The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study

OBJECTIVE

To describe the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 and to provide data on its performance characteristics in the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

METHOD

Data were collected on the DISC-2.3 at four sites on 1,285 randomly selected children, aged 9 through 17 years, and their parents. Two hundred forty-seven of these child-parent pairs were reassessed on the DISC-2.3 by a clinician interviewer, 1 to 3 weeks later.

RESULTS

Administration time was approximately 1 hour and the interview was acceptable to more than 90% of subjects. The reliability of questions to parents assessing impairment and age of onset was generally good to acceptable for most diagnoses but was less satisfactory for the child interview. Using information from parent and child, the prevalence for any diagnosis ranged from 50.6 if no impairment criteria were required to 5.4 if a Global Assessment Scale score of 50 or less was necessary. The prevalence of anxiety disorders and enuresis was markedly reduced by requiring attributable impairment.

CONCLUSIONS

The DISC-2 is a reliable and economical tool for assessing child psychopathology. Reliability of the DISC-P-2.3 is superior to that of the child DISC for most diagnoses but is least good for anxiety disorders. The 2.3 version of the instrument provides a significant improvement over earlier versions.

Mental health service use in the community and schools: results from the four-community MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study

OBJECTIVE

To describe the use of mental health and substance abuse services by children and adolescents as reported from the four community sites included in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study.

METHOD

As part of the MECA survey, questions were developed to identify children and adolescents utilizing mental health and substance abuse services. Youths aged 9 through 17 years and a parent/ caretaker were interviewed. Because the investigators had concerns about the capacities of the younger children in the study to describe their use of mental health services, more extensive questions were asked of parents than of youths.

RESULTS

The procedures developed by the MECA project identified patterns of service use that varied in the four communities surveyed. Agreement between reports of parents and youths regarding the use of mental health and substance abuse services showed substantial inconsistencies, similar to reports of psychiatric disorders. At three of the four sites, the majority of children meeting criteria for a psychiatric disorder and scoring 60 or less on the Children's Global Assessment Scale reported some mental health-related service in the previous year, although at two of the sites fewer than 25% of these youths were seen in the mental health specialty sector.

CONCLUSION

Community surveys show great promise for monitoring the need for mental health and substance abuse services and for identifying patterns of use.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology

OBJECTIVE

A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents.

METHOD

Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization.

RESULTS

More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend.

CONCLUSIONS

These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

The epidemiology of psychiatric disorders and the de facto mental health care system

Recent national epidemiologic studies have provided data on the number of people in the United States with mental and addictive disorders. Many of these people receive their care in the general medical care sector. This has important implications for diagnosis and treatment of mental and addictive disorders.

Education and change in cognitive function. The Epidemiologic Catchment Area Study

The association between educational attainment and decline in cognitive function over an interval of 1 year was examined for 14,883 subjects 18 years and older in the National Institute of Mental Health Epidemiologic Catchment Area Study. Cognitive function was assessed at both time points by the Mini-Mental State Examination (MMSE); cognitive decline was coded as a dichotomous variable and was defined as 1 if the subject's score had declined 3 or more points from the baseline MMSE score at the 1-year follow-up interview and as 0 otherwise. The association between educational attainment and decline in cognitive function over 1 year was examined in logistic regression models that were stratified by age group (< 65 years, > or = 65 years) and by baseline MMSE level (MMSE > 23, MMSE < or = 23). Covariates included age, baseline MMSE score, ethnicity, residence, lifetime diagnosis of abuse of alcohol or other drugs, and gender. In those with baseline MMSE > 23, education was a significant predictor of cognitive decline, not only in the elderly but also in younger subjects. Among those with baseline MMSE < or = 23, education was not a significant predictor of cognitive decline. The fact that education provides protection against cognitive decline even in those younger than 65 years, in whom the prevalence and incidence of dementia are very low, would seem to indicate that education or its correlates provides protection against processes other than dementia that might produce a decline in test performance in young persons.

The ICD-10 clinical field trial for mental and behavioral disorders: results in Canada and the United States

OBJECTIVE

To help evaluate the impact of proposed revisions to the chapter on mental and behavioral disorders for ICD-10, the World Health Organization (WHO) Division of Mental Health organized an international clinical field trial to evaluate draft clinical descriptions and diagnostic guidelines. The authors compare interrater diagnostic reliability results from this field trial for clinicians in Canada and the United States of American with those from all other clinicians worldwide, as well as with those from field trials conducted to evaluate drafts of DSM-III.

METHOD

Two or more clinicians at each clinical center independently evaluated each patient, following a study protocol that allowed clinicians to list up to six diagnoses. In Canada and the United States, 96 clinicians completed 1,781 assessments among 491 patients, and elsewhere in the world 472 clinicians completed 7,495 assessments among 1,969 patients.

RESULTS

Summary kappa coefficients at two-, three-, and four-character ICD-10 code levels were 0.76, 0.65, and 0.52, respectively, for Canadian and U.S. clinicians and 0.83, 0.75, and 0.62 for clinicians elsewhere. The mean number of diagnoses per assessment for Canadian and U.S. clinicians was 2.1; for clinicians elsewhere it was 1.7. More multiple coding of diagnoses for substance use disorders, mood (affective) disorders, and personality disorders by Canadian and U.S. clinicians accounted for much of the difference in diagnostic coding and in interrater reliability between them and clinicians elsewhere.

CONCLUSIONS

Interrater diagnostic reliability in Canada and the United States was similar to that of clinicians worldwide and also to results from the DSM-III field tests. Use of more multiple coding of selected disorders by Canadian and U.S. clinicians may reflect the influence of DSM-III and DSM-III-R, which encourage multiple diagnostic entries and the use of separate multiaxial coding for personality disorders, and may have reduced interrater concurrence for some categories. Further, collaborative development of ICD-10 with DSM-IV has aligned these two systems more closely.

Construction and in vitro properties of SIVmac mutants with deletions in "nonessential" genes

The so-called "nonessential" genes of primate lentiviruses can be deleted without abrogating the ability of virus to replicate under at least some cell culture conditions. In SIVmac, these genes are vif, vpx, vpr, and nef. Sequences in the upstream region of U3 in the LTR have also been shown to be dispensable for replication in cell culture. We report here the construction and characterization of a panel of 40 single and combination deletion mutants derived from the pathogenic molecular clone SIVmac239. Deletion of the vpr gene caused little or no change in the growth properties of SIVmac239 in CEMx174 cells, in rhesus monkey peripheral blood mononuclear cells (PBMCs), or in rhesus monkey alveolar macrophages. Deletion of the vpx gene resulted in a greatly reduced rate of replication of the virus in the primary PBMC and macrophage cultures, but no significant reduction in replication of the virus in CEMx174 cells. Deletion of the vpx gene appeared to have a greater effect on virus replication in macrophages than in PBMCs. Deletion of the vif gene caused a dramatic reduction in replication in all cell types tested. However, even delta 5, which contains deletions in all five targeted regions (vif, vpx, vpr, nef, and U3), can still replicate in CEMx174 cells albeit with greatly delayed kinetics. Deletion of nef, alone or in combination with deletions in U3 and vpr, had no observable effect on replication of the virus in any of the cells tested. Because the disease induced by the parental SIVmac239 clone in rhesus monkeys has been well characterized and is remarkably similar to AIDS in humans, this collection of mutants will be useful for relating in vitro properties and gene function with in vivo pathogenic potential.

Construction and in vitro properties of HIV-1 mutants with deletions in "nonessential" genes

Auxiliary genes that are not essential for viral replication in cell culture are found in all known lentiviruses. The "nonessential" auxiliary genes of HIV-1 are vif, vpr, vpu, and nef. Sequences within the upstream region of U3 in the LTR are also not required for virus replication in cell culture. We constructed a panel of 23 mutants with single and combination deletions in these regions in the wild-type HIV-1 infectious molecular clone NL4-3. Deletion of the vpu, vpr, and nef genes and the U3 upstream sequence (US), individually or in combinations, did not appreciably alter virus replication in either chimpanzee PBMCs, human PBMCs, or in the B/T cell hybrid line CEMx174. In contrast, deletion of the vif gene dramatically delayed virus replication in all three cell types. This collection of HIV-1 deletion mutants will be useful for elucidating the functions of these genes and for investigating antiviral immunity in animal models.

Construction and in vitro properties of SIVmac mutants with deletions in "nonessential" genes

The so-called "nonessential" genes of primate lentiviruses can be deleted without abrogating the ability of virus to replicate under at least some cell culture conditions. In SIVmac, these genes are vif, vpx, vpr, and nef. Sequences in the upstream region of U3 in the LTR have also been shown to be dispensable for replication in cell culture. We report here the construction and characterization of a panel of 40 single and combination deletion mutants derived from the pathogenic molecular clone SIVmac239. Deletion of the vpr gene caused little or no change in the growth properties of SIVmac239 in CEMx174 cells, in rhesus monkey peripheral blood mononuclear cells (PBMCs), or in rhesus monkey alveolar macrophages. Deletion of the vpx gene resulted in a greatly reduced rate of replication of the virus in the primary PBMC and macrophage cultures, but no significant reduction in replication of the virus in CEMx174 cells. Deletion of the vpx gene appeared to have a greater effect on virus replication in macrophages than in PBMCs. Deletion of the vif gene caused a dramatic reduction in replication in all cell types tested. However, even delta 5, which contains deletions in all five targeted regions (vif, vpx, vpr, nef, and U3), can still replicate in CEMx174 cells albeit with greatly delayed kinetics. Deletion of nef, alone or in combination with deletions in U3 and vpr, had no observable effect on replication of the virus in any of the cells tested. Because the disease induced by the parental SIVmac239 clone in rhesus monkeys has been well characterized and is remarkably similar to AIDS in humans, this collection of mutants will be useful for relating in vitro properties and gene function with in vivo pathogenic potential.

Paying for mental health and substance abuse care

Fifty-four billion dollars was spent on alcohol/drug abuse and mental health treatment in 1990. These expenditures were concentrated in the area of inpatient psychiatric care and on persons with severe mental health and substance abuse problems. The data on expenditure patterns for mental health and substance abuse care suggest that successful health care reform in this area must implement mechanisms for controlling inpatient utilization and managing the care of persons with the most severe disorders.

Concordance between two measures of depression in the Hispanic Health and Nutrition Examination Survey

A concordance analysis between the Center for Epidemiologic Studies Depression Scale (CES-D) and the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) for current major depression was conducted using data from Cuban Americans and Puerto Rican respondents to the Hispanic Health and Nutrition Examination Survey (HHANES). Overall agreement between the two depression measures was relatively high, which suggested that the CES-D might be appropriate as a first-stage screening instrument for community-based surveys of clinical depression. Female gender and indicators of social class (education, income, poverty index, and employment) were related to low specificity and low agreement. The estimated cutoff points of the CES-D that best predicted DIS current major depression were different between the two ethnic groups; 17 for Cuban Americans, and 20 for Puerto Ricans. A receiver operating characteristics (ROC) curve analysis revealed that the traditional method of defining CES-D cases by summing the scores for each item was superior to counting only the persistent symptoms, that is, those present nearly everyday.

One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study

The associations between the one-month prevalence rates of mental disorders and sociodemographic characteristics were investigated for 18,571 people interviewed in the first-wave community samples of all 5 sites in the US National Institute of Mental Health (NIMH) Epidemiologic Catchment Area program. Men were found to have a significantly higher rate of cognitive impairment than women after controlling for the effects of age, race or ethnicity, marital status and socioeconomic status. Marital status was one of the most powerful correlates of mental disorder risk: the odds of separated or divorced people having any NIMH Diagnostic Interview Schedule disorder were twice that of married people after controlling for age, gender, race or ethnicity and socioeconomic status. The odds of those in the lowest socioeconomic status group having any Diagnostic Interview Schedule disorder was about 2.5 times that of those in the highest socioeconomic status group, controlling for age, gender, race or ethnicity and marital status. For all disorders except cognitive impairment, race or ethnicity did not remain statistically significant after controlling for age, gender, marital status and socioeconomic status.

The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services

After initial interviews with 20,291 adults in the National Institute of Mental Health Epidemiologic Catchment Area Program, we estimated prospective 1-year prevalence and service use rates of mental and addictive disorders in the US population. An annual prevalence rate of 28.1% was found for these disorders, composed of a 1-month point prevalence of 15.7% (at wave 1) and a 1-year incidence of new or recurrent disorders identified in 12.3% of the population at wave 2. During the 1-year follow-up period, 6.6% of the total sample developed one or more new disorders after being assessed as having no previous lifetime diagnosis at wave 1. An additional 5.7% of the population, with a history of some previous disorder at wave 1, had an acute relapse or suffered from a new disorder in 1 year. Irrespective of diagnosis, 14.7% of the US population in 1 year reported use of services in one or more component sectors of the de facto US mental and addictive service system. With some overlap between sectors, specialists in mental and addictive disorders provided treatment to 5.9% of the US population, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary support sector for such care. Of those persons with any disorder, only 28.5% (8.0 per 100 population) sought mental health/addictive services. Persons with specific disorders varied in the proportion who used services, from a high of more than 60% for somatization, schizophrenia, and bipolar disorders to a low of less than 25% for addictive disorders and severe cognitive impairment. Applications of these descriptive data to US health care system reform options are considered in the context of other variables that will determine national health policy.

Use of services by persons with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program

The use of ambulatory and inpatient mental health and addiction services in the United States was estimated by means of data from the National Institute of Mental Health Epidemiologic Catchment Area Program standardized to the 1980 US census for adults 18 years of age and older. In a 1-year period, 22.8 million people used ambulatory services for mental or addictive disorder treatment; 54% of them had a current Diagnostic Interview Schedule/DSM-III mental disorder and another 37.4% had a history of psychiatric disorder or significant psychiatric symptoms. A total of 325.9 million ambulatory visits were made, and the average number of visits per treated person per year was 14.3. There were 1.4 million persons admitted to at least one inpatient mental health or addiction setting during a 1-year period; 80% of them had a current DIS/DSM-III disorder, and the remainder had a history of psychiatric disorder or significant psychiatric symptoms. Results were determined for specific mental and substance use diagnoses and service settings. Among treated persons with any mental or addictive disorder, the majority of visits were to mental and addictive disorders specialty settings (40.5% of total visits) and to support networks composed of friends, relatives, and self-help groups (37.0% of total visits). Although a large number of persons with mental and substance use disorders were seen in the general medical sector for mental health or addiction problems, they were seen less frequently and therefore made fewer visits to this sector (10.9% of total visits).

Congruence of service utilization estimates from the Epidemiologic Catchment Area Project and other sources

Service utilization estimates for inpatient and ambulatory mental health care from the Epidemiologic Catchment Area Project were compared with similar estimates from other sources, principally the Center for Mental Health Services National Reporting Program. Generally, results showed closer correspondence between estimates of the number of persons who used inpatient care than of similar estimates for ambulatory mental health care. Subtotal estimates for the specialty alcohol/other drug abuse/mental health and health care sectors were more similar than were estimates for individual settings. The specialty sector subtotals showed only a 7% difference in patient counts for inpatient care and 13% for ambulatory care, with an 11% difference in visits for the latter. Generally, a reasonable level of congruence was observed, given pronounced differences in methods, procedures, and instruments. Future directions may be able to close data gaps and improve the quality of the national mental health services database.

Progress toward achieving a common language in psychiatry. Results from the field trial of the clinical guidelines accompanying the WHO classification of mental and behavioral disorders in ICD-10

In preparing for the 10th revision of the International Classification of Diseases (ICD-10), the Division of Mental Health of the World Health Organization organized an international field trial to help evaluate draft clinical descriptions and diagnostic guidelines that were produced to facilitate use of the chapter dealing with mental and behavioral disorders. These clinical guidelines were prepared in equivalent versions in most of the world's widely spoken languages. The field trial aimed to obtain data that would help in assessing whether the classification fits the diagnoses made in different countries, whether it is easy to use, and whether psychiatrists after a short period of familiarization with the classification can reach agreement about their diagnoses and classification. The field trial was carried out at 112 clinical centers in 39 countries by 711 clinicians who conducted 15,302 individual assessments. The trial included joint clinical assessments of patients and case history exercises. The results of the joint assessment part of the trial are reported here. Most clinicians reported that the draft document was easy to use and that the classification provided a good fit for the vast majority of the clinical conditions encountered. While interrater reliability was satisfactory for most categories, some (for example, those dealing with personality disorders) were somewhat difficult to use, and reliability of assignment for those was lower. The trial demonstrated that the ICD-10 chapter dealing with mental and behavioral disorders is on the whole suitable for general use. It provided valuable indications about changes needed for subsequent versions and demonstrated the feasibility of large-scale international research on classification and diagnosis in psychiatry.

Estimating the prevalence of mental disorders in U.S. adults from the Epidemiologic Catchment Area Survey

The National Institute of Mental Health Epidemiologic Catchment Area Survey is a comprehensive, community-based survey of mental disorders and use of services by adults, ages 18 and older. Diagnoses are based on the criteria in the "Diagnostic and Statistical Manual of Mental Disorders," third edition, and were obtained in five communities in the United States through lay-interviewer administration of the National Institute of Mental Health Diagnostic Interview Schedule. Results from the survey provide the public health field with data on the prevalence and incidence of specific mental disorders in the community, unbiased by the treatment status of the sample. The population with disorders is estimated, and the survey findings that respond to some of the most common requests for information about the epidemiology of mental disorders in the United States are highlighted briefly. Based on the survey, it is estimated that one of every five persons in the United States suffers from a mental disorder in any 6-month period, and that one of every three persons suffers a disorder in his or her lifetime. Fewer than 20 percent of those with a recent mental disorder seek help for their problem, according to the survey. High rates of comorbid substance abuse and mental disorders were found, particularly among those who had sought treatment for their disorders.

Comparing age at onset of major depression and other psychiatric disorders by birth cohorts in five US community populations

Using data collected in the National Institute of Mental Health (Rockville, Md) Epidemiologic Catchment Area Program, we examined the proposed hypothesis that there has been a shift in major depression to younger ages at onset, or increased prevalence in younger age periods, for recent birth cohorts. Life-table survival methods were used to examine the hazard rates for major depression as well as for other specific mental disorders. The findings are consistent with a gradual shift to increased rates for major depression between the ages of 15 and 19 years for Epidemiologic Catchment Area respondents born more recently. The findings also suggest a similar shift for drug abuse/dependence; similar but less pronounced changes were found for alcohol abuse/dependence and obsessive-compulsive disorder. However, in this study, bipolar disorder, panic disorder, and phobias did not exhibit a consistent increase in onset at younger ages. Further research is required to determine if the shifts in major depression, drug abuse/dependence, and possibly alcohol abuse/dependence are linked. It is important to note that these shifts to adolescent onset are occurring when nearly half the 31 million Americans without health insurance are aged 24 years or younger.

Phobia: prevalence and risk factors

This article is the presentation of the main phobia data from the Epidemiologic Catchment Area (ECA) program, with a sample size of n = 18.571. Work on this article was initiated in 1981 at the beginning of the ECA study, but publication has been delayed a decade. Phobias are determined from information from the Diagnostic Interview Schedule (DIS), classified according to DSM III. Phobias are found to be the most common psychiatric disorder in the community, more common than major depression or alcohol abuse or dependence in the month prior to interview. The one month prevalence is between 4.0 and 11.1%, with the estimated prevalence in the United States being 6.2%. There were nine community surveys of the prevalence of phobia that pre-dated the ECA studies, which found a wide range of prevalence rates from 1.2% to 26.1%. By far the strongest risk factor associated with phobias is the presence of another psychiatric disorder. Prevalence rates of simple phobia and agoraphobia are found in the ECA studies to be significantly higher in women; social phobia, which is less prevalent, has no significant sex difference. The prevalence rates are higher in younger age groups, and in those with low socioeconomic status (SES). The onset of phobias occurs primarily in the childhood or teenage years, and they tend to be chronic conditions. Less than a quarter of phobics receive treatment.

The complete nucleotide sequence of a pathogenic molecular clone of simian immunodeficiency virus

The complete nucleotide sequence of an infectious clone of simian immunodeficiency virus of macaques, SIVmac239, has been determined. Virus produced from this molecular clone causes AIDS in rhesus monkeys in a time frame suitable for laboratory investigation. The proviral genome including both long terminal repeats is 10,279 base pairs in length and contains open reading frames for gag, pol, vif, vpr, vpx, tat, rev, and env. The nef gene contains an in-frame premature stop after the 92nd codon. At the nucleotide level, SIVmac239 is closely related to SIVmac251 (98%) and SIVmac142 (96%). It will not be possible to test which features of the viral sequence are critical molecular determinants for the pathogenesis of AIDS.