Background: This study presents estimates of lifetime and 12-month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a national probability sample in the United States. Methods: The DSM-III-R psychiatric disorders among persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States were assessed with data collected by lay interviewers using a revised version of the Composite International Diagnostic Interview. Results: Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. The most common disorders were major depressive episode, alcohol dependence, social phobia, and simple phobia. More than half of all lifetime disorders occurred in the 14% of the population who had a history of three or more comorbid disorders. These highly comorbid people also included the vast majority of people with severe disorders. Less than 40% of those with a lifetime disorder had ever received professional treatment, and less than 20% of those with a recent disorder had been in treatment during the past 12 months. Consistent with previous risk factor research, it was found that women had elevated rates of affective disorders and anxiety disorders, that men had elevated rates of substance use disorders and antisocial personality disorder, and that most disorders declined with age and with higher socioeconomic status. Conclusions: The prevalence of psychiatric disorders is greater than previously thought to be the case. Furthermore, this morbidity is more highly concentrated than previously recognized in roughly one sixth of the population who have a history of three or more comorbid disorders. This suggests that the causes and consequences of high comorbidity should be the focus of research attention. The majority of people with psychiatric disorders fail to obtain professional treatment. Even among people with a lifetime history of three or more comorbid disorders, the proportion who ever obtain specialty sector mental health treatment is less than 50%. These results argue for the importance of more outreach and more research on barriers to professional help-seeking.

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Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results From the National Comorbidity Survey

A baseline or control state is fundamental to the understanding of most complex systems. Defining a baseline state in the human brain, arguably our most complex system, poses a particular challenge. Many suspect that left unconstrained, its activity will vary unpredictably. Despite this prediction we identify a baseline state of the normal adult human brain in terms of the brain oxygen extraction fraction or OEF. The OEF is defined as the ratio of oxygen used by the brain to oxygen delivered by flowing blood and is remarkably uniform in the awake but resting state (e.g., lying quietly with eyes closed). Local deviations in the OEF represent the physiological basis of signals of changes in neuronal activity obtained with functional MRI during a wide variety of human behaviors. We used quantitative metabolic and circulatory measurements from positron-emission tomography to obtain the OEF regionally throughout the brain. Areas of activation were conspicuous by their absence. All significant deviations from the mean hemisphere OEF were increases, signifying deactivations, and resided almost exclusively in the visual system. Defining the baseline state of an area in this manner attaches meaning to a group of areas that consistently exhibit decreases from this baseline, during a wide variety of goal-directed behaviors monitored with positron-emission tomography and functional MRI. These decreases suggest the existence of an organized, baseline default mode of brain function that is suspended during specific goal-directed behaviors.

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A default mode of brain function.

Diagnostic systems of several kinds are used to distinguish between two classes of events, essentially "signals" and "noise". For them, analysis in terms of the "relative operating characteristic" of signal detection theory provides a precise and valid measure of diagnostic accuracy. It is the only measure available that is uninfluenced by decision biases and prior probabilities, and it places the performances of diverse systems on a common, easily interpreted scale. Representative values of this measure are reported here for systems in medical imaging, materials testing, weather forecasting, information retrieval, polygraph lie detection, and aptitude testing. Though the measure itself is sound, the values obtained from tests of diagnostic systems often require qualification because the test data on which they are based are of unsure quality. A common set of problems in testing is faced in all fields. How well these problems are handled, or can be handled in a given field, determines the degree of confidence that can be placed in a measured value of accuracy. Some fields fare much better than others.

https://science.sciencemag.org/content/sci/240/4857/1285.full.pdf

Measuring the accuracy of diagnostic systems

The full benefit of many effective medications will be achieved only if patients adhere to prescribed treatment regimens. Unfortunately, applying terms such as “noncompliant” and “nonadherent” to patients who do not consume every pill at the desired time can stigmatize them in their future relationships with health care providers. This article on medication adherence (or compliance) reviews strategies to assess and enhance this important aspect of patient care.

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Adherence to Medication

Guideline for Prevention of Surgical Site Infection, 1999 ☆ ☆☆ ★ ★★

The American Society of Anesthesiologists' (ASA) Physical Status Classification was tested for consistency of use by a questionnaire sent to 304 anesthesiologists. They were requested to classify ten hypothetical patients. Two hundred fifty-five (77.3 percent) responded to two mailings. The mean number of patients rated consistently was 5.9. Four patients elicited wide ranges of responses. Age, obesity, previous myocardial infarction, and anemia provoked controversy. There was no significant difference in responses from different regions of the country. Academic anesthesiologists rated a greater number identical than did those in private practice (P less than 0.01). There was no difference in ratings between those who used the classification for billing purposes and those who did not. The ASA Physical Status Classification is useful but suffers from a lack of scientific precision.

ASA Physical Status Classifications: A Study of Consistency of Ratings

Purpose Small-cell lung cancer (SCLC) is a histologic subtype of lung cancer with a distinct biology and clinical course. It has been observed that the incidence of SCLC has been decreasing over the last several years. Methods We used the Surveillance, Epidemiologic, and End Results (SEER) database to determine the incidence of SCLC over the last 30 years. In addition, we sought to determine sex- and stage-based differences in the incidence and survival of SCLC among a proportion of reported cases of lung cancer over the last 30 years (1973 to 2002). Joinpoint analyses were applied to test the trends in annual percentage change for statistical significance. Results The proportion of SCLC (among all lung cancer histologic types) decreased from 17.26% in 1986 to 12.95% in 2002. Of all patients with SCLC, the proportion of women with SCLC increased from 28% in 1973% to 50% in 2002. A modest but statistically significant improvement in 2- and 5-year survival was noted among both limited-stage SCLC and extensive-stage SCLC cohorts during the study period. Conclusion Our analysis indicates that the incidence of SCLC is decreasing in the United States, and only modest improvements have been seen in survival over the last 30 years. Possible explanations for the decreasing incidence include the decrease in the percentage of smokers and the change to low-tar filter cigarettes. Despite trends toward modest improvement in survival, the outcome remains very poor.

https://ascopubs.org/doi/pdf/10.1200/JCO.2005.04.4859

Changing Epidemiology of Small-Cell Lung Cancer in the United States Over the Last 30 Years: Analysis of the Surveillance, Epidemiologic, and End Results Database

Context Patients with cancer often have other medical ailments, referred to as comorbidity. Comorbidity may impact treatment decision-making, prognosis, and quality of care assessment. Objective To assess whether comorbidity information can provide important prognostic information in a hospital-based cancer registry. Design, setting, and participants An observational prospective cohort study using comorbidity data collected by trained hospital-based cancer registrars. Comorbidity was obtained through medical record review using the Adult Comorbidity Evaluation 27, a validated chart-based comorbidity instrument. A total of 17,712 patients receiving care between January 1, 1995, and January 31, 2001, for the primary diagnosis of new cancer of the prostate, lung (nonsmall cell), breast, digestive system, gynecological, urinary system, or head and neck were included. Main outcome measure Duration in months of overall survival. Results A total of 19,268 patients were included in the study; median duration of follow-up was 31 months. Of these patients, 1556 (8.0%) were excluded due to missing or unknown data. Severity of comorbidity strongly influenced survival in a dose-dependent fashion and the impact of comorbidity was independent of cancer stage. Compared with patients without comorbidity, the adjusted hazard ratio associated with mild comorbidity was 1.21 (95% confidence interval [CI], 1.13-1.30), moderate comorbidity was 1.86 (95% CI, 1.73-2.00), and severe comorbidity was 2.56 (95% CI, 2.35-2.81). Adjusted Kaplan-Meier survival curves revealed that at any point in time the patients with more severe levels of comorbidity had worse survival (partial chi2(3) due to comorbidity, 523.54; P Conclusions Comorbidity is an important independent prognostic factor for patients with cancer. The inclusion of comorbidity in hospital-based cancer registries will increase the value and use of observational research.

https://jamanetwork.com/journals/jama/articlepdf/198808/JOC32516.pdf

Prognostic importance of comorbidity in a hospital-based cancer registry

ContextDisasters expose unselected populations to traumatic events and can
be used to study the mental health effects. The Oklahoma City, Okla, bombing
is particularly significant for the study of mental health sequelae of trauma
because its extreme magnitude and scope have been predicted to render profound
psychiatric effects on survivors.ObjectiveTo measure the psychiatric impact of the bombing of the Alfred P. Murrah
Federal Building in Oklahoma City on survivors of the direct blast, specifically
examining rates of posttraumatic stress disorder (PTSD), diagnostic comorbidity,
functional impairment, and predictors of postdisaster psychopathology.Design, Setting, and ParticipantsOf 255 eligible adult survivors selected from a confidential registry,
182 (71%) were assessed systematically by interviews approximately 6 months
after the disaster, between August and December 1995.Main Outcome MeasuresDiagnosis of 8 psychiatric disorders, demographic data, level of functioning,
treatment, exposure to the event, involvement of family and friends, and physical
injuries, as ascertained by the Diagnostic Interview Schedule/Disaster Supplement.ResultsForty-five percent of the subjects had a postdisaster psychiatric disorder
and 34.3% had PTSD. Predictors included disaster exposure, female sex (for
any postdisaster diagnosis, 55% vs 34% for men; χ21=8.27; P=.004), and predisaster psychiatric disorder (for PTSD,
45% vs 26% for those without predisaster disorder; χ21=6.86; P=.009). Onset of PTSD was swift, with
76% reporting same-day onset. The relatively uncommon avoidance and numbing
symptoms virtually dictated the diagnosis of PTSD (94% meeting avoidance and
numbing criteria had full PTSD diagnosis) and were further associated with
psychiatric comorbidity, functional impairment, and treatment received. Intrusive
reexperience and hyperarousal symptoms were nearly universal, but by themselves
were generally unassociated with other psychopathology or impairment in functioning.ConclusionsOur data suggest that a focus on avoidance and numbing symptoms could
have provided an effective screening procedure for PTSD and could have identified
most psychiatric cases early in the acute postdisaster period. Psychiatric
comorbidity further identified those with functional disability and treatment
need. The nearly universal yet distressing intrusive reexperience and hyperarousal
symptoms in the majority of nonpsychiatrically ill persons may be addressed
by nonmedical interventions of reassurance and support.

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Psychiatric disorders among survivors of the Oklahoma City bombing.

• The objective of this study was to determine the relationship between prescribed daily dose frequency and patient medication compliance. The medication compliance of 105 patients receiving antihypertensive medications was monitored by analyzing data obtained from special pill containers that electronically record the date and time of medication removal. Inaccurate compliance estimates derived using the simple pill count method were thereby avoided. Compliance was defined as the percent of days during which the prescribed number of doses were removed. Compliance improved from 59.0% on a three-time daily regimen to 83.6% on a once-daily regimen. Thus, compliance improves dramatically as prescribed dose frequency decreases. Probably the single most important action that health care providers can take to improve compliance Is to select medications that permit the lowest daily prescribed dose frequency. ( Arch Intern Med . 1990;150:1881-1884)

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/613842/archinte_150_9_014.pdf

Edward L. Spitznagel

Papers

ASA Physical Status Classifications: A Study of Consistency of Ratings

Changing Epidemiology of Small-Cell Lung Cancer in the United States Over the Last 30 Years: Analysis of the Surveillance, Epidemiologic, and End Results Database

Prognostic importance of comorbidity in a hospital-based cancer registry

Psychiatric disorders among survivors of the Oklahoma City bombing.

The effect of prescribed daily dose frequency on patient medication compliance.