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) - 1980’S (WAKEFIELD)

• NCS - NATIONAL COMORBIDITY STUDY - 1990’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