Sex Differences and Depression in Puerto Rico

Sex differences in rates of depressive disorders and depressive symptomatology, as measured by the Diagnostic Interview Schedule, are examined for an island-wide probability sample of Puerto Rico. Consistent with previous research, depression is significantly more prevalent in Puerto Rican women than men. Risk factors associated with depressive symptomatology are examined from a sex-role perspective. The results of multiple regression analyses show that even after demographic, health and marital and employment status variables are controlled, women continue to be at higher risk of depressive symptomatology than men. These results are interpreted within a cultural and sex-role perspective.

Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D

Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.

Suicidality is associated with medication access problems in publicly insured psychiatric patients

BACKGROUND

Beginning January 1, 2006, the Medicare Part D prescription drug benefit shifted drug coverage from Medicaid to the new Medicare Part D program for patients who were eligible for both Medicare and Medicaid benefits ("dual-eligibles"). These patients were randomly assigned to a private Part D plan and came under specific formulary and utilization management procedures of the plan in which they were enrolled.

OBJECTIVE

To examine the relationship between physician-reported medication switches, discontinuations, and other access problems and suicidal ideation or behavior among "dual-eligible" psychiatric patients.

METHOD

Data were collected in 3 cross-sectional cycles in 2006 (January-April, May-August, and September-December) as part of the National Study of Medicaid and Medicare Psychopharmacologic Treatment Access and Continuity using through-the-mail, practice-based survey research methods. Data from the third cycle, representing all events since January 1, 2006, were used for these analyses. A national sample of psychiatrists randomly selected from the AMA Masterfile provided clinically detailed data on 1 systematically selected, dual-eligible psychiatric patient (N = 908). Propensity score analyses adjusted for patient sociodemographics, treatment setting, diagnoses, and psychiatric symptom severity.

RESULTS

Patients who experienced medication switches, discontinuations, and other access problems had 3 times the rate of suicidal ideation or behavior compared with patients with no access problems (22.0% vs 7.4%, P < .0001). Mean odds ratios and excess probabilities were highest for patients who were clinically stable but were required to switch medications (31.8%; mean OR = 4.87, mean P = 8.92(-5), excess probability = 0.21). Patients who experienced discontinuations (26.4%; mean OR = 2.13, mean P = 2.12(-2), excess probability = 0.12), other access problems (18.7%; mean OR = 3.01, mean P = 1.03(-5), excess probability = 0.15), and multiple access problems (22.3%; mean OR = 2.88, mean P = 4.10(-5), excess probability = 0.14) also had significantly increased suicidal ideation or behavior.

CONCLUSION

Increased occurrences of suicidal ideation or behavior appear to be associated with disruptions in patient medication access and continuity. Clinicians need to be aware of the possibility of increased suicidality when, for administrative reasons, a clinically stable patient's medication regimen is altered. Dual-eligible psychiatric patients represent a highly vulnerable group with a substantial burden of illness; these findings underscore the need to provide special protections for this population.

Medicaid medication access problems and increased psychiatric hospital and emergency care

OBJECTIVES

To quantify the extent to which Medicaid programs may incur increased psychiatric emergency department and hospital use associated with clinically unintended medication discontinuations, gaps, switches and other access problems attributed to prescription drug coverage and management.

METHOD

This study uses clinically detailed, physician-reported data. A total of 4866 psychiatrists in 10 states were randomly selected from the AMA Masterfile; 62% responded and 32% treated Medicaid patients and reported on 1625 systematically selected Medicaid patients. Propensity score multivariate models assessed predicted probabilities and mean number of emergency department visits and hospital days.

RESULTS

Many patients (46.0%, S.E.=1.3%) had medication access problems reported during the past year, including discontinuing or switching medications or inability to obtain clinically indicated prescriptions because of drug coverage or management. The expected number of emergency department visits was estimated to be 73.8% higher among patients with medication access problems reported compared to matched patients without access problems reported. Among acute stay inpatients, the expected number of hospital days was 71.7% higher for patients with medication access problems reported.

CONCLUSIONS

Medication access problems may have significant implications for Medicaid programs. The potential indirect costs of these policies in psychiatric and social services utilization should be considered in addition to direct pharmacy costs.

First-year Medicare Part D prescription drug benefits: medication access and continuity among dual eligible psychiatric patients

OBJECTIVE

This study provides national data on medication access and continuity problems experienced during the first year of the Medicare Part D prescription drug program, which was implemented on January 1, 2006, among a national sample of Medicare and Medicaid "dual eligible" psychiatric patients.

METHOD

Practice-based research methods were used to collect clinician-reported data across the full range of public and private psychiatric treatment settings. A random sample of psychiatrists was selected from the American Medical Association Physician Masterfile. Among these physicians, 1,490 provided clinically detailed data on a systematically selected sample of 2,941 dual eligible psychiatric patients.

RESULTS

Overall, 43.3% of patients were reported to be unable to obtain clinically indicated medication refills or new prescriptions in 2006 because they were not covered or approved; 28.9% discontinued or temporarily stopped their medication(s) as a result of prescription drug coverage or management issues; and 27.7% were reported to be previously stable on their medications but were required to switch medications. Adjusting for case mix to control for sociodemographic and clinical confounders, the predicted probability of an adverse event among patients with medication access problems was 0.64 compared to 0.36 for those without access problems (P < .0001). All prescription drug utilization management features studied were associated with increased medication access problems (P < .0001). Adjusting for patient case mix, patients with "step therapy" (P < .0001), limits on medication number/dosing (P < .0001), or prior authorization (P < .0001) had 2.4 to 3.4 times the increased likelihood of an adverse event.

CONCLUSIONS

More effective Part D policies and management practices are needed to promote clinically safer and appropriate pharmacotherapy for psychiatric patients to enhance treatment outcomes.

The dimensionality of alcohol use disorders and alcohol consumption in a cross-national perspective

AIMS

To replicate the finding that there is a single dimension trait in alcohol use disorders and to test whether the usual 5+ drinks for men and 4+ drinks for women and other measures of alcohol consumption help to improve alcohol use disorder criteria in a series of diverse patients from emergency departments (EDs) in four countries.

DESIGN

Cross-sectional surveys of patients aged 18 years and older that reflected consecutive arrival at the ED. The Composite International Diagnostic Interview Core was used to obtain a diagnosis of DSM-IV alcohol dependence and alcohol abuse; quantity and frequency of drinking and drunkenness as well as usual number of drinks consumed during the last year.

SETTING

Participants were 5195 injured and non-injured patients attending seven EDs in four countries: Argentina, Mexico, Poland and the United States (between 1995-2001).

FINDINGS

Using exploratory factor analyses alcohol use disorders can be described as a single, unidimensional continuum without any clear-cut distinction between the criteria for dependence and abuse in all sites.

RESULTS

from item response theory analyses showed that the current DSM-IV criteria tap people in the middle-upper end of the alcohol use disorder continuum. Alcohol consumption (amount and frequency of use) can be used in all EDs with the current DSM-IV diagnostic criteria to help tap the middle-lower part of this continuum. Even though some specific diagnostic criteria and some alcohol consumption variables showed differential item function across sites, test response curves were invariant for ED sites and their inclusion would not impact the final (total) performance of the diagnostic system.

CONCLUSIONS

DSM-IV abuse and dependence form a unidimensional continuum in ED patients regardless of country of survey. Alcohol consumption variables, if added, would help to tap patients with more moderate severity. The DSM diagnostic system for alcohol use disorders showed invariance and performed extremely well in these samples.

Part D and dually eligible patients with mental illness: medication access problems and use of intensive services

OBJECTIVE

This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits.

METHODS

Psychiatrists randomly selected from the American Medical Association's Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not.

RESULTS

Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one.

CONCLUSIONS

Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population.

Part D and dually eligible patients with mental illness: medication access problems and use of intensive services

OBJECTIVE

This study examined the occurrence of medication access problems and use of intensive mental health services after the transition in January 2006 from Medicaid drug coverage to Medicare Part D for persons dually eligible for Medicaid and Medicare benefits.

METHODS

Psychiatrists randomly selected from the American Medical Association's Physicians Masterfile reported on experiences of one systematically selected dually eligible patient (N=908) in the nine to 12 months after Part D implementation. Propensity score matching was used to compare use of psychiatric emergency department care and inpatient care between individuals who experienced a problem accessing a psychiatric medication after Part D and those who did not.

RESULTS

Approximately 44% of dually eligible patients were reported to have experienced a problem accessing medications. The likelihood of visiting an emergency department was significantly higher for those who experienced an access problem than for those who did not (mean odds ratio=1.75, mean p=.003). There was no difference in number of emergency department visits or hospitalizations for those who had at least one.

CONCLUSIONS

Many dually eligible patients had difficulty accessing psychiatric medications after implementation of Part D. These patients were significantly more likely to visit psychiatric emergency departments than patients who did not experience difficulties. These findings raise concerns about possible negative effects on quality of care. Additional study is needed to understand the full effects of Part D on outcomes and functioning as well as treatment costs for this population.

Medicare Part D prescription drug benefits and administrative burden in the care of dually eligible psychiatric patients

OBJECTIVE

With implementation of Medicare Part D, concerns were raised that patients with severe mental illness who were dually eligible for both Medicaid and Medicare benefits would be at clinical risk. In addition to concerns about medication access and continuity, there were concerns about administrative burden for physicians and their staffs. This study aimed to quantify the amount of administrative burden for psychiatrists and their staff related to Medicare Part D prescription drug plan administration in a national sample of dually eligible psychiatric patients and to identify factors associated with increased burden.

METHODS

A total of 5,833 psychiatrists were randomly selected from the American Medical Association's Physicians Masterfile. Responses were obtained from 64% (N=3,247) with a mailed survey using practice-based survey research methods during the first four months of Medicare Part D implementation (January to April 2006); 1,183 psychiatrists met eligibility requirements.

RESULTS

Psychiatrists and their staff spent 45 minutes in administrative tasks for every one hour of direct patient care for dually eligible patients. Drug plan features, including prior authorization and preferred drug formularies, and medication access problems were associated with increased administrative time.

CONCLUSIONS

Results of this study indicate several drug plan features and medication access problems related to Part D implementation were associated with significant increases in administrative burden for psychiatrists and their staff, which may result in less time for direct patient care. Given the vulnerability of this high-risk population, this increased administrative burden may pose a significant risk to the overall quality of care for psychiatric patients.

ADHD correlates, comorbidity, and impairment in community and treated samples of children and adolescents

Patterns of correlates, comorbidity and impairment associated with attention-deficit hyperactivity disorder (ADHD) in children and youth were examined in representative samples from the community and from treatment facilities serving medically indigent youth in Puerto Rico. Information from caretakers and youths was obtained using the Diagnostic Interview Schedule for Children, (version IV), measures of global impairment, and a battery of potential correlates. In the community (N = 1,896) and the treated samples (N = 763), 7.5 and 26.2% of the children, respectively, met criteria for DSM-IV ADHD in the previous year. Although the prevalence rates and degree of impairment differed, the general patterns of correlates, comorbidity and impairment were similar in both populations. The exceptions were associated with conduct disorder, anxiety, impairment in the ADHD comorbid group, and age factors that appeared to be related to selection into treatment.

ADHD and gender: are risks and sequela of ADHD the same for boys and girls?

BACKGROUND

Research comparing treatment-referred boys and girls with attention-deficit/hyperactivity disorder (ADHD) has yielded equivocal results. Contradictory findings may be associated with differential referral practices or unexplored interactions of gender with ADHD subtypes.

METHOD

We examined possible gender differences in ADHD and its subtypes among children aged 4 to 17 in a representative community sample (N = 1896) in Puerto Rico. Caretakers provided information through the Diagnostic Interview Schedule for Children (version IV) and a battery of impairment, family relations, child problems, comorbidity and treatment measures.

RESULTS

ADHD was 2.3 times more common in boys than girls, but with one exception there was little evidence that the patterns of associations of ADHD with correlates were different for boys and girls. The exception was school suspension, which was more common among ADHD boys than girls. Additional gender interactions were found when ADHD subtypes were considered. Among those with combined type (n = 50), boys were more likely to be comorbid with mood disorders than girls. For those with the inattentive type (n = 47), girls were more likely to be comorbid with anxiety disorders than boys.

CONCLUSIONS

Our findings lend cross-cultural generalizability to recent reports that gender does not interact with correlates for ADHD overall, but that it may play a role in subtypes.

Medication access and continuity: the experiences of dual-eligible psychiatric patients during the first 4 months of the Medicare prescription drug benefit

OBJECTIVE

This study attempted to systematically assess the experiences of Medicare and Medicaid "dual-eligible" psychiatric patients, including evaluating patients' access to medications and the administrative functioning of the program, during the first 4 months of the Medicare Part D prescription drug benefit.

METHOD

Psychiatrists (N=5,833) were randomly selected from the American Medical Association's Physicians Masterfile. After exclusion of those not practicing and with undeliverable addresses, 64% responded; 35% met study eligibility criteria of treating at least one dual-eligible patient during their last typical workweek and reported clinically detailed information on one systematically selected patient.

RESULTS

A total of 53.4% had at least one medication access problem to report between Jan. 1 and April 30, 2006. Although 9.7% experienced improved medication access, 22.3% discontinued or temporarily stopped taking medication because of prescription drug coverage or management issues, and 18.3% were previously stable but were required to switch medications. Among those with medication access problems, 27.3% experienced a significant adverse clinical event; 19.8% had an emergency room visit. Most drug plan features studied, including preferred drug/formulary lists, prior authorization, medication dosing/number limits, "fail-first" protocols, and requirements to switch to generics, were associated with significantly higher rates of medication access problems.

CONCLUSIONS

The findings indicate consequential medication access problems for psychiatric patients during the implementation of Medicare Part D. Although Centers for Medicare and Medicaid Services policies were enacted to ensure access to protected classes of psychopharmacologic medications, the high rates of medication access problems observed indicate further refinement of these policies is needed.

Developing the diagnostic and statistical manual V: what will "statistical" mean in DSM-V?

In February of 2004, the American Psychiatric Institute for Research and Education (APIRE) hosted a Launch and Methodology Conference to discuss the role statistics might play in the eventual revision of the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the Ninth Edition of the International Classification of Diseases (ICD9). The conference consisted of talks on specific topics by statisticians and epidemiologists from North America and Great Britain, followed by group discussion by experts in nosology and psychopathology. We report here on the development of specific themes related to the future interaction between statisticians and nosologists in DSM-V development that arose as a result of that meeting. The themes are related to (1) the nature of the statistician/nosologist interaction; (2) specific areas of concern in that interaction, and (3) the use of novel and complex statistical methods to challenge and inspire new avenues of thinking among nosologists.

Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?

OBJECTIVE

The purpose of this study is to present data on the rates of diagnosis and patterns of Axis I comorbidity treated by psychiatrists in routine psychiatric practice, ascertained by practicing psychiatrists, and compare them with those ascertained through structured interview in a national sample of individuals treated in the specialty mental health sector for evidence of underdetection or underdiagnosis of comorbid disorders in routine psychiatric practice.

METHODS

Data on 2117 psychiatric patients gathered by 754 psychiatrists participating in the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network's Study of Psychiatric Patients and Treatments (SPPT) were analyzed, assessing psychiatrist-reported rates of Axis I disorders and comorbidities. SPPT data on patients treated by psychiatrists were compared with a clinical subset of patients in the National Comorbidity Survey who had been treated in the specialty mental health sector (SMA).

RESULTS

Rates of comorbidity were higher in the SMA (53.9%) than in the SPPT (31.5%). The prevalence of schizophrenia diagnoses was more than twice as prevalent in the SPPT as in the SMA sample; anxiety disorders were 2 to 22 times more prevalent in the SMA sample. In the SPPT, 4 of the 10 most prevalent comorbid pairs included schizophrenia or bipolar disorder; only one pair in the SMA sample included either diagnoses. Of the 10 most prevalent comorbidity pairings in the SMA sample, 6 included a phobia diagnosis.

CONCLUSIONS

Results of these analyses suggest greater differences in the patterns and rates of comorbidities than one might expect between these 2 samples. Possible reasons for these disparities, including methodological differences in diagnostic ascertainment and underdiagnosis of anxiety disorders, are discussed.

Concomitant pharmacotherapy among youths treated in routine psychiatric practice

OBJECTIVES

The aim of this study was to assess rates and correlates of concomitant pharmacotherapy in children and adolescents treated by psychiatrists in a broad range of clinical settings.

METHODS

Cross-sectional data on 392 child and adolescent patients aged 2-17 years from the 1997 and 1999 American Psychiatric Practice Research Network Study of Psychiatric Patients and Treatments were used, and weighted estimates are provided.

RESULTS

Findings indicate that 84% of child and adolescent patients received one or more psychopharmacologic medications; 52% of patients treated with medications received concomitant pharmacotherapy (i.e., two or more medications). Patients who were treated with psychopharmacologic treatments received a median of 2 medications (range, 1-6). Highest rates of concomitant pharmacotherapy were among patients with bipolar disorder (87%). Correlates of concomitant pharmacotherapy included: (1) having a diagnosis of bipolar disorder, (2) having co-occurring Axis I or II disorders or general medical conditions, and (3) currently receiving treatment in an inpatient setting.

CONCLUSIONS

Over 40% of child and adolescent patients of psychiatrists were prescribed two or more psychopharmacologic medications. Patients with chronic and clinically complex conditions were more likely to receive concomitant pharmacotherapy. Most often, efficacy of U.S. Food and Drug Administration (FDA)-approved medications has been examined as monotherapy, and cautions on drug interactions and off-label use derived from multiple sources accompany each product. With high rates of concomitant pharmacotherapy among children and adolescents in psychiatric care, additional research on efficacy and safety of this treatment strategy is necessary.

The DSM-IV rates of child and adolescent disorders in Puerto Rico: prevalence, correlates, service use, and the effects of impairment

BACKGROUND

Few prevalence studies in which DSM-IV criteria were used in children in representative community samples have been reported. We present prevalence data for the child and adolescent population of Puerto Rico and examine the relation of DSM-IV diagnoses to global impairment, demographic correlates, and service use in an island-wide representative sample.

METHODS

We sampled 1886 child-caretaker dyads in Puerto Rico by using a multistage sampling design. Children were aged 4 to 17 years. Response rate was 90.1%. Face-to-face interviews of children and their primary caretakers were performed by trained laypersons who administered the Diagnostic Interview Schedule for Children, version IV (DISC-IV) in Spanish. Global impairment was measured by using the Children's Global Assessment Scale scored by the interviewer of the parent. Reports of service use were obtained by using the Service Assessment for Children and Adolescents.

RESULTS

Although 19.8% of the sample met DSM-IV criteria without considering impairment, 16.4% of the population had 1 or more of the DSM-IV disorders when a measure of impairment specific to each diagnosis was considered. The overall prevalence was further reduced to 6.9% when a measure of global impairment was added to that definition. The most prevalent disorders were attention-deficit/hyperactivity disorder (8.0%) and oppositional defiant disorder (5.5%). Children in urban settings had higher rates than those in rural regions. Older age was related to higher rates of major depression and social phobia, and younger age was related to higher rates of attention-deficit/hyperactivity disorder. Both overall rates and rates of specific DSM-IV/DISC-IV disorders were related to service use. Children with impairment without diagnosis were more likely to use school services, whereas children with impairment with diagnosis were more likely to use the specialty mental health sector. Of those with both a diagnosis and global impairment, only half received services from any source.

CONCLUSIONS

Because we used the DISC-IV to apply DSM-IV criteria, the study yielded prevalence rates that are generally comparable with those found in previous surveys. The inclusion of diagnosis-specific impairment criteria reduced rates slightly. When global impairment criteria were imposed, the rates were reduced by approximately half.

The use of multiple informants in identifying the risk factors of depressive and disruptive disorders--are they interchangeable?

OBJECTIVE

The aim of this study was to asses whether children and their parents identify the same risk factors for disruptive and depressive disorders and to analyze whether combining informant data with a rule that classifies the diagnosis as present if confirmed by at least one informant (OR rule) masks distinctive patterns identified in informant-specific analyses.

METHOD

Bivariate logistic regression equations were estimated using the diagnostic classification, based on DISC 2.1, as the outcome variable and informant (parent or child), characteristics of the youth (gender and age), indicators of the context of the interview (site), and family characteristics (income, parental monitoring, and adverse family environment) as predictors. The same predictors were also analyzed with the combined informant (OR rule) as outcome variable.

RESULTS

Prevalence of all diagnoses varied with informant. Depressive disorders were more prevalent when the informant was the youth and disruptive disorders when the informant was the parent. The effect of age varied with informant. Odds of being classified as having a DISC disorder increased with age when the informant was the youth but the same effect was not observed when the parent was the informant. When information from parents and youth are combined (with an OR rule) the age effect for disruptive disorders vanishes, and its effect for depressive disorders weakens.

CONCLUSIONS

Informants are not interchangeable. Parent- and youth-based estimates of the prevalence of disruptive and depressive disorders were different and showed distinctive age relationships. Combining information from different sources (parents and youths) obscures the apparent effect of age noted in the two informant groups.

Dimensional measures of psychopathology. The probability of being classified with a psychiatric disorder using empirically derived symptom scales

OBJECTIVES

We sought to develop a ranking scheme that assigns a probability of having one of four psychiatric disorders to children based on their scores on a symptom scale. We then estimated the impact of each scale symptom on the prevalence of the disorder in the population.

METHOD

Logistic regressions were specified for ADHD, ODD, depressive, and conduct disorders using all the individual symptoms in the pertinent scale as predictors. Individual fitted values from the regression function then served as a probability scale measure. We combined the prevalence and influence of each scale symptom to calculate its overall impact on the prevalence of the disorder.

RESULTS

Probability distributions had a wide range of values and discriminated between cases and non-cases. Those having a disorder were consistently associated with higher probabilities in the scale. The estimated probability corresponds to the empiric prevalence of the diagnosis in a group of persons sharing the same estimated probabilities. Symptoms varied on their impact on the prevalence of the disorder.

CONCLUSIONS

We recommend the estimated probability of the disorder based on the empirically defined scales as dimensional measures that complement prevalence of the disorder. Different symptoms are identified as targets for screening when selection is based on their impact on the prevalence of the disorder than when selection is based on the strength of the association with the disorder. We recommend using a common nosology with different classification schemes; the categorical definition of the disorder, the probability of having the disorder, and the impact of each symptom in the prevalence. Different measures serve different purposes.

Methodological challenges in assessing children's mental health services utilization

This paper describes the reliability and validity of the service assessment for children and adolescents (SACA) for use among Spanish-speaking respondents. The test-retest reliability of the instrument was assessed in a randomly selected clinical sample of 146 Puerto Rican children and adolescents aged 4-17. Both parents and children were administered the SACA twice by independent interviewers over an average 12-day follow-up period. The accuracy of parental and youth self-reports was assessed by comparing these reports to information obtained from medical records. The results showed that parents and children (aged 11-17) were able to report with fair to moderate reliability any last year use of mental health services, any outpatient mental health services, and school services. Residential and hospitalization services were reported by both informants with substantial test-retest reliability. Slight or no test-retest reliability was obtained for parent and child on the use of the specific type of mental health professionals, as well as parental reports of several treatment modalities. Substantial sensitivity of the SACA was obtained when comparing medical records to parental and child reports to lifetime use of any service and outpatient mental health service. Moderate sensitivity was obtained for last year use of mental health services for both parent and child informants.

Childhood asthma, chronic illness, and psychiatric disorders

Asthma is a serious and vexing problem for many children and their families. Asthma, like most syndromes, has many symptoms and potential causes and effects. Studies have shown that pediatric asthma is associated with psychiatric disorders, but the specificity and temporality of these relations is not well known. This study examined the associations between any and specific psychiatric disorders and both childhood asthma and other childhood chronic illnesses. The study used the Methods for the Epidemiology of Child and Adolescent Mental Disorders data, a four-site, community-based study of 1,285 pairs of youths and caretakers. Psychiatric disorders were assessed using the Diagnostic Interview Schedule for Children (DISC 2.3). Methods for the Epidemiology of Child and Adolescent Mental Disorders was also used to assess individual characteristics, parental reports of asthma, and other chronic illnesses. Asthma and 'other' chronic illnesses were associated with different psychiatric disorders. In particular, having a history of asthma was associated with having an anxiety disorder, after adjustment for potential confounding, but was not associated with having an affective disorder. Having a chronic illness other than asthma or cancer was associated with having any affective disorder and dysthymia but not anxiety disorder. These results call for more mechanistic research that explores the specific relations between childhood anxiety disorder and asthma and between affective disorder and other pediatric chronic illnesses.

Test-retest reliability of the Spanish version of the Diagnostic Interview Schedule for Children (DISC-IV)

The test-retest reliability of the Spanish Diagnostic Interview Schedule for Children (DISC-IV) is presented. This version was developed in Puerto Rico in consultation with an international bilingual committee, sponsored by NIMH. The sample (N = 146) consisted of children recruited from outpatient mental health clinics and a drug residential treatment facility. Two different pairs of nonclinicians administered the DISC twice to the parent and child respondents. Results indicated fair to moderate agreement for parent reports on most diagnoses. Relatively similar agreement levels were observed for last month and last year time frames. Surprisingly, the inclusion of impairment as a criterion for diagnosis did not substantially change the pattern of results for specific disorders. Parents were more reliable when reporting on diagnoses of younger (4-10) than older children. Children 11-17 years old were reliable informants on disruptive and substance abuse/dependence disorders, but unreliable for anxiety and depressive disorders. Hence, parents were more reliable when reporting about anxiety and depressive disorders whereas children were more reliable than their parents when reporting about disruptive and substance disorders.

The DISC Predictive Scales (DPS): efficiently screening for diagnoses

OBJECTIVE

To derive and test a series of brief diagnosis-specific scales to identify subjects who are at high probability of meeting diagnostic criteria and those who may safely be spared more extensive diagnostic inquiry.

METHOD

Secondary data analysis of a large epidemiological data set (n = 1,286) produced a series of gate and contingent items for each diagnosis. Findings were replicated in a second retrospective analysis from a residential care sample (n = 884). The DISC Predictive Scales (DPS) were then used prospectively as a self-report questionnaire in two studies, in which parents (n = 128) and/or adolescents (n = 208) had subsequent diagnostic interviewing with the Diagnostic Interview Schedule for Children or the Schedule for Affective Disorders and Schizophrenia for School-Age Children.

RESULTS

All analyses showed that gate item selection was valid and that any missed cases were due solely to inconsistent reports on the same questions. Screening performance of the full scales was shown to be good, and substantial reductions in scale length were not associated with significant changes in discriminatory power.

CONCLUSIONS

The DPS can accurately determine subjects who can safely be spared further diagnostic inquiry in any diagnostic area. This has the potential to speed up structured diagnostic interviewing considerably. The full DPS can be used to screen accurately for cases of specific DSM-III-R disorders.

Parent and child contributions to diagnosis of mental disorder: are both informants always necessary?

OBJECTIVE

To examine the unique cases contributed by parent and child informants to diagnostic classification, with the goal of identifying those diagnoses for which either or both informants are needed.

METHOD

The authors examined survey data from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, a 4-community epidemiology survey of 9- to 17-year-old children and their parents. Parent-child dyads (1,285 pairs) were independently interviewed by lay persons with the Diagnostic Interview Schedule for Children; a subset of these pairs (n = 247) were also interviewed by clinicians. Agreement between parents and children was examined with respect to levels of impairment, need for/use of services, and clinicians' diagnoses.

RESULTS

Parents and children rarely agreed on the presence of diagnostic conditions, regardless of diagnostic type. Nonetheless, most child-only- and parent-only-identified diagnoses were similarly related to impairment and clinical validation, with 2 exceptions: child-only-identified attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).

CONCLUSIONS

Overall findings suggest that most "discrepant" diagnoses (those reported by one but not the other informant) reflect meaningful clinical conditions. In some instances, however, diagnoses reported by one but not the other informant should be treated with caution, as they may not reflect the full diagnostic condition (e.g., possibly child-only-identified ADHD or ODD). Further research is needed to determine the salience of child-only- or parent-only-reported cases.

Informant-based determinants of symptom attenuation in structured child psychiatric interviews

Informant-related determinants of item attenuation, that is, the drop-off in symptom endorsement rates at retest, were examined in an enriched community subsample of 245 parent-child pairs drawn from the National Institute of Mental Health Methods for Epidemiology of Child and Adolescent Mental Disorders Study. Youngsters and their parents were interviewed with the Diagnostic Interview Schedule for Children (Version 2.3; DISC-2.3) on two occasions with a mean test-retest interval of 12 days. Item attenuation rates were high for both informants, with adults failing to confirm 42% and children 58% of baseline responses at retest. Stepwise regressions revealed that item attenuation at DISC-P retest was higher for adult informants who were younger, and who reported on older and less impaired children. On the DISC-C, attenuation was higher for children who were less impaired, rated as doing worse in school, and who had a longer test-retest interval. These results are broadly consistent with past studies examining the determinants of attenuation and test-retest reliability and have implications for the design and use of structured diagnostic instruments.

Test-Retest Reliability of the Computerized CIDI (CIDI-Auto): Substance Abuse Modules

This paper discusses the reliability of the Alcohol and Substance Abuse modules of the CIDI-Auto in two countries, Australia and Puerto Rico, and two languages, English and Spanish. CIDI-Auto is a computer-assisted version of the CIDI. Reliability estimates for DSM/ICD are presented at the diagnostic and symptom level. In total, 286 subjects, ages 17-60 years, who had at least 12 drinks of alcohol in their lifetime participated in the study. Adequate to good test-retest reliability estimates were obtained, with no major differences by nosology, site, substance, or time. Harmful use/abuse showed lower kappas than dependence. Reliability estimates for dependence ranged from 0.70 to 0.95. For harmful use, kappa's ranged from 0.45 to 0.66. The findings are encouraging; CIDI-Auto produces reliable classification across two settings and in two languages with an instrument that has good coverage of different manifestations of the illness.

The Spanish Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS): reliability and concordance with clinical diagnoses in a Hispanic population

OBJECTIVE

The study reports the process of translation into Spanish and adaptation to the Hispanic culture of the Alcohol Use Disorder and Associated Disabilities Schedule (AUDADIS). This instrument is a structured diagnostic interview schedule specifically developed for the assessment of substance-related disorders and their comorbid disorders and disabilities.

METHOD

A random sample (N = 169) of adults from a primary health care clinic in Puerto Rico was selected. The test-retest reliability of the instrument was examined across time and across interviewers, and the validity was assessed by comparing computer-derived diagnoses obtained through the administration of lay interviewers with best estimate diagnoses given by board-certified psychiatrists.

RESULTS

For most diagnoses and symptoms studied, as well as for most of the alcohol consumption measures, the test-retest reliability of the Spanish AUDADIS was consistent with results reported in other national and international studies using this instrument. Good to excellent test-retest reliability was obtained for the diagnoses of alcohol dependence and major depression. Similarly, good to excellent agreement was obtained between the lay administered AUDADIS and best estimate diagnoses for most diagnostic categories, with the exception of dysthymia. As in other studies, the reliability and validity of the substance abuse category was poor. When agreement for this category was estimated independent of lifetime dependence, both the reliability and validity coefficients were considerably improved.

CONCLUSIONS

The Spanish AUDADIS generally demonstrates good to excellent levels of reliability and validity that are comparable to findings reported for this instrument in other national and international studies.

The costs of schizophrenia in Puerto Rico

Mental illnesses generate social costs by reducing the productive capacity of manpower and increasing government and private expenditure in mental health services. The social costs associated with a mental illness depend on several factors: the level of impairment caused; the type of specialized service required, such as medical treatment; the chronicity of the disorder; and the age of onset of the disorder. Finally, the total cost to society depends on the size of the population affected by the disorder. Results confirm those of other research, which has found schizophrenia to be a costly illness. Annual loss of income represents 3.7% of the annual gross national product of the island. The expenditures for mental health services are 26.8% of the total budget of the Mental Health Secretariat. The large human capital cost caused by the disorder justifies more funds for research and treatment for people who are schizophrenic.

Prevalence of suicide ideation and suicide attempts in nine countries

BACKGROUND

There are few cross-national comparisons of the rates of suicide ideation and attempts across diverse countries. Nine independently conducted epidemiological surveys using similar diagnostic assessment and criteria provided an opportunity to obtain that data.

METHODS

Suicide ideation and attempts were assessed on the Diagnostic Interview Schedule in over 40000 subjects drawn from the United States, Canada, Puerto Rico, France, West Germany, Lebanon, Taiwan, Korea and New Zealand.

RESULTS

The lifetime prevalence rates/100 for suicide ideation ranged from 2.09 (Beirut) to 18.51 (Christchurch, New Zealand). Lifetime prevalence rates/100 for suicide attempts ranged from 0.72 (Beirut) to 5.93 (Puerto Rico). Females as compared to males had only marginally higher rates of suicidal ideation in most countries, reaching a two-fold increase in Taiwan. Females as compared to males had more consistently higher rates for suicide attempts, reaching a two- to three-fold increase in most countries. Suicide ideation and attempts in most countries were associated with being currently divorced/separated as compared to currently married.

CONCLUSIONS

While the rates of suicide ideation varied widely by country, the rates of suicide attempts were more consistent across most countries. The variations were only partly explained by variation in rates of psychiatric disorders, divorce or separation among countries and are probably due to cultural features that we do not, as yet, understand.

Child outpatient mental health service use: why doesn't insurance matter?

BACKGROUND: Several recent studies of child outpatient mental health service use in the US have shown that having private insurance has no effect on the propensity to use services. Some studies also find that public coverage has no beneficial effect relative to no insurance. AIMS: This study explores several potential explanations, including inadequate measurement of mental health status, bandwagon effects, unobservable heterogeneity and public sector substitution for private services, for the lack of an effect of private insurance on service use. METHODS: We use secondary analysis of data from the three mainland US sites of NIMH's 1992 field trial of the Cooperative Agreement for Methodological Research for Multi-Site Surveys of Mental Disorders in Child and Adolescent Populations (MECA) Study. We examine whether or not a subject used any mental health service, school-based mental health services or outpatient mental health services, and the number of outpatient visits among users. We also examine use of general medical services as a check on our results. We conduct regression analysis; instrumental variables analysis, using instruments based on employment and parental history of mental health problems to identify insurance choice, and bivariate probit analysis to examine multiservice use. RESULTS: We find evidence that children with private health insurance have fewer observable (measured) mental health problems. They also appear to have a lower unobservable (latent) propensity to use mental health services than do children without coverage and those with Medicaid coverage. Unobserved differences in mental health status that relate to insurance choice are found to contribute to the absence of a positive effect for private insurance relative to no coverage in service use regressions. We find no evidence to suggest that differences in attitudes or differences in service availability in children's census tracts of residence explain the non-effect of insurance. Finally, we find that the lack of a difference is not a consequence of substitution of school-based for office-based services. School-based and office-based specialty mental health services are complements rather than substitutes. School-based services are used by the same children who use office-based services, even after controlling for mental health status. DISCUSSION: Our results are consistent with at least two explanations. First, limits on coverage under private insurance may discourage families who anticipate a need for child mental health services from purchasing such insurance. Second, publicly funded services may be readily available substitutes for private services, so that lack of insurance is not a barrier to adequate care. Despite the richness of data in the MECA dataset, cross-sectional data based on epidemiological surveys do not appear to be sufficient to fully understand the surprising result that insurance does not enable access to care. IMPLICATIONS FOR POLICY AND RESEARCH: Limits on coverage under private mental health insurance combined with a relatively extensive system of public mental health coverage have apparently generated a situation where there is no observed advantage to the marginal family of obtaining private mental health insurance coverage. Further research using longitudinal data is needed to better understand the nature of selection in the child mental health insurance market. Further research using better measures of the nature of treatment provided in different settings is needed to better understand how the private and public mental health systems operate.

The comorbidity of alcoholism with anxiety and depressive disorders in four geographic communities

The comorbidity of alcoholism with anxiety and depressive disorders was examined in four epidemiologic investigations from diverse geographic sites. Despite variability in lifetime prevalence rates for these disorders, there was strong cross-site consistency in the magnitude and specific patterns of comorbidity. Individuals with alcohol abuse or dependence generally experienced a twofold to threefold increased risk of anxiety and depressive disorders. Phobic conditions typically preceded the onset of alcoholism, but no systematic pattern was observed for panic or depressive disorders. Considerable heterogeneity was also observed concerning the impact of comorbid conditions on symptoms of the index disorder. While the presence of comorbid anxiety or depressive disorders was consistently associated with moderate increases in the symptoms of alcohol abuse or dependence, alcoholism was associated with large increases in the number of depressive symptoms and little or no increase in phobic symptoms. The findings are discussed in terms of the self-medication hypothesis and the etiologic heterogeneity of these forms of comorbidity in the general population.

Concordance of DSM-IV alcohol and drug use disorder criteria and diagnoses as measured by AUDADIS-ADR, CIDI and SCAN

This study was designed to examine the agreement of DSM-IV alcohol and drug use disorder diagnoses generated by three WHO/NIH diagnostic instruments, the AUDADIS-ADR, the CIDI, and the SCAN. This substudy, conducted in three countries, Greece, Luxembourg, and the United States, was part of the larger joint project on diagnosis and classification of mental disorders and alcohol and drug-related problems, which was initiated to evaluate the cross-cultural applicability of the instruments and the criteria. Overall, concordance among the three assessments was good for alcohol and opiate dependence, fair to good for cocaine and sedative dependence, and low for amphetamine dependence. Cannabis dependence concordance was significantly more discrepant than any other substance. Agreement on abuse was low for all substances examined. In addition, the concordance of DSM-IV criteria for each substance was examined. Finally, reasons for discrepancies in responses among assessments were examined, based on discrepancy interview protocol methodology. Further investigation will help to refine these instruments in order to provide a more thorough understanding of alcohol and drug abuse diagnoses.

The epidemiology of mental disorders in the adult population of Puerto Rico

OBJECTIVES

The main objective of the manuscript is to present a review of the literature of the psychiatric epidemiological studies carried out in Puerto Rico in the last decade.

BACKGROUND

Data from three major epidemiological surveys carried out in the last decade is presented which provide evidence against prior long standing observations that Puerto Ricans reported higher levels of psychiatric symptomatology as compared to other populations and ethnic groups in the United States.

METHODS

The studies selected for review were the universe of population epidemiological studies carried out in Puerto Rico in the last decade. All studies used island wide probability sampling procedures to select the study population.

RESULTS

Rates of psychiatric disorders in Puerto Rico were found to be significantly different from those obtained in United States communities. Exceptions were somatization disorder and symptoms which were found to be significantly more common in Puerto Rico and drug abuse/dependence which was found to be considerably less common in the island as compared to the Unites States adults in the age range of 17 to 67 years old.

CONCLUSION

In spite of several indicators of social disruption in the island, the prevalence of most psychiatric disorders does not appear to be more prevalent than in other communities in the United States and other parts of the world. Risk factors for mental disorders are also similar, although sex ratios for gender linked disorders are more marked in the island.

What happens to depressed men? Application of the Stirling County criteria

In a recent issue of the Harvard Review of Psychiatry, results from the Stirling County Study showed that the prevalence and incidence rates of depression were similar in men and women when "gender-fair" criteria were used and help-seeking was not required. We attempted to replicate these findings by applying the criteria for depression from the Stirling County Study to two national and six international epidemiologic surveys conducted in the 1980s and 1990s. Depression was defined as dysphoric mood and disturbances of sleep, appetite, and energy, with at least a mild degree of impairment. The rates of depression were computed using this algorithm with data from the US Epidemiologic Catchment Area Study, conducted in the 1980s, the US National Comorbidity Survey, conducted in the 1990s, and independent community surveys from Canada, Puerto Rico, France, Taiwan, Korea, and New Zealand. For the US studies, these rates were recalculated after persons seeking treatment were removed from the analyses, where such data were available. Using Stirling County Study criteria, the lifetime prevalence rate of depression remains approximately twice as high in women as in men cross-nationally, except in Puerto Rico. Excluding help-seeking as a criterion and controlling for birth cohort do not change the findings. The Stirling County findings on absence of a sex difference in rates of depression using "gender-fair" criteria may be due to methodological variance in the collection of data, sample size, or the social and/or genetic uniqueness of the Atlantic Canadian community.

The cross-national epidemiology of panic disorder

BACKGROUND

Epidemiological data on panic disorder from community studies from 10 countries around the world are presented to determine the consistency of findings across diverse cultures.

METHOD

Data from independently conducted community surveys from 10 countries (the United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, and New Zealand), using the Diagnostic Interview Schedule and DSM-III criteria and including over 40,000 subjects, were analyzed with appropriate standardization for age and sex differences among subjects from different countries.

RESULTS

The lifetime prevalence rates for panic disorder ranged from 1.4 per 100 in Edmonton, Alberta, to 2.9 per 100 in Florence, Italy, with the exception of that in Taiwan, 0.4 per 100, where rates for most psychiatric disorders are low. Mean age at first onset was usually in early to middle adulthood. The rates were higher in female than male subjects in all countries. Panic disorder was associated with an increased risk of agoraphobia and major depression in all countries.

CONCLUSIONS

Panic disorder is relatively consistent, with a few exceptions, in rates and patterns across different countries. It is unclear why the rates of panic and other psychiatric disorders are lower in Taiwan.

Cross-national epidemiology of major depression and bipolar disorder

OBJECTIVE

To estimate the rates and patterns of major depression and bipolar disorder based on cross-national epidemiologic surveys.

DESIGN AND SETTING

Population-based epidemiologic studies using similar methods from 10 countries: the United States, Canada, Puerto Rico, France, West Germany, Italy, Lebanon, Taiwan, Korea, and New Zealand.

PARTICIPANTS

Approximately 38000 community subjects.

OUTCOME MEASURES

Rates, demographics, and age at onset of major depression and bipolar disorder. Symptom profiles, comorbidity, and marital status with major depression.

RESULTS

The lifetime rates for major depression vary widely across countries, ranging from 1.5 cases per 100 adults in the sample in Taiwan to 19.0 cases per 100 adults in Beirut. The annual rates ranged from 0.8 cases per 100 adults in Taiwan to 5.8 cases per 100 adults in New Zealand. The mean age at onset shows less variation (range, 24.8-34.8 years). In every country, the rates of major depression were higher for women than men. By contrast, the lifetime rates of bipolar disorder are more consistent across countries (0.3/100 in Taiwan to 1.5/100 in New Zealand); the sex ratios are nearly equal; and the age at first onset is earlier (average, 6 years) than the onset of major depression. Insomnia and loss of energy occurred in most persons with major depression at each site. Persons with major depression were also at increased risk for comorbidity with substance abuse and anxiety disorders at all sites. Persons who were separated or divorced had significantly higher rates of major depression than married persons in most of the countries, and the risk was somewhat greater for divorced or separated men than women in most countries.

CONCLUSIONS

There are striking similarities across countries in patterns of major depression and of bipolar disorder. The differences in rates for major depression across countries suggest that cultural differences or different risk factors affect the expression of the disorder.

Criterion validity of the NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3)

OBJECTIVE

To examine the criterion validity of the NIMH Diagnostic Interview Schedule for Children (DISC) Version 2.3 in the NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, using a design that permitted several comparisons of DISC-generated diagnoses with diagnoses based on clinician symptom ratings.

METHOD

Two hundred forty-seven youths were selected from the 1,285 parent-youth pairs that constituted the four-site MECA sample. Subjects who screened positive for any of the five diagnostic areas under investigation in the validity study (attention-deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, depressive disorder, and the major anxiety disorders) were recruited, as well as a comparable number of screen negatives. Clinicians reinterviewed separately both the youth and the primary caregiver using the DISC followed by a clinical-style interview, and then they rated the presence of symptoms and impairment. Computer algorithms combined this information into diagnoses using comparable rules for both DISC and clinical rating diagnoses.

RESULTS

In general, the DISC showed moderate to good validity across a number of diagnoses.

CONCLUSIONS

Results suggest some specific diagnostic areas in which further revision of the DISC is warranted. Three main sources of variability in DISC-clinician diagnostic agreement were evident over and above that due to the instrument itself, including (1) the informant used, (2) the algorithm applied in synthesizing symptom reports, and (3) the design of the validity comparison.

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.

Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force

Associations between affective disorders, anxiety disorders, and substance use disorders were examined in epidemiological studies conducted in Germany, Switzerland, Puerto Rico, and the mainland US. There was a remarkable degree of similarity across studies in the magnitude and type of specific disorders associated with the affective disorders. Comorbidity with affective disorders was greater for the anxiety disorders than for substance misuse. Panic disorder was the subtype of anxiety that was most highly comorbid with depression. Social phobia was the specific phobic type with the strongest association with the affective disorders. The magnitude of associations between substance misuse and affective disorders generally was quite low and less consistent across sites. No major differences were found in the patterns of comorbidity by gender or age group, affective subtype or prevalence period. The onset of anxiety disorders generally preceded that of depression, whereas alcohol misuse was equally likely to pre-or post-date the onset of affective disorders. Finally, comorbidity was associated with an elevation in treatment rates across all sites, confirming Berkson's paradox on an international level.

The cross-national epidemiology of social phobia: a preliminary report

We present a preliminary report on cross-national rates, age at onset, comorbidity, suicide attempts and symptom profiles of social phobia. These data are based on epidemiologic community surveys using similar methods from the United States, Canada, Puerto Rico and Korea. The lifetime rate of social phobia (cases per 100 persons) varies by country, from 2.6 in the United States to 0.5 in Korea. Rates are higher in females than in males in all countries. The age of onset for any phobia is mid-teens to early twenties, and social phobia usually has its first onset before other psychiatric disorders. Only a third or fewer cases of social phobia are uncomplicated by another psychiatric disorder. The presence of social phobia increases the risk of suicide attempts in persons with any other psychiatric disorder. Symptom profiles vary by country. Our data indicate consistent patterns but different cultural expressions of social phobia in the countries studied. The early age of onset of social phobia followed subsequently by another psychiatric disorder raises the possibility that early treatment of social phobia could prevent the onset of other psychiatric disorders.

The Diagnostic Interview Schedule for Children (DISC-2.1) in Spanish: reliability in a Hispanic population

The reliability across time, informants and interviewers of the Spanish translation of the DISC-2.1 was tested on a Puerto Rican Hispanic sample using a test-retest design. Levels of reliability between clinic and community samples and between younger and older children were compared to explore the sources of low reliability for certain psychiatric disorders. Parents' reports tended to be more reliable than those of their children, although the difference was less obvious with older children. Reliability was generally higher for the externalizing disorders and when the second interviewer was a psychiatrist rather than a lay interviewer.

Test-retest reliability of the Diagnostic Interview Schedule for Children (DISC 2.1). Parent, child, and combined algorithms

BACKGROUND

Previous research has not compared the psychometric properties of diagnostic interviews of community samples and clinically referred subjects within a single study. As part of a multisite cooperative agreement study funded by the National Institute of Mental Health, 97 families with clinically referred children and 278 families identified through community sampling procedures participated in a test-retest study of version 2.1 of the Diagnostic Interview Schedule for Children (DISC 2.1).

METHODS

The DISC was separately administered to children and parents, and diagnoses were derived from computer algorithms keyed to DSM-III-R criteria. Three sets of diagnoses were obtained, based on parent information only (DISC-P), child information only (DISC-C), and information from either or both (DISC-PC).

RESULTS

Test-retest reliabilities of the DISC-PC ranged from moderate to substantial for diagnoses in the clinical sample. Test-retest kappa coefficients were higher for the clinical sample than for the community sample. The DISC-PC algorithm generally had higher reliabilities than the algorithms that relied on single informants. Unreliability was primarily due to diagnostic attenuation at time 2. Attenuation was greatest among child informants and less severe cases and in the community sample.

CONCLUSIONS

Test-retest reliability findings were consistent with or superior to those reported in previous studies. Results support the usefulness of the DISC in further clinical and epidemiologic research; however, closely spaced or repeated DISC interviews may result in significant diagnostic attenuation on retest. Further studies of the test-retest attenuation phenomena are needed, including careful examination of the child, family, and illness characteristics of diagnostic stability.

Psychometric properties of parents and children as informants in child psychiatry epidemiology with the Spanish Diagnostic Interview Schedule for Children (DISC.2)

Parent and child reports were examined to study how epidemiological researchers can best use the information provided to describe childhood psychopathology. As part of a multisite methodologic study of mental disorders in children, a probability sample (N = 248) of children aged 9 to 17 years from the San Juan metropolitan area was selected. This sample was enriched with 74 clinic cases. Both parents and children were administered the DISC.2. Results showed that prevalence estimates were influenced by the informant. The clinicians' diagnosis is more concordant with children's reports of depression and with parents' reports of disruptive disorders. Parents and children provided unique information when interviewed with a structured psychiatric interview about child psychopathology. Their unique perspectives contributed to the observed discordance that emerged when DISC parent and DISC child results are compared. Combining the two perspectives with a simple "OR" rule at the symptom level did not seem to capture the unique perspectives.

The cross national epidemiology of obsessive compulsive disorder. The Cross National Collaborative Group

Data on the epidemiology of psychiatric disorders from different parts of the world using similar methods and diagnostic criteria have previously not been available. This article presents data on lifetime and annual prevalence rates, age at onset, symptom profiles, and comorbidity of obsessive compulsive disorder (OCD), using DSM-III criteria, from community surveys in seven countries: the United States, Canada, Puerto Rico, Germany, Taiwan, Korea, and New Zealand. The OCD annual prevalence rates are remarkably consistent among these countries, ranging from 1.1/100 in Korea and New Zealand to 1.8/100 in Puerto Rico. The only exception is Taiwan (0.4/100), which has the lowest prevalence rates for all psychiatric disorders. The data for age at onset and comorbidity with major depression and the other anxiety disorders are also consistent among countries, but the predominance of obsessions or compulsions varies. These findings suggest the robustness of OCD as a disorder in diverse parts of the world.

The Spanish translation and cultural adaptation of the Diagnostic Interview Schedule for Children (DISC) in Puerto Rico

This article illustrates a comprehensive cross-cultural adaptation model used to translate into Spanish and to culturally adapt the Diagnostic Interview Schedule for Children (DISC). The process strived to identify similar phenomena to those identified by the original English version in a dissimilar context. To attain cross-cultural equivalency five important dimensions were addressed: semantic, technical, content, criterion and conceptual. To meet this challenge various steps were taken, including bilingual committee, back-translation, reliability and validity testing. The result is an instrument which could be used, not only in Puerto Rico, but also in other Spanish-speaking child and adolescent populations after appropriate cultural adaptations.