Research paperDepression burden in luxembourg: Individual risk factors, geographic variations and the role of migration, 2013–2015 European Health Examination Survey
Introduction
Depression is a complex mental disorder that contributes to an increasingly high percentage of the global burden of disease. Between 1990 and 2010, there was a 37.6% worldwide increase in the number of disability-adjusted life-years (DALYS) due to mental and behavior disorders, with major depressive disorders being the most important cause (Murray et al., 2013). Depressive disorders were among the ten leading causes of DALYS in central Europe in 2010, and the leading cause of disability worldwide (Murray et al., 2013; Whiteford et al., 2013). The WHO estimates that today 350 million people are affected by depression, a proportion expected to rise in the coming years. This seems to be in part due to the growth of the world population and higher life expectancies, which for individuals means longer lives and, in many cases, living with one or more chronic diseases (Marcus et al., 2012; Moussavi et al., 2007; Whiteford et al., 2013).
Several factors impact the prevalence of depression, including social and psychological factors such as job status, health perception and social support. Previous research has demonstrated the protective effects of employment, good perceived social support and health status, compared to unemployment and lower perceived social support or poor health (Modini et al., 2016, Stewart-Brown et al., 2015). Moreover, health promoting behaviors such as physical activity, a healthy diet, good sleep habits and normal body weight may reduce the odds of developing depression (Hayley et al., 2015, Harrington et al., 2010, Vallance et al., 2011, Zhao et al., 2009).
Evidences suggest that in addition to individual characteristics, social and environmental factors explained by geographic differences may play a role in the distribution of depression (Peen et al., 2010; Romans et al., 2011; Hoffman et al., 2015). This means that the place where a person lives or was born may have an impact on the development of depression. Results are mixed, however, with studies that have compared differences in depression between rural and urban regions showing in some cases differences on the prevalence of mental disorders that in others is not as clear (Peen et al., 2010; Romans et al., 2011; Breslau et al., 2014). Geographic differences may even be more subtle, with variations between municipalities, region of residence or neighborhoods, although more research is need to understand the complexity of the matter (Hoffman et al., 2015, Richardson et al., 2015).
Among the risk factors for depression, which have recently attracted attention, is immigration status. Findings remain inconclusive, however, with studies showing either an increased risk or a protective association of immigration with mental health (Breslau et al., 2011, Gilliver et al., 2014, Glaesmer et al., 2009; Sieberer et al., 2011). Overall, immigrants are likely to be exposed to several stress factors, e.g. poor working and living conditions, less access to health care and/or psychosocial stressors that can negatively affect their physical and mental health (Rechel et al., 2013). Factors such as acculturation and discrimination also significantly impact the relation between immigration and mental wellbeing with poor perceived health observed in immigrants as compared with local populations (Toselli et al., 2014).
International migration is a global reality that is affecting all countries. According to the United Nations, the number of international migrants has increased worldwide in the last 15 years, from 173 million people in 2000 to 244 million people in 2015. Of those, 76 million live in Europe (United Nations, 2016). Luxembourg experienced successive waves of immigration beginning in the late 19th century during the country's industrialization, and again in the 1960s-1970s following an increase in labor demand for the steel industry and construction (Kollwelter, 2007). Immigrants today account for the cultural diversity that characterizes Luxembourg, with 46% of residents with non-Luxembourgish nationalities, e.g. Portuguese (16.2%), French (7%), Italian (3.5%), Belgian (3.3%), German (2.3%), British (1.1%), Netherlandish (0.7%), other European (5.2%), and non-European countries (6.5%) (STATEC, 2015). Luxembourg is among the European countries with the greatest increase in net immigration from 1990 to 2010 (Rechel et al., 2013). As one of Europe's wealthiest countries, the number of foreigners in Luxembourg has been steadily increasing since the beginning of the world economic crisis in the late 2000s. Only four years into the crisis, the percentage of foreigners in Luxemburg went from 43% to nearly 46%, a percentage which is expected to continue to increase (STATEC, 2015). Given that immigration is a fundamental element in Europe's social, economic and cultural reality, investigating the possible association of immigration with mental health is a significant public health issue.
The present study aimed at estimating the prevalence of depressive symptoms in Luxembourg, its potentially associated risk factors, and its geographic variations. Moreover, we examined whether first- and second-generation immigrants in Luxembourg were at higher risk for depressive symptoms compared to non-immigrants.
Section snippets
Study population and recruitment
We used data from the European Health Examination Survey in Luxembourg (EHES-LUX), a cross-sectional population-based survey, conducted between February 2013 and January 2015 in Luxembourg. Residents of the Grand-Duchy of Luxembourg (aged 25–64), with the exception of institutionalized individuals, were randomly sampled in a one-stage sampling procedure and stratified by age, sex and district of residence (Ruiz-Castell et al., 2016). The sample was obtained from the national health insurance
Results
Table 1 presents the prevalence of depressive symptoms, anti-depressive medication, self-reported depression diagnosis and, immigration status. Nearly 22% of participants reported depressive symptoms: almost 5% of the total sample took anti-depressive medication in the two weeks prior to their participation in the study, and nearly 8% had been diagnosed with depression by a physician within the last year. Of those with depressive symptoms only 29% were aware. Nearly 64% of participants had a
Discussion
Results from the present study show that the point-prevalence of depressive symptoms in Luxembourg is 21.55% (16.63% in men and 26.22% in women) and the prevalence of moderate to severe depressive symptoms is 6%. These results are in line with findings from other European and non-European studies using similar assessments of depression (e.g. 25.6% in U.S), and with percentages of moderate to severe depressive symptoms ranging from 4.1% in Brazil to 8.1 in Germany (Ferrari et al., 2013b, Berk et
Funding
This study was funded by the Directorate and Ministry of Health and the Luxembourg Institute of Health.
Conflict of interest
All other authors declare that they have no conflicts of interest.
Contributors
Maria Ruiz-Castell and Saverio Stranges conceptualized and designed the study. Andrea Kuemmerle wrote the protocol. Maria Ruiz-Castell, Ngianga-Bakwin Kandala and Valéry Bocquet performed the statistical analysis. Maria Ruiz-Castell, Saverio Stranges, Claus Vögele and Magali Perquin interpreted the data. Maria Ruiz-Castell drafted the article. Saverio Stranges supervised the study. All authors participated in the revision of the article. All authors contributed to and have approved the final
Acknowledgements
We are grateful to the population of Luxembourg and to all the EHES-LUX team who have contributed to this study. We would like to thank Couffignal S, Dincau M, Mormont D, Chioti A, Gantenbein M, Lieunard C, Columeau A, Kiemen M, Weis J, Ambrozet G, Billy A, Larcelet M, Marcic D, Gauthier C, and Viau-Courville M for their valuable contributions.
Dr Ruiz-Castell is a researcher within the Epidemiology and Public Health Research Unit, Luxembourg Institute of Health (LIH), where she acts as project leader for the European Health Examination Survey in Luxembourg (EHES-LUX) and the European Health Interview Survey (EHIS). Dr Ruiz-Castell obtained her PhD in Biomedicine and MPh in Public Health from the Pompeu Fabra University, Barcelona. Her research interests range across the epidemiology and public health fields. Over the past several
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Dr Ruiz-Castell is a researcher within the Epidemiology and Public Health Research Unit, Luxembourg Institute of Health (LIH), where she acts as project leader for the European Health Examination Survey in Luxembourg (EHES-LUX) and the European Health Interview Survey (EHIS). Dr Ruiz-Castell obtained her PhD in Biomedicine and MPh in Public Health from the Pompeu Fabra University, Barcelona. Her research interests range across the epidemiology and public health fields. Over the past several years, she has contributed to the development of international research projects in epidemiology and global health with fieldwork and quantitative data analyses conducted in Luxembourg, Spain, highland Bolivia, and the Canadian Arctic.
Ngianga-Bakwin Kandala is Professor of Biostatistics and Direction of Business and Enterprise at Northumbria University, UK. Prior to this, he worked as Head of Health Economics and Evidence Synthesis Research Unit at the Luxembourg Institute of Health, Luxembourg and was Associate Professor in Health Technology Assessment, a joint appointment with the University of Oxford and University of Warwick. He is also affiliated with the University of Witwatersrand, South Africa as a Distinguished Professor of Biostatistics and a Visiting Professor at the University of Agder, Norway. For the past 15 years, his main research interests are in Bayesian statistical methods and their application to epidemiology and health ( maternal and child health and a variety of health-related health inequalities both in the developing countries and command economies, using large scale household data).
Dr Magali Perquin ‘s expertise is focused on risk factors of ageing-related pathologies. Magali Perquin is a doctor in Biologial Engineering. She obtained her PhD with the European label, from the University of Dundee in Scotland and from the french universities of Nancy and Metz. Throughout her career, she has been involved in (molecular) epidemiological surveys of chronic diseases. Her current main scientific interest is to investigate the processes of cognitive decline during ageing and associated biological conditions. Exploring the determinants of cognitive health, she is devoted to the understanding of the modulation of the occurrence of cognitive impairment with respect to cognitive reserve. She therefore initiated the MemoLingua project to explain how multilingualism can delay onset of cognitive impairment, developing a new neuroimaging approach in collaboration with Jülich ForschungZentrum (Germany).
Biostatistician at the Luxembourg Institute of Health (LIH) since 2008, Dr Bocquet (Ph.D. obtained in 2002) has essentially worked on projects using medico-administrative databases where each insured patient has several ambulatory prescription records. Since measures are repeated, the methodology used is mixed or GEE models in SAS®. His other activities concerned the monitoring data (Capture System®) and statistical analyses on data from questionnaires. More recent projects deal with statistical analyses in biomechanics domain, benzodiazepines high-dose and epidemiology related to diabetes.
Dr. Andrea Kuemmerle worked as a Project Leader at the Luxembourg Institute of health (LIH) in Luxembourg from 2010 to 2014 where she was responsible for the planing, organization and management of the operational part of the EHES-LUX survey. She is currently working as a Project Manager in the Department of Medicine at the Swiss Tropical and Public Health Institute (SwissTPH) in Basel, Switzerland. She is coordinating the safety reporting of clinical trial conducted at the Department of Medicine, which focusses on neglected tropical diseases such as Human African Tryponomiasis, Malaria and Schistosomiasis. She is also leading research activities in the area of pharmacovigilance especially in the context of remote places where infrastructure and resources are lacking. Dr. Andrea Kuemmerle graduated as Pharmacist and holds a PhD in Clinical Pharmacology of the University of Lausanne, Switzerland.
Claus Vögele graduated in Psychology at Landau University in 1983, and was awarded his PhD in Psychology from the University of Hamburg in 1988, and his professorial qualification (Habilitation) from the University of Marburg in 1997. Over the last 25 years he has held academic posts at both German and British Universities before joining the University of Luxembourg in February 2010 as Professor of Clinical and Health Psychology. He is Head of the research group Self-regulation and Health, Head of the Institute for Health and Behavior, and Director of the Master programme in Psychotherapy.
Professor Saverio Stranges is a medical doctor, public health specialist and chronic disease epidemiologist. He is originally from Italy (where he did his medical training), with previous academic experience in the US (SUNY at Buffalo), UK (Warwick University) and Luxembourg. Dr. Stranges was recently appointed as Professor and Chair of the Department of Epidemiology & Biostatistics at Western University in Canada. He is also Scientific Advisor for the Department of Population Health at the Luxembourg Institute of Health. Throughout his career, Prof Stranges has been involved in several international epidemiological projects and clinical trials, and has published extensively in the area of chronic disease epidemiology, with more than 160 publications (h-index =41).
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Current address: Swiss Tropical and Public Health Institute, Basel, Switzerland.