epidemiology study of rates of disorder in community populations focus on group rates of disorder...
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EPIDEMIOLOGY
• STUDY OF RATES OF DISORDER IN COMMUNITY POPULATIONS
• FOCUS ON GROUP RATES OF DISORDER NOT INDIVIDUAL CASES
• FOCUS ON UNTREATED CASES
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WHY WANT EPIDEMIOLOGY?
• SMALL PROPORTION OF PEOPLE WITH M.I. ENTER TREATMENT
• TREATED PEOPLE AREN’T REPRESENTATIVE
• MUST LOOK AT UNTREATED TO UNDERSTAND CAUSES, COURSE, AND TREATMENT
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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.
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HOW MEASURE M.I.?
• PSYCHIATRIC INTERVIEWS VERY EXPENSIVE AND IMPRACTICAL
• USE STANDARDIZED INSTRUMENTS
• STANDARD QUESTIONS
• STANDARD ANSWERS
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TWO TYPES OF MEASURES
• GENERAL MEASURES OF OUTCOME
• DIAGNOSTIC MEASURES OF OUTCOME
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GENERAL MEASURES
• MOST COMMON
• FREQUENTLY OCCURING SYMPTOMS – NOT COMPARABLE TO DSM CATEGORY
• E.G. CESD
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CES-D - QUESTIONS
DURING THE PAST WEEK
• I FELT SAD
• I DID NOT FEEL LIKE EATING; MY APPETITE WAS POOR
• MY SLEEP WAS RESTLESS
• I ENJOYED LIFE (REVERSED)
• 20 IN ALL
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ANSWER CATEGORIES
• NONE OR RARELY (LESS THAN 1 DAY); SOME (1-2 DAYS); MODERATE (3-4 DAYS); OFTEN (> 4 DAYS)
• 0, 1, 2, 3 SCORES
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SCORES
• ADD RESPONSES
• 16 NORMAL CUTOFF FOR CES-D
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ISSUES
• WHAT DOES IT MEASURE – DISORDER OR DISTRESS?
• HIGH RATES – 20% TO 30% OVER 16• SENSITIVE TO IMMEDIATE EVENTS• MUCH CHANGE – ONLY 1/3 OF
PEOPLE STAY IN SAME CATEGORY OVER SEVERAL MONTHS
• CAN’T SEPARATE DISORDER FROM DISTRESS
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USE FOR RATES
COMPARE GROUPS IN COMMUNITY - E.G. GENDER, SOCIAL CLASS, MARITAL STATUS, ETC.
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COMPARABLE TO DSM
• CAN’T TELL WHAT CESD MEASURES
• WANT SPECIFIC MEASURES OF DIAGNOSTIC CATEGORIES
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TWO MAJOR STUDIES
• ECA - EPIDEMIOLOGIC CATCHMENT AREA) - 1980’S (WAKEFIELD)
• NCS - NATIONAL COMORBIDITY STUDY - 1990’S (KESSLER)
• BOTH USE FORMAL DIAGNOSES
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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
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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.
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USUAL CONCLUSIONS (KESSLER)
• MENTAL DISORDER WIDESPREAD
• TREMENDOUS “UNMET NEED” FOR TREATMENT
• UNMET NEED GREATEST AMONG POOR, MINORITIES, MEN, OLDER
• MUST EXPAND MENTAL HEALTH SERVICES
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OVERESTIMATES (WAKEFIELD)
• SUPPOSED TO BE SAME AS CLINICAL
• 1. DISCRETION OF INDIVIDUAL
• 2. DISCRETION OF CLINICIAN
• COMMUNITY STUDIES
• NO DISCRETION OF EITHER
• NO CONTEXT (LIKE CESD)
• RESULT IS OVERCOUNTING
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DSM SYMPTOMS
• LACK INTEREST IN SEX
• ANXIETY ABOUT PERFORMANCE
• AROUSAL DIFFICULTIES
• UNABLE TO HAVE ORGASM
• CLIMAX TOO QUICKLY
• FIND SEX PAINFUL
• SEX NOT PLEASURABLE
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FINDINGS
• 43 % OF WOMEN AND 31% OF MEN HAVE SEXUAL DYSFUNCTION
• VERY WIDESPREAD PUBLIC HEALTH PROBLEM
• PEOPLE MUST KNOW THAT MEDICATIONS ARE AVAILABLE TO HELP
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SEXUAL DYSFUNCTION
• BEST PREDICTOR?
• LOW SATISFACTION WITH PARTNER
• PEOPLE WHO DON’T ENJOY SEX WITH PARTNERS ARE CALLED MENTALLY ILL AND SHOULD TAKE MEDICATION
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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