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Public Health Surveillance. “The ongoing, systematic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health.”

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public health surveillance
Public Health Surveillance
  • “The ongoing, systematic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health.”
      • Centers for Disease Control and Prevention, (2001). Updated guidelines for evaluating public health surveillance systems: Recommendations from the guidelines working group. Morbidity and Mortality Weekly Report 2001, 50 (No. RR-13), 1 – 35.
features of public mental health surveillance system galea norris
Features of Public Mental Health Surveillance System (Galea & Norris)
  • A functionally hybrid system to maximize cost-effectiveness because disease-specific surveillance of psychological disorders (diagnoses) would be prohibitively expensive,
    • they recommend ongoing syndromic surveillance focusing on key indicators of current depression, PTSD, dysfunction, anxiety/fears, and psychosocial resources, punctuated with occasional disease-specific surveys and more in-depth assessment of risk and protective factors
features of public mental health surveillance system galea norris3
Features of Public Mental Health Surveillance System (Galea & Norris)
  • Surveillance be implemented on a large enough scale to provide data for specific racial, ethnic, and socioeconomic groups.
    • This would increase understanding of the differences in the need for and use of mental health services.
  • Public Mental Health Surveillance must aim to educate major stakeholders, including the general public.
mental health epidemiologic studies
Mental Health Epidemiologic Studies
  • First-generation - 16 (Prior to World War II)
      • E. Jarvis: Insanity and Idiocy in MA: Report of the Commission on Lunacy, 1855. Cambridge, MA: HU ‘71
      • Institutional records and key informants
      • Prevalence in specialty mental health settings
  • Second-generation - 60 (1950 – 1980)
    • Stirling County Study (1952)
    • Baltimore Morbidity Survey (1953/54)
    • Midtown Manhattan Study (1954)
    • Mental Health Study in New Haven (1967-75)
      • Predefined “operationalized” criteria
      • Structured interviews by non-clinician interviewers
      • Prevalence in the community
mental health epidemiologic studies5
Mental Health Epidemiologic Studies
  • Third-generation (1980 - present)
    • Epidemiologic Catchment Area (1980-85)
      • In response to President’s Commission on Mental Health (PCMH)
      • Diagnostic Interview Schedule (DIS)
      • Prevalence and incidence of mental disorders
      • Use and need for services
      • Research teams from 5 universities
        • Yale, Johns Hopkins, Washington University, Duke, and UCLA in collaboration with NIMH
      • Community Mental Health Catchment Area sites:
        • New Haven, CT, Baltimore, MD, St Louis, MO, Durham, NC, and Los Angeles, CA
mental health epidemiologic studies6
Mental Health Epidemiologic Studies
  • Third-generation (1980 - present)
    • National Comorbidity Survey (NCS)
      • First nationally representative mental health survey in the U.S. to use a fully structured interview (WHO revised CIDI) to assess the prevalence and correlates of DSM-III-R disorders
      • Composite International Diagnostic Instrument (CIDI)
      • Interviews from Fall 1990 to Spring 1992
      • Re-interviewed in 2001 – 2002 (NCS-2)
mental health epidemiologic studies7
Mental Health Epidemiologic Studies
  • Third-generation (1980 - present)
    • NCS Replication (NCS-R)
      • Reinterviewed in 2001 – 2002 (NCS-2)
      • Interviewed a new nationally representative sample repeating many of the questions from the original NCS and expanding disease assessment criteria based on DSM-IV
      • Uncover trends in mental health
        • Prevalence
        • Impairment
        • Service use
instruments
Instruments
  • Diagnostic Interview Schedule (DIS)
    • Used in ECA
  • World Health Organization (WHO) Composite International Diagnostic Interview (CIDI)
    • Used in NCS
instruments9
Instruments
  • Short Form (SF-36)
    • Mental Component Score (MCS), and Mental Health (MH-5) 1 0f 8 domains
  • General Health Questionnaire (GHQ)
    • GHQ-12
  • Mini-International Neuropsychiatric Interview (MINI), Sheehan et al., (1998)
instruments10
Instruments
  • Patient Health Questionnaires (PHQ)
    • Prime-MD, PHQ-9, PHQ-8, and PHQ-2
    • PHQ-8 used in:
      • BRFSS 2006 and 2008
    • PHQ-9 used in:
      • NHANES 2005 - 2006
instruments11
Instruments
  • Kessler scales
    • K10 has been used in:
      • WHO World Mental Health (WMH) Surveys
        • 250,000 people
        • 30 countries
      • Australian Bureau of Statistics, National Survey of Mental Health and Wellbeing (SMHWB)
    • K6 (past 30 days) used in:
      • BRFSS 2007
      • NHIS (since 1997)
    • K6 (worst 30 days in past year) used in:
      • NSDUH
slide12
SMI
  • SAMHSA’s official definition of adults with SMI, based on a notice published in the Federal Register (SAMHSA, Center for Mental Health Services, 1993):
      • Age 18 and over, and
      • Currently have, or at any time during past year, had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet DSM-IV or ICD-9-CM equivalent, with the exception of substance use disorders, and developmental disorders;
      • Has resulted in functional impairment which substantially interferes with or limits one or more major life activities.
from smi
From SMI…
  • NSDUH implemented the modified K6 (worst 30 days in past year) to assess SMI based on a methodological study to evaluate several screening scales for measuring SMI
    • Truncated version of WHO-CIDI
    • K10/K6 scale of non-specific psychological distress
    • WHO-Disability Assessment Schedule
    • Respondents with a total score of 13 or greater were classified as having past year SMI
to spd
…to SPD
  • In 2003 NSDUH contained a broad array of questions about mental health that preceded the K6 items, and the four extra questions in the K10 scale interspersed among the items in the K6 scale.
  • In 2004 NSDUH, the sample of respondents 18 or older was split evenly between the “long form” as used in 2003 NSDUH, and a “short form” consisting of only K6 items.
  • Results showed large differences between the two samples in both the K6 total score and the proportion of respondents with a K6 total score of 13 or greater.
    • K6 scale was found not to be context independent
    • GAF score of less than 60 (moderate) not per definition
      • Changed: GAF score of less than or equal to 50 (serious)
clinically significant vs mild disorders
Clinically Significant vs Mild Disorders
  • Using data on clinical significance lowered past-year prevalence rates of “any disorder” among 18 – 54-year-olds by 17% in the ECA and 32% in NCS and discrepancies between these two surveys are largely due to methodologic differences.
  • Establishing the clinical significance of disorders in the community is crucial for estimating treatment need
          • Narrow WE, Rae DS, Robins LN, Regier DA. Revised prevalence estimates of mental disorders in the United States. Arch Gen Psychiatry. 2002;59:115-123
clinically significant vs mild disorders16
Clinically Significant vs Mild Disorders
  • Twelve-month NCS/DSM-III-R disorders were disaggregated into:
      • 3.2% severe, 3.2% serious, 8.7% moderate, and 16.0% mild case categories
      • All 4 case categories were associated with statistically significant (p<.05) elevated risk of NCS-2 outcomes compared with baseline non-cases, with odds ratios of any outcome ranging monotonically from 2.4 to 15.1 for mild to severe cases.
      • There is a graded relationship between mental illness severity and later clinical outcomes.
          • Kessler RC, Merikangas KR, Berglund P, Eaton WW, Koretz DS, Walters EE. Mild disorders should not be eliminated from DSM-V. Arch Gen Psychiatry. 2003;60:1117-1122.
managing depression as a chronic disease
Managing depression as a chronic disease
  • Evidence from trials of the efficacy of short term treatment
        • Nathan PE, Gorman, J, eds. A guide to treatments that work. Oxford: Oxford University Press, 1998
          • Four types of antidepressant drugs, cognitive behavior and interpersonal therapy, and electroconvulsive therapy produced benefits of 0.5 to 1.0 standard deviation over the response to placebo.
          • Depression is a disorder that remits
          • Depression also recurs
dynamic and chronic nature of depression
Dynamic and chronic nature of depression
  • Results from the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) indicate six-month recovery and remission rates of 50% and 70% respectively.
  • Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial evaluated depression treatment strategies comparing four sequential steps of different medications, medication combinations, or medication with cognitive behavior therapy.
      • 37% of depressed patients had remission after the first step (citalopram only),
      • a total of 67% achieved remission after all four steps, and
      • only 43% had sustained recovery.
take away messages
Take-away messages
  • Depression, while recognized as a highly recurrent and often a chronic disorder requiring long-term treatment, frequently remains unrecognized and untreated or inadequately treated.
  • Sub-threshold or minor depression is often associated with disability and poor psychosocial functioning, and a potentially more severe course that requires treatment.
  • If left untreated or inadequately treated, depression can be a source of much unnecessary personal distress, prolonged family burden, and significant morbidity and mortality.
  • When left untreated or inadequately treated, including premature termination of treatment, depression more likely persists, reoccurs, and worsens
take away messages20
Take-away messages
  • Need ongoing syndromic surveillance focusing on key indicators of current depression because disease-specific surveillance of psychological disorders (diagnoses) would be prohibitively expensive.
  • Occasional disease-specific surveys and more in-depth assessment of risk and protective factors.
  • Periodic combination of the two types of data (indicators and diagnoses) would facilitate interpretation of the indicator data, which would be collected more frequently and regularly.
  • Clinically significant and mild or sub-syndromal disorders need to be monitored
public mental health surveillance questions

Public Mental Health Surveillance: Questions

Satvinder “Pearly” Dhingra, MPH

Behavioral Surveillance Branch

[email protected]

770-488-5444

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