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

WHY WANT EPIDEMIOLOGY? SMALL PROPORTION OF PEOPLE WITH M.I. ENTER TREATMENT TREATED PEOPLE AREN’T REPRESENTATIVE MUST LOOK AT UNTREATED TO UNDERSTAND CAUSES, COURSE, AND TREATMENT

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

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

TWO TYPES OF MEASURES GENERAL MEASURES OF OUTCOME DIAGNOSTIC MEASURES OF OUTCOME

GENERAL MEASURES MOST COMMON FREQUENTLY OCCURING SYMPTOMS – NOT COMPARABLE TO DSM CATEGORY E.G. CESD

CES-D - QUESTIONS DURING THE PAST WEEK I FELT SAD I DID NOT FEEL LIKE EATING; MY APPETITE WAS POOR MY SLEEP WAS RESTLESS I ENJOYED LIFE (REVERSED) 20 IN ALL

ANSWER CATEGORIES NONE OR RARELY (LESS THAN 1 DAY); SOME (1-2 DAYS); MODERATE (3-4 DAYS); OFTEN (> 4 DAYS) 0, 1, 2, 3 SCORES

SCORES ADD RESPONSES 16 NORMAL CUTOFF FOR CES-D

ISSUES WHAT DOES IT MEASURE – DISORDER OR DISTRESS? HIGH RATES – 20% TO 30% OVER 16 SENSITIVE TO IMMEDIATE EVENTS MUCH CHANGE – ONLY 1/3 OF PEOPLE STAY IN SAME CATEGORY OVER SEVERAL MONTHS CAN’T SEPARATE DISORDER FROM DISTRESS

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

COMPARABLE TO DSM CAN’T TELL WHAT CESD MEASURES WANT SPECIFIC MEASURES OF DIAGNOSTIC CATEGORIES

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

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

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

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

OVERESTIMATES (WAKEFIELD) SUPPOSED TO BE SAME AS CLINICAL 1. DISCRETION OF INDIVIDUAL 2. DISCRETION OF CLINICIAN COMMUNITY STUDIES NO DISCRETION OF EITHER NO CONTEXT (LIKE CESD) RESULT IS OVERCOUNTING

DSM SYMPTOMS LACK INTEREST IN SEX ANXIETY ABOUT PERFORMANCE AROUSAL DIFFICULTIES UNABLE TO HAVE ORGASM CLIMAX TOO QUICKLY FIND SEX PAINFUL SEX NOT PLEASURABLE

FINDINGS 43 % OF WOMEN AND 31% OF MEN HAVE SEXUAL DYSFUNCTION VERY WIDESPREAD PUBLIC HEALTH PROBLEM PEOPLE MUST KNOW THAT MEDICATIONS ARE AVAILABLE TO HELP

SEXUAL DYSFUNCTION BEST PREDICTOR? LOW SATISFACTION WITH PARTNER PEOPLE WHO DON’T ENJOY SEX WITH PARTNERS ARE CALLED MENTALLY ILL AND SHOULD TAKE MEDICATION

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