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Fact sheet

Psychological problems and disorders in Norway - fact sheet

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Felles for alle psykiske lidelser er at de påvirker tanker, følelser, atferd, væremåte og omgang med andre.. Foto: Colourbox.com
Foto: Colourbox.com

Mental disorders range from simple phobias, mild anxiety and depressive disorders to severe illnesses such as schizophrenia. Common to all mental disorders is that they affect thoughts, feelings, behaviour and interactions with others. The most common disorders are anxiety and depression.


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What are psychological distress and mental disorders?

It is common to differentiate between psychological distress and mental disorders.

Psychological distress

By psychological distress we mean conditions that are experienced as strainful, but not to such a degree that they are characterised as diagnoses. 

To measure psychological distress, a questionnaire is usually completed by the subject. Sometimes the questions are also raised in an interview situation.

There are no generally accepted definitions of psychological distress, but for many questionnaires there are recommended threshold values.

If a number of studies are carried out with the same methods, researchers can compare the figures and study the development in mental health over time and compare population groups. Results from these questionnaires or interviews are also used to plan preventive actions.

Mental disorders

The term mental disorder is only used when specific diagnostic criteria are met.

Mental disorders range from simple phobias, mild anxiety and depressive disorders to severe illnesses such as schizophrenia.

Common to all mental disorders is that they affect thoughts, feelings, behaviour and interactions with others. Often, but not always, mental disorders involve a higher strain than psychological distress. Mental disorders are diagnosed by experienced clinicians and / or by using structured clinical interviews, in which one tries to ascertain whether the various diagnostic criteria are met.

Mental health in Norway

In Norway, two research groups have each studied the occurrence of a wide number of types of mental disorders. At the end of the last century, Kringlen, Kramer and Torgersen studied the incidence in Sogn og Fjordane and Oslo, while researchers at the Norwegian Institute of Public Health examined a national sample of twins a few years later. Table 1 shows the results of these investigations together with results from similar studies in Europe and the USA: 

  • Lifetime prevalence, i.e. the proportion of the population who will have one or other mental disorder during their lifetime, ranges from 25 per cent to 52 per cent. The average prevalence is around 40 per cent. 
  • The proportion of the population who have had a disorder in the last 12 months ranges from approximately 10 per cent to 33 per cent. The highest international figures are from the most reputable international studies, NCR and NEMESIS. The Norwegian figures resemble these. The results are described in more detail in the Norwegian Institute of Public Health’s report no. 2009:8.
Table 1 The prevalence of mental disorders. Source: NIPH-report 2009:8.
 

Lifetime prevalence (%)

12-month prevalence (%)

 

Disorder

Twin

Oslo

S and Fj

NCS

NCS-R

NEME-SIS

ESE-MeD

Oslo

S and Fj

NCS

NCS-R

NEME-SIS

ESE-MeD

Health

Anxiety disorders

26.7

   

24.9

28.8

19.3

13.6

   

17.2

18.1

12.4

6.0

4.2

Specific phobia

18.6

14.4

6.5

11.3

12.5

10.1

7.7

11.1

5.0

8.8

8.7

7.1

3.5

 

Social phobia

4.0

13.7

7.3

13.3

12.1

7.8

2.4

7.9

5.0

7.9

6.8

4.8

1.2

1.0

Agora-phobia *

4.8 *

6.1

3.6

5.3

1.4

3.4

0.9

3.1

1.6

2.8

0.8

1.6

0.4

1.2

Panic disorder

2.8

4.5

2.6

3.5

4.7

3.8

2.1

2.6

1.2

2.3

2.7

2.2

0.8

1.9

Generalised anxiety disorder

2.0

4.5

3.4

5.1

5.7

2.3

2.8

1.9

1.1

3.1

3.1

1.2

1.0

1.3

Obsessive compulsive disorder

0.7

1.6

0.6

 

1.6

0.9

 

0.7

0.3

 

1.0

0.5

   

Depressive disorders and bipolar disorder

     

19.3

20.8

19.0

14.0

   

11.3

9.5

7.6

4.2

6.5

Severe depression

14.0

17.8

8.3

17.1

16.6

15.4

12.8

7.3

3.7

10.3

6.7

5.8

3.9

4.9

Dysthymia

1.7

10.0

6.3

6.4

2.5

6.3

4.1

3.8

1.6

2.5

1.5

2.3

1.0

2.5

Bipolar disorder

 

1.6

0.2

 

3.9

1.8

 

0.9

0.1

 

2.6

1.1

   

Substance abuse-related ailments

     

26.3

14.6

18.7

     

11.3

3.8

8.9

   

Alcohol abuse / 
dependence

9.4

22.7

9.4

     

5.2

10.6

3.1

     

1.0

4.3

Alcohol abuse

 

14.0

6.9

9.4

13.2

11.7

   

2.3

2.5

3.1

4.6

 

0.3

Alcohol Dependence

 

8.8

2.4

14.1

5.4

5.5

   

0.8

7.2

1.3

3.7

 

3.9

Substance abuse / dependence

1.8

3.4

0.4

   

1 1

 

0.9

0.0

         

Substance abuse

 

1.5

0.1

4.4

7.9

1.5

   

0.0

0.8

1.4

0.5

   

Drug addiction

 

1.9

0.1

7.5

3.0

1.8

   

0.0

2.8

0.4

0.8

   

Other disorders

             

2.1

2.2

         

Somatoform disorder

 

3.7

3.4

       

0.7 

0.1

         

Eating disorders

1.7

1.8

0.5

   

0.7

 

 

 

   

0.4

   

At least one of the above disorders

45.9

52.4

30.9

48.0

46.4

41.2

25.0

32.8

16.5

29.5

26.2

23.2

9.6

12.3

* Agoraphobia without panic

Abbreviations:

Twin = NIPH Twin Study 1999-2004. 
Oslo = Kringlen et al, Oslo study 1994-1997. 
S og Fj. = Kringlen et al, Sogn og Fjordane-study 1997-1999. 
NCS = National Comorbidity Survey, USA 1990-1992 
NCS-R = National Comorbidity Survey Replication, USA 2001-2003. 
NEMESIS = The Netherlands Mental Health Survey and Incidence Study, Netherlands 1996. 
ESEMeD = The European Study of Epidemiology of Mental Disorders, Belgium, France, Germany, Italy, Netherlands, Spain 2001-2003. 
Health= The Health 2000 Study, Finland 2000 

How should we interpret the high prevalence figures?

The figures shown in Table 1 are high. In addition, there are some forms of mental disorders, such as personality disorders, that are not included in the table. From this, can we assume that approximately every third adult in Norway - and in Western countries in general – is mentally ill? Not necessarily. 

Many criteria for mental disorders included in the ICD (International Classification of Diseases) classification system are rather inclusive, Examples are alcohol abuse and alcohol dependence, specific phobias and mild depression.

Some substance abusers and probably some alcoholics are not perceived either by themselves or by others as mentally ill, but rather as quite well-functioning. 

In the group with the diagnoses "specific phobias", which includes 6-7 per cent of the population, there are many people with irrational fears of insects, mice, needles or flying. These can very unpleasant for those who must regularly confront the object of their fears, but not for those who are rarely exposed to them, e.g. infrequent flyers. Anyway, many people with these phobias are not perceived as mentally ill, although they may feel troubled. 

Another example is people who have been depressed for a shorter period, without being severely ill. Such mild depression is sometimes termed as "psychiatry’s cold" and usually passes by itself. 

The ICD Diagnosis system was developed by the World Health Organization and is used in most of the world, including Norway. The system defines sometimes complex combinations of criteria that must be met to make a specific diagnosis. Despite the unambiguous diagnostic criteria, it is wise to use some discretion when evaluating the psychological illness burden in the population. 

In Statistics Norway’s Health and Living Conditions Study in 2008, nine per cent of the adult population reported that they had sought professional help for psychological distress. Some may have sought help unnecessarily, but many have probably failed to seek help even though they needed it. For example, many may not have sought help because they were reluctant, they were unaware of available treatment, or they did not believe that treatment would be beneficial. 

Some experts believe that population studies that are based on ICD diagnoses or other diagnostic systems provide an elevated estimate of the proportion with mental illness in the population. On the other hand, the statistics about how many people are seeking help for mental problems or disorders are most likely to be too low. A realistic estimate is probably somewhere in between those from population-based studies and those from health service statistics.

Differences in mental health

Women and men

More women than men suffer from mental illness, but the gender differences vary between the different types of disorders. Eating disorders occur almost exclusively among women, and there is also a much higher incidence of anxiety and depression among women than among men. 

For personality disorders and schizophrenia, the results vary somewhat between the different studies. Some studies show no clear gender differences, others suggest predominance in males. Only substance abuse-related disorders are more common among men than among women. 

Table 2 below shows the relationship between women and men regarding occurrence of some disorders. For example, the value of 2.30 for depressive disorders in Oslo means that in this study these disorders were 2.3 times more common in women than in men. The figures in the table are extracted from several large studies.

Table 2 The relationship between women and men regarding the prevalence of mental disorders. The figures are based on Norwegian and international studies that have studied the incidence of mental disorders in the last 12 months.
   Oslo  S and Fj  NCS  ESEMeD  NEMESIS
 Depressive disorders  2.30  2.15  1.66  2.00  1.70
 Anxiety disorders  2.57  2.62  1.92  2.29  2.00
 Drug-related disorders  0.38  0.31  0.41  0.18  0.25
 Any disorder  1.25  2.00  1.26  1.69  1.00

Source: FHI-report 2009:8. NCS = NCS, National Comorbidity Survey, USA 1990-1992, ESEMeD = ESEMeD: The European Study of Epidemiology of Mental Disorders, Belgium, France, Germany, Italy, Netherlands, Spain 2001-2003. NEMESIS = NEMESIS: The Netherlands Mental Health Survey and Incidence Study, the Netherlands 1996.

Age

Symptoms of mental disorders vary at different ages up to adulthood. It can also be argued that many types of mental and behavioural disorders that affect children are essentially different from those affecting adults.

After early childhood and in adolescence the symptom picture is dominated by strong emotional reactions and violations. During puberty and the following few years the extent of anxiety and depression symptoms increases. Other "adult" illnesses, like schizophrenia, rarely appear before the late teens.

In adults, the age differences for most mental disorders are moderate, at least until 60 years of age. Results from Statistics Norway’s Health Interview Survey 2008 suggest a fairly constant risk of "severe psychological distress" throughout most of adulthood (FHI report 2011:2). The results were as follows:

  • 10.4 per cent in the age group 25-44 years
  • 9.9 per cent in the age group 45-64 years
  • 6.1 per cent in the age group 65-74 years
  • 8.7 per cent in the age group over 74 years

A literature review at the Norwegian Institute of Public Health in 2011 (Elderly in Norway: Prevalence of psychological distress and disorders) concludes that "while there are indications of a lower incidence of anxiety and depression disorders at about 65 years of age than in younger age groups, some of the results suggest a higher incidence in the oldest age groups." More anxiety and depression in later life may be due to losses encountered at this time, related to illness, diminished quality of life and loss of close friends and relatives. 

Geographical differences

The results from studies in different parts of Norway vary somewhat. The figures for Kringlen and colleagues in the first table shows an almost twice as high prevalence of any disorder during the past 12 months in Oslo as in Sogn og Fjordane. Figures from the Health Interview Survey 2008 [FHI report 2011:2] in the table below show the opposite tendency, a lower risk of depression during lifetime in big cities than in rural areas. The numbers are certainly within the uncertainty margins (or "confidence intervals" CI), but they do not confirm the results from Kringlen and colleagues.

Table 3. Prevalence of major lifetime depression in men and women in different geographical areas. Source: NIPH-report 2011:2. CI = 95% confidence intervals (uncertainty margins).
  Men, % (CI) Women, % (CI)
Rural  10.1 (2.8)  19.1 (3.5)
Small town  8.5 (2.4)  17.1 (2.8)
City  9.6 (3.5)  13.8 (4.0)
Health Region East  12.1 (2.5)  21.4 (3.0)
Health Region South  11.4 (3.6)  15.9 (4.3)
Health Region West  8.7 (3.2)  13.5 (4.0)
Health Region Central  9.0 (3.7)  14.9 (4.5)
Health Region North  5.9 (4.5)  17.5 (5.4)

The figures for the health regions in the lower part of table show relatively high figures in the east and low figures in the west. These better resemble the numbers from Oslo and Sogn og Fjordane. The difference between east and west is statistically reliable for women but not greater than it can be coincidental for men. 

Men from northern Norway also seem to come out well compared to men in the east and south but the uncertainty margin for this group is extra large. The differences are borderline significant, meaning that the differences may be coincidental. Data from an older health study (FHI Report 2009:6) shows only small differences between health regions. 

With the exception of Oslo, where the prevalence of mental disorders is high, and parts of western Norway where the prevalence is low, the regional differences in mental health are not clear.

Social inequality

We perceive Norway as a society with a relatively low level of social inequality. However there is also a clear relationship between social status and both physical and mental health. Forthcoming results from the NIPH’s twin study show, for example, that anxiety disorders are six times more common among people with only primary school than among those with top level education. 

A lot of research abroad and in Norway shows similar social gradients for depression and other disorders, including schizophrenia. While large health studies by the NIPH and other institutions show that although people with higher education drink at least as much alcohol as those with a lower education, addiction is more common in the latter group.

Social differences in mental illness are seen whether the differences are measured in terms of education or income. 

There is no consensus about the causes of social inequalities in health. Some research results show that poor living conditions during childhood and later life lead to poor health. However, also can poor health lead to reduced social status. It is easy to imagine that many types of mental disorders can have negative consequences for both education and a career. Both explanations are probably partially correct.

Changes over time

Several factors may give the impression that the occurrence of mental disorders is increasing in the population. The proportion of new disability pensions awarded for a mental disorder has increased over the past 15 years. There has also been a sharp increase in the number of people treated for mental disorders. 

Results from the USA and Europe however provide no support for deterioration in public health with an increased incidence of mental disorders. For example, NCS and NCS-R (Table 1) show approximately the same prevalence of various disorders in 1990 and 2003. In Norway, the four Health Interview Surveys studies from Statistics Norway in 1998-2008 show no significant changes in psychological distress (FHI-report 2011:2. FHI report 2009:8).

Risk and protective factors

Heredity

There are both hereditary (genetic) and environmental risk factors for mental disorders. The heredity coefficient (“heritability”) is the measure used to express the importance of genes. The coefficient varies between 0 (variation in disease prevalence is solely determined by environmental factors) and 1 (variation in a trait is exclusively genetically determined). 

In general, genes are important for variation in mental health. Heredity for psychological distress, depression, anxiety disorders and personality disorders are relatively moderate with heredity coefficients around 0.3 to 0.4. This means that environmental factors are collectively more important than genes for these disorders. Hereditability is slightly higher for substance abuse-related disorders. The highest heritability is found for bipolar affective disorder (formerly manic-depressive disorder) and schizophrenia, with heredity coefficients of 0.6 to 0.8. The tendency is that more severe mental disorders have higher heritability. 

Results from recent studies suggest that the same genes may contribute to various forms of mental disorders. For example, it appears that to some extent, genetic factors are common vulnerability or protective factors for anxiety and depression. Life events and other environmental factors are involved in determining which specific disorder, anxiety or depression, that develops. 

It is nevertheless important to remember that even if heritability explains some of the variation in mental health, this does not mean that the prevention or treatment has had no effect.

Other risk and protective factors

There are several known factors other than those mentioned above:

  • Generally it is agreed that a secure bond with caregivers in childhood has an influence on subsequent mental health. 
  • Throughout life, social isolation and loneliness gives an increased risk while social support and closeness to other people protects. As an extension of this, people who live in a relationship have better mental health than single people. Among individuals with a partner, it is important for their mental health that the relationship with their partner is perceived as good and close. 
  • Traumatic experiences, such as serious accidents or violence against oneself or one's loved ones, can cause permanent psychological damage. 
  • Daily and lasting strains are just as important as traumatic events. Typical examples of sustained stress are long-term problems with children or severe economic problems. Similarly, unemployment is an important risk factor. 
  • Several stress factors acting together over a long time give a high risk, apparently higher than the sum of the risk associated with each factor. Similarly, protective factors such as close and secure relationships provide extra protection against events or burdens that otherwise would have led to a high risk. 
  • A good self-esteem and especially the feeling of being able to master challenges and problems are very important for good mental health. Poor coping skills and low self-esteem can often be observed in people with anxiety or depressive disorder. There is still disagreement about the extent to which lack of experience of mastery can be understood as a key causal factor. Perhaps we should perceive a lack of mastery and sense of achievement as an important part of the symptoms rather than causing the symptoms.

International mental health

The World Health Organization (WHO) estimates that at any given time 450 million people have behavioural, mental or neurological problems. WHO estimates that one in four people who seeks health care also has a mental, behavioural or neurological problem. Most receive neither a diagnosis nor treatment. The organization expects that mental problems will increase in the years to come. 

The WHO health report for 2001 looked at mental health. One of the goals is to remove taboos so that problems can be recognised and treated in line with other health problems. 

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