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MEASURING MENTAL ILLNESS. EPIDEMIOLOGY. STUDY OF RATES OF DISORDER IN COMMUNITY POPULATIONS FOCUS ON GROUP RATES OF DISORDER NOT INDIVIDUAL CASES FOCUS ON UNTREATED CASES. WHY WANT EPIDEMIOLOGY?. SMALL PROPORTION OF PEOPLE WITH M.I. ENTER TREATMENT TREATED PEOPLE AREN’T REPRESENTATIVE
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EPIDEMIOLOGY • STUDY OF RATES OF DISORDER IN COMMUNITY POPULATIONS • FOCUS ON GROUP RATESOF DISORDER NOT INDIVIDUAL CASES • FOCUS ON UNTREATED CASES
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
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 AND IMPRACTICAL • USE STANDARDIZED INSTRUMENTS • STANDARD QUESTIONS • STANDARD ANSWERS
TWO TYPES OF MEASURES • GENERAL MEASURES OF OUTCOME • DIAGNOSTIC MEASURES OF OUTCOME
GENERAL MEASURES • MOST COMMON • FREQUENTLY OCCURING SYMPTOMS – NOT COMPARABLE TO DSM CATEGORY • E.G. CESD
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
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
SCORES • ADD RESPONSES • 16 NORMAL CUTOFF FOR CES-D
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
USE FOR RATES COMPARE GROUPS IN COMMUNITY - E.G. GENDER, SOCIAL CLASS, MARITAL STATUS, ETC.
COMPARABLE TO DSM • CAN’T TELL WHAT CESD MEASURES • WANT SPECIFIC MEASURES OF DIAGNOSTIC CATEGORIES
TWO MAJOR STUDIES • ECA - EPIDEMIOLOGIC CATCHMENT AREA) - 1980’S (WAKEFIELD) • NCS - NATIONAL COMORBIDITY STUDY - 1990’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.
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 • NO DISCRETION OF EITHER • NO CONTEXT (LIKE CESD) • RESULT IS OVERCOUNTING
DSM SYMPTOMS • LACK INTEREST IN SEX • ANXIETY ABOUT PERFORMANCE • AROUSAL DIFFICULTIES • UNABLE TO HAVE ORGASM • CLIMAX TOO QUICKLY • FIND SEX PAINFUL • SEX NOT PLEASURABLE
FINDINGS • 43 % OF WOMEN AND 31% OF MEN HAVE SEXUAL DYSFUNCTION • VERY WIDESPREAD PUBLIC HEALTH PROBLEM • PEOPLE MUST KNOW THAT MEDICATIONSARE AVAILABLE TO HELP
SEXUAL DYSFUNCTION • BEST PREDICTOR? • LOW SATISFACTION WITH PARTNER • PEOPLE WHO DON’T ENJOY SEX WITH PARTNERS ARE CALLED MENTALLY ILL AND SHOULD TAKE MEDICATION
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