Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions

An extensive series of investigations over the past 2 decades clearly demonstrate that mental disorders are present in approximately 25% of primary care patients and that physicians underdiagnose these illnesses. The factors producing this bias are poorly understood and should be focused upon in future research. Also requiring much more study is the efficacy of pharmacologic and psychosocial treatments initially validated with psychiatric populations. Clinical trials should determine whether standardized interventions can be utilized with medical patients whose symptom profiles and organic comorbidity may differ from those of psychiatric populations.     

Genetic epidemiologic studies of affective disorders in childhood and adolescence

Summary The application of the methods of genetic epidemiology appears to be one of the most promising avenues to unravel the complex mechanisms through which genes may exert their influence. The approaches of genetic epidemiology are particularly important for those diseases which are characterized by moderate degrees of heritability and lack of direct correspondence between the underlying vulnerability factors and the ultimate expression of the disease, as is the case for affective disorders. The application of the methods of genetic epidemiology to children of affected parents may also elucidate environmental risk factors and early signs of the disorder. Perhaps the most important implication of the identification of genetic markers for affective disorders is the opportunity for prevention of the disorders. Early identification of youngsters who do manifest early signs of the disorders would facilitate secondary and tertiary prevention of the consequences of those conditions.     

Sleep disturbances and mood disorders: an epidemiologic perspective

Epidemiologic studies of sleep disturbances and mood disorders that may provide more valid estimates of associations between these two conditions than clinical samples due to differential use of health care services. Increasing uniformity of questionnaires to assess sleep disturbances has decreased the variance in estimates of insomnia and hypersomnia within community samples. Women are more likely to report insomnia than men in every age group. There appear to be no clear racial or ethnic differences in rates of insomnia or hypersomnia. Several community-based studies have found that sleep disturbances are powerful risk factors for the development of new episodes of major depression in the following year. Individuals who report insomnia or poor quality sleep may be at higher risk for depression throughout their lifetime. Epidemiologic studies will be useful for developing the long-term perspective on the natural history of sleep disturbances and mood disorders and the consequences of treatment.     

Chronic daily headache: Transformational migraine, chronic migraine, and related disorders

Chronic daily headache is an important category of headache illness that affects 4% of the general population. Within this classification are four chronic headache entities: chronic migraine/transformational migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Chronic migraine/transformational migraine is the most common of these entities and is frequently accompanied by medication overuse, neurobehavioral comorbidity, and disability. The terminology and classification of this entity continue to be confounding. Current research is directed at identifying factors that might promote the progression of this disorder from episodic migraine to daily or almost daily headache, and at identifying the best approaches to treatment, which include both pharmacotherapeutic and non-medicinal interventions. Patients with intractable cases are often hospitalized as a consequence of the convergence of several factors that make outpatient management unlikely to succeed.     

Regulatory disorders in Israeli infants: epidemiologic perspective

The concept of regulatory disorders has been clinically defined. However, epidemiologic validity has not yet been investigated. Children between the ages of 6 and 36 months (N = 450) were included in the study. Two age groups were analyzed separately: 6 to 17 months (53%) and 18 to 36 months (47%). A specially designed questionnaire in Arabic and Hebrew pertaining to the physiologic and behavioral aspects of regulatory disorders was administered at the mother and child health clinics in northern Israel. It was established in the present study that a minimum of four regulatory items should be reported for the diagnosis of a regulatory disorder, as perceived by parents. Factor analysis revealed 6 and 10 different aggregates of regulatory items in the young and older age groups, respectively. The general prevalence of regulatory disorder as defined in the present study was found to be 18%. Age, maternal education, and sex were found to be significantly related to the prevalence of regulatory disorders. No difference in the prevalence of regulatory disorders between Arab and Jewish infants was found. Further validations of the concept of regulatory disorder as well as devising appropriate measurements in well-designed studies are warranted.     

Mood disorders in children and adolescents: an epidemiologic perspective.

Epidemiologic studies show that major depression is comparatively rare among children, but common among adolescents, with up to a 25% lifetime prevalence by the end of adolescence. Mania is much less common, with no more than a 2% lifetime prevalence by the end of adolescence. Developmental studies that include assessments of both hormonal changes and social changes through the pubertal transition are needed to investigate joint biological and environmental influences on the emergence of the gender difference in depression in puberty. Although subthreshold mood disorder symptoms are common, controversy exists about their clinical significance. This controversy is made more complex by methodologic uncertainties regarding inconsistent symptom reports obtained from parents, teachers, and children and by the pervasive existence of comorbidity. Retrospective reports about age of onset in adult studies suggest that at least 50% of youngsters with major depression and 90% of those with mania continue to have adult recurrences. These recurrences are mediated by adverse role transitions, such as truncated educational attainment and teenage childbearing, that typically occur before the time of initial treatment. Aggressive outreach and early treatment aimed at preventing the occurrence of adverse role effects might help decrease the persistence of child and adolescent mood disorders. Long-term follow-up studies are needed to resolve current uncertainties regarding nosology, methodology, and long-term treatment effects. Innovative epidemiologic research designs aimed at more quickly providing provisional information are also needed to advance understanding of long-term developmental processes.     

Mental illness and physical disorders

Close association between mental disorders, e.g. depressive or anxiety disorders, and numerous physical diseases has been consistently reported in clinical studies of patients with specific medical disorders, as well as among persons undergoing treatment for mental disorders. Accurate classification of this comorbidity has major implications for diagnosis, treatment, and course of both the psychological disorders and concomitant somatic diseases. The article summarises studies and reviews of comorbidity of mental disorders and selected somatic conditions (oncological, cardiovascular, endocrinological, and musculo-skeletal disorders). Methodological issues, risk factors, possible mechanisms of comorbidity, and implications of these associations for diagnosis, treatment, and planning of future studies are described.     

Mental disorders and suicide prevention

Abstract In the research phase of the National Suicide Prevention Project, all suicides ( n = 1397) in Finland between March 1987 and April 1988 were examined retrospectively using the psychological autopsy method. Careful retrospective diagnostic evaluation of the victims according to DSM-III-R criteria was done by weighing and integrating all available information. A series of studies addressing the mental disorders among suicide victims, the treatment received before death and the life events is now reviewed.
Among a random sample of suicide victims from the nationwide suicide population, at least one psychiatric diagnosis was made for 93% of the victims. The most prevalent disorders were depressive syndromes (66%) and alcohol dependence/abuse (43%). The prevalence of major depression was higher among women than among men. Major depression as the principal diagnosis was more common among the elderly suicides. Among adolescent victims, depressive syndromes were also the most prevalent disorders. Adjustment disorders were common (25%) among male adolescent suicides. The majority of suicide victims of all ages suffered from comorbid mental disorders.
Among suicide victims who had had contact with a health carer before death, inadequacy of treatment for mental disorders seems to have been common. Of the major depressive victims only 3% were found to have received adequate psychopharmacological treatment, and only 7% received weekly psychotherapy by a trained therapist.
The analysis of the massive database collected in the research phase of the National Suicide Prevention Project in Finland is still ongoing, and the implications of the findings for suicide prevention will be refined during the research process. The necessity to improve recognition and treatment for comorbid depressive disorders in all age groups seems evident already.     

Insomnia and heart disease: a review of epidemiologic studies

Since the discovery and successful treatment of sleep apnea, researchers seem to believe that the association between sleep disturbance and coronary heart disease (CHD) has been explained. To determine whether subjective nighttime sleep complaints (trouble sleeping, trouble falling asleep, trouble staying asleep), exclusive of apnea, predicted myocardial infarction and other coronary events, a MEDLINE search was conducted for articles published between January 1976 through August 1997. Ten studies with an explicit measure of association between an insomniac complaint and CHD were identified. Reported risk ratios for various sleep complaints and CHD events ranged from 1.0 for waking too early and CHD death in an elderly North Carolina community to 8.0 for the highest versus lowest quintile of a sleep scale in Finnish men. Higher quality studies showed risk ratios of 1.47-3.90 between trouble falling asleep and coronary events after adjusting for age and various coronary risk factors (combined effect=1.7, p<0.0001). While alternative explanations such as medication use still need to be ruled out, we theorize that a subjective insomniac complaint either may be part of a larger syndrome that includes poor health and depression, or it may be related to continual stressors, reduced slow-wave sleep, and autonomic dysfunction, which increase the risk of heart problems.     

Mental retardation and psychiatric disorders

Estimates of the prevalence of comorbidity of psychiatric disorders and mental retardation in community and clinical populations range from 14.3 to 67.3 percent. A wide variety of disorders have been reported in this population, including schizophrenia, depression, and, commonly, conduct disorder. The incidence of specific disorders appears to be related to the level of retardation and the concomitant presence of seizure disorder. Accurate assessment of psychiatric disorders in this population is difficult because mentally retarded patients have poor communication skills and because most diagnostic instruments were developed for persons of normal intellectual functioning. Treatment includes educational, behavioral, and pharmacological interventions, but guidelines for safe use of psychotherapeutic drugs are needed.     

Mental disorders and the incidence of migraine headaches in a community sample: results from the Baltimore Epidemiologic Catchment area follow-up study

BACKGROUND: The cross-sectional relation between migraine headaches and affective disorders has been demonstrated in studies of clinical and community populations. Few studies have investigated the prospective relation between psychiatric disorders and migraine headaches. METHODS: A prospective follow-up of the Baltimore, Md, cohort of the Epidemiologic Catchment Area Study assessed psychopathologic features in 1981 and again between 1993 and 1996. Interviews included a history of headaches at baseline and self-reported assessment of migraine headaches at follow-up. Risk estimates for incident migraine headaches by 1981 demographic variables and psychopathologic features were calculated. The cross-sectional association between prevalent migraine and lifetime psychiatric diagnoses was estimated. RESULTS: In the at-risk population of 1343, there were 118 incident cases of migraine headaches. The age- and sex-specific incident rates of migraine headaches followed the expected patterns, with younger age and female sex identified as risk factors. In cross-sectional analyses, major depression (odds ratio, 3.14; 95% confidence interval, 2.03-4. 84) and panic disorder (odds ratio, 5.09; 95% confidence interval, 2. 65-9.79) had the strongest associations, and alcohol and other substance abuse were not associated. In logistic regression models including age, sex, and psychiatric illness in 1981, only phobia was predictive of incident migraines (odds ratio, 1.70; 95% confidence interval, 1.11-2.58). Affective disorders were not predictive of incident migraine headaches. Including a history of tricyclic antidepressant use did not change the results. CONCLUSIONS: There is a strong cross-sectional relation between affective disorders and migraine headaches in this cohort. However, there is no association between antecedent affective disorders and incident migraine headaches in this population-based prospective study.