Reducing Risks for Mental Disorders Frontiers for Preventive Intervention Research (1994) / Chapter Skim
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5 DESCRIPTION OF FIVE ILLUSTRATIVE MENTAL DISORDERS
5 DESCRIPTION OF FIVE ILLUSTRATIVE MENTAL DISORDERS
Pages 73-126
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From page 73... ...
In this chapter, the discussion of this knowledge is organized around five major mental disorders: conduct disorder, depressive disorders, alcohol abuse and dependence, schizophrenia, and Alzheimer's disease. In Chapter 6, the same disorders are examined for risk and protective factors that may eventually offer targets for intervention.
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From page 74... ...
. Data on age of onset during the adult years are taken from the prospective one-year follow-up ECA study, designed, in part, to estimate the incidence of specific mental disorders (Eaton, Regier, Locke, and Taube, 1981~.
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From page 75... ...
and is the basis for the definitions used throughout the rest of this report. However, operational definitions of specific mental disorders as given in DSM-III, when major diagnostic criteria changes were made, were used in the ECA study and are used for determining onset in the analyses below.
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From page 76... ...
The denominator for the attack rate is different from that for first incidence in that it may include persons who have had an episode of disorder earlier in their lives, but who do not currently meet the criteria for disorder; that is, it includes remitted cases. For mental disorders and for many physical disorders, the force of morbidity may be expressed by the rate at which individuals cross a variety of thresholds, including onset, in the process of development of a disorder.
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From page 77... ...
At the present state of our knowledge of the onset of mental disorders, there are few or no signs and symptoms that predict onset with certainty. Nevertheless, precursor signs and symptoms can be helpful in identifying groups at much higher risk for onset than the general population.
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From page 78... ...
For example, Figure 5.1 presents data on the incidence of DIS/DSM-III alcohol abuse or dependence among males at four sites of the ECA study (Eaton, Kramer, Anthony, Dryman, Shapiro, and Locke, 1989~. The figure shows an upturn in incidence in the later years of life.
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From page 79... ...
Data on the cost of modifying risk factors could also be incorporated in such calculations in designing a preventive intervention research program.
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From page 80... ...
In the text and figures below, data are presented regarding prevalence and prodromal periods in individuals who have experienced the onset of disorder.* During these prodromal periods, precursor signs and symptoms were present, and ideally these individuals could have been identified as being at high risk.
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From page 81... ...
B If 18 or older, does not meet criteria for Antisocial Personality Disorder.
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From page 82... ...
FIGURE 5.3 Age of onset of DIS/DSM-III Antisocial Personality Disorder. Population estimates are from 46 new cases (with 20th and 50th percentiles marked)
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From page 83... ...
an exclusive substance abuse pathway with onset in middle to late adolescence. There is a marked difference between the early-onset form of conduct disorder in a temperamentally difficult child who has accompanying attention deficit disorder and learning difficulties, and the late-onset form appearing in an adolescent who has previously functioned weD but who in response to environmental stress suddenly changes patterns of behavior.
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From page 84... ...
Conduct disorder not only predicts later mental disorders in adulthood but also has wide-ranging poor prognosis in adult life with higher rates of school failure, joblessness, and poor interpersonal skills, especially marital difficulties (Robins, 1970~. As adults, males have more externalizing disorders (such as antisocial personality disorders and alcohol and drug abuse)
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From page 85... ...
: (a) significant unemployment for six months or more within five years when expected to work and work was available (b)
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From page 86... ...
There are two types of mood disorders, the first of which, bipolar disorder, is not the focus of this report. The second is depressive disorder, which has two subtypes: major depressive disorder (single episode or recurrent)
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From page 87... ...
Depressive disorders have a high rate of co-morbidity; that is, they are associated with a number of other serious mental disorders, in particular substance abuse, anxiety disorders, and schizophrenia. They frequently accompany severe life stress such as divorce, job loss, or bereavement.
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From page 88... ...
Major Depressive Episode codes: Digit code numbers and criteria for severity of current state of Bipolar Disorder, Depressed, or Major Depression: 1-Mild: Few, if any, symptoms in excess of those required to make the diagnosis, and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.
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From page 89... ...
Major Depression 296.2x Major Depression, Single Episode For fifth digit, use the Major Depressive Episode codes (p.
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From page 90... ...
of the disturbance. Note: There may have been a previous Major Depressive Episode, provided there was a full remission (no significant signs or symptoms for six months)
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From page 91... ...
Thus clinical depression is unusual among the major mental illnesses in having good treatments available. It is therefore particularly important for clinicians to recognize the signs and symptoms of depressive disorders as well as note the existence of risk factors in susceptible patients' lives, because much suffering can be eliminated by the effective treatments available.
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From page 92... ...
Estimates of the rate of depressive disorders also vary depending on the instruments and diagnostic systems employed and on the samples studied. A useful technique is a structured interview scored according to standard diagnostic criteria, such as the DIS/DSM-III system used in the ECA study.
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From page 93... ...
Recent evidence has shown that for the United States and several other nations, the more recent birth cohorts are at increased risk for major depression (CrossNational Collaborative Group, 1992~. In the ECA study, which included only persons age 18 and older and did not assess childhood or adolescent depression, major depressive disorder was shown to have its onset in young adulthood (Figure 5.4~.
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From page 94... ...
: (8) characteristic withdrawal symptoms (see specific withdrawal syndromes under Psychoactive Substance-induced Organic Mental Disorders)
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From page 95... ...
Moderate: Symptoms or functional impairment between "mild" and "severe." Severe: Many symptoms in excess of those required to make the diagnosis, and the symptoms markedly interfere with occupational functioning or with usual social activates or relationships with others.a In Partial Remission: During the past six months, either no use of the substance and some symptoms of dependence. In Full Remission: During the past six months, either no use of the substance, or use of the substance and no symptoms of dependence.
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From page 96... ...
Data from the ECA study indicate that alcoholics are 21 times more likely than nonalcoholics to also have a diagnosis of antisocial personality disorder, 6.2 times more likely to have mania, 4 times more likely to have schizophrenia, and 1.7 times more likely to have a diagnosis of major depressive disorder. Other studies indicate that approximately 10
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From page 97... ...
People who are homeless have higher levels of alcohol abuse and dependence than the general population, with prevalence estimates ranging from 20 to 45 percent and estimates of lifetime prevalence as high as 63 percent (DHHS, 1990~. Unlike the pattern in the general population, the incidence of problem drinking among the homeless appears to be highest in the middle years, and is substantially lower among both the young and the old.
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From page 98... ...
Alcoholism death rates were twice as high for men as for women and, among age groups, ranged as high as 96.8 deaths per 100,000 for men between the ages of 45 and 54. There have been significant efforts focused on treatment strategies, particularly to ameliorate alcohol abuse and dependence.
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From page 99... ...
Alcohol abuse and dependence is present in about 3 percent of the adult population at any given time (point prevalence) , and occurs in about 14 percent of the population over the life course (lifetime prevalence)
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From page 100... ...
C Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out, i.e., if a Major Depressive or Manic Syndrome has ever been present during an active phase of the disturbance, the total duration of all episodes of a mood syndrome has been brief relative to the total duration of the active and residual phases of the disturbance.
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From page 101... ...
The time from the beginning of the disturbance, when the person first began to show signs of the disturbance (including prodromal, active, and residual phases) more or less continuously, is less than two years, but at least six months.
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From page 102... ...
Schizophrenia is a major mental illness that drastically alters the life course of many individuals (Harding, 1988; Harding, Brooks, Ashikaga, Strauss, and Breier, 1987) , causes enormous family suffering, and results in an immense economic burden to families and to the nation.
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From page 103... ...
Substance abuse combined with schizophrenia can undermine the treatment of both disorders. The widely reported data from the ECA study deserve special comment because this study reports on coexistence of symptoms, without invoking the hierarchy implicit in the DSM and ICD classification systems.
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From page 104... ...
But of course, not everyone's risk is equal because some have a strong family history of schizophrenia and other risk factors that can multiply the risk for onset of the disorder by tenfold or greater. Schizophrenia usually appears after puberty, with the peak age of onset at about 20 to 24 years for males and 25 to 29 years for females (Lewine, 1988~.
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From page 105... ...
, although one survey, the East Boston study, found a higher proportion; that is, 91 percent of those with moderate or severe dementia had AD (Evans, Funkenstein, Albert, Scherr, Cook, Chown et al., 1989~. The onset of AD is typically heralded by a deterioration in recent memory with relative preservation of reference, or long-term, memory (see Figure 5.6 and Table 5.7 for DSM-III-R diagnostic criteria)
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From page 106... ...
The costs per patient in a nursing home were remarkably similar to the costs per patient in the community, approximately $47,000 in 1990, but the fraction of costs due to formal services was predictably much higher for those in nursing homes. Three quarters of the costs among community-dwelling patients were for informal care.
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From page 107... ...
judged to be etiologically related to the disturbance (2) in the absence of such evidence, an etiologic organic factor can be presumed if the disturbance cannot be accounted for by any nonorganic mental disorder, e.g., Major Depression accounting for cognitive impairment Critena for severity of Dementia: Mild: Although work or social activities are significantly impaired, the capacity for independent living remains, with adequate personal hygiene and relatively intact judgment.
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From page 108... ...
The costs of respite care, day care, and informal care through relatives and friends are also significant and were estimated at $27 billion in 1983 (Hu, Huang, and Cartwright, 1986; Huang and Hu, 1986~. Here again, the more recent study by Rice, although it did not project a national cost figure, suggests that this estimate is probably low by a factor of two or more (Rice et al., 1991~.
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From page 109... ...
Treatment of behavioral and emotional symptoms is nonetheless important, as is treatment of any other medical condition the patient may have, to keep the overall level of disability to a minimum (Katzman and Jackson, 1991~. Because the overall level of disability, including the agitation, depressive symptoms, behavioral problems, and psychotic symptoms often associated with AD, contributes to family burden and family burden is the strongest predictor of transfer to a nursing home or other formal care antidepressants, antipsychotics, antianxiety agents, and other medications to diminish psychosis and behavioral problems are the most commonly used drugs with Alzheimer's patients.
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From page 110... ...
One hope is that as we understand the nature of the final common pathway leading to cell death and discover a marker that will identify individuals at high risk for developing AD, ways can be found to inhibit a crucial step such as amyloid formation and prevent the emergence the illness. This might lead to indicated preventive interventions for high-risk individuals.
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From page 111... ...
GAPS IN OUR KNOWLEDGE Age-Specilic Prevalence In Children The most important limitation of the ECA data presented above for the illustrative mental disorders is the truncation at age 18. Although the bias of censorship is avoided, there may be significant numbers of
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From page 112... ...
Prevalence data on major depressive disorder from published sources are presented in Table 5.8 to give the reader some indication of how early in life prevention efforts might have to start. The standard assessment of depression in children and adolescents has involved the application of diagnostic interview schedules scored according to criteria for adults, with no modification for children.
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From page 113... ...
NOTE: Studies selected had the following characteristics: they were published In English; they used DSM-III criteria for major depressive disorder; and the general population sample was larger than 100. prospective design in which lifetime prevalence data are gathered at the baseline, so that an at-risk population can be defined.
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From page 114... ...
The range of prevalence figures for major depressive disorder in children, presented in Table 5.8, is quite broad, and there is no consensus in these data on the age at which major depressive disorder can first manifest itself. Even though it is possible to operationally define major depression using the DSM-III criteria, it is not clear that the disorder is the same in children below the age of puberty, because unportant features of the disorder, such as the vender ratio differ in orenuFr~rta1 ver~ no~ln~'h~rt~1 cl~nr~c~imn It in -- -A ~ r-~r~ ~~~~~ r -- -r~ ^ -- r-~vV^~ ^~^.
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From page 115... ...
The precursor signs and symptoms that are most predictive of disorder should be identified in epidemiological surveys, because they might suggest particular indicated preventions. For example, using the same base of data as in Figure 5.4, it is estimated that persons at risk for the first incidence of major depressive disorder, who have in the prior year experienced two weeks or more of sad mood, are 5.5 times more likely to have a first onset of major depressive disorder during the next year as those who have not had this precursor symptom.
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From page 116... ...
For example, the relative risk for first onset of major depressive disorder for those with a panic attack is 3.4, as estimated in a time-dependent proportional hazards model (Andrade, Chilcoat, and Eaton, 1993~. The prevalence of panic attack is about 10 percent (Eaton, Dryman, and Weissman, 1991~.
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From page 117... ...
· Many mental disorders, including conduct disorder, depressive disorders, alcohol abuse and dependence, schizophrenia, and Alzheimer's disease, are thought to be a cluster of several different illnesses or to have subtypes. Identification of these groups and clearer delineation of their etiologies may clarify which individuals may be most amenable to preventive interventions.
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From page 118... ...
· Prospective epidemiological studies could identify precursor signs and symptoms that are below the criterion level for the diagnosis of a mental disorder, as well as the age of the first occurrence of these precursor symptoms. Thus it may be possible to identify individuals at heightened risk for developing the full-blown disorder, who would then become candidates for indicated preventive interventions.
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From page 119... ...
(1982) Screening for mental disorders among prunary care patients.
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From page 120... ...
(1989) The incidence of specific DIS/DSM-III mental disorders: Data from the NIMH Epidemiological Catchment Area program.
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(1991) Alcohol abuse and dependence.
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From page 122... ...
(1986) The persistent risk of chronicity in recurrent episodes of nonbipolar major depressive disorder: A prospective follow-up.
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From page 123... ...
(1985) Birth-cohort trends in rates of major depressive disorder among relatives of patients with affective disorder.
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From page 124... ...
(1990) Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area study.
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From page 125... ...
(1989) A longitudinal analysis of selected risk factors for childhood psychopathology.
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From page 126... ...
American Journal of Psychiatry; 132: 650 651. Wyatt, R
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