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.

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.

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.

The prevalence of ataques de nervios in the Puerto Rico disaster study. The role of culture in psychiatric epidemiology

This paper presents one of the few epidemiological studies of a popular category of distress, ataques de nervios (attacks of nerves), in the cross-cultural psychiatric literature. As part of a major study of the psychological consequences of the 1985 floods and mudslides which caused considerable damage and death in Puerto Rico, a question was added to the Diagnostic Interview Schedule/Disaster Supplement concerning ataques de nervios. This additional item provided the opportunity to carry out the first study of this important Puerto Rican popular category of distress using a representative, community-based sample. This paper addresses several key questions about ataques de nervios which come from previous psychiatric and anthropological literatures concerning the social correlates of who experiences an ataque de nervios and the relationship of ataques to social distress and psychiatric disorder. People who reported an ataque de nervios were more likely to be female, older, less educated, and formerly married. They were also more likely to meet criteria for anxiety and depressive disorders than those who had not experienced an ataque. The picture that emerges from our analyses is that those who suffer from a combination of social disadvantage, psychiatric disorder, and poor perceived health are more likely to experience an ataque de nervios.

Drug abuse and illicit drug use in Puerto Rico

OBJECTIVES

Based on an epidemiologic field survey of community households in Puerto Rico, this study estimates the frequency of illicit drug use and clinically defined drug abuse and/or dependence syndromes. Results are compared with those from surveys on the United States mainland. Suspected risk factors are studied as well, with a special focus on childhood misbehavior.

METHODS

Trained lay interviewers administered a Spanish Diagnostic Interview Schedule to 912 respondents aged 17 to 68 years who were selected by multistage probability sampling of island households.

RESULTS

An estimated 8.2% of the population had a history of illicit drug use and 1.2% qualified for a standardized lifetime diagnosis of drug abuse, dependence, or both. An estimated 18.4% of the male drug users and 7.7% of the female drug users met criteria for drug abuse and/or dependence. A history of drug use was related to the diagnoses of alcohol abuse and/or dependence and antisocial personality, but few persons who had used illicit drugs at least once in their lifetime reported a history of receiving treatment for alcohol, drug, or mental health problems.

CONCLUSIONS

The data were consistent with a suspected association between level of childhood misbehavior and occurrence of illicit drug use, even after statistical control for potentially confounding variables.

Functional somatic symptoms: a cross-ethnic comparison

Type, distribution, and comorbidity of functional somatic symptoms were examined in four community samples, three Hispanic and one non-Hispanic white. Important intergroup and intragroup differences between Hispanic and non-Hispanic white groups were identified. Of the four groups, Puerto Rican respondents reported the highest level of somatic symptoms; this finding was apparently independent of sociodemographic factors.

Somatic symptoms after a natural disaster: a prospective study

The authors prospectively examined the prevalence of somatization symptoms among community respondents after a natural disaster in Puerto Rico. Exposure to the disaster was related to a higher prevalence of medically unexplained physical symptoms, particularly gastrointestinal ones (abdominal pain, vomiting, nausea, excessive gas) and pseudoneurological ones (amnesia, paralysis, fainting, unusual spells/double vision).

Are attentional-hyperactivity deficits unidimensional or multidimensional syndromes? Empirical findings from a community survey

Factor analysis on teacher ratings of symptoms in a probability community sample of children aged 6 to 16 years (N = 614) yielded two factors: Inattention and Hyperactivity-Impulsivity. Subsequent cluster analyses on the scores of factorially derived scales for a subsample of 170 children with a diagnosis of attention deficit disorder with (ADDH) and without hyperactivity (ADDWO), or normals, resulted in five clusters that accounted for 88% of the variance. The existence of these clusters was confirmed using external validating criteria. The data support a bidimensional conceptualization of attention deficit disorder with hyperactivity, one dimension consisting of symptoms of inattention and another of symptoms of hyperactivity-impulsivity. The data also suggests that a condition very similar to the DSM-III-R description of undifferentiated attention-deficit disorder also exists as a distinct entity.

[Importance of the family as a resource in social support in Puerto Rico]

In this article we examine the role of the family in the provision of social support by studying the identity of persons which the participants consider available for providing support. We define social support as that human relationship in which socio-emotional (closeness, intimacy counseling), instrumental (goods and services) and recreational (companionship for recreation) resources are interchanged. Based on a probabilistic sample of the adult (17-68 yrs.) population, 912 persons were successfully interviewed (response rate = 90.4%) using a structured interview schedule. Results indicate that close relatives (parents, brothers/sisters, sons/daughters) are the main resource of all types of support, not only of the general population but also of specific demographic groups defined by their gender, age (17-39, 40-68) and schooling (0-11, 12 + yrs). The marital partner was also identified as an important support resource, especially emotional and recreational; more distant relatives were also important for providing instrumental support. Although the compared groups showed many similarities, they also differed in various aspects both when individually and jointly analyzed. It is concluded that the family is very important in the provision of social support in Puerto Rico (PR).

[The Composite International Diagnostic Interview (CIDI): an epidemiologic instrument suitable for using in conjunction with different diagnostic systems in different cultures]

The Composite International Diagnostic Interview (CIDI), written at the request of the World Health Organization/US Alcohol, Drug Abuse, and Mental Health Administration Task Force on Psychiatric Assessment Instruments, combines questions from the Diagnostic Interview Schedule with questions designed to elicit Present State Examination items. It is fully structured to allow administration by lay interviewers and scoring of diagnoses by computer. A special Substance Abuse Module covers tobacco, alcohol, and other drug abuse in considerable detail, allowing the assessment of the quality and severity of dependence and its course. This article describes the design and development of the CIDI and the current field testing of a slightly reduced "core" version in Puerto Rico. The field test was being conducted in 19 centers around the world to assess the interviews' reliability and its acceptability to clinicians and general people in different cultures and providing data on which to base revisions that may be found necessary. In addition, questions to assess International Classification of Diseases, ninth revision, and the revised DSM-III diagnoses are being written. If all goes well, the CIDI will reliably allow investigators to assess mental disorders according to the most widely accepted nomenclatures in many different populations and cultures.

[Use of health services in Puerto Rico by persons with mental disorders]

As part of a major study on the prevalence of mental disorders in Puerto Rico, this paper describes the mental health care utilization patterns of persons with a DIS/DSM-III disorder within the last year. The main findings of this analysis show that (a) There is a high rate of health service utilization, (b) The public sector is the main provider of services, (c) People with a DIS disorder tend to resort to the non-psychiatric physician, (d) People with alcohol abuse and/or dependence tend to use the services of general practitioners while schizophrenics, somatizers, and people with cognitive impairment tend to apply for the services of mental health specialists. Seeking help from other sources such as clergymen or spiritualists does not substitute the use of health services.

[Utilization of health services in Puerto Rico of persons with mental disorders]

As part of a major study on the prevalence of mental disorders in Puerto Rico, this paper describes the mental health care utilization patterns of persons with a Diagnostic Interview Schedule (DIS) disorder within the last year. The main findings of this analysis show that a) there is a high rate of health service utilization, b) the public sector is the main provider of services c) persons with a DIS disorder use more the non psychiatric physician d) those with alcohol abuse and/or dependence tend to use more the services of general practitioners while schizophrenics, somatizers and those with cognitive impairment use more the services of mental health specialists. The use of other resources such as clergy or spiritualists do not substitute the use of health services.

A cross-cultural adaptation of a psychiatric epidemiologic instrument: the diagnostic interview schedule's adaptation in Puerto Rico

The advent of the use of structured interview schedules that generate psychiatric diagnoses in epidemiologic studies has promoted an intense interest in its cross-cultural use. However, the valid use of these instruments across cultures requires a careful adaptation process which goes beyond mere language translation. In this article the authors illustrate the application of a comprehensive cross-cultural adaptation model to both the translation into Spanish and the adaptation to the population of Puerto Rico of a widely used psychiatric epidemiologic research instrument: the Diagnostic Interview Schedule (DIS). The process aimed to ensure the development of a research instrument that is not only in correct Spanish and comprehensible for most Spanish-speaking people, but also culturally adapted to Puerto Rico's population. Various steps were taken (including bilingual committee, back-translation, instrument testing and diagnostic comparisons) to address cross-cultural validity in five important dimensions (i.e., semantic, technical, content, criterion and conceptual equivalence). The result is an interview schedule that is not only linguistically and culturally adequate for the targeted population but also includes elements which can contribute to the development of the instrument both in its original English language and in its translated versions.

Children of alcoholic parents in the community

The relationship between parental alcoholism and risk for maladjustment in the offspring was investigated in a community sample. Children of parents who met criteria for DIS/DSM-III alcohol abuse or dependence and children of parents who met criteria for ten other diagnoses were compared to children of "normal" parents. The data were obtained from the merging of the data banks of two major psychiatric epidemiology studies of the adult (17-64) and child (4-16) population of Puerto Rico. Results indicated that parental alcoholism in addition to creating an adverse family environment had an effect on the relative risk for maladjustment in the offspring (as measured by scores on the Child Behavior Checklist). Although previous studies have reported higher levels of externalizing behaviors in children of alcoholics, an increased risk for internalizing symptoms was observed in the children studied. Similar findings were obtained for the children of parents with other psychiatric disorders suggesting that the effects of parental alcoholism in children ages 4 to 16 may not be different from the consequences of parental mental illness per se.

Screening for childhood psychopathology in the community using the Child Behavior Checklist

One of the uses of the Child Behavior Checklist is as a screening instrument for childhood psychopathology in two-phase designs. The present report involves a two-phase epidemiological survey conducted in Puerto Rico in which the CBCL was used as a screening instrument during the first stage, and children were evaluated clinically during the second stage. The data indicate that in using the CBCL for screening for psychopathology in children, parent information is most informative, particularly for children in the adolescent age group. Nevertheless, the data also reinforce the need to obtain teacher information with the Teacher Report Form to enhance screening sensitivity. In this population, the data obtained with the Youth Self-Report were found to be of limited usefulness for screening purposes.

[Projections for the prevalence of psychiatric disorders. Puerto Rico, year 2000]

Projections for the prevalence of psychiatric disorders were calculated for the estimated population between 17 and 64 years of age in Puerto Rico for the year 2000. These projections were based on the results of an epidemiologic research study conducted in 1984 using a community based sample and the population estimate for the year 2000. The psychiatric disorders included affective and anxiety disorders, somatization, schizophrenic disorders, and alcohol abuse and/or dependence. The prevalence of each of these disorders will increase by the year 2000. The prevalence of affective and anxiety disorders, in particular, will have a relative increase of 5%. The simultaneous increase in the prevalence of psychiatric disorders and the increase in the population will have the combined effect of increasing the number of expected psychiatric cases by 25%.

Impairment in the epidemiological measurement of childhood psychopathology in the community

The desirability of incorporating a measure of impairment to the categorization of childhood psychopathology in the community is examined. The use of the Children's Global Assessment Scale (CGAS) for this purpose is recommended. The choice of 61 (definite case) and 71 (probable case) as cutpoints on the Children's Global Assessment Scale is supported empirically by the data on service utilization, parental perceived need, and behavior problem scores obtained in the Puerto Rico Child Psychiatry Epidemiological Study.

The internal consistency and concurrent validity of a Spanish translation of the Child Behavior Checklist

The Child Behavior Checklist's applicability to a Hispanic sample was assessed by an examination of the instrument's internal consistency and concurrent validity. The CBCL and TRF were administered to a community sample representative of children of Puerto Rico aged 4 to 16. Cronbach's alpha was used to assess the internal consistency of empirically derived scales. The relation of CBCL and TRF scores to clinical diagnosis, adaptive functioning, and need for services served as indicators of the concurrent validity of the instrument's Spanish version. The results indicate that the total behavior problem scores on the instruments are good continuous measures of maladjustment for children in Puerto Rico. A child with high values on the scales has a high probability of being classified as a case by a psychiatrist. High levels of internal consistency were found in most subscales. Only scales comprising low prevalence problems showed poor internal consistency.

Children of parents with psychiatric disorder in the community

The relationship between parental psychopathology and risk for maladjustment in the offspring was investigated in a community sample. The children of 130 parents who met criteria for 12 DIS/DSM-III disorders were compared to the children of 235 normal parents. Significantly more children of disturbed parents were functionally impaired and had higher scores in the parent and youth Child Behavior Checklist total behavior scores as compared to children of normal parents. These associations were maintained even after accounting for an adverse family environment, suggesting a strong relationship between parental and childhood psychopathology as well as a mediating influence of environmental adversity.

Spiritism in Puerto Rico. Results of an island-wide community study

Using data from the first community-based, epidemiological survey of Puerto Rico, this paper examines the current prevalence of use of spiritist healers by Puerto Ricans, the role of spiritism in the provision of mental health services, and the association between spiritism and psychiatric disorders and symptoms. Those who visit spiritists were found to be more likely to work outside the home, to have a low family income, to have sought help for emotional problems from mental health professionals, and to have mild symptoms of depression.

Epidemiological comparisons of Puerto Rican and U.S. mainland children: parent, teacher, and self-reports

U.S. mainland and Puerto Rican nonreferred samples were compared via the Child Behavior Checklist (ages 4 to 16), Teacher's Report Form (ages 6 to 16), and Youth Self-Report (ages 12 to 16). Problem scores were significantly higher in parent and teacher ratings of Puerto Rican than mainland subjects, but were significantly lower in self-ratings by Puerto Rican adolescents. Adolescents in both cultures reported significantly more problems than their parents or teachers did. Most of the significant cross-cultural differences in parent, teacher, and self-ratings of competencies showed more favorable scores for the mainland subjects. High referral rates, a high prevalence of DSM diagnoses, and low scores on the Children's Global Assessment Scale are consistent with the high problem rates reported by Puerto Rican parents and teachers but not with the lower rates reported by adolescents. Different clinical cutoffs may be needed for all assessments in the mainland versus Puerto Rico.

Ataques de nervios in the Puerto Rican Diagnostic Interview Schedule: the impact of cultural categories on psychiatric epidemiology

This paper examines the effect of the cultural category ataques de nervios on responses to the Puerto Rican Diagnostic Interview Schedule (DIS), a Spanish version of structured psychiatric diagnostic interview developed for the NIMH Epidemiologic Catchment Area study. An ataque de nervios scale was created from the Somatization items of the DIS to explore the effect of this culturally meaningful category of distress on responses to a standard psychiatric interview. Analysis of 1,513 cases from a representative sample of the island of Puerto Rico indicated that people reporting ataque symptoms fit the social characteristics described for ataques sufferers in the ethnographic literature. Qualitative data indicated that Puerto Ricans were reporting ataques de nervios in the panic section of the DIS. Questions are raised about the validity of the somatization and panic sections of the DIS in cross-cultural research with Hispanics.

Somatic symptom index (SSI): a new and abridged somatization construct. Prevalence and epidemiological correlates in two large community samples

An abridged somatization construct (the Somatic Symptom Index) derived from the Diagnostic Interview Schedule's somatization disorder items was tested on community epidemiological samples to examine its prevalence, risk factors, and predictive value. The construct had a high prevalence (range, 4.4% to 20% compared with .03% to 0.7% for the full DSM-III somatization disorder diagnosis), was related to low socioeconomic status, female gender, older chronological age, and Hispanic ethnic background. The presence of this construct determined preferential use of medical services and predicted high indices of disability. The Somatic Symptom Index may have practical utility for clinical and community studies of somatoform phenomena.

Estimates of the prevalence of childhood maladjustment in a community survey in Puerto Rico. The use of combined measures

A two-stage epidemiologic survey was carried out on a probability sample of the population aged 4 through 16 years in Puerto Rico. The survey used the Child Behavior Checklist as a screening instrument, and prevalence rates were estimated on the basis of clinical diagnoses and other measures provided by child psychiatrists during the second stage. Maladjustment was operationally defined through the use of combined measures, including DSM-III diagnosis and a scale of functional impairment. Data were provided on the demographic correlates of maladjustment and on the comorbidity of DSM-III diagnostic domains. The prevalence rates obtained vis-à-vis the availability of mental health services on the island reflected a major public health problem.

[Psychiatric diagnostic classification in transcultural epidemiologic studies]

The utility of transcultural psychiatric epidemiology research is discussed as well as the methodological difficulties inherent in this type of investigation. The comparison across different cultures of the prevalence and incidence of mental illness in population studies can be used to obtain a better understanding of the risk and etiological factors involved in the development of specific psychiatric disorders. Nevertheless, most population studies have been carried out in developing countries mostly due to the complexity and high cost of these studies. As a consequence, a gap in psychiatric knowledge is created between the developed and developing countries resulting in the false notion that many of the psychiatric disorders observed in developed countries are universal to all human beings. The cross-cultural validity of certain psychiatric disorders based on the American Psychiatric Nosology (DSM III) are discussed. The article discusses the methodological difficulties which arise from the need of maintaining methods and criteria uniform in cross-cultural studies in order to allow comparisons, as well as the need of incorporating into the methodology the cultural differences existent in the manifestation or definition of the specific psychiatric disorders studied. Various possible methodologies are discussed which address this dilemma, such as the combination of empirical and ethnographic approaches and the cross-cultural comparison of empirically defined syndromes.

Further measures of the psychometric properties of the Children's Global Assessment Scale

The Children's Global Assessment Scale (CGAS), a measure of overall severity of disturbance, is an adaptation of the Global Assessment Scale for adults. Data obtained on the CGAS during a pilot study in Puerto Rico demonstrate high interrater reliability and both concurrent and discriminant validity. A discriminant function was generated that highly correlates with other measures of impairment. Use of the CGAS can be of heuristic value to complement other methods of diagnostic categorization.

The Spanish Diagnostic Interview Schedule. Reliability and concordance with clinical diagnoses in Puerto Rico

A Spanish translation of the Diagnostic Interview Schedule (DIS) was assessed using samples of Puerto Rican patients and community subjects from the San Juan area. Concordance between DIS results from psychiatrists' interviews and from laypersons' interviews was similar to results with the DIS in mainland samples. Comparisons of laypersons' DIS results with psychiatrists' clinical diagnoses yielded generally poorer agreement. Levels of agreement improved when diagnoses were clustered into higher-rank categories. These results raise cultural issues related to the use of the DIS in Puerto Rico.

The prevalence of specific psychiatric disorders in Puerto Rico

An epidemiologic survey of the lifetime and six-month prevalence rates of several psychiatric disorders was conducted in Puerto Rico. This study, carried out in 1984, applied selected schedules of a Spanish translation of the Diagnostic Interview Schedule to a stratified, island-wide probability sample of the population. With few exceptions, prevalence rates in this study were similar to those obtained in the US communities studied in the Epidemiologic Catchment Area program. The demographic correlates of the disorders are reviewed, and differences between the results of this study and those of previous studies suggesting a higher rate of mental disorder among Puerto Rican populations are discussed.