• Selected sociodemographic and clinical features of social phobia were assessed in four US communities among more than 13 000 adults from the Epidemiologic Catchment Area study. Rates of social phobia were highest among women and persons who were younger (age, 18 to 29 years), less educated, single, and of lower socioeconomic class. Mean age at onset was 15.5 years, and first onsets after the age of 25 years were uncommon. Lifetime major comorbid disorders were present in 69% of subjects with social phobia and usually had onset after social phobia. When compared with persons with no psychiatric disorder, uncomplicated social phobia was associated with increased rates of suicidal ideation, financial dependency, and having sought medical treatment, but was not associated with higher rates of having made a suicide attempt or having sought treatment from a mental health professional. An increase in suicide attempts was found among subjects with social phobia overall, but this increase was mainly attributable to comorbid cases. Social phobia, in the absence of comorbidity, was associated with distress and impairment, yet was rarely treated by mental health professionals. The findings are compared and contrasted with prior reports from clinical samples.

https://jamanetwork.com/journals/psych/articlepdf/495695/archpsyc_49_4_004.pdf

Social Phobia: Comorbidity and Morbidity in an Epidemiologic Sample

Background: Data are presented on the general population prevalences, correlates, comorbidities, and impairments associated with DSM-III-R phobias. Methods: Analysis is based on the National Comorbidity Survey. Phobias were assessed with a revised version of the Composite International Diagnostic Interview. Results: Lifetime (and 30-day) prevalence estimates are 6.7% (and 2.3%) for agoraphobia, 11.3% (and 5.5%) for simple phobia, and 13.3% (and 4.5%) for social phobia. Increasing lifetime prevalences are found in recent cohorts. Earlier median ages at illness onset are found for simple (15 years of age) and social (16 years of age) phobias than for agoraphobia (29 years of age). Phobias are highly comorbid. Most comorbid simple and social phobias are temporally primary, while most comorbid agoraphobia is temporally secondary. Comorbid phobias are generally more severe than pure phobias. Despite evidence of role impairment in phobia, only a minority of individuals with phobia ever seek professional treatment. Conclusions: Phobias are common, increasingly prevalent, often associated with serious role impairment, and usually go untreated. Focused research is needed to investigate barriers to help seeking.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=psych&articleId=497537&pdfFileName=archpsyc_53_2_009.pdf

Agoraphobia, Simple Phobia, and Social Phobia in the National Comorbidity Survey

OBJECTIVES: This study assessed seroprevalence rates of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) among individuals with severe mental illness. METHODS: Participants (n = 931) were patients undergoing inpatient or outpatient treatment in Connecticut, Maryland, New Hampshire, or North Carolina. RESULTS: The prevalence of HIV infection in this sample (3.1%) was approximately 8 times the estimated US population rate but lower than rates reported in previous studies of people with severe mental illness. Prevalence rates of HBV (23.4%) and HCV (19.6%) were approximately 5 and 11 times the overall estimated population rates for these infections, respectively. CONCLUSIONS: Elevated rates of HIV, HBV, and HCV were found. Of particular concern are the high rates of HCV infection, which are frequently undetected. Individuals with HCV infection commonly fail to receive appropriate treatment to limit liver damage and unknowingly may be a source of infection to others.

Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.

This article describes recent research on the prevalence of alcohol, drug, and mental (ADM) disorders and the characteristics of homeless substance abusers and persons with mental illness. Methodological problems in homelessness research are reviewed, particularly in relation to definitions of homelessness and sampling- and case-ascertainment methods. Prevalence rates of ADM disorders are much higher in homeless groups than in the general population. As is true of homeless people in general, homeless substance abusers and mentally ill persons are characterized by extreme poverty; underutilization of public entitlements; isolation from family, friends, and other support networks; frequent contact with correctional agencies; and poor general health. Knowledge of these disadvantages should be used to advocate for better services to prevent homelessness and support homeless people.

The epidemiology of alcohol, drug, and mental disorders among homeless persons.

• Lifetime and current prevalence of Diagnostic Interview Schedul/DSM-IIIdisorders were determined for a probability sample of homeless adults in the Skid Row area of Los Angeles. Compared with findings from a household sample, prevalence was substantially higher for every disorder assessed. Rates of major mental illnesses were the most disproportionately high. Substance abuse was more highly prevalent among older individuals and Native Americans, while schizophrenia was most highly prevalent among those subjects between 31 and 40 years of age. Rates of both substance abuse and schizophrenia were elevated among individuals who had been homeless many times or for long periods of time. it was estimated that 28% of subjects in this inner-city homeless sample were chronically mentally ill, a percentage that was consistent with results of well-designed studies employing nondiagnostic standardized measures of mental illness, but lower than results of studies relying on clinical judgment to assess the prevalence of specific disorders. There is a need for simultaneous attention to the social welfare and mental health needs of homeless mentally ill individuals.

The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles.

The shifts in the pattern and locus of mental health care arising from the deinstitutionalization movement have resulted in a lack of definitive information on the scope of the problem of chronic mental illness. In addition, there is a lack of consensus on the boundaries that define the chronically mentally ill population, boundaries that can guide national policy-makers in a more scientific assessment of needs. In a national study following up the recommendations of the President's Commission on Mental Health, the authors developed a detailed definition of the chronically mentally ill population based on diagnosis, disability, duration of illness, and the institutional and community settings in which chronic mental patients may be found. They used prevalence data from a number of sources to arrive at a national estimate of between 1.7 million and 2.4 million in the target population, including 900,000 in institutions.

Defining and counting the chronically mentally ill.

Many past studies of data on deinstitutionalization have used an overly simplistic and often misleading approach, which has led to a number of "myths" of deinstitutionalization. The authors present data on the changing mental health service system collected by the Division of Biometry and Epidemiology of the National Institute of Mental Health, and they analyze the data to reveal trends that disprove a number of the commonly accepted myths. Through their analysis they show that outpatient care has not replaced inpatient care, that public institutions, particularly state mental hospitals, have not been replaced by community-based facilities, and that private resources have not replaced public ones as the bearer of the cost of caring for the mentally ill. They conclude that the availability and quality of mental health services and the effect of these services on patients and their communities are difficult issues for future research.

Deinstitutionalization: The Data Demythologized

Under the new federal prospective payment system, 15 of the 467 diagnosis-related groups (DRGs) cover mental disorders, including alcohol and substance abuse. The authors compare these 15 DRGs with some criteria of an ideal patient classification system. According to their assessment, the DRGs for mental disorders pose no administrative problems, but are not sufficiently homogeneous within categories or beterogeneous between categories. The authors conclude by discussing their own attempt to develop alternative DRGs, based on such variables as age, marital status, and type of treatment as well as on diagnosis.

Diagnosis-related groups for mental disorders, alcoholism, and drug abuse: evaluation and alternatives.

Evaluation of assertive community treatment programs has demonstrated that they are highly effective in reducing the need for psychiatric hospitalization of chronic mentally ill patients. However, the programs also tend to cost more than traditional outpatient care, and their impact on other areas of patient functioning is not clear. The authors believe more rigorous studies of the programs are needed before policymakers can properly evaluate their role in the overall mix of services. Future studies should extend previous research by comparing the programs to current state-of-the-art treatment in community mental health centers or county mental health programs; assessing the total system costs of assertive community treatment programs, as well as the amount of cost shifting by payers; analyzing outcomes of clients in mature programs over longer time periods; standardizing the measurement of various client outcomes; and determining the impact of individual program elements—alone and in combination—on diffe...

Carl A. Taube

Papers

Defining and counting the chronically mentally ill.

Deinstitutionalization: The Data Demythologized

Diagnosis-related groups for mental disorders, alcoholism, and drug abuse: evaluation and alternatives.

New Directions in Research on Assertive Community Treatment

Patterns of use of psychiatric facilities by the aged: Past, present, and future.