The Epidemiologic Catchment Area Program of the National Institute of Mental Health

We hope that the ECA Program can make a significant, and perhaps unique, contribution to the field of psychiatric epidemiology and to mental health services research. If the Program provides total true prevalence data on mental disorders according to the latest diagnostic criteria, that in itself will be a significant contribution. Such data should be of enormous benefit to those interested in etiology as well as those interested in health services research. For researchers interested in etiology, the data can be used to identify, by comparison, high-risk groups; for those interested in health services research, the results can serve as a health planning guide that does not depend on the presence or absence of treatment facilities in a given area. Incidence data will be the second major contribution of the ECA Program. Its two-wave design enhances the study of incidence, etiology, and the natural history of disorders and also allows study of the social behavior of persons entering treatment for mental disorders--a subject important to health planners. Finally, a significant result of the ECA Program may be the establishment of a viable standardized methodology for the epidemiologic study of mental disorders by means of which demonstrably replicable results can be produced. Once we demonstrate the equivalence of method and results, then the stage is set for comparative studies of all sorts.     

The prevalence of severe mental disorder among male urban jail detainees: comparison with the Epidemiologic Catchment Area Program.

This paper presents the prevalence rates of schizophrenia and major affective disorders by age and race among a random sample of male jail detainees. Subjects were administered the National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS). The jail prevalence rates were then compared with general population data from the five-city Epidemiologic Catchment Area program using difference of proportion tests and loglinear analysis. After controlling for demographic differences between the jail and five-city samples, the jail prevalence rates were still two to three times higher than those in the general population. These findings suggest several public policy modifications concerning the psychiatric management of our burgeoning jail population.     

Taking chances: problem gamblers and mental health disorders--results from the St. Louis Epidemiologic Catchment Area Study.

OBJECTIVES: This study determined prevalence estimates of problem gambling and relationships to other psychiatric and substance use disorders. METHODS: In 1981, the Diagnostic Interview Schedule was used to collect epidemiological information on problem gambling and other disorders from 3004 adults in St. Louis, Mo. RESULTS: The lifetime prevalence of pathological gambling was 0.9%; 46% of those surveyed gambled recreationally. Problem gamblers (those reporting at least one gambling-related problem) were 9.2% of the sample and were predominately White (69%), male (78.2%), and young than nongamblers. They were at increased risk for several psychiatric diagnoses, especially for antisocial personality disorder, alcoholism, and tobacco dependence. CONCLUSIONS: Clinicians treating alcoholism and tobacco dependence may need to screen for problem gambling. Additional research in the context of increased gambling opportunities is needed.     

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.     

The prevalence of adult sexual assault. The Los Angeles Epidemiologic Catchment Area Project

Data were collected as a supplement to the Los Angeles Epidemiologic Catchment Area project, one of five field sites of a National Institute of Mental Health-initiated program. The authors used a two-stage probability sampling technique to interview 3,132 Los Angeles residents of two mental health catchment areas during the period January 1983-August 1984. Hispanics and non-Hispanic whites were about equally represented in the sample, as were males and females. Respondents were asked, "In your lifetime has anyone ever tried to pressure or force you to have sexual contact? By sexual contact I mean their touching your sexual parts, your touching their sexual parts, or sexual intercourse?" Persons who reported an assault were asked additional questions, including information about the most recent assault. Lifetime prevalence of sexual assault during adulthood (at or after age 16 years) was estimated at 10.5% for the entire sample. Women, non-Hispanic whites, and young people (less than age 40 years) reported higher rates of sexual assault than men, Hispanics, and older people. Highest rates were reported by young non-Hispanic white women with some college education (26.3%). In the most recent sexual assault, three-fourths of respondents knew their assailant, over half experienced harm or the threat of harm, and half experienced sexual contact including but not limited to intercourse.     

The prevalence of childhood sexual assault. The Los Angeles Epidemiologic Catchment Area Project

This study reports childhood sexual assault data collected as part of a community-based population study on mental health. A household sample, stratified by catchment area, was selected using a two-stage probability technique. A total of 3,132 adults (18 years or older) were interviewed between January 1983 and August 1984. The sample was 46% Hispanic and 42% non-Hispanic white, 47% male and 53% female. Childhood sexual assault was defined as incidents before age 16 years which involved pressure or force for sexual contact. The prevalence (weighted for sampling design and nonresponse) of childhood sexual assault for the total sample was 5.3%. Rates were higher for non-Hispanic whites (8.7%) compared with Hispanics (3.0%), women (6.8%) compared with men (3.8%), and younger persons at the time of interview (6.5%) compared with older persons (3.9%). Most assaults were by an acquaintance and occurred for the first time around age 10 years. Data from a subsample of assaulted respondents show that childhood sexual assaults are not usually accomplished through physical aggression, but rather through persuasion, and through the psychological threat of the assailant being bigger or stronger. Research is needed on the natural history and sequelae of childhood sexual assault.     

How service users become empowered in human service organizations: the empowerment model.

This article presents an empowerment model (EM) to be used by service users in human service organizations (HSOs). The EM is a structure for service user input to be integrated within the HSO at various administrative levels through a four-step sequential process. The article fills a distinct void in the literature as there are numerous accounts about the importance of empowerment, but few on processes that need to be defined to operationalize the concept. Implications are directed toward administrators as they need to take leadership in implementing the EM in order to deliver more efficient and relevant services to their clients.     

Psychiatric complications of medical drugs.

General drug toxicity has long been a concern of physicians. Recently, there has been increasing concern about the psychological side effects of drugs. This paper reviews the literature on psychological side effects of those drugs which have been most studied in recent years. It also includes a section reviewing the literature on miscellaneous drugs associated with psychological symptoms. This review, although not exhaustive, is intended to alert the physician to drug related causes for psychological symptoms which patients may experience while taking drugs.     

High-cost users of medical care.

Based on data from the National Medical Care Utilization and Expenditure Survey, the 10 percent of the noninstitutionalized U.S. population that incurred the highest medical care charges was responsible for 75 percent of all incurred charges. Health status was the strongest predictor of high-cost use, followed by economic factors. Persons 65 years of age or over incurred far higher costs than younger persons and had higher out-of-pocket costs, absolutely and as a percentage of income, although they were more likely to be insured.     

Finding evidence for comparing medical interventions: AHRQ and the Effective Health Care Program

Objective

This article discusses search methodology to identify evidence for comparative effectiveness reviews (CERs) as practiced by the Effective Health Care program.

Study Design and Setting

Review.

Results

Search methods described attempt to overcome the bias inherent in the publication and distribution of clinical evidence. Bibliographic databases and search strategies are discussed with special emphasis on searching for observational studies and harms data. Other techniques described include the use of key articles, citation tracking, hand searching, and personal communications. Strategies for locating gray literature, such as clinical trial protocols and regulatory information, are described. Search reporting and other practical matters are also discussed.

Conclusion

Better reporting and further research on search strategies is needed to develop additional evidence-based recommendations.     

A service users' research advisory group from the perspectives of both service users and researchers

Much has been written about the importance of involving service users in the research process. Far less is available about the experience of involvement from the perspective of service users themselves. The present paper is a joint account by service users and researchers of a service users' advisory group set up to support and advise a project to evaluate diabetes services in Bradford, UK. The establishment of a separate advisory group for service users is, to our knowledge, an innovative approach to lay involvement within mainstream National Health Service (NHS)-based research. Factors that contributed to the group's success included personal contact, continuity of membership and integration into the management structure of the project. Also valued were the confidence in numbers which membership of the group gave, and the opportunity to meet and discuss issues away from the formal and somewhat intimidating atmosphere of the project's steering group. Aside from the personal value to participants and any impact on the quality of research outcomes, wider benefits included the ability to share knowledge with others and gain greater intercultural understanding.     

Psychiatric disorders and labor market outcomes: evidence from the National Comorbidity Survey-Replication

This paper uses the National Comorbidity Survey-Replication to estimate effects of recent psychiatric disorder on employment, hours worked, and earnings. We employ methods proposed in Altonji et al. (2005a) which use selection on observable traits to provide information regarding selection along unobservable factors. Among males, disorder is associated with reductions in labor force participation and employment. When selection on observed characteristics is set equal to selection on unobserved characteristics, the magnitudes of these effects for males are 9 and 14 percentage point reductions for participation and employment, respectively. Among females, we find negative associations between disorder and labor force participation and employment, but these estimates are more sensitive to assumptions about selection. There are no effects of disorder on earnings or hours worked among employed individuals.     

A paradox in healthcare service development: Professionalization of service users

Policy makers increasingly regard user involvement as an important dimension of service development. However, research suggests user involvement is often unrepresentative and tokenistic. Drawing on an in-depth case study in mental health carried out in 2008–2012, we examine the processes that give rise to unrepresentative service user involvement. We show that through a combination of self-selection by those wanting to be involved, and professionals actively selecting, educating and socializing certain users, unrepresentative involvement occurs. The selected users tend to be more articulate and able to work with professionals, and are complicit in the processes which give rise to unrepresentative involvement. They pursue their own professional status by delineating a distinctive body of ‘expert’ management knowledge that bounds their jurisdiction, and from which they can exclude those they perceive as ‘less expert’ users.     

Good practice towards homeless drug users: research evidence from Scotland

Evidence of large numbers of people who are both homeless and drug dependent, the complexity of their needs, and the many difficulties which they can encounter when trying to access assistance highlight the importance of basic standards of good practice in working with homeless drug users. This is particularly relevant given the growth of new managerialism and the expansion of social care markets occurring within the UK public sector since the 1980s. Within this context, the aim of the present paper is to further understanding of how best to provide support to homeless drug users by examining good practice from the perspectives of both service providers and service users. Data were collected from 48 semi-structured interviews (12 with staff and 36 with clients) conducted in six case study agencies (three homelessness agencies and three drug agencies). Interviews were audio-recorded and the data were analysed using Framework. Findings from the study revealed that good practice related to five broad areas. These were: (1) staffing; (2) agency environment; (3) support provided; (4) service delivery; and (5) agency aims and objectives. Similarities between the views of service providers and users were evident. However, differences of opinion suggested that the best definitions of good practice are achieved by consultation with a range of stakeholders (including staff and clients). Data also showed that good practice is fundamentally related to the qualitative and intangible aspects of service provision, and not just to more easily quantifiable inputs, processes, outputs and outcomes. The paper concludes by arguing that the challenge for new managerialism is to build evaluation frameworks which can accommodate this complexity, and thus, begin to portray good practice in a more accurate and meaningful light.     

从合作医疗制度向医疗保险制度变迁的条件

借鉴其他国家医疗保障制度发展经验,结合我国实际国情,文章从合作医疗制度向全民基本医疗保险制度变迁的基本条件要素角度进行了分析论证,为将来推行全民医疗保险制度的可行性论证提供理论依据.     

Measuring satisfaction with social care amongst older service users: issues from the literature

Issues of quality and accountability in social care for older people are of increasing importance. A key factor in determining quality is the extent to which older people themselves are satisfied with both the assessment of their needs and the services provided. The 1997 White Paper, Modernising Social Services, stated that local authorities will need to establish authority-wide objectives and performance measures to improve the quality and efficiency of services. In measuring quality, the White Paper stipulated that social service departments would need to design and administer satisfaction surveys as one means of capturing user and carer perceptions and experiences of services. This paper attempts to highlight some of the main issues to be considered when designing and conducting such surveys with older users of community care services. Through a review of the British and North American literature on older people's satisfaction with services, current approaches to measuring satisfaction are outlined and the relationship between the characteristics and circumstances of older people and their responses to satisfaction questions is examined. The paper concludes by offering some solutions to overcoming current problems by drawing conclusions about quality from survey findings, so that older people's opinions about the services they receive can begin to be assessed in a more meaningful way.