Mental disorders and burden of disease: how was disability estimated and is it valid?

OBJECTIVE

The Global Burden of Disease study found mental disorders to be the world's leading cause of disability. Few studies have examined the validity of the novel approach used to estimate disability, the person trade-off preference method. This paper describes, and examines the validity of, the burden of disease person trade-off protocol.

METHOD

The person trade-off provides preferences for health states (how good or bad you think it is in relation to perfect health). General practitioners (n = 20) with training in mental health provided preferences for 19 mental disorders using the person trade-off method. Descriptions for the mental disorders were derived from the average symptom severity and disability observed in the Australian National Survey of Mental Health and Wellbeing. Validity was investigated by comparison with two other methods (rating scale and rank order).

RESULTS

The general practitioners found the person trade-off complex and affronting. Only a moderate concordance was observed with two validity comparisons; however, validity was significantly increased following the opportunity for group discussion among the clinicians. The disability weights were higher than those used in the global study, a possible consequence of differences in disorder descriptions.

CONCLUSIONS

The present study is limited by small subject numbers and by using only one type of key informant (clinicians). While this study provided some evidence for the validity of the person trade-off, it also echoes concerns from recent commentaries about the feasibility of this method. These concerns are particularly relevant for mental disorder burden, which relies heavily on the magnitude of the disability weights. Further work is required to ensure that disability burden is validly estimated, and thus can appropriately be used to inform mental health policy.

What people say about their general practitioners' treatment of anxiety and depression

OBJECTIVE

To determine from self-report how often people with anxiety and depressive disorders consult GPs and what treatment they receive.

DESIGN

The study was derived from the 1997 Australian National Survey of Mental Health and Wellbeing. A probability sample of adults was interviewed to determine how many had which mental disorders, how disabled they were by those disorders, and what treatment they had received.

PARTICIPANTS

10641 adults, a 78% response rate.

MAIN OUTCOME MEASURES

Prevalence of anxiety and depressive disorders and related disability; frequency of consultations for a mental problem; treatment received.

RESULTS

13.6% of the population both met criteria for an anxiety or depressive disorder in the 12 months before the survey and, when they suffered from more than one disorder, nominated this as their principal complaint. They reported some disability in 7 of the previous 28 days, and consulted a GP or other health professional 1.4 times in that period. Over half did not seek a consultation for a mental health problem at any time during the year, many because they thought they had no need.

CONCLUSION

Many people who could benefit from treatment for anxiety and depressive disorders are not being reached. If people were registered with a general practice it would be possible for GPs to take a proactive stance that could result in greater benefit to patients at a lower cost to the health system.

Disability measurement in the anxiety disorders: comparison of three brief measures

General measures of disablement are powerful tools in clinical settings as they provide a link between clinic and community populations and allow cross-disorder comparisons. Because of their generic nature, they allow the transmittal of comprehensible health planning information to decision makers. We located no studies of such general disability measures in the anxiety disorders and decided to examine the properties of three brief generic measures in an anxiety disorders clinic. Consecutive attenders (N=168) were administered the Medical Outcomes Study Short Form-12 item (SF-12), the Brief Disability Questionnaire (BDQ), and a measure of the number of disability days due to health over the past 4 weeks. These measures were compared on their ability to discriminate within the clinic and in comparison to a representative community group. The mental health scale of the SF-12 was the most sensitive of the generic measures to differences in functioning, and is recommended as a measure of such for people with anxiety disorders. Attenders at this anxiety clinic reported high levels of disablement, and normative data on the general measures are provided.

Using postoperative cardiac Troponin-I (cTi) levels to detect myocardial ischaemia in patients undergoing vascular surgery

BACKGROUND

Cardiac complications occur commonly in vascular surgery patients. Diagnosis of cardiac complications is difficult because of the inaccuracies associated with traditional cardiac enzyme measurements. CTi, a highly sensitive and specific marker of myocardial injury, may be able to detect cardiac complications with greater ease and accuracy.

METHODS

The study prospectively examined 100 consecutive patients who underwent major vascular surgery between 6/7/98 and 31/12/98 at the Royal Brisbane Hospital. Daily measurements of cTi, creatine kinase (CK), creatine kinase MB (CKMB), CKMB index, renal function and haemoglobin were taken for three postoperative days. One postoperative electrocardiograph (ECG) was taken. An extensive cardiac history was taken. Intraoperative and postoperative events were recorded.

FINDINGS

There were 100 patients. 18 patients (18%) had a cTi elevation. On the basis of classical diagnostic criteria, 15 patients (15%) suffered one or more cardiac complication (either myocardial infarction, congestive cardiac failure, unstable angina or atrial fibrillation). One patient (1%) who had a cTi elevation died. CTi elevation occurred in five patients (5%) who were not diagnosed with cardiac complications based on traditional criteria. Despite not meeting specific diagnostic criteria for cardiac complications, all patients showed signs and symptoms that could be attributed to myocardial ischaemia. Every patient who developed congestive cardiac failure or atrial fibrillation had a cTi elevation. A Chi-square analysis revealed a significant association between cTi elevation and postoperative cardiac complications. Four variables contributed small but significant amounts of unique variance to the prediction of peak cTi on linear regression analysis. These were peak CKMB index, postoperative congestive cardiac failure, postoperative chest pain and postoperative cardiac complications.

CONCLUSIONS

Routine cTi monitoring of postoperative vascular patients would be an effective and inexpensive way to detect patients with cardiac complications. The relationship between postoperative cTi elevation and significant coronary artery disease remains to be shown.

Do doctors know best? Comments on a failed trial

A randomised controlled trial was planned to compare two different treatment strategies--structured problem solving and selective serotonin reuptake inhibitor (SSRI) medication--for patients with mild to moderate major depression. The trial was to be conducted in the primary care setting with all treatment given by general practitioners. When no patients had been recruited into the study after six months, we performed an audit of all patients with depressive symptoms attending the doctors' practices over three weeks. Exclusion criteria were changed to ease entry into the trial, but still no patients were recruited over the following six months. What went wrong?

Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey

BACKGROUND

Health planning should be based on data about prevalence, disability and services used.

AIMS

To determine the prevalence of ICD-10 disorders and associated comorbidity, disability and service utilisation.

METHOD

We surveyed a national probability sample of Australian households using the Composite International Diagnostic Interview and other measures.

RESULTS

The sample size was 10 641 adults, response rate 78%. Close to 23% reported at least one disorder in the past 12 months and 14% a current disorder. Comorbidity was associated with disability and service use. Only 35% of people with a mental disorder in the 12 months prior to the survey had consulted for a mental problem during that year, and most had seen a general practitioner. Only half of those who were disabled or had multiple comorbidity had consulted and of those who had not, more than half said they did not need treatment.

CONCLUSIONS

The high rate of not consulting among those with disability and comorbidity is an important public health problem. As Australia has a universal health insurance scheme, the barriers to effective care must be patient knowledge and physician competence.

Changing the trend: a prospective study on factors contributing to the growth rate of peritoneal dialysis programs

Compared with countries worldwide, the United States currently has one of the lowest peritoneal dialysis (PD) populations as compared with its hemodialysis (HD) population. Approximately 12% of the total dialysis population in the United State is on PD. This figure correlates with the take-on rate [percentage of end-stage renal disease (ESRD) patients enrolling in PD programs] of about 12%-15% in the United States. Over a two-year period, we prospectively examined the role that developing a comprehensive infrastructure and support system had on expanding our PD program. The changes made included these: nephrologists placing PD catheters using the laparoscopic method; active identification of, and training for, family members and personnel in nursing homes and daycare centers to perform PD; improvements in home conditions through support by social workers; early ESRD patient education; and provision of in-center intermittent PD (IPD) for selected patients. We then compared the results from the two years after commencement of the changes against the two years before the changes were made. Training of personnel in nursing homes increased enrollment from 3 to 11 patients (p = 0.01); training of personnel in daycare centers increased enrollment from 0 to 5 patients (p = 0.05); training family members and providing family support increased enrollment from 4 to 15 patients (p = 0.03); early patient and family education increased enrollment from 4 to 24 patients (p = 0.008); improving home conditions increased enrollment from 1 to 14 patients (p = 0.01); and providing an IPD program for selected patients added 6 patients (p = 0.05). Introducing a program for nephrologists to place PD catheters by the laparoscopic technique decreased catheter mechanical failure (and subsequent transfer to HD), from 22 to 3 patients (p = 0.005). Our PD take-on rate (percentage of ESRD patients choosing PD modality) increased from 19% to 76% (p = 0.002). The total number of patients in the PD program over the two years after initiation of the changes increased from 33 to 93 (p = 0.01), while the number of HD patients decreased from 168 to 142 (p = 0.05). Developing a comprehensive infrastructure and support system for PD programs permits enrollment of patients who otherwise would have been excluded as PD candidates and eliminates loss of PD patients to HD. Implementation of such programs can contribute considerably to enhancing the PD population growth rate.

DSM-IV and ICD-10 generalized anxiety disorder: discrepant diagnoses and associated disability

BACKGROUND

It is commonly assumed that diagnoses according to DSM-IV and ICD-10 are equivalent. Recent discussions on generalized anxiety disorder (GAD) have suggested that ICD-10 criteria may be identifying a milder form of the disorder than DSM-IV. This report examines prevalence and associated disability of DSM-IV and ICD-10 GAD.

METHODS

The Composite International Diagnostic Interview was administered to a community sample of 10,641 people, and the diagnostic criteria that contributed to discrepancies between DSM-IV and ICD-10 GAD were identified. A multiple linear regression analysis was carried out to determine the strength of the relationship between disability, as measured by the SF-12, and discrepant diagnoses of GAD.

RESULTS

The concordance between DSM-IV and ICD-10 GAD was fair (kappa = 0.39). The two sources of discrepancy when DSM-IV was positive and ICD-10 was negative resulted from the requirement in ICD-10 that the respondent endorse symptoms of autonomic arousal (ICD-10 criterion B) and the requirement that ICD-10 GAD does not co-occur with panic/agoraphobia, social phobia or obsessive-compulsive disorder (ICD-10 criterion C). The two major sources of discrepancy when ICD-10 was positive and DSM-IV was negative resulted from the requirement in DSM-IV that the worry be excessive (DSM-IV criterion A) and that it causes clinically significant distress or impairment (DSM-IV criterion E). DSM-only GAD cases had significantly higher levels of disability than ICD-only cases of GAD after controlling for demographic variables and the presence of comorbid psychiatric disorders.

CONCLUSIONS

While the prevalence rates for DSM-IV and ICD-10 GAD are almost identical, these classification systems are diagnosing different groups of people.

Case ascertainment: the Composite International Diagnostic Interview

OBJECTIVE

To outline the utility of the Composite International Diagnostic Interview (CIDI) in the diagnosis of psychosis.

METHOD

Report current situation.

RESULTS

The CIDI was designed as a fully structured interview to be used by lay interviewers. It generates false positive diagnoses in community surveys and false negative diagnoses in psychiatric settings. A new psychosis module has been developed to reduce these problems.

CONCLUSIONS

The diagnosis of psychosis by fully structured diagnostic interviews is difficult.

Anxiety disorders. Recognition and management

BACKGROUND

Anxiety disorders are common and disabling. Yet they often go unnoticed: sufferers do not always complain of symptoms, and when they do they often present with primarily somatic concerns. Also, they are sometimes dismissed as being 'just anxious', 'very shy', or 'worriers' rather than being recognized as suffering from very treatable disorders.

OBJECTIVE

To briefly describe the assessment, diagnosis, differential diagnosis, and management of the major anxiety disorders.

DISCUSSION

Anxiety disorders are common and treatable. Cognitive behavioural therapy and medications are the two main treatment modalities. Ways of increasing skills with psychological techniques are also discussed.

Australia's mental health: an overview of the general population survey

OBJECTIVES

The objectives of this study were to estimate the 1-month and 1-year prevalence of mental disorders in the Australian adult population; to determine the amount of disablement associated with this; and to determine the use of health and other services by persons with common mental disorders.

METHOD

For the Adult Survey, a household sample of 10600 persons aged 18 years and over were interviewed across Australia by experienced field staff of the Australian Bureau of Statistics. This was 78% of the target sample. The interview consisted of the composite international diagnostic interview in its automated presentation (CIDI-A) and other components to determine disablement, use of services and satisfaction with services received. The diagnostic classifications used in the analyses were both ICD-10 and DSM-IV. Only the results from ICD-10 are reported here.

RESULTS

A total of 17.7% of the sample had one or more common mental disorders, anxiety, depression, alcohol or substance abuse and neurasthenia. This morbidity was associated with considerable disablement in daily life: 3 days of impaired social role performance in the previous 4 weeks, compared with 1 day for the general population. Of all cases, 64.6% had had no contact with health services in the previous year; 29.4% had seen GPs and 7.5% had seen psychiatrists.

CONCLUSION

Australia now has its own national estimates of psychiatric morbidity. The morbidity is associated with considerable disablement, but most of it is untreated. General practitioners encounter by far the largest proportion of those reaching services.

Contraception: what has changed over the past decade?

The past decade has seen major advances in contraceptive technology. These have resulted in the launch of several new highly effective methods of contraception and also significant improvements in existing methods. The main purpose of this article is to review how the contraceptive field has changed over the past 10 years, explain the new methods that have become available, e.g. hormone-releasing intrauterine systems, hormone implants and female condoms, re-examine existing methods, and mention new research and how this has affected clinical practice over the past decade. When discussing contraception, clients should be given up-to-date and accurate information on currently available methods: their efficacy, advantages, disadvantages and how the method works. As with any other specialty in medicine, nurses offering contraceptive advice should ensure they regularly update their knowledge and are aware of new developments and research in order to facilitate their clients in making an informed choice. New research and developments affect the choices and potentially the health of a large part of the population.

Identifying personality disorders: towards the development of a clinical screening instrument

The study objective was to identify a set of personality disorder (PD) criteria from the DSM PD diagnostic sets that can be used to detect subjects with an increased likelihood of having a PD diagnosis. In a series of outpatients evaluated systematically in two waves for every criteria item for 12 DSM-III-R PDs, stepwise logistic regression identified 45 criteria as discriminative for their specific PDs, which are selected for further analysis to assess their ability to discriminate for any PD. Receiver operating characteristic (ROC) analysis is used to evaluate their discriminative power in an independent conjoined sample (N = 1,342) from six centers that assessed every PD criteria item by structured instrument (Structured Clinical Interview for DSM-III-R PDs [SCID-II, Personality Disorder Examination [PDE], and Structured Interview for DSM-III-R PDs [SIDP-R]). The cutoff that maximizes information gain is used to determine the diagnostic threshold (DT). Initially, 15 of 45 criteria are identified. At the 0.43 PD prevalence, a DT of 2 or more of the 15 PD criteria across samples is optimal. The maximum information gain (MIG) is .42 bits, and the AUR is 0.94+/-.007. Other performance indices at this cutoff are .90 sensitivity, .84 specificity, .81 positive predictive power (PPP), .91 negative predictive power (NPP), and .86 hit rate (HR). Taken collectively, the 15 PD criteria selected by the data reduction techniques suggest a narrowed set to be assessed in screening for the presence or absence of any PD with comparable or better psychometric properties than other tests routinely used for diagnosing medical and psychiatric disorders. If specific PD categorization is needed, a second-step comprehensive assessment should follow.

Why does the burden of disease persist? Relating the burden of anxiety and depression to effectiveness of treatment

Why does the burden of mental disorders persist in established market economies? There are four possibilities: the burden estimates are wrong; there are no effective treatments; people do not receive treatment; or people do not receive effective treatments. Data from the Australian National Survey of Mental Health and Wellbeing about the two commonest mental disorders, generalized anxiety disorder and depression, have been used in examining these issues. The burden of mental disorders in Australia is third in importance after heart disease and cancer, and anxiety and depressive disorders account for more than half of that burden. The efficacy of treatments for both disorders has been established. However, of those surveyed, 40% with current disorders did not seek treatment in the previous year and only 45% were offered a treatment that could have been beneficial. Treatment was not predictive of disorders that remitted during the year. The burden therefore persists for two reasons: too many people do not seek treatment and, when they do, efficacious treatments are not always used effectively.

Recall of depressive episode 25 years previously

BACKGROUND

Lifetime rates of depression reported in epidemiological surveys are generally only twice the 12 month rates. Either people forget the symptoms of depression or many people who have a depressive episode remain depressed for many years. Both may be true. There is a need to examine the long-term clinical validity of interviews that are used to make lifetime diagnoses.

METHODS

Forty-five patients who were part of a long-term follow-up study of depression were interviewed 25 years after the index episode. The diagnoses from the original, fully structured interviews were compared with the responses people made for that period when interviewed using the CIDI 25 years later.

RESULTS

Twenty-seven patients met CIDI DSM-III-R criteria for depression at index episode. At the 25 year follow-up, 19 of the 27 reported the essential symptoms of 'depression or loss of interest' being present at the index time, and in 14 of the 27 the depressive symptoms recalled met criteria for DSM-III-R major depressive episode at that time.

CONCLUSIONS

Seventy per cent of people who were hospitalized for a major depressive episode can recall being depressed but only half can recall sufficient detail to satisfy the diagnostic criteria when interviewed 25 years later. As depressive episodes, especially those severe enough to warrant admission, are recalled better than many other diagnoses, one must be cautious about the lifetime rates for mental disorders reported in retrospective epidemiological surveys.

Efficacy, effectiveness and efficiency in mental health service delivery

OBJECTIVE

The aim of this paper is to review the status of treatments in psychiatry.

METHOD

The criteria for good treatment are defined and then treatments in psychiatry are examined for efficacy, effectiveness and efficiency.

RESULTS

A large number of treatments were listed by Nathan and Gorman as having satisfied the criteria for efficacy: that is, they had been shown to be superior to placebo in randomised controlled trials. The problem of effectiveness (does the treatment still work when used by the average clinician with the average patient?) is a general one in medicine, but the evidence in psychiatry is not outstanding. The problem of efficiency (what level of resources are required to produce benefit?) is being addressed in a piecemeal fashion, and again this is no different to the situation in general medicine.

CONCLUSIONS

A considerable number of treatments have been shown to satisfy the criteria for efficacy. Effectiveness requires that psychiatrists apply such proven treatments and demonstrate benefit through the use of outcome measurement. A system that separated the health budget into segments for prevention, cure and care might ensure that these three goals were pursued equitably and efficiently.

A comparison of ICD10 and DSM-IV criteria for posttraumatic stress disorder

The assumption that participants receiving an ICD10 diagnosis of posttraumatic stress disorder (PTSD) will also receive a DSM-IV diagnosis of PTSD was tested. Data were gathered for 1,364 participants using the Composite International Diagnostic Interview (CIDI). The 12-month prevalence of PTSD was 3% for DSM-IV and 7% for ICD10 Diagnostic Criteria for Research (ICD10-DCR). The agreement between the two systems was fair (kappa = .50). Forty eight percent of the discrepancies between the systems were accounted for by the additional criterion requiring clinically significant distress or impairment included in DSM-IV. The inclusion of symptoms of general numbing of responsiveness accounted for 18% of the discrepancies. It is concluded that ICD10-DCR PTSD cannot be assumed to be identical to DSM-IV PTSD.