The epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean.

OBJECTIVE: To report on the epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean. METHODS: The MEDLINE, MEDCARIB and West Indiana electronic databases were searched with the phrases Caribbean AND psychiatry OR mental OR suicide, and items with specific reference to epidemiology were culled and reviewed. RESULTS: The age-corrected incidence rate for schizophrenia per 10,000 is 2.09 in Jamaica, 2.2 per 1000 in Trinidad, and 2.92 in Barbados. These rates are lower than the incidence rates reported for white British people, and significantly lower that the 6- to 18-fold higher risk ratio incidence reported for African Caribbeans living in Britain. A comparative diagnostic study carried out in the United Kingdom (UK) suggests that misdiagnosis plays a significant role in this difference. Relatively low incidence figures for affective disorders, anxiety states, suicide and attempted suicide have been reported for Jamaica, Trinidad, and Barbados. DISCUSSION: Most published epidemiological studies of Caribbean populations center on schizophrenia, because of the startling findings of a large increase in risk ratios for African Caribbean people living in England compared to the white native British people. The etiological evidence is shifting toward factors of racism and social alienation experienced by black people in the UK, and to misdiagnosis by white British psychiatrists. Studies of the role of colonial enslavement and social engineering raise the etiological possibility of a role for social and structural community organization in the genesis of schizophrenia. The Caribbean thus represents a rich crucible for research in the epidemiology and etiology of mental health disorders.     

Social deprivation and psychiatric service use for different diagnostic groups

Recent research has shown that the relationship between social deprivation and admission rates varies according to diagnosis. We have replicated a study of this kind. Furthermore, in addition to admission rates, we also look at variations in length of stay and the proportion of readmitted patients. Psychiatric admission data for the 79 Amsterdam neighbourhoods was obtained from the City Psychiatric Register. This data covered all the admissions between 1992 and 1995 of people from Amsterdam aged 19 and older, with the exception of short-term crisis admissions to the Crisis Centre. These admissions were divided into six diagnostic groups. The admission rates, the average length of stay and the proportion of patients readmitted were compared to the level of socio-economic deprivation in the area concerned, a factor which was determined using factor analysis. Admission rates for schizophrenia, other psychoses and neurosis disorders showed a significant relation with the level of socioeconomic deprivation. Admission rates for affective disorders, organic psychoses and personality disorders showed no significant relation with deprivation. The findings on average length of stay and proportion of readmitted patients showed no clear relation with deprivation according to diagnosis category. As was found in previous studies, the relationship with socio-economic deprivation varies according to diagnosis. The average length of stay and the risk of readmission, given the diagnosis, do not vary according to level of deprivation.     

The nosological position of transsexualism

Transsexualism, a behavioral state assuming increasing contemporary significance, is examined here as to its nosological position within psychiatry. Clinical features are compared with schizophrenia, affective psychoses, neuroses, personality disorders, perversions, and paranoid syndromes. Transsexualism is also compared to other disorders with regard to sexual drive, erotic interests, and responses to castration and behavior therapy. No standard psychiatric category of mental disorder comfortably embraces the syndrome of transsexualism. Its nosological uniqueness characterizes our dilemma over etiology, diagnosis, and treatment.     

Somatotyping of schizophrenic and affective disorder patients

INTRODUCTION: Constitutional traits have been found to show a distinct relevance to major psychiatric disorders. Syndromal modified expressivity is also closely related to somatotypic constitution. In this view somatotyping appears valuable in diagnosis and prognosis of mental disorders. AIM: The present study was conducted in an attempt to outline somatotypic characteristics of schizophrenia and affective disorders with the aim of providing a logical basis for diagnosis of these major psychiatric disorders. MATERIAL AND METHODS: The somatotype of 54 schizophrenic and 68 affective disorder inpatients who fulfil the DSM-IV criteria for schizophrenia (subjects with schizophreniform, schizoaffective, schizoid and schizotypal personality disorders were excluded from the sample) and affective disorder (bipolar and unipolar) was assessed using the Health-Carter anthropometric method. RESULTS: The overall assessment of the somatotypes determined both groups as endomorphs mesomorphs with somatotype components 4.50-4.44-1.90 for schizophrenic patients and 5.87-5.40-0.36 for affective disorder patients. The difference between the two groups was statistically significant for any of the somatotype components. CONCLUSION: It is suggested that the constitutional and somatotypic characterization appears reasonable element in the multifactorial analysis of diagnostic decisions in these major psychiatric disorders.     

Affective disorders: analysis of their comorbidity in the more frequent psychiatric disorders

Comorbidity is defined as the presence of two or more independent diseases in the same subject. This paper reviews the comorbidity of affective disorders with other mental disorders. We focus on the disorders of anxiety, schizophrenia, dependence on psychoactive substances, eating disorders, personality disorders and obsessive-compulsive disorder. To this end, we have carried out an extensive review that has taken account of numerous studies, as well as of different diagnostic orientations (categorical or dimensional). In general the presence of affective symptoms and/or disorders in the context of other mental pathologies is high. Moreover, comorbidity has a high transcendence with respect to clinical prognosis (worse response to treatments, greater symptomatic persistence, greater tendency to chronicity and greater risk of mortality) and the social consequences (decline in work performance and greater use of resources). Nonetheless, we must bear in mind that the analysis of the comorbidity of affective disorders in other mental disorders is complex and controversial, not only because of its high frequency, but also because of the existence of symptomatic overlap, scarcity of signs and pathognomonic symptoms, variability of diagnostic criteria, applied methodological differences, as well as a scarcity of longitudinal and prospective studies.     

Symptom heterogeneity in comorbid alcohol disorder

The heterogeneity of signs and symptoms of alcohol disorder was examined in a community sample of 1,955 persons with either alcohol disorder alone or alcohol disorder plus one of four categories of major mental disorder (antisocial personality disorder, schizophrenia, affective disorder, anxiety disorder). When all diagnostic categories were combined, persons with comorbid mental and alcohol disorders showed evidence of more severe alcohol-related symptoms than did persons with alcohol disorder alone. Distinct symptom patterns distinguished the four diagnostic groups, reflecting heterogeneity in the manifestation of comorbid alcohol disorder. Most notably, comorbid antisocial personality disorder and schizophrenia were associated with higher levels of alcohol consumption and more severe social consequences of alcohol use. These findings substantiate the need for development of specialized dual diagnosis programs and suggest that additional specialization may be required to address diagnostic group differences in the characteristics of comorbid alcohol disorder.     

Management of psychosis in Australian general practice

The BEACH program, a continuous national study of general practice activity in Australia, gives us an overview of consultations involving the management of psychoses. In this analysis we have included schizophrenia, affective disorders/bipolar, organic psychoses, and senile psychoses, with undefined psychosis and chronic brain syndrome grouped as 'other'. This synopsis provides a backdrop against which the theme articles in this issue of Australian Family Physician can be further considered.     

Genetic influences on smoking behavior and nicotine dependence: a review

Molecular epidemiologic studies suggest genetic factors in the etiology of smoking behavior. Dopamine receptor genes, transporter genes (serotonin and dopamine), and other genes related to metabolism of nicotine are plausible functional candidate genes. Research examining the role of allelic variation in those genes is being actively pursued with respect to nicotine dependence as well as personality characteristics and mental disorders. Some of these genes were reported to be connected with schizophrenia. Although nicotine dependence itself is one of the mental disorders according to the fourth edition of Diagnostic and Statistical Manual of Mental Disorders and the World Health Organization's International Statistical Classification of Diseases and Related Health Problems-10 nomenclature, the high comorbidity between nicotine dependence and other mental disorders such as schizophrenia or affective disorders has been noted. Therefore, the relationship between those mental disorders and tobacco addiction should be cleared up considering the interactive effect of genetic and environmental factors.     

How do Trends for Behavioral Health Inpatient Care Differ from Medical Inpatient Care in U.S. Community Hospitals?

BACKGROUND: Inpatient care in the United States accounts for one third of the health care expenditures. There exists a well-established trend towards fewer inpatient admissions and shorter lengths of stay for all inpatient care, which can be attributed to cost containment efforts through managed care and advances in treatment technologies. However, different illnesses may not necessarily share the same pattern of change in inpatient care utilization. In particular, mental health and substance abuse (MHSA) care has experienced a particularly dramatic growth of specialized managed behavioral organizations, which could have led to an even faster decline. AIMS OF THE STUDY: This study contrasts the trends of MHSA inpatient care in U.S. community hospitals with medical inpatient care over the years 1988 to 1997. It also analyzes the trends for subgroups of MHSA stays by diagnostic groups, age and primary payer. METHODS: We use the National Inpatient Sample (NIS) from the Health Care Cost and Utilization Project (HCUP) to estimate both number of inpatient discharges per 1,000 population and average length of stay over the years and relate the two indices. Inpatient MHSA stays are categorized into subgroups by age, primary payer of the care, and diagnostic group. We use the Clinical Classification Software (CCS) to distinguish between affective disorders, schizophrenia and related disorders, other psychoses, anxiety and related disorders, pre-adult disorders, and alcohol-, substance- related mental disorders and other mental disorders. Trends of population adjusted discharges and length of stay were tested using a weighted least squares method. RESULTS: Population-adjusted MHSA discharges from community hospitals increased by 8.1% over the study period, whereas discharges for all conditions decreased. Within MHSA discharges, the 20-39 and 40-64 age groups experienced significant increase relative to other age group; the increase was particularly high for affective and psychotic disorders, which are only partially offset by a decrease for other diagnostic groups. Hospitalization for both MHSA and medical conditions displayed trends towards shorter lengths of stay, but with the decline for MHSA stays steeper (40%) than for all stays (21%). The reduction in length of stay not only applied to the privately insured, for which managed behavioral health care had the highest penetration rate, but held for all other payers as well, although the rate of decline is higher for private insurance than for other insurance. Inpatient stays with pre-adult disorders displayed the greatest percentage decline for both population-adjusted discharges and average length of stay. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Different pattern of utilization emerged for MHSA inpatient care as compared to hospitalization for all medical care over the years 1988-97. The more rapid decline in length of stay for MHSA stays than for all stays may have been a result of greater incentive for cost containment and therefore more intensive care management, and advances in treatment technology, especially medication. However, the fast decline in length of stay may also have led to repeat hospitalization as a result of premature discharges for patients with affective or psychotic disorders. Some financial incentives, such as case-rates or DRG-type payments to hospitals could have contributed to such adverse effects. Increases in discharges for severe disorders could also be a consequence of shifts from long-term facilities (for which no comparable data are available) to community hospitals, although the largest absolute and relative increases were for affective disorders rather than schizophrenia or other psychoses, the two disease subgroups that make up the majority of the institutionalized patients. International comparisons, assisted by new data, may help disentangle the effect of institutional change and that of development in treatment technology or practice pattern.     

Mental health care for mentally ill employees. Part 1. Detection of mental disorders

A mental health program was commenced in 1957 in an electric power company which has about 360 offices and 17,000 employees scattered throughout Kyushu (excluding Okinawa). During a period of 30 yr from 1957 to 1986, a total of 949 mentally ill employees sought consultation regarding various mental health problems. The mean annual number of new cases that sought consultation was 32, giving a rate of 0.19% of the number of employees as of the end of year. The rate increased with length of service and reached 4.4% of the initially employed number after 25-29 yr of service. In addition to cases of direct interview, indirect consultation was sought from family members and/or superiors of the employees. About one-half of this number later sought direct interview, but the remaining cases remained as latent cases in places of work. Psychiatric diagnoses of the subjects by interview included neurotic disorders, alcoholic mental disorders (alcoholic psychoses and dependence), schizophrenic psychoses, affective psychoses, personality disorders, epilepsy and other non-organic psychoses (reactive psychoses).     

情感性障碍分析流行病学的假说相关性研究

分析流行病学是对假说因素进行观察的流行病学方法。本文分析情感性障碍发病的社会心理因素，按分析流行病学方法，确立假说因素与疾病的相关性，推论两者的因果关系。结果表明，情感性障碍发病与精神刺激因素显著相关。     

Characteristics of older adults referred to a psychiatric emergency outreach service

Although older adults typically underutilize mental health services, problems associated with dementing illnesses, chronic medical illnesses, affective disorders, social isolation, and multiple medication use, among other phenomena, have increased referrals of the elderly to psychiatric emergency services. The present study reviewed characteristics of elderly adults referred to a psychiatric emergency outreach/screening service. Of all individuals for whom a referral was made, 24% were aged 60 or older. Among those older adults referred, 63% were seen by screening service personnel; 37% did not meet screening criteria or voluntarily sought mental health services. Diagnoses of individuals evaluated included dementia (27%), affective disorders (27%), schizophrenia (16%), psychosis (12%), alcohol abuse (7), and diagnosis deferred (11%). Findings highlight the limited options available for mental health care of the aged.     

Care requirements for chronic psychiatric patients in general practice: shared responsibility with mental health professionals

Every year in the Netherlands, at least 41,000 patients in mental health care suffer from long-lasting (> 2 years) psychiatric problems such as psychoses, affective disorders, anxiety disorders or personality disorders. A representative survey reveals that during certain periods of time about 20% of them only receive care from their general practitioner. The general practitioner has to deal with the many and complex needs of care in the areas of, for example, psychological complaints, psychotic symptoms, social contacts and information about treatment. According to the patient, one in four of these needs are unmet, resulting in a reduced quality of life. This situation calls for a pro-active attitude on the part of the general practitioner who should nevertheless leave the key role in managing the care of these patients to the mental health professionals.     

Successful deinstitutionalization of mental health care: increased life expectancy among people with mental disorders in Finland

To assess impact of deinstitutionalization of mental health care, we studied life expectancy for 341 630 people with hospitalization or early retirement pension for mental disorders in 1981-2003 in Finland. Life expectancy at the age of 15 years was significantly shorter for men/women with serious mental disorder (59.0/70.8 years) than in the general population (75.3/82.1 years) in 2001-03. Life expectancy increased for people with schizophrenia and other psychoses, mood disorders and neurotic disorders, but decreased for people with substance use disorders. Deinstitutionalization and decentralization of mental health services did not affect life expectancy negatively. Policy measures to control adverse effects of alcohol and substance abuse have failed.     

浙江省15岁及以上人群精神疾病流行病学调查

目的了解浙江省15岁以上人群各类精神疾病的时点患病率和分布特点,为制定全省精神卫生规划提供科学依据。方法2001年9至12月采用多阶段分层整群抽样方法随机抽取14个县(市)、70个乡镇(街道)、140个村(居委会)中15000名≥15岁的人为调查对象,由精神科护士用扩展的一般健康问卷(GHQ-12)将调查对象分为患精神疾病高、中、低危险组,然后由精神科医生以美国精神障碍诊断标准(DSM-IV)依次对100％、40％、10％的调查对象进行定式检查(SCID),对各类精神障碍进行诊断。结果14639人完成筛选,4788人完成诊断。调整后精神疾病总时点患病率为17．3％(95％CI为16．0％-18．7％),除外各类未特定障碍后,总时点患病率下降至13．4％(12．2％-14．7％)。最常见的疾病为心境障碍(8．6％,7．9％-9．5％)、焦虑障碍(4．3％,3．6％-5．1％)和物质使用障碍(3．0％,2．4％～3．8％)。最常见的特定精神疾病为重性抑郁障碍(4．3％,3．7％～4．9％)、酒精使用障碍(2．9％,2．3％-3．7％)、心境恶劣障碍(1．6％,1．3％-1．9％)和特殊恐怖症(1．2％,0．8％-1．8％)。总患病率农村高于城市(RR=1．23,95％CI为1．11～1．37),女性略高于男性(RR=1．11,1．00—1．22)。结论精神障碍是严重影响浙江省社会经济发展的、迫切需要解决的公共卫生问题,有必要在全省范围内开展和实施全面性的精神卫生规划并定期评估其效果。     

Schizophrenia

The diagnostic criteria for schizophrenia have been extensively changed by the third edition of the Diagnostic and Statistical Manual of Mental Disorders, recently adopted by the American Psychiatric Association (DSM III). To receive this diagnosis, the patient must have onset of illness before age 45 years, have had a chronic course, manifest the presence of characteristic symptoms, such as delusions, hallucinations, or loose associations during a phase of the illness, and have experienced a downhill social and vocational course; affective disorders and organic brain syndrome must be carefully excluded. The utilization of this "narrow" definition has caused a major shift toward increasing the diagnosis of affective disorders and decreasing the diagnosis of schizophrenia in the United States. The etiology of schizophrenia is still uncertain, but recent research has elucidated one subgroup of schizophrenic patients who have subtle indices of neurological damage and a clinical course similar to that found in dementia. Dopamine excess in the mesolimbic system is the predominant inferred cause for the majority of schizophrenia cases, and antipsychotic medications all rely on dopamine receptor blockade for their efficacy. Antipsychotic medications are effective in schizophrenia but are less potent against such negative symptoms as apathy, neglect of personal hygiene, and social withdrawal.     

Zur Epidemiologic der Demenz im 20. Jahrhundert Ein Übersichtsbericht Teil 1: Epidemiologie der Demenz im Rahmen allgemeinpsychiatrischer Epidemiologie

In this essay (part one) psychiatric-epidemiological studies of the 20th century, dealing with senile psychoses in the elderly are discussed. A small number of studies before World War II found rates for senile psychoses between 0,2 and 1,5 % (mean = 0,77 %) in the elderly. After World War II the number of studies has multiplied. They all show now much higher prevalence rates, between 2,5 and 12 % with a mean of 5,8 % of the elderly. Also the prevalence rates for all mental disorders in the whole population are much higher in studies since 1945, compared with those before World War II. One reason for this is, that more and more psychic or mental disorders were categorized as psychiatric diagnoses in modern psychiatry. Also the methodological change in psychiatric epidemiology from case finding studies (via medical, psychiatric and/or administrative institutions) to population surveys (sample or total) resulted in higher prevalence rates. Because of these methodological different approaches it cannot be said, that the true prevalence of mental disorders is higher in the studied populations after World War II. For senile psychoses a rise of true prevalence is possible because of the rising proportion of the very old (the group with highest risk for such mental disorders) in the elderly. In part two (publication later) a quantitative analysis of prevalence rates for dementia (this term is being used more and more for senile psychoses) of all relevant studies after 1945 follows. Also longitudinal studies of prevalence and incidence of dementia are discussed.     

Mental disorders in hospitalized children

The authors made a statistical analysis of 1491 case histories in children aged 4-14 years treated for various psychotic disorders at a mental hospital in 1992-2001. The proportion of these children remained to be relatively stable and averaged 14.2% of the total number of inpatients. Throughout the 10-year follow-up, among children with psychoses, boys were prevalent: an average ratio of boys to girls being 3.4:1. In Saint Petersburg, there has been recently a steady reduction in the number of children with psychosis admitted to hospitals, the number patients treated in the outpatient setting being on the increase. At the same time the rates of rehospitalizations are also on the rise of patients mainly with severest psychoses. In the past 10 years, Saint Petersburg has been a town of a steady rise in the number of disabled individuals due to mental diseases among children with schizophrenia and dementia admitted to the hospital.     

Prenatal ultrasound scanning and the risk of schizophrenia and other psychoses

BACKGROUND: Prenatal ultrasound exposure has been associated with increased prevalence of left-hand or mixed-hand preference, and has been suggested to affect the normal lateralization of the fetal brain. Atypical lateralization is more common in patients with schizophrenia. We evaluated possible associations of prenatal ultrasound with schizophrenia and other psychoses. METHODS: We identified a cohort of individuals born in Sweden 1973-1978. During this period, one Swedish hospital (Malm? University Hospital) performed prenatal ultrasound on a routine basis, and all individuals born at that hospital were considered exposed to ultrasound. Children born at hospitals where ultrasound was not used routinely or selectively were considered unexposed. We used Poisson regression analysis to estimate the effect of ultrasound exposure on the incidence of schizophrenia and other psychoses. RESULTS: In all, 370,945 individuals were included in the study, of whom 13,212 were exposed to ultrasound. The exposed group demonstrated a tendency toward a higher risk of schizophrenia (among men, crude incidence rate ratio = 1.58 [95% confidence interval = 0.99-2.51]; among women, 1.26 [0.62-2.55]). However, men and women born in several of the 7 tertiary level hospitals without ultrasound scanning also had higher risks of schizophrenia compared with those born in other hospitals. For other psychoses there were no differences between groups. CONCLUSIONS: No clear associations between prenatal ultrasound exposure and schizophrenia or other psychoses were found. Other factors related to place of birth might have influenced the results.     

Expenditures in Mental Illness and Substance Use Disorders among Veteran Clinic Users with Diabetes

Few studies have looked at the health-care expenditures of diabetes patients based on the type of co-occurring conditions of mental illness (MI) or substance use disorders (SUD). Our study analyzes the health-care expenditures associated with various diagnostic clusters of co-occurring drug, alcohol, tobacco use, and mental illness in veterans with diabetes. We merged Veteran Health Administration and Medicare fee-for-service claims database (fiscal years 1999 and 2000) for analysis (N = 390,253) using generalized linear models; SUD/MI were identified using International Classification of Diseases, 9th edition codes. The total average expenditures (fiscal year 2000) were lowest ($6,185) in the “No MI and No SUD” and highest ($19,801) for individuals with schizophrenia/other psychoses and alcohol/drug use. High expenditures were associated with both SUD and MI conditions in diabetes patients, and veterans with alcohol/drug use had the highest expenditures across all groups of MI. These findings reinforce the need to target groups with multiple comorbidities specifically those with serious mental illnesses and alcohol/drug use for interventions to reduce health-care expenditures.