Mental health promotion: guidance and strategies

Public mental health incorporates a number of strategies from mental well-being promotion to primary prevention and other forms of prevention. There is considerable evidence in the literature to suggest that early interventions and public education can work well for reducing psychiatric morbidity and resulting burden of disease. Educational strategies need to focus on individual, societal and environmental aspects. Targeted interventions at individuals will also need to focus on the whole population. A nested approach with the individual at the heart of it surrounded by family surrounded by society at large is the most suitable way to approach this. This Guidance should be read along with the European Psychiatric Association (EPA) Guidance on Prevention. Those at risk of developing psychiatric disorders also require adequate interventions as well as those who may have already developed illness. However, on the model of triage, mental health and well-being promotion need to be prioritized to ensure that, with the limited resources available, these activities do not get forgotten. One possibility is to have separate programmes for addressing concerns of a particular population group, another that is relevant for the broader general population. Mental health promotion as a concept is important and this will allow prevention of some psychiatric disorders and, by improving coping strategies, is likely to reduce the burden and stress induced by mental illness.

Interpreting the structure of diagnosis in initial evaluations: primary, auxiliary and rule out patterns

The study evaluates DSM III as a natural taxonomy, a system of categories devised for identifying complex objects represented as clinical conditions. Adults seeking initial evaluations constitute the study's population. An individual's clinical condition is examined in terms of a diagnostic format consisting of primary, auxiliary and rule out positions in Axis I and presence and number of diagnoses in Axis II. Each clinical condition thus differs with respect to complexity and diagnostic formats of such conditions are analyzed quantitatively. Differences between the sexes and the races with respect to number of Axis I and Axis II diagnoses are presented. The frequency of use of a diagnostic category is analyzed with respect to position on Axis I, and Axis II, and ratings of the perceived salience and efficacy of treatment plans of the disorders referenced by the category. The number of symptoms in conditions that differ with respect to level of complexity (i.e., number of diagnoses) are compared. An attempt is made to understand how Axis I and Axis II of the DSM III system are used by clinicians and also how they operate as devices to codify clinical information under conditions of relative uncertainty.

Racial effects on the clinical presentation of alcoholics at a psychiatric hospital

Despite the clinical importance of race effects on comorbidity and symptom patterns in recent community studies, little is known about such effects in various treatment facilities. This study evaluated the effect of race on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. The factor that most strongly distinguished the racial groups was socioeconomic status (SES). After controlling for SES and other factors, no significant difference was noted between ethnic groups in the prevalence of major depressive disorder (MDD) or antisocial personality disorder. However, after controlling for SES and other factors, alcohol and drug use were more severe in African-American alcoholics, along with four symptoms associated with alcohol and drug use. In contrast, reversed neurovegetative symptoms, anxiety-related symptoms, and some personality-related symptoms were more severe in white alcoholics.

Disproportionate suicidality in patients with comorbid major depression and alcoholism

OBJECTIVE

The two purposes of this study were to provide a comprehensive description of the clinical features of patients who presented to an intake psychiatric setting with major depression and alcohol dependence and to determine which clinical features distinguished this dual-diagnosis group from patients with the two relevant single diagnoses.

METHOD

During a recent 5-year period, a total of 107 patients who came to a psychiatric facility for initial evaluation were diagnosed as having both major depression and alcohol dependence. The clinical profile of this dual-diagnosis group was compared to that of nondepressed alcoholics (N = 497) and nonalcoholic patients with major depression (N = 5,625), assessed at the same facility, on the basis of information from the Initial Evaluation Form, a semistructured instrument containing a standardized symptom inventory that includes ratings of severity.

RESULTS

The psychiatric symptom that most strongly distinguished the depressed alcoholics from the two comparison groups was the level of suicidality. The depressed alcoholics differed significantly from the nonalcoholic depressed patients on only two depressive symptoms, suicidality (59% higher) and low self-esteem (22% higher); they were also significantly distinguished from the nonalcoholic depressed patients by factors such as greater impulsivity, functional impairment, and abnormal personal and social history markers.

CONCLUSIONS

Suicidality was disproportionately greater than other psychiatric symptoms in the depressed alcoholics. The clinical profile of depressed alcoholics suggests that they suffer an additive or synergistic effect of two separate disorders, resulting in a disproportionately high level of acute suicidality upon initial psychiatric evaluation.

Characterizing organic mood syndrome, manic type

The purpose of this study is to provide the first empirically based description of the clinical features of organic mood syndrome, manic type (OMS-M). During a recent 5-year period, 14,889 new patients presented for initial evaluation and care at our institute. Of these patients, a total of 12 cases of OMS-M were diagnosed. Evaluations were conducted using the Initial Evaluation Form, which was developed to be compatible with the DSM-III. The symptom profile of OMS-M was compared with that of "functional" manics (bipolar disorder, manic type [BD-M]). A variety of associated clinical factors were also assessed. The OMS-M patient demonstrated somewhat less severe acute symptomatology but more longstanding functional impairment than in BD-M. OMS-M patients also displayed a lower age at onset of illness and a higher level of perinatal problems and developmental delays compared with BD-M patients. The OMS-M group displayed a low family burden of mania. The most striking distinguishing feature of OMS-M was the prevalence of neurological disorders, with a surprisingly high prevalence of seizure disorders. Seizure disorders were more prevalent in OMS-M than in other organic brain syndromes (OBS).

Characterizing organic mood syndrome, depressed type

In this report, a first comprehensive description of the clinical features of patients with organic mood syndrome, depressed type (OMS-D), in a psychiatric hospital population is presented. This description is based on information from 130 OMS-D patients among 14,889 patients who presented for initial evaluation over a 5-year period. This description includes an enumeration of the common clinical symptoms of this syndrome. Following this, the severity of the symptoms of OMS-D are compared with those of its crude "functional" equivalent of major depressive disorder, single episode (MDD-SE). In addition, associated factors are presented concerning demographics, level of functioning, comorbidity, electroencephalographic and computed tomographic abnormalities, and current physical problems. These findings provide preliminary support for the validity of this diagnostic category, and provide relevant information concerning proposed changes in this category as listed in the DSM-IV Options Book.

Personality disorders diagnosed at intake at a public psychiatric facility

OBJECTIVE

The purpose of the study was to determine the prevalence of personality disorders among a large population of persons seeking treatment in a public psychiatric facility and to examine the role of personality disorders in the clinical conditions of persons frequenting such facilities.

METHODS

Clinical and demographic data were retrospectively examined for 18,179 adults who visited a walk-in clinic of a public psychiatric facility between 1983 and 1989. Patients who received a diagnosis of personality disorder were compared with those who did not.

RESULTS

A total of 2,344 patients (12.9 percent) were diagnosed as having a personality disorder, a lower prevalence rate than generally found in treatment populations. The most frequent diagnoses were atypical, antisocial, and borderline personality disorders. Compared with other subjects, those with a personality disorder were significantly more likely to be men, to be 35 years old or younger, to have a higher level of social impairment, and to have more symptoms and more severe symptoms.

CONCLUSIONS

The relatively low prevalence rate was attributed in part to underdiagnosis, largely due to the need for making rapid assessments in a public intake setting. The authors conclude that clinicians in such facilities may be likely to diagnose personality disorders when patients with certain axis I disorders such as substance use, affective, and adjustment disorders present with an overall greater level of symptomatology and social impairment.

Can multiaxial diagnosis predict future use of psychiatric hospitalization?

Demographic and diagnostic intake data on about 10,000 patients at a public psychiatric facility were used to assess whether information recorded on various DSM-III axes could predict the frequency of patients' psychiatric hospitalizations over a follow-up period. Compared with patients who had been hospitalized only once or not at all, patients with three or more hospitalizations during the study period were more likely to be single and black and to come from lower social classes. They were more likely to have an axis I diagnosis of an alcohol-related disorder, a substance use disorder, or a psychotic disorder. When samples from the patient groups were matched on key demographic variables and primary axis I diagnosis, the multiaxial resources of DSM-III were not helpful in predicting future use of hospitalization. The results reinforce the importance of axis I diagnosis and demographic characteristics in assessing course and prognosis.

On the homogeneity of personality disorder clusters

This study was conducted using as subjects persons seeking psychiatric care in a public intake facility. Patients who received a diagnosis of a personality disorder (PD) on axis II constituted the study sample. The study is unique in that it attempts to analyze in a treatment population the relationships between all of the personality disorders (PD) stipulated in DSM-III with emphasis on their relationships to the associated features recorded in the remaining axes of DSM-III. The specific aim of the study was to determine the variation that exists with respect to clinical and demographic variables across the PD clusters categorized in DSM-III and across the PD types of each of the DSM-III PD clusters. In general, considerable inhomogeneity was shown within and across clusters in both demographic and clinical variables, although differences among clusters were noted as well. Cluster B differs prominently from its cohorts with respect to demographic and clinical characteristics. Some of the limitations of these results are emphasized.

Characterizing organic delusional syndrome

We present a first comprehensive description of the clinical features of patients with organic delusional syndrome. This description is based on information from 39 patients with organic delusional syndrome among 14,889 patients who presented for initial evaluation over a 5-year period at our institution. This description includes an enumeration of the common clinical symptoms of this syndrome and the respective prevalence and mean severity of each symptom. The severity of the symptoms of organic delusional syndrome are compared with those of schizophrenia to determine which symptoms distinguish between these two diagnostic categories. Patients with organic delusional syndrome demonstrated significantly more symptoms of "acquired intellectual impairment," "impaired sensorium," and "hallucinations of smell, taste, or touch," while schizophrenic patients demonstrated more "flat affect," "emotional coldness," and "thought disorganization." In addition, associated factors are presented concerning demographics, modes of treatment, level of functioning, and current physical problems associated with organic delusional syndrome.

Characterizing organic hallucinosis

A first comprehensive description of the clinical features of patients with the rare diagnosis of organic hallucinosis (OH) is presented, based on information from 11 OH patients among 14,889 patients who presented for evaluation over a 5-year period at our institution. This characterization is of particular current relevance to diagnosticians and clinicians because of the proposed major changes in the diagnostic system for OH in the upcoming DSM-IV and because of the virtual total lack of published information concerning this syndrome. This description includes a listing of the prevalence and mean severity of each symptom. The severity of the symptoms of OH are then compared with those of its crude "functional" equivalent of schizophrenia to determine which symptoms distinguish between these categories. Associated factors are also presented concerning demographics, modes of treatment, level of functioning, and current physical problems associated with OH.

Females and males in an intake psychiatric setting

It is generally acknowledged that some psychiatric disorders are more commonly found among members of one sex rather than the other (e.g., Dohrenwend and Dohrenwend 1976; Gove and Tudor 1973; Kass et al. 1983; Robins et al. 1984; Rosenfield 1980; Weissman and Klerman 1977). Females, moreover, are consistently overrepresented in treatment populations of different sorts, and various reasons involving responses to illness and inclination to seek treatment have been offered to account for this (Finkler 1984; Kessler et al. 1981; Nathanson 1975; Verbrugge and Wingard 1987). In contrast to accepted gender differences in prevalence, incidence and inclination to use services, a prevailing view about psychopathology is that the actual content or manifestations of a disorder should be "culture free" or universal. In the theory of psychopathology (e.g., implicit in DSM-III), general descriptors of the person (i.e., demographic and cultural) play a comparatively minor role in the stipulation of the manifestations of psychiatric illness. Among socially and culturally oriented psychiatrists, on the other hand, such descriptors are considered important clues to origins of psychopathology. However, in such analyces, sociocultural is usually equated with altogether different symbolic/language traditions (e.g., Finkler 1985; Lieban 1978), although reports exist of sex differences in symptom expression in Western societies (Brown and Harris 1976; Hinkle et al. 1960; Nathanson 1979). Feminist critics assert that even within the sociocultural tradition linked to Anglo-American society, a bias exists with respect to how psychopathology is shaped, defined and handled (Kaplan 1983; Showalter 1985). The topic of gender differences in psychiatric morbidity is thus of considerable general interest and one that can be approached from a number of different perspectives. In this study we compare psychopathology in males and females who were referred to an intake setting. The DSM-III formulations and level and type of symptoms were the focus of analysis. The results are interpreted in light of findings in psychiatric epidemiology and social psychiatry.

Explaining diagnostic complexity in an intake setting

A one patient-one illness paradigm is implicit in the history and theory of psychiatry, and in basic research. Yet, in clinical practice and treatment populations in general, more than one diagnosis per patient is frequently encountered. How clinicians formulate comorbidity by means of DSM-III has rarely been investigated. In this study, the ideas of clinical condition and that of its diagnostic complexity are used to analyze descriptive features of a large number of patients seen in an intake setting. Axis I of DSM-III is used to measure diagnostic complexity. Complexity is analyzed in relation to demographic variables, to ratings entered in the remaining axes of DSM-III formulations, to symptom levels of patients, and to decisions involving disposition. Results indicate that analysis of diagnostic complexity by means of DSM-III yields a definable structure and that it can be related meaningfully to clinical factors. The idea of information uncertainty in diagnosis, i.e., the opacity versus transparency of a clinical condition, is also used to explain results. The ideas introduced and studied are shown to have value for social psychiatric research.

Variation in cognitive functioning in nonorganic psychiatric disorders

Level of cognitive function is usually conceptualized as a feature of organic psychiatric disorders. Classically, its assessment is part of the mental status examination. Standardized tests, such as the Folstein battery, are used to screen for organic disorders by measuring level and possible impairment of cognitive function through the stipulation of cutoff points. However, contemporary definitions of psychiatric disorders do not embrace such a categorical view of cognitive function. It is important to measure the level of cognitive function in all types of psychiatric disorders in relation to demographic characteristics. Consequently, it is better to view cognitive function as a continuous variable. The Cognitive Function Inventory (CFI), which can also yield a Folstein score, was used to assess cognition in patients diagnosed as having nonorganic psychiatric disorders. A number of different parameters of cognitive function are examined. Differences associated with demographic background and type of disorder are reported. The implications of these results are discussed.

Somatoform disorder in a psychiatric setting. Systematic comparisons with depression and anxiety disorders

Somatoform disorder (SD) is recognized as an important clinical entity in general medicine although its psychiatric nature is insufficiently appreciated. Its prevalence and descriptive validity among psychiatric patients have not been investigated. These two aspects of SD are examined by comparing it with depressive and anxiety disorders, both of which include somatic symptoms and often are confounded with it. A semistructured evaluation procedure applied in a naturalistic clinical setting yielded a diagnosis and ratings of a large array of symptoms. The relative rarity of SD stands out, as well as the unique way in which it tends to be used in diagnostic formulations of psychiatric patients seeking evaluation and care. These results may reflect these patients' reluctance to seek psychiatric care and to define their problems as mental, as well as the bias of clinicians working in psychiatric settings geared to looking for traditional psychopathology. The distinguishing symptoms of SD vis-à-vis depressive and anxiety syndromes are outlined. These symptoms suggest that SD patients resemble depressives, but harbor traits that reflect personality and interpersonal difficulties. However, rater bias may have influenced these results as well.

Black-white differences in psychopathology in an urban psychiatric population

The study was conducted in a psychiatric setting that services a large metropolitan population. It relied on the semi-structured Initial Evaluation Form which is completed by expert trained clinicians and which is geared to a comprehensive evaluation along the lines stipulated in DSM-III. The symptoms of a large sample of white and black patients are compared. The study relied on an Analysis of Variance (ANOVA) procedure which controlled for age, gender and education and concentrated exclusively on ethnic differences in clinically homogenous subgroups. The sample was partitioned into relatively pure groups of DSM-III diagnoses that are frequent in the population, including schizophrenia, affective and anxiety disorders, dementia, paranoid and manic disorders. Prominent black/white differences in psychopathology were noted, but in only a few instances included items generally thought of as typical of a specific disorder. Some differences appeared to be due to selection factors and others raised the question of alternate expressions of psychopathology among blacks as versus whites. The significance of the results obtained is discussed together with questions requiring further research. Some of the issues involved in the study of black/white differences in psychopathology are critically analyzed.

Adjustment disorder and psychiatric practice: cultural and historical aspects

A universal concern of healers and health practitioners of all social groups is that of caring for individuals reacting to social and interpersonal hardships. One could view individuals experiencing such hardships as prototypical patients of a society's health profession, however this may be defined. In contemporary psychiatry, such individuals are diagnosed as showing an "adjustment disorder." In view of the time-honored legitimacy of caring for individuals meeting criteria for an adjustment disorder, it is ironic that the status of this "disorder" in the discipline's contemporary nosology is controversial and anomalous. In this paper, these and related issues are discussed. Emphasis is given to some of the cultural, historical and clinical-epidemiologic factors that render disturbances that can be diagnosed as adjustment disorder important in psychiatry and, indeed, worthy of inclusion in DSM-III. Theoretical and empirical problems that would render this entity a more legitimate one in contemporary biomedical psychiatry are reviewed.

Schizophrenia-primary affective disorder discrimination. I. Development of a data-based diagnostic index

A nine-variable diagnostic measure for discriminating schizophrenia and primary affective disorder was developed. The nine variables, which were selected by discriminant function analysis, reflect past and current symptomatology, duration of symptoms, and behavioral ratings. The measure was cross-validated by a jackknife procedure that accurately classified nine of ten of the cases. Such accuracy suggests that brief, data-based diagnostic instruments have considerable promise as practical checks of clinical diagnoses.

Schizophrenia-primary affective disorder discrimination. II. Where unclassified psychosis stands

Cases of unclassified psychosis were assessed with a nine-variable diagnostic measure designed to discriminate schizophrenia and primary affective disorder. As a group, the unclassified cases occupied a midway position between and overlapping with cases of schizophrenia and primary affective disorder. Also, the mean discriminant-function score of the unclassified group was significantly different from the mean scores of the groups with affective disorder and schizophrenia, although one subgroup of unclassified cases was statistically indistinguishable from the group with schizophrenia. While this investigation was essentially unsuccessful in reclassifying unclassified psychosis, it demonstrates a method for reclassifying diagnostic groups. When this procedure is used in conjunction with follow-up and family studies, it provides a basis for modifying diagnostic criteria.