Epidemiologic assessment of overmet need in mental health care

The traditional purpose of psychiatric epidemiologic surveys has been the assessment of mental illness and, by implication, the need for care. Previous research has focused on unmet need, defined as those who meet "caseness" but do not receive care, but has rarely examined the converse. Since survey respondents receiving care but not meeting caseness have been found to represent up to one-half of mental health service users, this is a significant service delivery issue. The data are drawn from the Mental Health Supplement to the Ontario Health Survey (the Supplement), a household survey of 9,953 respondents, which used the University of Michigan's version of the Composite International Diagnostic Interview (UM-CIDI) as its diagnostic instrument. Community residents who used formal mental health services in the past year but who did not have a concurrent UM-CIDI/DSM-III-R (Diagnostic and Statistical Manual 3, revised) diagnosis were defined as "treated without CIDI disorder". Their need for care was evaluated by comparing them to "treated depressed" and "healthy" respondents, using indicators of functional impairment, vulnerability to developing disorder, and risk of relapse. The match between need and care levels was examined by comparing their type and intensity of use with those of the treated depressed. Results present strong evidence for conceptualizing need as continuous, rather than discrete. The results for the group defined as "treated without CIDI disorder" were consistently between those for the other two groups (with the "treated depressed" always showing the highest need) on all indicators as well as on a summary need index. However, their type and intensity of service use appeared to be unrelated to their level of need. Although some of the "treated without CIDI disorder" group may require preventive or follow-up treatment, the need for service for others is not as convincingly demonstrated. Outcome studies are needed to provide comparative data to describe more fully the problems experienced by this group and indicate whether treatment is helpful. In an age of fiscal restraint, when resource reallocation (rather than generation of new resources) is the likely scenario, such close examination of the fit between need and care is critical if services are to be targeted appropriately.     

Performance of the Composite International Diagnostic Interview Short Form for major depression in community and clinical samples

The CIDI Short Form is a brief survey instrument designed to identify episodes of major depression. The instrument was developed for inclusion in the US National Health Interview Survey, but has also been used in the Canadian National Population Health Survey (NPHS). In this study, data deriving from use of the CIDI Short Form in the NPHS are compared to published data from the Mental Health Supplement of the Ontario Health Survey, which utilized a fully validated structured interview: the Composite International Diagnostic Interview (CIDI). In an additional analysis, the sensitivity and specificity of the Short Form were evaluated in relation to the full CIDI mood disorders section in a clinical sample of 122 psychiatric in-patients. Relative to published data from the Ontario Health Survey, application of the CIDI Short Form in the NPHS resulted in an overestimation of major depression prevalence by approximately 50%. In the clinical sample, the CIDI Short Form was highly sensitive (98.4%), but not highly specific (72.7%). Active medical conditions, substance use disorders and dysthymia were frequently observed among subjects with false positive CIDI Short Form ratings. The CIDI Short Form appears to overestimate the 12-month period prevalence of major depression when it is applied in community samples. Since the Short Form does not make exclusions for organically induced symptoms, it is probable that some subjects with depressive symptoms secondary to physical illnesses and/or drug exposures score above the instrument's threshold, perhaps leading to an elevation in period prevalence rates.     

Psychiatric disorders and dissatisfaction with social relationships: Does type of relationship matter?

The specificity of the association between 9 Axis I psychiatric disorders and quality of the relationship with spouse, relatives, and friends was evaluated for married participants who completed the Ontario Health Survey Mental Health Supplement (N?=?4,933). When the authors controlled for the quality of other social relationships, not getting along with one's spouse was related to 6 disorders, with the strongest associations found for generalized anxiety disorder, major depression, panic, and alcohol problems; 4 associations remained significant when they controlled for comorbid disorders. Not getting along with relatives and friends was generally unrelated to psychiatric disorders when they controlled for the other social relationships. Results indicate that the association between marital quality and psychiatric disorders is not an artifact of general social dissatisfaction and that this association is significant for several disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Maturation-dependent apoptotic cell death of oligodendrocytes in myelin-deficient rats

Early geographic relocation has been implicated as an important correlate of psychopathology, learning difficulties, and behavioural problems among child and adolescent populations, yet systematic studies of the potential influence of relocation on youthful drug use have not been conducted. This study explored the relationship between number of geographic moves before the age of 16 and the timing of onset of drug use and progression to drug-related problems. Data were obtained from 3,700 young adults aged 18 to 35 years participating in the 1990-1991 Ontario Mental Health Supplement, a large random probability survey of the residents of the Province of Ontario, Canada. Holding constant potential confounding factors, results showed highly significant positive relationships between moving and early initiation of illicit drugs including marijuana, hallucinogens, crack/cocaine, and illicit use of prescribed drugs. Among marijuana users, moving was also associated with a hastening of time to marijuana-related problems. Relationships between moving and measures of alcohol use/problems (onset of first drink, onset of any alcohol-related problem) were either weak or nonsignificant. Important sex differences were found, with statistically significant relationships between moving and early drug use initiation and progression occurring primarily among males. Future research is required to test for possible mediating mechanisms linking relocation with drug use as well as moderating influences. Efforts should also focus on finding out why drug use appears to be a more common response to relocation among boys.     

Psychiatric disability in Ontario

OBJECTIVE: To describe the disability associated with psychiatric disorder in a community sample in order to refine estimates of service need and identify subgroups with greater priority for intervention. METHOD: Disability is conceptualized broadly as performance difficulties, troubled relationships, and dissatisfaction in various life domains. Data from the Mental Health Supplement are used to compare disability between those with and without disorder and among various subtypes of disorder. RESULTS: Although the majority of those with disorder do not report disability, their difficulties with functioning are far greater than for the rest of the population. Those with comorbid or affective disorders typically have more disability than those with anxiety or substance abuse disorders. CONCLUSIONS: Society needs to recognize the high human and economic costs associated with the prevalence of psychiatric disorder. Assessments of service need and decisions about priorities should take both disorder and disability into consideration.     

Which workers smoke?

OBJECTIVES: This article examines differences by occupation in daily cigarette smoking prevalence and intensity among full-time workers, and how these differences are associated with smoking restrictions at work. DATA SOURCES: Most of the data are from a Health Canada-sponsored Supplement to the 1994/95 National Population Health Survey (NPHS). The analysis is based on 5,674 respondents aged 15 to 64 who were full-time workers at the time of their interview. Comparable information is presented from the 1978/79 Canada Health Survey and the 1986 Labour Force Survey Smoking Supplement. MAIN RESULTS: In 1994/95, 28% of full-time workers were daily smokers, and about a third of them smoked 25 or more cigarettes a day. Smoking prevalence and intensity were lowest among white-collar workers and highest among blue-collar workers. Since 1978/79, there has been an overall decline in smoking prevalence, and since 1986, a decline in smoking intensity among all workers except those in outdoor blue-collar occupations. About 6 in 10 full-time workers who smoked daily encountered restrictions at work.     

Socioeconomic disparities in preventive care persist despite universal coverage. Breast and cervical cancer screening in Ontario and the United States

OBJECTIVE: To compare the association of income and education with breast and cervical cancer screening in Ontario, Canada, and the United States. DESIGN: Survey using data from the Ontario Health Survey and the US National Health Interview Survey. PARTICIPANTS: A multistage random sample of women aged 18 years and older living in households in Ontario (N = 23,521) and the United States (N = 23,932) in 1990. MAIN OUTCOME MEASURE: Persons were considered screened if they reported a Papanicolaou test within the previous 2 years, a clinical breast examination within the previous year, or a mammogram within the previous year. RESULTS: Papanicolaou test and clinical breast examination rates were similar between countries, but mammography rates were two to three times higher in the United States across all age groups. Compared with women with less than a high school degree, college graduates were more likely to receive screening (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2 to 1.7) and there was no difference between countries. Across all procedures, women with higher incomes were more likely to receive screening. For Papanicolaou test and clinical breast examination, there was no difference between countries. Compared with the lowest income, the OR was 1.7 (95% CI, 1.3 to 2.1) in Ontario and 1.9 (95% CI, 1.6 to 2.2) in the United States for Papanicolaou test and 2.1 (95% CI, 1.6 to 2.8) in Ontario and 2.1 (95% CI, 1.8 to 2.6) in the United States for the clinical breast examination for women with income greater than $45,600 (US dollars). For mammography screening, the association of income with use was greater in the United States: the OR was 1.8 (95% CI, 1.3 to 2.6) in Ontario and 2.7 (95% CI, 2.3 to 3.2) in the United States for women with income greater than $45,600 (US dollars). CONCLUSIONS: Despite the long-time presence of universal insurance coverage in Ontario the disparities in the use of cancer screening procedures by the poor were similar to the United States. Universal coverage is not sufficient to overcome the large disparities in screenings across socioeconomic status demonstrated in both countries.     

Stability of diagnosis of obsessive-compulsive disorder in the Epidemiologic Catchment Area study

OBJECTIVE: This study examined the 1-year temporal stability of a National Institute of Mental Health Diagnostic Interview Schedule (DIS) lifetime diagnosis of obsessive-compulsive disorder in the Epidemiologic Catchment Area (ECA) study. METHOD: In that study, 20,862 individuals, aged 18 years and over, at five sites were evaluated by lay interviewers using the DIS (wave 1). All of those who were available 12 months later were reinterviewed (wave 2). In the present study, the temporal stability of wave 1 obsessive-compulsive disorder diagnoses at wave 2 was examined, as well as relationships with comorbid diagnoses. The consistency of reports of "new-onset" illness was also examined. Factors contributing to these measures were evaluated. RESULTS: The temporal stability of the diagnosis of obsessive-compulsive disorder was very low. Subjects with a stable diagnosis of obsessive-compulsive disorder had a higher rate of both obsessions and compulsions, an earlier age at onset, and more comorbid anxiety, affective, and alcohol abuse/dependence disorders at initial assessment. The originally reported 1-year incidence estimates for obsessive-compulsive disorder primarily reflect data from subjects at wave 2 who reported the onset of symptoms as preceding the wave 1 interview. Older and less-educated subjects had significantly higher error rates in reporting onset. CONCLUSIONS: The DIS diagnosis of obsessive-compulsive disorder has poor validity, leaving the true incidence and prevalence of the disorder unknown. Older and less-educated subjects require special attention in the design of instruments for use with community samples.     

At risk of first or recurring heart disease

OBJECTIVES: The self-reported prevalence of risk factors for heart disease among Canadians with and without heart disease is estimated. The characteristics associated with these risk factors are examined in order to identify groups to be targeted for primary and secondary prevention. DATA SOURCE: The data are from the household component of the 1994/95 National Population Health Survey (NPHS). ANALYTICAL TECHNIQUES: For the population aged 20 and older with and without heart disease, bivariate and multiple regression analyses were used to determine associations between four risk factors (smoking, high blood pressure, diabetes, and inactivity) and demographic characteristics and socioeconomic status. MAIN RESULTS: According to the NPHS, 4.4% of people aged 20 and older reported that they heart disease. However, many more adults had risk factors for this disease. As well, about one-quarter of those without heart disease and half of those with heart disease had two or more risk factors. To some extent, many of these risks are modifiable. The groups particularly at risk were people older than 35, those with less than high school graduation, those in households with inadequate income, people who consumed three or more drinks a day, and residents of the Atlantic provinces, Quebec and Ontario.     

Healthy behaviors among women in the United States and Ontario: the effect on use of preventive care

OBJECTIVES: This study examined how several healthy behaviors among women in Ontario and the United States explained (1) the use of preventive health services, (2) differences in use between socioeconomic groups, and (3) differences in use between the two health systems. METHODS: 1990 data on women from the Ontario Health Survey (n = 22,985) and the US National Health Interview Survey (n = 19,092) were analyzed. A woman who avoided smoking and obesity, used seatbelts, and regularly engaged in aerobic exercise was defined as having a healthy lifestyle. Women were considered screened if they reported a mammogram or a breast exam within the previous year or a Pap smear within 2 years. RESULTS: A healthy lifestyle was more common in the United States than Canada among more highly educated groups (odds ratio [OR] = 1.40; 95% confidence interval [CI] = 1.22, 1.60 for college educated) but less common in the United States for those with less than a high school education (OR = 0.52; 95% CI = 0.40, 0.67). Each additional unhealthy behavior decreased the odds of having undergone a mammogram in the previous year by 20%. However, adjusting for the number of unhealthy behaviors did not substantially change the relationship between socioeconomic status and use of preventive services. CONCLUSIONS: The number of healthy behaviors is an important measure of demand for preventive health services. This measure varies across country and socioeconomic group.     

Attenuation of cyclic nucleotide-mediated smooth muscle relaxation in blacks as a cause of racial differences in vasodilator function

BACKGROUND: Diagnostic criteria for somatization disorder emphasize its early onset and long-term stability. Research assessments of somatization disorder depend on lifetime recall of medically unexplained somatic symptoms. METHODS: Longitudinal data from the World Health Organization Psychological Problems in General Health Care study were used to examine stability of somatization disorder and somatization symptoms over 12 months. At 15 study sites in 14 countries, consecutive primary care patients (N = 25916) were screened using the 12-item General Health Questionnaire. A stratified random sample (n = 5447) was selected for a baseline diagnostic assessment using the Composite International Diagnostic Interview. All cases and a random sample of noncases were asked to complete a follow-up diagnostic assessment 12 months later (n = 3196). RESULTS: While the baseline and 12-month interviews identified a similar number of patients with DSM-IV somatization disorder (74 and 70), only 21 cases were consistently identified at both assessments. Examination of individual symptoms found that 61% of lifetime medically unexplained somatic symptoms detected at baseline were not detected during the lifetime interview 12 months later. When analyses were broadened to all lifetime symptoms reported at baseline (including those found to be "medically explained" or "not clinically significant"), 43% of lifetime symptoms reported at baseline were "lost" 12 months later. CONCLUSIONS: Given that the baseline and follow-up assessments both asked about lifetime symptoms, the loss of somatization disorder or individual somatic symptoms can only represent inconsistent recall. The instability of recall observed here has significant implications for the diagnosis of somatization disorder by structured interview and may also have implications for current diagnostic criteria.     

Treatment of multiple personality disorder: a survey of current practices

OBJECTIVE: Reported cases of multiple personality disorder have increased dramatically in the last decade. Few data are available on the treatment of multiple personality disorder. Current recommendations are based on the experience of individual clinicians rather than on systematic research. METHOD: A questionnaire study of 305 clinicians representing a spectrum of mental health professionals was conducted to survey the types and relative efficacy of treatment modalities currently used with cases of multiple personality disorder. RESULTS: Individual psychotherapy facilitated by hypnosis was uniformly endorsed as the primary treatment by all practitioner groups. The average patient was in twice-weekly psychotherapy facilitated by hypnosis for 3.8 years. Antidepressant and anxiolytic medications were reported to be moderately useful adjunctive treatments. CONCLUSIONS: These findings support current impressionistic treatment recommendations for multiple personality disorder regarding the primacy of psychotherapy and the moderate benefits of psychopharmacology with antidepressant and antianxiety agents.     

Interleukin-1beta expression after inhibition of protein phosphatases in endotoxin-tolerant cells

BACKGROUND: There are cogent reasons why public health specialists should take an active interest in and measure the psychological health and well-being of populations. The literature was searched and reviewed with the aim of evaluating survey instruments that would enable public health specialists to measure the psychological health and well-being of populations. METHODS: The search and review were restricted to instruments that were applicable to adults of working age, and that did not focus on psychotic disorder or organic brain disorder. An attempt was also made to identify instruments that were designed to measure some form of positive well-being and could be applied in population-based surveys. Detailed evaluation was then carried out of two or three instruments that appeared representative of a particular field or approach. RESULTS: The literature search revealed three major fields of research, 'Psychiatric Epidemiology', 'Stress Studies' and 'Subjective Well-being'. Accordingly, the results of the review are presented under these three headings. Results pertaining to commonly used survey instruments in the field of 'Psychiatric Epidemiology' are presented. (Those on 'Stress Studies' and 'Subjective Well-being' are presented in Part 2 of this study.) CONCLUSIONS: Although some questionnaires in the field of 'Psychiatric Epidemiology', such as the General Health Questionnaire and the HAD Scale, offer a valid and convenient means of measuring degrees of neurotic disorder in a population, they do not measure any form of positive well-being. In Part 2, methods of measurement from the other two fields are reviewed and overall conclusions are drawn about the options available to public health specialists.     

Hospital utilization in Ontario and the United States: the impact of socioeconomic status and health status

We compared hospital use in Ontario and the United States for persons with different socioeconomic and health status. METHODS: Cross-sectional study using the 1990 Ontario Health Survey and the 1990 National Health Interview Survey. RESULTS: Admission rates averaged 31% higher in Ontario than in the United States, but international differences varied markedly across income and health status. At each level of health status, poor Canadians received one quarter to one third more admissions than their counterparts in the United States. However, higher income Canadians reporting excellent to good health had 50% more admissions than Americans, whereas those reporting fair or poor health had 10% fewer admissions. CONCLUSIONS: The observation that higher income sick persons receive less hospital care in Ontario than in the U.S. provides support at the population level for what has been observed for specific technologies. This represents, in part, a redistribution of inpatient care to those most vulnerable to illness, such as the poor, who receive substantially more hospital care in Ontario.     

Cognitive potentials in children with learning disabilities

This study investigated factors predicting help-seeking from the Department of Veterans' Affairs (DVA) by Vietnam veterans. Data used were from a national Australian survey of Vietnam veterans' health (n = 641) conducted between July 1990 and April 1993. The survey involved current clinical assessments and retrospective questionnaires, supplemented with health and service records retrieved from the DVA and Army personnel files. Measures included the 1989-90 Australian Bureau of Statistics Health Survey questionnaire, and mental health, sociodemographic and operational deployment history questionnaires. For both current and lifetime diagnoses of post-traumatic stress disorder, a third of the veterans with the disorder had never obtained any health care entitlement from the DVA. Other than physical and mental problems, which accounted for the greatest proportion of the help-seeking odds, significant factors predicting help-seeking included factors such as: predeployment personality, combat exposure, the veterans' own attitudes towards their deployment, experiences during deployment, experiences during repatriation and membership of ex-service organisations. These findings on how post-traumatic stress disorder and other health problems relate to help-seeking patterns could help in developing prevention and care programs for stress disorder.     

Perioperative blood transfusions and decreased long-term survival in esophageal cancer

BACKGROUND: The aim of this study was to assess accessibility to health care services and the needs of the population and demands on the health service in the areas most affected by the current crisis in the former Yugoslavia. The delivery of health care services and problems in its realization and the status of the population's health in the crisis period (from the second half of 1993 to the end of the first half of 1994) were also investigated together with the results of Government measures concerning health care priorities during the period of UN Sanctions in Yugoslavia. METHOD: By the end of the 1980s, as an alternative to traditional data collection, a new method called 'Rapid Health Assessment' appeared. The EPI design (Experienced Programme on Immunization), the most frequently applied method, was used in this study. It is a cluster sample selection, where a household is the basic unit. RESULTS: This study showed that the first effects of the crisis appeared in the field of health care delivery and then in the population's health status. The difficulties were not the same for all categories of the population, and children and urgent cases had less problems than others. The expected difficulties in vaccination coverage were not shown in this survey. The morbidity structure for children and adults changed in comparison with routine statistical data but the size of the chosen sample, as well as the short period of the crisis investigated, mean that definite conclusions cannot be drawn on this issue. This study provides recent data on health care delivery, morbidity structure, and vaccination coverage, as well as giving a more complex and precise estimate of the real situation.     

The latent structure of social anxiety disorder: Consequences of shifting to a dimensional diagnosis.

Despite longstanding debate over the nature of the boundary between social anxiety disorder (SAD) and less severe social anxiety, no study has tested directly whether the defining features of the disorder correspond to a latent category or dimension. The present study examined this question using data from the National Comorbidity Survey Replication (NCS-R), a nationally representative survey of the U.S. household population. Indicators representing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV; American Psychiatric Association, 1994) criteria for SAD were submitted to taxometric analyses in a subsample of adults (n = 2,166) who reported excessive social fear in their lifetime. Multiple taxometric procedures and consistency tests converged on a dimensional solution, suggesting that SAD is continuous with milder social anxiety. In follow-up analyses, a dimensional SAD diagnosis outperformed the DSM–IV diagnosis in predicting the subsequent onset of a range of clinically important outcomes. Large differences in associations with comorbid mood disorders, suicidality, and treatment seeking in particular favored the prognostic value of dimensional over categorical diagnosis. These findings support the validity and potential utility of a dimensional conceptualization of SAD that may inform efforts to revise the diagnosis for DSM–V. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Access to health care. Part 2: Working-age adults

OBJECTIVES: This report presents data on access to health care for U.S. working-age adults, 18-64 years old. Access indicators are examined by selected sociodemographic characteristics including sex, age, race and/or ethnicity, place of residence, employment status, income, health status, and health insurance status. METHODS: Data are from the 1993 Access to Care and 1993 Health Insurance Surveys of the National Health Interview Survey (NHIS), a continuing household survey of the civilian noninstitutionalized population of the United States. The sample contained 61,287 persons in 24,071 households. RESULTS: In 1993, approximately 3 out of 4 working-age adults had a regular source of medical care. Nine out of 10 adults with health insurance had a regular source of care compared with 6 out of 10 adults without health insurance. For adults with a regular source of care, 86 percent received care in a private doctor's office, 9 percent in a clinic, and 2 percent in a hospital emergency room. The two main reasons given for not having a regular source of care were "do not need a doctor" (49 percent), and "no insurance can't afford it" (22 percent). Persons in the highest income group were more likely to report no need for a doctor (59 percent) than persons in the lowest income group (35 percent). About 40 percent of uninsured persons and 16 percent of insured persons reported an unmet medical need. CONCLUSIONS: Health insurance plays a key role in the access to medical care services. Persons who are uninsured or have low incomes are at the greatest risk of having unmet medical needs.     

Comparison of parents with and without disabilities raising teens: Information from the nhis and two national surveys.

Objectives: To contrast families headed by parents with disabilities raising children ages 11-17 years with families headed by parents without disabilities. Study Design: There were 3 sources of data: (a) the National Health Institute Survey (National Center for Health Statistics, 2000), (b) a previous national survey (L. T. T. Barker & V. Maralani, 1997), (c) a new national survey of parents with disabilities (n = 273) and their teens (ages 11-17 years; n = 246) and a control group of parents without disabilities (n = 48) and their teens (n = 37). Main Measure: Participants completed a survey designed for this study. Results: Parents with disabilities were generally quite similar to parents without disabilities, with some notable differences, particularly in employment and income. Deaf parents exhibited certain differences from parents with other disabilities. Conclusion: Survey responses provided a snapshot of parents with disabilities and their families from community samples, including aspects in which disabled and nondisabled participants were similar. (PsycINFO Database Record (c) 2010 APA, all rights reserved)