Current Medical Diagnosis & Treatment in Psychiatry

Conclusion: Epidemiology, Etiology, & Public Health

Epidemiology places psychiatric disorders in a broad context, which is not always apparent with individual patients. This comprehensiveness is the basis of the biopsychosocial model. Goldberg suggests a version of this model that considers three kinds of factors: those that promote vulnerability (or indeed resilience), those that “release” symptoms at a particular time, and those that determine how long a particular disorder will last. Koopman adds that there is now a shift to studying complex systems that create patterns of disease. Such studies are conducted by the comprehensive monitoring of individuals as individuals and when they interact with others and their environment.

Research by Kendler and colleagues, investigating the risk factors for depression among twins, is among the first of an increasing number of epidemiologic studies based on an integrated biopsychosocial approach. Henderson extends this approach along the causal continuum in a slightly different way, noting that “the concept of populations having different frequency distributions of morbidity, not just different prevalence rates for clinical cases, carries with it the implication that some factor or factors are pushing up the over-all distribution in some groups, but not in others.” He suggests that there may be some instrumental “force” in the environment that promotes disease. According to Susser and Susser, epidemiology historically offered the paradigm of the “black box,” in which exposure was related directly to outcome, without much interest (and thus investigation) into contributing factors or pathogenesis. Moving toward a more fundamental, comprehensive, and integrative goal, these authors would suggest the alternative paradigm of “eco-epidemiology” or the study of “causal pathways at the societal level and with pathogenesis and causality at the molecular level.” Among the lessons that may be drawn then are (1) that intervention by those in health policy and practice must involve a population-based strategy rather than a singular focus on afflicted or vulnerable individuals, (2) that the web of causation is multidimensional, and (3) that theory and practice are interdependent.

Korkeila and colleagues investigated factors predicting readmission to a psychiatric hospital previous admissions, long length of stays, and a diagnosis of psychosis or personality disorder. This study was particularly important because it reconfirmed earlier work that showed that, in this era of an emphasis on community care, there may be a small group of patients who, with the current treatment strategies available, may always need frequent or longer hospital treatment.

Another important lesson was carefully drawn by Vander Stoep and Link, who emphasized the importance of using valid data in the formation of health policy. They revisited Edward Jarvis’s landmark study on the prevalence of mental illness in Massachusetts in the early 19th century. In examining social class, ethnicity, and insanity, Jarvis, wrongly interpreting his data, concluded that immigrants born in Ireland had a higher prevalence of insanity in each social stratum than did those from other ethnic groups. Jarvis then formulated elaborate theories to explain his findings, and his work had a major impact on the formation and direction of health policy of that day. A later reanalysis of the data showed that, to the contrary, the prevalence of mental illness was much lower in the foreign born than in those persons born in the United States.

Public health prevention and treatment strategies drawn from any research must be carefully and critically constructed. This will not be easy. Intervention with individuals and even populations of individuals may be both more difficult and less effective when the real “. . . target is a social entity with its own laws and dynamics.” To begin to address these issues of profound complexity and increasing topical relevance, many authors have strongly supported the reintegration of population-driven epidemiology into public health. Adding support and some urgency to this drive has been the advent of managed care, which has created information needs that only more sophisticated epidemiologic investigations can address. Questions on specific treatments for specific patient populations in specific settings; the effectiveness of various forms of health care, including management and finance strategies; and the relentless quest for ways to improve quality while simultaneously attending to related costs will all require methodologically sound investigations.

The Biopsychosocial Model & the Web of Causation

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Morris JN: Uses of Epidemiology. Williams & Wilkins, 1964.

Historical Perspective

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Bassuk EL et al: Prevalence of mental health and substance use disorders among homeless and low-income housed mothers. Am J Psychiatry 1998;155:1561. 
Blazer DG, Kessler RC, Swartz M: Epidemiology of recurrent major and minor depression with a seasonal pattern. The National Comorbidity Survey. Br J Psychiatry 1998;172:164.
Breslau N et al: Trauma and post traumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 1998;55:626. 
Kessler RC et al: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Study. Arch Gen Psychiatry 1994;51:8. 
Kessler RC et al: Lifetime panic-depression comorbidity in the National Comorbidity Survey. Arch Gen Psychiatry 1998;55:801.
Kessler RC et al: Prevalence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. J Affect Disord 1997;45:19.
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Spitzer R, Endicott J, Robins E: Research Diagnostic Criteria. Arch Gen Psychiatry 1978;35:773.
Strole L et al: Mental Health in the Metropolis: the Midtown Manhattan Study. McGraw-Hill, 1962.
Wittchen HU, Reed V, Kessler RC: The relationship of agoraphobia and panic in a community sample of adolescents and young adults. Arch Gen Psychiatry 1998; 55:1017. 

Mental Disorder, Physical Health, & Social Functioning

Gossop M et al: Substance use, health, and social problems of service users at 54 drug treatment agencies. Intake data from the National Treatment Outcome Research Study. Br J Psychiatry 1998;173:166.
Kelly C et al: Nithsdale Schizophrenia Surveys. 17: Fifteen year review. Br J Psychiatry 1998;172:513.
Makikyro T et al: Comorbidity of hospital-related psychiatric and physical disorders with special reference to schizophrenia: a 28 year follow-up of the 1966 Northern Finland General Population Birth Cohort. Public Health 1998;112:221.
Spitzer RL et al: Health-related quality of life in primary care patients with mental disorders. J Am Med Assoc 1995;274:1511.
Wells KB et al: The functioning and well-being of depressed patients. J Am Med Assoc 1989;262:914.

Conclusion: Epidemiology, Etiology, & Public Health

Goldberg D: A biosocial model for common mental disorders. Psychiatr Scand 1994;90:66.
Henderson AS: The present state of psychiatric epidemiology. Aust N Zeal J Psychiatry 1996;30:9.
Kendler KS et al: The prediction of major depression in women: towards an integrated etiologic model. Am J Psychiatry 1993;150:1139.  [PMID: 8328557]
Koopman J: Comment: emerging objectives and methods in epidemiology. Am J Public Health 1996;86:630.
Korkeila JA et al: Frequently hospitalized psychiatric patients: a study of predictive factors. Soc Psychiatry Psychiatr Epidemiol 1998;33:528.
Susser M, Susser F: Choosing a future for epidemiology. I. Eras and paradigms. Am J Public Health 1996;86:668.
Susser M, Susser F. Choosing a future for epidemiology. II. From black box to Chinese boxes and eco-epidemiology. Am J Public Health 1996;86:674.
Vander Stoep A, Link B: Social class, ethnicity and mental illness: the importance of being more than earnest. Am J Public Health 1998;88:1396.

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