OUTLINE

• HOW MEASURE M.I. IN COMMUNITY POPULATIONS?

• MAJOR INSTRUMENTS AND FINDINGS

• PROBLEMS WITH INSTRUMENTS

• POLICY IMPLICATIONS

Treatment for Depression

0

0.5

1

1.5

2

2.5

3

3.5

4

1981-82 1991-92 2001-02

% of pop.

REASONS FOR ENTERING TREATMENT

• MENTAL ILLNESS

• CHANGING CULTURE SO MORE RECOGNITION

• EDUCATIONAL CAMPAIGNS

• PHARMACEUTICAL ADS

• CHANGE IN FINANCING

PROBLEMS WITH TREATED SAMPLES

• CAN REFLECT UNDERTREATMENT

• OR OVERTREATMENT

• SO NOT ACCURATE REFLECTION OF AMOUNT

• NOT REPRESENTATIVE OF TYPES OF PEOPLE

• “CLINICIAN’S ILLUSION”

EPIDEMIOLOGY

• FOCUS ON UNTREATED CASES

• STUDY OF RATES OF DISORDER IN COMMUNITY POPULATIONS

• FOCUS ON GROUP DIFFERENCES IN DISORDER NOT INDIVIDUAL CASES

GOALS

• 1. SEE HOW WIDESPREAD M.I. IS

• 2. LOOK AT UNMET NEED FOR SERVICES

• 3. EXAMINE GROUP DIFFERENCES IN RATES

• 4. BETTER WAY TO DISCOVER CAUSES AND COURSE OF M.I.

HOW MEASURE M.I.?

• PSYCHIATRIC INTERVIEWS VERY EXPENSIVE, IMPRACTICAL, UNRELIABLE

• USE STANDARDIZED INSTRUMENTS

• STANDARD QUESTIONS

• STANDARD ANSWERS

DIAGNOSTIC INTERVIEWS

TWO MAJOR STUDIES

• ECA - EPIDEMIOLOGIC CATCHMENT AREA) - 1980’S (WAKEFIELD)

• NCS - NATIONAL COMORBIDITY STUDY - 1990’S and EARLY 2000’S (KESSLER)

• BOTH USE FORMAL DIAGNOSES

FINDINGS

• MENTAL ILLNESS WIDESPREAD

• DEPRESSION - 10% IN PAST YEAR; 25% OVER LIFETIME

• ANXIETY - 20% IN PAST YEAR; 30% OVER LIFETIME

• SUBSTANCE ABUSE - 15% PAST YEAR; 25% OVER LIFETIME

FINDINGS

• ALL DISORDERS - 1/3 OF POPULATION HAS DISORDER IN PAST YEAR; 1/2 OVER LIFETIME

• MANY PEOPLE “COMORBID” - MORE THAN ONE DISORDER

• MANY GROUP DIFFERENCES - CLASS, ETHNIC, GENDER, AGE, ETC.

GENERALIZED QUESTIONNAIRES

• MORE PRACTICAL, CHEAPER

ISSUES WITH BOTH TYPES

• HIGH RATES – 20% TO 30% • FEW FALSE NEGATIVES• MANY FALSE POSITIVES• IGNORES CONTEXT OF SYMPTOMS• PHYSICAL ILLNESS?• INSTABILITY – ONLY 1/3 IN SAME

CATEGORY OVER SEVERAL MONTHS• EXPLOITATION BY DRUG CO?

USEFUL FOR RATES

COMPARE GROUPS IN COMMUNITY - E.G. GENDER, SOCIAL CLASS, MARITAL STATUS, ETC.

USUAL CONCLUSIONS (KESSLER)

• MENTAL DISORDER WIDESPREAD

• TREMENDOUS “UNMET NEED” FOR TREATMENT

• UNMET NEED GREATEST AMONG POOR, MINORITIES, MEN, OLDER

• MUST EXPAND MENTAL HEALTH SERVICES

OVERESTIMATES (WAKEFIELD)

• SUPPOSED TO BE SAME AS CLINICAL

• 1. DISCRETION OF INDIVIDUAL

• 2. DISCRETION OF CLINICIAN

• COMMUNITY STUDIES LACK DISCRETION OF EITHER

• RESULT IS OVERCOUNTING – FALSE POSITIVES

POLICY STEMMING FROM COMMUNITY STUDIES

• OVERCOME PROBLEM OF UNMET NEED

Screening for Depression

SCREENING

• FIND UNTREATED INDIVIDUALS

• SETTINGS THAT HAVE HIGH % OF M.I.

• PRIMARY MEDICAL CARE

• SCHOOLS

BENEFITS AND COSTS

• GET TREATMENT TO UNTREATED

• PREVENT FROM BECOMING MORE SERIOUS

• SAVE MONEY

• TOO INTRUSIVE?• STIGMA• IS IT EFFECTIVE?• TELL ANYTHING

NEW?• BE CAUTIOUS, NOT

SWEEPING

CONCLUSION

• MENTAL ILLNESS IS WIDESPREAD

• BUT CAN’T SEPARATE DISTRESS FROM DISORDER

• STUDIES OVERESTIMATE AMOUNT OF MENTAL ILLNESS

• LEAD TO MEDICALIZATION

• NEED TO INCORPORATE CONTEXT INTO STUDIES