Age-related psychiatric comorbidities and level of functioning in alcoholic veterans seeking outpatient treatment.

The relationship of age and of level of adaptive functioning to comorbidity of mental disorders among alcoholics was studied in a survey of all alcoholics seeking outpatient mental health treatment in the Veterans Affairs mental health care system during a one-month period in 1986 (N = 22,463). More than half of the alcoholic outpatients had one or more comorbid psychiatric diagnoses. Rates for comorbid substance abuse disorders, posttraumatic stress disorder, schizophrenia, and personality disorders peaked in younger alcoholics and then decreased with age. Age-related increases were observed for major depression, anxiety disorders, and organic brain syndrome or dementia. DSM-III axis V ratings of poor to grossly impaired functioning were consistent across age groups. More than half of alcoholics with a comorbid psychiatric disorder were rated as severely impaired, compared with less than a third of those with no comorbid mental disorder.     

Use of mental health care and substance abuse treatment among adults with co-occurring disorders

OBJECTIVES: This study investigated patterns of use of mental health care and substance abuse treatment for a nationally representative sample of adults with co-occurring mental health problems and a substance use disorder and compared these patterns with those of persons with either a mental health problem or a substance use disorder. METHODS: Data were from the 2001 and 2002 National Surveys on Drug Use and Health. The study examined rates of substance use disorders and mental health problems among adults aged 18 years and older, rates of substance use disorders among adults with mental health problems, and rates of mental health problems among adults with substance use disorders. Next, rates of substance abuse treatment and mental health care use were calculated among five groups that were formed on the basis of the presence of a substance use disorder, mental health problems, or both in the past year. RESULTS: A total of 2,851 respondents had a substance use disorder only, 1,633 had a substance use disorder with one or more mental health symptoms and without serious mental illness, 1,872 had a substance use disorder with serious mental illness, 13,759 had one or more mental health symptoms only, and 7,530 had a serious mental illness only. A substantial proportion of adults with comorbid mental health problems and a substance use disorder did not receive any treatment (46 percent of those with serious mental illness and 65 percent of those with one or more mental health symptoms). Co-occurring substance use disorder was not associated with increased use of mental health care. The likelihood of receiving any substance abuse treatment increased with the presence and severity of mental health problems. Across all five groups, use of mental health care was more common than use of substance abuse treatment. Less than one-third of patients with comorbid mental health problems and a substance use disorder who used mental health care also received substance abuse treatment. CONCLUSIONS: The large proportion of untreated individuals with mental and substance use disorders reinforces existing concerns about barriers to beneficial treatment. Low rates of use of substance abuse treatment among patients who have comorbid mental health problems and a substance use disorder and use mental health care suggest that recommendations that substance use disorders be treated before, or concurrently with, mental disorders have not been widely adopted.     

Long-term use of VA mental health services by older patients with substance use disorders

OBJECTIVE: The authors studied long-term patterns and predictors of use of mental health services by older surviving patients with substance use disorders in the Veterans Affairs (VA) health care system. METHODS: In this prospective longitudinal study, patient treatment records were used to determine long-term (ten-year) patterns and predictors of use of VA mental health services in a nationwide cohort of 10,678 surviving patients with a substance use disorder who were 55 years of age or older. The patients were categorized into three groups based on diagnosis during the index episode: patients with alcohol or drug abuse or dependence, patients with alcohol or drug psychosis, and patients with both a substance use and a psychiatric disorder. Most of the patients had alcohol use disorders. RESULTS: Over the ten-year period, successively fewer patients obtained outpatient and inpatient mental health care. Among patients who did obtain such care, the intensity of service use increased. Medical care did not substitute for mental health treatment. Younger age, being unmarried, and having a more severe disorder were associated with a greater likelihood of mental health service use over the ten-year period. Patients with a dual diagnosis were significantly more likely to obtain outpatient mental health care. Treatment on a residential care unit and longer initial hospital stay were associated with a lower rate of mental health readmissions. CONCLUSIONS: Of the substantial number of patients with substance use disorders who survive into old age, those with more long-standing substance use problems and with dual diagnoses have the greatest need for long-term mental health treatment.     

Use of mental health services in a developing country

BACKGROUND: Evidence from developed industrialized countries suggests poor uptake of mental health services. No data exist in developing resource-constrained countries about met and unmet need for mental health service in the community. METHOD: A four-stage stratified probability sample of households was studied in the Yoruba-speaking part of Nigeria (population, approximately 25 million people or 22% of the Nigerian national population). Face-to-face interviews were conducted with persons 18 years old and above (n=4,984) using the World Mental Health version of the Composite International Diagnostic Interview. We determined the proportions of respondents with 12-month Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety, mood, or substance use disorder who had received any mental health treatment and the correlates of treatment receipt. RESULTS: Only 9.0% of those with any 12-month DSM-IV disorder had received treatment. While 11% of those with a mood disorder had received some treatment, none of those with substance use disorders had used a mental health service. Most treatments were received from general medical settings, with only about 1% of those with DSM-IV disorders receiving specialist mental health service. Surprisingly, complementary or alternative health providers were also consulted by only about 4% of those with mental disorders, although a much higher proportion of 57% of those with no DSM-IV disorders but who nevertheless received mental health treatment did so from such providers. Irrespective of the disorders or the sector where treatment was received, virtually no treatment was adjudged minimally adequate. CONCLUSION: There is a striking level of unmet need for mental health service in the community in this developing country setting. While inadequacy of the formal public health sector may be partly responsible for this observation, there is the likelihood that receipt of treatment for mental health problems may also be hampered by the public's poor knowledge of the nature of the disorders and by stigma.     

Predicting violence using structured professional judgment in patients with different mental and behavioral disorders

We examined whether a leading instrument for the prediction of future violence in those with a mental disorder. The Historical, Clinical, Risk Management-20 (HCR-20) was equally effective across a wide range of mental health diagnoses. Records at the time of discharge from secure psychiatric services were used to score the HCR-20 risk assessment scheme. Patients were stratified according to whether they had received a particular mental health diagnosis. Reconvictions within 2 years of discharge were obtained from official sources and classified as to whether the offence was violent or not. Those with a diagnosis of either personality disorder or substance abuse were most likely to be reconvicted, whilst those with either a diagnosis of schizophrenia or mental retardation were the least likely. The HCR-20 was a statistically significant predictor of future violence in all groups; however, it returned only weak effects for the personality disordered group, but strong effects for those in the schizophrenia or mental retardation group. The HCR-20 risk assessment scheme is effective across a wide range of diagnoses. Nevertheless, the prediction of future events appears more difficult in those disorders characterized by impulsive behaviors and further research efforts are needed to understand how such prediction can be improved.     

Predictors of mental disorders and their outcome in a community based cohort

BACKGROUND: Only a limited number of population-based studies have been able to prospectively follow the mental health of their participants. We aimed to describe diagnostic changes in a population based cohort over a two year period, and to explore associations between a range of individual factors and recovery from, or onset of, disorders. METHODS: Two year, face-to-face follow-up of a community-based cohort drawn from random telephone screening using the CIDI as diagnostic instrument. Unlike most similar research we did not exclude individuals with prior history from analysis. RESULTS: 1407 participants were administered face-to-face interviews and 968 were re-interviewed. In multivariate analysis, recent adverse life events, poor physical health, and high neuroticism score were significant predictors of developing a mental disorder in participants who were disorder free at baseline. Higher baseline levels of physical activity were protective of new disorders in univariate analysis. Most participants with a baseline disorder and not lost to follow-up were disorder-free two years later. For participants with a disorder at both interviews, there was marked lability in diagnoses, with only a small minority having an unchanged diagnosis at both baseline and follow-up. Factors predicting a poor outcome in participants with a disorder included the number of baseline diagnoses, high neuroticism score and adverse life events. CONCLUSIONS: These findings suggest that the diagnosis of common mental disorders is complex and that diagnoses are relatively unstable. The factors that influence the emergence of mental disorders in individuals who may, or may not, have had a disorder in the past, are similar to those associated with the development of new disorders in subjects without a lifetime history.     

Japanese midwives as psychiatric diagnosticians: application of criteria of DSM-IV mood and anxiety disorders to case vignettes

It is believed in Japan that only psychiatrists are capable of providing reliable psychiatric diagnosis. However, more awareness of mental health issues related to perinatal care means that midwives are now required to have psychiatric diagnostic skills. The purpose of the present paper was to examine how well Japanese midwives agreed with a psychiatrist on diagnoses of different psychiatric disorders. Vignettes of 29 cases including DSM-IV mood disorders (major depressive disorder and bipolar disorder) and anxiety disorders (generalized anxiety disorder, panic disorder, phobic disorders, and obsessive-compulsive disorder) were distributed to 12 Japanese midwives. They decided the DSM-IV diagnoses independently and compared them with those made by an expert. The kappa coefficients of the diagnoses with a base rate of 0.1 or more were moderate to almost perfect (0.64-0.83). The accuracy of symptom assessment was also satisfactory. Appropriately trained Japanese midwives can use the diagnostic criteria for psychiatric disorders reliably. It is therefore feasible to dispatch midwives who are trained in psychiatric diagnosis to antenatal clinics.     

Beyond treatment effects: comorbid psychopathologies and long-term outcomes among substance-abusing delinquents

Secondary analyses of a randomized clinical trial controlled for treatment condition effects and examined the impact of comorbid psychopathologies on the mental health, physical health, and criminal behavior of 80 substance abusing delinquents approximately 5 years later in emerging adulthood. Overall, emerging adults with a comorbid disorder during adolescence scored higher on psychopathology, criminal behavior, and health problems. Participants with both internalizing and externalizing disorders exhibited more negative outcomes than those with a comorbid externalizing disorder. For the entire sample, more internalizing diagnoses forecasted higher internalizing and aggression scores, more criminality, and poorer physical health. More externalizing disorders predicted higher internalizing, delinquency, and criminality scores, but was unrelated to physical health. More internalizing diagnoses for females but not males predicted greater criminality, and especially more aggressive crimes in emerging adulthood.     

Mental Health Visits: Examining Socio-demographic and Diagnosis Trends in the Emergency Department by the Pediatric Population

The emergency department (ED) is increasingly being used for mental health visits by children and adolescents. It is estimated that 21–23% of youth have a diagnosable psychiatric or substance use disorder. Using data from the ED of a tertiary medical center, we examined trends in mental health diagnoses over a 5-year period. In school age children the most prevalent diagnoses were anxiety disorders (28.4%); disorders first usually diagnosed in infancy, childhood, or adolescence (26.5%), and mood disorders (18.6%). High school students were more likely to visit the ED for anxiety disorders (30%). Females (34.5%) presented more for anxiety disorders compared to males (22.7%). Mental health visits and diagnoses were higher during school months (September–May) and lower in the summer months (June–August). The diagnosis trends identified in this study have clinical implications that can contribute to evidence-based restructuring of mental health resources and screenings.     

Use of health services for major depressive and anxiety disorders in Finland

Factors associated with people suffering from major depressive disorder (MDD) or anxiety disorders seeking or receiving treatment are not well known. In the Health 2000 Study, a representative sample (n=6005) of Finland's general adult (> or =30 years) population was interviewed with the M-CIDI for mental disorders and health service use for mental problems during the last 12 months. Predictors for service use among those with DSM-IV MDD (n=298) or anxiety disorders (n=242) were assessed. Of subjects with MDD, anxiety disorders, or both, 34%, 36%, and 59% used health services, respectively. Greater severity and perceived disability, psychiatric comorbidity, and living alone predicted health care use for MDD subjects, and greater perceived disability, psychiatric comorbidity, younger age, and parent's psychiatric problems for anxiety disorder subjects. The use of specialist-level mental health services was predicted by psychiatric comorbidity, but not characteristics of the disorders per se. Perceived disability and comorbidity are factors influencing the use of mental health services by both anxiety disorder and MDD subjects. However, still only approximately one-half of those suffering from even severe and comorbid disorders use health services for them.     

Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study

OBJECTIVE: The authors examined the self-reported presence and treatment of current depressive disorder, posttraumatic stress disorder (PTSD), and alcohol-related disorder in a group of outpatient veterans. METHOD: Data were obtained from the Veterans Health Study, a longitudinal investigation of male veterans' health. A representative sample of 2,160 outpatients (mean age = 62 years) was drawn from Boston-area U.S. Department of Veterans Affairs (VA) outpatient facilities. The participants completed screening measures for depression, PTSD, and alcohol-related disorder. Mental health treatment was assessed by interviews. RESULTS: The screening criteria for at least one current mental disorder were satisfied by 40% (N = 856) of the patients. Screening rates were 31% (N = 676) for depression, 20% (N = 426) for PTSD, and 12% (N = 264) for alcohol-related disorder. Patients who screened positively for current mental disorders were younger, less likely to be married or employed, and more likely to report traumatic exposure than were those without mental disorders. Of those who met the screening criteria for any of the targeted mental disorders, 68% (N = 579) reported receiving mental health treatment. Younger, Caucasian men and those who reported more traumatic exposure were more likely to report receiving mental health treatment than were others who screened positively for mental disorders. CONCLUSIONS: Screening rates of depression and PTSD and rates of mental health treatment were considerably higher among these VA outpatients than among similar patients in primary care in the private sector. Although the VA is currently meeting the mental health care needs of its patients, future fiscal constraints could affect most adversely the treatment of non-Caucasian and older patients and those with a history of traumatic exposure.     

Depression and anxiety disorders in pediatric epilepsy

PURPOSE: This study examined affective disorders, anxiety disorders, and suicidality in children with epilepsy and their association with seizure-related, cognitive, linguistic, family history, social competence, and demographic variables. METHODS: A structured psychiatric interview, mood self-report scales, as well as cognitive and language testing were administered to 100 children with complex partial seizures (CPSs), 71 children with childhood absence epilepsy (CAE), and 93 normal children, aged 5 to 16 years. Parents provided behavioral information on each child through a structured psychiatric interview and behavior checklist. RESULTS: Significantly more patients had affective and anxiety disorder diagnoses (33%) as well as suicidal ideation (20%) than did the normal group, but none had made a suicide attempt. Anxiety disorder was the most frequent diagnosis among the patients with a diagnosis of affective or anxiety disorders, and combined affective/anxiety and disruptive disorder diagnoses, in those with suicidal ideation. Only 33% received some form of mental health service. Age, verbal IQ, school problems, and seizure type were related to the presence of a diagnosis of affective or anxiety disorder, and duration of illness, to suicidal ideation. CONCLUSIONS: These findings together with the high rate of unmet mental health underscore the importance of early detection and treatment of anxiety disorders and suicidal ideation children with CPSs and CAE.     

Mental disorders and the use of alternative medicine: results from a national survey

OBJECTIVE: The study examined the relationship between mental disorders and the use of complementary and alternative medicine. METHOD: Data from a national household telephone survey conducted in 1997-1998 (N=9,585) were used to examine the relationships between use of complementary and alternative medicine during the past 12 months and several demographic variables and indicators of mental disorders. Structured diagnostic screening interviews were used to establish diagnoses of probable mental disorders. RESULTS: Use of complementary and alternative medicine during the past 12 months was reported by 16.5% of the respondents. Of those respondents, 21.3% met diagnostic criteria for one or more mental disorders, compared to 12.8% of respondents who did not report use of alternative medicine. Individuals with panic disorder and major depression were significantly more likely to use alternative medicine than those without those disorders. Respondents with mental disorders who reported use of alternative medicine were as likely to use conventional mental health services as respondents with mental disorders who did not use alternative medicine. CONCLUSIONS: We found relatively high rates of use of complementary and alternative medicine among respondents who met criteria for common mental disorders. Practitioners of alternative medicine should look for these disorders in their patients, and conventional medical providers should ask their depressed and anxious patients about the use of alternative medicine. More research is needed to determine if individuals with mental disorders use alternative medicine because conventional medical care does not meet their health care needs.     

Prospective assessment of treatment use by patients with personality disorders

OBJECTIVE: This study examined the utilization of mental health treatments over a three-year period among patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders compared with patients with major depressive disorder and no personality disorder. METHODS: A prospective, longitudinal study design was used to measure treatment use for 633 individuals aged 18 to 45 years during a three-year period. RESULTS: Patients with borderline personality disorder were significantly more likely than those with major depressive disorder to use most types of treatment. Furthermore, all patients continued using high-intensity, low-duration treatments throughout the study period, whereas individual psychotherapy attendance declined significantly after one year. CONCLUSIONS: Although our data showed that patients with borderline personality disorder used more mental health services than those with major depressive disorder, many questions remain about the adequacy of the treatment received by all patients with personality disorders.     

Prevalence of psychiatric disorders in New Zealand prisons: a national study

OBJECTIVE: The paper describes the methodologies and results obtained on a large cohort of prison inmates in New Zealand who were screened for psychiatric disorder. METHOD: All women and remanded male inmates in New Zealand prisons, and a randomly selected cohort of 18% of sentenced male inmates were interviewed. Interviewers used the Composite International Diagnostic Interview - Automated to establish DSM-IV diagnoses, and the Personality Disorders Questionnaire to identify personality disorder. All prisons in New Zealand were visited. RESULTS: The results indicate markedly elevated prevalence rates for major mental disorder in the prison population when compared with community samples. This is especially the case for substance misuse, psychotic disorders, major depression, bipolar disorder, obsessive- compulsive disorder and posttraumatic stress disorder. Of particular concern is not only the increased prevalence rates for schizophrenia and related disorders but also the high level of comorbidity with substance misuse disorders demonstrated by this group. While 80.8% of inmates diagnosed with bipolar disorder were receiving psychiatric treatment in the prison, only 46.4% of depressed inmates and 37% of those suffering from psychosis were receiving treatment. Maori inmates were grossly overrepresented in the remand, female and male sentenced inmate population compared with the general population. CONCLUSIONS: A significant increase in provision of mental health services is required to cope with the high number of mentally ill inmates. The level of need demonstrated by this study requires a level of service provision that is quite beyond the capacity of current forensic psychiatry services, Department of Corrections Psychological Services or the prison nursing and medical officers. The elevated rates of common mental disorders argues for the use of improved psychiatric screening instruments, improved assessment and treatment capacities in the prison and an increased number of forensic psychiatric inpatient facilities to care for those psychotic inmates who are too unwell to be treated in the prison.     

Prevalence and severity of mental health-related disability and relationship to diagnosis.

OBJECTIVE: Psychiatric disability has been defined largely from measures that focus on serious mental illness. This practice may have led to substantial underestimation of the total impact of mental disorders on community health. In this study a generic measure of mental health-related disability was used to examine disabilities attributable to various common mental disorders. METHODS: Data were drawn from the Australian National Survey of Mental Health and Wellbeing, a household survey of 10,641 adults that assessed participants for 14 DSM-IV disorders with use of the Composite International Diagnostic Interview. Screening instruments were used to identify likely cases of ICD-10 personality disorder, neurasthenia (an undifferentiated somatoform disorder), and psychosis. Mental health disability was assessed with the Medical Outcomes Study 12-item Short Form (SF-12) mental health summary scale, which was administered to all participants. RESULTS: Disability was significantly greater among participants with a current psychiatric diagnosis, and disability varied by type of disorder. Diagnosis remained a strong predictor of disability after sociodemographic factors and physical illness were controlled for. Disorders found to be independently associated with disability were depression, panic disorder, agoraphobia, social phobia, generalized anxiety disorder, alcohol dependence, and drug dependence. CONCLUSIONS: Substantial proportions of persons with mental disorders that are not usually classified as major mental disorders reported moderate and severe disability. A generic measure of mental health-related disability was able to detect variations in disability among persons with different diagnoses. Although such a measure is not as sensitive as a disorder-specific measure developed for use in psychiatric populations, it can facilitate comparison of disability across common mental disorders.     

Alcoholics in acute medical settings have increased risk for other drug, mood, and personality disorders

OBJECTIVE: Brief medical management and alcohol pharmacotherapy are effective treatments for alcoholic participants enrolled in randomized controlled trials, and this suggests that alcoholism treatment may be delivered successfully in medical settings. However, medical patients may differ from clinical trial participants in ways that suggest a need for more intensive alcoholism treatment. To explore this possibility, this study evaluated the prevalence of mental health disorders in the U.S. population stratified by alcoholism and recent hospitalization or emergency room use. METHODS: Data from the National Epidemiological Survey on Alcohol and Related Conditions were analyzed. Subjects with information on alcohol use disorders, emergency room use, hospitalization, and several mental health diagnoses were included (n = 41,961). Methods appropriate for complex survey data were used to determine the relative risk for mental health diagnoses as a function of a current alcohol use disorder and receipt of acute medical care (hospitalization or emergency room visits) within the past year. RESULTS: Results showed that, relative to alcoholic adults who did not have an emergency room visit or hospitalization, alcoholic adults with use of these services had an increased prevalence of personality disorders, depression, and other drug use disorders. CONCLUSION: Research is needed to evaluate if these and other differences will lead to poorer treatment outcomes for this group relative to the more selected populations included in medical management efficacy trials.     

Locus of mental health treatment in an integrated service system

OBJECTIVE: Epidemiological surveys suggest that half of mental disorders in the community are treated in general medical settings. This paper examines delivery of mental health services in psychiatric, primary care, and specialty medical clinics in the Department of Veterans Affairs (VA), the largest integrated public-sector health care system in the United States. METHODS: The study examined all outpatient visits to VA clinics between October 1996 and March 1998, a time during which VA policy promoted a shift to a primary care model. For veterans with a primary diagnosis of a mental or substance use disorder who made any visit to a VA psychiatric, primary care, or specialty medical clinic, we compared the locus of care and case mix as well as changes in treatment patterns during the study period. RESULTS: Of 437,035 veterans treated for a mental disorder during the final six months of the study period, only 7 percent were seen for their mental disorders exclusively in primary care and specialty medical clinics. Compared with veterans with mental disorders treated in specialty mental health clinics, those treated in medical clinics had less serious psychiatric diagnoses and made fewer visits. While there was a substantial shift of care from specialty to primary care during the study period, no comparable change in the distribution of care between medical and mental health settings was found. CONCLUSIONS: Treatment patterns in VA clinics differ markedly from those in the private sector. Research is needed to determine whether and how staffing models developed in HMOs and community samples should be extended to these public-sector settings.