Department of Psychiatry

Revising an international health classification presents a number of challenges that impose a balance between methodological demands and cultural imperatives. The classification must be based on a natural or consensual framework that makes it useful for multiple purposes (eg, policy development, health communications, epidemiological research, or third party payment systems). It should accommodate significant differences between cultures based on language, belief, physical conditions and values. It needs to be ...

Context: Although numerous studies have examined the role of latent variables in the structure of comorbidity among mental disorders, none has examined their role in the development of comorbidity. Objective: To study the role of latent variables in the development of comorbidity among 18 lifetime DSM-IV disorders in the World Health Organization World Mental Health Surveys.

International nosological research was conducted to determine cross-system agreement on alcohol and drug dependence and harmful use (abuse). ICD-10, DSM-IV and DSM-III-R diagnoses were compared in 1811 subjects from a variety of treatment and other types of settings from 12 sites around the world. Three diagnostic instruments were used: the Alcohol Use Disorders and Associated Disabilities Interview Schedule-Alcohol/Drug-Revised (AUDADIS-ADR), the composite international diagnostic interview (CIDI), and the schedules for clinical assessment in neuropsychiatry (SCAN). At seven of the study sites, two or more of these instruments were used. Results for dependence diagnoses showed excellent cross-system agreement across sites and instruments, especially for current diagnoses. Cross-system agreement for harmless use (abuse) was much lower and less consistent. Geographic location or culture appeared to have little influence on the results for either dependence or harmful use.

Aims - The paper reviews recent findings from the WHO World Mental Health (WMH) surveys on the global burden of mental disorders. Methods - The WMH surveys are representative community surveys in 28 countries throughout the world aimed at providing information to mental health policy makers about the prevalence, distribution, burden, and unmet need for treatment of common mental disorders. Results - The first 17 WMH surveys show that mental disorders are commonly occurring in all participating countries. The inter-quartile range (IQR: 25th-75th percentiles) of lifetime DSM-IV disorder prevalence estimates (combining anxiety, mood, externalizing, and substance use disorders) is 18.1–36.1%. The IQR of 12-month prevalence estimates is 9.8–19.1%. Prevalence estimates of 12-month Serious Mental Illness (SMI) are 4–6.8% in half the countries, 2.3–3.6% in one-fourth, and 0.8–1.9% in one-fourth. Many mental disorders begin in childhood-adolescence and have significant adverse effects on sub...

To improve recognition and treatment of depression in primary care it would be advantageous to have criteria for identification of later depression. Only a few studies were performed on primary care samples to examine risk factors for new depressive episodes. These were mostly cross-sectional and did not include psychiatric symptoms as possible predictors. This is the first one-year-follow-up study investigating prospectively psychiatric symptomatology as risk factors for depressive episodes in a primary care sample. An international primary care sample of initially non-depressed subjects (n = 2,445) was examined for the presence of depression (ICD-10) at follow-up. Initial measures addressed presence of psychiatric symptoms according to the CIDI-Primary Health Care Version and sociodemographic variables. Logistic regression analysis was carried out to determine the relationship with the development of new depressive episodes. After one year, 4.4 % of primary care patients met ICD-10 criteria for a depressive episode. Logistic regression analysis revealed that symptoms of depression and physical, mainly pain-related symptoms were associated with depression at follow-up. General practitioners therefore should be careful in the consideration of depressive symptoms but also of somatic complaints which might precede depression or mask depressive symptomatology. The present results might be helpful for future development of prediction scales.

Therapeutic factors in an inpatient group from Turkey are presented. A total of 40 patients were seen over a period of 2 years and each patient was given Yalom's (1983) 60-item therapeutic factor list on discharge. The first four most valued therapeutic factor groups were Catharsis, Existential Factors, Cohesiveness and Hope. There were significant differences in the highly valued factors in different diagnostic groups. Patients with diagnoses of anxiety/somatization and borderline~identity problem preferred factors resembling those in many outpatient studies. The results are discussed in the light of relevant literature.

This paper outlines the approach that the WHO's Family of International Classifications (WHO-FIC) network is undertaking to create ICD-11. We also outline the more focused work of the Quality and Safety Topic Advisory Group, whose activities include the following: (i) cataloguing existing ICD-9 and ICD-10 quality and safety indicators; (ii) reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering; (iii) substantial restructuring of the healthcare related injury concepts coded in the ICD-10 chapters 19/20, (iv) mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats; (v) the review of vertical chapter content in all chapters of the ICD-11 beta version and (vi) downstream field testing of ICD-11 prior to its official 2015 release. The transition from ICD-10 to ICD-11 promises to produce an enhanced classification that will have better potential to capture important concepts relevant to measuring health system safety and quality-an important use case for the classification.

Estimation of comparative disease burden in epidemiological surveys is complicated by the fact that high comorbidities exist among many chronic conditions. The easiest way to take comorbidity into consideration is to distinguish between pure and comorbid conditions and to evaluate the incremental effects of comorbid conditions in prediction equations. This approach is illustrated here in an analysis of the effects of pure and comorbid major depression (MD) and generalized anxiety disorder (GAD) on a number of different measures of role impairment in the US National Comorbidity Survey (NCS) and the Mental Health Supplement to the Ontario (Canada) Health Survey (the Supplement). Pure MD and pure GAD were found to have roughly equal independent associations with role impairments. The incremental effects of having comorbid MD and GAD were found to vary depending on the outcome under investigation. The paper closes with a discussion of the methodological complexities associated with generalizing to comorbidities that involve rare conditions or more than two disorders.

The development and psychometric testing of the new World Health Organization (WHO) disablement screening instrument for the general population is described. Two samples were used for the empirical tests: the crosscultural sample of the WHO Disablement Assessment Schedule (WHO-DAS II) field tests in 19 countries (N = 1323), and an Ontario (Canada) general population sample (N = 802). Psychometric tests included procedures from classical test theory as well as analyses based on item response theory (IRT), both parametric and non-parametric. Results showed that the disablement screener had good properties with respect to classical test theory, but lacked compatibility with respect to IRT criteria. This lack of compatibility with IRT criteria generally leads to a test that must be redefined for each new sample and each time it is administered. Hence, the results reported in this paper suggest that the WHO disablement screener needs revision, if it is to serve as an international cross-cultural instrument.

This paper introduces the Composite International Diagnostic-Screener (CID-S) for mental disorders, a 12-item self-report questionnaire that is based on core diagnostic questions from the Composite International Diagnostic Interview for the assessment of DSM-IV and ICD-10 disorders (CIDI) for use in two-stage epidemiological designs. Data are reported relating to the performance of the CID-S in a two-stage study of a random sample of 1095 respondents, using a wide range of DSM-IV/CIDI diagnoses (somatoform, anxiety, depressive, other affective, and substance-use disorders). In the first stage, all subjects filled out the screening instrument. Seven to 30 days later trained clinical interviewers administered the computer-assisted full CIDI. The CID-S had an overall sensitivity of 85.3% (range for specific diagnoses 74.7% for alcohol use disorders to 100% for panic disorders) and negative predictive value (NPV) of 92.0% (range 91.0%-100%) for any current (12-month) diagnosis and similar values for lifetime disorders (80.7%, NPV: 85.1%). Likelihood for a DSM-IV diagnosis increased steadily from 10.5% among screen negatives, to 24.9% among those endorsing one screening item to 100% among those endorsing more than eight of the screening items. The performance of the individual CID-S items overall was good, except for three disorders: agoraphobia, somatoform disorders and substance use disorders. Overall, the CID-S was found to be a time-efficient diagnostic screening tool for most mental disorders (except for some somatoform and substance use disorders), when used in a two-stage design with a two to 12 week interval between investigations.

Background: In 1992, the ICD-10 introduced the concept of mixed anxiety-depression disorder (MAD). However, a study examining the stability of this ICD-10-diagnosis is lacking. Our objective was to examine the 12 month outcome of MAD in comparison to the outcome of depression, anxiety, and comorbid depression and anxiety. Methods: 85 MAD patients, 496 patients with major depression, 296 patients with anxiety disorders, and 306 comorbid patients were reassessed after 12 months. Rates of depression, anxiety, and MAD were compared using v 2-tests. Results: While depressive disorders and anxiety disorders showed relatively high stability, MAD Patients had no higher rates of MAD at follow-up than patients with depression, anxiety or both. Limitations: Detailed information regarding treatment and disorders during the follow-up interval was lacking. Prevalence rates of MAD in single centres were too small for contrasting centres. Conclusions: MAD cannot be seen as a stable diagnosis: Most of MAD patients remit; many of them shift to other diagnoses than depression or anxiety. The ICD-10 criteria have to be specified more exactly.

Objective: To exemplify the construction of interval scales for specified categories of the International Classification of Functioning, Disability and Health (ICF) by integrating items from a variety of patient-oriented instruments. Study Design and Setting: Psychometric study using data from a convenience sample of 122 patients with rheumatoid arthritis. Patients completed six different patient-oriented instruments. The contents of the instrument items were linked to the ICF. Rasch analyses for ordered-response options were used to examine whether the instrument items addressing the ICF category b130: Energy and drive functions constitute a psychometrically sound interval scale. Results: Nineteen items were linked to b130: Energy and drive functions. Sixteen of the 19 items fit the Rasch model according to the chi-square (c 2) statistic (c 2 df532 5 38.25, P 5 0.21) and the Z-fit statistic (Z Mean 5 0.451, Z SD 5 1.085 and Z Mean 5 À0.223, Z SD 5 1.132 for items and persons, respectively). The Person Separation Index r b was 0.93. Conclusion: The ICF category interval scales to operationalize single ICF categories can be constructed. The original format of the items included in the interval scales remains unchanged. This study represents a step forward in the operationalization and future implementation of the ICF.

Objective: Outcome research seeks to understand the end results of health services. Researchers use a wide variety of outcome measures including technical, clinical and patientoriented measures. The International Classification of Functioning, Disability and Health (ICF) as a common reference framework for functioning may contribute to improved outcome research. The objective of this paper is to provide an updated version of the linking rules published in 2002 and illustrate how these rules are applied to link technical and clinical measures, health-status measures and interventions to the ICF. Results: Three specific linking rules have been established to link health-status measures to the ICF and one specific linking rule has been created to link technical and clinical measures and interventions. A total of 8 linking rules have been established for use with all different outcome measures and with interventions. Conclusion: The newly updated linking rules will allow researchers systematically to link and compare meaningful concepts contained in them. This should prove extremely useful in selecting the most appropriate outcome measures among a number of candidate measures for the applied interventions. Further possible applications are the operationalization of concrete ICF categories using specific measures or the creation of ICF category-based item bankings.

Background The Global Burden of Disease study provided international statistics on the burden of diseases, combining mortality and disability, that can be used for priority setting and policy making. However, there are concerns about the universality of the disability weights used. We undertook a study to investigate the stability of such weighting in different countries and informant g!OUps. Methods 241 key informants (health professionals, policy makers, people with disabilities, and their carers) from 14 countries were asked to rank 17 health conditions from most disabling to least disabling. Kruskal-Wallis ANOVA was used to test for differences in ranking between countries or informant groups and Kendall t-B correlations to measure association between different rank orders. FIndings For 13 of 17 health conditions, there were significant (p<0.O5) differences in ranking between countries; in the comparison of informant groups, there were significant differences for five of the 17 health conditions. The overall rank order in the present study was, however, almost identical to the ranking of the Global Burden of Disease study, which used a different method. Most of the rank correlations between countries were between 0.50 and 0.70 (average 0.61 [95% CI 0.59-0.64]). The average correlation of rank orders between different informant groups was 0.76. Interpretation Rank order of disabling effects of health conditions is relatively stable across countries, informant groups, and methods. However, the differences are large enough to ca$t doubt on the assumption of universality of experts' judgments about disability weights. Further studies are needed because disability weights are central to the calculation of disability-adjusted life years.

BackgroundThe methodology commonly used to estimate disease burden, featuring ratings of severity of individual conditions, has been criticized for ignoring co-morbidity. A methodology that addresses this problem is proposed and illustrated here with data from the World Health Organization World Mental Health Surveys. Although the analysis is based on self-reports about one&#39;s own conditions in a community survey, the logic applies equally well to analysis of hypothetical vignettes describing co-morbid condition profiles.MethodFace-to-face interviews in 13 countries (six developing, nine developed; n=31 067; response rate=69.6%) assessed 10 classes of chronic physical and nine of mental conditions. A visual analog scale (VAS) was used to assess overall perceived health. Multiple regression analysis with interactions for co-morbidity was used to estimate associations of conditions with VAS. Simulation was used to estimate condition-specific effects.ResultsThe best-fitting model in...

The formulation of disability (or &quot;functional impairment&quot;) is currently not operationalized in either the ICD or the DSM. In the DSM system, making a diagnosis depends on a conjoint assessment of symptoms and functioning, whereas the ICD keeps the disability construct separate from the diagnosis of mental disorders. We need an internationally agreed conceptualization between ICD and DSM in terms of better operationalization of disease and disability components. No functioning or disability should appear as part of the threshold of the diagnosis in either system.

The International Classification of Functioning, Disability and Health (ICF) is the framework developed by WHO to describe functioning and disability at both the individual and population levels.While condition-specific ICF Core Sets are useful, a Generic ICF Core Set is needed to describe and compare problems in functioning across health conditions. The aims of the multi-centre, cross-sectional study presented here were: a) to propose a method to select ICF categories when a large amount of ICF-based data have to be handled, and b) to identify candidate ICF categories for a Generic ICF Core Set by examining their explanatory power in relation to item one of the SF-36. The data were collected from 1039 patients using the ICF checklist, the SF-36 and a Comorbidity Questionnaire.ICF categories to be entered in an initial regression model were selected following systematic steps in accordance with the ICF structure. Based on an initial regression model, additional models were designed ...