OUTLINE HOW MEASURE M.I. IN COMMUNITY POPULATIONS? MAJOR INSTRUMENTS AND FINDINGS PROBLEMS WITH INSTRUMENTS POLICY IMPLICATIONS

Treatment for Depression

REASONS FOR ENTERING TREATMENT MENTAL ILLNESS CHANGING CULTURE SO MORE RECOGNITION EDUCATIONAL CAMPAIGNS PHARMACEUTICAL ADS CHANGE IN FINANCING

PROBLEMS WITH TREATED SAMPLES CAN REFLECT UNDERTREATMENT OR OVERTREATMENT SO NOT ACCURATE REFLECTION OF AMOUNT NOT REPRESENTATIVE OF TYPES OF PEOPLE “CLINICIAN’S ILLUSION”

EPIDEMIOLOGY FOCUS ON UNTREATED CASES STUDY OF RATES OF DISORDER IN COMMUNITY POPULATIONS FOCUS ON GROUP DIFFERENCES IN DISORDER NOT INDIVIDUAL CASES

GOALS 1. SEE HOW WIDESPREAD M.I. IS 2. LOOK AT UNMET NEED FOR SERVICES 3. EXAMINE GROUP DIFFERENCES IN RATES 4. BETTER WAY TO DISCOVER CAUSES AND COURSE OF M.I.

HOW MEASURE M.I.? PSYCHIATRIC INTERVIEWS VERY EXPENSIVE, IMPRACTICAL, UNRELIABLE USE STANDARDIZED INSTRUMENTS STANDARD QUESTIONS STANDARD ANSWERS

DIAGNOSTIC INTERVIEWS

TWO MAJOR STUDIES ECA - EPIDEMIOLOGIC CATCHMENT AREA) ’S (WAKEFIELD) NCS - NATIONAL COMORBIDITY STUDY ’S and EARLY 2000’S (KESSLER) BOTH USE FORMAL DIAGNOSES

FINDINGS MENTAL ILLNESS WIDESPREAD DEPRESSION - 10% IN PAST YEAR; 25% OVER LIFETIME ANXIETY - 20% IN PAST YEAR; 30% OVER LIFETIME SUBSTANCE ABUSE - 15% PAST YEAR; 25% OVER LIFETIME

FINDINGS ALL DISORDERS - 1/3 OF POPULATION HAS DISORDER IN PAST YEAR; 1/2 OVER LIFETIME MANY PEOPLE “COMORBID” - MORE THAN ONE DISORDER MANY GROUP DIFFERENCES - CLASS, ETHNIC, GENDER, AGE, ETC.

GENERALIZED QUESTIONNAIRES MORE PRACTICAL, CHEAPER

ISSUES WITH BOTH TYPES HIGH RATES – 20% TO 30% FEW FALSE NEGATIVES MANY FALSE POSITIVES IGNORES CONTEXT OF SYMPTOMS PHYSICAL ILLNESS? INSTABILITY – ONLY 1/3 IN SAME CATEGORY OVER SEVERAL MONTHS EXPLOITATION BY DRUG CO?

USEFUL FOR RATES COMPARE GROUPS IN COMMUNITY - E.G. GENDER, SOCIAL CLASS, MARITAL STATUS, ETC.

USUAL CONCLUSIONS (KESSLER) MENTAL DISORDER WIDESPREAD TREMENDOUS “UNMET NEED” FOR TREATMENT UNMET NEED GREATEST AMONG POOR, MINORITIES, MEN, OLDER MUST EXPAND MENTAL HEALTH SERVICES

OVERESTIMATES (WAKEFIELD) SUPPOSED TO BE SAME AS CLINICAL 1. DISCRETION OF INDIVIDUAL 2. DISCRETION OF CLINICIAN COMMUNITY STUDIES LACK DISCRETION OF EITHER RESULT IS OVERCOUNTING – FALSE POSITIVES

POLICY STEMMING FROM COMMUNITY STUDIES OVERCOME PROBLEM OF UNMET NEED

Screening for Depression

SCREENING FIND UNTREATED INDIVIDUALS SETTINGS THAT HAVE HIGH % OF M.I. PRIMARY MEDICAL CARE SCHOOLS

BENEFITS AND COSTS GET TREATMENT TO UNTREATED PREVENT FROM BECOMING MORE SERIOUS SAVE MONEY TOO INTRUSIVE? STIGMA IS IT EFFECTIVE? TELL ANYTHING NEW? BE CAUTIOUS, NOT SWEEPING

CONCLUSION MENTAL ILLNESS IS WIDESPREAD BUT CAN’T SEPARATE DISTRESS FROM DISORDER STUDIES OVERESTIMATE AMOUNT OF MENTAL ILLNESS LEAD TO MEDICALIZATION NEED TO INCORPORATE CONTEXT INTO STUDIES