Increased 12-Month Prevalence Rates of Mental Disorders in Patients with Chronic Somatic Diseases

Transcription

1 Regulr Artile Psyhother Psyhosom 2007;76: DOI: / Inresed 12-Month Prevlene Rtes of Mentl Disorders in Ptients with Chroni Somti Diseses Mrtin Härter Hrld Bumeister Ktrin Reuter Frnk Jobi Mihel Höfler Jürgen Bengel b Hns-Ulrih Witthen Deprtment of Psyhitry nd Psyhotherpy, Setion of Clinil Epidemiology nd Helth Servies Reserh, Freiburg University Medil Center, nd b Deprtment of Rehbilittion Psyhology, University of Freiburg, Freiburg, nd Deprtment of Clinil Psyhology nd Psyhotherpy, Tehnil University of Dresden, Dresden, Germny Key Words Mentl disorders Depression Anxiety Musuloskeletl diseses Crdiovsulr diseses Neoplsms Respirtory trt diseses Abstrt Bkground: Although it is well estblished tht hroni somti diseses re signifintly ssoited with wide rnge of psyhopthology, it remins unler to wht extent subjets with hroni somti diseses re t inresed risk of experiening mentl disorders. The present epidemiologil study investigtes ge- nd sex-djusted 12-month prevlene rtes of mentl disorders in ptients with ner, nd musuloskeletl, rdiovsulr nd respirtory trt diseses, bsed on omprehensive physiins dignoses nd ompred with physilly helthy probnds. Methods: Prevlene rtes were lulted from two lrge epidemiologil surveys. These studies investigted inptients nd ptients from the generl popultion with ner (n = 174) nd musuloskeletl (n = 1,416), rdiovsulr (n = 915) nd respirtory trt diseses (n = 453) s well s helthy ontrols (n = 1,083). The prevlene rtes were bsed on the Munih Composite Interntionl Dignosti Interview, stndrdized interview for the ssessment of mentl disorders. Results: Prevlene rtes were very similr for inptients (43.7%) nd ptients from the generl popultion (42.2%). The djusted odds rtios (OR) of ptients with hroni somti diseses were signifintly elevted for mentl disorders in omprison with helthy probnds (OR: 2.2). Mood, nxiety nd somtoform disorders were most frequent. The prevlene rtes did not differ signifintly between the somti index diseses. The number of somti diseses per ptient hd higher ssoition with mentl disorders. Conlusions: There is strong reltionship between hroni somti diseses nd mentl disorders. A future tsk is to improve the re of mentl disorders in ptients with hroni physil illness, speifilly with multimorbid onditions. Copyright 2007 S. Krger AG, Bsel A lose reltionship hs onsistently been reported between somti diseses, mentl disorders nd the negtive impt of omorbid mentl disorders on mortlity, qulity of life nd helth osts [1 7]. Although mny ptients with hroni somti diseses suffer from mentl disorders [8 16], the extent to whih ptients with hroni somti diseses re, in generl, t inresed risk of experiening mentl disorders remins unexplored. Only smll number of studies hve shown tht prevlene rtes of mentl disorders djusted for demogrphi vribles (e.g. ge nd sex) re higher in ptients with Fx E-Mil krger@krger.h S. Krger AG, Bsel /07/ $23.50/0 Aessible online t: Mrtin Härter, MD, PhD, Deprtment of Psyhitry nd Psyhotherpy Freiburg University Medil Center, Setion of Clinil Epidemiology nd Helth Servies Reserh, Huptstrsse 5, DE Freiburg (Germny) Tel , Fx E-Mil mrtin.herter@uniklinik-freiburg.de

2 hroni somti diseses thn in physilly helthy omprison group. Most of these studies foused on speifi somti diseses, e.g. sthm, ner, hroni spinl pin nd theroslerosis [9, 10 14], while others foused on ertin mentl disorders suh s somtoform or ffetive disorders [8, 13]. The only study to omprise broder rnge of somti diseses nd mentl disorders ws the NIMH Epidemiologi Cthment Are Study [16], but this study hd severl limittions: (1) it ws bsed on DSM-III riteri nd foused only on the tegories ffetive disorders, nxiety disorders nd substne-relted disorders ; (2) dignoses of hroni somti diseses originted only from ptients self-evlutions nd were not bsed on physiins dignoses; (3) ptients were seleted from the generl popultion, nd therefore did not inlude inptients. In the present study, for the first time, the frequeny of mentl disorders in ptients with somti diseses dignosed by physiins in omprison with physilly helthy probnds will be investigted. The following 4 questions will be ddressed: 1 Do prevlene rtes of mentl disorders differ between ptients from different settings (inptient setting vs. generl popultion)? 2 Wht re the ge- nd sex-djusted 12-month prevlene rtes of mentl disorders ording to DSM-IV in ptients with frequent hroni somti diseses (musuloskeletl diseses, rdiovsulr diseses, respirtory trt diseses nd ner)? 3 Do prevlene rtes of mentl disorders differ between musuloskeletl diseses, rdiovsulr diseses, respirtory trt diseses nd ner? 4 Is somti omorbidity ssoited with the prevlene of mentl disorders? Methods Study Design nd Smples Ptients with hroni somti diseses nd helthy probnds were seleted from the Germn Ntionl Helth Interview nd Exmintion Survey Mentl Helth Supplement (GHS-MHS) nd the Epidemiology of Mentl Disorders in Medil Rehbilittion Study (EMDMR). Both studies were bsed on epidemiologil smpling proedures. The 2-stge ross-setionl design inluded (1) the sreening of representtive popultion smples nd (2) strtified rndom smpling of probnds for dignosti interview. () The GHS-MHS ws the first ntionwide epidemiologil study of mentl helth rried out in the dult generl popultion in Germny [17, 18]. The dt olletion for the GHS-MHS ws bsed on 2-stge proedure: first, ll prtiipnts of the GHS Core Survey (n = 7,124) were sreened for mentl disorders using the sreening questionnire [19] of the Munih Composite Interntionl Dignosti Interview (M-CIDI) nd dignosed s hving somti illness. The somti exmintion took ple in speil enters t the study sites nd begn with self-report questionnire to evlute the subjets urrent nd pst somti symptoms nd omplints, helth re utiliztion, impirments nd disbilities. Completion of the questionnires ws followed by strutured interview onduted by study physiin in order to reexmine nd refine the dt from the self-report pket. This interview ws omputer ssisted for stndrdiztion nd integrity purposes (omputer-ided personl interview). Dignoses were then supplemented nd, depending on the medil ondition, revised on the bsis of lbortory test dt, whih were vilble 2 weeks lter. The men durtion of the overll ssessment ws 2 h [10]. Seond, ll prtiipnts who sreened positively ording to the sreening interview of the M-CIDI nd 50% of those who sreened negtively were exmined by mens of stndrdized linil interview for mentl disorders (M-CIDI; n = 4,181 [17] ). All probnds of the GHS-MHS with dignosed ner or musuloskeletl, rdiovsulr or respirtory trt diseses present within the previous 12 months were inluded in this study (n = 1,662). The physilly helthy omprison group inluded ll probnds of the GHS-MHS who were not dignosed s hving 1 of the 4 somti index diseses or ny other hroni somti disese within the previous 12 months (n = 1,083). (b) The EMDMR Study exmined the frequeny of mentl disorders mong inptients with ner or musuloskeletl, rdiovsulr or respirtory trt diseses. The smple originted from 16 Germn inptient rehbilittion enters. Ptient reruitment ws bsed on 2-stge proedure nlogous to the smpling proedure of the World Helth Orgniztion study on mentl illness in generl helth re [15] : ll newly dmitted ptients were sreened by mens of the Generl Helth Questionnire (GHQ; n = 2,902 [20] ). Ten perent of low GHQ-12 sorers (0 4), 30% of medium GHQ-12 sorers (5 7) nd 50% of high GHQ-12 sorers (8 12) were then seleted rndomly for the stndrdized linil M-CIDI (n = 648 [21] ). All inptients pssed through omprehensive dignosti proedure bsed on the ptients dmission reports, lbortory test dt nd omplete physil exmintion. Physiins were instruted to doument ll dignoses ording to ICD-10 using stndrdized medil hrt. This proedure ws very similr to the physiins interview (omputer-ided personl interview) used in the GHS. A s s e s s m e n t n d In t e r v i e we r s In both epidemiologil studies, mentl disorders were ssessed using the M-CIDI in the DIA-X version [22]. It enbles relible nd effiient ssessment of symptoms, syndromes nd dignoses of mentl disorders, long with informtion bout ge of onset, durtion of symptoms nd linil nd psyhosoil severity. The min dvntges of this proedure re its high objetivity nd test-retest relibility ( : [22] ). The M-CIDI ws used to determine the presene of substne buse/dependene, mood, nxiety nd somtoform disorders ording to DSM-IV riteri. All interviewers were linilly experiened psyhologists, physiins or other helth professionls. The interviewers reeived stndrdized interview trining for onduting the M-CIDI interviews, onsequently wrrnting high relibility. Interviewers were monitored losely nd supervised by trined M-CIDI linil supervisors [17, 21]. Mentl Disorders nd Chroni Somti Diseses Psyhother Psyhosom 2007;76:

3 Tble 1. Sex- nd ge-djusted 12-month prevlene rtes of DSM-IV mentl disorders in ptients from two different smples (inptients nd ptients from the generl popultion) in omprison with helthy probnds Inptients (n = 648) Generl popultion (n = 1,662) Helthy (n = 1,083) % OR 95% CI % OR 95% CI % Totl * * Mood disorders * * Anxiety disorders * * Somtoform disorders * * Substne use disorders More thn one disorder * * * p < 0.01 (two-tiled). CI = Confidene intervl. OR re bsed on the djusted prevlene rtes of the helthy omprison group. 1 At lest one of the mentioned disorders. 2 Exluding niotine dependene. D t An ly s i s The dt nlysis ws ompleted using Stt Sttistil Softwre [23]. Sttistil weighting proedures were used to ompenste for the oversmpling of probnds [17, 21]. For exmple, with regrd to the GHS-MHS, sreen negtives reeived twie the weight of sreen positives. The verge weight ws set to 1 [17]. Anlogous smpling weights were lulted for ptient subgroups with high, medium or low GHQ sores within the EMD- MR study [21]. Within the GHS-MHS, subjets were further weighted to djust the smple to mth the ge, sex nd regionl distribution of the ntionl dministrtive sttistis in Germny [17]. These weighting proedures llow for representtive nlyses for both the inptient smple nd the generl popultion smple. The weighted distribution of 12-month mentl disorders (yes/ no) in somtilly ill smple ptients ws ompred with the helthy omprison group by logisti regression, ontrolling for ge nd sex. Regression oeffiients were trnsformed to odds rtios (OR). Bsed on the weighted 12-month prevlene rtes of the physilly helthy omprison group, prevlene rtes of somtilly ill ptients were lulted using the estimted OR. Thus, one would expet prevlene rtes of mentl disorders to be illustrted in the physilly ill smples if their ge nd sex distribution orresponded with the distribution in the helthy smple. In order to rry out orret weighting nd strtifition of the rndom smples, the Stt SVY (survey) ommnds were used. These ommnds enble n dequte hndling of weighted nd strtified dt. Between-ptient-group omprisons were onduted vi the logisti regression using postestimtor (linom), whih enbles omprison of oeffiients on signifint differenes. R e s u l t s The totl smple onsisted of 3,393 probnds, who were interviewed using the stndrdized linil interview. A totl of 2,310 probnds entered the ptient group, mnifesting t lest 1 of the index diseses within the previous 12 months. During the sme period, 1,083 probnds were physilly helthy. The men ge of the helthy probnds ws 36.3 yers, nd 40.6% were femle. The men ge of the hronilly ill probnds ws 49.8 yers, nd 49.3% were femle. The following 12-month prevlene rtes of mentl disorders re djusted for ge nd sex. We exluded further smple hrteristis tht my onfound the prevlene rtes of mentl disorders. More detiled hrteristis omprising mritl sttus, edution, inome nd employment sttus of ll 8 smples (ptients in generl, helthy ontrols, 4 disese groups, 2 settings) re vilble on request. Question 1 Inptients (43.7%; OR: 2.3) nd ptients from the generl popultion (42.2%; OR: 2.2) showed similrly inresed risk of hving ny mentl disorder ompred with helthy probnds ( tble 1 ). The inresed risk ws minly due to signifintly higher prevlene rtes of mood disorders, nxiety disorders nd somtoform disorders in both ptient smples. There were no signifint differenes between inptients nd ptients from the generl popultion regrding prevlene rtes of mood disorders (OR: 1.2; onfidene intervl, CI: ), nxiety disorders (OR: 1.1; CI: ), ny mentl disorders (OR: 1.1; CI: ) or the number of omorbid mentl disorders (OR: 0.8; CI: ). Somtoform disorders (OR: 0.6; CI: ) nd substne-relted disorders (OR: 0.5; CI: ) were signifintly more frequent in 356 Psyhother Psyhosom 2007;76: Härter /Bumeister /Reuter /Jobi / Höfler /Bengel /Witthen

4 Tble 2. Sex- nd ge-djusted 12-month prevlene rtes of DSM-IV mentl disorders in ptients with hroni illness in omprison with helthy probnds Ptients (n = 2,310) Helthy Cner (n = 174) MSD (n = 1,416) CVD (n = 915) RTD (n = 453) (n = 1,083) % OR 95% CI % % OR 95% CI % OR 95% CI % OR 95% CI % OR 95% CI Totl ** * ** ** ** Mood disorders ** ** ** ** ** Anxiety disorders ** * ** ** ** Somtoform disorders ** ** ** ** Substne use disorders More thn one disorder ** ** ** ** ** * p < 0.05, ** p < 0.01 (two-tiled). MSD = Musuloskeletl diseses; CVD = rdiovsulr diseses; RTD = respirtory trt diseses. OR re bsed on the djusted prevlene rtes of the helthy omprison group. 1 At lest one of the mentioned disorders. 2 Exluding niotine dependene. ptients from the generl popultion. The similr rtes of ny mentl disorder justify omprehensive nlysis of ptients versus helthy probnds from both smples. Question 2 The ge- nd sex-djusted prevlene rte of mentl disorders ws signifintly higher in ptients with hroni somti diseses (42.5%) ompred with physilly helthy probnds (25.0%; OR: 2.2; tble 2 ). Mood (21.1%) nd nxiety disorders (22.9%) were most ommon in somtilly ill ptients s well s in helthy probnds (9.4%; 11.6%). The prevlene rtes of mood (OR: 2.6) nd nxiety disorders (OR: 2.3) differed signifintly in ptients versus helthy probnds. The differene between physilly ill (15.3%) nd helthy probnds (5.7%) ws found to be most distint for somtoform disorders (OR: 3.0). The prevlene rte of substne use disorders in ptients with hroni somti diseses (7.0%) did not differ signifintly from tht of helthy ontrols (5.3%; OR: 1.3). Furthermore, ptients (20.9%) displyed more thn one mentl disorder signifintly more often thn helthy probnds (7.1%; OR: 3.5). Question 3 Ptients with musuloskeletl (45.3%), rdiovsulr (40.7%) nd respirtory trt diseses (42.1%) showed omprbly inresed prevlene rtes of mentl disorders ( tble 2 ). Mood nd nxiety disorders were most prevlent in ptients who hd respirtory trt diseses, wheres somtoform disorders o-ourred minly in ptients with musuloskeletl diseses. Ptients with respirtory trt diseses most often hd more thn one mentl disorder. The prevlene rtes of nxiety disorders, somtoform disorders nd substne use disorders were lowest for ner ptients. Moreover, ner ptients reported lower rte of mentl omorbidity. However, the ORs for ny mentl disorder were still high in ll 4 disese groups when ompred with helthy probnds. Question 4 The mount of somti omorbidity is ssoited with higher risks for mentl disorders. Tble 3 shows inresed prevlene rtes for ny mentl disorder ording to the number of somti diseses. In omprison with helthy probnds, ptients with 3 or more somti diseses, subgroup ounting for more thn hlf of ll physilly ill ptients, showed the highest inrese in prevlene rtes of ny mentl disorders (OR: 2.8). However, prevlene rtes of mentl disorders still remin signifintly inresed for ptients with only 1 somti disese, with the exeption of substne use disorders. Disussion The present study is the first to ompre ge- nd sexdjusted 12-month prevlene rtes of mentl disorders in ptients with somti diseses bsed on physiins dignoses ompred with helthy probnds. The rtionle for inluding ombintion of inptients nd ptients from the generl popultion ws to minimize seletion Mentl Disorders nd Chroni Somti Diseses Psyhother Psyhosom 2007;76:

5 Tble 3. Sex- nd ge-djusted 12-month prevlene rtes of DSM-IV mentl disorders in ptients with 1, 2, nd more thn 2 somti diseses in omprison with helthy probnds 1 disese (n = 421) 2 diseses (n = 526) >2 diseses (n = 1,363) Helthy (n = 1,083) % OR 95% CI % OR 95% CI % OR 95% CI % Totl ** ** ** Mood disorders ** ** ** Anxiety disorders ** * ** Somtoform disorders * ** ** Substne use disorders More thn one mentl disorder ** ** ** * p < 0.05, ** p < 0.01 (two-tiled). OR re bsed on the djusted prevlene rtes of the physilly helthy omprison group. 1 At lest one of the mentioned disorders. 2 Exluding niotine dependene. bis, the so-lled Berkson s bis [24], whih sttes tht smples from the generl popultion re restrited to the noninstitutionlized popultion. While 1 in 4 persons without somti disese reported mentl disorder within the previous yer, this perentge ws lmost twie s high mong hronilly ill ptients. In ddition, ptients show n OR of 3.5 for hving more thn one mentl disorder. The differenes in overll prevlene rtes between physilly ill ptients nd helthy probnds re due minly to higher frequenies of mood, nxiety, nd somtoform disorders (OR: ). In line with previous studies [10, 11, 14, 16], mood nd nxiety disorders re most frequent in physilly ill ptients. However, while ptients often rte the severity of their mood disorder s serious, there is onsiderble mount of mild nxiety disorders, nd in prtiulr mild speifi phobis, whih n led to n overemphsis of the need for tretment of nxiety disorders [25]. Almost s frequent s ffetive nd nxiety disorders re somtoform disorders. A smll number of epidemiologil studies hve reported prevlene rtes of somtoform disorders [8, 15, 18, 26, 27]. Somtiztion lone ounts for pproximtely 16% of the yerly helth re expenditure of the USA [28]. However, problems with relibility nd vlidity s well s diffiulties in opertionliztion omplite the mesurement of this dignosti tegory, prtiulrly in ptients with somti diseses [8, 29, 30]. Ptients my be more likely to ttribute their symptoms to somti ftor thn helthy probnds. Moreover, physilly ill inptients my hve more somti ttribution style thn ptients from the generl popultion due to their intensive somti tretment [8]. However, our results undersore the ft tht these disorders lso our when they re ssoited with orgni medil illness (see lso the urrent debte on somtoform disorders nd DSM-V). Prevlene rtes of substne disorders re low ompred with previous studies [16]. Beyond different lssifition lgorithms (DSM-III vs. DSM-IV), possible explntion for the lower prevlene rtes my be tht inptients in prtiulr tend to dissimulte their substne-relted symptoms. This dissimultion my be due to possible negtive onsequenes of reporting symptoms of substne-relted disorders in the ontext of primrily somti tretment environment. Finlly, it is well known from interntionl omprisons tht substnerelted disorders re more frequent in US Amerin smples [31]. Prevlene rtes of mentl disorders differ signifintly between persons who hve hroni somti disese nd those who do not, while there re only slight differenes in prevlene rtes of mentl disorders mong the disese groups investigted. However, similr frequenies between disese smples my be ttributble to other inherent uses, suh s frequent omorbid somti disese. Therefore, we lulted dditionl prevlene rtes of mentl disorders of ptients with the respetive index disese ompred to those without the index disese, nd djusted for ge, sex nd number of somti omorbidities. The OR for mentl disorders proved to be very similr between disese groups, highlighting one gin the smll differenes of mentl disorders between somti diseses. However, ptients who disply more thn 2 somti diseses show n inresed risk for mentl disorders of 40% in omprison with ptients who hve just 1 somti disese. 358 Psyhother Psyhosom 2007;76: Härter /Bumeister /Reuter /Jobi / Höfler /Bengel /Witthen

6 This investigtion tried to overome the limittions of previous studies by using 2 lrge, independent smples with the sme stndrdized interview proedure tht overs wide rnge of mentl disorders. Furthermore, omprehensive physiin-bsed medil dignoses were used rther thn self-reports of ptients, s ws the se in erlier investigtions. However, some methodologil issues should be noted. First, this is ross-setionl study nd therefore nnot demonstrte usl ssoitions between somti diseses nd mentl disorders. Moreover, the effet of depression-triggered mortlity in some somti diseses [1, 32] on prevlene rtes of mentl disorders is not refleted in ross-setionl studies. Seond, even though the CIDI is regrded s the gold stndrd for lrge epidemiologil surveys, there re limittions in terms of the relibility nd vlidity of some speifi dignoses [22]. Third, the inptient smple omprises minly ptients from rehbilittion enters. The similr prevlene rtes within the 2 smples suggest, however, tht the impt of the setting on prevlene rtes of mentl disorders is low. Fourth, for resons of brevity, we used brod tegories of somti diseses. There is literture showing tht the strength of ssoition of t lest some of these tegories my vry depending on the speifi diseses inluded [33, 34]. Therefore, the prevlene rtes of mentl disorders shown for somti disese groups in our study should be exmined for differenes within disese groups (e.g. respirtory trt disese: sthm, hroni obstrutive pulmonry disese; rdiovsulr disese: hypertension, oronry diseses, myordil infrtion et.). The findings undersore the overll high impt of omorbid mentl disorders in ptients with hroni somti diseses. Unfortuntely, omorbid mentl disorders often remin unreognized nd untreted [35, 36]. Comorbid mentl disorders n negtively influene ptients dherene to interventions nd effetiveness of tretment, qulity of life, mortlity nd osts of disese nd re [1 7]. Furthermore, psyhosoil interventions n improve linil outomes in orgni diseses [4, 5, 32, 37 39]. Due to the lrge rnge of somti nd psyhitri diseses, there re no generl reommendtions tht n be mde for effetive tretments. However, reent onsensus sttement of experts on mood disorders in the medilly ill highlighted evidene-bsed ntidepressnt nd psyhotherpy tretments for severl medil onditions omprising disese-dependent ntidepressnts (seletive serotonin reuptke inhibitors, triyli ntidepressnts et.) nd ognitive-behviorl therpy [32]. More of these types of pprohes re needed, prtiulrly for further frequent disorders suh s nxiety disorders. A k n ow l e d g m e n t s This work resulted from the following two soures: () the reserh projet Epidemiology of Mentl Disorders in Medil Rehbilittion (grnts No. 01 GD 9802/4 nd 01 GD 0101) of the Freiburg/Bd Säkingen Rehbilittion Network (prinipl investigtors: M.H. nd J.B.); the projet ws supported by the Federl Ministry of Edution nd Reserh nd by the Federtion of Germn Pension Insurne Institutes; (b) the reserh projet GHS-MHS (grnt No. 01 EH970/8) ws supported by the Federl Ministry of Edution nd Reserh. We would like to thnk the Robert Koh Institute for providing the GHS Core Survey dt [40]. Referenes 1 Brth J, Shumher M, Herrmnn-Lingen C: Depression s risk ftor for mortlity in ptients with oronry hert disese: metnlysis. Psyhosom Med 2004; 66: Bumeister H, Blke K, Härter M: Psyhitri nd somti omorbidities re negtively ssoited with qulity of life in physilly ill ptients. J Clin Epidemiol 2005; 58: Benninghoven D, Kduk A, Wiegnd U, Speht T, Kunzendorf S, Jntshek G: Influene of nxiety on the ourse of hert disese fter ute myordil infrtion Risk ftor or protetive funtion? Psyhother Psyhosom 2006;75: Glssmn AH: Does treting postmyordil infrtion depression redue medil mortlity? Arh Gen Psyhitry 2005; 62: Simon GE, von Korff M, Lin E: Clinil nd funtionl outomes of depression tretment in ptients with nd without hroni medil illness. Psyhol Med 2004; 34: Sørensen C, Friis-Hshé E, Hghfelt T, Beh P: Postmyordil infrtion mortlity in reltion to depression: systemti ritil review. Psyhother Psyhosom 2005; 74: Wng HX, Mittlemn A, Leineweber C, Orth-Gomer K: Depressive symptoms, soil isoltion, nd progression of oronry rtery theroslerosis: The Stokholm Femle Coronry Angiogrphy Study. Psyhother Psyhosom 2006; 75: Bumeister H, Härter M: Somtoform disorders in ptients with musuloskeletl nd rdiovsulr diseses in omprison to the generl popultion. At Neuropsyhitr 2003; 15: Coyne JC, Plmer C: Ntionl Comorbidity Survey dt onerning ner nd depression lk redibility. Psyhother Psyhosom 2005; 74: Goodwin RD, Jobi F, Thefeld W: Mentl disorders nd sthm in the ommunity. Arh Gen Psyhitry 2004; 60: Hond K, Goodwin R: Cner nd mentl disorders in ntionl ommunity smple: findings from the Ntionl Comorbidity Survey. Psyhother Psyhosom 2004; 73: Hond K, Goodwin R: Reply. Psyhother Psyhosom 2005; 74: Mentl Disorders nd Chroni Somti Diseses Psyhother Psyhosom 2007;76:

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