion of treatment
needs to be accompanied by a parallel emphasis on treatment quality improvement.
Although community surveys of mental disorders have been conducted in
the United States since the end of World War II,1-3 it
was not until the early 1980s that fully structured lay interviews were developed
to diagnose specific mental disorders. The first such instrument was the Diagnostic
Interview Schedule (DIS),4 which was developed
for use in the Epidemiologic Catchment Area (ECA) study5 to
estimate the general population prevalence of mental disorders by Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) criteria.6 Major
depressive disorder (MDD) prevalence estimates in the ECA sites were 3.0%
to 5.9% for lifetime and 1.7% to 3.4% for 12-month.7
The first nationally representative survey using a method similar to
the ECA, the National Comorbidity Survey (NCS),8 was
conducted a decade later in 1990-1992. The NCS diagnostic instrument was a
modified version of the Composite International Diagnostic Interview (CIDI)9 to assess mental disorders by Diagnostic
and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria.10 The
NCS age range was 15 years to 54 years, rather than 18 years or older in the
ECA. The prevalence estimates of MDD in the NCS were substantially higher
than in the ECA: 14.9% for lifetime and 8.6% for 12-month.11
Despite their different prevalence estimates, the ECA and NCS results
were very similar in finding early age of onset of MDD12,13 and
high comorbidity with other DSM disorders.11,14 A methodological study showed that
the ECA-NCS prevalence differences in the age range of 18 years to 54 years
could be substantially reduced by combining the 2 waves of ECA data to make
up for the memory priming strategies and respondent motivation techniques
used in the NCS.15
Although the estimated number of individuals in the total population
who seek treatment for a mental health problem in a given year was somewhat
lower in the ECA (12.3%) than the NCS (13.3%), 12-month treatment among respondents
who met criteria for MDD was higher in the ECA (53.9%) than in the NCS (36.4%).16,17 A plausible interpretation is that
the higher NCS prevalence estimate included more mild cases, with patients
with mild MDD less likely to seek treatment. Consistent with this possibility,
multiplication of estimated prevalence by conditional treatment rate leads
to an estimate that 2.7% of the population was in treatment for MDD in the
12 months before the ECA survey compared with 3.1% before the NCS survey.
In the decade since the NCS was conducted, a large increase in the proportion
of Americans who receive medication for depression was reported18 and
a number of large programs to promote awareness of depression were launched.19,20 At least part of this growth in depression
awareness and treatment has occurred as a result of a growing realization
that depression is a very common and very serious illness.21,22 Indeed,
the World Health Organization (WHO) now ranks major depression as one of the
most burdensome diseases in the world.23
This growing recognition of the public health burden of depression also
has led to the development and evaluation of model primary care programs for
depression detection and treatment.24-26 Even
though a number of these programs have been shown to be cost-effective, dissemination
has been hampered by reluctance to implement them on the part of primary care
During this same time period, the American Psychiatric Association introduced
the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV) system, which emphasizes
the clinical significance requirement for a diagnosis of MDD more prominently
than did in the earlier DSM editions.28 This
new emphasis occurred, in no small part, in reaction to the perception that
the prevalence estimates in the ECA study were unrealistically high. The even
higher NCS estimates, which were published only after the DSM-IV criteria were established, only reinforced this concern.15 Indeed, a recent critique of the ECA and NCS argued
that a substantial proportion of respondents classified as cases were clinically
insignificant, leading to an overestimation of the 12-month depression prevalence
of 29% in the ECA and of 58% in the NCS.29 However,
this critique was based on the use of imprecise indicators for severity symptoms,
raising questions about adjusted prevalence estimates.30
Based on the introduction of the DSM-IV criteria,
in conjunction with evidence of changes in treatment over the past decade,
a new national survey of mental disorders was conducted in 2001-2002. The
survey was designed to update information on the prevalence, correlates, and
clinical significance of DSM disorders, and to study
patterns and correlates of treatment and treatment adequacy. The current report
is the first presentation of results from this new survey, the National Comorbidity
Survey Replication (NCS-R).31
The NCS-R is a nationally representative face-to-face household survey
of 9090 respondents ages 18 years or older conducted between February 2001
and December 2002. Respondents were selected from a multistage area probability
sample of the noninstitutionalized civilian population in the 48 contiguous
states. The response rate was 73.0%. All respondents were administered a part
1 diagnostic interview as described below, while 5554 respondents also received
a part 2 interview that included assessments of risk factors and additional
mental disorders. The sample receiving part 2 consisted of all respondents
who screened positive for any disorder found in part 1 plus a probability
subsample of other part 1 respondents.
The sample receiving part 1 was weighted to adjust for differential
probabilities of selection within households and for differences in intensity
of recruitment effort among hard-to-recruit cases and poststratified to match
the 2000 census population distribution on a number of geographic and sociodemographic
variables. The sample receiving part 2 was additionally weighted to adjust
for differential probabilities of selection. The weighted sample distributions
closely match those of the US population on a variety of sociodemographic
and geographic variables (Table 1).
A probability sample of 308 NCS-R respondents completed a clinical reappraisal
interview to evaluate lifetime diagnoses, and a nonoverlapping probability
sample of 335 respondents completed a separate reappraisal interview to evaluate
12-month diagnoses. These reappraisal samples oversampled CIDI cases. The
data were weighted to adjust for this oversampling so that estimates of sensitivity,
specificity, and total classification accuracy would be unbiased.
Recruitment to the initial NCS-R interview began with a letter and study
fact brochure mailed to sample households followed by an in-person interviewer
visit. Interviewers explained the study procedures and obtained verbal informed
consent before beginning the interview. Participants received $50 as a gift
to thank them for participating. Recruitment and consent procedures were approved
by the human subjects committees of both Harvard Medical School and the University
Diagnostic Assessment. The NCS-R diagnostic
instrument was an expanded version of the WHO's CIDI,9 a
fully structured instrument for use by trained interviewers who do not have
clinical experience. Diagnoses are based on DSM-IV criteria.28 Organic exclusions and diagnostic hierarchy rules
were both applied in making diagnoses. In addition to the prevalence and correlates
of MDD, in this article we also report comorbidity with anxiety disorders
(panic disorder, agoraphobia without panic, social anxiety disorder, specific
phobia, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic
stress disorder), substance use disorders (alcohol and drug abuse and dependence),
and a group of disorders that we refer to as "impulse-control disorders" (intermittent
explosive disorder, antisocial personality disorder, bulimia, and pathological
Previous methodological research documented acceptable-to-good concordance
between the NCS/CIDI diagnoses and blind clinical diagnoses, but found that
the NCS CIDI overdiagnosed MDD because of false-positive assessments of dysphoria
and anhedonia.32 The CIDI false-positive assessments
included both respondents with clinically nonsignificant distress and those
whose symptoms did not persist for most of the day, nearly every day, or for
2 weeks or longer. The NCS-R revisions attempted to correct these problems
by including explicit probes for severity of dysphoria and anhedonia, by requiring
clinically significant distress or impairment associated with these symptoms,
and by asking separate questions about symptom duration (hours per day, days
per week, and duration of depressive episodes).
The core of the clinical reappraisal interviews was the structured clinical
interview for DSM-IV (SCID),33 a
diagnostic interview that requires clinical expertise to administer. Nonaffective
psychosis and mania were not included in the SCID because they are being assessed
in separate, in-progress, focused reappraisal studies. Because of the absence
of mania, the SCID cannot be used to generate diagnoses of MDD. However, it
can be used to diagnose major depressive episode (MDE). A comparison of the
CIDI and SCID for MDE classifications in the clinical reappraisal samples
(Table 2) shows good concordance
for lifetime (κ = .59; 95% CI, .47-.71) and fair concordance for 12-month
(κ = .40; 95% CI, .20-.60) estimates. CIDI lifetime prevalence for MDE
is significantly lower than SCID prevalence (χ21 =
8.1, P = .004) while CIDI 12-month prevalence is
marginally higher than SCID prevalence (χ21 = 3.2, P = .07).
Role Impairment. Respondents with CIDI/DSM-IV 12-month MDD were administered the Sheehan Disability
Scale (SDS)34 to assess the extent to which
depression interfered with functioning in work, household, relationship, and
social roles in the worst month of the past year. Responses were scored with
a 0-to-10 visual analogue scale having response options labeled none (0),
mild (1-3), moderate (4-6), severe (7-9), and very severe (10). In addition,
an open-ended question asked respondents to estimate the number of days in
the past 365 days when they were "totally unable to work or carry out your
normal activities" because of depression.
All respondents to part 2 of the NCS-R completed the WHO disability
assessment schedule (WHO-DAS)35 to assess functional
impairments in 6 domains during the past 30 days: domain 1, the number of
days in the past 30 days when the respondent was completely unable to work
or carry out their normal activities because of physical or mental health
problems; and domains 2 to 6, the severity-persistence of impairments in 5
domains of functioning during the same time period. These domains include
self-care (eg, bathing, dressing), mobility (eg, standing, walking), cognition
(eg, concentrating, remembering), social functioning (eg, conversing, maintaining
emotional control while around others), and role functioning (eg, quality
and quantity of normal activities at home or work). All 6 WHO-DAS scales were
transformed to a theoretical range of 0 (no impairment at any time in the
past 30 days) to 1.0 (complete inability to perform the functions throughout
the full 30 days).
Symptom Severity. Respondents who met CIDI/DSM-IV criteria for 12-month MDD were self-administered
a truncated version of the Quick Inventory of Depressive Symptomatology Self-Report
(QIDS-SR)36 to assess symptom severity in the
worst month of the past year. The QIDS-SR is a fully structured measure that
is strongly related both to the clinician-administered Inventory of Depressive
Symptomology (IDS-C)37 and to the Hamilton
Rating Scale of Depression (HRSD).38 Transformation
rules developed for the QIDS-SR39 were used
to convert scores into clinical severity categories mapped to conventional
HRSD ranges of none (ie, not clinically depressed), mild, moderate, severe,
and very severe.
12-Month Treatment. All respondents to part
2 of the NCS-R were asked about receiving 12-month treatment for emotional
problems, the type of professional seen, as well as use of support groups,
self-help groups, and hotlines. Number and duration of 12-month visits also
were assessed. Responses were used to classify 12-month treatment in the specialty
mental health (SMH) sector (inpatient treatment or outpatient treatment with
a psychiatrist, psychologist, any other mental health professional, or a social
worker or counselor in a mental health specialty setting, or use of a hotline),
the general medical (GM) sector (outpatient treatment with a primary care
physician, other medical specialist, nurse, or any other health professional
not previously mentioned), the human services (HS) sector (outpatient treatment
with a religious or spiritual advisor or with a social worker or counselor
in any setting other than a specialty mental health setting), and the complementary-alternative
medical (CAM) sector (outpatient treatment with any other type of healer,
participation in an internet support group, or participation in a self-help
group). In addition, a pharmaco-epidemiologic section asked respondents about
use of psychotropic medications in the past 12 months. Information was recorded
by having respondents give their medicine bottles to the interviewer to inspect
and to record the type of medication, duration of treatment, maximum prescribed
dose, and specialty of prescribing physician.
Based on the above data, minimally adequate medical treatment for MDD
was defined as receiving either (1) at least 4 outpatient visits with any
type of physician for pharmacotherapy that included use of either an antidepressant
or mood stabilizer for a minimum of 30 days or (2) at least 8 outpatient visits
with any professional in the specialty mental health sector for psychotherapy
lasting a mean of at least 30 minutes. The decision to require at least 4
pharmacotherapy visits was based on the recommendation from evidence-based
treatment guidelines that no fewer than 4 visits for follow-up and medication
monitoring were required during the acute and continuation phases of treatment
for depression.40,41 At least
8 psychotherapy visits were required based on evidence from clinical trials
that time-limited depression psychotherapy treatment with demonstrated effectiveness
requires at least 8 sessions.40,41
Human services and CAM treatments were classified as not being adequate
based on the absence of experimental data documenting effectiveness in treating
MDD. Health care treatment, which was defined as treatment in either the SMH
or GM sectors, was considered inadequate when this treatment failed to meet
either of the above 2 criteria for minimally adequate treatment. Respondents
who reported 12-month use of psychotropic medications under the supervision
of a health care professional, but who never made a visit to that professional
at any time during those 12 months, were coded as receiving inadequate health
care treatment, but not receiving either inadequate SMH or inadequate GM treatment.
Sociodemographics. A standard battery of sociodemographic
variables (eg, age, sex, employment status, education, income) was administered
to all respondents. In addition, sample information was linked to interview
location records to classify each respondent by major census region (Northeast,
Midwest, South, and West), and by the Department of Agriculture's urban-rural
continuum of counties (major metropolitan counties, other urbanized counties,
and rural counties).
Interviewer Training and Field Quality Control
Professional lay interviewers from the Institute for Social Research
at the University of Michigan administered the NCS-R. More than 300 interviewers
participated in the study, each receiving 7 days of study-specific training
and successfully completing 2 practice interviews before beginning production
work. Interviews were administered using laptop computer–assisted software
that included built-in skip logic, timing flags, and consistency checks. Regional
supervisors recontacted a random 10% of respondents for quality control.
Five experienced clinical psychologists administered the clinical reappraisal
SCID interviews. Each received 80 hours of training and successfully completed
2 practice interviews before beginning production work. Interviews were conducted
by telephone and were tape recorded with the verbal permission of respondents.
Interviewers wrote extensive notes to justify ratings. A clinical supervisor
reviewed the notes and reviewed the tape recordings of the first 10 interviews
for each interviewer plus other tape recordings as needed. The interviewer
or supervisor recontacted the respondent to obtain additional information
when there was ambiguity about ratings. Biweekly review meetings were used
to prevent interviewer drift.
Cross-tabulations were used to calculate prevalence, comorbidity, symptom
severity, impairment, treatment, and treatment adequacy. The Kaplan-Meier
method42 was used to generate age-at-onset
curves. Logistic regression analysis43 was
used to study demographic correlates of prevalence and treatment. The logistic
regression coefficients were transformed to odds ratios (ORs) for ease of
interpretation. Ninety-five percent confidence intervals (CIs) were estimated
using the Taylor series linearization method implemented in the SUDAAN software
package.44 Multivariate significance tests
were calculated using Wald χ2 tests based on coefficient variance-covariance
matrices that were adjusted for design effects using the Taylor series method.
Statistical significance was based on 2-sided design-based tests evaluated
at the .05 level of significance.
The prevalence estimates for CIDI/DSM-IV MDD
in the total NCS-R sample were 16.2% (95% CI, 15.1-17.3) for lifetime and
6.6% (95% CI, 5.9-7.3) for the 12 months before the interview; the ratio of
12-month to lifetime prevalence was approximately 40%. These prevalences were
equivalent to national population projections of 32.6 to 35.1 million US adults
with lifetime MDD and 13.1 to 14.2 million with 12-month MDD.
Kaplan-Meier curves for age-at-onset of MDD were generated separately
for 4 groups of birth cohorts (Figure 1)
and defined by age at interview (18-29, 30-44, 45-59, or ≥60 years). The
curves are significantly different from each other (χ23 = 290.1, P <.001 for all). Risk is fairly
low until the early teens, when it begins to rise in roughly linear fashion
with an increasingly steep slope in successively more recent cohorts.
Either lifetime MDD or 12-month MDD among lifetime cases was meaningfully
elevated (ie, statistically significant at the .05 level with ORs ≥1.5)
among respondents in the age range of 18 years to 59 years for lifetime or
18 years to 44 years for 12-month, and for women (lifetime only), homemakers
(12-month only), respondents who were classified as "other" in employment
status (consisting mainly of those who were unemployed or disabled), the never
married (12-month only), the previously married (lifetime only), those with
less than 12 years of education (12-month only), and those living in or near
poverty (http://aspe.hhs.gov/poverty/01poverty.htm) (12-month only).
(Table 3) Other employment status,
being previously married, and low income also were associated with meaningfully
elevated severe MDD (defined by the QIDS-SR) among 12-month cases. The prevalence
of lifetime MDD was meaningfully lower (ie, statistically significant at the
.05 level with ORs ≤0.67) among people who were retired and Non-Hispanic
blacks than among comparison cases, while 12-month MDD was less likely to
be clinically severe in the Northeast and Midwest than other regions of the
country. Major depressive disorder was largely unrelated to geography (region
of the country or urbanicity). Despite the large number of meaningful associations,
only a few were strong (ie, ORs >3.0 or <0.33).
Nearly three fourths (72.1%) of respondents with lifetime MDD also met
the criteria for at least 1 of the other CIDI/DSM-IV disorders
assessed in the NCS-R, including 59.2% with anxiety disorder, 24.0% with substance
use disorder, and 30.0% with impulse control disorder. (Table 4) Approximately two thirds (64.0%) of respondents with 12-month
MDD met the criteria for at least 1 other 12-month disorder, with anxiety
disorders (57.5%) again more common than either substance use (8.5%) or impulse
control (16.6%) disorders (Table 4).
Comparison of age-at-onset reports (Table
4) shows MDD to be temporally primary to all other comorbid disorders
among 12.3% of respondents with lifetime MDD and 12.6% of those with 12-month
MDD. For lifetime and 12-month MDD, temporally prior MDD was much more common
in relation to substance use disorders (41.3% and 49.2%) than either anxiety
(13.7% and 14.6%) or impulse control (16.9% and 20.8%) disorders.
Role Impairment of 12-Month MDD
Nearly all (96.9%) respondents with 12-month MDD reported at least some
role impairment associated with their depression in at least 1 of the 4 SDS
role domains, with 87.4% describing this impairment as at least moderate,
59.3% as either severe or very severe, and 19.1% as very severe. (Table 5) Impairment was greatest in the
social role domain (43.4% severe or very severe) and was least in the work
role domain (28.1% severe or very severe).
Respondents with 12-month MDD reported a mean of 35.2 (95% CI, 26.8-43.6)
days in the past year when they were totally unable to work or carry out their
normal activities because of their depression. Overall SDS scores are significantly
related (F4,617 = 17.1, P<.001) to
days out of role (Table 5), from
a high of 96.5 days among respondents who reported very severe role impairment
to a low of zero among those who reported no role impairment.
Comparison of respondents with MDD vs those with no lifetime history
of MDD on the WHO-DAS dimensions provides additional evidence of broad-based
impairment associated with MDD (Table 6). Recent MDD (within 30 days of the interview) is associated with
statistically significant impairments in all 6 WHO-DAS domains compared with
respondents who never met criteria for MDD. These include impairments more
than a full SD above the sample-wide mean in 30-day cognitive functioning
and social functioning, more than 75% of an SD above the mean in days out
of role and role functioning, more than 60% of an SD above the mean in mobility,
and nearly 50% of an SD above the mean in self-care (all adjusted for age,
sex, and race/ethnic differences between respondents with and without MDD).
These impairments appear to be state dependent, as the mean levels of impairment
among respondents who had an episode of MDD earlier in the year are less strongly
and consistently elevated (4 of the 6 WHO-DAS scores significantly elevated,
with effect sizes 20%-45% of an SD about the mean), while respondents with
a history of MDD who were not depressed in the past year have no significant
elevations on any of the WHO-DAS dimensions.
Clinical Severity of 12-Month MDD
More than 99% of respondents with 12-month CIDI/DSM-IV MDD are independently
classified by the QIDS-SR as having been clinically depressed during the worst
month of the year, with 10.4% mild, 38.6% moderate, 38.0% severe, and 12.9%
very severe (Table 7). Mild through
severe cases as measured by QIDS-SR have mean durations of 13.8 to 16.6 weeks,
while very severe cases have a mean duration of 23.1 weeks (Table 7). Symptom severity is strongly related both to role impairment
and to comorbidity.
An estimated 57.3% of respondents with 12-month MDD received some type
of treatment in the 12 months before their interview (Table 8). The SMH sector was involved in the highest proportion
of these cases (55.1% of treated cases) and the HS sector in the lowest proportion
(16.0% of treated cases), with 90.0% of treated cases seen in the health care
(HC) sectors (SMH, GM, or psychotropic medication use). Treatment met our
criteria for being at least minimally adequate in 64.3% (95% CI, 55.4-73.1)
of cases in SMH treatment, 41.3% (95% CI, 31.3-57.2) of cases in GM treatment,
and 41.9% (95% CI, 35.9-47.9) in HC treatment (Table 8). Given that 51.6% (95% CI, 46.1-57.2) of cases received
HC treatment for their depression, no more than 21.6% of all respondents with
12-month MDD (ie, 41.9% of the 51.6% in treatment) received adequate treatment
in the year of the interview.
Because there was overlap in sectors of treatment, we also compared
respondents who received SMH, but not GM, treatment (n = 99), among whom 56.2%
(95% CI, 43.7-68.7) received adequate treatment, with those who received GM,
but not SMH, treatment (n = 74), among whom a significantly lower 9.6% (95%
CI, 6.0-15.5) received adequate treatment (z = 6.3, P<.001).
Symptom severity is significantly related to 12-month treatment in both
the SMH sector (χ23 = 13.4, P = .004) and the GM sector (χ23 = 8.1, P = .04), but not in either the HS sector (χ23 = 0.2, P = .97) or the CAM sector
(χ23 = 2.6, P = .46). Symptom
severity is also significantly related to patients in the SMH sector receiving
adequate treatment (χ23 = 7.9, P = .048). Even so, fewer than half the respondents with 12-month very
severe MDD (39.1%) and fewer than one fourth of those with 12-month severe
MDD (24.6%) received adequate 12-month HC treatment for MDD.
In addition to symptom severity, other clinical correlates of treatment
and treatment adequacy include role impairment, duration, proportional days
out of role during depressive episodes, and psychiatric comorbidity (Table 9). Sociodemographic correlates of
treatment adequacy also were examined (results not shown, but available on
request from R.C.K.) using the same measures and procedures as in Table 3. None of these measures was significantly
related to adequate treatment after adjusting statistically for clinical variables.
The NCS-R MDD prevalence estimates are intermediate between the ECA
and NCS estimates. Concordance between CIDI and clinical reappraisal diagnoses
in the NCS-R is higher than in previous DIS and CIDI surveys.32,45 In
addition, the QIDS-SR confirms more than 99% of 12-month CIDI MDD cases. This
improved accuracy is presumably because of CIDI modifications in the NCS-R.
The lower CIDI prevalence estimates than those in the NCS are consistent with
the fact that these modifications operated largely by reducing false-positive
The ratio of 12-month CIDI MDD prevalence to lifetime prevalence being
approximately 40% is broadly consistent with ratios between one third and
one half in previous epidemiologic surveys.46,47 These
ratios are consistent with both retrospective reports in cross-sectional community
surveys7,11 and prospective assessments
in a small number of community48,49 and
clinical50 samples in suggesting that MDD is
an episodically chronic recurrent disorder.51
The NCS-R age-at-onset results are consistent with previous surveys
in finding that MDD has an early onset distribution.12,46,52 The
strong MDD cohort effect in NCS-R also is consistent with previous surveys.13,46,53 Age-related differential
recall, differential willingness to disclose, or other methodologic factors
could play important parts in this pattern,54,55 although
a genuine increase in the prevalence of MDD in recent cohorts might have occurred.56,57
The sociodemographic correlates of prevalence are for the most part
consistent with those of previous epidemiologic studies,46,58-66 as
is the finding that MDD is comorbid with anxiety and substance use disorders.67,68 Although little epidemiologic evidence
is available about comorbidity between depression and impulse control disorders
among adults, significant comorbidity for MDD and impulse control disorder
has been documented in clinical studies.69,70 Comorbid
impulse control disorder is often thought to be more strongly related to bipolar
than to unipolar depression.71 The NCS-R MDD
impulse control disorder comorbidity could reflect broader factors or the
existence of what has recently been called a "soft bipolar spectrum" in which
comorbid impulse control disorder among patients with MDD represents a marker
of bipolar susceptibility.72
The finding that comorbid anxiety disorders typically have an earlier
age of onset than does MDD is consistent with previous epidemiologic research46 as well as with prospective family studies of at-risk
children.73 The finding that the same is true
for comorbid impulse control disorder has not, to our knowledge, been examined
in previous epidemiologic studies of adults, although the evidence on this
point is mixed in studies of children and adolescents.74
The results regarding MDD impairment are consistent with other evidence
that MDD is a seriously impairing condition.75 The
35.1 mean days out of role because of MDD is striking in comparison with recent
results from another national survey in which mean time out of role was less
than 15 days for most chronic conditions.76
The QIDS-SR symptom severity results speak directly to the concern that
prevalence estimates in community surveys might be upwardly biased due to
the inclusion of clinically insignificant cases.29 This
concern is clearly misplaced with respect to MDD, as close to 90% of 12-month
CIDI cases are classified as moderate, severe, or very severe using standard
HRSD symptom severity thresholds.
The 57.3% of 12-month MDD cases who received treatment in the past year,
when multiplied by the estimated 12-month prevalence of MDD, represents 3.7%
of the population. This is a meaningful increase over the 2.1% in the ECA
in the early 1980s and the 2.7% in the NCS in 1990-1991.14,16 The
ratio of NCS-R to ECA percentages (3.7:2.1) represents a 37% increase in MDD
treatment. This large increase is consistent with trend data from the National
Medical Expenditures Survey for changes between 1987 and 1997.18
The NCS-R results are less positive with regard to treatment adequacy,
implying a need for treatment quality improvement.77 This
improvement will require both a redirection of patient help-seeking to sectors
where guideline-concordant care can be provided and an increase in the implementation
of evidence-based treatment recommendations by health care providers.40,41 The growing number of cost-effective
depression disease management programs24,26,78 represent
feasible opportunities for promoting quality improvement. However, implementation
of established performance standard79 and report
card80 monitoring systems also are needed for
Comstock GW, Helsing KJ. Symptoms of depression in two communities. Psychol Med.1976;6:551-563.
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