Background-Mental disorders are leading causes of disability worldwide, including in lowand middle-income countries least able to bear such burdens. To begin understanding and improving their treatment, we describe mental health care in 17 countries of the WHO World Mental Health (WMH) Survey Initiative.

CONTEXT Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity. OBJECTIVE To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the WHO World Mental Health (WMH) surveys. SETTING/PARTICIPANTS Nationally or regionally representative community surveys in 14 countries with a total of 21,229 respondents. MAIN OUTCOME MEASURES First onset of 18 lifetime DSM-IV anxiety, mood, behavior, and substance disorders assessed retrospectively in the WHO Composite International Diagnostic Interview (CIDI). RESULTS Separate internalizing (anxiety and mood disorders) and externalizing (behavior and substance disorders) factors were found in exploratory factor analysis of lifetime disorders. Consistently significant positive time-lagged associations were found in survival analyses for virtually all temporally primary lifetime disorders predicting subsequent onset of other disorders. Within-domain (i.e., internalizing or externalizing) associations were generally stronger than between-domain associations. The vast majority of time-lagged associations were explained by a model that assumed the existence of mediating latent internalizing and externalizing variables. Specific phobia and obsessive-compulsive disorder (internalizing) and hyperactivity disorder and oppositional-defiant disorder (externalizing) were the most important predictors. A small number of residual associations remained significant after controlling the latent variables. CONCLUSIONS The good fit of the latent variable model suggests that common causal pathways account for most of the comorbidity among the disorders considered here. These common pathways should be the focus of future research on the development of comorbidity, although several important pair-wise associations that cannot be accounted for by latent variables also exist that warrant further focused study.

EPRESSION IMPOSES ENORmous societal burdens, 1-3 with annual US economic costs of tens of billions of dollars due largely to productivity losses. 4,5 Indeed, comparative cost-of-illness studies show that depression is among the most costly of all health problems to employers. [6][7][8][9][10] Despite evidence that guidelineconcordant treatment can be effective, 11-21 many depressed workers are untreated or inadequately treated. [22][23][24][25][26] Effectiveness trials have demonstrated that organized depression screening and enhanced-care programs can significantly improve treatment and clinical outcomes. [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41] Based on the magnitude of depression-related lost productivity, one might expect employer-purchasers (ie, those who purchase corporate health benefits) to invest in enhanced depression screening-treatment programs. However, widespread uptake has not occurred 42,43 due in part to employerpurchasers being unsure of the returnon-investment of such programs. 44,45 Few controlled trials have evaluated effects of such programs on work outcomes and those few focused on primary care samples rather than on the workplace samples that would be the focus of em-For editorial comment see p 1451.

Objective-To update estimates of the associations between mental disorders and earnings from those of Rice et al. for 1985and Harwood et al. for 1992. Current estimates, for 2002, are based on data from the National Comorbidity Survey Replication (NCS-R).Methods-The NCS-R is a nationally representative survey of the US household population administered in 2001-03. Following the same basic approach as the prior studies, with some modifications to improve model-fitting, we predicted personal earnings in the 12 months before interview from information about 12-month and lifetime DSM-IV mental disorders among respondents ages 18-64, controlling for socio-demographics and substance disorders. We used conventional demographic rate standardization methods to distinguish predictive effects of mental disorders on amount earned by people with earnings from predictive effects on probability of having any earnings.Results-Twelve-month DSM-IV serious mental illness (SMI) significantly predicted reduced earnings. Other 12-month and lifetime DSM-IV/CIDI disorders did not. Respondents with SMI had 12-month earnings averaging $16,306 less than other respondents with the same values on control variables ($26,435 among males; $9,302 among females), for a societal-level total of $193.2 billion. Of this total, 75.4% was due to reduced earnings among mentally ill people with any earnings (79.6% males; 69.6% females). The remaining 24.6% was due to reduced probability of having any earnings.Conclusions-These results add to a growing body of evidence that mental disorders are associated with substantial societal-level impairments that should be taken into consideration in making decisions about the allocation of treatment and research resources.Send reprint comments to

Despite often higher disability, mental disorders are under-treated compared with physical disorders in both high-income and in low- and middle-income countries.