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Management in Health 3/2009

THE ROMANIAN MENTAL HEALTH STUDY

main aspects of lifetime prevalence and service use of DSM-IV disorders DSMSilvia FLORESCU 1 , Marius CIUTAN 1 ,
MD, PHHM specialist MD, PhD, researcher, PHHM senior specialist

Georgeta POPOVICI 1 ,
MD, Family practice senior specialist

Mihaela GLON 1 ,

Maria LADEA 2 ,
MD, PHD

MD, PHHM specialist, researcher MD, PhD, psychiatry senior specialist

The article shows the findings of Mental Health Survey Romania 2007, regarding the lifetime prevalence, the age group variation, the onset age of mental disorders, the projected risk by 75 years, and the comparison of the projected risk with the observed lifetime prevalence the proportion of those making initial treatment contacts in the year of onset and by 75 years. The lifetime prevalence for any mental disorders, among those of 18 years old and older is 13.4% with the onset in the adolescence or early adulthood. Among the mental disorders the highest prevalence can be found for anxiety disorders. For some of the anxiety disorders (specific phobia, social phobia, posttraumatic stress disorders, panic disorders, and alcohol abuse with or without dependence) can be noticed an increase of prevalence in adulthood compared to younger ages, following a decrease at 65 years or older ages. The major depressive episode registers continuous increase reaching the highest prevalence at elderly people. The projected lifetime risk shows higher values compared to the observed lifetime prevalence. The proportion of those making initial treatment contact in the year of onset is 32-63% for those with bipolar disorder, dysthymia, drug abuse, 10,2-24,6% for mood disorders and agoraphobia and under 10% for major depressive episode, panic disorder specific phobia alcohol abuse and substance use disorders. Keywords: mental health, mental disorders, lifetime prevalence, services use

Maria PETHUKOVA 3 ,

Alison HOFFNAGLE 3 ,
WMH Project Manager, Harvard Medical School National School of Public Health and Health Services Management 2 Psychiatry Clinical Hospital Prof. Dr. Al. Obregia 3 Departement of Health Care Policy, Harvard Medical School, Boston, MA, USA
1

ontext: In the last decades it was not available in Romania any nationally representative population based study about age of onset of DSM-IV disorders, life time prevalence and the services use related to these diseases. A very important step in the help seeking process is making prompt initial contact with a treatment provider after first onset of a mental disorder [1]. The purpose of the current article is to present nationally representative estimates of lifetime prevalence and initial treatment contact of the DSMIV disorders assessed in the Romanian Mental Health study. Objective: To estimate lifetime prevalence and age-of onset distributions of DSM-IV disorders[2], to describe patterns of delay in making initial treatment contact after first onset of mental disorders in Romania.

Design and Setting Nationally representative face-to face household survey conducted between 2005-2007 using World Health Organization World Mental Health Survey Initiative (WMHI) version of the Composite International Diagnostic Interview (CIDI). This is a fully structured interview designed to be administered by trained lay interviewers, known as (WMH-CIDI) [3]. The survey was administered as Computer Assisted Personal Interview (CAPI version). The interviewers explained the study and obtained verbal informed consent prior to beginning each interview. Sample The Romanian Mental Health Study is a nationally representative survey of

Romanian-speaking household residents aged 18 years and older in Romania. Participants: 2537 subjects of 18 years or older. The sample contained 940 cases of 44 years old or less. Obsessive compulsive disorder (OCD) was estimated on a random subsample of 562 cases. The response rate was 70.9%. Diagnostic Assessment The diagnoses are based on the World Mental Health Survey Initiative Version of the World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay-administered diagnostic interview that generates both International Classification of Diseases, 10th Revision [4] and DSM-IV diagnoses [5], [6].

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The DSM-IV criteria are used here and diagnoses include: - anxiety disorders, including panic disorder (PD), agoraphobia without panic (AG), specific phobia (SP), social phobia (SoP), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD) and separation anxiety disorder (SAD); - mood disorders, including major depressive episode (MDE), dysthymia (DYS), and bipolar disorder (BPD); - impulse control disorders, including intermittent explosive disorder (IED), oppositional defiant disorder (ODD), conduct disorder (CD) and attention-deficit/ hyperactivity disorder (ADHD). - substance disorders, including alcohol abuse (AA), alcohol dependence (AD), drug abuse (DA), and drug dependence (DD). The four disorders that require onset of symptoms in childhood (separation anxiety disorder, oppositional-defiant disorder, conduct disorder, and attention-deficit/ hyperactivity disorder) were limited to respondents in the age range of 18 to 44 years because of concerns about recall bias among older respondents [5], [6]. Hierarchy was used for the following disorders: Major Depressive Disorder, Dysthymia, Generalized Anxiety Disorder, and oppositionaldefiant disorder. Substance use disorders were diagnosed without hierarchy (the abuse being frequently a stage in the way towards dependence). Information about age of first professional treatment contact for each lifetime DSM-IV/WMH-CIDI disorder assessed in the survey was collected and compared with age at onset of the disorder in order to study typical duration of delay. Retrospective age-of-onset reports were obtained in the WMH-CIDI using a series of questions. The sequence began with a question designed to emphasize the importance of accurate responses: Can you remember your exact age the

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Survival analysis was used to make estimated projections of cumulative lifetime probability of treatment contact from year of onset. The survival curves were also used to estimate the proportion of cases that made treatment contact in the year of first onset of the disorder and the median delay among people who eventually made treatment contact after the year of first onset. The data were weighted to adjust for differential probabilities of selection, differential non-response, and differences in socio-demographic variables between the sample and Census population. All significance tests were evaluated at .05 with two-sided tests [9].

very first time you (had the syndrome)? Respondents who answered no were probed for a bound of uncertainty by moving up the age range incrementally (e.g., Was it before you first started school? Was it before you became a teenager?). Age of onset was set at the upper end of the bound (e.g., age 12 years for respondents who reported that onset was before they became a teenager). Although age-of-onset questions were asked about both important symptoms (e.g., first panic attack) and full syndromes, the ages used herein are for syndromes [7]. Close to the end of each WMH-CIDI diagnostic section, respondents were asked whether they ever in their life talked to a medical doctor or other professional about the disorder under investigation. In asking this question, the interviewer clarified that the term other professional was meant to apply broadly to include psychologists, counselors, spiritual advisors, herbalists, acupuncturists, and any other healing professionals. Respondents who reported ever talking to any of these professionals about the disorder in question were then asked how old they were the first time they did so. The response to this question was used to define age of first treatment contact. The typical duration of delay in initial treatment contact was defined as the median number of years from disorder onset to first treatment contact among cases that eventually made treatment contact [8]. Analysis Methods By lifetime prevalence is understood the proportion of those in the population who had a disorder at some time in their life up to their age at interview. The projected lifetime risk is the estimated proportion of those in the population who will have the disorder by the end of their life. The lifetime risk estimates are useful in assessing societal burden.

esults

Lifetime prevalence The lifetime prevalence of any disorder was 13.4%, while 4.5% of respondents had two or more lifetime disorders and 1.4% had three or more. Anxiety disorders were the most prevalent class of disorders (6.9%), followed by mood disorders (4.3%), and substance use disorders (3.4%) and impulse-control disorders (2.1% and 2.9% for those 44 years old or less). Among anxiety disorders, the most frequent is specific phobia (3.8%), following the social phobia (1.3%) and post traumatic stress disorder (1.2%). Have a prevalence under 1%: separation anxiety disorder SAD/ASA (0.9%), generalized anxiety disorder GAD with hierarchy (0.8%), panic (0.7%), obsessive compulsive disorder OCD* (0.6%), agoraphobia without panic (0.5%). The lifetime prevalence for any mood is 4.3%; for mood with hierarchy is 2.9%, lower for bipolar disorders (1.4%) and very low for dysthymia with hierarchy (0.3%). Any substance use prevalence is 3.4%; the lifetime prevalence for alcohol abuse with or without dependence is 3.1%. We can see lifetime prevalence under 1% for alcohol dependence without abuse (0.7%), drug abuse with without dependence (0.2%), drug dependence with abuse (0.1%). Any impulse disorder lifetime prevalence is 2.1%, (2.9% for those aged 44 or less), IED with hierarchy 1.3%. The prevalence is < 0.5% for ODD with hierarchy and CD (0.4%) and ADHD (0.2%). 23

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Prevalence age group variation Within each category of disease, generally, it was found out an increase of prevalence from the youngest (18-34 years) to the older (for the most part, 50-64 years) age group and then a decline in the oldest age group. Will be considered the following age groups 18-34 years old, 35-49, 50-64 and 65 years and over. For any anxiety disorder, the lifetime prevalence increases from 5.5% at 18-34 age group to 6.8% for 35-49 age group and to 10.3% for 50-64 group (almost double compared with those in 18-34 age group), consequently decreasing to 5.2% for those of 65 years old and over (Graph 1). The same trend can be noticed for specific phobia, social phobia and posttraumatic stress disorder. For specific phobia, the lifetime prevalence is increasing with 1.7 percentage points from 2.9% (18-34 age group) to 4.6% (for those of 3549 years old), and further only with 0.6 percentage points for those of 50-64 years old (5.2%); it is sharply decreasing then, to 2.6% for those of 65 years old and over. For social phobia, the lifetime prevalence is slowly but constanly increasing from one age group to another, being 1.2% for 18-34 group, 1.5% for 35-49 group, 1.9% at 50-64 group. It is hafly decreasing to 0.8% for those of 65 years old and over. For posttraumatic stress disorder, the lifetime prevalence is increasing with almost half percentage point for each of the first three age groups, registering the value 0.8% for 18-34 group, 1.4% for 35-49 years old, 1.9% for 50-64 years old, and decreasing 4 times for those older than 65 years (0.5%). Discussing about anxiety di-sorders with lifetime prevalence (less than 1%), the pattern above is kept only for panic disorder (Graph 2): so, the lifetime prevalence is increasing, progressively with half percentage point from one age group to

Management in Health 3/2009

Graph 1. Lifetime prevalence variation by age for anxiety disorders with lifetime prevalence higher than 1%

Source of data presented in this article: Mental Health Study 2007 , National School of Public Health and Health Services Management

another, being 0.3% for 18-34 group, 0.7% for those of 35-49 years old, 1.2% for those of 50-64 years old, decreasing to 0.7% for those of 65 years old and over. This pattern of progressive increase from youth to maturity and decrease at elderly is not anymore noticed for the others anxiety disorders. For agoraphobia without panic, the values of lifetime are almost similar for 18-34 and 35-49 years old respon-

dents (0.7 respectively 0.8%), decreasing 8 times for 50-64 years old ( to 0.1%) and being zero for 65 and over age group. The same small differences (0.1-0.2%) between age groups was noticed for obssesive compulsive disorder, the exception being registred for 35-49 age group where the value of revalence was zero. the lifetime prevalence is 0.7% for 18-34 years old, 0.9-1% for those of 5064 age group and those older than 65 years old.

Graph 2 Lifetime prevalence variation by age for anxiety disorders with lifetime prevalence under 1%

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Graph 3 Lifetime prevalence variation by age for mood disorders

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Regardless the age group, the lifetime prevalence for major depressive episode is 2.9%. The major depressive episode is one of the disorders where can be noticed a constant increase as the people is ageing. In the category with those with bipolar disorder, the higher lifetime prevalence can be seen at age 18-34 (2%), decreases with half percentage point at groups of 35-49 and 50-64 years old, where are registered values of 1.4 respectively 1.3%, decreasing to half value for those of 65 years old and over (0.7%). The lifetime prevalence for dysthimia with hierachy has low values of 0.1% for 35-49 age group, is increasing to 0.7% for those of 5064 years old and is decreasing to half of this value to 65 years old and over The age group patterns of lifetime (0.4%) . prevalence it is difficult to be inter- When we consider all the mood preted because of the small number of disorders, the lifetime prevalence is cases. A bigger sample, could clarify 4.3% and by age is as following: this aspect. close values for the age groups of The variation by age of mood 18-34 and 35-49 years old on one disorders, is as follows: for the major side (3.7, respectively 3.5%) and for depressive episode, we can see a the age groups 50-64 and 65 years minor increase at age 35-49 (2%) old and over on the other side (5.1compared to 18-34 (1.8%), becoming 5.7%). double for those of 50-64 years old From mood disorders, the number of group (3.9%) and increasing further cases was more consistent for major (to 5%) for those of 65 years old depressive episode. (Graph 3). Generraly for impulsive disorders, the lifetime prevalence is higher at age 18-34, decreasing progressively at age 35-49, 50-64, registering a new increase after 65 years old (Graph 4). The lifetime prevalence for impulsive disorders in general population is 2.1% but reaches 4.3% at 18-34; decreases 4 times for 35-49 (1.1%) and further for those 50-64 years old (0.7%), becoming double for 65 years old and over (1.3%). The same pattern can be seen for intermitent explosive disorder; In the general population the lifetime prevalence is 1.3%, for the age group 18-34, it records values of 2.3%, becoming less than half (0.9%) at 35-49 age group and decreasing continously at 50-64 (0.6%), becoming double for those of 65 25 and over age group (1.2%).

Regarding the generalised anxiety disorder with hierarchy, a young from 100 meets the diagnostic criteria, the lifetime prevalence being 0.9% for 1834 years old; is decreasing 3 times for those of 35-49 years (0.3%), becaming double at 50-64 age group (0.6%) and increases almost 3 times for those of 65 years old and over (1.6%). For separation anxiety disorder, equal values can be seen at 35-49 and 65 and over groups (0.9%), a litlle bitt higher at 18-34 years (1.1%) and lower for 50-64 years old (0.6%).

Graph 4 Lifetime prevalence variation by age for impulse disorders

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Management in Health 3/2009

The conduct disorder with a lifetime Graph 5 Lifetime prevalence variation by age for substance use disorders prevalence of 0.4% in the general population, registers values of 1.1% for 18-34 years old age group, 10 times less for the age groups of 5064 and 65 years old and over (0.1%), becoming zero for those of 35-49 years old. The oppositional defiant disorder has a lifetime prevalence of 0.4%, having a value of 1.3% for 18-34 age group. Attention deficit/ hiperactivity disorder has a lifetime prevalence of 0.2%, the value being 3 times higher for the age group 18-34 compared to 35-49 age group (0.6% compared to 0.2%). As there are extremely few cases for attention deficit hiperactivity disorder, conduct disorder and opositional defiant disorder, it is very difficult any data analysis. (1.6%), decreasing to 1.1 for those of As mentioned before, for the general population, the lifetime prevalence is 13.4%. The under discussion pattern, of 65 years old and over. The drug dependence with abuse has a If for 18-34 years old, the lifetime progressive increase from younger to maturity age groups and decline low prevalence of 0.1%, with values 4 prevalence is 13.2%, it decreases after 65 years old, can be noticed for times higher for 18-34 years old group slowly for those of 35-49 (12.5%); it is the alcohol abuse with or without (0.4%). The alcohol abuse with or without increasing to 15.6% for those of 50-64 dependence (Graph 5). The increase dependence has a value of 0.2%, by three years old and decreasing again to is minor for those of 35-49 years old times higher conpared with the values for 12.5% for those of 65 years old and over (Graph 6). compared to 18-34 age group (2.9% those aged 18-34 (0.7%). The number of cases within the sample The lifetime prevalence for those with compared to 2.7%), being more pronounced to those of 50-64 years is extremely low, making extremely minimum 2 mental disorders is 4.5% in general population. old (4.1%). For those of 65 years old difficult any interpretation. and over, the lifetime prevalence is decreasing to 3% and still remaining Graph 6 Lifetime prevalence variation by age for mental disorders to a value superior to that of younger age groups. The lifetime prevalence for alcohol abuse with or without prevalence is 3.1% in general popu-lation. The lifetime prevalence for any substance use disorder is 3.4% in general population. For 18-34 age group the lifetime prevalence is 3.3%, decreasing slowly to 2.9% for 35-49 age group. It is increasing with 1.2 percentage points for those of 50-64 years old, reaching the value of 4.1% and further is decreasing to 3% for those older than 65 years. The alcohol dependence with abuse has a lifetime prevalence of 0.7% for general population: is 0.4% for 1834 age group. It is increasing 4 times for those of 50-64 years old

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Among those with minimum 2 disorders, those of 18-34 years old group register a value of 5%; this value is decreasing for the 35-49 age group (3.5%), is increasing again to 5.5% for 50-64 group age and is decreasing to 3.8% for those of 65 years old and over. Among those with minimum 3 mental disorders, we saw a lifetime prevalence in the general population of 1.4%, with similar values for 1834 and 50-64 age groups (1.7, respectively 1.6%) and a lower value for 35-49 and 65 and over age groups (1% respectively 1.3%).

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lifetime prevalence 6.9%), for mood disorders, 7.2% (versus 4.3%), for substance use disorders, 4.5% (versus 3.4%) for impulse control disorders is 2.6% (versus 2.1% for the general population and 2.9% for those having 44 or less) and 18.3% for any disorder (versus 13.4%) (Graph 7). The projected lifetime risk by the age of 75 years, based on the age of onset distributions, was 13% higher than lifetime prevalence estimates for anxiety disorders-specific phobia, 24% higher for any impulse disorder, 26% higher for any anxiety disorders, 32% higher for any substance use disorders, and 37% higher for any disorder. It was even much higher, 39% for alcohol abuse with/without dependence, 58% higher for PTSD, 67% for any mood and 90% higher for mood with hierarchy. The observed prevalence was considered as 100% and the value of the projected risk was computed. The disorders with the largest increases of prevalence and projected risk were: alcohol abuse with/without dependence, PTSD, any mood, mood disorder with hierarchy.

The interquartile range was larger (2932 years) for: PTDS (21 - 50 years old), mood with hierarchy (28-58 years old), any mood disorder (24-55 years old), any mental disorder (13-45 years old). It was even larger (34-40 years) for: any impulse disorder (11-45 years old) and any anxiety (8-48 years old).

The projected lifetime risk by the age of 75 years compared with the observed lifetime prevalence

The estimated lifetime risk of psychiatric disorders at age 75 years are generally higher than the observed lifetime prevalence. The median age of the onset The median age of onset indicates This situation can be noticed for each up to what age half of cases had the mental disorder. onset for a certain mental disorder. The median age of onset (e.g., 50th Trying to overcome the limitations of percentile on the age-of-onset distri- the cross sectional studies - an image at bution) was much earlier for specific one moment about present and past phobia (age 9 years), any impulse- status - and translating the findings in control disorders (age 14 years) or longitudinal perspective, it was revealed any anxiety (17 years) compared to that with high likelihood, the prevalence substance use disorders (age 28 could be higher than that observed at years), alcohol abuse with or without certain time. dependence (age 30 years), any The projected risk at age 75 is for anximood disorders (age 34 years), ety disorders 8.7% (versus the observed PTSD (38 years) or mood disorder with hierarchy (44 years old). Graph 7 Projected lifetime risk at age 75 compared to lifetime prevalence From all lifetime cases, 25% start-ed by age 13 years, half of all cases by age 25 years and 75% by age 45 years. The interquartile ranges (IQRs) of the onset age The interquartile ranges for the ageof-onset are the number of years between the 25th and 75th percentiles of the age-of-onset distributions, showing when had the onset 50% of all cases with a certain disorder, excluding those 25% who had the onset very early and 25% having the onset very late. The interquartile ranges (IQRs) were of 13-20 years for some disorders: of 13 years for specific phobia (age 5 and18 years), of 15 years for any substance use disorders (age 21 and 36 years) and 20 years for alcohol abuse with/without dependence (age 21 and 41 years).

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Management in Health 3/2009

Graph 8 Proportional treatment contact in the year of disorder onset and by 50 years for anxiety disorders

Graph 9 Proportional treatment contact in the year of disorder onset and by 50 years for mood disorders

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The median duration of delay for the initial treatment contact is 22-23 years for any mood disorder any anxiety disorder and 30 years for any substance disorder. Within the anxiety disorders, the median duration of delay is 1 year for generalized anxiety disorder, agoraphobia, post traumatic stress disorder, 3 years for adult separation anxiety disorder and vary from 21-22 years for social phobia and panic disorder to 32 years for specific phobia. Within the mood disorders, the median duration of delay varies from 1 year (Dysthymia, Bipolar disorder) to 13 years for major depressive episode. Almost the same range can be found within substance disorders, varying from 1 year (drug abuse) to 15 years for alcohol abuse; for alcohol abuse with dependence, the delay is 5 years.

The largest increases of prevalence and projected risk can be noticed for major depressive disorder with hierarchy (89.7%), any mood disorder (67.4%), and posttraumatic stress disorder (58.3%). It is between 23.8-38.7% for: alcohol abuse with or without dependence (38.7%), mental disorders (36.6%), any substance use disorders (32.4%), any anxiety disorders (26.1%), impulse disorders (23.8%). The smallest increase is for specific phobia (13.2%). Failure and delay in initial treatment contact after the first onset of mental disorders

The proportion of cases that made treatment contact by 50 years ranges from 41.9% for any substance disorder), 43% for any anxiety disorders to 79.8% for any mood disorders. Within the category of anxiety disorders, the proportion of cases making treatment contact by 50 years is higher for panic disorder (66.5%), social phobia (47.6%), specific phobia (32.4%), and adult separation anxiety disorder (30.3%). The proportion becomes lower for agoraphobia (24.6%) and extremely low for generalized anxiety disorder (6.3%) and posttraumatic stress disorder (4.8%). For mood disorder, the proportion of cases making treatment contact by 50 years ranges within a narrow area, from 63.8% (bipolar disorder) to 73% (dysthymia), being of 68.7% for major depressive episode.

The proportion of cases that began treatment contact in the year of disorder onset is 2-3% for any substance disorder and any anxiety disorder and is 10.2% for any mood Among those with anxiety disorders, disorder. improve their help seeking mostly those with panic disorder (66.5% versus Within anxiety disorders, is no treat- 7.9%), any anxiety disorder (43% ment contact in the first year of on- versus 3.1%), specific phobia (32.4% set for social phobia obsessive com- versus 3%), social phobia (47.6% pulsive disorder, adult separation versus zero) and separation anxiety anxiety disorder. disorder (30.3% versus zero). Only for agoraphobia the proportion is higher of 24.6% but for other The proportion of those making anxiety disorders is very low, under treatment contact by 50 years is 10% as follows: 7.9% for panic dis- identical to those with treatment contact order, 6.3% for generalized anxiety in the onset age for agoraphobia, disorder, 4.8% for posttraumatic generalized anxiety disorder and stress disorder and 3% for specific posttraumatic stress disorder. phobia (Graph 8). Among those with substance use disRegarding the mood disorders, the orders the help seeking process is proportion of cases making treat- improving for alcohol abuse with dement contact in the year of onset is pendence (17.2 % versus 6.5%), alcohigher for bipolar disorder (32.5%) hol abuse (25.2% versus 2.2%) and and dysthymia (40.8%) but much any substance use disorder (41.9 verlower for major depressive episode sus 2%). (only 9.1%) (Graph 9). For mood disorders, the help seeking Within the substance disorders, the process is improving by 50 years versus proportion of cases making treatment the year of onset for mood disorders contact in the year of onset is highest (79.8% versus 10.2%), major for drug abuse (63.2%) but much depressive episode (68.7% versus lower, under 10% for alcohol abuse 9.1%), for dysthymia (73% versus with dependence (6.5%) and much 40.8%) and bipolar disorder (63.8% lower for alcohol abuse (2.2%). versus 32.5%).

About one eighth of the Romanians meets the criteria for a DSM-IV disorder sometime in their life, with first onset usually in adolescence or young adulthood. Lifetime prevalence estimates are as follows: any disorder 13.4%, anxiety disorders 6.9%, mood disorders 4.3%, substance use disorders 3.4%, impulse control disorders 2.1% for all adults and 2.9% for those having 44 or less. The median age is 9 years old for specific phobia; 14 years old for any impulse disorder and 17 years old for any anxiety disorder. It is between 18 and 34 years old for any disorder (25 years old), any substance disorder (28 years old), alcohol abuse with or without dependence (30 years old) and any mood disorder (34 years old). The median age is much higher for PTSD (38 years old) and mood disorder with hierarchy (44 years old). The proportion of cases making treatment contact in the year of disorder onset is largely varying from 3% to 24.6% for anxiety disorders, from 9.1% to 40.8% for mood disorders, from 2.2% to 63.2% for substance disorders.

onclusions:

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The delay among those who eventually make treatment contact ranges from 1 year to 32 years for anxiety disorders, from 1 to 13 years for mood disorders, from 1 year to 15 years for substance use disorders. One can notices a delay in making initial treatment contact, which denotes the population lack of knowledge about disease and treatment opportunities, addressing barriers belonging to the patients and health services as well, finally being an aspect of unmet need for mental health care [10]. A high proportion of people with mental disorders in Romania are untreated, despite of the fact that their disorders are source of distress and impairment. It is very important for public health decision makers and psychiatrists specialists to be aware about the lack of treatment of a great part of the people with mental disorders. Interventions to accelerate and accomplish timely the initial treatment contact could reduce the burden and various individual, medical and societal consequences of untreated mental disorders. Giving the age of onset, interventions aimed to the prevention or early treatment need to focus on teenagers and young adults, on family and social close environment, as schools and workplaces.

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Acknowledgment The "Policies in Mental Health Area" and "National Study regarding Mental Health and Services Use" were carried out in conjunction with the World Health Organization World Mental Health (WMH) Survey Initiative. We thank the WMH staff for assistance with instrumentation, fieldwork, and data analysis.

These activities were supported by the United States National Institute of Mental Health (R01MH070884), the John D. and Catherine T. MacArthur Foundation, the Pfizer Foundation, the US Public Health Service (R13MH066849, R01-MH069864, References and R01 DA016558), the 1. WANG, P.S., BERGLUND, P.A., KESSLER, R.C., OLFSON, M., PINCUS, H.A., Fogarty International Center WELLS, K.B. (2005), Failure and delay in initial treatment contact after first onset of (FIRCA R03-TW006481), the mental disorders in the National Comorbidity Survey Replication (NCS-R), Archives of P a n A m e r i c a n H e a l t h General Psychiatry 62(6), 603-613. Organization, the Eli Lilly & 2. KESSLER, R.C., BERGLUND, P.A., DEMLER, O., JIN, R., WALTERS, E.E. (2005), Company Foundation, OrthoLifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National McNeil Pharmaceutical, Inc., Comorbidity Survey Replication (NCS-R), Archives of General Psychiatry 62, 593-602. GlaxoSmithKline, and Bristol3. KESSLER R.C., USTUN T.B., The World Mental Health (WMH) survey initiative Myers Squibb, and Shire. A version of the World Health Organization (WHO) Composite International Diagnostic complete list of WMH Interview (CIDI), Int J Methods Psychiatr Res. 2004;13:93-121. 4. World Health Organization, International Classification of Diseases, 10th Revision publications can be found at internet address: http:// (ICD-10), Geneva, Switzerland: World Health Organization; 1992. www.hcp.med.harvard.edu/ 5. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), Washington, DC: American wmh/. Psychiatric Association; 2000. The Romania WMH study 6. American Psychiatric Association, 2000, Diagnostic and statistical Manual of Mental projects "Policies in Mental Disorders, Fourth Edition, Text revision (DSM-IV, TR); Printed in Romanian by The Romanian Psychiatrists Association, Bucharest, under Scientific Coordination of Prof. Health Area" and "National Study regarding Mental Health Dr. Aurel Romil 7. WHO International Consortium in Psychiatric Epidemiology, Cross-national and Services Use" were carried comparisons of the prevalence and correlates of mental disorders, Bull World Health out by the National School of Organ. 2000; 78:413-426. Public Health & Health 8. OLFSON M., KESSLER R.C., BERGLUND P.A., LIN E., Psychiatric disorder onset Services Management (former and first treatment contact in the United States and Ontario., Am J Psychiatry. 1998; National Institute for Research 155:1415-1422. & Development in Health), with 9. WANG P.S., BERGLUND P.A., OLFSON M., KESSLER R.C., Delays in initial treat- technical support of Metro ment contact after first onset of a mental disorder., Health Serv. Res. 2004;39:393-415. Media Transilvania, the 10. DEMYTTENAERE K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, National Institute of StatisticsAngermeyer MC, Bernert S, de Girolamo G, Morosini P, Polidori G, Kikkawa T, National Centre for Training in Kawakami N, Ono Y, Takeshima T, Uda H, Karam EG, Fayyad JA, Karam AN, Statistics, SC. Cheyenne Mneimneh ZN, Medina-Mora ME, Borges G, Lara C, de Graaf R, Ormel J, Gureje O, Shen Y, Huang Y, Zhang M, Alonso J, Haro JM, Vilagut G, Bromet EJ, Gluzman S, Services SRL, Statistics Webb C, Kessler RC, Merikangas KR, Anthony JC, Von Korff MR, Wang PS, Brugha Netherlands and were funded TS, Aguilar-Gaxiola S, Lee S, Heeringa S, Pennell BE, Zaslavsky AM, Ustun TB, by Ministry of Public Health Chatterji S; WHO World Mental Health Survey Consortium, Prevalence, severity and (former Ministry of Health) unmet need for treatment of mental disorders in the World Health Organization World with supplemental support of Eli Lilly Romania SRL. Mental Health Surveys, JAMA. 2004;291:2581-2590.

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