Public Health Surveillance

1. Public Health Surveillance • “The ongoing, systematic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health.” • Centers for Disease Control and Prevention, (2001). Updated guidelines for evaluating public health surveillance systems: Recommendations from the guidelines working group. Morbidity and Mortality Weekly Report 2001, 50 (No. RR-13), 1 – 35.

2. Features of Public Mental Health Surveillance System (Galea & Norris) • A functionally hybrid system to maximize cost-effectiveness because disease-specific surveillance of psychological disorders (diagnoses) would be prohibitively expensive, • they recommend ongoing syndromic surveillance focusing on key indicators of current depression, PTSD, dysfunction, anxiety/fears, and psychosocial resources, punctuated with occasional disease-specific surveys and more in-depth assessment of risk and protective factors

3. Features of Public Mental Health Surveillance System (Galea & Norris) • Surveillance be implemented on a large enough scale to provide data for specific racial, ethnic, and socioeconomic groups. • This would increase understanding of the differences in the need for and use of mental health services. • Public Mental Health Surveillance must aim to educate major stakeholders, including the general public.

4. Mental Health Epidemiologic Studies • First-generation - 16 (Prior to World War II) • E. Jarvis: Insanity and Idiocy in MA: Report of the Commission on Lunacy, 1855. Cambridge, MA: HU ‘71 • Institutional records and key informants • Prevalence in specialty mental health settings • Second-generation - 60 (1950 – 1980) • Stirling County Study (1952) • Baltimore Morbidity Survey (1953/54) • Midtown Manhattan Study (1954) • Mental Health Study in New Haven (1967-75) • Predefined “operationalized” criteria • Structured interviews by non-clinician interviewers • Prevalence in the community

5. Mental Health Epidemiologic Studies • Third-generation (1980 - present) • Epidemiologic Catchment Area (1980-85) • In response to President’s Commission on Mental Health (PCMH) • Diagnostic Interview Schedule (DIS) • Prevalence and incidence of mental disorders • Use and need for services • Research teams from 5 universities • Yale, Johns Hopkins, Washington University, Duke, and UCLA in collaboration with NIMH • Community Mental Health Catchment Area sites: • New Haven, CT, Baltimore, MD, St Louis, MO, Durham, NC, and Los Angeles, CA

6. Mental Health Epidemiologic Studies • Third-generation (1980 - present) • National Comorbidity Survey (NCS) • First nationally representative mental health survey in the U.S. to use a fully structured interview (WHO revised CIDI) to assess the prevalence and correlates of DSM-III-R disorders • Composite International Diagnostic Instrument (CIDI) • Interviews from Fall 1990 to Spring 1992 • Re-interviewed in 2001 – 2002 (NCS-2)

7. Mental Health Epidemiologic Studies • Third-generation (1980 - present) • NCS Replication (NCS-R) • Reinterviewed in 2001 – 2002 (NCS-2) • Interviewed a new nationally representative sample repeating many of the questions from the original NCS and expanding disease assessment criteria based on DSM-IV • Uncover trends in mental health • Prevalence • Impairment • Service use

8. Instruments • Diagnostic Interview Schedule (DIS) • Used in ECA • World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) • Used in NCS

9. Instruments • Short Form (SF-36) • Mental Component Score (MCS), and Mental Health (MH-5) 1 0f 8 domains • General Health Questionnaire (GHQ) • GHQ-12 • Mini-International Neuropsychiatric Interview (MINI), Sheehan et al., (1998)

10. Instruments • Patient Health Questionnaires (PHQ) • Prime-MD, PHQ-9, PHQ-8, and PHQ-2 • PHQ-8 used in: • BRFSS 2006 and 2008 • PHQ-9 used in: • NHANES 2005 - 2006

11. Instruments • Kessler scales • K10 has been used in: • WHO World Mental Health (WMH) Surveys • 250,000 people • 30 countries • Australian Bureau of Statistics, National Survey of Mental Health and Wellbeing (SMHWB) • K6 (past 30 days) used in: • BRFSS 2007 • NHIS (since 1997) • K6 (worst 30 days in past year) used in: • NSDUH

12. SMI • SAMHSA’s official definition of adults with SMI, based on a notice published in the Federal Register (SAMHSA, Center for Mental Health Services, 1993): • Age 18 and over, and • Currently have, or at any time during past year, had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet DSM-IV or ICD-9-CM equivalent, with the exception of substance use disorders, and developmental disorders; • Has resulted in functional impairment which substantially interferes with or limits one or more major life activities.

13. From SMI… • NSDUH implemented the modified K6 (worst 30 days in past year) to assess SMI based on a methodological study to evaluate several screening scales for measuring SMI • Truncated version of WHO-CIDI • K10/K6 scale of non-specific psychological distress • WHO-Disability Assessment Schedule • Respondents with a total score of 13 or greater were classified as having past year SMI

14. …to SPD • In 2003 NSDUH contained a broad array of questions about mental health that preceded the K6 items, and the four extra questions in the K10 scale interspersed among the items in the K6 scale. • In 2004 NSDUH, the sample of respondents 18 or older was split evenly between the “long form” as used in 2003 NSDUH, and a “short form” consisting of only K6 items. • Results showed large differences between the two samples in both the K6 total score and the proportion of respondents with a K6 total score of 13 or greater. • K6 scale was found not to be context independent • GAF score of less than 60 (moderate) not per definition • Changed: GAF score of less than or equal to 50 (serious)

15. Clinically Significant vs Mild Disorders • Using data on clinical significance lowered past-year prevalence rates of “any disorder” among 18 – 54-year-olds by 17% in the ECA and 32% in NCS and discrepancies between these two surveys are largely due to methodologic differences. • Establishing the clinical significance of disorders in the community is crucial for estimating treatment need • Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States. Arch Gen Psychiatry. 2002;59:115-123

16. Clinically Significant vs Mild Disorders • Twelve-month NCS/DSM-III-R disorders were disaggregated into: • 3.2% severe, 3.2% serious, 8.7% moderate, and 16.0% mild case categories • All 4 case categories were associated with statistically significant (p<.05) elevated risk of NCS-2 outcomes compared with baseline non-cases, with odds ratios of any outcome ranging monotonically from 2.4 to 15.1 for mild to severe cases. • There is a graded relationship between mental illness severity and later clinical outcomes. • Kessler RC, Merikangas KR, Berglund P, Eaton WW, Koretz DS, Walters EE. Mild disorders should not be eliminated from DSM-V. Arch Gen Psychiatry. 2003;60:1117-1122.

17. Managing depression as a chronic disease • Evidence from trials of the efficacy of short term treatment • Nathan PE, Gorman, J, eds. A guide to treatments that work. Oxford: Oxford University Press, 1998 • Four types of antidepressant drugs, cognitive behavior and interpersonal therapy, and electroconvulsive therapy produced benefits of 0.5 to 1.0 standard deviation over the response to placebo. • Depression is a disorder that remits • Depression also recurs

18. Dynamic and chronic nature of depression • Results from the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) indicate six-month recovery and remission rates of 50% and 70% respectively. • Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial evaluated depression treatment strategies comparing four sequential steps of different medications, medication combinations, or medication with cognitive behavior therapy. • 37% of depressed patients had remission after the first step (citalopram only), • a total of 67% achieved remission after all four steps, and • only 43% had sustained recovery.

19. Take-away messages • Depression, while recognized as a highly recurrent and often a chronic disorder requiring long-term treatment, frequently remains unrecognized and untreated or inadequately treated. • Sub-threshold or minor depression is often associated with disability and poor psychosocial functioning, and a potentially more severe course that requires treatment. • If left untreated or inadequately treated, depression can be a source of much unnecessary personal distress, prolonged family burden, and significant morbidity and mortality. • When left untreated or inadequately treated, including premature termination of treatment, depression more likely persists, reoccurs, and worsens

20. Take-away messages • Need ongoing syndromic surveillance focusing on key indicators of current depression because disease-specific surveillance of psychological disorders (diagnoses) would be prohibitively expensive. • Occasional disease-specific surveys and more in-depth assessment of risk and protective factors. • Periodic combination of the two types of data (indicators and diagnoses) would facilitate interpretation of the indicator data, which would be collected more frequently and regularly. • Clinically significant and mild or sub-syndromal disorders need to be monitored

21. Public Mental Health Surveillance: Questions Satvinder “Pearly” Dhingra, MPH Behavioral Surveillance Branch SDhingra@cdc.gov 770-488-5444