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.

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.

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.

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.

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.

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.

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.

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.

Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program.

The use of ambulatory and inpatient mental health and addiction services in the United States was estimated by means of data from the National Institute of Mental Health Epidemiologic Catchment Area Program standardized to the 1980 US census for adults 18 years of age and older. In a 1-year period, 22.8 million people used ambulatory services for mental or addictive disorder treatment; 54% of them had a current Diagnostic Interview Schedule/DSM-III mental disorder and another 37.4% had a history of psychiatric disorder or significant psychiatric symptoms. A total of 325.9 million ambulatory visits were made, and the average number of visits per treated person per year was 14.3. There were 1.4 million persons admitted to at least one inpatient mental health or addiction setting during a 1-year period; 80% of them had a current DIS/DSM-III disorder, and the remainder had a history of psychiatric disorder or significant psychiatric symptoms. Results were determined for specific mental and substance use diagnoses and service settings. Among treated persons with any mental or addictive disorder, the majority of visits were to mental and addictive disorders specialty settings (40.5% of total visits) and to support networks composed of friends, relatives, and self-help groups (37.0% of total visits). Although a large number of persons with mental and substance use disorders were seen in the general medical sector for mental health or addiction problems, they were seen less frequently and therefore made fewer visits to this sector (10.9% of total visits).

Congruence of service utilization estimates from the Epidemiologic Catchment Area Project and other sources.

Service utilization estimates for inpatient and ambulatory mental health care from the Epidemiologic Catchment Area Project were compared with similar estimates from other sources, principally the Center for Mental Health Services National Reporting Program. Generally, results showed closer correspondence between estimates of the number of persons who used inpatient care than of similar estimates for ambulatory mental health care. Subtotal estimates for the specialty alcohol/other drug abuse/mental health and health care sectors were more similar than were estimates for individual settings. The specialty sector subtotals showed only a 7% difference in patient counts for inpatient care and 13% for ambulatory care, with an 11% difference in visits for the latter. Generally, a reasonable level of congruence was observed, given pronounced differences in methods, procedures, and instruments. Future directions may be able to close data gaps and improve the quality of the national mental health services database.

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.

Estimating the prevalence of mental disorders in U.S. adults from the Epidemiologic Catchment Area Survey.

The National Institute of Mental Health Epidemiologic Catchment Area Survey is a comprehensive, community-based survey of mental disorders and use of services by adults, ages 18 and older. Diagnoses are based on the criteria in the "Diagnostic and Statistical Manual of Mental Disorders," third edition, and were obtained in five communities in the United States through lay-interviewer administration of the National Institute of Mental Health Diagnostic Interview Schedule. Results from the survey provide the public health field with data on the prevalence and incidence of specific mental disorders in the community, unbiased by the treatment status of the sample. The population with disorders is estimated, and the survey findings that respond to some of the most common requests for information about the epidemiology of mental disorders in the United States are highlighted briefly. Based on the survey, it is estimated that one of every five persons in the United States suffers from a mental disorder in any 6-month period, and that one of every three persons suffers a disorder in his or her lifetime. Fewer than 20 percent of those with a recent mental disorder seek help for their problem, according to the survey. High rates of comorbid substance abuse and mental disorders were found, particularly among those who had sought treatment for their disorders.

Depression among Cuban Americans. The Hispanic Health and Nutrition Examination Survey.

This paper presents the findings on depressive symptomatology and major depressive disorder in Cuban American respondents to the Hispanic Health and Nutrition Examination Survey (HHANES). The HHANES represents the first population-based assessment of the mental health status of Cuban Americans. High levels of depression, as measured by a CES-D score of 16 or more, were found in ten percent of the sample. Female gender was independently associated with CES-D caseness. The lifetime, six-month, and one-month prevalence rates of major depressive disorder, as measured by the National Institute of Mental Health Diagnostic Interview Schedule (DIS), were 3.15%, 2.12%, and 1.50%, respectively. An income level of less than ten thousand dollars was independently associated with a lifetime diagnosis of major depression.