MEASURING MENTAL ILLNESS

1. MEASURING MENTAL ILLNESS

2. OUTLINE • HOW MEASURE M.I. IN COMMUNITY POPULATIONS? • MAJOR INSTRUMENTS AND FINDINGS • PROBLEMS WITH INSTRUMENTS • POLICY IMPLICATIONS

3. Treatment for Depression

4. REASONS FOR ENTERING TREATMENT • MENTAL ILLNESS • CHANGING CULTURE SO MORE RECOGNITION • EDUCATIONAL CAMPAIGNS • PHARMACEUTICAL ADS • CHANGE IN FINANCING

5. PROBLEMS WITH TREATED SAMPLES • CAN REFLECT UNDERTREATMENT • OR OVERTREATMENT • SO NOT ACCURATE REFLECTION OF AMOUNT • NOT REPRESENTATIVE OF TYPES OF PEOPLE • “CLINICIAN’S ILLUSION”

6. EPIDEMIOLOGY • FOCUS ON UNTREATED CASES • STUDY OF RATES OF DISORDER IN COMMUNITY POPULATIONS • FOCUS ON GROUP DIFFERENCES IN DISORDER NOT INDIVIDUAL CASES

7. 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.

8. HOW MEASURE M.I.? • PSYCHIATRIC INTERVIEWS VERY EXPENSIVE, IMPRACTICAL, UNRELIABLE • USE STANDARDIZED INSTRUMENTS • STANDARD QUESTIONS • STANDARD ANSWERS

9. DIAGNOSTIC INTERVIEWS

13. 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

14. 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

15. 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.

16. GENERALIZED QUESTIONNAIRES • MORE PRACTICAL, CHEAPER

18. 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?

19. USEFUL FOR RATES COMPARE GROUPS IN COMMUNITY - E.G. GENDER, SOCIAL CLASS, MARITAL STATUS, ETC.

20. USUAL CONCLUSIONS (KESSLER) • MENTAL DISORDER WIDESPREAD • TREMENDOUS “UNMET NEED” FOR TREATMENT • UNMET NEED GREATEST AMONG POOR, MINORITIES, MEN, OLDER • MUST EXPAND MENTAL HEALTH SERVICES

21. 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

22. POLICY STEMMING FROM COMMUNITY STUDIES • OVERCOME PROBLEM OF UNMET NEED

23. Screening for Depression

24. SCREENING • FIND UNTREATED INDIVIDUALS • SETTINGS THAT HAVE HIGH % OF M.I. • PRIMARY MEDICAL CARE • SCHOOLS

27. GET TREATMENT TO UNTREATED PREVENT FROM BECOMING MORE SERIOUS SAVE MONEY TOO INTRUSIVE? STIGMA IS IT EFFECTIVE? TELL ANYTHING NEW? BE CAUTIOUS, NOT SWEEPING BENEFITS AND COSTS

28. 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