Three Approaches to Understanding and Classifying Mental Disorder: ICD-11, DSM-5, and the National Institute of Mental Health’s Research Domain Criteria (RDoC)

The diagnosis of mental disorder initially appears relatively straightforward: Patients present with symptoms or visible signs of illness; health professionals make diagnoses based primarily on these symptoms and signs; and they prescribe medication, psychotherapy, or both, accordingly. However, despite a dramatic expansion of knowledge about mental disorders during the past half century, understanding of their components and processes remains rudimentary. We provide histories and descriptions of three systems with different purposes relevant to understanding and classifying mental disorder. Two major diagnostic manuals—the International Classification of Diseases and the Diagnostic and Statistical Manual of Mental Disorders—provide classification systems relevant to public health, clinical diagnosis, service provision, and specific research applications, the former internationally and the latter primarily for the United States. In contrast, the National Institute of Mental Health’s Research Domain Criteria provides a framework that emphasizes integration of basic behavioral and neuroscience research to deepen the understanding of mental disorder. We identify four key issues that present challenges to understanding and classifying mental disorder: etiology, including the multiple causality of mental disorder; whether the relevant phenomena are discrete categories or dimensions; thresholds, which set the boundaries between disorder and nondisorder; and comorbidity, the fact that individuals with mental illness often meet diagnostic requirements for multiple conditions. We discuss how the three systems’ approaches to these key issues correspond or diverge as a result of their different histories, purposes, and constituencies. Although the systems have varying degrees of overlap and distinguishing features, they share the goal of reducing the burden of suffering due to mental disorder.

Child Affected by Parental Relationship Distress

OBJECTIVE

A new condition, "child affected by parental relationship distress" (CAPRD), was introduced in the DSM-5. A relational problem, CAPRD is defined in the chapter of the DSM-5 under "Other Conditions That May Be a Focus of Clinical Attention." The purpose of this article is to explain the usefulness of this new terminology.

METHOD

A brief review of the literature establishing that children are affected by parental relationship distress is presented. To elaborate on the clinical presentations of CAPRD, four common scenarios are described in more detail: children may react to parental intimate partner distress; to parental intimate partner violence; to acrimonious divorce; and to unfair disparagement of one parent by another. Reactions of the child may include the onset or exacerbation of psychological symptoms, somatic complaints, an internal loyalty conflict, and, in the extreme, parental alienation, leading to loss of a parent-child relationship.

RESULTS

Since the definition of CAPRD in the DSM-5 consists of only one sentence, the authors propose an expanded explanation, clarifying that children may develop behavioral, cognitive, affective, and physical symptoms when they experience varying degrees of parental relationship distress, that is, intimate partner distress and intimate partner violence, which are defined with more specificity and reliability in the DSM-5.

CONCLUSION

CAPRD, like other relational problems, provides a way to define key relationship patterns that appear to lead to or exacerbate adverse mental health outcomes. It deserves the attention of clinicians who work with youth, as well as researchers assessing environmental inputs to common mental health problems.

Planning Patient-Centered Health Homes for Medicaid Psychiatric Patients at Greatest Risk for Intensive Service Use

This study identified characteristics of Medicaid psychiatric patients at risk of hospitalizations and emergency department (ED) visits to identify their service delivery needs. A total of 4,866 psychiatrists were randomly selected from the AMA Physician Masterfile; 62 % responded, 32 % met eligibility criteria and reported on 1,625 Medicaid patients. Patients with schizophrenia, substance use disorders, suicidal and violent ideation/behavior, and psychotic, substance use, or manic symptoms were at high risk for intensive service use, along with homeless and incarcerated patients. Patients with schizophrenia or psychotic symptoms represented 37 % of patients, but used 73 % of all hospital days and 61 % of all ED visits. Patients with substance use problems comprised 21 % of patients, but used nearly half of all ED visits. Our findings highlight opportunities to enhance treatments and interventions, and inform the development of patient-centered health homes to address the needs of patients at high risk for intensive service use.

Feasibility and acceptability of the DSM-5 Field Trial procedures in the Johns Hopkins Community Psychiatry Programs

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) contains criteria for psychiatric diagnoses that reflect advances in the science and conceptualization of mental disorders and address the needs of clinicians. DSM-5 also recommends research on dimensional measures of cross-cutting symptoms and diagnostic severity, which are expected to better capture patients' experiences with mental disorders. Prior to its May 2013 release, the American Psychiatric Association (APA) conducted field trials to examine the feasibility, clinical utility, reliability, and where possible, the validity of proposed DSM-5 diagnostic criteria and dimensional measures. The methods and measures proposed for the DSM-5 field trials were pilot tested in adult and child/adolescent clinical samples, with the goal to identify and correct design and procedural problems with the proposed methods before resources were expended for the larger DSM-5 Field Trials. Results allowed for the refinement of the protocols, procedures, and measures, which facilitated recruitment, implementation, and completion of the DSM-5 Field Trials. These results highlight the benefits of pilot studies in planning large multisite studies.

APIRE Practice Research Network: accomplishments, challenges, and lessons learned

The Practice Research Network (PRN) was established in 1993 to bridge the gap between the science base and the clinical practice of psychiatry by expanding the generalizability of findings and involving clinicians in the development and conduct of research. It began as a nationwide network of psychiatrists and has evolved to conduct large-scale, clinical and policy research studies using randomly selected samples of psychiatrists from the AMA Physician Masterfile. This paper provides an overview of major PRN initiatives and the impact of these studies. It describes the benefits to clinicians of participating in PRN research, as well as strategies developed to address key challenges.

Testing DSM-5 in routine clinical practice settings: feasibility and clinical utility

OBJECTIVE

This article describes the clinical utility and feasibility of proposed DSM-5 criteria and measures as tested in the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP). METHODS RCP data were collected online for six months (October 2011 to March 2012). Participants included psychiatrists, licensed clinical psychologists, clinical social workers, advanced practice psychiatric-mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians received staged, online training and enrolled at least one patient. Patients completed self-assessments of cross-cutting symptom domains, disability measures, and an evaluation of these measures. Clinicians conducted diagnostic interviews and completed DSM-5 and related assessments and a clinical utility questionnaire.

RESULTS

A total of 621 clinicians provided data for 1,269 patients. Large proportions of clinicians reported that the DSM-5 approach was generally very or extremely easy for assessment of both pediatric (51%) and adult (46%) patients and very or extremely useful in routine clinical practice for pediatric (48%) and adult (46%) patients. Clinicians considered the DSM-5 approach to be better (57%) or much better (18%) than that of DSM-IV. Patients, including children age 11 to 17 (47%), parents of children age six to ten (64%), parents of adolescents age 11 to 17 (72%), and adult patients (52%), reported that the cross-cutting measures would help their clinicians better understand their symptoms. Similar patterns in evaluations of feasibility and clinical utility were observed among clinicians from various disciplines.

CONCLUSIONS

The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.

DSM-5 field trials in the United States and Canada, Part I: study design, sampling strategy, implementation, and analytic approaches

OBJECTIVE

This article discusses the design,sampling strategy, implementation,and data analytic processes of the DSM-5 Field Trials.

METHOD

The DSM-5 Field Trials were conducted by using a test-retest reliability design with a stratified sampling approach across six adult and four pediatric sites in the United States and one adult site in Canada. A stratified random sampling approach was used to enhance precision in the estimation of the reliability coefficients. A web-based research electronic data capture system was used for simultaneous data collection from patients and clinicians across sites and for centralized data management.Weighted descriptive analyses, intraclass kappa and intraclass correlation coefficients for stratified samples, and receiver operating curves were computed. The DSM-5 Field Trials capitalized on advances since DSM-III and DSM-IV in statistical measures of reliability (i.e., intraclass kappa for stratified samples) and other recently developed measures to determine confidence intervals around kappa estimates.

RESULTS

Diagnostic interviews using DSM-5 criteria were conducted by 279 clinicians of varied disciplines who received training comparable to what would be available to any clinician after publication of DSM-5.Overall, 2,246 patients with various diagnoses and levels of comorbidity were enrolled,of which over 86% were seen for two diagnostic interviews. A range of reliability coefficients were observed for the categorical diagnoses and dimensional measures.

CONCLUSIONS

Multisite field trials and training comparable to what would be available to any clinician after publication of DSM-5 provided “real-world” testing of DSM-5 proposed diagnoses.

DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses

OBJECTIVE

The DSM-5 Field Trials were designed to obtain precise (standard error,0.1) estimates of the intraclass kappa asa measure of the degree to which two clinicians could independently agree on the presence or absence of selected DSM-5 diagnoses when the same patient was interviewed on separate occasions, in clinical settings, and evaluated with usual clinical interview methods.

METHOD

Eleven academic centers in the United States and Canada were selected,and each was assigned several target diagnoses frequently treated in that setting.Consecutive patients visiting a site during the study were screened and stratified on the basis of DSM-IV diagnoses or symptomatic presentations. Patients were randomly assigned to two clinicians for a diagnostic interview; clinicians were blind to any previous diagnosis. All data were entered directly via an Internet-based software system to a secure central server. Detailed research design and statistical methods are presented in an accompanying article.

RESULTS

There were a total of 15 adult and eight child/adolescent diagnoses for which adequate sample sizes were obtained to report adequately precise estimates of the intraclass kappa. Overall, five diagnoses were in the very good range(kappa=0.60–0.79), nine in the good range(kappa=0.40–0.59), six in the questionable range (kappa = 0.20–0.39), and three in the unacceptable range (kappa values,0.20). Eight diagnoses had insufficient sample sizes to generate precise kappa estimates at any site.

CONCLUSIONS

Most diagnoses adequately tested had good to very good reliability with these representative clinical populations assessed with usual clinical interview methods. Some diagnoses that were revised to encompass a broader spectrum of symptom expression or had a more dimensional approach tested in the good to very good range.

DSM-5 field trials in the United States and Canada, Part III: development and reliability testing of a cross-cutting symptom assessment for DSM-5

OBJECTIVE

The authors sought to document, in adult and pediatric patient populations, the development, descriptive statistics,and test-retest reliability of cross-cutting symptom measures proposed for inclusion in DSM-5.

METHOD

Data were collected as part of the multisite DSM-5 Field Trials in large academic settings. There were seven sites focusing on adult patients and four sites focusing on child and adolescent patients.Cross-cutting symptom measures were self-completed by the patient or an informant before the test and the retest interviews, which were conducted from 4 hours to 2 weeks apart. Clinician-report measures were completed during or after the clinical diagnostic interviews. Informants included adult patients, child patients age 11 and older, parents of all child patients age 6 and older, and legal guardians for adult patients unable to self-complete the measures. Study patients were sampled in a stratified design,and sampling weights were used in data analyses. The mean scores and standard deviations were computed and pooled across adult and child sites. Reliabilities were reported as pooled intraclass correlation coefficients (ICCs) with 95% confidence intervals.

RESULTS

In adults, test-retest reliabilities of the cross-cutting symptom items generally were good to excellent. At the child and adolescent sites, parents were also reliablereporters of their children’s symptoms,with few exceptions. Reliabilities were not as uniformly good for child respondents, and ICCs for several items fell into the questionable range in this age group. Clinicians rated psychosis with good reliability in adult patients but were less reliable in assessing clinical domains related to psychosis in children and to suicide in all age groups.

CONCLUSIONS

These results show promising test-retest reliability results for this group of assessments, many of which are newly developed or have not been previously tested in psychiatric populations

Dimensional approaches to psychiatric diagnosis in DSM-5

BACKGROUND

The Diagnostic and Statistical Manual of Mental Disorders is the compendium of disorder listings and diagnostic criteria used by clinicians in the United States and many other countries. The forthcoming fifth edition of the manual (DSM-5) represents an opportunity to not only update diagnostic information in concert with recent advances in the science and practice of psychiatry, but also to more strongly consider the integration of systematically gathered patient self-assessments of symptom severity.

AIMS OF THE STUDY

To present information on planned changes to the DSM diagnostic assessment strategies that incorporate patient-reported data.

METHODS

Activities of the DSM-5 work groups and study groups related to patient-reported assessments are summarized. These activities include critical reviews of past research, reviews of assessment instruments, development of assessment strategies incorporating dimensional assessments of patients' clinical symptoms, and testing of proposed strategies.

RESULTS

Limitations of the current DSM diagnostic assessment system are discussed. With the current approach to diagnosis used in DSM-IV, clinicians must decide whether a patient meets the diagnostic criteria set forth for a disorder and then diagnose the disorder as present or absent. This categorical approach to the diagnostic threshold constricts the range of clinical information that may be of high importance to treatment planning, prognosis, and monitoring treatment outcomes. Advantages to incorporation of a dimensional assessment strategy are also discussed. A dimensional approach to psychiatric diagnosis provides clinicians with more information, and with standardized dimensional rating scales, can give patient self-reports a greater role in the clinical process. A description of the proposed methods for integrating dimensional assessments into DSM-5 is presented. Initial pilot testing of these changes to DSM indicate that clinicians and patients/patient informants found the dimensional measures to be useful, simple, and relevant to clinical care.

DISCUSSION

The introduction of patient-reported symptom assessments as part of the DSM would represent a major change in psychiatric practice, with implications for patient care, mental health policy, and health care funding. The ultimate goal of such a change is to increase patient satisfaction with care and improve treatment outcomes. These goals will be the subject of continuing evaluation after the DSM-5 is published.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

The use of patient-reported dimensional assessments of symptom severity will aid in more comprehensive and systematized characterizations of baseline clinical status and subsequent changes in clinical status with treatment.

IMPLICATIONS FOR HEALTH POLICIES

The use of principles of evidence-based medicine and measurement-based care are likely to increase in the United States as health care reform measures are put into place. The DSM-5 proposals for patient-reported measures can serve as an initial method for gauging the outcomes of treatments.

IMPLICATIONS FOR FURTHER RESEARCH

As with previous editions of the DSM, the changes implemented in DSM-5 will continue to be the focus of research efforts after publication. Results from this research will serve as the basis for further refinements in measurement recommendations.

Research planning for the future of psychiatric diagnosis

More than 10 years prior to the anticipated 2013 publication of DSM-5, processes were set in motion to assess the research and clinical issues that would best inform future diagnostic classification of mental disorders. These efforts intended to identify the clinical and research needs within various populations, examine the current state of the science to determine the empirical evidence for improving criteria within and across disorders, and stimulate research in areas that could potentially provide evidence for change. In the second phase of the revision process, the American Psychiatric Institute for Research and Education (APIRE) recently completed the 5-year international series of 13 diagnostic conferences convened by APA/APIRE in collaboration with the World Health Organization and the National Institutes of Health (NIH), under a cooperative grant funded by the NIH. From these conferences, the DSM-5 Task Force and Work Groups have developed plans for potential revisions for DSM-5, including the incorporation of dimensional approaches within and across diagnostic groups to clarify heterogeneity, improve diagnostic validity, and enhance clinical case conceptualization. Use of dimensions for measurement-based care has been shown to be feasible in psychiatric and primary care settings and may inform monitoring of disorder threshold, severity, and treatment outcomes. The integration of dimensions with diagnostic categories represents an exciting and potentially transformative approach for DSM-5 to simultaneously address DSM-IV's clinical short-comings and create novel pathways for research in neurobiology, genetics, and psychiatric epidemiology.

Service utilization differences for Axis I psychiatric and substance use disorders between white and black adults

OBJECTIVE

Although studies have shown disparities between black and white populations in service utilization for mental disorders, little information exists on whether such disparities apply equally across disorders. The objective of this study was to examine racial differences in lifetime prevalence of service utilization for mood and anxiety disorders and for alcohol and drug use disorders, with controls for predisposing, enabling, and need-for-service variables unequally distributed between racial-ethnic groups.

METHODS

Data were from a face-to-face epidemiologic survey of 32,752 non-Hispanic white or black adults ages 18 and older residing in households and group quarters in the United States. Main outcome measures were treatment for mood, anxiety, and alcohol and drug use disorders.

RESULTS

White adults were consistently more likely than black adults to have had treatment for mood disorders (odds ratio [OR]=2.16, 95% confidence interval [CI]=1.80-2.59) and anxiety disorders (OR=1.77, 95% CI=1.43-2.19) after adjustment for predisposing and enabling factors and need for service (severity of disorder). In contrast no evidence of lower service utilization for treatment of alcohol use disorders emerged among black respondents (OR=.87, 95% CI=.69-1.10). Moreover, white respondents with drug use disorders were significantly less likely than black respondents to receive treatment for a drug problem (OR=.64, 95% CI=.47-.88).

CONCLUSIONS

Differences in treatment between black and white adults depended on the specific disorder and type of treatment considered. Prevention and intervention strategies should address disorder-specific disparities in services received.

Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population: results from the national epidemiologic survey on alcohol and related conditions

OBJECTIVE

This study sought to determine whether black/white disparities in service utilization for mental health and substance use disorders persist or are diminished among individuals with psychiatric comorbidity in the general population.

METHOD

The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to identify individuals with lifetime co-occurring substance use disorders and mood/anxiety disorders (N = 4250; whites, N = 3597; blacks, N = 653). Lifetime service utilization for problems with mood, anxiety, alcohol, and drugs was assessed.

RESULTS

Compared to whites, blacks with co-occurring mood or anxiety and substance use disorders were significantly less likely to receive services for mood or anxiety disorders, equally likely to receive services for alcohol use disorders, and more likely to receive some types of services for drug use disorders. Regardless of race/ethnicity, individuals with these co-occurring disorders were almost twice as likely to use services for mood/anxiety disorders than for substance use disorders.

CONCLUSION

Despite the fact that comorbidity generally increases the likelihood of service use, black/white disparities in service utilization among an all-comorbid sample were found, although these disparities differed by type of disorder. Further research is warranted to understand the factors underlying these differences. Prevention and intervention strategies are needed to address the specific mental health needs of blacks with co-occurring disorders, as well as the overall lack of service use for substance use disorders among individuals with co-occurring psychiatric conditions.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit

OBJECTIVE

This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit.

METHOD

Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient.

RESULTS

A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems.

CONCLUSIONS

The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?

OBJECTIVE

The purpose of this study is to present data on the rates of diagnosis and patterns of Axis I comorbidity treated by psychiatrists in routine psychiatric practice, ascertained by practicing psychiatrists, and compare them with those ascertained through structured interview in a national sample of individuals treated in the specialty mental health sector for evidence of underdetection or underdiagnosis of comorbid disorders in routine psychiatric practice.

METHODS

Data on 2117 psychiatric patients gathered by 754 psychiatrists participating in the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network's Study of Psychiatric Patients and Treatments (SPPT) were analyzed, assessing psychiatrist-reported rates of Axis I disorders and comorbidities. SPPT data on patients treated by psychiatrists were compared with a clinical subset of patients in the National Comorbidity Survey who had been treated in the specialty mental health sector (SMA).

RESULTS

Rates of comorbidity were higher in the SMA (53.9%) than in the SPPT (31.5%). The prevalence of schizophrenia diagnoses was more than twice as prevalent in the SPPT as in the SMA sample; anxiety disorders were 2 to 22 times more prevalent in the SMA sample. In the SPPT, 4 of the 10 most prevalent comorbid pairs included schizophrenia or bipolar disorder; only one pair in the SMA sample included either diagnoses. Of the 10 most prevalent comorbidity pairings in the SMA sample, 6 included a phobia diagnosis.

CONCLUSIONS

Results of these analyses suggest greater differences in the patterns and rates of comorbidities than one might expect between these 2 samples. Possible reasons for these disparities, including methodological differences in diagnostic ascertainment and underdiagnosis of anxiety disorders, are discussed.

Patterns and quality of treatment for patients with schizophrenia in routine psychiatric practice

OBJECTIVES

This study provided generalizable national data on the treatment of adult patients with schizophrenia in the United States and assessed conformance with the practice guideline treatment recommendations of the Schizophrenia Patient Outcomes Research Team and the American Psychiatric Association.

METHODS

National data from the American Psychiatric Institute for Research and Education's 1999 Practice Research Network study of psychiatric patients and treatments were used to examine treatment patterns for 151 adult patients with schizophrenia. Analyses were performed and adjusted for the weights and sample design to generate nationally representative estimates.

RESULTS

Findings indicated that patients with schizophrenia who were treated by psychiatrists had complex clinical problems and were markedly disabled. Forty-one percent of patients had a comorbid axis I disorder, and 75 percent were currently unemployed. Thirty-five percent were currently experiencing medication side effects, and 37 percent were currently experiencing problems with treatment adherence. Although most patients received guideline-consistent psychopharmacologic treatment, treatment was characterized by significant polypharmacy. Rates of conformance with the guideline recommendations were significantly lower for psychosocial recommendations than for psychopharmacologic recommendations. Although 69 percent of patients received at least some psychosocial treatment, none of the unemployed patients received vocational rehabilitation services in the past 30 days.

CONCLUSIONS

These data suggest unmet need for psychosocial treatment services among individuals with schizophrenia. These findings raise questions about whether currently available antipsychotic medications are being used optimally or whether they offer limited effectiveness for patients with complex clinical problems who are treated in routine psychiatric practice.

Concomitant pharmacotherapy among youths treated in routine psychiatric practice

OBJECTIVES

The aim of this study was to assess rates and correlates of concomitant pharmacotherapy in children and adolescents treated by psychiatrists in a broad range of clinical settings.

METHODS

Cross-sectional data on 392 child and adolescent patients aged 2-17 years from the 1997 and 1999 American Psychiatric Practice Research Network Study of Psychiatric Patients and Treatments were used, and weighted estimates are provided.

RESULTS

Findings indicate that 84% of child and adolescent patients received one or more psychopharmacologic medications; 52% of patients treated with medications received concomitant pharmacotherapy (i.e., two or more medications). Patients who were treated with psychopharmacologic treatments received a median of 2 medications (range, 1-6). Highest rates of concomitant pharmacotherapy were among patients with bipolar disorder (87%). Correlates of concomitant pharmacotherapy included: (1) having a diagnosis of bipolar disorder, (2) having co-occurring Axis I or II disorders or general medical conditions, and (3) currently receiving treatment in an inpatient setting.

CONCLUSIONS

Over 40% of child and adolescent patients of psychiatrists were prescribed two or more psychopharmacologic medications. Patients with chronic and clinically complex conditions were more likely to receive concomitant pharmacotherapy. Most often, efficacy of U.S. Food and Drug Administration (FDA)-approved medications has been examined as monotherapy, and cautions on drug interactions and off-label use derived from multiple sources accompany each product. With high rates of concomitant pharmacotherapy among children and adolescents in psychiatric care, additional research on efficacy and safety of this treatment strategy is necessary.

Challenges in increasing access to buprenorphine treatment for opiate addiction

The aims of this study are to assess psychiatrists' comfort using office-based opiate agonist treatment (OBOT) and to identify psychiatrist characteristics associated with OBOT comfort. A random sample of 2,323 AMA Masterfile of Physicians psychiatrists were surveyed through the 2002 APIRE National Survey of Psychiatric Practice (NSSP). Of the 52% responding (N = 1,203), 80.6% (SE = 1.8%) were not comfortable providing OBOT. Males, addiction-certified psychiatrists, and those treating substance abuse patients were more comfortable providing OBOT. These findings highlight significant barriers in providing buprenorphine treatment. Increasing the understanding of specific financing and services delivery barriers that clinicians face is needed to inform the development of effective integrated services models and policies to facilitate OBOT implementation.

Prevalence of mood disorders in a national sample of young American adults

BACKGROUND

Availability of nationally representative mood disorder prevalence estimates in the United States, based on structured psychiatric interviews is limited. This report estimates overall lifetime prevalence of major depressive episode, dysthymia, and bipolar disorder using the Third National Health and Nutrition Examination Survey (NHANES III) and compares these estimates to the Epidemiologic Catchment Area Study (ECA) conducted 10 years earlier. Additionally, prevalence estimate breakdowns by selected sociodemographic and health characteristics are investigated.

METHODS

NHANES III, conducted from 1988 to 1994, is a large nationally representative cross-sectional sample of the United States. A population-based sample of 8,602 men and women 17-39 years of age were eligible to participate, of whom 7,667 (89.1 %) completed interviews. Mood disorder assessments came from the Diagnostic Interview Schedule (DIS) administered as one component of the NHANES III.

RESULTS

Lifetime prevalence estimates were assessed for six mood measures: 1) major depressive episode (MDE) 8.6%, 2) major depressive episode with severity (MDE-s) 7.7%, 3) dysthymia 6.2%, 4) MDE-s with dysthymia 3.4%, 5) any bipolar disorder 1.6%, and 6) any mood disorder 11.5%. All estimates except for MDE and MDE-s were significantly higher than comparable ECA estimates.

CONCLUSIONS

These data provide recent national prevalence estimates. Based on their overall magnitudes, subgroup excesses, and observed increases compared to the ECA, continued monitoring of these estimates is warranted.

The impacts of mental health parity and managed care in one large employer group

We examine the impacts of a state mental health parity mandate on a large employer group, which simultaneously introduced a managed behavioral health care carve-out. Overall, we find that mental health/substance abuse (MH/SA) costs dropped 39 percent from the year prior to three years after parity, with managed care offsetting increases in demand induced by parity coverage. Managed care was most effective in reducing very high inpatient use among adolescents and children. The effect of the parity mandate on access was ambiguous: While treatment prevalence rose nearly 50 percent, similar increases were observed for groups not subject to the mandate.

The APA classification of mental disorders: future perspectives

After 8-10 years of experience with the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) and the tenth edition of the International Classification of Diseases (ICD-10), it is an ideal time to begin looking at the clinical and research consequences of these diagnostic systems. The American Psychiatric Association, in conjunction with the National Institutes of Health, has initiated a research development process intended to accelerate an evaluation of existing criteria while developing and testing hypotheses that would improve the validity of our diagnostic concepts. Over the past year, a multidisciplinary, international panel has developed a series of six white papers which define research opportunities in the following broad areas: Nomenclature, Disability and Impairment, Personality Disorders, Relational Disorders, Developmental Psychopathology, Neuroscience, and Cross-Cultural aspects of Psychopathology. Recommendations for future national and international research in each of these areas will be discussed.

Revised prevalence estimates of mental disorders in the United States: using a clinical significance criterion to reconcile 2 surveys' estimates

BACKGROUND

Current US mental disorder prevalence estimates have limited usefulness for service planning and are often discrepant. Data on clinical significance from the National Institute of Mental Health Epidemiologic Catchment Area Program (ECA) and the National Comorbidity Survey (NCS) were used to produce revised estimates, for more accurate projections of treatment need and further explication of rate discrepancies.

METHODS

To ascertain the prevalence of clinically significant mental disorders in each survey, responses to questions on life interference from, telling a professional about, or using medication for symptoms were applied to cases meeting symptom criteria in the ECA (n = 20,861) and NCS (n = 8098). A revised national prevalence estimate was made by selecting the lower estimate of the 2 surveys for each diagnostic category, accounting for comorbidity, and combining categories.

RESULTS

Using data on clinical significance lowered the past-year prevalence rates of "any disorder" among 18- to 54-year-olds by 17% in the ECA and 32% in the NCS. For adults older than 18 years, the revised estimate for any disorder was 18.5%. Using the clinical significance criterion reduced disparities between estimates in the 2 surveys. Validity of the criterion was supported by associations with disabilities and suicidal behavior.

CONCLUSIONS

Establishing the clinical significance of disorders in the community is crucial for estimating treatment need. More work should be done in defining and operationalizing clinical significance, and characterizing the utility of clinically significant symptoms in determining treatment need even when some criteria of the disorder are not met. Discrepancies in ECA and NCS results are largely due to methodologic differences.

The DISC Predictive Scales (DPS): efficiently screening for diagnoses

OBJECTIVE

To derive and test a series of brief diagnosis-specific scales to identify subjects who are at high probability of meeting diagnostic criteria and those who may safely be spared more extensive diagnostic inquiry.

METHOD

Secondary data analysis of a large epidemiological data set (n = 1,286) produced a series of gate and contingent items for each diagnosis. Findings were replicated in a second retrospective analysis from a residential care sample (n = 884). The DISC Predictive Scales (DPS) were then used prospectively as a self-report questionnaire in two studies, in which parents (n = 128) and/or adolescents (n = 208) had subsequent diagnostic interviewing with the Diagnostic Interview Schedule for Children or the Schedule for Affective Disorders and Schizophrenia for School-Age Children.

RESULTS

All analyses showed that gate item selection was valid and that any missed cases were due solely to inconsistent reports on the same questions. Screening performance of the full scales was shown to be good, and substantial reductions in scale length were not associated with significant changes in discriminatory power.

CONCLUSIONS

The DPS can accurately determine subjects who can safely be spared further diagnostic inquiry in any diagnostic area. This has the potential to speed up structured diagnostic interviewing considerably. The full DPS can be used to screen accurately for cases of specific DSM-III-R disorders.

Childhood obsessive-compulsive disorder in the NIMH MECA study: parent versus child identification of cases. Methods for the Epidemiology of Child and Adolescent Mental Disorders

Abstract-Because as many as 50% of obsessive-compulsive disorder (OCD) cases have had onset by age 15, interest in its detection in childhood is strong. Clinical experience indicates that children often try to keep their OCD secret and that parental report may give marked underestimates. The authors examined the prevalence of childhood OCD in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, a four-site community survey which allowed comparison of both parent and child report of the child's OCD and related symptoms and disorders. OCD cases, based on structured interviews (DISC-2.3 with DSM-III-R criteria) with 1,285 caretaker-child pairs, were identified separately for parent and child (aged 9 through 17) informants from the MECA database. Cases were then examined for demographic characteristics, for obsessive-compulsive symptoms and other diagnoses reported in cases "missed" by one reporter, and for comorbid disorders. Of a total of 35 (2.7%) identified cases, four (0.3%) were identified by the parent and 32 (2.5%) were identified by the child, with only one overlapping case. In general, when OCD cases were "missed" by one reporter, that reporter did not substitute another disorder. These findings support clinical data that children with OCD often hide their illness and underscore the importance of child interviews for its detection.

How specific is specific impairment?

OBJECTIVE

To describe the usefulness of impairment items placed at the end of each diagnostic section of a structured instrument (the Diagnostic Interview Schedule for Children Version 2.3) in an attempt to link impairment to specific diagnoses.

METHOD

Data from 3 sites of the Methods for the Epidemiology of Child and Adolescent Mental Disorders Study were used to assess the reliability of the specific impairment measures by diagnosis, the extent to which global and specific measures of impairment impact on prevalence rates, the concordance between global and specific impairment, and the degree to which there may be a "halo effect" among specific impairment ratings.

RESULTS

Test-retest reliability was better for parent than youth ratings. Fewer children were rated as impaired on well-validated global scales than on specific impairment ratings, suggesting that the threshold for specific ratings needs to be reevaluated. Agreement between specific and global ratings was poor. Most subjects with 2 or more diagnoses for which impairment was attributed to one diagnosis also had impairment attributed to other diagnoses for which they met symptom criteria, suggesting a halo effect in these ratings of specific impairment.

CONCLUSIONS

Impairment measures are important in diagnostic assessments to distinguish those individuals whose psychopathology is of clinical significance. Specific impairment ratings used in structured instruments could be improved by including parameters of impairment that are diagnosis-specific.

The Service Assessment for Children and Adolescents (SACA): adult and child reports

OBJECTIVE

To describe differences in parent-child responses to the Service Assessment for Children and Adolescents (SACA).

METHOD

Studies were done at UCLA and Washington University based on service-using and community subjects drawn from community households or public school student lists, respectively. Results are presented for 145 adult-youth pairs in which the youth was 11 or older.

RESULTS

The SACA adult-youth correspondence for lifetime use of any services, inpatient services, outpatient services, and school services ranged from fair to excellent (kappa = 0.43-0.86, with most at 0.61 or greater). Similarly, the SACA showed a good to excellent correspondence for services that had been used in the preceding year (kappa = 0.45-0.77, with most greater than 0.50). The parent-youth correspondence for use of specific service settings in the above generic categories ranged from poor to excellent (kappa = 0.25-0.83, with half at 0.50 or greater).

CONCLUSIONS

The SACA has better adult-youth correspondence than any service use questionnaire with published data, indicating that both adult and youth reports are not needed for all research on mental health services. This is especially encouraging news for researchers working with high-risk youth populations, in which a parent figure is often not available.

Mental health service use by Americans with severe mental illnesses

BACKGROUND

The aim of this study was to determine the patterns and determinants of service use in severely mentally ill persons drawn from the National Institute of Mental Health Epidemiological Catchment Area (ECA) program, a community-based epidemiologic survey. This information provides a baseline against which to track ongoing changes in the US mental health service system.

METHODS

Severe mental illness (SMI) was defined according to US Senate Appropriations Committee guidelines. Comparisons were made with persons who had a mental disorder that did not meet these criteria (non-SMI). Sociodemographic factors, and 1-year volume and intensity of mental or addictive services use were determined. Differences between those who used services and those who did not were examined using logistic regression.

RESULTS

Persons with SMI differed from persons with non-SMI in most sociodemographic characteristics. A higher proportion of persons with SMI used ambulatory services, but the mean number of visits per person did not differ from the non-SMI population. Persons with SMI comprised the bulk of hospital inpatients admitted during a 1-year period. Several significant sociodemographic determinants of service use were found, with different patterns for general medical and specialty service use, pointing out potential barriers to care.

CONCLUSIONS

As health care reform measures continue to be debated, attention to the service needs of the severely mentally ill is of crucial importance. Pre-managed care (pre-1993) baseline service use benchmarks will be essential to assess the impact of managed care on access to care, particularly for the severely mentally ill. Periodic collection of epidemiologic data on prevalence and service use would thus greatly facilitate service planning and addressing barriers to receiving mental health services in this population.

Depressive and disruptive disorders and mental health service utilization in children and adolescents

OBJECTIVE

To examine the relationship of depressive and disruptive disorders with patterns of mental health services utilization in a community sample of children and adolescents.

METHOD

Data were from the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. The sample consisted of 1,285 child (ages 9-17 years) and parent/guardian pairs. Data included child psychopathology (assessed by the Diagnostic Interview Schedule for Children), impairment, child need and use of mental health services, and family socioeconomic status.

RESULTS

After adjusting for potential confounding factors, disruptive disorder was significantly associated with children's use of mental health services, but depressive disorder was not. For school-based services, no difference was found between the 2 types of disorders. Parents perceived greater need for mental health services for children with disruptive disorders than for those with depression. Conversely, depression was more related to children's perception of mental health service need than was disruptive disorder.

CONCLUSIONS

The findings highlight the need for more effective ways to identify and refer depressed children to mental health professionals, the importance of improving school-based services to meet children's needs, and the necessity to better educate parents and teachers regarding the identification of psychiatric disorders, especially depression.

A comparison of federal definitions of severe mental illness among children and adolescents in four communities

OBJECTIVE

Using data from an epidemiological survey, the study compared existing definitions of severe mental illness and serious emotional disturbance among children and adolescents to demonstrate the range of prevalence rates resulting from application of different definitions to the same population.

METHODS

Three definitions of severe mental illness and serious emotional disturbance were applied to data from the Methods for the Epidemiology of Child and Adolescent Mental Disorders survey, with a sample of 1,285, conducted in 1991-1992 by the National Institute of Mental Health. The resulting proportions of cases identified, demographic characteristics, service use, and perceived need for services were compared.

RESULTS

From 3 to 23 percent of the sampled youth met criteria for severe mental illness or serious emotional disturbance. From 40 percent to as many as 78 percent of the defined youth used a mental health service in the year before the survey. School and ambulatory specialty settings were used most frequently. Generally, more than half of the parents of children with severe mental illness or serious emotional disturbance thought that their child needed services.

CONCLUSIONS

The prevalence and characteristics of severe mental illness and serious emotional disturbance among children are sensitive to the definition used and its operationalization. Care should be taken by policy makers and service planners to avoid either over- or underestimating the prevalence of impaired youth in need of intensive interventions.

Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders

BACKGROUND

The co-occurrence of anxiety disorders with other mental, addictive, and physical disorders has important implications for treatment and for prediction of clinical course and associated morbidity.

METHOD

Cross-sectional and prospective data on 20,291 individuals from the Epidemiologic Catchment Area (ECA) study were analysed to determine one-month, current disorders, one-year incidence, and one-year and lifetime prevalence of anxiety, mood, and addictive disorders, and to identify the onset and offset of disorders within the one-year prospective period.

RESULTS

Nearly half (47.2%) of those meeting lifetime criteria for major depression also have met criteria for a comorbid anxiety disorder. The average age of onset of any lifetime anxiety disorder (16.4 years) and social phobia (11.6 years) among those with major depression was much younger than the onset age for major depression (23.2 years) and panic disorder.

CONCLUSIONS

Anxiety disorders, especially social and simple phobias, appear to have an early onset in adolescence with potentially severe consequences, predisposing those affected to greater vulnerability to major depression and addictive disorders.

Measurement of risk for mental disorders and competence in a psychiatric epidemiologic community survey: the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study

This paper describes the implementation of the National Institute of Mental Health Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) study's goals of measuring risk factors and competence. The emphasis is on the development and testing of the measures. Relevant constructs for measurement of risk and competence in relation to psychopathology were selected and pilot tested prior to the field trials. A structured interview was developed and field tested using lay interviewers. Using the full sample from the field trials (n = 1285 caretaker-youth pairs), sample means, standard deviations, internal consistencies, parent-youth agreement, and associations with childhood disorder were computed. Descriptive statistics reveal a range of scores and means consistent with norming samples, when available, Internal consistencies were moderate to high. Parent-youth agreement on factual items was excellent and on scales was consistent with the literature. Several strong associations were found between risk factors and disorder, although most were related to disorder in general and not specific to a diagnostic category. This instrument provides a means of obtaining data that will be useful to researchers conducting epidemiologic and clinical studies designed to contribute to the understanding of mental disorders in children and adolescents, including nosology, risk factors, context, adaptive functioning, and treatment.

Correlates of unmet need for mental health services by children and adolescents

BACKGROUND

Little is known about the extent and correlates of unmet need for mental health services in community samples of children and adolescents.

METHODS

Data were obtained from the 1285 parent/youth pairs interviewed at four sites in the USA and Puerto Rico in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Unmet need was defined to exist if psychopathology and associated functional impairment were present but no mental health services had been received in the previous 6 months.

RESULTS

Of the total sample, 17.1% had unmet need. Adjusting for demographic variables, logistic regression analyses revealed that unmet need was significantly associated with: indicators of economic disadvantage, such as being on public assistance and not being covered by health insurance; opinions of the parents and children or adolescents that the latter had poor mental health; parental psychopathology; poor school grades; and parent-reported access barriers such as concern that the child would want to solve the problem unassisted, would refuse to attend mental health services, or would be hospitalized or taken away against the parent's will. No youth-reported access barriers were significantly associated with unmet need.

CONCLUSIONS

The economic correlates of unmet need may attain increased importance in the light of current reform in health care financing in the USA. Access may be facilitated by increasing parental knowledge of mental health services and enabling children and adolescents to initiate contact with services independently of their families.

Prevalence of mental illness in Germany and the United States. Comparison of the Upper Bavarian Study and the Epidemiologic Catchment Area Program

The objective of the present study was to compare data on the prevalence of mental illness in Germany and the United States. For this purpose, data from the Upper Bavarian Study (UBS) and the Epidemiologic Catchment Area (ECA) are presented and compared. In both studies, personal interviews were administered to a sample of community residents. The UBS sample consisted of 1,847 persons aged > or = 18 years, and the ECA study consisted of 24,371 household members aged > or = 18 years in five sites; 1,876 persons from the ECA sample lived in rural sites, and they were used for comparison with the (rural) UBS sample. The diagnostic classification (according to DSM-III) obtained by clinical interviewers in the UBS and by lay interviewers in the ECA was used. The total 6-month prevalence for any axis I Diagnostic Interview Schedule mental disorder (corrected for sample stratifications and adjusted for age) was 18.5% in the (rural) UBS, 18.0% in the total ECA sample (five sites), and 13.4% in the rural sites of the ECA. High morbidity rates for substance use disorders (UBS, 5.8%; ECA rural sites, 3.4%) and affective disorders (UBS, 6.8%; ECA rural sites, 4.1%) were observed in both studies. The 6-month prevalence rates for alcohol use disorders (3.1% considered marked or severe) were 5.1% in the UBS and 2.9% in the ECA rural sites. Concerning anxiety disorders (UBS, 1.6%; ECA rural sites, 6.7%) there was a substantial difference between the studies, which mainly resulted from a higher prevalence of phobia in the ECA program. There were higher rates of dysthymia (3.8% considered marked or severe) in the UBS (5.4%) than in the ECA rural sites (2.6%), whereas the rate of major depression was somewhat lower in UBS (1.4%) as compared with the ECA rural sites (2.4%). Alcohol use disorder was the most frequent category of mental disorder for men in both studies; for women, affective disorder and phobia (in the ECA) were the most frequent categories. Despite differences in methodology concerning sampling, instruments, and case identification the similarities between the results of the two studies were considerable.

Mental health service use in the community and schools: results from the four-community MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study

OBJECTIVE

To describe the use of mental health and substance abuse services by children and adolescents as reported from the four community sites included in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

METHOD

As part of the MECA survey, questions were developed to identify children and adolescents utilizing mental health and substance abuse services. Youths aged 9 through 17 years and a parent/ caretaker were interviewed. Because the investigators had concerns about the capacities of the younger children in the study to describe their use of mental health services, more extensive questions were asked of parents than of youths.

RESULTS

The procedures developed by the MECA project identified patterns of service use that varied in the four communities surveyed. Agreement between reports of parents and youths regarding the use of mental health and substance abuse services showed substantial inconsistencies, similar to reports of psychiatric disorders. At three of the four sites, the majority of children meeting criteria for a psychiatric disorder and scoring 60 or less on the Children's Global Assessment Scale reported some mental health-related service in the previous year, although at two of the sites fewer than 25% of these youths were seen in the mental health specialty sector.

CONCLUSION

Community surveys show great promise for monitoring the need for mental health and substance abuse services and for identifying patterns of use.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology

OBJECTIVE

A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents.

METHOD

Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization.

RESULTS

More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend.

CONCLUSIONS

These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

Concordance between two measures of depression in the Hispanic Health and Nutrition Examination Survey

A concordance analysis between the Center for Epidemiologic Studies Depression Scale (CES-D) and the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) for current major depression was conducted using data from Cuban Americans and Puerto Rican respondents to the Hispanic Health and Nutrition Examination Survey (HHANES). Overall agreement between the two depression measures was relatively high, which suggested that the CES-D might be appropriate as a first-stage screening instrument for community-based surveys of clinical depression. Female gender and indicators of social class (education, income, poverty index, and employment) were related to low specificity and low agreement. The estimated cutoff points of the CES-D that best predicted DIS current major depression were different between the two ethnic groups; 17 for Cuban Americans, and 20 for Puerto Ricans. A receiver operating characteristics (ROC) curve analysis revealed that the traditional method of defining CES-D cases by summing the scores for each item was superior to counting only the persistent symptoms, that is, those present nearly everyday.

The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services

After initial interviews with 20,291 adults in the National Institute of Mental Health Epidemiologic Catchment Area Program, we estimated prospective 1-year prevalence and service use rates of mental and addictive disorders in the US population. An annual prevalence rate of 28.1% was found for these disorders, composed of a 1-month point prevalence of 15.7% (at wave 1) and a 1-year incidence of new or recurrent disorders identified in 12.3% of the population at wave 2. During the 1-year follow-up period, 6.6% of the total sample developed one or more new disorders after being assessed as having no previous lifetime diagnosis at wave 1. An additional 5.7% of the population, with a history of some previous disorder at wave 1, had an acute relapse or suffered from a new disorder in 1 year. Irrespective of diagnosis, 14.7% of the US population in 1 year reported use of services in one or more component sectors of the de facto US mental and addictive service system. With some overlap between sectors, specialists in mental and addictive disorders provided treatment to 5.9% of the US population, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary support sector for such care. Of those persons with any disorder, only 28.5% (8.0 per 100 population) sought mental health/addictive services. Persons with specific disorders varied in the proportion who used services, from a high of more than 60% for somatization, schizophrenia, and bipolar disorders to a low of less than 25% for addictive disorders and severe cognitive impairment. Applications of these descriptive data to US health care system reform options are considered in the context of other variables that will determine national health policy.