Twelve‐months prevalence of mental disorders in the German Health Interview and Examination Survey for Adults – Mental Health Module (DEGS1‐MH): a methodological addendum and correction

Abstract

We recently published findings in this journal on the prevalence of mental disorders from the German Health Interview and Examination Survey for Adults Mental Health Module (DEGS1‐MH). The DEGS1‐MH paper was also meant to be the major reference publication for this large‐scale German study program, allowing future users of the data set to understand how the study was conducted and analyzed. Thus, towards this goal highest standards regarding transparency, consistency and reproducibility should be applied. After publication, unfortunately, the need for an addendum and corrigendum became apparent due to changes in the eligible reference sample, and corresponding corrections of the imputed data. As a consequence the sample description, sample size and some prevalence data needed amendments. Additionally we identified a coding error in the algorithm for major depression that had a significant effect on the prevalence estimates of depression and associated conditions. This addendum and corrigendum highlights all changes and presents the corrected prevalence tables. Copyright © 2015 John Wiley & Sons, Ltd.

Introduction

We recently published in this journal two papers describing the design and methods (Jacobi et al., 2013) and the 12‐month prevalence findings from the Mental Health Module of the German Health Interview and Examination Survey (DEGS1‐MH; Jacobi et al., 2014). These papers were also meant to be baseline publications for the study program, allowing future users of the data set to understand how the study was conducted, analyzed and interpreted. Thus, towards this goal highest standards regarding transparency, consistency and reproducibility should be applied. Unfortunately, three seemingly minor events have made an addendum and corrigendum to the first two papers necessary: First, one of the study participants withdrew consent post hoc and after publication of these papers, forcing us to delete this case from the data base for future analyses. Additionally, quality assurance measures revealed problems with the supplementary diagnostic imputation procedures that had some effect on the reported prevalence estimates in one analysis. Thirdly, a coding error in the depression algorithm led to the unfortunate situation that some cases were not assigned a diagnosis, despite meeting all mandatory criteria for depression. In this addendum we present a revised sample description, including a revised flow chart and comment on the prevalence findings.

Methods

Sample

The DEGS1‐MH study design and weighting procedures for the estimation of prevalences have been described in detail in a methods paper (Jacobi et al., 2013) and in the method section of the prevalence publication (Jacobi et al., 2014). The sample and method description in these publication should be modified for two reasons: (a) one person with full interview information post hoc withdrew consent for participation; (b) quality assurance measures suggest the need to delete 14 participants of the imputation sample (of formerly n = 834 subjects) because in these cases more than 20% of the Composite International Diagnostic Interview (CIDI) stem questions had not been answered (Figure 1 presents the corrected new numbers of subjects in the study sample). Further, the DEGS1 steering board made a small conceptual change regarding the composite education variable (CASMIN; Kamtsiuris et al., 2013) that led to slight differences in the distribution of education and socio‐economic status compared to Jacobi et al. (2014, Table 3, left column) but this did not affect results in the respective correlates.

Figure 1.

Response and non‐response in DEGS1‐MH. ^aSee Scheidt‐Nave et al. (2012). ^bAfter a minimum of 10 contact attempts by telephone or letter (different days and times).

Table 3.

Socio‐demographic correlates of major diagnostic subgroups (12‐month; DEGS1‐MH weighted data from sample with full CIDI information; N = 4483)

	Distribution of correlate in sample	Twelve‐month prevalence if correlate present
		Any substance use disorder				Any possible psychotic disorder				Any mood disorder				Any anxiety disorder				Any somatoform disorder
	%w	%w	ORa	95% CI	p‐Value	%w	ORa	95% CI	p‐Value	%w	ORa	95% CI	p‐Value	%w	ORa	95% CI	p‐Value	%w	ORa	95% CI	p‐Value
Sex
Men	49.2	8.0	ref.			2.1	ref.			6.5	ref.			9.6	ref.			1.8	ref.
Women	50.8	3.6	0.4	0.3–0.6	0.000	3.2	1.5	0.9–2.5	0.118	13.4	2.3	1.7–3.0	0.000	22.1	2.7	2.1–3.4	0.000	5.5	3.2	2.0–4.9	0.000
Age
18–34	24.4	8.0	1.4	0.9–2.2	0.202	4.5	2.1	1.1–4.1	0.028	15.7	1.6	1.1–2.2	0.010	18.8	1.1	0.8–1.5	0.441	4.4	1.1	0.6–1.9	0.777
35–49	29.5	6.1	ref.			2.2	ref.			10.5	1.0	1.0–1.0		16.9	ref.			4.0	ref.
50–64	25.4	5.9	1.0	0.6–1.5	0.874	2.6	1.2	0.6–2.4	0.568	7.0	0.6	0.5–0.9	0.010	16.1	0.9	0.7–1.2	0.644	3.8	0.9	0.5–1.6	0.805
65–79	20.7	2.5	0.4	0.2–0.7	0.001	1.4	0.6	0.3–1.5	0.306	6.3	0.6	0.4–0.8	0.005	11.2	0.6	0.4–0.8	0.003	2.1	0.5	0.3–0.9	0.028
Marital status
Married	59.3	3.8	ref.			1.5	ref.			6.6	ref.			14.3	ref.			2.7	ref.
Never married	13.5	7.9	2.2	1.3–3.5	0.002	3.8	2.5	1.2–5.2	0.014	16.0	2.7	1.8–3.9	0.000	20.0	1.5	1.1–2.0	0.010	5.4	2.1	1.2–3.7	0.014
Separated/divorced/widowed	27.1	9.0	2.5	1.7–3.7	0.000	4.6	3.1	1.7–5.5	0.000	14.5	1.7	1.1–2.5	0.018	17.7	1.3	1.0–1.7	0.047	4.9	1.9	1.2–2.9	0.009
Current partnership
Yes	73.7	4.9	ref.			2.0	ref.			7.4	ref.			15.2	ref.			3.3	ref.
No	26.2	8.1	1.7	1.2–2.5	0.004	4.6	2.4	1.4–4.0	0.001	17.3	2.3	1.7–3.2	0.000	18.0	1.2	1.0–1.6	0.102	4.7	1.5	0.9–2.3	0.090
Educational levelb
Low	34.0	6.5	1.1	0.8–1.6	0.598	3.0	1.1	0.6–2.0	0.735	9.7	1.2	0.9–1.7	0.269	16.8	1.0	0.8–1.3	0.871	3.1	0.6	0.4–1.0	0.063
Medium	52.1	5.9	ref.			2.7	ref.			10.8	ref.			16.5	ref.			4.7	ref.
High	13.9	3.4	0.6	0.3–1.0	0.063	2.1	0.8	0.4–1.5	0.488	7.5	0.8	0.5–1.1	0.156	12.2	0.7	0.5–1.0	0.022	1.0	0.2	0.1–0.4	0.000
Socio‐economic statusc
Low	19.5	9.7	2.3	1.5–3.5	0.000	4.6	1.9	1.0–3.6	0.041	15.1	1.8	1.3–2.5	0.001	21.3	1.4	1.1–1.9	0.017	3.6	0.9	0.5–1.6	0.730
Medium	60.2	4.6	ref.			2.4	ref.			9.4	ref.			16.0	ref.			4.0	ref.
High	20.3	5.4	1.2	0.8–1.9	0.454	1.6	0.7	0.4–1.2	0.200	6.7	0.7	0.5–1.0	0.055	11.0	0.7	0.5–0.9	0.002	2.5	0.6	0.4–1.1	0.086
Employment
Yes	60.2	5.0	ref.			2.3	ref.			9.8	ref.			15.1	ref.			3.1	ref.
Nod	39.8	6.9	1.4	1.0–2.0	0.068	3.3	1.5	0.9–2.5	0.135	10.3	1.4	1.0–2.0	0.042	17.3	1.2	0.9–1.5	0.138	4.5	1.4	1.0–2.2	0.084
Urbanization
<20,000 inhabitants	39.2	5.8	ref.			2.5	ref.			8.2	ref.			15.2	ref.			2.8	ref.
20,000–<100,000	29.8	4.7	0.8	0.5–1.2	0.328	1.7	0.7	0.4–1.2	0.200	10.8	1.3	1.0–1.8	0.096	16.0	1.1	0.8–1.4	0.657	4.1	1.5	0.9–2.4	0.124
100,000–<500,000	15.2	6.2	1.1	0.6–1.8	0.790	2.7	1.1	0.5–2.4	0.855	8.7	1.0	0.7–1.5	0.940	14.1	0.9	0.7–1.3	0.606	3.7	1.3	0.7–2.4	0.363
>500,000	15.8	7.3	1.3	0.8–2.1	0.339	5.2	2.2	1.1–4.3	0.028	14.2	1.7	1.1–2.4	0.012	19.6	1.4	1.0–1.9	0.057	4.8	1.7	0.9–3.3	0.091

^aOdds ratios (ORs) from logistic regression and 95% confidence intervals (CIs); marital status, partnership, educational level, socio‐economic status, employment and urbanization controlled for age and sex.

^bCASMIN classification.

^cIndex of social class (Lampert et al., 2013) derived from information on education, income and current (job) position.

^dNumber of unemployed, retired, student.

Imputation and weighting

Out of the 5303 participants N = 4483 completed the full DEGS1‐MH assessment. Of these N = 820 completed only the core diagnostic part of the assessment package, based on the CIDI stem screening questions (CID‐S; Wittchen et al., 1999), because of time constraints (N = 450), health problems (N = 49), and other reasons (N = 321). Prevalence rates in this paper are based on the 4483 persons with a full data set and the 820 persons for which diagnostic information was imputed by using the screening questionnaire, resulting in the total sample of N = 5303. Model‐based estimates of probabilities for diagnoses were filled in to reduce selection bias due to those who did not complete the full CIDI and to enhance statistical precision for prevalence estimation and subsequent analyses. The identical method as described in Jacobi et al. (2013) was used for the N = 5303 sample (instead of 5318 in the original publication). Also, a new sampling weight was calculated in the reduced sample of N = 5303 as described in Jacobi et al. (2013).

Correction of the diagnostic algorithm

For use in the DEGS1‐MH study, the CIDI was modified to allow for a separation of symptoms during the past 12 months and symptoms in the time period before. When making the according changes in the diagnostic algorithm a programming error (use of an AND instead of an OR statement) was made. This led to the unfortunate result that some subjects were not diagnosed as having major depression, although they should have been. Due to the differential diagnostic rules, this also affected the estimate for dysthymia as well as the overall count.

Results

Based on the sample size of N = 4483 with full interview information, and N = 820 used for imputation (resulting in a total sample of N = 5303), we present the corrected tables on 12‐month prevalence, comorbidity and correlates in Tables 1, 2, 3.

Table 1.

Twelve‐month prevalences of mental disorders (M‐CIDI/DSM‐IVTR) in the general population (DEGS1‐MH; N=5303)a

	Total				Men				Women				18–34				35–49				50–64				65+
	N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI
Any mental disorder due to general medical condition or substance induced disorders (F06)	56	1.2	0.9	1.6	28	1.2	0.8	1.8	28	1.2	0.8	1.9	11	1.7	0.9	3.2	10	0.7	0.4	1.3	19	1.3	0.8	2.1	16	1.3	0.7	2.3
Any substance use disorder (F1)b	766	16.7	15.5	18.0	424	19.4	17.6	21.4	342	14.0	12.5	15.7	221	23.5	20.5	26.7	240	19.4	17.0	22.0	220	15.4	13.3	17.8	85	6.1	4.8	7.8
Any substance without nicotine dependencec	259	5.7	5.0	6.6	170	8.0	6.7	9.4	89	3.5	2.8	4.5	77	8.4	6.64	10.6	66	5.9	4.5	7.8	78	5.5	4.2	7.2	38	2.5	1.7	3.5
Alcohol abuse	80	1.8	1.4	2.3	71	3.1	2.4	4.1	9	0.4	0.2	0.9	35	3.4	2.4	4.9	23	2.0	1.2	3.1	15	1.0	0.5	2.0	7	0.4	0.2	0.8
Alcohol dependence	137	3.0	2.5	3.6	96	4.4	3.5	5.5	41	1.6	1.2	2.2	43	4.8	3.5	6.5	36	2.6	1.9	3.7	45	3.4	2.4	4.8	13	0.8	0.5	1.4
Medication abuse	70	1.6	1.2	2.1	29	1.5	1.0	2.2	41	1.7	1.1	2.4	13	1.5	0.9	2.7	19	2.1	1.2	3.5	23	1.4	0.9	2.2	15	1.0	0.6	1.8
Medication dependence	20	0.5	0.3	0.8	6	0.3	0.13	0.6	14	0.7	0.4	1.3	3	0.5	0.2	1.5	4	0.4	0.2	1.1	6	0.6	0.3	1.3	7	0.5	0.2	1.2
Nicotine dependence	597	13.2	12.1	14.3	315	14.6	13.0	16.3	282	11.8	10.4	13.4	177	18.9	16.3	21.8	204	15.9	13.8	18.3	163	11.8	9.9	13.9	53	4.1	3.0	5.4
Possible psychotic disorder (F2)c	114	2.6	2.1	3.2	47	2.1	1.6	2.9	67	3.1	2.3	4.1	36	4.2	2.9	6.2	31	2.2	1.5	3.2	31	2.5	1.6	3.7	16	1.3	0.7	2.4
Any mood disorder (F3)	481	9.8	8.8	10.8	157	6.4	5.4	7.6	324	13.1	11.5	14.8	135	15.1	12.6	18.0	136	10.3	8.6	12.4	130	7.0	5.8	8.5	80	5.9	4.5	7.7
Unipolar depression	414	8.2	7.3	9.2	131	5.1	4.3	6.1	283	11.3	9.8	12.9	102	11.7	9.5	14.4	114	8.5	7.0	10.4	118	6.3	5.2	7.6	79	5.9	4.5	7.7
Any bipolar disorder	66	1.5	1.1	2.0	26	1.3	0.8	2.0	40	1.7	1.2	2.5	33	3.3	2.2	4.9	21	1.7	1.0	2.8	11	0.7	0.4	1.4	1	0.1	0.0	0.2
Major depressive disorder	338	6.8	6.0	7.7	103	4.0	3.3	4.9	235	9.5	8.2	11.1	87	10.0	7.9	12.5	96	7.2	5.7	9.0	96	5.2	4.2	6.4	59	4.4	3.2	6.0
Dysthymia	85	1.7	1.3	2.1	29	1.2	0.8	1.8	56	2.1	1.6	2.8	17	2.1	1.3	3.4	23	1.7	1.1	2.5	24	1.3	0.8	2.0	22	1.6	1.0	2.7
Bipolar I disorder	45	1.0	0.7	1.4	17	0.9	0.5	1.5	28	1.1	0.8	1.7	20	1.9	1.2	3.0	13	1.1	0.6	2.1	10	0.7	0.4	1.4	1	0.1	0.0	0.2
Bipolar II disorder	23	0.6	0.4	1.0	10	0.48	0.2	1.1	13	0.7	0.4	1.4	14	1.6	0.9	3.0	9	0.7	0.3	1.6	1	0.0	0.0	0.1	0	0.0	0.0	0.0
Any anxiety disorder (F40. F41. F42. F43)	762	15.4	14.2	16.6	224	9.3	8.1	10.8	538	21.4	19.5	23.4	177	18.1	15.4	21.0	214	16.2	14.0	18.7	227	15.3	13.3	17.6	143	11.1	9.0	13.5
Panic disorderd	105	2.0	1.6	2.5	27	1.2	0.8	1.8	78	2.8	2.2	3.6	19	1.5	0.9	2.3	38	2.9	2.0	4.2	34	2.5	1.7	3.7	14	0.8	0.4	1.5
Agoraphobia (“without panic” disorder?)	192	4.0	3.4	4.7	59	2.3	1.7	3.1	133	5.6	4.6	6.9	40	4.2	2.9	5.9	57	4.1	3.0	5.5	61	4.1	3.1	5.5	34	3.5	2.3	5.4
Social phobia	113	2.8	2.2	3.4	44	1.9	1.4	2.6	68	3.6	2.7	4.9	37	4.6	3.2	6.7	35	3.1	2.1	4.6	31	2.2	1.4	3.2	9	0.7	0.3	1.5
Generalized anxiety disorder	103	2.3	1.8	2.9	37	1.5	1.1	2.2	66	3.0	2.2	4.0	22	3.3	2.0	5.2	29	2.0	1.4	2.9	35	2.3	1.6	3.3	17	1.3	0.6	2.6
Specific phobiase	507	10.3	9.3	11.4	125	5.1	4.2	6.2	382	15.47	13.85	17.2	120	12.3	10.1	14.9	128	9.5	7.9	11.5	155	10.9	9.1	12.9	103	8.4	6.6	10.5
Obsessive compulsive disorder	154	3.6	3.0	4.3	64	3.3	2.5	4.2	90	3.99	3.12	5.1	60	7.2	5.5	9.5	44	3.6	2.6	4.9	33	2.2	1.5	3.1	17	1.1	0.7	1.9
Post‐traumatic stress disorder	108	2.3	1.8	2.9	22	0.9	0.6	1.5	85	3.6	2.8	4.7	32	3.7	2.5	5.5	30	2.5	1.7	3.8	20	1.0	0.6	1.5	25	1.8	1.2	2.8
Any somatoform disorder/syndrome (F45)f	186	3.5	3.0	4.2	48	1.7	1.3	2.4	138	5.3	4.3	6.4	45	4.2	3.0	5.9	54	3.8	2.8	5.2	57	3.6	2.6	5.0	30	2.1	1.3	3.1
SSI4.6	37	0.8	0.6	1.1	17	0.6	0.4	1.0	20	0.9	0.6	1.6	7	0.9	0.4	1.9	8	0.6	0.3	1.3	14	0.9	0.5	1.6	8	0.8	0.3	1.9
Pain disorderd	165	3.2	2.6	3.8	35	1.3	0.9	1.8	130	5.1	4.1	6.2	41	4.0	2.8	5.6	53	3.8	2.8	5.1	46	3.0	2.1	4.4	25	1.6	1.0	2.5
Any eating disorder (F50. F51)g	45	0.9	0.7	1.3	11	0.5	0.3	0.9	35	1.4	0.9	2.1	23	2.3	1.4	3.7	7	0.5	0.2	0.9	9	0.7	0.3	1.3	7	0.4	0.1	1.1
Anorexia nervosa	32	0.8	0.5	1.1	6	0.3	0.2	0.8	25	1.2	0.7	1.8	18	2.0	1.1	3.4	5	0.4	0.2	0.9	3	0.3	0.1	1.0	6	0.4	0.1	1.1
Bulimia Nervosa	12	0.2	0.1	0.3	2	0.1	0.0	0.3	10	0.3	0.2	0.5	5	0.4	0.2	0.8	2	0.1	0.0	0.2	4	0.3	0.1	0.7	0	0.0	0.0	0.0
Eating disorder NOS	6	0.1	0.1	0.2	3	0.1	0.0	0.2	3	0.1	0.0	0.4	1	0.1	0.0	0.6	2	0.1	0.0	0.5	2	0.1	0.0	0.4	0	0.0	0.0	0.0
Any of the above	1713	34.5	33.0	36.1	710	30.5	28.3	32.7	1004	38.6	36.4	40.8	427	44.0	40.5	47.5	477	36.4	33.4	39.4	507	32.9	30.2	35.8	303	22.6	19.9	25.5
Any of the above (without nicotine dependence)	1403	27.8	26.4	29.3	527	22.1	20.2	24.1	876	33.5	31.4	35.7	348	35.8	32.5	39.3	372	28.0	25.3	31.0	416	26.4	23.8	29.1	268	19.6	17.1	22.4

^aWeighted data; cell counts sometimes do not add up to total counts because missings in the diagnostic variable were imputed; DSM‐IV hierarchy rules were dropped.

^bWithout illicit drug abuse/dependence (not assessed).

^cScreening for schizophrenia and other psychotic disorders without further differential diagnosis; includes psychotic features occurring as part of mood disorders and psychotic disorders due to general medical conditions.

^dWith or without agoraphobia.

^eAnimal, natural environment, blood‐injection‐injury, and situational type.

^fSomatic Symptom Index (SSI4.6), pain disorder.

^gAnorexia Nervosa, Atypical Anorexia Nervosa, Bulimia Nervosa, Atypical Bulimia Nervosa, binge eating disorder.

Table 2.

Comorbidity among the DEGS1‐MH cases with at least one 12‐month diagnosis (DEGS1‐MH data from N = 4483 with full diagnostic information)a

	Total				Men				Women				18–34				35–49				50–64				65+
Number dx	N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI		N	%w	95%CI
one	704	55.0	51.2	58.7	291	63.2	57.2	68.8	413	49.8	45.1	54.5	154	50.6	43.3	57.9	173	53.8	46.6	60.8	223	57.23	50.6	63.6	154	63.1	53.9	71.4
two	252	22.0	19	25.4	94	21.8	17.1	27.3	158	22.2	18.4	26.5	59	22.2	16.5	29.1	66	22.5	17.2	29	72	20.32	15.4	26.4	55	23.5	16.4	32.4
three	109	10.0	8	12.5	28	6.9	4.5	10.4	81	12.0	9.2	15.5	30	9.9	6.5	14.9	39	12.8	8.7	18.6	30	10.3	6.8	15.2	10	4.2	2.1	8.3
four	61	5.5	4	7.4	17	3.4	1.9	5.8	44	6.8	4.7	9.7	22	7.4	4.5	12	11	3.0	1.5	6	19	6.2	3.7	10.1	9	5.0	1.8	13.3
five+	71	7.5	5.5	10.0	20	4.8	2.8	8.1	51	9.2	6.4	12.9	21	9.9	5.8	16.2	21	7.8	4.6	13.1	21	6.0	3.5	10.1	8	4.3	1.9	9.2

^aDEGS1‐MH data from N = 4483 with full diagnostic information (note: if among the sample of 4483 a specific diagnostic CIDI section was not completed, such missings in diagnoses were replaced with predicted probabilities, using the CIDI stem questions, age and gender). Among N = 1403 estimated cases (among N = 5303) with any diagnosis (without nicotine dependence) 206 cannot be evaluated with regard to comorbid proportions because they result from adding up imputed probabilities < 1. Among the N = 1197 cases with at least one diagnosis, a total of 2218 diagnoses (unweighted) were assigned (male 12‐month cases: mean (M) = 1.74, standard deviation (SD) = 1.46; female 12‐month cases: M = 2.16, SD = 1.72; weighted).

As compared to the original paper, prevalence estimates (Table 1) changed only in the following rows: any mood disorder, unipolar depression, major depressive disorder, dysthymia and any mental disorder. The combined effect of all corrections was overall minimal. For example the estimate for any mood disorder increased from 9.3% to 9.8%, the rate for major depression increased from 6.0% to 6.8% (12‐month diagnoses). The overall 12‐month rate for having any diagnosis increased marginally from 34.4% to 34.5% (any diagnosis without nicotine dependence increased from 27.7% to 27.8%).

Changes in Table 2 on comorbidity patterns reveal a few minor changes in the range of less than one percentage point. Overall the proportion of subjects with only one major diagnosis decreased from 55.6% to 55.0%.

Table 3, summarizing the socio‐demographic correlates of major syndromes reveals changes only for the column mood disorder. Changes were minimal regarding the odds ratios (ORs) as well as the p‐values.

Comment

As unpleasant, confusing and potentially damaging corrections after publication undoubtedly are, we want to emphasize that the corrections did not in any way change the findings, the content and the conclusions. None of these changes had any impact on the numbers and findings of previous publications from the DEGS1‐MH program. The aim of the present addendum and corrigendum was to communicate correct and detailed information about case numbers and prevalence rates for the DEGS1‐MH survey. The tables in the corrigendum should replace the original tables and should be taken as the correct reference in the future. We also highlight that the optional e‐tables have been updated accordingly as well.

Supporting information

Supporting info item

Jacobi, F. , Höfler, M. , Strehle, J. , Mack, S. , Gerschler, A. , Scholl, L. , Busch, M. A. , Hapke, U. , Maske, U. , Seiffert, I. , Gaebel, W. , Maier, W. , Wagner, M. , Zielasek, J. , and Wittchen, H.‐U. (2015) Twelve‐months prevalence of mental disorders in the German Health Interview and Examination Survey for Adults – Mental Health Module (DEGS1‐MH): a methodological addendum and correction. Int. J. Methods Psychiatr. Res., 24: 305–313. doi: 10.1002/mpr.1479.