1. State of Mental Health in Ukraine: 2002 Evelyn J. Bromet September, 2007

2. Global Burden of Disease  Late 1990s, WHO published a list of top 10 causes of disease burden in the world  Depression and alcohol use are in top 10  Decision was made to organize prevalence studies around the world to determine the rates and need for treatment.

3. Assessment schedule Composite International Diagnostic Interview (CIDI) Covers major psychiatric disorders, alcoholism, disability, and use of medical and psychiatric services Also medical problems, childhood disorders, marital conflict, demographic

4. Strength Strength: all countries used virtually the same interview, sampling strategy, centralized quality control Ukraine: first former Soviet country to participate and the only one with published data (Bulgaria has data; Romania is collecting data)

5. Countries in World Mental Health Europe+South AmericaAsia Belgium Brazil (one city) India France Costa Rica (planned) China (2 cities) Germany Colombia China (nat’l planned) Italy Mexico Australia (planned) Spain Peru (not done) New Zealand Netherlands Middle East Japan Portugal (planned) Israel Africa N. Ireland Lebanon South Africa Turkey Palestine (in field) Nigeria Ukraine Iraq (in field) Bulgaria Romania (in field)

7. Ukraine WMH  Funded by US National Institutes of Health  Collaboration of Kiev International Institute of Sociology, Ukrainian Psychiatric Association, and Stony Brook

11. Focus Group Work  Examine the face validity of the items in key sections of the interview (depression, PTSD, alcoholism employment, services)  Big discussion on consent form

12. Two Studies  Population Survey  Clinical Reappraisal Study

13. Population survey  National probability sample adults 18+  N=4725  Response rate = 78.3%

14. Number of respondents in each oblast

15. Characteristics of 4,725 respondents 1/3 rural, 1/3 mid-size urban, 1/3 large urban areas 47% interviewed in Ukrainian 44% currently employed; 38% retired 16% adequate financial status, 51% inadequate, 33% very inadequate

16. Characteristics of 4,725 respondents Sex: 38% male Age: median=49 44% education beyond high school 60% currently married Therefore data were weighted to census for all analyses

17. Prevalence Overall, 32% of population had 1+ disorder in their lifetime; 18% in year before interview. Consistent with WHO report, depression and alcoholism were the two most common disorders.

18. Alcohol Abuse and Dependence Abuse: Persistent use for 12 months or more in spite of: 1.Physical hazards 2.Being arrested for drunken behavior 3.Getting into major fights while drunk Dependence: Period of 12 months or more with: 1.Tolerance (needing more for an effect) 2.Withdrawal (needing alcohol in morning) 3.Persistent desire for alcohol 4.Can’t cut down 5.Give up normal activities in order to drink

19. Prevalence of Any Alcohol Disorder

21. Lifetime prevalence compared with Europe

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23. Generational differences in alcoholism Median age of onset = 25

24. Risk factors for alcoholism Male Russian-speaking Low education Separated and divorced Adequate finances

25. Hospitalization 7.7% of men and 14.9% of women were hospitalized overnight for alcoholism

26. DSM-IV major depression Period of 2 weeks or more with 5 of 9 persistent symptoms 1.Depressed mood most of day 2.Loss of interest 3.Weight loss or gain 4.Sleep problems 5.Agitated or slowed down 6.Fatigue, loss of energy 7.Worthlessness or guilt 8.Concentrate problems 9.Suicidal thoughts

27. Prevalence of Depression in Ukraine

29. Lifetime prevalence compared with Europe

30. Generational differences in depression Median age of onset 28

31. Risk factors for depression Female Older Widowed, separated or divorced Retired Western region Low education Poverty

32. Talked to a professional… 17% talked to a professional (usually general doctor) 25% with suicidal thoughts spoke to their doctor Thus most did not seek help.

33. Chornobyl story AFTER assessing disorders, asked if ever lived in area contaminated by Chornobyl. 388/4725 exposed to Chornobyl, 8% Slightly more exposed (p<0.05) --rated health poor (25% vs 21%) --depression (18% vs 14%) --alcoholism (19% vs 11%)

34. Chornobyl story: liquidators After completed the study, RCRM did the interview with 295 liquidators from 5 regions Compared them with 397 men from same regions who were in World Mental Health Liquidators >depression, anxiety, suicide ideation and severe headaches, and missed more days from work.

35. Validity study Diagnostic Reinterview Study SCID Dr. Gutkovich, Kostyuchenko & Havenaar Trained 15 psychiatrists from 3 cities: Lviv, Kyiv, Donetsk

37. Method 176 respondents were assessed by psychiatrist Interviews were tape recorded Tapes reviewed in Kyiv and at Stony Brook Comparisons between CIDI and SCID

38. Results CIDI –SCID agreement: 98% alcoholism 78% depression Areas of disagreement: SCID alcoholism > CIDI SCID depression < CIDI

39. Conclusion Ukraine among countries with highest rates of disorder, especially alcoholism

40. Lifetime Rates Any Disorder: Top 5 Countries

41. Conclusion Ukraine among countries with lowest rates of mental health treatment

42. Mental health specialty care past 12 months: Lowest 5 Countries Ukraine: 1.2% of population, 4% of those with a 12-month disorder; 0.6% without

43. Conclusion In most countries, treatment, if sought, is from general practitioners In all countries, especially Ukraine, poorly trained to treat mental health and alcohol problems. Challenge for Ukraine, given the small number of mental health professionals, is to train general practitioners to recognize and adequately treat mental health and alcohol problems.