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Major depressive episodes (MDE) as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DMS-IV) were evaluated in face-to-face interviews using the World Health Organization Composite International Diagnostic Interview (CIDI). Data from 18 countries were analyzed in this report (n = 89,037). All countries surveyed representative, population-based samples of adults.
Major depression is a serious, recurrent disorder linked to diminished role functioning and quality of life, medical morbidity, and mortality [1, 2]. The World Health Organization ranks depression as the fourth leading cause of disability worldwide , and projects that by 2020, it will be the second leading cause . Although direct information on the prevalence of depression does not exist for most countries, the available data indicate wide variability in the prevalence rates. Weissman et al.  published the first cross-national comparison of major depression as defined by the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) from 10 population-based surveys that used the Diagnostic Interview Schedule (DIS) . The lifetime prevalence ranged from 1.5% (Taiwan) to 19.0% (Beirut), with the midpoints at 9.2% (West Germany) and 9.6% (Edmonton, Canada). The 12-month prevalence ranged from 0.8% (Taiwan) to 5.8% (Christchurch, New Zealand), with the midpoints at 3.0% (US) and 4.5% (Paris). A subsequent cross-national comparison  included 10 population-based studies that used the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) for the revised third edition and the fourth edition of the DSM (DSM-III-R) and (DSM-IV) . Consistent with the earlier report , the lifetime rates ranged from 1.0% (Czech Republic) to 16.9% (US), with midpoints at 8.3% (Canada) and 9.0% (Chile). The 12-month prevalence ranged from 0.3% (Czech Republic) to 10% (USA), with midpoints at 4.5% (Mexico) and 5.2% (West Germany). Most recently, Moussavi et al.  summarized data on depressive episodes as defined by the International Classification of Diseases, 10th revision (ICD-10) in participants in the WHO World Health Survey used in 60 countries, noting that the 1-year prevalence was 3.2% in participants without comorbid physical disease, and 9.3% to 23.0% in participants with chronic conditions.
The wide variability in lifetime and 12-month prevalence estimates of major depression is presumably due to a combination of substantive (genetic vulnerability and environmental risk factors) and measurement (cultural differences in the acceptance and meaning of items, and the psychometric properties of the instruments) factors. Differences in study design might also be involved. That is, apart from administering a common interview schedule, the surveys were not designed as replications with a standard protocol for translation, interviewer training, sampling and quality control. More recently, the WHO World Mental Health (WMH) Survey Initiative conducted a coordinated series of studies using a common protocol and a common instrument, the WHO CIDI, version 3.0 , to assess a set of DSM-IV disorders in countries from every continent . The 12-month prevalence of DSM-IV major depressive episode (MDE) in 18 countries ranged from 2.2% (Japan) to 10.4% (Brazil) . The mid-point across all countries was similar to that in previous surveys (5%), as was the weighted average 12-month prevalence for the ten high-income (5.5%) and eight low- to middle-income (5.9%) countries.
The current report presents data on the prevalence, age of onset and sociodemographic correlates of MDE in 18 countries participating in the WHO WMH Survey Initiative. As noted earlier, each of the WMH surveys used the CIDI for DSM-IV. The CIDI includes a series of diagnostic stem questions to determine which diagnoses are assessed. Unlike previous reports from the WMH or previous surveys, our study used the screening information for MDE in responses to these diagnostic stem questions to conduct an examination of the screen-positive percentages, and of the conditional lifetime and 12-month prevalence of MDE in respondents who endorsed the diagnostic stem questions. This was carried out to investigate the possibility that cross-national differences in prevalence estimates of MDE are due, at least in part, to differences across countries in the optimal threshold of CIDI symptom scores for detecting clinical cases. If such variation exists, we would expect much smaller cross-national differences in endorsement of diagnostic stem questions (which merely ask respondents if they had episodes of several days of being sad or depressed or losing interest in usual activities), than in diagnoses. If this were the case, we would expect the largest cross-national differences in conditional prevalence estimates of MDE to occur in screened positives. If differential variation of this sort exists, it would provide more reason than currently exists to suspect that cross-national differences in optimal diagnostic thresholds of the CIDI symptom scale lead to biased estimates of cross-national differences in prevalence in the WMH data.
A justification for this line of thinking comes from an earlier cross-national WHO study of major depression in primary-care patients, which found strong similarity in the latent structure of depressive symptoms across 14 different countries in different parts of the world, but also found that countries with the highest prevalence estimates generally reported the lowest impairment associated with depression . The authors concluded from these results that although cross-national differences in the estimated prevalence of depression cannot be attributed to differences in the nature or validity of the concept of a depressive episode, it is possible that DSM criteria may define different levels of depression severity in different countries. Our cross-national comparison of responses to diagnostic stem questions, described in the previous paragraph, was designed to shed some light on this possibility. In addition, we carried out a parallel analysis of cross-national differences in impairment associated with MDE.
In considering a substantive interpretation of our findings, it is noteworthy that although lifetime prevalence estimates were found to be significantly higher in high than low- to middle-income countries overall, no significant difference in 12-month prevalence was found. The ratio of 12-month to lifetime prevalence estimates, furthermore, was significantly higher in low- to middle-income than in high-income countries. It might be that these results reflect genuinely lower lifetime prevalence but higher persistence of depression in low- to middle-income than high-income countries, but another plausible and more parsimonious explanation is that error in recall of previous lifetime episodes is higher in low- to middle-income than high-income countries. Longitudinal data collection would be required to document such a difference rigorously [28, 29]. Although such data do not exist in all WMH series, it is important to recognize this possibility of cross-national variation in recall error before launching an extensive investigation of substantive explanations. It might be that a fruitful focus of subsequent WMH analysis would be on the youngest respondents, where lifetime recall error might be least pronounced. Alternatively, it might be that the investigation of cross-national differences in lifetime prevalence should be abandoned in favor of a focus on recent prevalence in recognition of the plausibility of significant cross-national variation in recall error of lifetime prevalence.
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